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‘How NHIA Act redefines roles of HMOs, health insurance coverage’

prof. Mohammed Sambo is the Director General of the National Health Insurance Authority (NHIA). In this interview, he speaks about the rebranding agenda of the organization, expansion of health insurance for Nigerians and the operationalization of the NHIA law, among other things.

Wwhat is the current health insurance coverage level for Nigerians?

Current health insurance coverage is about 16 million people right now, so it’s still hovering below 10 percent.

The National Health Insurance Scheme (NHIS) was originally modeled to provide health insurance for individuals in the public sector. What has been done to broaden the scope?

Much has been done to ensure that everyone is on board with the National Health Insurance Scheme (NHIS), now known as the National Health Insurance Authority (NHIA).

You are aware of the crisis that plagued the organization years ago until 2019, and the presidential inquiry panel that led to some bold steps being taken to reshape the organization; which came as a product of that presidential panel report.

When we came on board, we vetted the ecosystem and realized there were so many issues. Apart from an x-ray of the situation, the presidential panel’s report showed many problems and outlined about ten key problem areas that needed to be addressed quickly.

Our first year was therefore all about bringing stability to the organisation. We then started what we call the organization’s rebranding agenda, which was anchored on three pillars.

One, restoring a value system that makes the organization credible and results-oriented; second, how to establish transparency and accountability throughout the organization’s operations; and third, accelerate efforts to achieve Universal Health Coverage (UHC).

We believed that rebranding efforts are very important in stabilizing the organization; number two, to reshape the organization and number three, to refocus the organization for better performance.

And we immediately started deconstructing the pillars into different elements. If you look at the first pillar, it has about three elements related to creating a very good and stimulating environment, ensuring discipline within the organization and creating mutual respect and harmony, and ensuring that equality is created in the process of managing the organization.

And we stepped in to implement all those elements that we felt were essential to stabilizing the organization.

Therefore, this organization that was notorious in terms of crisis has now completely transformed; you no longer hear a single crisis inside or outside the organization.

What are you doing to ensure transparency and accountability in the health insurance ecosystem?

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We have worked very closely with all stakeholders in the health insurance ecosystem and we have consistently started educating, educating and informing the people so that they know what health insurance entails and what their roles and responsibilities are.

We also recognized that in order to have an overarching transparency system, we need to digitize the system so that everything that is done in the organization, across the entire ecosystem, can be digitally driven.

As chief executive officer, you can be here and oversee everything that happens in terms of services, finances etc; so we all did.

Can you briefly tell us how you can increase the fiscal space?

We have pursued it in a two-pronged approach that is in line with the third pillar of the rebranding. First, we’ve tried to consolidate the existing programs out there; programs for formal sector workers and non-formal sector workers.

There were a lot of bottlenecks in the execution of these programs, so we tried to look at those bottlenecks to fix them, and we went a long way in addressing most of the major critical issues that affect smooth operation of that system.

Then the second has to do with innovation. We have created many innovations aimed at increasing fiscal space.

One of the things we’ve done, although we’ve met it on the spot but haven’t implemented it, is the issuance of the Basic Health Care Provision Fund (BHCPF); this is a creation of the National Health Act.

It comes from one percent of the Consolidated Revenue Fund, and about 50 percent goes to the NHIA, and we in turn distribute it to the states because states have their state health insurance funds so they can cover the vulnerable segment of the population. Vulnerable refers to the poor, women of childbearing age and children under the age of five, people with disabilities and other people in a disadvantaged position.

This is what the BHCPF aims to achieve and if you go to almost all states except Rivers and Akwa Ibom you will realize that many vulnerable people are already benefiting from the program.

Second, we also created the so-called Group Individual and Family Social Health Insurance Program (GIFSHIP). About a year and a half ago, the Minister of Health launched the program and it is intended to bring in the informal sector.

If you look at the informal part of the population, I mean those who are self-employed, people who work in organizations with less than five employees, they make up the majority, the largest part of the population.

Before we entered, there was no significant provision to provide health insurance to this group of Nigerians. But GIFSHIP now allows people regardless of their employment status, be it an individual or a family or a group bound by one form of cohesion or the other, to join the National Health Insurance System.

But the most important thing we’ve done in expanding the physical space is to make sure that we changed the law establishing the National Health Insurance Scheme (NHIS) to what you now have as National Health Insurance Authority (NHIA).

So, how did you operationalize the NHIA law?

The most important aspect of that law is that it provides for what we call the Vulnerable Group Fund (VGF), and the fund is intended to take responsibility for approximately 83 million poor Nigerians who have no financial access to the healthcare system.

With the signing of this law, health insurance has now been made compulsory. So regardless of where you are and regardless of your ability to pay, you should sign up for the National Health Insurance Scheme.

If you don’t have a paid job to the extent that you can’t afford health care or health insurance, through this Fund for Vulnerable Groups, you have the option of being covered.

And in order to achieve that, we need to develop an operational guideline. We also need to have a very robust conversation on the issue of innovative financing that can bring a lot of resources into healthcare, and we’re already working on that.

What is the role of Health Maintenance Organizations (HMOs) under the new law?

There is social health insurance, a solidarity scheme primarily designed to cater to those who do not have access to health care, which is what the government’s health insurance system aims to encourage.

On the second part there is private health insurance. Private health insurance is an insurance system that people who have financial access can turn to.

So what the new law says is that we need to have a very clear delineation between the two. You drive social health insurance with little or no participation from healthcare organizations. Then you have private health insurance that will drive HMOs.

By the time we start implementing this law as a package, you will realize that many things will change with regard to the surgery, as the health insurance plans to offer what is called a Minimum Health Care Package – a package that every Nigerian should have access to regardless of his or her socio-economic status.

And under this new law, this will be driven solely by the National Health Insurance Authority and the national health insurers. The bottlenecks that often occur on the interface with healthcare organizations will therefore no longer exist.

However, HMOs are allowed to do other things. First, HMOs will drive what is called supplemental health insurance, any insurance beyond the minimum health care package can be driven by them.

Healthcare organizations can also drive what I call private health insurance, as I explained.

Then there is a provision in the law of what is called Third Party Administration (TPS), and HMOs can act as third party administrations. Third party administrations are privately oriented organizations that may come to work with national or state health insurance plans to handle certain aspects.

For example, a state wants to set up a call center system where an enrollee can call for investigation or to file their complaints. The state might say we don’t have call authority or we don’t have a structure to do that, the outside administrator can then help the state or other things like a financial management system and so forth.

So the rumor going around that we’re trying to ditch HMOs isn’t entirely true. We are redefining their functions for the betterment of everyone in Nigeria.

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