Professor Yusuf and the pains of selling insurance
The financing and provision of health insurance by the Nigerian government has its roots in a theoretical basis that argues that the private health insurance market could fail, and the access of healthcare by the poor can be stalled by certain externalities. But by and large, the performance of any health insurance scheme that seeks to cover a nation can be examined by asking certain fundamental questions, e.g. who are the beneficiaries, what are the efficiency effects, how is the equity on financing, what are the level of administrative costs, and how politically acceptable is the scheme? It is upon these foundational bases, subject to a satisfactory potential, that countries consider the need to establish and sustain a national health insurance scheme.
When he was appointed the Executive Secretary and Chief Executive Officer of the National Health Insurance Scheme (NHIS) by President Muhammadu Buhari in August 2016, Usman Yusuf assumed the job straightway as a diasporean from the academia. “I came from the academia, so I ask the tough questions” said Yusuf, who is a professor of pediatric hematology and oncology at the St. Jude Children Research Hospital in Memphis, Tennessee, United States. It can be painful to go from medical research and clinical practice in the United States to selling insurance in Nigeria. But it can also be more painful to assume the leadership of an organization that has not only refused to live up to its mandates but persistently lacks the intention to do so. This reality is enough frustration to anyone tasked with the leadership of the NHIS; even when that person has the slightest sincerity of purpose.
Although Yusuf is undoubtedly a very brilliant professional who will make a good public official on a normal day, however, given the appalling state he met the NHIS at the time he assumed its leadership, it seems that for him to make a difference, it is not just enough to be brilliant. Yusuf needed to be also bold and fearless. And expectedly, it didn’t take long for the egotistical cartel that held the NHIS by the jugular over the years to sense that with the new sheriff in town, it was no longer business as usual. Soon, altercations ensued between Yusuf and the Health Maintenance Organizations (HMOs) — the companies that serve as ‘middlemen’ between NHIS and the hospitals. Now, what is unbelievable is that even after thirteen years of their existence, the NHIS, which is mandated to provide health insurance coverage to all Nigerians, only succeeded in covering about three million people. But being trained in the tradition of asking tough questions, Yusuf’s first line of probe was on why the NHIS could only cover three million Nigerians after more than a decade of its inception. Questions along these lines, of course, wouldn’t sit well with those at the HMOs who derive enormous financial benefit by the NHIS being unable to serve the greater number of Nigerians.
But as Yusuf asks the tough questions as a way of arriving at the truth, it reminds us that there are two categories of public officers in Nigeria. In the first category are those who strongly need the offices desperately and would stop at nothing to keep the jobs even at the expense of playing ball with saboteurs who continue to use every opportunity to achieve selfish means. In the second category are people like Yusuf who need to be in public offices only because the instrument of power comes handy as a tool for making beneficial corrections. For those in the former category, they cannot be taken seriously and there should not be expectations for change in the affairs of the place they manage as they are often vulnerable and cannot be principled in the discharge of their duties. The latter, on the other hand, are not vulnerable and can afford to be principled. It is important to state, however, that while there are people who may not be vulnerable but are yet unprincipled, in generic terms, almost all the time, the vulnerable person cannot be principled on the mere fact of their vulnerability.
It is against this backdrop that the Governor of Kaduna State, Nasir El-Rufai, once reminded us that during the President Olusegun Obasanjo administration, only himself and a few other cabinet ministers who had achieved considerably well in their pre-ministerial lives had the courage to disagree with President Obasanjo’s decisions in Federal Executive Council (FEC) meetings. Those who must be in the jobs for they were not tied to auspicious careers before their emergence as cabinet ministers could not muster the courage to disagree with the boss for fear of losing their jobs. It is for these reasons that to have a country that works for all of us, it is important to give the top jobs to people who can afford to be principled.
While very many Nigerians seem to sympathize with Yusuf whose effort is being contested by a notoriously corrupt alliance that feeds on depriving Nigerians of their deserved insurance covers, unfortunately, very many others defend the actions of the HMOs that constantly devalue their humanity. Interestingly, it is hardly tenable to defend the HMOs if they keep avoiding answering the fundamental questions posed by Yusuf, all this while. For example, why would the HMOs find it difficult to adhere to simple regulatory requirements such as providing monthly certificates of non-indebtedness from hospitals as a prerequisite for accessing additional funds from the NHIS? Still, others have claimed, albeit ridiculously, that President Buhari supports Yusuf’s actions because both are from Katsina State. According to Nigerian journalist, Na-Allah Mohammed Zagga, the right question will be to ask if the Katsina brother of the president is doing the right thing or not. And if indeed he is doing the right thing, why must the president throw off Yusuf to the wolves, simply for being right?
Before answers to these questions are provided to revamp the NHIS for the benefit of all Nigerians, Nigeria’s poor healthcare status will continue to attract global concerns. The need for equity and national coverage will continue to dominate healthcare policy debates worldwide. Purposeful changes and planning will be central in reforming the system. But planning will only be effective if it ensures that funds are collected, pooled, and used for prudent purchase and provision of health services.
November 3, 2018
