Financial Gamble for Health: Nigeria and Universal Health Coverage, By Adaeze C. Oreh
As we head towards the next round of election campaigns, it is important that the voting public are conscious and aware of critical aspects of issues regarding the lives of the populace – universal health coverage being one of such vital issues… The days of waiting for political action are rapidly exiting, citizenry must now reject complacency and demand their rights…
A large number of the world’s 1.3 billion people who survive on very low incomes still have little or no access to effective, affordable medications and interventions due to weak healthcare financing systems. Nigeria is one of the countries hugely beleaguered by this lack of access.
The 12th of December is globally recognised as Universal Health Coverage Day, set aside to draw world-wide attention to the dangers of financial inaccessibility to healthcare, and advocate for national strategies for protection of individuals and families against financial hardship due to burdensome out-of-pocket spending on health. Last year was no different, with countries placing universal health coverage as a key national priority, and at the heart of achieving the Sustainable Development Goals (SDGs).
In 2005, representatives of the World Health Organisation (WHO) member states adopted a resolution encouraging countries to develop healthcare financing systems aimed at providing Universal Health Coverage (UHC). The aim of this was to ensure access to appropriate healthcare services, whether preventive, curative or rehabilitative at affordable cost, without exposing the user to financial difficulty.
It has been inferred that when a household spends more than 40 percent of its entire disposable income after basic food expenses on basic healthcare services, such expenditure could push them over the poverty line, resulting in impoverishment. When one considers prevalent economic issues, such as global and national economic recession, naira devaluation, meteoric inflation and unemployment, it goes without saying that many households do not need much prodding to tip over the edge of financial imbalance into abject penury from healthcare expense. In many cases, families manage to bear these expenses using coping strategies such as the sale of asset, borrowing and reduced household food consumption, all of which have negative impact on the health and wellbeing of the family. These strategies end up perpetuating the cycle of poverty, thus keeping families indebted, even long after recovery from the illness.
The WHO’s advocacy for universal health coverage is therefore aimed at highlighting the responsibility of member nations to protect the poorest families from the often-devastating financial implications of paying out-of-pocket (from their personal funds) for health services. Universal health coverage, therefore, not only provides financial risk protection, but emphasises the extent of population and health service coverage through a system of organised prepayment, where funds are equitably pooled in readiness for a time of need in order to combat financial inaccessibility to health.
The Nigerian Health System and Health Financing Policy
Data on Nigeria from the WHO reveal that with a country population of over 182 million, 368 people out of every 1000 are likely to die between the ages of 15 and 65 years. That is almost 40 percent of our population. Despite this abysmal life expectancy projection, total health expenditure as a percentage of the country’s GDP stood at 3.7 percent by the end of 2014, in stark contrast to Liberia’s 10.0 percent, Sudan’s 8.4 percent, and even neighbourly Niger’s 5.8 percent (Source: World Bank, 2017). Nigeria’s out-of-pocket spending is currently at above 96 percent – ranking amongst the highest in the world with countries like Afghanistan, Algeria, Congo, Eritrea, Iraq and Libya.
It, therefore, does not require the keenest mental acumen to acknowledge that the Nigerian health sector is poorly funded. A combination of poor health sector funding, skewed health resource allocation that have long favoured secondary and tertiary facilities, have led to chronic system inefficiencies and inequities of access and payment, especially for the rural poor.
Unattractive remuneration options and incentives for health workers in rural-based primary care centres have contributed to this ‘allocative inefficiency’, which has over time resulted in the over-provision of healthcare services in urban and semi-urban areas, to the detriment of rural areas. Join this with an absence of social security for the most vulnerable groups, regressive taxation, poor planning and allocation of public funding for health, corruption and a lack of systemic coordination across all three tiers of government, and one sees a situation where these health inequities literally run amok and unchecked amongst the populace, leading to even greater poverty.
Enormous potential exists for strengthening primary healthcare through the Basic Healthcare Provision Fund (BHCPF) stipulated in the National Health Act. If implemented, half of this fund would provide basic packages of services in primary healthcare centres through the NHIS.
A major reason for the lack of end-user confidence in Nigeria’s National Health Insurance Scheme (NHIS) is restrictions to the use of many health services by spending limits and reduced number of services enrolled individuals and families can access due to inadequate funding. Currently, the scheme caters to only about 4 percent of the country’s entire population, majority of whom are formal sector employees, despite the scheme’s launch over a decade ago. Ghana’s national health insurance scheme currently covers about 50 percent of their total population. A health financing policy directed at universal health coverage must therefore focus on the following: equitable and efficient revenue collection in sufficient quantities; pooling of contributions to ensure cost-sharing and financial accessibility; and lastly, prudent, equitable and responsible purchasing or provision of efficient and effective healthcare interventions.
Subsequently, government must clearly exhibit political will necessary to drive universal health coverage, and show capacity to exercise good stewardship of the process. Recently publicised controversies between the NHIS and the Federal Ministry of Health (FMOH) being a case in point. The inability of large sections of the populace to access health services, catastrophic health expenditure and impoverishment are strongly linked to the extent to which countries rely on individual out-of-pocket payments as a means of financing their health systems. Conversely, how equitably and efficiently run the systems will be, largely depends on a combination of both well-targeted legislation and systemic frameworks for revenue collection, contributions-pooling and the purchasing or provision of appropriate and effective health care services.
Recommendations for Government
The Nigerian government’s commitment to spending not less than 15 percent of its general expenditure on health, as declared in the ironically named 2001 ‘Abuja Declaration’, would demonstrate political will to protect the populace from financial risk and economic hardship. Enormous potential exists for strengthening primary healthcare through the Basic Healthcare Provision Fund (BHCPF) stipulated in the National Health Act. If implemented, half of this fund would provide basic packages of services in primary healthcare centres through the NHIS. 45 percent would be disbursed through the National Primary Healthcare Development Agency (NPHCDA) for the provision of essential medicines, maintenance and equipping of primary care facilities, provision of transportation to convey emergency patients and life-saving commodities to and from hard-to-reach areas, in addition to human resource capacity development. The left-over 5 percent is designed to be ear-marked to respond to national emergencies and epidemics.
The fund would be primarily financed from annual grants from the federal government, and supplemented by international donor funds and innovative financing schemes. States and local governments should also be mandated to contribute not less than 25 percent respectively as counterpart funding for PHC projects. The underlying principle being sustainable financing for health, with internally generated government funding being the primary source of financing and international aid and grants acting as supplements in every sense of the word.
Revenue generation using innovative financing schemes such as the taxation of goods which pose health risks to consumers, such as tobacco, alcohol and even fast foods; levies on mobile phone calls or purchases, dedicated taxes on airline tickets, foreign exchange transactions, and luxury goods is another viable option for generating finances.
Tackling the scarcity of skilled manpower in rural areas via the recruitment, training and support of rural-based community health workers (CHWs) through the National Primary Health Care Development Agency (NPHCDA) is a possible solution to the unavailability of skilled manpower at the rural primary care level, and has been employed successfully in other African countries. These CHWs must be fully integrated into the health sector, with training and support given for the diverse skills needed to function in these hard-to-reach areas where the majority of people in desperate need of care reside. Their standards of training, job description, career progression, monitoring and supervision must also be clearly spelt out for them to succeed.
The impact of CBF schemes has been widely studied in various Nigerian states and reported to be a sustainable health financing mechanism with potentials for positive health and economic outcomes. Information and Communication Technology (ICT) and private sector engagement using lessons from banking and telecoms can rapidly change the narrative for community health financing.
As part of its stewardship role, the Federal Ministry of Health (FMoH) must regularly monitor the process of healthcare financing reform via the NHIS. By monitoring the number of beneficiaries/enrolees; frequency of utilisation and cost of services; number of service providers; and quality assessments based on feedback from beneficiaries and staff; staff performance evaluations, and health indicators such as maternal, infant and child mortality; and prevalence rates of communicable and non-communicable diseases, the NHIS will be in a better position to ensure the delivery of sustainable, quality health care services to end-users.
Regarding legislation, by facilitating the process of amendment of the 1999 National Health Insurance Scheme Act 35, government can ensure legal backing for compulsory health insurance, thus paving the way for universal health coverage. In India, for example, it is constitutionally mandatory for formal insurance companies to serve the rural sector as a means of ensuring equitable access.
In addition, the engagement and encouragement of stakeholders such as State governments to initiate State Health Insurance Schemes under NHIS guidance opens up another avenue for increasing access for rural populations. The private sector by the focused and strategic use of Public-Private Partnerships (PPPs) can be enlisted to strengthen this process recognised to be a cost-effective system with enormous potentials for increased efficiency in the management and deployment of scarce resources for health care delivery. These partnerships could be in the form of privately-run PHCs in partnership with government, especially in communities where these firms operate and do business. While the implementation of PPPs in Nigeria may be difficult, the benefits can be maximised if contracts and agreements are clear and legally-backed ab initio, authorising the health service providers to make their own decisions, and manage their operational budgets with limited political interference. There must then be a clearly defined system for monitoring the process of service delivery, as this has over time been recognised as the ‘Achille’s heel’ or weakness of PPPs.
Currently, Community Based Financing (CBF) Schemes are based in very few communities, affecting less than 1 percent of the total population of Nigeria; the design and development of Community based health insurance (CBHI) or financing schemes targeted at often neglected semi-urban, rural and informal sectors is another mechanism with potential for a wider reach than conventional health insurance pre-payment schemes. The impact of CBF schemes has been widely studied in various Nigerian states and reported to be a sustainable health financing mechanism with potentials for positive health and economic outcomes. Information and Communication Technology (ICT) and private sector engagement using lessons from banking and telecoms can rapidly change the narrative for community health financing.
A healthy population is a healthy and more productive workforce which in turn will boost the country’s economic capacity in a background of favourable economic and capital market policies. UHC as recognised as far back as 1978 at the International Primary Health Care Conference in Alma-Ata, USSR is a clear path to the lowering of Nigeria’s poor health indices which greatly contribute to the global burden of disease. This can only be achieved through primary essential health-care services that are made universally accessible to individuals and families through their full participation and at affordable cost.
As we head towards the next round of election campaigns, it is important that the voting public are conscious and aware of critical aspects of issues regarding the lives of the populace – universal health coverage being one of such vital issues. Its implementation will therefore greatly depend on political will and commitment, accountability and transparency across the healthcare delivery value chain from policy to financing and lastly provision of care. The days of waiting for political action are rapidly exiting, citizenry must now reject complacency and demand their rights to quality, accessible and affordable healthcare. The time has come for universal health coverage to transit from being a hashtag or a tag line to becoming the reality in Nigeria.
Adaeze C. Oreh writes from Abuja.