As a result of poor service delivery to patients enrolled in Nigeria’s state and national health insurance schemes, the National Health Insurance Authority (NHIA) has delisted at least six and suspended four healthcare facilities, while sanctioning 47 health maintenance organisations (HMOs).
According to the Authority, the developments followed investigations into complaints received from enrollees throughout 2024, as detailed in its Annual Complaints Report compiled by the agency’s Enforcement Department.
The report highlighted recurrent grievances against healthcare facilities, including the unavailability of medicines, denial of services, out-of-pocket payments for covered treatments, and non-provision of payment narrations.
For the HMOs, according to the report, the issues related to delays or denials of referral authorization codes, delays in settlement of agreed reconciled payments, refusal to monitor quality assurance in facilities etc.
In line with Section 17 of the NHIA Act of 2022, which mandates mechanisms for complaint resolution across health insurance schemes, the Authority reviewed a total of 3,507 complaints during the year. Of these, 2,929 cases—representing 84 percent were successfully resolved.
A breakdown of the distribution of complaints reveals that 2273 were reports against HCFs, 1232 were against HMOs. Only two reports were recorded against enrollees by providers.
According to the report, in 2024, all complaints were fully investigated and responded to within the standard response time of 10 to 25 days. The average complaint resolution time for complaints that required investigation was 15 days. The complaints resolution rate (within timeline) was 84%. Where issues could not be resolved within the timelines an explanation was provided to complainants while the resolution process continued.
The complaints received in 2024 were submitted through the following routes: in-person, written letters, email, telephone, the NHIA call center and other channels.
Speaking on the development, NHIA DG, Kelechi Ohiri, described the NHIA’s complaints management process as organic to the agency’s efforts to enhance accountability, rebuild trust and improve quality of care, adding that it will ultimately drive higher enrolment by encouraging providers to offer current enrollees an enhanced quality of service.
“Enrollees deserve the best care and we will continue to do our best to ensure they get it. The sanctions are meant to send a clear message that the NHIA will not tolerate substandard service for enrollees” Ohiri said.
“We commend providers who are delivering high quality services to our enrollees. They are worthy partners in our collective journey towards UHC. With the recent actuarially derived increases of capitation and fee-for-service payments to providers, the first in 12 years, we expect more to be done for patients, not less. We must continue to work together to reduce delays in receiving care”, he added.
Beyond sanctions, the NHIA has also issued a circular mandating a limit of one hour for issuance of referral codes for treatment. If HCFs do not get a response from HMOs within 1 hour for enrolled patients, they should commence treatment based on the protocol established to deal with such situations.
