by M. M. Alhaji
Access to quality healthcare is one of the fundamental human rights listed by the World Health Organization (WHO). Nigeria, being a signatory and member of the WHO, is thus bound to provide its citizens quality healthcare. Consequently, National Health Insurance Scheme (NHIS) was established in 2004 with the mandate of ensuring “access to adequate and affordable healthcare for all Nigerians” with total commitment to “securing universal coverage” to “improve the health status of Nigerians.”
Thirteen years after the establishment of the NHIS, the exact number of Nigerians covered under the scheme – which provides for just basic health services – is unknown. The Executive Secretary of NHIS, currently under suspension, had put the figure at 1.5%. This is after spending more than ‘N351 billion and trillions of Naira in underhand dealings’ since the establishment of the scheme! While participating Health Care Providers (HCPs) as well as the regulatory body (NHIS) continue to heap blames of financial irregularities that had impeded the efficiency of the scheme on Health Management Organizations (HMOs), the biggest culprits remain the inherently flawed setup of the scheme—the lack of sufficient political and financial foresight, and sustained poor investment on infrastructure and manpower in the health sector—and until a clear blueprint, devoid of ambiguity, and streamlined efforts are put in place, no significant progress towards universal health coverage (UHC) will be possible.
This piece would rather sidestep the political shenanigans and allegations of corrupt practices that have bedeviled the scheme (not because they are not equally important but because those are problems that could be solved with a stern wave of hand from the right quarter) and focus on the nub of the matter: the need to restructure or overhaul the trite arrangement in our health insurance arena in tandem with the aspirations of UHC.
In April 2001, African Union countries converged in Abuja and pledged to dedicate 15% of their annual budgets to improving their health sectors. Ironically, Nigeria’s annual health budgets had instead progressively declined ever since, from, for example, 11% in 2015 to 8% in 2016 to about 5% in 2017. This singular consistent insouciance by the successive governments towards the health sector does not only pose the biggest threat to achieving UHC in Nigeria but also remains the biggest driver for the worrisome development of 8 out of every 10 Nigerian doctors wanting to emigrate out of Nigeria. Similarly, this lack of investment in the health sector remains the biggest factor behind our health system’s persistent inability to contain some of our recurrent infectious diseases such as Lassa fever and malaria.
The first step towards achieving UHC in Nigeria is to increase public investment, financial and political, in the health sector. Two important reference points are the commitments toward Abuja declaration and the implementation of the 1% Consolidated Revenue Fund for the revitalization of our basic healthcare system (Basic Healthcare Provision Fund, BHPF), as provided for in the National Health Act 2014. Considering that our health insurance scheme is Primary Health Care (PHC)-centered, government at all levels must foster a pact that progressively injects funds toward upgrading PHC infrastructures and increasing (and retaining) manpower through pragmatic approaches, among which service leadership and accountability, and increasing incentives for PHC health workers should be prioritized. This pact should consider setting up a Basket Fund where revenues are raised, funds and grants are pooled equitably between the three tiers (federal, state and local government) for wider health coverage of people in their domains, prioritizing those in the lowest rung of socio-economic ladder. This improved partnership and leadership have the capacity to restore the now non-existent confidence in the health governance and health facilities in the country.
Second, the NHIS benefit programmes are heavily fragmented with incredible crevasse between the formal and informal sectors. This serves to widen inequality in health access between the employed and unemployed—a status quo that is inimical to the spirit of UHC. NHIS coverage shall remain low for the simple reason that majority cannot afford to pay for health and the current insurance plans for the informal sectors are, at best, unrealistic and unsustainable. Fourteen % of Nigerians are unemployed and 67% live below poverty line.
While our NHIS was built on the US Medicare model, Thailand and Rwanda offer more practical and suitable models for achieving UHC in a setting like Nigeria. Rwanda, for example, spends about 23% of its annual budget on health and, expectedly, its mandatory, class- and income-sensitive health insurance programmes cover up to 95% of its population. Mutuelles, Rwanda’s household-based mutual insurance, is heavily subsidized for the poorest Rwandans so much that in its first decade of implementation, coverage was more than 70% amongst other feats such as the reduction out-of-pocket payment from 28 to 12%, and increase in service contact (patient-health provider) by 1.8 per year. Apart from being considerate of the low-income and high-risk individuals, systems like Mutuelles have a capacity for checking the propensity for moral hazards of overconsumption and free-riding of health care services and reducing lack of foresight—which are common among those in the lowest hierarchy of socioeconomic ladder—despite their intricate logistics.
When Thailand decided to reform its public health financing system in 2002, the results were self-evident. Over 40 million (representing more than half of its population) who were uninsured or underinsured gained comprehensive coverage that not only provides basic services such as free prescription drugs and hospitalization but also afforded the masses access to expansive healthcare such as radiotherapy, emergencies and eventually renal replacement therapy, funded by the Thailand government. Rwanda and Thailand are a proof that to achieve UHC, health insurance must be mandatory, pragmatic and class sensitive. Perhaps, the biggest lesson from Rwanda and Thailand is that political will is the most important currency for UHC.
Political will towards health governance and financing in Nigeria should begin with increased funding to the health sector and making NHIS accountable and transparent. While also there is need to strengthen NHIS’s oversight powers, ample policy space should be provided to allow it evolve and accommodate realistic changes without having to go through longwinded bureaucratic processes. Further, a strong decision on HMOs should be reached. If health stakeholders are convinced that HMOs are relevant in our health space, then they should be strengthened and carried along, while the bridge between end users and health providers as well as the HMOs be bridged. Reward and punishment policy; technological advances for service tracking and financial claims; and periodic brainstorming and surveys should be introduced in the scheme. And importantly, NHIS must actively involve itself in manpower development, including funding medical students and continuous in-service health workers training, and performance-based upgrading of health centres.
An improved health insurance coverage for Nigerians could even be used as an incentive for several social services such making childhood immunization, exclusive breastfeeding, primary school enrolment as prerequisites for enjoying public health coverage. However, what is needed now is for the government to move quickly and prosecute corrupt elements in the NHIS service chain and restore public confidence in the scheme.
Op–ed pieces and contributions are the opinions of the writers only and do not represent the opinions of Y!/YNaija
M. Alhaji is a G20 Young Global Changer, and a PhD candidate in Public Health at University of Brunei. He is on Twitter @moohh_