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Nigeria: Escaping the health-poverty trap

I was recently forced to acknowledge again that people believe what they are told repeatedly especially when that is all that they hear. Narratives are powerful tools to condition a society.

This is relevant to our healthcare journey as a country. Often, the narrative is on how the government is not doing enough and is spending so little of the GDP on healthcare, how citizens of other countries get free healthcare and how much is spent on medical tourism etc. Then there is the talk of brain drain with our doctors and other medical personnel leaving Nigeria to get better paid elsewhere. Finally, you have the talk about fake drugs.

So, the first issue is that most of the talk on healthcare is about problems. This needs to change – not that there are no issues, but they cannot be the focus of our narratives. You pitch opportunities and not problems.

Even when there is a more technical conversation, it is often about the supply side i.e. the provision of health services with topics like hospital capacity, medical personnel needs, the cost of equipment and access to finance. There is almost no discussion about the demand side i.e. the payment for purchase of health services. The only time the demand side is discussed is when the government is accused of not spending enough or when health insurers (HMOs) are in the spotlight for one thing or another. Sadly, this is the equivalent of the proverbial “attempting to clap with one hand”. This may seem easier, but the resultant culture is one of learned helplessness and our people continue to wait to be saved by someone AKA government.

So, the second issue is that to build a sustainable healthcare system, we must be committed to supporting the provision of the service as well as the purchase of the service.

When demand and supply occur naturally, the government can play the role of regulator more effectively with the added benefits of greater potential tax revenues and investments in the sector. We have seen it happen in the banking, telecoms, technology, and entertainment industries; and it is happening slowly too in agriculture. In contrast, the industries where the government maintains intervention, for example oil and gas, power and of course healthcare remain in shambles and are underdeveloped. Not everything is bad – but the parts of these sectors that have worked are also those where the operators addressed the issues themselves and focused on developing their market with sustainable principles.

The point is simple: we have to ensure that medical service businesses can offer their services profitably and people can afford to access medical services as they need it. Unfortunately, it is easier to discuss offering the service and much harder to focus on paying for it. It is even harder when everyone thinks the government should pay for it. This is why it is so important to focus on the demand side. The demand side is the side that discusses our responsibilities and rights as individuals and the opportunity to create a sustainable market for healthcare in Nigeria. This is the sure road to arriving at Universal Healthcare for Nigerians.

Today, the biggest purchasers of healthcare are the federal government on behalf of its staff through the National Health Insurance Scheme (NHIS) in particular, and corporate organisations through the private plans they buy for their staff. The impact of the State Governments and private individuals are still negligible. So, the real problem is that we have a very small predictable consumer market for health care.

Healthcare is not a hustle. It takes about 16 years to train a consultant physician (perhaps more, depending on the specialty) and you can only train a minimum qualified nurse in about 3 years. It can take 5-10 years to develop a medicine to cure a specific illness so drug companies often get patents of up to 20 years for their inventions before they can be produced as generic drugs.

So, this is the third issue – everything takes time in healthcare so we should not imagine that there is an over the counter or instant solution that we can just buy or that all problems can be resolved magically by having enough money to pay for it.

COVID-19 has shown us how sometimes money is useless to you in healthcare when the service is not even available to be bought. A carefully calibrated demand cycle is what determines the sustainability of the health system in any society. In some countries, the government acts as the proxy for the demand side, while in others, the private sector is allowed to curate the demand in the market. In Nigeria today, the private sector is better at allocating resources and from our experience, mission critical assignments will only thrive if privatised. This is not a matter of good or bad or of right or wrong – it simply is what appears to work for us. So, we must leverage our entrepreneurial strengths and create an appropriate environment to harness the power of private capital to create what we need.

This is not to say that the government can be excluded from healthcare – No way! Unlike other sectors that are not a matter of life and death, we cannot do without the government in healthcare both for rules and for responsible intervention when the private market is unable to assure an equitable allocation of the resources. For example, on the supply side, it may make sense for the government to handover primary and secondary healthcare services to the private sector and focus on tertiary care. Similarly, for the demand side, it makes sense for individuals to buy health insurance for access to primary and secondary care while the government pays for tertiary care as a residual since this may often be catastrophic and the cost of insurance may be beyond the private market.

To illustrate, if Isa has a cold or a fever, it may make more sense for him to go to a nearby private medical facility to get care. This care will be paid for by his health insurer to whom he has paid an annual premium. The healthcare provider will not worry about getting paid first or whether Isa can afford the care because they know the insurer will pay for it. If Isa however develops brain cancer, the cost of his care will likely be prohibitive for the private market today and this is where the government’s tertiary care centres can come in.

We desperately need to adopt a system of buying healthcare that enables the development of a bankable operating model for healthcare businesses to sustainably access finance. This is the main reason why health insurance represents Nigeria’s most viable route out of health poverty. Simply put, every Nigerian must have access to health insurance as their primary way to pay for health care expenses. Everyone that employs another person should ensure that the employee is covered for health insurance.

Parents should cover their wards, and each of us should become our brother’s keeper and support those around us to be covered. We should stop looking to the government for free care and should rather purchase health insurance in the same way our communities developed the Esusu or Ajo systems to pool their resources (& risks!) for their benefit. And in the same way these systems empowered their members financially, so also the financial burden of health care will be reduced for every insurance subscriber.

There are other details required for this to be entirely successful including regulatory intervention on pricing (supply and demand) as well as some consumer-centricity supported by the Federal Competition and Consumer Protection Commission, FCCPC (formerly Consumer Protection Council). But the message is really simple – Buy a health insurance plan today – for yourself, your relatives and your neighbour. You are only as healthy as the sickliest person in your network.

Obinnia Abajue

Abajue is the CEO of Hygeia HMO Limited, the leading private health insurer in Nigeria.

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