Community Pharmacists Advocate Reforms In NHIS For Effective Implementation

Chioma Umeha 

From left: Senator (Pharm) Matthew Uroghide, Chairman, Senate Public Accounts committee; Samuel Adekola Chairman, ACPN; Dr Uzor Uwaga, Chairman, BOT, ACPN and Albert Alkali immediate Past Chairman ACPN at the inauguration ceremony of Adekola as Chairman ACPN at Etherno Hotel GRA Benin city recently.

Though the National Health Insurance Scheme is one of the most credible alternatives for funding the country’s healthcare, Community Pharmacists fault its implementation and call for reforms that would usher a new partnership that can work maximally in the interest of the public, CHIOMA UMEHA writes.

Community Pharmacists under the aegis of the Association of Community Pharmacists of Nigeria (ACPN) have called for a wide range of reforms in health insurance to offer better and robust therapeutic outcomes for consumers of health in Nigeria. The pharmacists said they would collaborate with stakeholders in health to institute a well-defined prescription policy for prescribers and dispensers in both public and private sectors in accordance with the law.

The Community Pharmacists are worried that the prescriptions are non-existent in the private sector of our healthcare practice to the detriment of patients.

Pharm. Samuel Adekola, the National Chairman of ACPN, explained that as part of the agenda of the newly elected NEC, the community pharmacists were already mobilising its membership, especially in Lagos and Abuja to kick-start a new labelling initiative geared towards optimising drug delivery in conformity with Good Pharmacy Practice.

Adekola listed their area of focus to include the Primary Care Concept, National Health Insurance Scheme payment mechanisms and global capitation as well as the Drug Use and Procurement in the National Health Insurance Scheme (NHIS).

“Perhaps, our biggest priority in the quest to ensure accessible healthcare for all citizens is to facilitate proper enforcement plans in the overall implementation of the National Health Insurance Scheme,” he said.

On the poor state of affairs, the ACPN Chairman said that in one of the most embarrassing reflections in contemporary times, the United Nations rated Nigeria’s Health System a wretched 187 out of 191 nations of the World, such that even war-ravaged countries were far ahead of us.

“The only reason remains our inclination to a Nigerian style of healthcare practice. One would have expected the NHIS to help correct some of the aberrations which have prevented proper stratification of services along well-defined health tiers via Primary, Secondary and Tertiary.

“Today, under the deceit of “easy access to care facilities” which negates valid Acts of Parliament, NHIS capitates secondary and tertiary healthcare facilities; hospitals and clinics are also encouraged to run in-house pharmacies with quacks or auxiliary nurses thus compromising the quality of health care dispensed in these facilities.

“This encourages such facilities to take over core primary care function from the ideal primary care centres,” he said.

He explained that in a country where 60 percent of clinical visitations are malaria based, patients would continue to visit teaching hospitals for malaria while distracting the centres from handling the specialist cases and research for which they were conceived.

“A care centre that inculcates specialist services, diagnostic facilities and so on is certainly no longer a primary care centre. This is why in tune with global practices only primary healthcare centres, nursing care homes, comprehensive health centres, clinics and OPDs of non-specialist hospitals should be capitated as gatekeepers or primary providers in managed care.

“Today, the experience in Nigeria is that enrollees in Nigeria’s version of Social Health Insurance which is unprecedented anywhere in the world as most renowned teaching hospitals (tertiary) and other secondary facilities at state government level especially are capitated.

“What this has done is a drift of the enrollee pool to established public health facilities. The reality in Nigeria is that the NHIS has become a public sector driven concept rather than the norm of private sector-led initiative,” he stated.

Adekola posited that various fundamental distortions in managed care were responsible for the refusal of state governments, the private sector and professional associations to key into the vision of Social Health Insurance, noting that prior to the incumbent management team of the NHIS, coverage was less than three per cent of the estimated population of 170 million.

“If Rwanda has an enrollee base of 92 per cent, Ghana 60 per cent and Nigeria has about four per cent after eight years of implementation of the NHIS, then it is obvious that the Frankenstein monster called the Nigerian factor is at work again in an endeavour which optimists had imagined would bring far-reaching reforms to the totality of the healthcare industry in our country,” the ACPN chairman stated.

On her part, Bose Idowu, the ACPN National Secretary, expressed concerns over the National Health Insurance Scheme (NHIS)-payment mechanisms and global capitation.

Idowu said, “Perhaps, the biggest of the assaults on the NHIS remains the implementation of the unlawful concept of Global Capitation. For the records, the only lawful payment mechanisms in the statutes (Decree 35 of 1999) manuals and guideline of the NHIS are Capitation, Fee for Service, Case payment and Per diem.

“The global capitation concept was a shortcut devised by HMOs for administrative convenience to suit themselves but which shortchanges other key stakeholders,” she stated.

The ACPN National Secretary explained that global capitation involves payment of capitation and all elements of other payment modes meant for other providers (secondary and tertiary) to the primary provider.

“This system compromises service delivery to the enrollee because he is not guaranteed the best drugs or diagnostic services since the primary provider who has been paid upfront for these services tries to maximize his profit from the advanced payment.

“Similarly, the Nigerian factor is such that the primary provider can hold the secondary and tertiary providers to ransom when he diverts monies collected for their services to other uses. In such situations, how is the Pharmacist, who dispenses upfront and waits for four weeks to be paid or other care-providers, protected adequately?

“This is why the HMOs must be made to pay secondary and tertiary providers after signing contract agreements in line with provisions of the law,” she said.

She said the need arises to tackle the excesses of HMOs who have interests in same provider network or facilities and therefore take advantage of their privileged position to divert a huge chunk of enrollees to these facilities.

Idowu warned that Nigerians would also continue to pay a high cost for healthcare for as long as the government continues to encourage health providers to render services not within their immediate areas of due competence. For instance, WHO studies revealed that private health clinics were shown to charge up to 184 percent more than the public health facilities and 193 percent more than private retail pharmacies in Nigeria for drugs. Yet, the government continues to overtly and covertly support these private clinics to dispense drugs thereby increasing the overall cost of healthcare to Nigerians.

She said that despite pharmacists misgivings arising from the poor implementation of the scheme, they believe that NHIS is one of the most credible alternatives for funding healthcare in Nigeria.    

“It is assumed that this scheme will offer equitable and physical accessibility to the enrollee but in my assessment, the scheme is yet to ensure delivery of efficient, quality assurance, effectiveness, sustainability and harmony amongst providers.

“We are at a loss as to why the prescribed working guidelines that were extensively reviewed and rehearsed by stakeholders were never tried,” she stated.

Albert Alkali, the immediate past ACPN Chairman, also faulted the system of drug use and procurement in NHIS.

Alkali said, “At both personal and official level of interactions we have always lamented the abysmal ignorance the drivers of the NHIS choose to embrace with regards to the use of medicines in the scheme.      

“For the records, Nigeria is the only country where branded drugs, blister packs and mono-patient packs are used in Health Insurance especially in the private window.

“The norm is to engage the pharmaceutical industry to produce customised bulk packs in 1000’s or more for solid dosage forms and special multi-dose packs for paediatrics. This type of intervention alone will reduce the cost by over 150 percent.

“It is apparent that because those who dispense medicines in the scheme have no expertise on procurement and distribution and other tenets of Good Pharmacy Practice (GPP), they have not been able to identify and logically deal with this major drawback,” he stated.

“The Association of Community Pharmacists despite these challenges in the NHIS observes the new resolve to achieve results by the incumbent Executive Secretary of the NHIS which encourages us to seek a new partnership that can work maximally in the public interest.

“We, therefore, call on the secretariat of the NHIS to open borders of restriction in the running of Social Health Insurance as witnessed through some state statutes (Ondo State is an example) which now gives opportunities to all health professionals to excel in service rendition.