Thursday, 9 April 2015


I have to warn you, this is a very lengthy post. There was no way to get around it.

Something happened in the hospital last week and I'll like to share my thoughts on it. It’s about the health insurance scheme; however, before I go on to spill my guts, I’d like to share with you some facts about NHIS in Nigeria at least. Also, for the purpose of this post, I’ll stick with the patients on capitation; they are the ones mostly with the issues


The National Health Insurance Scheme (NHIS) was started as a means to provide health care at affordable cost for all. It is meant to help many underdeveloped and developing countries to meet the goals of primary health care and now the millennium development goals (MDGs). In the United Kingdom, it is referred to as the National Health Service (NHS). A brief run-down of how it's practiced here in Nigeria to help you better understand the events that unfolded last week.

  • First, the overall governing body, NHIS can't do it alone. They encourage individuals and corporate bodies to set up health management organizations (HMOs) to help recruit clients.

  • The HMOs solicit for clients and gets them to register under different groups depending on the capability of the client (as per their monthly income). The clients are called enrollees and they are entitled to have a spouse and 4 children under them.

  • Some of the clients register under NHIS using the HMOs, while other register directly under NHIS. These are the ones that a capitation is paid for. The capitation in Nigeria is N750 per head per month. That's about $4 for health each month. (It's better now, used to be N500 - almost $3). This amount is paid to the hospital every month whether or not the enrollees show up for treatment.

  • There are other clients who prefer to register as private patients under the HMOs and their treatment is paid for only when they or their beneficiaries come for treatment. This is called "fee for service".

  • The NHIS also has a drug list, so you are limited to prescribing those drugs to the patient (and they are not necessarily the best in the market or that which you would prefer to prescribe). For example, the drug in the NHIS essential drug list for the treatment of malaria is Chloroquine, which is very obsolete. The current drugs are the ACTs (Artemisinin combination therapy).

  • Depending on your (the patient's) designation, mostly those on capitation, you may be limited to the extent of care the HMO can cover for.

On the part of the NHIS and the HMOs, they use the drug list to checkmate fraudulent activities of some doctors who may want to prescribe unnecessary investigations and branded drugs when it’s not recommended. Secondly, the N750 paid per head is paid under the assumption that not everyone will show up every month, and so the money for the people who didn't show up will cover for those that did and leave the hospital some change as profit.

Now, most hospitals are in the business to make a profit (even though the world thinks it should be a charity organization), they have to make the patient feel cared for while following the NHIS guidelines. Many decided that only certain necessary investigations and drugs could be prescribed for the patients. If they had more problems, they could be referred to the consultants or an approval code gotten for them.

On the other hand, the patients feel that a lot of money is being collected from their salary every month and that they have to make use of it somehow. So, you have some of these patients come to the hospital when there is absolutely nothing wrong with them so they can collect medicines. I’ve seen parents show up with 3 children jumping about the waiting room and throwing back-dives, and when asked what the problem is, the children usually answered “nothing” innocently, while the parents hush them and say all of them have cough and catarrh and they have to be treated for malaria. Problem is, they aren't told the actual amount pay per head per month.


Now away with all the boring information and to the events that took place last week. I saw a pregnant lady who was very ill requiring admission, but she didn’t want to stay because she had a toddler at home with no one to cater for him. I was caught between the devil and the deep blue sea on this one, I couldn’t go all out and do all that was necessary for her, (an admission would have covered that, but she declined). I couldn’t render half treatment either. To refer her wouldn’t have made much sense either since it was a primary case. So, I chose to stand in the middle, trying to give the patients my best, but also trying my best not to break the rules in doing so. I used the approval code for her. My decision to stand in the middle almost didn’t pay off, infact it almost got me into trouble with the hospital management. However, after much explanations, it was sorted out.

The conclusion I came to was that "managed care is not meant to manage (treat) the patient, it was made to manage their money". If all this mumbo – jumbo I just wrote didn’t make any sense to you, I recommend you watch the movie John Q.

In the meantime, what does you think of health insurance policies?


  1. Some of this went a little of my head as I don't understand everything with health insurance. I'm glad you didn't get into trouble by management. I think I would've done the same thing to treat that pregnant woman.

    1. I'm sure glad it worked out well in the end

  2. I agree with you that "managed care" is usually about the financial bottom line, not patient well-being. You made the best decision you could under the circumstances, but I sure don't envy you being in that position.

  3. Well doctor Keren, I think it's a step in the right direction. Obviously there are loose strings which need to be addressed. In the mean time the public will benefit from the efforts of medical professionals ,such as yourself, who understand that health care shouldn't be withheld over red tape.

    1. You are right about the loose strings Mr. Adela. I believe the problem is everyone trying to maximize profits. The HMOs, the hospitals and most definitely the patients

  4. Hubby says "Insurance companies should be outlawed = operating under conflict of interest.... Ohhh and "John Q" was a great movie :-)

    1. I think they believe they start out with the interest of the client at heart but later turn to profit. Don't know

  5. Hello Dr. Karen,i just had a group assignment on the state of NHIS in Nigeria in one of my courses for M.Sc. Public Health and i find it a very good programme which if well followed and properly implemented would have done a lot of good rather than some disadvantages been seen here in Nigeria. The state of NHIS in Nigeria is so pathetic and hasn't been successful at all due to the low budget allocation to health and other political issues.
    Unfortunately,even the citizenry that is meant for do not fully understand the benefits and at the end still suffer the consequences of not enrolling.The insurance companies as you said are more after the profits rather than the quality of health enrollees acquire but who wants to set up a business and not gain?? There is still alot of dialogue and negotiations and enlightenment to be done by all involved to achieve this important national goal.
    Thanks for adding more to my knowledge.

    1. You are welcome Rashidah. Glad to be of some help.


Thank you for visiting.