The Lagos State Health Scheme (LSHS) Ilera Eko was, among other things, established to ensure the attainment of Universal Health Coverage (UHC) by all residents of the state. But some subscribers are alleging that some healthcare service providers are robbing them of their legitimate rights, IJEOMA NWANOSIKE reports.

Eight months ago, the Lagos State Health Management Agency (LASHMA) warned that it would sanction any healthcare provider under the Lagos State Health Scheme (LSHS) that denies Ìlera Èkó enrollees of their legitimate rights while accessing healthcare services. The caution notwithstanding, complaints have continued to mount, while enrollees are compelled to make out-of-pocket payments for services covered by the scheme.

The Ìlera Èkó health insurance initiative is targeted at achieving universal health coverage, and ensuring that all residents of the state, including public and private sectors, as well as those in the informal sector, have access to affordable and quality healthcare.

Despite the lofty nature of the initiative, many subscribers are still living with financial distress resulting from the huge medical bills they still have to pick up, their health insurance packages notwithstanding.

Findings by The Guardian showed that some service providers, especially private hospitals insist on the subscribers making out-of-pocket payments once services rendered exceed the sum of N5,500.

While a few other hospitals claim that the scheme does not cover some specialised treatments and minor surgeries, others treat enrollees based on the package plan coverage, including availing them of minor surgeries, and dental and optical services.

These claims by the service providers, and the apparent confusion generated is discouraging more residents from enrolling or keying into the scheme. Indeed, the apathy expressed by other residents stems from the lamentation and dissatisfaction expressed by present subscribers of the scheme.

Ultimately, without uniformity and clarity across the board regarding services that out-of-pocket payment should be made, the scheme is unlikely to achieve its objective of reducing financial health burden on residents, and its goal of attaining UHC for all residents of the state.

In the social health insurance scheme, the benefits of the Standard Plus Plan include, but are not limited to registration and general consultation, specialist consultation, including general surgeons, pediatricians, gynaecologists, physicians, and orthopedics.

It also covers malaria and other acute uncomplicated febrile illnesses amongst other infections treatments. Additionally, it includes follow-up treatment of chronic illnesses, e.g., hypertension, diabetes mellitus, sickle cell, and asthma. Treatment of minor eye ailments, including conjunctivitis, and parasitic as well as allergic ailments.

Family planning and oral contraceptives, antenatal, child welfare services, and immunisation programmes. Others include hospital care and admission of up to 15 days cumulative per annum, HIV/AIDS and tuberculosis services, hematology, and pharmaceutical care with provision of prescribed drugs in line with LSHS for primary care cases amongst other unlisted benefits.

While Bayo Olumide, an enrollee told The Guardian that his standard-plus package plan covers common sicknesses like malaria and typhoid (for him and his wife, and even her antenatal and child delivery fees), Joseph Onyekwere, another enrollee, complained that he had to pay cash at his hospital of choice when his medical needs exceeded that of malaria and typhoid treatments.

According to him, he was asked to make payment before being availed a specialist consultation in the hospital’s orthopedics clinic, and on further inquiry into his package, The Guardian reliably confirmed that his standard-plus plan covers specialist consultations amongst other benefits.

Number 1.5 of the terms and conditions of the Ilera-Eko scheme clearly states that “Some types of medical treatment may require pre-authorisation in accordance with the procedures stipulated in the table of benefits, the package benefits itself enlists orthopedic consultation under special care as one of its provisions without any form of pre-authorisation requirements.”

Another enrollee, Wole Onabanjo, told The Guardian that his standard plan package has only been able to afford Paracetamol tablets for him and his dependents, as he always pays for any test that the hospital is conducting in the course of the treatment.

“They always tell me that my prescribed drugs are not available in the hospital, so, I always have to buy them outside. The highest drug that I and my family have got from my hospital using the Ìlera Èkó insurance scheme is Paracetamol tablets, they direct us to buy everything else outside the hospital. If we have to do any lab test there now, I have to pay for it,” he said.

Onyekwere and Onabanjo are just a few of the many subscribers who are ignorant of their insurance package coverage or are made to pay on the go since the state government appears to pay scant attention to what the service providers are doing to enrollees, or whether the latter are getting value for their money or not.

It Is amid the taciturnity displayed by the state government that the question of who benefits from all these discrepancies arises, since the subscriber, who is supposed to be the ultimate beneficiary of the scheme is writhing in pain.

The scenario also throws up issues of lack of absolute compliance to laid down rules by hospitals, hence the failure to deliver quality healthcare services to enrollees.

A customer representative of Ìlera Èkó who refused to disclose her name to The Guardian emphasised that every enrollee who feels mistreated, under-served, or ripped off by any service provider only needs to call the scheme’s toll-free line for prompt resolution.

According to her, leaving the hospital premises and making a complaint afterward without substantial evidence is largely of no consequence. She also noted that in a case where a particular prescribed drug is not available for dispensation at the pharmacy of an enrollee’s hospital, the enrollee only needs to call their office with the required evidence so that they can remit the drug money to him or her to purchase it elsewhere.

“For any issue with the hospital, we have our toll-free line. Enrollees should endeavor to use it and not resort to making a complaint without sufficient evidence after he/she might have left the hospital. If you are at the hospital and you notice some kind of issue, or preferential treatment given to other patients because you are not making out-of-pocket payments, you call our attention to it so that everything can be resolved, and that is why we have our toll-free line. Leaving the hospital and making such complaints would not solve anything,” she said.

The Association of Private Practicing Surveyors of Nigeria (APPSN) is also worried about increasing complaints from its members, who are subscribed to the Ilera-Eko scheme.

The National Publicity Secretary of the group, Adams Benjamin Olugbenga, said that consequent upon mounting complaints from members, which have not been addressed by the scheme’s initiator, the group may be forced to withdraw from the scheme. He emphasised that despite all emails and visits to the scheme’s office to register members’ complaints, nothing has changed for good, rather the complaints are getting worse.

“We were using a private HMO before we moved to Ìlera Èkó and shortly after changing to Ìlera Èkó, our members started complaining about several issues, and when we contacted their office, they were unresponsive for the most part as the fellow who is in charge of our policy in their office does not answer our calls. Whenever he answers, he promises to get back to us, even when our people are in the hospital and need to be attended to. Unfortunately, he will not call back.

“There are already so many complaints that we have tabled before them through emails, as well as, during physical meetings in their office, but all they do is keep on making promises that they never keep to. I don’t blame them maybe it is because they are salary earners, who are not on target. So, whatever happens, they believe that the Lagos State government that they work for will still pay them their salaries at the end of the month,” he said.

Olugbenga also alleged that some healthcare providers constantly claim to be out of stock for drugs that they prescribe to subscribers, but end up dispensing those drugs to other patients who make out-of-pocket payments.

The APPSN chief further alleged that getting a refund for drugs purchased outside the enrollee’s hospital of choice has always been very difficult, and sometimes futile.

“Some of these hospitals claim not to have in stock, drugs that they prescribe for you, but they give those same drugs to people who are not on HMO. Sadly, even when you get these drugs from pharmacies elsewhere, getting a refund from Ìlera Èkó is always a problem.

But amid the barrage of complaints against the scheme, the Permanent Secretary, LASHMA, Dr Emmanuella Zamba, assured that the agency would continue to do its best to ensure universal health coverage. She, however, warned service providers who deviate from providing the stipulated services that apart from a warning letter, or getting fined, they would also be deleted for failing to ensure that enrollees enjoy the benefits of the scheme.

Zamba urged enrollees to always call on the office for verifications whenever there is confusion. Zamba, who admitted that some service providers were very compliant, and played by the rules, lamented that others take advantage of subscribers’ ignorance with their poor services and unethical practices, which ultimately endanger the scheme’s sustenance.

“If a provider is asking you to pay for something and you are not sure if it is covered or not, just call us. People will always try to play a fast one on other people, or try to gain from peoples’ ignorance, but some providers are good and very compliant. It is for the enrollee to know their rights and assert them because they are paying for it, and should be able to get it,” the permanent secretary said.

Zamba added: “Providers know that if they collect funds for something that is already covered by the scheme, we will deduct the money from their net fee as soon as we find out about it, and refund the customer. All the customer has to do is to send us the receipt and this could happen especially in emergency cases where the customer couldn’t wait to get a response from us, but went ahead to make payments. If a provider does this twice or three, they get sanctioned,” she said.

She stressed the need for customers to understand the exact extent of their package coverage to avoid disenfranchisement by greedy providers.

She said: “Even though the National Health Insurance Scheme has been there for a long time, insurance is still a relatively foreign and new culture to people generally, and even some of the providers don’t understand, while some are trying to gain from the system or take advantage of customers’ ignorance.’’

“These providers receive tariff and capitation fees from us every month, but this is not the only money that they receive from us. We also pay them an agreed amount for surgeries as stipulated in the packages, and they are called ‘claims.”

On stepping up awareness and educating subscribers of benefits associated with the scheme, she said: “We go to churches, mosques, and are all over the place to speak about the scheme, but the truth is that the enrollees have a responsibility too because you can only take a horse to the river, but you can’t force it to drink water.”

A consultant and public health physician, Dr Adeyinka Adeniran, said the state government must step up sensitisation about the scheme, which still has about one million enrollees five years into its commencement.

“In Nigeria, the health insurance uptake is very low, and in Lagos, which started its scheme – LASHMA around 2019 still has less than 800,000 enrollees even though it was established because not everyone can afford private health insurance,” he said, emphasised that a lot of people are still ignorant of the scheme and how it works.

“We conducted research in partnership with LASHMA last year where we studied more than 4,000 residents of Lagos across urban and rural local governments. And based on the research, less than 30 percent of the respondents are on any health insurance scheme.

“This shows that a lot of people are not on the scheme, and even a lot more are not aware of the scheme how it works. The awareness is still very poor like-wise the number, so it is not because they cannot afford it since it is less than N10,000 per person compared to registration cards in some hospitals, which are sometimes more than that amount in a year,” Adeniran said. (The Guardian)

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