Globally, health insurance is seen as a necessity meant to lessen the high cost of medical care for citizens.
In Nigeria, such is meant to reduce the burden of out-of-pocket expenditure on citizens trying to access healthcare services, and this no doubt, led to the launch of Nigeria’s National Health Insurance Scheme (NHIS) in 2005.
However, tales emanating from enrolees, especially employees of the Yaba College of Technology in Lagos, have not been pleasant and have painted the scheme as being institutionalised to achieve a pecuniary interest – enriching pockets.
The enrollees, many of whom claimed to have at various times, had close shaves with death after allegedly being denied access to health care by a Health Maintenance Organisation (HMO), Princeton Health Limited, which was listed by the NHIS as a licensed healthcare provider.
Refused MRI scan
One of the enrollees is Mrs. Folasade Idowu, who after enduring pain in one of her legs for more than two months, decided to visit the hospital for medical evaluation.
As a Federal Government worker and NHIA enrollee, registered under Princeton Health Limited, she is meant to access quality medical care.
She explained that a certain amount of money, called capitation, is deducted from her salary monthly for medical purposes, whether she goes to the hospital for treatment or not.
Idowu said sadly, when the need arose for her to access health care, she was denied the right and was left with no option but to personally finance her treatment.
She recalled visiting the Military Hospital in Yaba, Lagos State, to treat a lingering pain in her leg, which almost made it impossible for her to walk.
At the hospital, she was sent to a clinic in Ebutte-Meta, to carry out a magnetic resonance imaging scan and was given a referral code by an NHIA staff at the military health facility.
She, however, said the clinic rejected the referral code, claiming that HMO was owing them for backlogs of treatment.
Idowu said several attempts to get the scan done, which include putting calls across to the HMO, failed and she had to pay for the test.
She recounted, “One of the nurses at the clinic told me they can’t attend to enrollees under Princeton HMO and referred to them as debtors. I called the HMO but was told by a staff that they don’t know why the clinic refused to attend to me. Meanwhile, it was the HMO that generated the referral code given to me at the military hospital.
“I later carried out the scan at the Lagos University Teaching Hospital for N79,900. To date, the HMO is yet to get back to me on the matter, even after asking me to send them the code given to me.
Idowu’s travails did not end after the MIR scan, she told PUNCH Healthwise that the military hospital referred her to the National Orthopaedic Hospital, Igbobi, for further treatment but claimed the referral letter was also rejected by the facility after being told that the hospital does not attend to Princeton enrollees.
“I was told they can’t attend to Princeton HMO enrollees and claimed that the hospital was also being owed. I had to use my money to register and buy drugs. What I discovered is that the HMO only attend to medication that cost between N1,000 and N2,000.
“I also had another bitter experience, when I developed an ulcer. NHIA gave me a code to go to LASUTH, but when I got there and presented it to them, I was told that they can’t take Princeton enrollees because they won’t get paid.”
NHIS ACT
The NHIS was established by the Federal Government of Nigeria under Act 35 of 1999, but was launched in 2005, to “Protect families from the financial hardship of huge medical bills; limit the rise in the cost of health care services; to ensure equitable distribution of health care costs among different income groups, and to maintain high standards of health care delivery services within the scheme.”
In 2022, former President, Major General Muhammadu Buhari (retd.), signed into law, the National Health Insurance Authority Bill 2022.
The bill repealed the National Health Insurance Scheme Act of 1999 and established the National Health Insurance Authority Act, of 2022, to oversee and regulate Health Insurance Schemes.
According to the summary of the new Act, the NHIA was given new and enlarged duties that enable it to operate as a regulator, implementer, investor, and insurer of health insurance policies and programs in Nigeria.
With the establishment of the NHIA Act, every Nigerian is now mandated to get health insurance.
Also under this Act, employers are to pay 3.25%, while employees are to pay 1.75%, representing 5% of their consolidated salary.
Insurance firms called HMOs are licensed by the NHIA to oversee the delivery of quality healthcare services using various health institutions.
An employer, who is satisfied with a health plan meant to be provided for its employees by a particular HMO, pays once an agreement has been reached.
Once a health insurance enrollee has paid the premium, which is a sum for the predetermined healthcare services, the HMO will then pay the capitation (money deducted from the beneficiaries’ salaries) to accredited healthcare providers, such as hospitals and clinics, on behalf of the enrollees.
After this has been done, the employees can access the health services covered by the plan.
However, just like the employees at Yaba College of Technolgy, other FG employees that enrolled have tales of regrets revolving around allegations of outright denial of treatment to the non-availability of quality drugs.
And like Idowu, 90 per cent of the employees in the FG institution, enrolled under Princeton HMO, shared stories of abandonment and medical negligence at hospitals recommended by the HMO.
Tales of sorrow
On May 25, 2023, when our correspondent visited Yabatech, more than 20 FG workers claimed they enrolled under Princeton HMO, the company of frustrating their efforts to access health care services.
They claimed to have been footing their medical bills out-of-pocket, even though NHIA contributions were deducted directly from their salaries monthly for that sole purpose.
Adewale Samuel, an academic staff, said the HMO referred his ailing wife to a hospital in Sagamu, Ogun State, but she was rejected at the hospital.
“I spent over N200,000, despite being enrolled in the insurance scheme,” he lamented.
While accusing the HMO of being in the habit of looking for cheap services for its enrollees, Samuel said, “When I got to Shagamu with my wife, we were told that the hospital stopped working with Princeton HMO a long time.
“When we returned to Lagos, the HMO sent us to another hospital where the doctor was unable to give her proper treatment because the HMO was seeking cheap service. My wife ended up with complications that cost me so much money to treat in a private hospital.
“Later, my wife needed to have her tooth urgently removed after being mismanaged in a facility she was referred to by the same HMO. I ended up paying from my pocket. The same thing happened when she had to see a gynaecologist and was referred by the HMO to a hospital different from the one we have been using for years.
Another enrollee, a technologist at Yabatech, Simon Jejelowo, said after personally nursing an ear problem for several months, he decided to reach out to Princeton HMO but was denied access to medical treatment.
He accused the insurance firm of deliberately refusing to pick up calls made by the hospital he was referred to for treatment.
“The hospital wanted confirmation of treatment but they refused to respond. I have spent over N100,000 on treatment. The insurance company has not been living up to its responsibility.”
Meanwhile, while NHIA enrollees are supposed to enjoy free doctor’s consultations, Oluwabusayomi Adewale had to pay before she could see a gynaecologist.
According to her, “I noticed some inconsistency in my health and went to the hospital to find out what the problem was and asked to see a gynaecologist.
“When I took the paper to those at the front desk, I was told that my HMO has to be called for a referral because they (HMO) don’t usually support the use of the hospital’s gynaecologist because of the consultation fee involved. Knowing what that meant based on my past experience, I opted to pay for the 10,000 consultation fee and yet another N5,000 to see a general practitioner, despite being an enrollee of the NHIA.”
Operating with impunity
Founded in 1999 and incorporated in 2000, Princeton Health Limited is a certified HMO that was created with the mission of bridging the gap between patients and healthcare professionals.
On its official website, it was stated that the HMO was established to guarantee access to high-quality medical care regardless of age, tribe, level of education, or social standing.
A brief profile of the company on the website read, “We aim to inspire and promote the image, lifestyle, and healthy living of our Clients by promptly responding to health issues around the clock.
“Our team is made up of experienced and highly professional staff unified by a collaborative culture that fosters integrity, and outstanding value, thus guaranteeing continuity in the provision of our professional services to our Clients. We exist to help every organization achieve set out corporate objectives.”
However, all that was stated, according to the Yabatech employees that spoke with PUNCH Healthwise, run contrary to the treatment they have been receiving since they enrolled.
The federal workers also alleged that efforts to get across to Princeton HMO management have always proved abortive.
They also claimed that they only pick up calls at will, and are inaccessible during emergencies.
While noting that the challenges they faced with Princeton HMO started getting complicated in 2021, the FG workers lamented that many of them have suffered untold pains due to the alleged negligence of their health needs.
Dismissive HMO staff
To ascertain some allegations put forward by the staff, our correspondent called three of the customer toll numbers available on the Princeton official website. Two of the numbers rang multiple times without being picked, while the third one was picked by a lady with a sultry voice.
After pretending to be an enrollee in need of medical care, the lady said our correspondent should tell the hospital to reach out to the HMO directly
In a harsh, dismissive tone, she said enrollees are not meant to place calls across to the HMO for treatment, stressing that the hospital knows what to do.
However, the Yabatech workers, who were with our correspondent when he made the calls, disagreed with the Princeton HMO staff’s stance, claiming that the insurance firm failed to answer calls put across to them by several hospitals listed to provide health service to them.
Idowu, the woman with the leg pain, specifically detailed the number of times she reached out to the Princeton HMO staff and was either not given a positive response or dismissed.
“This is the chat and call records between me and the HMO. I am beginning to see the scheme as a scam. I am still spending my money to get treated at the orthopaedic hospital. The money for health insurance is being deducted from our salary every month and the HMO keeps dodging its responsibilities.
Nigerians lack access to health
With many Nigerians barely able to afford a three-square-meal, accessing health care even in public health facilities has been a hopeless wish.
In Nigeria’s Multidimensional Poverty Index Survey, 63 per cent of persons in Nigeria -133 million, are living in abject poverty.
The survey was conducted by the National Bureau of Statistics, the National Social Safety-Nets Coordinating Office, the United Nations Development Programme, the United Nations Children’s Fund, and the Oxford Poverty and Human Development Initiative.
The country’s healthcare sector is plagued by several challenges which include brain drain, medical tourism, deteriorating medical infrastructure, low government budget allocation and poor remuneration for health workers
Healthcare infrastructures in Nigeria are in shambles and lack modern medical facilities, this is even as the country’s healthcare indicator is rated to be among the worst in Africa
Medical professionals are in short supply, with only about 35,000 doctors available despite needing 237,000, according to World Health Organisation.
According to the Nigerian Medical Association, Nigeria loses at least $2 billion every year to medical tourism, with India accounting for more than half of this outflow.
To reverse this trend and ensure access to health for all Nigerians, the FG approved the second National Strategic Health Development Plan (NSHDP II, 2018-2022).
The Nigerian Sovereign Investment Authority, in partnership with the Federal Ministry of Health, signed a series of agreements to modernize and expand healthcare services through private-sector participation.
The agreements look to develop the capacity of specialist hospitals and diagnostic centres to provide advanced medical care services.
The Nigerian government says it is also aiming to lower obstacles to insurance coverage in addition to raising infrastructural standards and treatment quality.
According to the Lancet Nigeria Commission’s recommendations, the new insurance law would guarantee coverage for 83 million low-income Nigerians who cannot afford premiums.
Meanwhile, the NHIA has said the non-mandatory nature of health insurance in Nigeria is a significant barrier to raising participation rates.
While the majority of federal public servants are presently enrolled in the programme, the majority of civilians, particularly those employed in the country’s sizable informal sector, are still not covered by the NHIA.
Workers beg FG for better service
For Samuel and other employees at the Yaba College of Technology, there is an urgent need for the government to review the activities of many HMOs licensed by the NHIA.
“The government should give workers access to quality healthcare. Imagine being informed by your HMO that as a government employee, you are not eligible for certain basic health services. Free healthcare that covers any health issues should be a privilege enjoyed by government staff and their families,” he said.
HMO’s contract not based on merit- Expert
A registered nurse and human rights activist, Abiodun Thomas, said many HMOs were licensed based on who they knew in government rather than on merit.
She maintained that many of them are not qualified for the job and noted that the NHIA scheme has been tainted by corruption, unprofessionalism, and misappropriation.
Thomas, who claimed to have worked in several hospitals, alleged that cheap drugs are administered to NHIA enrollees due to the inability of many HMOs to pay well.
She said, “Most of those HMOs are owned by bigwigs, politicians or friends of politicians. Most of them are overwhelmed and can’t perform up to expectations in health care delivery.
“I have worked in some hospitals where when NHIS patient comes, we would be told not to give them some brand of drugs because they are expensive and the HMO won’t be able to pay for them.
“There is also corruption in NHIS itself because they are not releasing enough funds. They are meant to be patient-focused, but corruption has made it difficult to access health care via the scheme.
“Some of these HMOs don’t employ qualified personnel and this has really affected service delivery. There are many people that have no business in the health sector but are there.”
On how government can curb illegalities, the activist said national policies should be formulated with state governments to allow active participation of HMOs based on merit with strict punishment put in place should there be a deviation.
“Government needs to discourage corruption by conducting forensic audits every quarter of the year. There should be prosecution of offenders to serve as a lesson to others.
“Proper supervision of HMOs is paramount and the employment of more capable hands (qualified personnel) into the scheme,” she added.
Yabatech management promises to investigate
When contacted, the Deputy Registrar and Head of Public Relations of Yabatech, Joe Ejiofor said the management was unaware of the difficulties faced by its employees in accessing health care through the insurance scheme.
He, however, gave an assurance that the institution will reach out to Princeton HMO, to find a lasting solution to the challenges.
Ejiofor said, “The Health Insurance Scheme is a policy of the FG targeted at federal workers for their welfare and benefit.
“Who are the staff making these allegations? Have they channelled their grievances to the management of the college? I don’t think so. However, if they are experiencing any challenges, I expect them to bring them forward to management.
“The College has not been docile when it comes to the welfare of staff. Despite having an HMO, the College Health Center still offer free medical services to all staff.
“Let me assure you that with this new information. We will reach out to Princeton to find out the nature of challenges being experienced by our staff and how they can be ameliorated.”
Princeton says allegations untrue
When contacted, the Head of Claims and Underwriting for Princeton HMO, Akinola Sunday, described many of the allegations made by the staff as untrue and unfounded.
He claimed the HMO responds speedily to issues raised by its enrollees, noting that many of such issues have been resolved.
While admitting that the HMO had an issue with the National Orthopaedic Hospital that has to do with an enrollee, Sunday, however, said efforts are on to find a lasting solution to it.
He also denied the allegation that Princeton HMO recommends hospitals in other states to enrollees.
“This scheme has been on for about 17 years now, and Yaba College of Technology has been one of the organisations we are managing.
“We have three levels under this programme: primary, secondary, and tertiary. Hospitals are not recommended for any federal staff, but they are picked by them from among NHIA-accredited hospitals.
“So, when we have a case that can’t be handled by a primary hospital, it is transferred to a secondary facility. Some of these enrollees have been enjoying such facilities.
“We have a forum where we engage with enrollees one-on-one. We had one in Yaba last year. And I believed that those complaining didn’t attend, despite the publicity made by the school management.
While admitting that scheme had faced some challenges, Sunday said, “We know there would be challenges anywhere humans are, especially when there is a third party. On the issue of payment, we have two forms of payment for our enrollees. We have primary and secondary payments. People can be referred from one place to another.”
“You mentioned LASUTH and, as I talk to you, we don’t have any problem with LASUTH. I know there are difficulties we had with them about a month ago, but it has been resolved.
“Issues like this if they are brought to our notice, would have been resolved because we are in touch with these hospitals on a regular basis.
Sunday said enrollee that pays out of pocket can tender their claims and get a refund if all documents are available.
“For someone that says he pays a certain amount of money, the person can engage us maybe it’s something else they have to pay for. If they can engage us, we will know precisely what this person actually paid for. This can be done by giving us information about the hospital involved, what they paid for and the receipt given.
“If the scan is not among the things to be done by the government, won’t we help an enrollee out? But the facility must be accredited by NHIA. If it is not, the charges will be more, which may be more than what we are paid for. So, we ask them to go to hospitals where there is NHIA accreditation.
“These are peculiar cases, and when we are informed, there is a way to it, not the way other cases are being handled. We don’t leave our hospitals alone. We engage them. It is a secondary hospital and not a primary hospital.”
On why there is always delay to approve treatment for enrollees, Sunday said, “We have over 2,000 of them, and as I said, we are engaging them. The peculiarities of these hospitals are different from each other, and we address their issues based on these.
“There are a lot of other hospitals in the waiting and requests are processed one after the other to avoid mixed-up diagnosis and approvals. To say that there is no one to attend to them or give approval will be inappropriate.
New Act will address challenges – NHIA DG
When contacted, the Director-General and Chief Executive Officer of the NHIA, Professor Mohammed Sambo, admitted that there are challenges with the scheme that the new act is trying to address.
He said NHIA has developed a strategy known as decentralised reconciliation to ensure the smooth running of the insurance scheme between health providers, enrollees and the HMOs.
“I don’t think there is any system without challenges. But what behoves on any system is the ability to detect the challenges and put their house in order; NHIA is not an exception.
“In fact, NHIA has multiple stakeholders, and they are bound to have such problems and complaints. Ever since the creation of NHIA, multiple challenges have been around and I might want to say with all sincerity that in the last two years, we had to do a lot in reducing these challenges to the barest minimum.
“We have developed a strategy where we do decentralised reconciliation. So that there can be a smooth running between the health management organisation and the health service providers.
“Through this decentralised reconciliation, we have been able to recoup billions of naira held by healthcare maintenance organisations and we will ensure that such money is used to fund the healthcare providers.
“We manage the relationship between enrollees and health maintenance organisations. We have developed a framework whereby, we label a facility green, yellow, or red depending on the response.
“If we realise that a facility is getting notorious in terms of poor response to clients, we will put it in our new guidelines of NHIA and ensure that such facility is delisted and stopped from providing service to our teeming clients.”
