The new NHIA Act has further empowered us – Femi Akingbade

Our editorial team spoke with Mr. Femi Akingbade, GM and Lagos Coordinator of NHIA, on the new law and how it would impact the industry from the perspective of the regulator. he disclosed that the new law was what the industry has been waiting for and that it has further empowered the federal agency in many ways. His perspectives will educate readers on other sundry issues within the industry.

As a major industry stakeholder, what are your association’s general thoughts on the new NHIA Act?

Thank you very much. The Act is one particular document or milestone we have been agitating to get done in Nigeria for a long time now because we believe, as Health Care Providers Association of Nigeria, this Act will be the one to usher in properly, Universal Health Coverage. By the language of the Act that makes health insurance mandatory in the country, it is the only tool by which you can accelerate achieving Universal Health Coverage. So for the stakeholders, it is a very welcome development. It is one particular milestone that I have every reason to thank God for that it is happening during my tenure as HCPAN President. And I must congratulate everyone that this is coming on board at a time that we have economic uncertainties, when the value of our naira is really low. So we are happy to tell Nigerians, Eureka! We have found it. And during the process of anticipated implementation, we expect that we should all be able to “walk the talk”. Once that is done, then the hopes of every stakeholder, every healthcare provider, even the Health Maintenance Organizations (HMOs) and possibly the Third Party Administrators (TPAs) will be realized that we have something to rely on as far as healthcare delivery in Nigeria is concerned.

With your response it shows that you are very impressed with it. Would you say it is an improvement over the old one?

It is an improvement indeed over the old one because the old one (NHIS Act 35 of 1999) gave effect to the extent that insurance procurement by individuals or groups or families read “MAY” instead of “SHALL”. “MAY” means voluntary or conditional while “SHALL” means it is mandatory or compulsory. So, that particular clause of “MAY” that has now been changed to “SHALL” makes a lot of difference. To be specific therefore, the new NHIA Act 17 of 2022 says it is mandatory or compulsory to have one form of health insurance cover or the other as long you are residing in Nigeria at any material time. And in fact, you have to go in first of all through a mandatory social protection gate-keeping health insurance which will give us the basic benefit package after which individuals, as their choice may be, can now proceed to get a top-up to under private health insurance.

We should also not forget that the Basic Health Care Provision Fund (BHCPF) made available a percentage of our gross national budget to cover the vulnerable group and to this extent, 83million Nigerians who are vulnerable will have their premium paid by government. And 83 million people is not a small number especially when you look at what we have done as a nation between 2005 and May this year, which we have only been able to cover just about 5% of the population. Out of over 200million people, we have not been able to do up to 3% or 4% even private and public put together. That is just not good enough. Even though we came up with innovations and initiatives of “health insurance under one roof”, we have not been able to do much. Everybody has been busy with fragmented health insurance. So with this one on board, we are sure that there will be acceleration in the coverage area.

The beauty of it all is that, hitherto, over 76% of Nigerians have been doing “out-of-pocket” payment for their health care access. That is catastrophic and dangerous. But with health insurance mandatory provision, that will be a thing of the past. That is our dream and expectation.

Looking at the funding of 83 million vulnerable people, do you think government has enough resources to constantly fund that?

That is a good question. One, there will be appropriation of special health intervention fund. We are looking at also health levy which is like health taxation. We are also looking at what we can get from GSM service provider where government can charge 1kobo on every call made by Nigerians. There is also possible funding through value added tax (VAT) as well as contributions from development partners and charitable organizations. There is also “adoption tree” by members of the national assembly from constituency allowance. There is also the melting point of the Nigerian budget unit where we special taxes like the sweets and sweetened beverages tax can come from. So we are optimistic.

Even our flight tickets are also there. Government can place special healthcare contribution of N1,000 on every domestic flight ticket. We can also do road show display, toll gate to generate fund that can be pushed to the health sector. There are many resources out there that we can harvest and utilize for this particular purpose. What is more, you can even deduct N200 per person from the trader moni of N5,000 given to 40million Nigerians. Imagine how much that gives you per month.

You sounded so confident that government can harvest these funds to finance the vulnerable people. Are you also confident about the transparency in our system? How do we ensure that these funds are deployed for the intended purpose?

Nigeria is not the only country where corruption thrives. It is true that we have very significant scale of corruption in Nigeria; it also thrives in other climes. However, let us concentrate on our country. Some of us have had the opportunity of being sent out for studies- some to Ghana, some to Rwanda and United Kingdom. Some of us have even been to at least two or three countries to study their health insurance pattern and why some of them have covered so much ground. How has Rwanda covered about 90% of its population? How has Ghana achieved 70%? Even in the UK, NHS is being sponsored or funded purely by taxation. We have brought back those experiences from those countries. I just want to make this one point clear. The HMOs have become an industry and for me, I do not like destroying an industry. They should be given their roles and responsibilities according to what the new Act has made provision for. Everybody has a role to play. Nobody should be afraid to lose his or her job. We can only re-direct how we warehouse our funds. We can redirect how we will pay these healthcare providers. What is the payment mechanism for the providers because the worries we have is how are we going to do this funding that somebody will not misappropriate it? If we sit down as a people and we agree and marshal out how for instance, if I am a third party administrator, you only give me my admin fee and I would be comfortable to do the job. So whatever will bring suspicion, I will say let us begin to hold people responsible for issues put on their jugular. If you put people in charge of resources or money, make them accountable. So we cannot even do this thing as it is now without using the civil society, the media like yours (Health Insurance Today) to monitor and see that we are transparent. Even Transparency International and other agencies can be brought to see what we are doing. If you go to Rwanda, at a particular time of the year, they will bring a minister to a field like Liberty Stadium (in Ibadan) to come and render accountability with evidence to the people what you have done and failed to do. And people would be free to ask questions such that if you are found wanting, you can lose your job right there and then

So we should adopt a tool where people will be made responsible for the duties or functions put at their doorstep. When we are able to do that and we are transparent with what we are doing, then we will be walking the talk. But if we cannot do that and we are trying to patch issues and patch things. I can tell you it will not work. But I must let you know that the optimist will be the aeroplane but the pessimist will build the parachute. We must consider all the factors that will make things work.

We expect that there will be increase in the number of enrollees since everybody must be on one form of cover or another. Do you think healthcare facilities (your members) are ready for this imminent huge change?

As we speak, we are at the level of advocacy, enlightenment, education, and even interpretation of the Act itself. This is because you can only get power from information. Information is power. When people are well educated, when they have awareness; when they understand the Act, when they know what the law is talking about, then we can all be good healthcare provider players. For example, we will tell them that now is the time to begin to think of urban-rural migration, not rural-urban. We should begin to build our facilities in the form of primary health care units, hospitals that will take care of primary care patients, clinics at the rural level where the population is. Seventy percent of our population in Nigeria resides in the rural areas while 30% is in the urban centres. I will give you a quick example. About five years ago, we did some studies. And we found out that, as at then, Nigeria had about 40,000 doctors and we based the study then on 170million people. We then discovered from the study that 28,000 doctors representing 70% were residing and practicing in the urban areas. So that is 70% of doctors serving 30% of the population and 30% attending to 70% of the population! This is skewed and I have only used doctors as an example. It is the same for other healthcare professionals. So it means people who really need the services of these professionals do not have access to them.

And so we are now telling our people, move away from urban centers, spread yourself out, and begin to migrate to villages and rural areas where you can build or get your practices ready for Universal Health Coverage and mandatory insurance. Our members are ready but we need empowerment, we need encouragement, we need motivation, we need relaxation from multiple taxation. Part of the encouragement is for schools and other social amenities to be made available in the rural areas so that as doctors, for example, move there, there will be schools for where their children to attend. What we are advocating for is social reforms and engineering of the social facilities so that all together, we can have this revolution positively workout.

So, our people are getting prepared. And I am not talking about doctors alone. No. I am talking about pharmacists, about nurses, laboratory scientists, physiotherapist, radiographers, dental surgeons, etc. I am talking on behalf of all professionals who have something to do with health insurance. HCPAN is not a doctors association; it is an association that belongs to all private healthcare providers.

In which specific areas do you think your members need to develop and build more capacity to deliver good quality service in anticipation of what is about to happen?

You must have been hearing about Land Use charge, signage fee, etc. In fact, the bills that healthcare providers pay are too many. You know that as a healthcare provider and business man; whatever you are doing (in terms of cost) will ultimately be passed on to your patients or clients. The other issue is drug procurement. Now, and luckily enough, we have NHIA-branded medicines. This should reduce the drug out-of-stock syndrome. There have been these drug management agencies (DMAs) or drug management organizations (DMOs), which one is public while the other is for-profit. These talk about how do you procure or distribute drugs to the users. If we DMAs and DMOs that are properly managed and you have NHIA-branded medicines, it means that providers can have access to drugs being supplied by manufacturers and let the NHIA stand as guarantors for them, which HCPAN has been part of the committee piloting that. If providers do not have immediate cash to pay, they can be given five or six weeks credit or grace while they sign an MoU or the money can even be deducted from source from the provider’s capitation. When such guarantor arrangement is done and liberalized through the NHIA, I can assure you that procurement would be an easy thing as it will assure quality because the Pharmaceutical Manufacturing Association of Nigeria (PMAN) is being engaged and have agreed to give high price mark-down on drugs. For example, a drug that costs N1,000 could be given out for a discounted price of N500. The remaining N500, NHIA could say we will pay 30% while the patient pays 20%. So the patient is only responsible for N200 for a drug that costs N1,000! This we have been doing for the past two years under the NHIA-Branded Medicine initiative. Even some previously excluded drugs, e.g. cancer drugs have now been included dispensing started in some teaching hospitals such that, for example, the first N1million worth of drugs is covered before the patient starts to pay. So if all hands are on deck and we decide to shun manipulation and cheating, the light is bright at the end of the tunnel for us as an industry.

In Nigeria, as you know, there is no industry that is worst hit with migration abroad, which we call “Japa“, than the medical industry. In what way do you think that the brain drain will affect the implementation of the NHIA Act?

Now we are taking about human resource issue. It is true there has been exodus of doctors from Nigeria to what is called “greener pastures”. It is not only doctors. Nurses, pharmacists and other health workers are involved in it. Perhaps, it is most pronounced among doctors. We have reached a level where we will be doing what we call application of appropriate technology. We have reached a level where we will be doing what the Indians did years back when they had to begin to train medical assistants. We have to raise human resources in health that will be peculiar to our situation. I do not want to be too emphatic, in some East African countries like Kenya, Ethiopia and others; we have non-medical doctors do caesarean section. See, what you are passing through will determine what you will do in task-shifting and task-sharing. What we have been calling quackery before, we have to redefine it, possibly redirect our energy into organizing a curriculum for this people; put them in formal education that will invariably yield the kind of health workers that will attend to our peculiar situation. Let me just be frank with you, the type of money that our children, our colleagues, our peers are being paid outside the shores of Nigeria is so attractive that they will be migrating. We are serving as a kitchen “baking” the health workers while other countries are taking them away from us. It is economic disadvantage. Yes, there is this dictum “brain drain” is “brain gain”. Are you going to wait for them to repatriate back home the foreign currencies they gained and we are clapping that we are gaining something? When somebody develops acute emergency in Nigeria, that money they are throwing at us cannot be as effective as having manpower on ground. And these are professionals you cannot train overnight. There are mundane duties you give somebody who is not so specialized. We have human resource challenge. We have a duty and responsibility to begin to train people to especially handle our primary health care centres, people who are not necessarily doctors or highly-skilled. Primary health is at the base of the pyramid, if you get I right there, the challenges at the secondary and tertiary levels will not be too much to handle. And so we must develop a curriculum for those who will perform those tasks them and encourage them to even take over more tasks. So we need to know who and where we are and make adjustment as necessary.

Recently, your association threatened to cancel all HMO contracts over service tariff dispute. However, following the intervention of the NHIA, we understand that engagements are ongoing between you and the HMOs on the adoption of a single tariff system for the industry. What is the update on this, and when would implementation begin?

Thank you very much. You will agree with me that when an Act like the NHIA Act comes up like this, one task we should all be prepared to face is later implementation. Just like the National Health Act of 2012, one task you should be waiting for is the implementation of the Act. One cap can never fit all. No one single tariff can fit all because we are going to have various schemes, programmes and project under the Act that people will key into. For example, people are expected to come in through the social scheme of about N15,000 with the option of top-up if the benefit package is not adequate for you. This means you will go the HMO to buy private health insurance. So there is no how a single tariff can cover this. Also, the state social health insurance schemes that are to run the basic health care provision will only be able to do that based on the tariff generated by the state to suit their purpose. What is being charged in Bayelsa will not be charged in Oyo State. Even the level of counterpart funding of the BHCP will vary across states and will largely determine how it can pay for services. So there is no way we can a single tariff.

That is on one hand, on the issue between HCPAN and HMOs, the NHIA Act was signed while we were having engagements and negotiations on the issues we raised with the HMOs, However that did not stop the process as the issues were on tariff for private health insurance and not for social health insurance tariff. There is no way we will not come back to the issue under the new law as people may still buy private health insurance as top-ups from HMOs meaning we will still interface with HMOs on their private tariff. So the issue will still come up. However, under the social health insurance scheme, NHIA may decide to pay capitation directly to healthcare providers and not through HMOs but that is left to the operational guideline to spell out. That document will resolve a lot grey areas.   

The new Act has created a situation where the private HMOs are complementary or secondary to the state agencies, they are not to exist side by side. What is your view about this?

Yes. But you know even the state health insurance agencies are still using HMOs. However, they have limited the function of the HMOs to administrative assignments while those states pay their health providers directly on their own. So, the function of the HMOs has been redefined because, you will not believe it, what has been causing argument and suspicion is fund management and disbursement. If you owe providers, surely you will not get what you want. The state too must be careful about taking responsibility because if anybody dips hand into the fund meant to pay providers, health insurance will fail in that state. That is basic. I cannot come and pick the product you are selling and not pay you and still expect you to service me tomorrow. That was what truncated Ghanaians formula recently when they owed providers so much money and there were arguments all over the place. There is no how you owe such an uptaker for example or such person that is helping you on the demand or supply side and you will expect seamless flow of services because they too have workers to pay, they have their hospital or clinics to run, they have a lot of bills to pay.

On the question of seeming over-centralization of benefit access, industry watchers have criticized that part of the law by saying it is like making Central Bank of Nigeria the first port of call for banking services for all Nigerians rather than what we have now that you can go to your bank. Why make health insurance package primarily available from only government-whether federal or state agency- and that of HMO’s supplementary?

Government is usually concerned with social protection. They want the public to see them as living up to their responsibilities. So you cannot go straight to buy private health insurance. Everybody will have to first buy the basic health package whoever you are. You pay the N15,000 into the general pool to allow for cross subsidization and to make the money for the rich and poor to come into one basket. If you then feel you are rich and want more you go buy private but at least you would have contributed to the social net.

Also if you have private health insurance, you cannot say you want to benefit from what vulnerable people are benefiting having identified you as strong enough to buy private health insurance. So, society wants to do socio-economic stratification- those who are rich, poor and even those below poverty level. There was a study that identified 83million vulnerable people and it is only fair that everybody comes in through a common “one gate” to put money in one large basket. So you compare the job with commercial and central bank. If you say you do not want to over centralize it, they are seeing those of us who have HMO as organization for profit. Banking and health issues are not the same. Health is part of government’s social responsibility to take up and it is people’s fundamental human right. Banking is not fundamental human right. I can put my money under my pillow and sleep. So you cannot easily compare the two. Health is basic, just like education. Somebody will say I have a right to be educated. Nobody comes up to show muscle that I have a right to keep my money in the bank. Those are the things that are on ground and we have to understand. This Act may not necessarily benefit health care providers and HMOs. The important thing is that it should be of benefit to all of us. We should look at the larger society. We must be our brother’s keeper. We should not be thinking of the profit part of it.

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It has also been said that because the new in the implementation has the potential to reduce the amount of business to HMOs that that could impact on investor’s confidence in the industry…

Do you know that the Basic Healthcare Provision Fund is being used by many states to patronise their government-owned primary health centres and that the money they realise from it they use it to develop the primary health care centres? Is it not also a reduction of business for private healthcare practitioners? When people who I would have seen (treated) and who would have paid me money or the basic health care provision you are trying to do, you are not involving me as a private practitioner to use my facility, have you not reduce the volume of my business? This is what is happening. The issue we are facing is not about reducing business volume. It will naturally be because the truth is simple, how many people can voluntarily foot the health bills we have in Nigeria today? Health is not cheap. If they say N30,000 is the minimum wage, how many states are able to pay that N30,000? Besides that, in a family of four, five or six members, a single outburst of malaria can cost N40,000 on a child if the payment will be out-of-pocket. How many of the families will become disastrously affected if two, three members are hit by infections in one month and the breadwinner of the family is earning N30,000 minimum wage? The matter we have on ground is being our brother’s keeper.

Like I mentioned to you earlier, if I am to think of the business erosion of the Act across the divides, I would not be speaking the way I am speaking. There is nobody that will not be affected. If everybody will be affected but for the general good of the populace, we will all have to make the sacrifice. Government wants to prove a point that they are taking care of the health care needs of the populace. That is what is happening. This is regardless of whether or not investors are going to be affected.

One of the notable differences between the old NHIS and the new NHIA is that the health care providers have been excluded from the council of NHIA. What is the view of your association about this?

It is not only health care providers that are excluded HMOs are also excluded. The argument of the government is how can we include people we are regulating as part of the members of the board of regulators? We have also raised our counter-observations. That is an anomaly. It does not go down well with us and we may see a backlash. Even the Nigeria Judicial Council, the Medical and Dental Council of Nigeria, etc, have those they regulate as part of the council. That is the simple logic in transparency. There is this old dictum that says “you cannot shave a man’s head in his absence”. If you form a council, you are operating there and I am not a member, I do not know what you are doing then you are in a secret society and I can tell you that that body is not defending my interest. I can become suspicious of whatever you bring out. And so if I were them, I would not allow that policy to stand. Who say some of the members of the council do not have HMOs or healthcare facilities? How have you screened them to be sure they are free of this affiliation we are talking about? How can you be sure they are not at extra advantage of knowing far ahead of the rest of us? We will raise our memorandum to Hon. Minister of Health because these are fundamental issues. And we know that Prof. Sambo-led NHIA has demonstrated high sense of responsibility and transparency and has carried stakeholders along as much as possible but that does not stop backlash in documents and policies. Our position was not taken onboard the law but we will engage.   

The NHIA has decided to pay capitation directly to health care facilities. Is this a welcome development for your association?

It is still early days to compare HMOs with regulator in payment performance.  You have to experience what the other alternative will offer you. So it will be too early for us to talk. But it is on record that Prof. Nasir Sambo has put his foot down that HMOs must not owe healthcare providers. He has actually helped healthcare providers to collect money from HMOs. We give kudos to him for that. So if this is how those who brought the policy want to do it, they probably have their reasons. We at the receiving end have official complaint as regards HMO claims payment. What they will use as a replacement depends on what you experience in the course of the relationship.

How do you think the debt from huge medical claims bedeviling your members and HMOs can be addressed?

What I think should be done is that once an agreement is signed, either MOU or MOA, to say we will pay you after 30days, you stick to it. Let members go by the rules. If you stick to it, cumulative debt of two four, five and, even, ten months will not happen. Any invoice or bills that have issues should be tracked and audited. Reconciliation of bills should be timely done, come out with your findings and come to an agreement without necessarily changing the rules of the game.

Finally, there is the allegation of poor services and sometimes sharp practices against health care providers. How are you engaging your members to ensure quality improves?

The first thing we are advocating all the time is to ensure sanity and no quackery or ensure that quackery is reduced to the barest minimum. Also, quality is not cheap. If you do not price healthcare appropriately, it will not help. Your capitation is low and is not backed by any reasonable actuarial determination; you should not expect any quality service as providers will not be able to break even.

As for sharp practices, that one can happen anywhere but we have a way we audit our members. We have told them if you are arrested for sharp practices you are on your own. Anything that will affect the integrity of our association we do not encourage it.

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