Book: Practical Working of the Health Insurance System in Nigeria
By Frank, Chukwuka Osimi
June 19, 2019
Chapter 2: The structure of health insurance system and the relationship and synergy that exist among the stakeholders in health insurance sector in Nigeria
In Chapter 1 of this book, we identified the four key stakeholders in the health insurance system in Nigeria. They are the National Health Insurance Scheme (NHIS), the Health Management Organisations (HMOs); healthcare providers (hospitals, diagnostic centres, specialists centres and clinics, doctors, nurses, laboratory scientists, radiologists, HMO managers and officers, etc; and the enrollees or insureds.
This chapter examines the structure of health insurance system in Nigeria and the relationship and synergy that exist among the key stakeholders listed above.
2.1 Structure of the health insurance system in Nigeria
Health insurance system is a health financing system that is designed to pool funds to provide access to quality affordable personal health services for all insureds or enrollees, based on their health needs, irrespective of their socio-economic status.
In Nigeria, the National Health Insurance Scheme (NHIS) is the umpire that oversees the health insurance system. It was created in May 2005 but became fully operational in 1999, during the administration of former President Olusegun Obasanjo. The scheme was created to provide equitable access and financial coverage for basic healthcare services to all enrollees or insureds in Nigeria.
The NHIS occupies topmost position in the the health insurance structure in Nigeria and oversees her health insurance practice. It is headed by the Executive Secretary with a governing board and has its head office in Abuja. The NHIS also has offices in Lagos and other states in Nigeria.
As a body, the NHIS monitors and regulates the health insurance system in Nigeria. It is therefore a regulatory agency of the health insurance system in Nigeria. It regulates the activities of health insurance companies, popularly called Health Management Organisations (HMOs) and ensures they play by the rules and regulations guiding health insurance practice in Nigeria. It also approves registration of HMOs and grants them licences to operate or do business in the health insurance sector in Nigeria.
Furthermore, the NHIS also grants accreditation to hospitals and other healthcare providers to do business of health insurance in Nigeria, especially as it has to do with working with NHIS itself.
Next to the National Health Insurance Scheme, is the Health Management Organisation.
The Health Management Organisation (HMO) as it is called in the United States of America, Nigeria and a few other places in he world, is a health insurance company. Unlike other insurance companies that are registered and licenced to do the business of general and other insurance, the HMO is registered and licenced strictly to do health insurance business to its enrollees, insureds or members, as they are called in health insurance practice.
There are many Health Management Organisations in Nigeria. They include Hygeia Nigeria Ltd, Total Health Trust Ltd, Clearline International, Healthcare International, United Healthcare Services, etc.
Health Management Organisations (HMOs) provide health insurance services, such as corporate, retail, and SME plans and also provide healthcare services to their enrollees, insureds or subscribers through healthcare providers (hospitals, clinics, diagnostics homes, specialists centres, etc,).
Health Management Organisations source enrollees (customers) and help pool funds to provide access to quality affordable personal health services for all their insureds, based on their policy plans and health needs, irrespective of their socio-economic status.
Now to the healthcare providers.
In health insurance practice, healthcare providers refer to healthcare facilities, medical experts and other healthcare professionals that provide direct healthcare services to the insureds or enrollees covered by insurance policy or coverage.
Examples of healthcare facilities that come under healthcare providers include hospitals, eye clinics, dental clinics, diagnostics centres/homes, specialists centres, etc.
Examples of persons or individuals that are healthcare providers in health insurance system, include: medical doctors, nurses/midwives, laboratory scientists, dentists, eye specialists, radiologists, sonographers, health insurance mangers or HMO managers and officers, etc.
Generally speaking, healthcare providers provide healthcare services to health insurance enrollees, insureds or subscribers, with a view to taking care of their health and well-being.
Now, the enrollees or insureds.
In health insurance practice, an insured is a person covered or protected by health insurance policy put in place between the insured and the health insurance company or insurer. An insured is also called an enrollee or health insurance subscriber.
In the course of this book, insured, enrollee and subscriber are used interchangeably.
Health insurance enrollee is an eligible person or eligible employee who is enrolled in a health insurance plan. We have individual or private enrollee and company or corporate enrollee who is enrolled with an health insurance company by his or her company or employer in an health insurance scheme.
The enrollee is a very critical stakeholder in the health insurance system in Nigeria and elsewhere in the world. This is because he is the customer who patronises and pays the health insurance companies or health management organisations. The health insurance companies in turn, patronise and give business to healthcare providers to take care of the healthcare needs of their enrollees or insureds. The National Health Insurance Scheme (NHIS), through regulations and monitoring, ensures that both the health insurance companies and healthcare providers provide quality healthcare services being paid for by the enrollees or insureds.
Therefore, while we agree that the enrollees are critical stakeholders in the health insurance system, it is also important to add here that the other stakeholders, the NHIS, HMOs and healthcare providers, play very critical roles towards ensuring smooth working of the health insurance system for the health benefits of the enrollees or insureds.
We shall continue with the relationship and synergy that exist among the key four stakeholders in the healthcare system in Nigeria.
Frank, Chukwuka Osimi is an Health Insurance Consultant and Manager. You may contact him via Facebook for anything you wish to know about the health insurance system in Nigeria.
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