Healthcare lapses leave even the insured paying out of pocket

…As patients struggle to access medicines

Lapses in the healthcare system have forced several Nigerians, including those that are insured, to cough out loads of cash for their medical needs.

Interviews with insured Nigerians reveal a system struggling to deliver on its promise of financial protection for patients.

Patients reported long waiting times at public hospitals, limited access to specialists and, most notably, lack of essential drugs, forcing them to purchase medicines from private pharmacists at expensive prices.

“I thought getting health insurance would reduce my healthcare bills,” said an expectant mother receiving care at the National Hospital Abuja under a public Health Maintenance Organisation (HMO).

She complained that the hospital always refers her to private pharmacists to get basic drugs that her plan should ordinarily cover.

“Since I started accessing maternal care here, they have never given me any drug. I have to buy drugs myself all the times,” she said.

“Seeing a doctor is a problem. You wait a long time before they generate a code for you. Just come in the morning, you will see a huge crowd waiting to see the doctors. And they are often delayed for hours,” she added.

A code is required for treatment approval at the hospital. The National Health Insurance Authority (NHIA) recently directed HMOs to authorise the treatment of patients within an hour of request by hospitals. This is aimed at addressing persistent delays that negatively affect patient care. Healthcare Facilities (HCFs) were also instructed to promptly submit authorisation requests to HMOs to prevent service disruptions.

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NHIA also increased the capitation rate, a fixed annual payments to health care providers for enrolled patients, and a fee for service delivery.

This adjustment aims to incentivise healthcare providers and improve service delivery.

According to the Authority, they not only aim to address outdated rates but also to align compensation with the reality of rising medical costs and incentive quality care, while ensuring patients receive better and more reliable care.

Despite these measures expected to reform the system, many enrollees continue to voice their dissatisfaction. While some enrollees who spoke with BusinessDay noted some improvements in waiting time, several others lamented that they still pay significantly out of pocket, thereby questioning the essence of the insurance.

An enrollee who identified herself as Eno Uko under a private HMO and accesses care at the National Hospital, Abuja, noted that wait times have significantly improved from over three hours to under one hour.

However, Eno, who is managing high blood pressure, said the unavailability of medicines remains a critical issue.

“There is an improvement in the waiting time. But the hospital does not always have drugs. So, I always have to buy drugs outside the hospital. I am managing high blood pressure, and I recall the last time I spent N23,000 on just a drug which my insurance covers, but they said I had to buy outside.

“I want the health authorities to work on the drug aspect of the insurance. They should provide medicines as we cannot all afford to keep buying drugs outside,” she said.

She added that some diagnostic tests are also unavailable at the hospital, with patients instructed to carry them out at private labs due to the lack of reagents.

Also expressing her frustration, Khadijat Zuberu, a hospital patient in Abuja said, “Can you believe that I left home before 7 am and exited the hospital by 2pm without doing anything? I was transferred from Garki Hospital to the National Hospital and they are yet to update my health insurance.

“When I was in Garki Hospital during my child birth, they didn’t give me any drug at all. I paid for everything myself,” she noted.

Also sharing a similar experience, an enrollee who identified herself as Hajia Jumai, said drugs remain the most essential item for patients, noting that one should not endure a long wait to see a doctor only to end up paying for drugs from one’s pocket.

She explained that the health insurance section at her hospital used to operate from multiple desks, noting regrettably that it now functions from just one, resulting in increased congestion.

“The problem now is the crowd in the morning. But the important thing is the drugs.

“The waiting time is not the problem. The problem is the drugs. The only help they can render us is that they should provide the drugs that we need. When you see only doctors and go and buy medicine, it’s not good. What then is the essence of the insurance?” she queried.

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The NHIA itself acknowledged that health care facilities are in the habit of not providing medicines to enrollees. Speaking with BusinessDay, Emmanuel Ononokpono, the public relations officer of NHIA, condemned the act. stating that “it is wrong.”

“It is wrong because the capitation we provide covers generic drugs. But we are aware of the complaints. What we do is that we asked those with complaints to report to us and bring receipts of purchases, and it is their right to receive refunds.”

When asked what the Authority is doing to address the problem, he said, “There are no sanctions for hospitals in our guidelines, but the Authority is sensitivity to people’s rights to get a refund.”

HMOs, NHIA delay payments, expert says

Weighing in on the issue, Adaobi Onyechi, a public health expert, explained that healthcare providers and pharmacies often face delayed payments from Health Maintenance Organisations (HMOs) or the National Health Insurance Authority (NHIA). When reimbursements are not made promptly, providers may reduce the availability of covered medicines or suspend certain services altogether, she explained.

Despite the establishment of NHIA, the financial burden of healthcare on Nigerian households continues to rise. A large portion of the population, particularly those in the informal sector, remains excluded from the scheme. According to the World Health Organisation (WHO)’s Global Health Observatory, only about 5 percent of Nigerians are currently covered by health insurance, while over 70 percent still finance their healthcare through out-of-pocket expenditure.

However, the NHIA recently reported that 19.2 million citizens have enrolled in various health insurance schemes—surpassing its target for 2024.

Experts argue that while expanding access to health insurance is crucial, it is equally important to ensure that enrollees receive quality care and value for money.