Universal health care in Nigeria: is the future here?

Recently, there was an important meeting of stakeholders in Lagos.  It was tagged the Nigeria Health Summit. The major talking point was a keynote address presented by Senator (Dr) Lanre Tejuosho – Chairman of the Senate Committee on Health. He started off by reeling off some of the depressing statistics on the state of Health of the Nigerian. Nigeria was the greatest contributor to maternal deaths in the world. Stunted growth among children was spiraling upwards.

Nigeria could not achieve the economic progress it aspired to without significantly improving the health of its people. It was no rocket science, and did not require the perspicacity of a Bill Gates. To jump-start the required transformation in Nigerian Health, the Senate would do a number of things, he averred. It would activate the implementation of the National Health Act by ‘padding’ the 2018 Budget with a provision for the Basic Healthcare Provision Fund (BHCPF). The National Health Act, signed in 2014 but not significantly implemented since, mandated that not less than 1% of the nation’s Consolidated Revenue Fund be allocated for the purpose of driving activities geared towards the provision of Universal Health Coverage (UHC) in the country.

Secondly, it would move to change the existing National Health Insurance (NHIS) legislation to make the possession of health insurance by citizens not voluntary but mandatory going forward. The example of other nations that had achieved success in that area showed that health Insurance only helped to achieve Universal Health Coverage if it was mandatory.

 

The third game-changer was to recommend to government that, instead of spending most of its health budget – especially the budget for tertiary healthcare, on paying for inputs in the form of subvention, it should consider spending a substantial part of the money on paying ‘reimbursement’ for outputs and outcomes rendered by health facilities.

 

Yet another change in the pipeline, according to the Senator, was that the current regulatory law for Pharmacy in Nigeria, which made it impossible for non-pharmacists to invest substantially in retail pharmacy in the country, would be repealed. A new one would make possible the injection of private sector capital to expand the pharmaceutical value chain.

 

To anyone with an interest in the Health of Nigerians, the Senator’s pronouncements gave cautious cause for cheer. However, some of the issues required close examination.

 

The language of the existing legislation on National Health Insurance, and the proposed changes to it, suggested that it was an area of exclusive interest for the ‘federal’ government. This ignored the fact that some states – such as Lagos and Delta, had already passed laws establishing a system of Basic Health Insurance which was intended to cover all their citizens.

 

There were also private sector Health Management Organisations providing Social Health Insurance to indviduals and corporate organisations.

In the past, even such exercises as running pilots of Community Based Health Insurance had been politicized, with ‘federal’ agencies spending huge amounts of money running no-impact ‘pilot’ programmes in states without carrying the states along, especially when such states were governed by a different political party.

 

The structure and operations of the National Health Insurance Service itself would need to be substantially changed if it was to serve a useful regulatory role in an expanded mandatory health insurance system. A separate, independent structure would need to be created to manage insurance funds, hitherto a magnet for dishonest administrators and carpetbaggers of various descriptions.

 

The allocation of money for Basic Healthcare Provision Fund (BHCPF) was clearly a welcome development. But it was no panacea, and it was bound to bring its own challenges. Even if the Senate somehow managed to get it signed, the next issue would be how to ‘protect’ the fund, and to ensure it served the purpose for which it was meant.

 

By the provisions of the National Health Act, 50% of the fund should go to the NHIS, for the purpose of providing basic health insurance for Nigerians. The exact mechanism and criteria were not clearly spelt out. Would they be running ‘in parallel’ with the states, thereby wasting resources through duplication, or synchronizing with them?

 

The guidelines in the Act were riddled with problematic loopholes open to subjective, even mischievous interpretation, such as ‘eligible primary and secondary health care facilities’. Who would decide? Where did the states come in?

The experience from the past, if it was anything to go by, was of an overweening central bureaucracy trying to control and micro-manage everything out of Abuja.

 

The paradigm shift of beginning to focus on rewarding outputs and outcomes by paying ‘reimbursement’ instead of ‘subvention’ to government health facilities was an attractive notion. However, given the ‘civil service’ nature of recruitment, deployment and organization of human resources in virtually all of these government facilities, a major factor in the perennial strikes in the sector, it would be a very hard sell indeed, and certain to be vigorously resisted by the professional unions.

 

Still, it was necessary that government, more and more, should see itself as a regulator and enabler, and be less directly involved in the actual provision of services. It needed to encourage the private sector to have a presence everywhere, including currently under-served areas, instead of building ‘white elephant’ hospitals and primary healthcare centres it could not man. It could then regulate the practice of these entities, and ‘buy’ services from them as and when needed for the generality of the public, whether this was through health insurance or ‘direct commissioning’.

 

The merit of loosening the stranglehold of professionals over their professions in order to allow the ‘business’ side of healthcare to grow and thrive was clear, whether the reference was to pharmacies, hospitals, or diagnostic centres.

 

All in all, it was clear, from the Senator’s words, that there were promising developments afoot. If they could be followed through, a big ‘if’, the future, for Nigerian health could indeed be here, sooner than anyone might have dared to hope.

 Femi Olugbile