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Universal health coverage in Nigeria: What else apart from funding is required?

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When the citizens of a country are healthy, it shows in the growth and wealth of that nation. Universal Health Coverage (UHC) is critical to wealth creation, social equity and social inclusion. In Nigeria, as elsewhere, there are building blocks for achieving UHC other than financing only and these include adequate human resources and adequate facilities that are fully provided with essential drugs and equipment. This piece in no particular order addresses additional funding options, governance and people & infrastructure dimensions of achieving UHC in our country.

The National Health Insurance Scheme (NHIS) commenced operations officially in 2005. It is generally believed that ongoing review of the enabling legislation of NHIS to make contributions compulsory rather than optional will cause national coverage to increase and hence enlarge the pool of health insurance funds. All true but it will take time and how much will be left after payments for services rendered to beneficiaries.

Given the level of penetration already achieved in telecommunications, is it impossible to levy an amount of NGN100 per month per capita for every active line in Nigeria? At 80% penetration, that translates to about US$533 million per annum. (One of the mobile network operators offers health cover for a prepaid weekly fee of NGN250 that gives access to any of 6,000 health facilities in Nigeria twice a month and maximum of seven times a year). This amount could be dedicated to retooling Primary Health Care centres (PHCs) across the country.

If the taxation of mobile use is not attractive, then it may be time to consider a sugar tax on sugary drinks. Alternative funding sources are important because over the coming years, Nigeria due to its improving economic performance would become ineligible for a range of external health financing grants. The minimum 1% of Consolidated Revenue Fund being dedicated to Basic Health Care Provision Fund (BHCPF) is a very positive development that brings us closer to full implementation of the 2014 National Health Act, which itself empowers government to partner with the private sector for implementation.

As a general principle, government and its agencies should focus on policy making, regulation and enforcement. All citizen facing and fund collection/management responsibilities should be handled by the private sector on behalf of government. All parties win – government focuses on what it does best, it earns steady, secure and transparent income from outsourcing arrangement (a very simple PPP type arrangement) while the private sector generates employment and provides prompt service to the public.

On policy implementation and governance, this author is of the view that the primary responsibilities of health maintenance at the primary care level need to be in the first instance, handled by the Federal Government – it is at that level where we have the most need, most frequently and by the majority of our people. Inadequate attention at that level is what causes national health statistics to be very poor. Post retooling of PHCs, given reasonable guaranteed cash flows from private or public sector contributors, is it then impossible to sell down ownership of the PHCs to communities of healthcare professionals led by medical doctors resident in the PHC areas? Let doctors own the PHCs and maintain them under strict oversight of the Federal Government through the National Primary Health Care Development Agency (NPHCDA). The result will be job security for doctors and sustainable medical service provision. What purpose does it serve decentralising crucial health functions to the weakest tier of government that covers areas where almost 70% of our people (who have little means) live?

Still on governance, do we need circa fifty (50) HMOs in Nigeria? Last year, all except one of the HMOs did not meet full accreditation criteria set by NHIS. Fewer, bigger, HMOs will allow for scale, ease of monitoring by regulators and will provide better service. Going even further, is it impossible to extend the role of pension fund custodians and administrators to offer separately, custody and administration of medical benefits? Reforms that build on existing structures or institutions that already work are more likely to succeed.

With respect to the Basic Health Care Provision Fund, why for instance does the Ministerial Fund Oversight Committee (MFOC) which is solely appointed and constituted by the Health Minister have responsibility for emergency medical treatment for all Nigerians via ambulance services and designated emergency care facilities? How does a committee based in the Ministry of Health in Abuja respond swiftly to an accident that happens in Bama for instance? What we need is private businesses to create regional and/or national ambulance and emergency services networked to PHCs and secondary and tertiary health care facilities across the country through seamless information and communication technologies. Payments to these emergency services companies will be from either the HMOs or NHIS or even both.

It is time we had an Independent Government Ethics and Accountability Office that would a-priori test laws, policies, rules and regulations for financial and organisational efficiency and effectiveness before implementation.  For instance, why does NHIS receive public sector contributions while also being a regulator?

What is medical infrastructure without people to man and run it? Medical and allied personnel (including teachers) need to be urgently classified, protected and remunerated tax free as “National Callings.” Women professionals will have super priority. Such action will motivate our best medical professionals mainly doctors to stay in Nigeria.

One of the least cost methods of improving our health system is preventive healthcare anchored on public health education, access to and consumption of clean water, immunisation and maintenance of a clean environment especially devoid of open defecation. Proper implementation of preventive strategies can eradicate deadly communicable and non communicable diseases. In that regard, we need to create employment and bring back health and sanitation officers.

Let us be known and respected globally for a great, functional health care system anchored on mass health education and sustainable universal coverage. Let’s get to work. As always, yes we can do this!

 

Mayowa Amoo

Amoo is an investment banker based in Lagos

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