Posted on: Mon 08-04-2019

The Healthcare Providers Association of Nigeria (HCPAN) held a Special and Extra- ordinary NEC Meeting addressing very pressing National issues affecting the Health sector, especially on Health Insurance and Managed Care in Nigeria.

In attendance were the National Executive Council members across the country, Past Presidents,  State Chapter Officers, and other relevant Stakeholders.  A National Press Conference followed immediately.

The following observations were made:

OBSERVATIONS/PROBLEMS IDENTIFIED

The house made the following observations and identified challenges facing the NHIS and Managed care in general.

• The Scheme is more than twelve years in existence.
• Lingering weak and Politicized NHIS Leadership.
• There is low uptake and national coverage is far less than 5%.
• Absence or few enrollees in most of the accredited healthcare facilities.
• Out of pocket payment is skyrocketing, leading to frequent displeasure and litigation by end users/patients.
• High Morbidity and Mortality rates as recorded in most health indices in Nigeria.
• Awareness on NHIS and managed care is generally low in the Nigerian communities (Social Marketing issue).  
• Poor Budgetary allocation to health against the WHO recommendations 
• Lack of relevant IT infrastructures in most healthcare facilities due to paucity financial empowerment of providers 
• Providers are impoverished by inappropriate pricing and remunerations services rendered thereby leading to unhappiness and poor psyche on the part of service providers.
• Stand alone Secondary Provider facilities, as well as Secondary care services (especially of Private Care Providers that provide over 65% of services to Nigerians) seem to be undermined and not properly incorporated In the Operations Guidelines by the present structure of most of the State Support Health insurance Schemes across the country so far identified, targeted at achieving UNIVERSAL HEALTH COVERAGE.
• Teaching Hospitals have taken over the bulk of enrollees and primary cases, thereby making them unable to adequately attend to referred tertiary cases, training and research for which they were originally established.
• Occasional friction between enrollees and providers occasioned by ambiguous terms of payment mechanisms, especially on issues of medico/surgical emergencies.
• Dual roles of some stakeholders affecting the adherence to NHIS ACT 35 of 1999. The Act frowns at Providers assuming the role of HMOs as well as some HMOs doubling as Providers. This brings moral hazards.
• HMO Instability: A lot of HMOs are practising with some Impunity with most of them doing providers for several months, or out rightly becoming insolvent. It is on good records that some  HMOs are VERY GOOD  and follow due process. We have observed  INADEQUATE Regulatory functions that have watched some  UNREGISTERED HMOs operate, collect funds from purchasers of private health insurance programs, while the unsuspecting Healthcare providers were contracted in ambush’.
• Deliberate Insolvency by some HMOs and  bailing out with providers funds running into several millions of naira. This is Worrisome.
• Skepticism and apathy from good number of Healthcare providers who now see Health insurance as a Bad Mechanism of getting them robbed out of practice and impoverishing many.
•  Health Insurance is not made compulsory.
• Informal sector yet to be covered by NHIS.
• Benefit package, tariff and operating guidelines not in tune with present economic realities and the sustainability and survival of providers. The Fee-For-Service Tariffs of NHIS have remained without implementing a review since inception of NHIS in Nigeria. Capitation reviewed once in 2012 never addressed the time value of money. There is a huge disconnect.
• Most of the State Support Health Insurance projects across the country are currently offering capitation and tariffs less than 50% of present unacceptable capitation and Fee-For – Service of even the present day NHIS.
• Poor Actuarial studies due to poor and unrealistic statistics being adopted by the various state support health insurance projects.
• Health Insurance is a game of numbers.
• Paucity of investors in the health sector.
• Poor or lack of use of electronic medical devices and keeping of data.
• Poor quality of care due to poor pay for services rendered.
• Lack of trust and equity and transparency.
• Managed care is poorly run in Nigeria.
• Utilizing global capitation that is alien to the NHIS Act.
• National Health Act, NHA is being implemented piecemeal while the issue of the Certificate of Standard, Payment Mechanisms (Especially on emergencies) is still pending and unresolved, thereby causing litigations and other havocs.
• The NHA is not explicit on the payment mechanism for emergencies but expects the provider to attend to all emergencies without stating clearly who pays the provider for his services. In times of Social responsibility, government often expect Private Medicare as Social services. But when it is time to appraise us, were are seen as purely commercial, paying all taxes, fines, levies etc without consideration. This is another disconnect.
• Having identified some of the pressing issues, HCPAN resolves as follows, giving directives to all her members nationwide to use as guide.

RESOLUTIONS

1. Tertiary Institutions must be stopped from attending to primary cases and receiving capitation. However they may be allowed to treat their own in-house staff if they so decide.
2. Health Insurance MUST be made compulsory for all Nigerians. The NHIS Act shown be amended accordingly.
3. Tariff must be reviewed and done regularly to reflect the economic realities in the country.
4. All HMOs must be made to pay providers as, and when due.
5. Public enlightenment, in the various communities, to improve public awareness of the National Health Insurance Scheme, as well as managed care should be undertaken by all stakeholders.
6. Providers must be encouraged to have number of enrollees necessary to break even.
7. Providers to improve on their IT infrastructures. This will serve to improve keeping and rendition of data, including encounter and utilization rate.
8. Government is to encourage use of futuristic medical devices. Embrace e-health.
9. Government to encourage reversal of Medical Tourism by finding ways to bring bade our health workers in the Diaspora.
10. Government, various Professional Group Leaders, The Media, and the civil society should encourage cooperation and love amongst the various stakeholders in the health care that can sow seed of discord should always be avoided. Team playing and mutual respect is key amongst all players in the health sector. This will seamlessly make practices patient-centred.
11.  Secondary care providers should be paid for services rendered directly by the HMOs
12. Facilities segregation of roles is key; Primary, Secondary and Tertiary professional roles.
13. NHIS to be re-tolled in order to achieve UHC.  
14. Efforts should be intensified by the NHIS to mobilise the Organised Private Sector e.g. NECA, the Civil Society etc to give effects to quicker coverage of the informal sector for UHC (Universal Health Coverage). The Present less than 5% National coverage is not acceptable.
15. HMOs to streamline their roles to Health Maintenance only and not involved in providing care.
16. Unbundling the “Global Capitation” to improve trust, equity and transparency.  
17. All stakeholders must come together and work together to achieve results in the health sector.
18. Strengthening the already established indigent funds by Government.
19. Encourage the NHIS facilities global accreditation process with the aim of achieving equitable distribution of enrollees.  NHIS should recall she is a Regulator to both Private and Public intent HMOs. If on the contrary she is not in charge of Private HMOs, the Providers nationwide should be so informed.
20. Providers of Healthcare nationwide are advised to put quality as priority in their service to humanity.
21. All Healthcare Providers across the country should carefully study, appraise, and give Business Effect of running Profitable Health Insurance before getting enlisted with the State Support health Insurance Projects. Where it is obvious the terms are not favourable to providing ethical healthcare delivery, a quick appraisal of already established engagement should be done with a view to disengaging as the case may be from state to state. The Legal Department of HCPAN will always be of help in discerning what is acceptable legal framework or otherwise as may be Contained in the documents of any State Support Health Insurance program.
22. While HCPAN embraces and puts value on National patriotism for her members expressing interest in participating in the State Support Health Insurance in some states across the country, there will be continuons need for dialogue and engagement of government operator of the scheme across the nation jointly fashion out what could be mutual y acceptable to all the stakeholders, especially in terms of Benefit package and  remuneration using proper Actuary determination. Whenever there is a deadlock, HCPAN National Leadership will rise to her responsibility with a view to protecting the interest of her members.
23.  HCPAN frowns at incessant harassment of Healthcare Providers by Security operatives. A proper Medico-Legal Desk will suffice. All aggressions should be against quackery and not against legitimately qualified personnel carrying  out their routines.
24. Strengthening the HMCAN/HCPAN Ethics Committee to help providers address various issues affecting them. Providers are to contact the under listed numbers in case of complaints: HMCAN: 08080638134. Dr. Ladele (07038003427), Dr. Peter (08062910443), Dr. Awosika, Dr. Adeyeye J. Arigbabuwo (08033350495).
25. There is urgent need to reawaken the Tripartite Committee of NHIS/HMOs/PROVIDERS nationwide for harmonious consultations and interaction.

Dr. Adeyeye .J. Atigbabuwo

National President, HCPAN

(Tel: 08033350495)

Mrs. Chioma Onuorah,

National Publicity, Secretary

Tel: 08033077714

Mr. Ajewole, Joshua

National Secretary, HCPAN

Tel: 08033566491

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