Published On: Wed, Nov 27th, 2019

Achieving the Universal Health Coverage by 2030

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WEDNESDAY COLUMN by USSIJU MEDANER

info@medaner.com, justme4justice@yahoo.com

The most important and established criteria for good livelihood globally, is good health. For a nation to achieve this, there must be unfettered access to quality healthcare which is guaranteed by adequate government legislation and spending on health and nutrition. Quality health is a universal fundamental need and a basic functional requirement for a flourishing labour force. It’s often said that “a healthy nation is a prosperous nation”. That is the reason for the global desire on achieving the Universal Health Coverage (UHC); a means to national and global prosperity.
Health is a human right. No one should get sick and die just because they are poor, or because they cannot access the health service. Health is also wealth for our nation can only become as wealthy as we are healthy.
In Nigeria, it is surprising how easy it was for past governments to literally underservice the nation’s healthcare system and allow corruption to dig deep into such a sensitive sector. We had no clear cut measure to address all the major public health challenges facing us as a people: the diseases, maternal and infant mortality, poor sanitation and hygiene, disease surveillance, road traffic injuries and a host of other aspects we ought to have the means to contain but which we still struggle with.
Collapsing a nation does not require atomic bombs or chemical weapons but as easy as lowering the standard and quality of healthcare delivery and allowing the citizens to groan under the burden of lack of access to healthcare services. With every child that dies as a result of poor prenatal healthcare; for every youth that dies of an untreated ailment we could have possessed the capacity to prevent, the nation’s future and present workforce is depleted and the nation, dying. The death of the health sector is the death of the nation.
As far back as 2005, we took the decision to engage all our resources towards becoming compliant with the Universal Health Coverage (UHC). We began setting up machineries to ensure all legal residents of Nigeria have access to quality healthcare services without recourse to out-of-pocket spending on health facilities at a walking distance from their immediate homes. We set up the National Health Insurance Scheme (NHIS), resources were disbursed and capital invested to enrol Nigerians on the scheme.
In 2006, there were just 450,000 enrolees on the NHIS scheme, that figure was raised to 5.6million over the course of six years. We must all agree that the major step to fulfilling the objectives of UHC in Nigeria is to continuously increase the number of Nigerians enrolled on the scheme until a large number of the population of Nigerians are on the scheme. During that period (2006) the then management of NHIS, increased the pooled fund for the NHIS from N12 billion to N94.8 billion in just six years but since then the reverse is case.
After years down the line, only less than four per cent of Nigerians are captured on the scheme. Which is a population composed almost wholly of the elite currently enjoy the nation’s health insurance despite all the resources expended and noise made in 14 years. All along, we seemed content with the situation; the drive to improve the enrolment is near non-existing. It is only recently under the current administration that the NHIS scheme got a wake-up call from the government to capture more Nigerians as well as include specialized treatments such cancer and other deadly diseases which had been ignored by some of the bureaucrats. While nations are striving to have UHC full compliance, we have been busy over the years politicizing the scheme and making all our achievement on papers.
Where we have been since 1999
Our challenges in the health sector are among the most worrisome of all our problems as a nation. Though it is an offshoot of corruption itself, the implication of not addressing them appropriately and in time would spell a greater danger for the country beyond other vices.
Our inability to end the plague of vaccine preventable deaths till now is a worrisome development. In 2015 alone, over 750,000 children died of several preventable diseases, in the same year less than half of all new-born babies in the country were duly and fully immunized to prevent death from common diseases.
Immunization is a proven tool for controlling and eliminating life threatening infectious diseases and has been estimated to avert almost 3 million death due to diphtheria, hepatitis B, haemophilus influenzae type b (Hib), measles, pertussis (whooping cough), pneumococcal, polio (poliomyelitis), rotavirus, congenital rubella syndrome (CRS), mother and new-born contract tetanus, tuberculosis (TB), yellow fever and a couple of others, each year. While the 2015 allocation for the Routine Immunisation Vaccines stood at N2.62 billion, the 2017 national budget proposed N12.51 billion for the Routine Immunisation Vaccines, 2018 budget, N12.31 billion and in 2019, N23.58 billion, the figures, though representing a yearly increment are still a far cry from what is needed to stop the unbecoming trend.
A recent research carried out by the Global Alliance for Improved Nutrition concluded that approximately 33% of Nigerians aged 5 and below suffer from malnutrition and in some cases acute malnutrition. Although there was a brief response in 2015 to the threat of probable death in the region of about 500,000 children if nothing was done to arrest the situation but subsequent response, till date, has been minimal. Federal Government spending to address the issue has remained inadequate.
As a nation and on record, we faced serious nutrition crisis and on multiple fronts. One out of every three children in Nigeria is stunted; 7.8 per cent of all Nigerian children are wasted while about 2 million children suffer acute malnutrition and at risk of premature death.
Though malnutrition is a global challenge but there are encouraging reports of nations showing real commitment to tackling the menace and stepping up to lead action towards achieving this objective. We read of Tanzania adopting a wide range of target actions to stem stunting, anaemia, low birth rate and four other very significant components of malnutrition. The nation has set up a plan under the direct leadership of the Prime Minister to reduce all forms of the malnutrition associated with deficiency and excesses/imbalances.
We failed to advance from continuous paper works to action. As far back as 2009, the Ministry of Health in collaboration with the United Nations Children Fund (UNICEF) created the Community-based Management of Acute Malnutrition (CMAM), piloted in Gombe and Kebbi states and later spread over 11 northern states. Resources were allocated and disbursed. The program was on paper designed to treat acutely malnourished children from six months old to five years old. It was claimed that 830,000 children had been attended to by the program. Where are the impacts of such intervention in our present day Nigeria? Something always goes wrong somewhere.
The low quality both in structural facilities and healthcare givers’ capacity across the country is a general source of worry for the nation and the excuse given for the unbecoming excessive medical tourism of Nigerians outside the shores of the country. This unwholesome medical tourism is a consequence of the gross underfunding of the healthcare sector. It is practically improbable for a Briton to seek medical service outside of Britain; because he doesn’t belief he could get better treatment anywhere outside his country. That country, like several others, recognizes early, the imperative of developing a strong and quality healthcare delivery system. They didn’t play politics with the finance, legislation, management and staffing of the sector.
I read about a former lawmaker from Kaduna state, Ibrahim Bello who had to go to India to get the best treatment for his diabetes. In his words “comparative analysis between Nigerian case and where I passed through in India, honestly, I cannot do it here because the margin is so wide that every Nigerian who has any health issue; his prayer is how he can be moved to India”.
This is pathetic. How can we not, after over 59 years, develop our healthcare facilities to truly represent a healthcare facility? That definitely is not beyond us if it is our priority, we are not short of resources to pull it but no we wouldn’t. This is a national shame on all of us.
Yes the current administration is making attempts to revamp the sector but the efforts are a far cry from what needs to be done. What will it cost us to revamp all the existing medical centres across the country and even build new ones across the geopolitical zones with the capacity to handle cancer treatments, brain tumours, brain surgeries, fine surgery interventions and respond adequately and efficiently to several other conditions we travel out of the country for.
The finance
Inappropriate healthcare financing has been constant for the nation’s healthcare sector and one of the reasons we have not been able to develop the sector as appropriate. If we hope to reverse the declining trend of the sector and realign our economy for inclusive growth, then a healthy population is a necessity. We must consciously upgrade the sector financing to meet our health aspirations
From established data, every day, approximately 2,300 children under the age 5 years and 145 women of child-bearing age die in Nigeria. Unfortunately, these deaths are preventable. Most of the maternal deaths are as a result of pre-eclampsia and eclampsia, obstetric haemorrhage and complications from unsafe childbirths and abortions. Our spending on health has failed to address these deaths and many other preventable deaths in our country. The size of our annual allocation to the sector is a mockery of our capacity to truly attend to the sector. Not only has the annual allocation always fallen marginally below what is needed to show commitment to the revamping of the sector, it also go down the drain of corruption as has been the custom for decades.
This is why Nigerian states and local governments spent N55.36 trillion on healthcare delivery between 1999 and 2006 and yet, we have one of the highest figures of new-born deaths in Africa, a neonatal mortality rate of 37 per 1000 live births and about 250,000 deaths yearly.
Despite all our spending, approximately 96 per cent of Nigerians still groan under the burden of high cost of healthcare. Our people were dying on daily basis of ailments that could be treated because they have no money to pay. How many Nigerians are blind today because they cannot afford the cost of simple treatments, medications and surgeries?
In a bid to gear up commitment to the sector and join the league of nations in the drive towards Universal Health Coverage, we appended our signature to the Abuja Accord of 2001; we concurred to allocate a minimum of 15 per cent of the nation’s annual budget to the health sector, but a critical analysis of allocations to the sector over the years only depicted a clear under funding. For the record, I hereby reproduce the budgetary allocation to the health sector over the years:
Year Allocation to health sector
(Billion Naira)
2000 17.10
2001 42.63
2002 44.65
2003 52.15
2004 59.79
2005 71.69
2006 106.94
2007 172.40
2008 138.18
2009 154.57
2010 164.91
2011 235.87
2012 282.77
2013 282.50
2014 264.46
2015 259.75
2016 250.06
2017 308.46
2018 404.60
2019 423.92
Though the figure seems to be on the rise lately, but it is still a far cry from what is expected. The increased expenditure on vaccination, cancer treatment and a few others in 2019 are welcome developments but we need much more and a holistic response to the sector.
The way-out
It is time we proactively respond to the needs of the nation’s health sector and take a turn that would reposition the sector in the nearest future. We must start with a comprehensive organisational restructuring of the sector; who is controlling what and how do we command accountability at all levels of administration within the sector? This is about stopping institutionalized corruption in the sector and paving the way for full and efficient dispensation and utilization of funds for the sector.
The decisions that need to be made are few but very important. We must begin with the reappraisals of the various legal documents guiding the administration in country; this we will do by revisiting the nation’s healthcare bills, possibly with the objective of an unbundling of the legal frameworks into units for maximum policy implementation, creation of different legal frameworks for the primary healthcare management, public health management, routine immunization, vaccination and a few other significant sub-sectors within the health sector.
The NHIS legal framework must also be revisited and restructured to remove bottlenecks that limit the enrolment of beneficiaries on the scheme, pooling of funds into the scheme and the number of healthcare centres that are registered on the scheme (it is advised that every registered and operating healthcare delivery facility in the country must mandatorily be an NHIS service provider, as much as all Nigerians are mandatorily beneficiaries of the scheme). This means that our laws must mandate all legal residents of Nigeria to be on the NHIS and enjoy access to health services without direct out-of-pocket payment. The new legislation must be drafted such that Nigerians would not be able to benefit from any government social provisions without evidence of enrolment on the national health insurance scheme.
Equally, the general funding framework of the nation’s health care must be revisited and restructured. Our law must get to the point where all Nigerians are mandated to contribute to the national health purse. The federal government and state government must be mandated by this framework to allocate a minimum of 15% of their annual budget to the sector while the local government must equally contribute a minimum of 10% of their monthly allocation to the purse. Every employed citizens of Nigeria must also be mandated to contribute a flat percentage of their monthly salaries to the purse while all corporate businesses in the country are to be legally mandated to contribute a fixed percentage of their annual net profit to the health purse.
Around January 2019, President Muhammadu Buhari rolled out the Basic Health Care Provision Fund (BHCPF) appropriated by the National Assembly in the 2018 budget. The BHCPF is the one per cent of the Federal Government Consolidated Revenue and contributions from donor grants set aside to fund the basic health needs of Nigerians. It is the fundamental funding provision under the National Health Act which was appropriated for the first time in the 2018 budget since the Act was signed in 2014.
The federal government earmarked 55.1 billion for the CRF to the basket fund of the BHCPF, while the Bill and Melinda Gates Foundation contributed $2 million, out of which $ 1.5 million has been released. Even at this, much is needed to be done in terms of funding.
Then a legal framework for the creation of a national health fund management body should be enacted. The body when created would oversee the accumulation, disbursement and accountability of the national health fund. The legal framework for engagement of private hospitals, clinics and insurance companies on the NHIS scheme should also be amended and activated to take effect.
Aside the need for fresh legislation and legal frameworks to revamp the national health sector, we must do all it takes to extend the coverage of national health care delivery to reach the most health-disadvantaged populations subset of the nation. Of course these populations are prominently rural dwellers and as such, we must address the shortage of healthcare facilities in the rural areas. To this effect, I humbly suggest that; we recognize that the major problem is funding, and as such the government should declare a massive financial intervention for the rural medical facilities as seen in the agricultural sector.
Reprioritizing of the primary health care services should be the next agenda on the way to revamping the sector. The poor condition of PHCs across the country is worrisome and inappropriate. Most of these centres are short of healthcare practitioners, medications and capacity to respond to regular emergencies. This is beside the fact that facilities are in short supply nationwide.
It is suggested that the ministry of health expands its primary health care facilities to the interior villages to reach the most vulnerable citizens. The Central Bank of Nigeria should set up a fund structure that enables individuals or groups to establish clinics and health centres in the rural areas across the country.
We could as well set up a model that enables the formation of cooperative healthcare facilities. The cooperative should consist of at least 3 members (a medical doctor, nurse and a pharmacist) at the least. The government would provide funding and other technical logistics while the members run the clinic and pay back the initial government start-up fund over a period of time at a single-digit interest rate.
These rural healthcare facilities should be captured to respond to regular diseases and ailment and possess real time communication with nearest comprehensive health facilities in cases of emergencies beyond their capacity. The same model could be replicated in the cities and urban settlements but with special interventions to provide equipment and personnel for specialized health situations. This would lead to existence of specialized health facilities and reduce the incidences of foreign medical tourism by Nigerians.
Taking note of the fact that the health care industry is one giant business and putting on the table the fact that Nigerians spend over $1 Billion yearly in hospitals abroad, we should set up a committee to woo established hospitals abroad to invest in the health sector of Nigeria by setting up general hospitals and specialized health centres in the country. These specialized interventions would go a long way to set the sector on a growth path.
We should also move to end expert drain of healthcare givers from Nigeria. Incentives and engagement satisfaction packages should be implemented to retain and possibly bring back many Nigerian health practitioners abroad. When we do this, we will not only drastically stop the massive cash export through medical tourism but would also probably join the league of contemporary nations such as Dubai and the UAE that are fast becoming a health haven for many across the globe.
Finally, establishment of a virile management and orientation program is needed. A ministerial healthcare intervention committee domicile in the office of the minister should be set up. The committee of experts and professionals in health and healthcare financing sectors would have the mandate of coordinating the health fund and management of all direct and indirect government intervention units of the reinvigorated healthcare sector.
It is very important that Nigerians understand all new developments in the sector and actively participate in the process to deliver healthcare for all by 2030 as envisage by the country. To this effect, we need also to establish a functional health table at the National Orientation Agency (NOA) to regularly educate Nigerians on the national, state and local government health policies, initiatives and projects and to repeatedly give directions for all to get registered on the NHIS. Finally, we have to strive to get to the point in the nearest future where and when we will be able to close our borders against all unnecessary overseas medical tourism.

God bless the Federal Republic of Nigeria!

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