CRITICAL ISSUES IN THE MANAGEMENT OF HEALTH CARE SYSTEMS: THE NIGERIAN NATIONAL HEALTH INSURANCE SCHEME (NHIS)
Leadership and management of health care systems are increasingly receiving attention from countries and international organisations. While acknowledging that the achievement of the Millennium Development Goals will generally require additional and international resources, leadership and management are key to using these resources effectively to achieve measurable results. Good leaders set the strategic vision and mobilise the efforts towards its realisation; and good managers ensure effective organisation and utilisation of resources to achieve results and meet aims.
However, the challenge for many countries (both developed and developing) is how to provide this much needed leadership and management within resource constraints and peculiar country contexts.
In 2003, Kane and Turnbull[i] proposed a framework for managing health systems, which argues that most health systems are managed care entities which can be successfully managed by employing managed care tools such as managing cost (managing insurance risk, provider and supplier prices and utilisation of services), managing care (developing and managing community-wide practice guidelines, care pathways, case management processes, and disease management across the continuum of care) and managing health (development and management of population-based interventions and pooling/shifting resources among health and other sectors). They however, emphasise that the success of these tools depend on some features of a country’s health system, which include: level of system funding, structure of provider market, proportion of population covered by health insurance, information and communication system infrastructure, consumer expectations and socio-political values.
While all of the managed care tools may not apply in all the systems in the overall health system of a country, they do provide a useful basis for analysing the management of health systems, generally.
This article uses the National Health Insurance Scheme (NHIS) of Nigeria as a case study, to analyze its effectiveness in managing cost, care and health, including the effectiveness of the leadership and management provided and; the need for and applicability of reform.
Overview of the NHIS
The Nigerian NHIS was established in 1999 by act 35 of the Federal Government of Nigeria, with the overall goal of enhancing access to quality and affordable health care to all Nigerian citizens. It became operational in 2005 and targets universal coverage of all Nigerians by 2015.
The scheme has developed programmes to cover formal sector workers, the urban self-employed and families and individuals in rural areas; pregnant women and children under five years of age.
Leadership and management structure
Leadership and management of the NHIS are provided through the National Health Insurance Scheme (NHIS), Health Maintenance Organisations (HMOs) and Health Care Providers (HCPs). The NHIS is responsible for policy formulation, issuing of relevant guidelines, setting premiums, capitations, fee-for-service rates, regulatory oversight and registration of HMOs, HCPs and accreditation of banks and insurance companies.
HMOs are responsible for collection and management of contributions, administration and quality oversight of providers, while HCPs are responsible for providing covered services to contributors. HCPs are expected to render monthly reports to HMOs who render quarterly reports to the NHIS.
Managing Cost, Care and Health
Under the NHIS, costs are managed through the enshrining in Decree 35 of a defined benefit package for the formal sector programme and the definition of benefit packages for the other schemes in accompanying guidelines. This approach is consistent with some social health insurance programmes and controls costs by limiting the scheme to an actuarially determined scope and prevents it from cost overruns resulting from claims that may beyond its financial capacity.
The disadvantage in this approach may be that individuals are restricted in the choice of benefits they ordinarily may want to enjoy. However, even in more developed and better financed systems, such as the NHS in the United Kingdom, rationing of benefits occurs.
Other cost management procedures under the NHIS include explicit underwriting criteria, adoption of a national drug formulary, laboratory and procedures price list and the use of prior authorisation and concurrent review by HMOs. Consumer cost sharing, through the use of co-payments for drugs, is used to counter moral hazard and also helps to control costs. Care is managed mainly by using nationwide protocols for prevention and treatment of specific conditions and care pathways for management of acute episodes. Managing health is limited to health education provided to enrollees by HMOs and health care providers.
The major challenges to the scheme are as outlined below:
- Weak provider network comprised of mainly solo and uncoordinated health care providers.
- Inadequate, weak and unreliable ICT system.
- Shortage of skilled personnel – As much as 57% of primary health care facilities operated without a midwife in 2002.
- Inadequate funding.
Need for and Applicability of Reform
In terms of policy formulation and management structure and systems for managing cost and care, the NHIS system appears to be well articulated and capable of ensuring coverage for the population, while promoting equity.
However, the challenges outlined above need to be addressed for the scheme to achieve its objectives. The following reforms are recommended
- 1. Development of multi-specialty provider networks
This may not be an easy task in an environment that has long been used to individual practitioners. However, it may be possible to encourage providers to form multi physician groups through incentives that reward providers for doing this. Incentives may include recognition, tax reliefs on equipment purchases and financial rewards.
- 2. Information communication technology
It is vital that health information and communication systems are strengthened, as a matter of urgency, and this will require strong political will and commitment on the part of government to ensure that this is achieved.
- 3. Shortage of skilled workers
In the short term, strategies such as re-evaluation of reward systems to ensure that health workers are provided with incentives sufficient to discourage migration and encourage health workers to go to rural areas, and the use of substitute workers (taking into consideration quality concerns) may be considered. In the long term, more workers will be need to be trained and conducive working environments provided for them
- 4. Inadequate funding
The Nigerian Health Care System is grossly underfunded. Budgetary allocations to the health sector needs to be increased to at least 15 per cent, while other sources, such as dedicated sales tax etc needs to be explored.
Several challenges face leaders and managers of health care systems. An understanding of the issues influencing policy formulation and planning can assist leaders and managers to lead and manage better.
The managed care tools for managing cost, care and health is not only useful for analysing how successful the management of health systems are, but can be used to improve leadership and management of the system.