Healthcare providers have no right to set tariff for health insurance — Sambo – Guardian Nigeria

Prof. Mohammed Sambo is the Executive Secretary of National Health Insurance Scheme (NHIS). In this interview with journalists, Sambo spoke on efforts taken to restore public confidence in the scheme, among other issues. NKECHI ONYEDIKA-UGOEZE was there for The Guardian. 

On assumption of office in 2019, you reeled out a three-point agenda, how far have you been able to actualise them? 
On July 15, 2019, when I assumed duties in the National Health Insurance Scheme (NHIS), I unveiled a three-point rebranding agenda. One of the agenda is to restore the value system of the organization and make it a credible, result-oriented outfit. The second is to enforce general transparency and accountability in our operations, while the third is to accelerate the drive to attain Universal Health Coverage (UHC).

The first agenda has to do with the restoration of value system. We made it the first because NHIS has been bedeviled by so many problems, which have made people to lose confidence in the organisation. It is supposed to attend to the health needs of over 200 million people, but it is unfortunate that it has no credible plans to achieve the mandate. There have been a lot of squabbles within the organisation to the extent that almost every two years, a new chief executive officer emerges. I am the 12th CEO in the organisation’s 20 years existence and if you do the calculation you will realise that in less than two years, one CEO leaves; so, it has become a joke in the organisation that a CEO cannot exceed two years in office. This was the reason people celebrated me when I completed two years in office. Many of them said it has been long they witnessed a CEO serve beyond two years in office. I think we have been able to achieve stability in this area and have also been able to develop a roadmap that will help the organisation have robust health coverage. The squabbles are over and staff can now work to meet the organisation’s objective.

This is the level we have taken NHIS to. Going into specifics, as to what we have achieved, you can look at the governance and leadership, the human resource, the financial management system, operation of the health insurance, the partnership and collaboration as well as the real technical operation. And if we are to dwell on each of them, we will talk for hours without end.

On the leadership and governance, I must point out that before now, all the organization activities were largely controlled at the headquarters. We have about nine zonal offices, 38 state offices and the FCT; by 38 state offices, Lagos State has two different state offices as designated. Those state offices were there, but they were not functioning because most of the activities were driven from the headquarters. More than 40 per cent of about1,400 NHIS workforce were at the headquarters, while 60 per cent were distributed among the states. The state offices were in a situation where you go and see only six staff, most of them had less than 10 staff. With staff concentrated at the headquarters, this meant people residing in the states had less officers to cater for them. To solve this challenge, we engaged the principle of decentralisation of governance to strengthen the state offices and made them credible to carry out a decentralised function. We also injected relevant, critical human resources that will drive the organisation’s activities at that level.

In my previous interview, I mentioned that of the 1400 NHIS staff only 46 are healthcare workers and by healthcare workers, I meant medical doctors, nurses, lab scientists and pharmacists. The core mandate of health insurance scheme is to interface with the enrollees who are patients going to the facilities to receive healthcare services. We accredit healthcare facilities, ensure enrollees receive the appropriate healthcare services. If you do not have relevant healthcare professionals to do the job, how would you be able to execute such a huge and technical function? It is with this that we engaged at least five healthcare workers —two medical doctors, one pharmacist, one nurse and a medical lab scientist — in each state. These people are now turning things around for good at the various centres.

With such improvements, how many Nigerians are now covered by the scheme?
I have said on several occasion that I do not want to use figures. Before I came in, states were not performing health insurance until a law was passed to that effect. So far, we have 37 states that have started the implementation of the basic healthcare insurance scheme and they have covered a lot of grounds in terms of numbers. So, if you want to get the actual number, it requires aggregation. Some states have covered about 70,000 people, some 50,000, others 20,000, the figures are no regular, but the states are surely working.

Last week, we launched the NYSC programme, where about 360,000 Youth Corps members will be registered. If you have been following us, you will see that the National Assembly has put in a lot of fund in their constituencies, we have been visiting these constituencies and are enrolling them into the social health insurance scheme. We have also launched what we call ‘GIFSHIP.’

With GIFSHIP — Group, Individual and Family Social Health Insurance Programme — we aim at driving the formal and informal sectors into social health insurance programme.
The programme aims at bringing the informal sector into the healthcare scheme and through it, more Nigerians including those in Diaspora will register. We hope to automate our system to store and aggregate data. I can tell you that a lot of work has been done through our reforms, but I will not be able to give you a very accurate data because I am a public health physician; I do not want to talk about statistics.

But in absolute number, we can say we have covered over 15 million Nigerians. As I am talking to you, if you go to our NHIS MCC office, you might see more numbers dropping; so, it is continuous process.

Last year you partnered Roche to subsidy drugs for cancer treatment and also, established Catastrophic Fund for terminal illnesses. How are these projects doing? 
NHIS came up with the idea of establishing a catastrophic fund for terminal illness, however, before I came here, there was a budget for cancer, but the unfortunate thing is that the money for that was sent to the Ministry of Health. To further care for the people, we introduced the NHIS drug initiative to ensure that drugs are available in our system and the cost subsidised. We have a very good interaction with drug manufacturers association of Nigeria on this. They have agreed to collaborate with NHIS and all the stakeholders on board. This means we can start branding drugs with health insurance prescriptions. Doing this, we will make the drugs available and at a reduced cost too. In fact, we have a Memorandum of Understanding with Roche Pharmaceuticals to subsidise cancer drugs by 70 per cent; so, NHIS 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 its anti-cancer drugs with NHIS prescriptions. This is how far we have gone. We are determined to make cancer drugs available through this kind of collaboration. With this, issues that have to do with prescribed generic drugs or substandard generic drugs will be a thing of the past. We are going to have a branding and the Minister of Health has approved it.

Would the N3trillion you once proposed for insurance healthcare coverage still be adequate to cater for 200 million Nigerians in this current economy?
It is a simple arithmetic, assuming no Nigerian has access to healthcare services globally and you want to bring all of them into the system at the current cost of N15,000 per head per year, it will involve huge sums of money. So, if you multiply N15,000 by 200 million people you will be talking about N3 trillion, this is just a projection. We are not saying you have to give NHIS the money for healthcare services; it is just the cost required.

You said social health insurance would cover the vulnerable and, also the one-kobo-per-second telecom charges will boost funding if linked to NHIS. Since the one-kobo-per-second telecom charge has been removed from the proposed amended act, what is replacing it; when will the health insurance start and when will the president accent to this amended Act? 
I know Mr. President will sign the NHIS Amended Act because social insurance is very critical to the healthcare delivery system of any nation. There was a controversy in the one-kobo-per-second call and cannot be implemented for now until all the grey areas are removed.

However, National Assembly members have created a vulnerable fund within the proposed Amendment Bill. But 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 having a mandatory social universal coverage because we have been informed that through dialogue we can have the vulnerable fund included in the financial act. Even if top policy-makers accept it, the proposal still has to pass through the appropriate channels; maybe the financial act. So, hope is not lost, as we shall continue to dialogue to achieve our aim.

How have you been able to address the differences between HMOs and healthcare providers, and the complaints that service providers exploit subscribers by giving them only pain relieves drugs in their facilities?
You have asked two questions in one, but I will separate them for this discussion. The first question has to do with the differences between service providers and HMOs. When I came into NHIS, the HMOs were alleged to be owing healthcare providers a lot of money; in fact, we did not know the exact amount, so, we sent out advertorial in three national dailies for service provider owed by HMO to submit evidence of indebtedness to the NHIS. We got a lot of complains claims from the healthcare providers and because of this, we setup a committee that went through the claims and discovered that HMOs were owing healthcare providers over N5billion. With this, we came up for the first time with what we called decentralised reconciliation system, where we reconciled both parties at the state level.

We developed a tool for this and trained our staff at the state level on how to operate them. We sent information to them as it pertains to their state and they worked for almost four weeks reconciling the two groups. Satisfied with the committee’s work, some of the HMOs paid the health provides what they were owing them out rightly, while others signed agreement to pay in two or three months’ time. We can conveniently say that we recovered over N2.3 billion from that process. Although, there were some contentious issues, but because some of the healthcare providers have no proof to substantiate their claims their issues remain pending.

Recently, healthcare providers introduced a new tariff, saying from February 1, 2022, HMOs would pay them based on the new tariff or they stop attending to their clients. What is your take on this?
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 from the national health insurance scheme. There was a squabble between healthcare providers and the HMOs that the NHIS had to intervene. We summoned them to a meeting, where 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 the health insurance, therefore, that tariff they have set is void and of no consequence.

Secondly, we realised that the HMOs and healthcare providers have introduced a payment system they called roaming, which is alien to the national health insurance. The payment system is neither according to our guideline nor in our law. We have told them categorically that the payment is alien to NHIS and have complied them to revert to health insurance proper if they are to be regulated and any HMO that is not playing according to the rules or guidelines of NHIS will have itself to blame. NHIS has increased its fees for services, which is why the healthcare providers are happy and have asked the HMOs to increase tariff for their private lines. Since the HMOs have not done this, the health providers held a conference and develop the new tariff.

We have reconciled them and are also looking into the tariff to see if it could be implemented by NHIS. The meeting ended on a nice note, which is why no provider has denied any enrollee from getting its services.

The second question is excessive complaints by the enrollees in the provider’s setting. This is one of the major problems we have inherited. Prior to this period, there was room for enforcement, monitoring and tracking, but the tracking tools are no more there for us to use, so, providers are now doing what they want. However, since we have stepped in to reconcile debt, we have successfully settled the healthcare providers, and increase tariff.

The problems in the organisation are systemic and if you want to address them, you need to understand the root causes and put credible structure on ground to check them. To achieve this, we have developed a framework to aggregate all complaints from healthcare providers. This will enable us to sanction any healthcare provider that is registered with NHIS and is not living up to its responsibilities to the clients.

With the eNHIS we are developing, enrollees can call management centres with NHIS toll free number from anywhere and file complaints, if any, of the healthcare facilities defaults. Once the call gets to our MCC in Wuse, we will en-route it to our medical doctors or healthcare workers in the concerned state or states and they will attend to the complaints and probe the facilities if necessary.

At the state level all our facilities have a contact person to attend to complaints; we have created the structure and will launch it soon. Through this, we will be able to aggregate monthly complaints of each healthcare facility. There would be a tolerable limit of complaints we can take and if a facility goes beyond that limit, we give the facility a warning. And if by next month the facility does not improve, we will issue a warning, to be followed by a yellow card if the situation persists. And if after that, nothing has changed we will issue a red card and move all the enrollees to another responsible facility. In the past there was no structure, but today, we have developed one and I hope in the next few months you will begin to see the fruits of our reforms and rebranding.