36 States and FCT Have Commenced Health Insurance Scheme, Says Sambo

The National Health Insurance Scheme was established under Act 35 of 1999 constitution of Nigeria to help improve the health of all Nigerians at an affordable cost. However, 21 years after its establishment, the scheme has remained largely under-subscribed with very limited coverage across the country. But in this interview with some journalists, NHIS Executive Secretary, Prof. Mohammed Sambo, said a lot of things have changed including the roll out of the scheme in all the 36 states of the federation and the Federal Capital Territory FCT. Onyebuchi Ezigbo presents excerpts: .

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What has changed in the Health Insurance Scheme (NHIS) since your assumption of office?

By July 15, 2019, when we assumed duty in the NHIS, we unveiled three point rebranding agenda. If I can recall vividly, one of them is restoring value system that will make NHIS to be a credible, result-oriented organisation.

Secondly is general transparency and accountability in the entire operations of the National Insurance Scheme. Thirdly is to accelerate the drive towards attaining universal health coverage and if you remember vividly we have constructed the element of each and every one of these agenda.

For the first one which has to do with restoring value system, the reason why we would put it as the first agenda that we would pursue is because NHIS has been bedeviled by so many problems and there was no internal cohesion and externally there was loss of confidence in the system. The organisation that is supposed to attain a universal health coverage with over 200 million population had no credible roadmap to achieve that and there was a lot of scrambles within the organisation.

The organisation wasn’t stable before and through the implementation of the value orientation element, we have been able to stabilise the organisation.

We have been able to create a clearly defined roadmap that will help us attain robust health coverage. The scramble whereby tear gas was being thrown into the organisation is no longer news in the organisation and you now see people working assiduously towards meeting the objectives of the organisation.

We even developed a mantra that when you go outside and say ‘NHIS’, people will spontaneously respond ‘result-oriented’ and if you say ‘result-oriented’, people will respond ‘NHIS’. This is the level we have taken NHIS to.

In going into specifics as to what we have achieved, you can look at NHIS from various dimensions; the governance and leadership issue, the human resource, the financial management system, operation of the health insurance, the partnership and collaboration as well as the real technical operation. So if you take each one of them we can talk for hours and hours.

In what state did you meet NHIS and how have things improved since your appointment? We need to know with statistics when you talk about improvement in NHIS coverage

I have said severally that I don’t want to use numbers. Number is very crucial. The health insurance first is a decentralised system. Before I came in, states were not performing health insurance. There was a law that says that states should have their own social health insurance system.

As at 2019 when I came, there was no state that had technically commenced social health insurance but because there is a provision under the national Health Act to bring about states to come to deliver the basic healthcare provision fund which is a federal government fund that is supposed to cover the vulnerable population, we have been able through the Minister of Health and other stakeholders to bring about that programme in line now.

About 36 states and FCT, let me say 37 because just last week Akwa Ibom has passed their own state law. So we now have 37 states that have started the implementation of the basic healthcare provision fund and based on the resources that we have delivered to them, they have been able to cover a lot of ground in terms of numbers. So if you want to get the actual number, it requires aggregation.

All this coverage that has been done at the state level, some are basic healthcare provision fund that we have given them which some have covered about 70,000 people, some have covered 50,000 people, some have covered 20,000 people.

This is the basic healthcare provision fund. Some states under our guidance of health insurance under one roof have started their formal sector. For you to get the totality of the number of people under health insurance you need to do that mathematics and it is not only those people that have been covered since my coming, last week we just launched the NYSC programme where we are going to have about 360,000 youth corps members that are registered.

If you have been following us critically, you will see that the National Assembly has put in a lot of monies in their constituencies which they call constituency projects and we have been visiting those communities and we are getting them enrolled into the health insurance scheme.

Then we have also launched what we call Group Individual Family Social Health Insurance Programme – (Gifship). That is why the initial assertion by my friend wasn’t too correct; NHIS is driving the formal sector social health insurance programme and the informal sector health insurance programme which is through GifShip.

This is an attempt to bring informal sector into the scheme of things and through these programmes, thousands of Nigerians are coming in to register and we are expecting to see more coming even people at the level of diaspora. We know that these efforts are going on across the country but we have discussed about trying to automate our system whereby we would be getting data real-time and very soon we are going to launch NHIS platform. We have done a lot of investments in the level of our state offices. Even at the level of the state health insurance agencies, we have been able to put infrastructure that will enable us aggregate data. So what I can tell you is that a lot of work has been done through our reform efforts.

What about the coverage level in terms of percentage?

Maybe in absolute number, we can say we have covered over 15 million Nigerians and as I am talking to you, if you go to our NHIS MCC office you would see another dropping so it is continuous process.

How far have you gone with the plan of the NHIS to subsidise cancer treatment?

NHIS came up with the idea of establishing a catastrophic fund and before I came there was a budget that was appropriated for cancer for NHIS but unfortunately that money was sent to the Ministry of Health and you know once money gets into a system it is very difficult to move to another system but I know that the ministry has aggregated stakeholders and they are trying to drive that process. However, at the level of health insurance you might have known about NHIS drug initiative which is a very noble programme that we have introduced to ensure that we have drugs available in our system and cost also subsidised where we had a very good interaction with drug manufacturers association of Nigeria and they have agreed to collaborate with NHIS and all the stakeholders so we can start branding drugs with health insurance prescription and by doing so we will be able to have availability of the drug and we will be able to have the cost of the drug coming down.

In fact we have a Memorandum of Understanding with Roche that they are going subsidise the cancer drugs by 70 per cent. So it means that NHIS for its enrollees will only pay 30 per cent of the cost. Last week, Roche informed us that they have secured the approval of NAFDAC to start branding these anti-cancer drugs with NHIS branding.

This is how far we have gone. We are determined to make cancer drugs available through this kind of collaboration that will bring down the cost of the drugs and it is not even the cancer drugs under our drug management initiative. You may need to understudy that drug management initiative after this interview and propagate it to Nigerians. All the issues that have to do with people going to the facilities, being prescribed generic drugs and those generic drugs are substandard and of low quality will be a thing of the past with social healthcare insurance.

We are going to have a branding and the manufacturers have agreed, we have gotten approval from the Minister of Health and very soon we are going to start advertising with the stakeholders that would come and join. The future is very bright.

Some time ago you talked about NHIS requiring about N3 trillion to provide health insurance coverage for 200 million Nigerians. Can you speak more on this?

You see it is a simple arithmetic; assuming no Nigerian has access to healthcare services globally and you want to bring all of them into the health insurance system at the cost we are currently using which is N15,000 per head per annum. So if you multiply N15,000 by 200 million people you are talking about 3 trillion, this is just a projection. We are not saying you have to give NHIS N3 trillion to get healthcare delivery service, this is the cost that is required and this is the effort we need to make but you know already that the formal sector are on the national healthcare insurance scheme.

Then we have a basic Healthcare Provision Fund already. We also have state health insurance that are coming. We have private sector which has a role in health insurance. So those ones and their family we have to deduct them because they already have access to healthcare delivery.

The self-employed are divided into two; those that have the capacity to pay and those that can’t pay who are now within the vulnerable segment.

So if you want to even make a case for people that are not covered under the health insurance, you have to do all these subtractions and now get the real number of vulnerable and it is those vulnerable that you would want to create some innovative financing mechanisms that will enable NHIS as an agency to generate funds to cover them.

That is if the law of the national health insurance scheme is mandatory but as we speak the law of national health insurance scheme is not mandatory. No country will dream of attaining universal healthcare coverage if the law of health insurance is not mandatory.

The reason being that the rich who has capacity to have access to every big healthcare service will not want to join healthcare insurance scheme but if you make it mandatory, the director in Shell will contribute to the fund and the passenger in Lafia local government will contribute to the same pool, then you now have a big pool and when you have a pool, you will be able to extend services to the vulnerable even from the contribution of the existing contributors.

If you do that, the number of people that are not covered are the vulnerable segment of the population and every country where you see universal health coverage ascertained, there are those vulnerable groups and there are mechanisms which the government put in place to pay for them.

There is a popular innovative financing mechanism that is moving across sub-Saharan countries which has to do with telecommunication funds. How do you get one kobo per second to be accumulated for the coverage of social health insurance? Assuming that initiative let’s say will bring about N600 billion into the health insurance, how many vulnerable we will be covered with it? Health insurance is a very dynamic system whereby there is need for a lot of thinking and brainwave to be able to harness resources in an innovative manner to bring about funds that will cover the vulnerable.

The bill on mandatory health insurance for Nigerians has been submitted to President Muhammadu Buhari for his assent. What do you think is delaying the president’s assent?

Anytime soon I think Mr. President by the grace of God will sign because this mandatory social insurance is very critical to the turnaround of the healthcare delivery system and I think there is no contention in whether to sign. There was a controversy in the one kobo per second call that was objected by the ministry of finance based on their understanding of financial management system whereby NHIS is not a tax collecting agency and therefore it can’t do that.

However, the National Assembly members have created a vulnerable fund within the proposed amendment bill and the whole idea is that you should know that do we have mandatory social health insurance?

No! We should also think of how to innovatively fund it. The creation of that vulnerable fund is the first step towards attainment of getting to have the mandatory social universal coverage because we have been informed that through dialogue we can have innovative funds to be encapsulated in the Finance Act and that is the mechanism.

What are the findings of the panel which reviewed the conflict between the Healthcare Maintenance Organisations and Healthcare Providers?

When I came to the NHIS, the Health Maintenance Organisation (HMO) was alleged to be owing healthcare providers a lot of money. How much was it, we didn’t know at that point in time. We sent advertorials in three national dailies that any provider who is owed by HMO should submit evidence to the National Health Insurance Scheme. So we collected a lot of complaints/claims from the healthcare providers.

So we set up a committee to do analysis and we were able to analyse the total submission and the alleged fund was over N5 billion. So for the first time we developed what we called decentralised reconciliation system whereby we do reconciliation at the state level. We developed a tool for the reconciliation, we trained our staff at the state level because I told you we were trying to strengthen our state offices. We sent them information as it pertains to their state and they worked for almost four weeks bringing the HMOs, bringing providers on a round table. There were claims and counter claims. At the end of the day when we did the analyses, the total alleged funds for those who submitted up to 2019 when I came in because it is a very long debt, we analysed that and there was as much as over N5 billion but we realised that over N2 billion wasn’t in contention.

The healthcare provider have submitted it, they have sat with the healthcare providers and they have agreed so there was no contention and there were clear evidence. For that amount, the facilities signed agreement, some of the HMO paid outrightly and some signed agreement for two or three months. We conveniently say that we have recovered over N2.3 billion for that one.

There are some that were in contention and there are some that healthcare facilities have no proof at all and we were not magicians. Since we are not magicians we can only work with evidence. Some of the healthcare facilities in all honesty have no credible system within their healthcare facility to manage their relationship with HMO. So the documentation was very poor.

So because of our limitations we were able to recruit a forensic auditor who had gone deeper because they have the tools and knowledge to probe deeper and they submitted their report just some few months ago and it is through that report that they are working with the providers to ensure that the complains are resolved. But for those ones that they can’t provide any justification, even the external forensic auditors can’t ascertain the authenticity there was nothing we could do. So that is how far we have gone.

Then there was a new scramble between the healthcare providers and the HMOs recently whereby the healthcare providers one day held a conference and they rolled out new tariff and they said by February 1, 2022, if HMOs don’t pay them that tariff they would stop attending to their clients. So it is important to understand that there are two ways health insurance works.

Even though we frown at the other one, the first one is the one that comes through the NHIS wholely and by the time HMOs have relationship with providers on what they call private lines. So that is an aspect that there was a contention between them but with the NHIS, there was no contention. So there was a lot of bad blood between them. NHIS had to intervene and we summoned them to a meeting and we said without fear of contradiction that the healthcare providers have no right to set tariff for health insurance.

The responsibility of setting tariff is that of health insurance. Therefore that tariff they have set is void and of no consequence. Secondly, the relationship between HMOs and providers, we realised that they had introduced one payment system which they call roaming as we have in telecommunication system which is very alien to the national health insurance. It is neither in our guideline nor in our law and we told them categorically that the kind of payment system that they are doing is alien to the NHIS and we compelled them to revert to health insurance proper if they are to be regulated and any HMO that isn’t playing according to the rules and guidelines of the NHIS will have itself to blame.

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“NHIS is driving the formal sector social health insurance programme and the informal sector health insurance programme which is through GifShip.
This is an attempt to bring informal sector into the scheme of things and through these programmes, thousands of Nigerians are coming in to register and we are expecting to see more coming even people at the level of diaspora”