Improving health insurance’s operational efficiency

The National Health Insurance Scheme (NHIS) was designed to ensure that healthcare services are available to Nigerians whenever such services are needed.
It is an attempt to make healthcare available whenever needed irrespective of how much money the individual has in his pocket.
The individual (enrollee) who has subscribed to the Scheme and the hospitals/clinics (healthcare providers) rendering the services are stakeholders.
The Health Maintenance Organisations (HMOs) that serve as the link between the NHIS, healthcare providers and enrollees are also key stakeholders.
While the idea of a National Health Insurance Scheme is a noble one, it is characterised by some operational challenges.
A major operational challenge of the Scheme is the fact that some Health Maintenance Organisations (HMOs) go as far as inflating the number of registered enrollees under their care and at the end of the day, make false claims for capitation from the NHIS.
The NHIS has not hidden the fact that it has removed thousands of ghost enrollees from the Scheme.
Clearly, the nation has lost billions of naira through this manipulative inflation of the number of enrollees.
The scarce resources spent on the ghost enrollees would have actually been used to improve the quality of healthcare given to the real enrollees.
The persons who enrolled these ghosts into the scheme should be decisively dealt with as a deterrent to others who are planning such destructive act.
Criminal prosecution and stronger penalties in the NHIS Act will serve as good deterrents.
It is recommended that registration with the NHIS or private health insurance should be linked with the Bank Verification Number (BVN)System and National Identity Management System.
Another operational challenge of the Health Insurance Scheme is the fact that some HMOs withhold funds due to healthcare providers.
Previously, the Scheme pays HMOs three months capitation upfront and the HMOs are expected to ensure timely payment to the healthcare provider in order to facilitate timely and qualitative delivery of healthcare service to the enrollee.
However, sometimes, the healthcare providers are unable to receive their pay from the HMOs in a timely manner despite the fact that they have already rendered healthcare services to the enrollees.
Currently, the prepayment period has been reduced to one month.
It is recommended that reports of logistic challenges from healthcare providers and the HMOs should be taken seriously by the regulator and any party that is guilty of one infraction or the other should be thoroughly sanctioned.
Also, some HMOs shortchange their enrollees and offer them health benefit packages that differ from what is approved by the regulator.
Enrollees have been denied basic healthcare services by healthcare providers because the contract binding the HMO and the healthcare provider does not make provision for such basic services, despite the fact that NHIS had empowered the HMOs to provide such services.
When these enrolees complain that they are denied basic healthcare services that should be in their health benefit packages, the healthcare providers defend themselves by stating that such services were not covered in the existing contracts with the HMOs.
This is actually against one of the cardinal parameters of the right to life which is availability of services to attend to those who need such services.
In order to checkmate this sharp practice, it is recommended that enrolees receive aggressive sensitisation on their rights and entitlements under the Scheme as stated in the enrollee bill of rights.
The aggressive sensitization and information should be done by the NHIS, the HMOs, the healthcare providers, professional associations in the health sector and civil society organizations working in the health sector.
Another operational challenge of the Scheme is the issue of poor quality assurance by the HMOs to the enrollees.
The HMOs are expected to provide oversight functions to ensure that qualitative services are offered to the enrollees by the healthcare providers.
The HMOs are expected to investigate cases of medical malpractices and resolve queries promptly.
However, due to inefficient management practices, some HMOs are unable to carry out this very important oversight function.
This has made many enrollees to lose confidence in the Scheme and hence prefer to pay out-ofpocket for qualitative healthcare service despite being an enrollee of the Scheme.
Also, because treatment of patients under the Scheme has being prepaid, some healthcare providers prefer to concentrate their services on private patients who are not enrolled in the scheme and will pay out-of-pocket.
In order to address this discrimination against enrollees by healthcare providers, the HMOs are encouraged to up their game of oversight function and quality assurance.
Eke (08035066196) is a Programme Officer at the Centre for Social Justice, Abuja