By Gafar Alawode
It is no longer news that Nigeria did not meet its health related Millennium Development Goals (MDGs) and the country has a long mileage to cover in the journey towards achieving Universal Health Coverage (UHC) as several UHC related indices suggest. However, the good news is that necessary policy thrusts are now in place and promising coalitions and consensus on UHC are emerging. UHC, defined as access to needed health care by all citizens without financial hardship, “ is the most important concept that the Global Health has to offer” in the words of the immediate past Director General of WHO, Dr Margret Chan. UHC is desirable not only because of the inherent health benefits, but it’s also an economic, social and political imperative.
Since 2014 when a Presidential Summit on UHC took place in Abuja, Nigeria is increasingly demonstrating interest to be part of global crusade geared towards achieving UHC. UHC is now shaping health policy priorities as government at all levels now gradually recognize UHC as the overarching goal of health system reform efforts. Therefore, major policy thrusts of health insurance decentralization and PHC revitalization are major demand and supply sides policy thrusts that if well implemented have significant potential of transforming the health sector landscape in Nigeria.
Decentralization of health insurance through introduction of State Social Health Insurance Scheme (SSHIS) is aimed at expansion of health insurance coverage to all Nigerians. Although the SSHIS will strive to meet certain international quality benchmarks, it will be adapted to suit local socio-cultural peculiarities of each state in order to engender ownership and sustainability. The SSHIS will ensure that citizens’ access to health care is based on need and payment is based on ability to pay and those not able to pay will be protected through equity fund to be financed partly from statutorily earmarked 1% Consolidated Revenue Fund of each of the states. The aforementioned is the design of the SSHIS on paper. However, concerted effort is needed to translate the attractive design into reality. State governments need to demonstrate commitment towards putting in place necessary legal, policy and institutional frameworks towards achieving the UHC dream through the instrument of SSHIS in their respective states. Government also needs to provide funding for the SSHIS takeoff and equity fund needed to buy health insurance premiums for the priority population i.e. the indigent, children under five and pregnant women. Strong governance and accountability is also needed to ensure the objective of expanded health access with financial protection is achieved.
While the National Health Insurance Scheme (NHIS) should be commended for leading the health insurance decentralization reform, the agency needs to do more towards providing necessary guidance to the states to ensure that all Nigerians are able to enroll on SSHIS and access quality health care without suffering financial hardship while doing so. The Federal Ministry of Health, NHIS and National Primary Health Care Development Agency and other relevant MDAs should therefore continue to harness and align all available local and donor partners’ resources towards shaping health financing landscape in Nigeria to achieve the UHC goal.
As we aspire to put in place an effective and efficient health insurance system in place as part of UHC national quest, PHC revitalization should also receive deserved attention as the goal of UHC will remain a mirage without functioning and reliable PHC system.
Available evidence shows that countries that make significant progress towards UHC invest sizable proportion of public resources on health. The level of prioritization of health in Nigeria, however, does not align with our expressed UHC quest. Nigeria’s spending on health falls short of all health spending benchmarks, including government health spending per capita, government health spending as a share of total government spending and government spending as a share of Gross Domestic Product benchmarked at 86 US Dollar, 15% and 5% respectively. However, volume of money is not the only determinant of health outcome; efficiency of spending is the other half of good health financing picture. Hence, the slogan “more money for health and more health for the money”. In other words, spend more and spend well.
Locally and internationally, sources of inefficiency in health spending include, but are not limited to, how the health system is organized, inefficient procurement and supply managements systems, weak human resource management capability that often leads to suboptimal mix of health workers, inefficient distribution, absenteeism, moonlighting and so on.
We therefore need to appraise the entire health system, especially the health financing subsystem, if we are serious about achieving UHC. Among other things, we need health financing subsystem that can convincingly attract both public and private funds to the health system and use such funds efficiently to produce the best result for the populace. We also need to embrace the principle of strategic purchasing rather than passive purchasing i.e. available funds should be used to target higher level results instead of just inputs. As a case in point, money voted for procurement of an ambulance for a given hospital should address delayed referral of patients to and from the hospital, and consequently reduce deaths associated with suboptimal referral system. If principle of strategic purchasing is applied, the focus of such expenditure is to buy reduction in morbidity and mortality associated with delayed referral and not just an ambulance which is an input. The difference between strategic purchasing approach and passive purchasing in this example is that the often experienced scenario where an ambulance is procured and not used for the intended purpose, or not used at all, does not arise because the system sets out to buy improved referral system in the first place and we cannot claim to have done that with a mere purchase of an ambulance. It therefore follows that all other necessary inputs needed for improved referral, including maintenance of the ambulance and needed personnel, are well catered for.
As part of efforts geared towards advancing the cause of UHC in the country, Nigeria lawmakers have taken a giant step by establishing Legislative Network for UHC which is a veritable tool for harnessing and aligning statutory functions of the legislators towards achieving UHC goal in Nigeria. The lawmakers have therefore committed themselves towards deploying their appropriation, legislation, oversight and accountability roles to the national UHC quest. Highly commendable is the recent resolution by the Senate to implement the National Health Act provisions, especially the Basic Health Care Provision Fund (BHCPF), that earmarks not less than 1% of Consolidated Revenue Fund of the Federal Government to fund basic minimum package of care for all Nigerians. The additional funding for health by the Federal Government should serve as an impetus for the states to also contribute the 1% Consolidated Revenue Fund to their respective SSHIS. The stage is therefore set for leapfrogging health access and financial protection with renewed commitment from executive and legislative arms of government and Civil Society Organizations.
Finally, Nigeria’s policy makers should be mindful of the strategic leadership position of the country in Africa and realize that Nigeria’s progress on UHC will provide impetus for other Africa countries to make progress. Nigeria, therefore, cannot afford to relent in its quest to leapfrog coverage of health insurance for citizens which is a major ingredient needed to expand access to quality care without financial hardship. Nigeria has what it takes to be the centre of best practice and a model for best health system among equals. Showing unalloyed commitment towards UHC cannot be more auspicious than now.
Dr. Gafar Alawode is the Chief of Party, Health Finance and Governance Project