By Okechukwu Emeh

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Conceptually,  health denotes the condition of being physically and mentally sound. The essential role this could play in promoting sustainable economic and social development of any polity cannot be underestimated. Interestingly, health, which is equated with wealth by one aphorism, is an integral part of human capital that is greatly needed for the realisation of our full potentials in life, in the same way as education, skill and equal opportunity. No wonder many developed countries, especially those in the West, place high premium on providing their citizens with best health care services.
In Nigeria, with an estimated population of over 170 million people, the necessity of government to ensure that the citizenry have access to quality and affordable medicare is at the core of reasons behind the establishment of National Health Insurance Scheme (NHIS) in the country several years ago. In fact, this ambitious and laudable scheme introduced by the Federal Government is laden with the classical social contract philosophy of those in political authority delivering common good.
Instructively, the NHIS has various programmes to cater for different segments of the Nigerian society. In seriatim, these are: Formal sector (comprising federal, state and local governments, organised private sector, armed forces, police and other uniformed services and students of tertiary institutions) Informal sector (including community-based and voluntary contributors) and Vulnerable group (encompassing pregnant women, children under five, orphans, the elderly, the poor, physically challenged persons, prisons inmates, refugees, internally displaced persons, immigrants and victims of human trafficking). Of these service components of social health insurance, the most developed is that of formal sector in which the health care of employees is paid from funds created by pooling their contributions and those of employers. The roles and responsibilities of the three parties involved in implementing the aforementioned social health insurance programmes in Nigeria are well-defined. For NHIS, they include setting guidelines and standards, accrediting Health Management Organisations (HMOs) and Health Care Facilities (HCFs), carrying out continuous quality assessment to ensure effective and efficient health care services and programme management, technical support, sensitisation and mobilisation. Among the roles and responsibilities of HMOs are effecting timely payments to health care facilities, ensuring effective processing of claims, carrying out continuous quality assurance of health care services, ensuring timely approval of referrals and undertaking necessary follow-up to complete the process, marketing approved health plans to employers/enrolees, collecting appropriate contributions and making necessary payments to the appropriate pools in a timely manner and effecting necessary returns to NHIS in line with the Operational Guidelines.
Those of HCFs involve securing appropriate accreditation with NHIS, providing services as agreed with HMOs in the benefit package, complying with NHIS Operational Guidelines, signing contract with NHIS through HMOs, ensuring enrolees’ satisfaction, providing returns on utilisation of services and other data to NHIS through HMOs, reporting any complaints to HMOs and NHIS and limiting delivery of services to level of accreditation.
Despite the noble idea underpinning the setting up of NHIS, the social health insurance in Nigeria, since its inception, has been bedevilled with awful tales by many enrolees. This include the pains and inhumanity they encounter while trying to access medicare. This is not to gloss over a number of other factors militating against the scheme, including inadequate funding of the regulatory body (NHIS rarely gets a faction of what it generates), lack of political will by some of the past chief executives of the agency to catapult it to greater height through institutional and capacity building, overbearing and exploitative tendencies of some HMOs and HCFs that are not well-disposed to enrolees and inability of NHIS to exert necessary enforcement obligations on defaulting HMOs and HCFs.
Other factors that have not augured well for the social health insurance scheme in the country are deficiency of trust by many subscribers in the scheme due to corruption, inefficiency and political patronage that wracked it in the past, poor data formation on all enrolees that has made the programmes to be susceptible to wastage and fraud, low awareness by enrolees on their rights and privileges, non-extension of the scheme to the grassroots, especially in states and local governments across the federation, and the gap of well-to-do corporate bodies and international agencies not buying into the health insurance scheme by way of subsidising treatment and medication of subscribers suffering from cash-gulping terminal illnesses like heart disease, cancer, diabetes and kidney failure. Amid such difficult challenges facing social health insurance programmes in Nigeria, it is heartwarming that the unimpressive narratives surrounding the programmes are about to change with the appointment of Prof. Usman Yusuf as the Executive Secretary/Chief Executive Officer (CEO) of NHIS by President Muhammadu Buhari last August. As regards the professional profile of Prof. Yusuf whose well-deserved appointment into the position is akin to putting a round peg in a round hole because of his reputable track records in medical practice, he is an erudite professor of paediatric haematology and oncology.
Emeh writes from Abuja
After his graduation in flying colours from the famous Ahmadu Bello University (ABU), Zaria, in 1982 and his subsequent short stint as a resident doctor in Nigeria, he had been living in abroad since 1988, mainly in the United States of America (USA) where he was lecturing in a university, as well as doing bone marrow transplantation for children with terminal diseases like cancer of the blood.
Since his appointment as the Executive Secretary/CEO of NHIS, Prof. Yusuf has hit the ground running with unflinching commitment, determination and creative energy to expand the frontiers of social health insurance in Nigeria with his tested, proven and trusted experience garnered over the years during his sojourn in the United Kingdom (UK) and the USA. Indeed, his passion to demonstrate the confidence of Mr President in his ability to make a difference in this critical sector is encapsulated in his sincerity of purpose to expedite universal health care coverage to all Nigerians. And deeply disturbed that African states with less material endowment like Kenya, Rwanda and Ghana have recorded wider coverage of social health insurance for their populace, the Executive Secretary/CEO of NHIS is of the opinion that Nigeria, given her abundant material and human resources, can do more in expanding her own programmes based on the best global practices.
So far, as part of his determined effort to make major stakeholders see potentials in NHIS to do good, Prof. Yusuf has had a series of meetings with some of them with a view to eliciting their wholehearted support and regaining the trust of the enrolees in the scheme. In this connection, he had met with both management and staff of the regulatory agency, seeking their cooperation to enable him actualise his goal and set objectives, while sounding a wake-up call for them to effectively discharge their responsibilities and obligations since it would no longer be business as usual under his promising tenure.
Part of the networking activities by the Executive Secretary/CEO of NHIS to ensure a hitch-free social health-insurance scheme in Nigeria is his recent interactive sessions with associations of doctors, apart from those of nurses and midwives. The essence of such meetings is to hear their experiences about the scheme, as well as tell them where they have failed the enrolees in terms of unfair treatment in spite of monthly deductions of their hard-earned incomes. Against this background, Prof. Yusuf has directed the Quality Insurance Department of the agency to assess the professional and commitment status of accredited doctors in the social health insurance scheme and their facilities to guarantee qualitative service delivery to subscribers. In a similar vein, during his recent address of Chief Medical Directors (CMDs) of teaching hospitals in the country in Calabar, he had implored the CMDs to change the horror stories of some NHIS patients who reportedly often undergo neglect, exploitation and indignity in the hands of some HCFs.
In his meeting with all HMOs in Abuja not long ago, the Executive Secretary/CEO of NHIS had, first of all, admitted that the accredited companies had failed the social health insurance scheme in Nigeria by feeding fat on the enrolees. As he put it, “The scheme is somehow skewed in favour of HMOs and, alas, against the underprivileged”. Warning that a new sheriff is now at the helm of affairs of the regulatory body to check such anomalies, Prof. Yusuf had vowed to empower enrolees by making them be in the driving seat of the social health insurance scheme since all HMOs and HCFs are dependent on their contributory funds for operation. According to him: “NHIS, under my watch, will talk to the subscribers and listen to them. I will tell them that any HMO or HCF that  fail to perform to their delight will be sanctioned”.
Thankfully, Prof. Yusuf is vehemently opposed to the clamour by HMOs to amend the existing social health insurance law in Nigeria, cautioning that such change would enable the companies to have complete control of the contributory funds of employees and employers participating in the scheme. As he explained: “NHIS is a kind of central bank of all contributory funds to the scheme in the country”. So, according to him, “the key to a successful social health insurance scheme in Nigeria is re-strengthening and galvanising the regulatory body to be the repository of funding of the scheme”.
As part of his special efforts to salvage NHIS, the Executive Secretary/CEO has sought the support of both Senate and House of Representatives’ committees on Health in empowering the agency. Other key stakeholders like the Nigerian Labour Congress (NLC) and Trade Union Congress (TUC) whose members form the greater bulk of contributors to the scheme have also not been left out in Prof. Yusuf’s hopeful search for social health insurance programmes that will work for the expectant Nigerian masses. This is not to mention his meetings with some state governors and traditional rulers across the country whose subjects are in dire need of universal health care coverage, especially vulnerable groups. In this regard, the NHIS superintendent is of moral convictions that the scheme can be replicated at the grassroots level in equitable and fair manner. He is optimistic that it is achievable through counterpart funding, citing the landmark National Health Act of 2014, which stipulates that 1% of National Consolidated Fund shall be dedicated to subsidisation of public health in Nigeria.
Added to the number of important stakeholders Prof. Yusuf has met in continuation of his current campaign on the imperative of viable and subscribers’ friendly social health insurance programmes in Nigeria are the mass media and civil society organisations (CSOs). He has enlisted their support in the strategic area of creating public awareness, enlightenment and advocacy on the scheme.
Mindful that NHIS is the custodian of all contributory funds to the social health insurance scheme in Nigeria, the Executive Secreatary/CEO of the agency has been acutely conscious of addressing the inadequacies and mistakes that have characterised the scheme. Such a stance is commendable against the backdrop of underlying assumption in some quarters that social health care financing in the country has been a huge fraud that is worse than the controversial oil subsidy regime, considering the human suffering and deaths occasioned by some of the actions and inactions of some HMOs and HCFs. To change this negative trajectory, Prof. Yusuf has expressed that NHIS under his authority is set to embark on biometric registration of all enrolees in the scheme with an eye to closing existing loopholes. This is in addition to tackling the vexed issues of the agency not being able to strictly enforce social health insurance guidelines and standards on HMOs and HCFs. To this end, the Executive Secretary/CEO of NHIS has disclosed that an autonomous Enforcement Unit has been created in the regulatory body, while, at the same time, its Legal Department has been directed to write defaulting HMOs to offset debts owed to accredited hospitals/clinics or face sanctions. Already, following this directive, some of the HMOs have begun to remit monies after the HCFs were instructed by the regulatory body to compile debts owed them. As Prof. Yusuf categorically stated, “The winning card of NHIS lies in its Act, which empowers it to hit at the pockets of erring HMOs and HCFs through fines/penalties.
Having recognised the competence, hard work and dedication of NHIS staff, Prof. Yusuf has assured to motivate them towards upholding their duties and obligations without any let or hindrance. Of course, this laudable position is in synch with his avowed mission of making social health insurance something Nigerians should be proud of. Suffice it to say that the priority areas he has mapped out to shepherd NHIS to an enviable height include institutional and capacity building, extending coverage of the scheme to all Nigerians, effective and unrestricted monitoring and regulation of HMOs and HCFs and relentless advocacy campaign on subscribers’ friendly social health insurance in Nigeria, using the broad-based instruments of mass media and CSOs. While girding his loins for the arduous task of cleansing NHIS of adverse factors, the Executive Secretary/CEO has given repeated assurances that the agency under his stewardship would deploy available resources judiciously and equitably.
In recognition of the fact that social health insurance in Nigeria is, at the present, heavily titled towards providing primary and secondary health care services, Prof. Yusuf has not foreclosed the possibility of an all-purpose scheme that will provide for those suffering from terminal health problems like cardiovascular disease, cancer, kidney malfunction and sickle-cell anaemia. In his estimation, “The obvious reason why NHIS is not inclined to foot the bills of such patients, in the meantime, is because of the expensive nature of their treatment and medication that could wipe out the entire financial base of the scheme”. Nevertheless, he is upbeat that with the saving grace of the National Health Act of 2014 and possible enlisting of the support of wealthy corporate and charitable bodies, development partners and international agencies, based on trust, such challenges of extending social health insurance to the terminally sick in the country can be surmounted.
In all, with the confidence-building action plans of Prof. Yusuf for NHIS barely three months of his appointment as its Executive Secretary/CEO, there is no question that he is implacably committed to repositioning the agency to be a world-class social health insurance regulator. While hoping and praying that he would leverage on his ongoing efforts to mark a watershed in this regard, it behoves all stakeholders to give him the much-needed support and cooperation to make the well-thought out scheme a win-win affair that will be collaborative, affordable, reliable and subscribers’ friendly.
Emeh writes from Abuja