How We Uncovered Decade-Old Fraud at NHIS – Prof Yusuf
Usman Yusuf, a professor of pediatrics, is the current executive secretary of the National Health Insurance Scheme (NHIS). He was one of the heads of health agencies appointed by President Muhammadu Buhari in July this year. In this interview, Yusuf spoke
How did you feel when your name was announced as the new executive secretary of the NHIS? The feeling was that of truly being honoured. This is because out of millions that are qualified, I was honoured and chosen by the commander-in-chief to help him take care of this agency. It is also a huge burden and responsibility that out of many, you are chosen to handle an assignment.
Did you entertain any fear?
Not at all! I mean, you are like a soldier given orders; you have to get on and do the job, especially knowing that whoever gave you that job saw something in you. It is then left for you not to disappoint that person and the nation. So, fear was not an option for me.
What kind of situation did you meet on the ground when
you assumed duties?
When I came, the first thing I did was to study the place and consult very widely from within. I met with my top management in the first two days. In the headquarters, we have 13 general managers. The third day, I met with my middle management: the assistant general managers and deputy general managers; and the fourth day, I met with my nonmanagement staff, department by department, to hear their views. I did this because if you are a general and you don’t listen to
Here in Nigeria, we took a system that is already flawed - the American health care system. And when we brought it here, from the beginning it was skewed against the enrollees; it was skewed for the HMOs. We are paying the HMOs three months in advance on behalf of the enrollees, to pay hospitals. But they do not pay hospitals. I have heard and seen pain and suffering from enrollees
your troops, you would be doing that at your peril. So I listened to everybody. On the fifth day I met with the in-house union. It is important because unions everywhere are an important part of any organisation. They may be a pain, but they are very important advocates for the rights of their workers. I met with them for two days. Of course, what I heard were issues that confronted me long before I came; but I listened. I told them I could not give what I did not have, but I promised to always listen to them. I said I would be fair, just but firm, and our door is open.
After meeting the unions, I met the drivers. I met everybody in my house. After that, I stepped out to meet the leadership of the Nigeria Labour Congress (NLC). Let us not forget that the NHIS is contributions from federal government workers, so you need to listen to the leadership of labour. I met them here in Abuja and went to Lagos and met the leadership of the Trade Union Congress (TUC).
I came back to Abuja and met doctors, nurses, pharmacists and laboratory scientists. I also met an organisation of general practitioners and private doctors. I told them clearly that I was in their midst as friends, so I would tell them the truth. I told them that they don’t treat our enrollees and patients well when they go to their hospitals. They are treated as if they had infectious diseases. They are not treated with the honour and dignity they deserve. ‘They pay you money; it is out of their enrolment that we pay you every month, but you don’t treat them well.’
I came with many other complaints I heard from enrollees when I visited hospitals anonymously at night. Many of the heartbroken patients or their families go to hospitals and are not treated well because they are NHIS enrollees. So I asked the doctors and nurses to tell me why. When we became doctors we took an oath to treat everybody well. Even during the time of war, you treat friends and foes alike. I told the doctors that they were reneging on your solemn oath to patients.
We spent over two hours and had a fruitful deliberation. Everywhere I go, the first person or group of people I blend with are members of the NHIS staff. We are the regulatory agency, but we have not done our job as we should have done it. If you go out to blame somebody and fail to look at yourself, then you will never change. Our problem has been corruption, inefficiency, political patronage. And we are being dictated to by the Health Management Organisations (HMOs), which we are supposed to regulate.
Were you confronted with complaints by the doctors, nurses and other stakeholders?
A lot of time they would tell you that the HMOs have not paid them; and they are
running businesses, not charity organisations. So how would they cope if they are not paid? The second complaint is that the benefit the NHIS gives them is not enough to cover their cost. But I told them that this is not true because, in capitation, if you have a wife and four children, N750 is given per head to the facility every month, whether or not you go to hospital.
There are some facilities that have more than 10,000. So multiply 10,000 by N750; that is what they get, whether or not the patients go to hospital. Capitation is constant. Whether or not you go to hospital, every month, N750 is given to the hospital where you registered. This is a lot of money. In many hospitals across the country, it is the capitation that sustains them. And there is a purpose for that; at least it gives hospitals and clinics some viability to be able to treat patients. The reason for setting up the NHIS is noble, but in the aspect of implementation there’s a lot of room for improvement.
Recently in Kaduna, you said the level of fraud in the NHIS was worse than the fuel subsidy scam. Can you give details?
I really get emotional about this. I had practised medicine in Nigeria long before I went out, so I saw the dysfunctional health care in Nigeria long ago. I went to the UK and I saw the system there - not the best. I also went to the United States and saw the inequitable and wasteful system there, which is why you have the Obama Care. The Obama Care came to cover millions of people that were left out.
So I have seen three health care systems in the world - Nigeria, Britain and the United States. None of them is perfect. Here in Nigeria, we took a system that is already flawed - the American health care system. And when we brought it here, from the beginning it was skewed against the enrollees; it was skewed for the HMOs. We are paying the HMOs three months in advance on behalf of the enrollees, to pay hospitals. But they do not pay hospitals. I have heard and seen pain and suffering from enrollees.
In fuel subsidy, people cash the cheques and run away, but here, human beings are suffering and deaths occur from our inability or refusal to regulate. This is seen from the fraud that the HMOs have become and from the irresponsible manner care providers treat patients.
We are simply giving huge money without questions. The HMOs are supposed to be the custodians of that money to pay to patients when they go to hospitals, but oftentimes they do not. They issue cheques that bounce. Under our laws it is an offence. So patients go to hospitals and are not treated well because HMOs have not paid. And monies that are supposed to be returned to the NHIS are not returned.
They owe the NHIS and many health care facilities. They keep the money and grow fat for doing nothing. I said it before, and I will say it again, that the HMOs as they operate in Nigeria are a huge fraud. We are going to make them do a good job because we are going to be a better regulator. We will bring you the numbers of what HMOs owe us and what they owe health care facilities across the land. The numbers are terrible.
You also vowed to make them return the money. Has there been any response in this regard?
Not yet; when we tally we will let you know.
Have you started initiating any prosecution against the culprits?
When I came here, I pulled out our financial records and saw how many HMOs owe the NHIS. I will get my money. I will ask all the hospitals to send me how much they are owed and I will recoup that money from them. This I promise. I do not need any new laws; the laws are there, it’s just that we have not been enforcing them. I will create a very strong enforcement department in the NHIS that would hold them responsible. We are a country of laws, and the laws are clear.
Does it mean that your predecessors did not do their homework very well in terms of enforcing these laws you are talking about?
I cannot speak for anybody; every one of them is alive. I am not here to investigate anybody; I am here to do a good job. This is what I have found; this is what I will tell the world.
Have you found any of them culpable in the fraud you talked about?
Some of the cases are with the Independent Corrupt Practices Commission (ICPC). That is public knowledge; it is not for me to rehash this.
How many fresh cases will you be sending to the ICPC?
That is not why I am here. The true reason I am here is not to investigate anybody but to tell what I found. The NHIS is in good shape in terms of the people I found there. Good, decent human beings that are very much motivated and qualified: lawyers, doctors, accountants, auditors. There is no other organisation you
Our enrollees do not even know their rights, and politicians do not even know what the NHIS is about. They ask of us that which we cannot deliver. If you allow that to happen, you get into trouble
will find this good mix of people. All you need is to motivate them, and I am bringing the best out of people.
When you talked about political patronage, what actually did you mean?
What I meant is that we at the NHIS have not done our job in educating the world about what we do. Our enrollees do not even know their rights, and politicians do not even know what the NHIS is about. They ask of us that which we cannot deliver. If you allow that to happen, you get into trouble. The world does not know what we do at the NHIS. By the world I mean the enrollees, the general public and our elected representatives. That is why I am going all over the country. This weekend, I am going to address the APC governors in Jos. I have visited the Emir of Kano. I am going to see every governor in this country. I am going to see every traditional ruler. The whole idea is to give the NHIS a better publicity. The people need to trust us because it is their money. But, ladies and gentlemen, trust is earned.
Do you have the current data of enrollees?
This is a very good question. To be honest with you I will say no. Nobody will tell you how many we have enrolled over the last 11 years; that is the honest truth. This is because we do not have a robust ICT system that will tell me with a click of the bottom, how many enrollees I have in Kano, Kaduna, Sokoto, Ogoja, Calabar. My goal is to have a robust ICT platform that would show me who I give money to, why, and whether it is used for the intended purpose. Has that which has not been used returned back? How many enrollees do I have?
This is what I endeavour to do in order to plug waste and fraud. We know there is a lot of fraud where you have ghost enrollees. That is why I am planning to do a biometrics of all our enrollees. The HMOs and hospitals get money based on enrollees.
Are you implying that you currently have ghost enrollees?
It is possible if I don’t know the actual number of enrollees I have. We have heard stories of ghost enrollees. How do I find a ghost? I am going to spend people’s money on biometrics to save their money.
How do you pay the HMOs when you don’t have accurate data?
That is why I tell you it is flawed and we need to change that. I will do that as soon as possible. That is what truly makes me want to throw up.
Do you have any specific plan of health insurance for rural dwellers?
The NHIS, as it is now, is the contribution of federal government workers. There is no single penny from the state or local government areas. And we can never achieve universal health coverage unless we are able to go out to reach the states, local government areas and hamlets. That is why we encourage state governments to enact laws to create their own health insurance schemes. But after creating the law, state governments need to sit down and decide how to fund the agency to provide health insurance for their people.
The NHIS is there to help them as technical partners. We do not have the financial resources to help any state or local government. That is not our mandate. Our mandate is to use this contribution of federal government workers to provide health care for them.
What are you doing to include kidney failure, HIV, cancer and other major and terminal illnesses in the NHIS?
The NHIS is primarily like Medicaid in America. It is Primary Health Care (PHC)- centered. Most health problems are primary health care related. Tertiary health care issues are very expensive; they are truly not provided for in the NHIS. If we intend to go that route, all of NHIS money will be expended at the expense of the millions of people we can take care of.
There needs to be a thorough discussion in all the health institutions between the NHIS, the government and the Federal Ministry of Health. The federal or state government needs to discuss how to take care of those people left behind, such as the poor, the vulnerable , the internally displaced persons, the aged, prisoners, pregnant women, and children under five, among others.