The National Health Insurance Authority (NHIA) has taken disciplinary action against 57 health service providers, including the delisting of six healthcare facilities, suspension of four others, and sanctions on 47 health maintenance organisations (HMOs) over substandard care delivered to enrollees under Nigeria’s state and national health insurance schemes.
These actions stem from the findings of NHIA’s 2024 Annual Complaints Report, compiled by its Enforcement Department, following thorough investigations into grievances lodged by enrollees throughout the year.
Widespread Complaints from Enrollees
The report identified recurring issues among healthcare facilities (HCFs), including:
- Non-availability of essential medications
- Denial of insured services
- Unjustified out-of-pocket charges for covered treatments
- Failure to provide payment narrations
Among HMOs, complaints centered on:
- Delays or refusals to issue referral authorization codes
- Late settlement of reconciled payments
- Neglect of quality assurance oversight in partner facilities
These violations prompted the NHIA to act, in line with Section 17 of the NHIA Act, 2022, which requires mechanisms for resolving complaints under national health insurance programs.
3,507 Complaints Reviewed, 84% Resolved
According to the report, the NHIA received a total of 3,507 complaints in 2024, of which 2,929 cases (representing 84%) were successfully resolved.
Breakdown of complaints:
- 2,273 lodged against healthcare facilities
- 1,232 against HMOs
- 2 complaints filed by providers against enrollees
The agency noted that all complaints were investigated and addressed within the standard response window of 10 to 25 days, with an average resolution time of 15 days. Where delays occurred, explanations were provided and resolution efforts continued.
Complaints were submitted through multiple channels including walk-ins, letters, emails, phone calls, the NHIA call centre, and other digital platforms.
NHIA Reinforces Accountability and Service Quality
Commenting on the report, NHIA Director-General, Dr. Kelechi Ohiri, described the complaint resolution process as fundamental to the agency’s mission of improving care quality and restoring trust in the health insurance system.
“Enrollees deserve the best care, and we are committed to ensuring they receive it. These sanctions send a clear signal: the NHIA will not tolerate substandard services,” Ohiri stated.
He also acknowledged providers that consistently deliver quality services, calling them “worthy partners in the drive toward Universal Health Coverage (UHC).”
Dr. Ohiri further emphasized that with the recent actuarial adjustments—93% increase in capitation and a 378% rise in fee-for-service payments, the first in over a decade—expectations for improved service delivery are higher than ever.
“We expect more to be done for patients, not less. Timely access to care must improve, and we must all work together to eliminate delays,” he added.
New Policy to Tackle Referral Delays
As part of broader reforms, the NHIA has issued a circular mandating that referral authorization codes must be provided within one hour. If HMOs fail to respond within this timeframe, healthcare facilities are instructed to proceed with treatment based on an established emergency protocol.
