A Nigerian Perspective:Why NHIS Is Not Effective

Pharmacists under the Pharmaceutical Society of Nigeria (PSN), Lagos Branch have given an insight into why health care provision in the country is unaffordable and the National Health Insurance Scheme (NHIS) has not been effective. They also faulted the adoption of the global capitation concept as payment mechanism by Health Management Organisations (HMOs) under the NHIS to pay retainer hospitals. Chairman, PSN, Lagos State, Lanre A. Familusi, said the cost of healthcare to Nigerians would remain high as long as government encouraged health providers to render services not within their immediate areas of due competence. “For instance, World Health Organisation (WHO) studies revealed that private health clinics were shown to charge up to 184 per cent more than the public health facilities and 193 per cent more than private retail pharmacies in Nigeria for drugs. Yet, government continues to overtly and covertly support these private clinics to dispense drugs, thereby increasing overall cost of healthcare to Nigerians,” he said. Lamenting that the NHIS in its current form was not working, Familusi said: “One would have expected the NHIS to help correct some of the aberrations which have prevented proper stratification of services along well defined health tiers viz, primary, secondary and tertiary. “But today, under the deceit of ‘easy access to care facilities’, which negates valid Acts of Parliament, NHIS capitates secondary and tertiary healthcare facilities. This encourages such facilities to take over core primary care function from the ideal primary care centres. “In a country where 60 per cent of clinical visitations are malaria-based, patients will continue to visit teaching hospitals for malaria while distracting these centres from handling the specialist cases they were conceived for. A care centre that inculcates specialist services, diagnostic facilities and so on is certainly no longer a primary care centre. This is why in tune with global practices, only Primary Healthcare Centres, Nursing Care Homes, Comprehensive Health Centres, Clinics and Out Patient Departments (OPDs) of non-specialists hospitals should be capitated as gatekeepers or primary providers in the NHIS.” In his view, Familusi said the biggest of the assaults on the NHIS remained the implementation of the unlawful concept of global capitation. The only lawful payment mechanism in the statutes (Decree 35 of 1999), manuals and guidelines of the NHIS are: Capitation; fee for service; case payment; and Per diem. Familusi explained: “Global capitation involves payment of capitation and all elements of other payments modes meant for other providers (secondary and tertiary) to the primary provider. “According to him, the global capitation concept is a shortcut devised by HMOs for administrative convenience but which allegedly short-changes other key stakeholders “This system short-changes the enrollee because he is not guaranteed the best drugs or diagnostic services since the primary provider who has been paid upfront for these services tries to maximise his profit from the advanced payment. “Similarly, given the Nigerian factor, the primary provider can hold the secondary and tertiary providers to ransom when he diverts monies collected for their services to other use. In such situations, how is the pharmacist, who dispenses upfront and waits for four weeks to be paid, protected adequately?” Familusi said this was why HMOs must be made to pay secondary and tertiary providers after signing contract agreements in line with the provisions of the law. He said there was also a need to tackle the excesses of HMOs who have interests in some provider network or facilities and therefore, take advantage of their privileged position to divert a huge number of enrollees to these facilities. The PSN Chairman, however, said that despite the society’s misgivings arising from poor implementation of the scheme, pharmacists believe that the NHIS is one of the most credible alternatives for funding healthcare in Nigeria. “It is assumed that this scheme will offer equitable and physical accessibility to the enrollee but in our assessment, the scheme is yet to ensure delivery of efficient, quality, effective, sustainable service and harmony amongst providers,” Familusi said. The PSN accused the NHIS of assisting business entrepreneurs who own HMOs to rip-off enrollees in the scheme, as the services they obtain were not designed to enable them enjoy the expertise of pharmacists and other care providers or gain access to good quality drugs. “The economic interest of the HMOs has been well protected in the NHIS to the extent that they all run turnovers in the billion naira range to the detriment of the Nigerian people. Some of these huge sums are shared with favoured primary providers who never rendered quality services in the scheme,” Familusi said. The PSN recommended that the Economic and Financial Crime Commission (EFCC) be mandated to probe the NHIS secretariat, especially in the last four years, to unravel the extent of possible abuse.