In a recently published blog, my friend Dr Abiodun Awosusi narrated this very touching story. “I walked into the pediatric unit of a teaching hospital in Nigeria a few years ago to review a patient. On the first bed was a lifeless child. He was brought in dead a few minutes earlier by his parents. His mother, “Bisi”, wept uncontrollably. While in tears, she recounted how difficult it was for them to borrow money to get to the hospital. Although they got some money from a chief in the community, the two-year-old baby died before they got to the hospital”.
Numerous households such as this one have been tilted into poverty, debt and financial hardship as a result of seeking health care. In Nigeria, private expenditure accounts for almost 70% of total expenditure on health out of which more than 90 % is out-of-pocket. The obvious victims of course are the poor who have become disillusioned and dissatisfied with the general low quality of health care provided by the public health system and which they must also struggle to pay for out of their own pockets.
Therefore universal health coverage (UHC) which can facilitate a pre-payment mechanism and improve access to healthcare is an inevitable policy direction that Nigeria must vigorously pursue as a mechanism that will ensure a fair distribution of the burden of paying for health services, protect households against the risk of catastrophic levels of expenditure on health and reduce barriers to health service use while promoting equitable distribution of public expenditures. Massive scale up and expansion of the current national health insurance program to include more groups of people especially the poor and other vulnerable groups remains the most critical ingredient needed for Nigeria to achieve UHC.
The key question however is this one: what must we do right as a nation in order to achieve the much needed comprehensive health care coverage to those that need it the most?
First of all, Nigeria as a nation must make health care provision a priority by increasing the budgetary allocation to the health sector from the present 6.4 % to globally accepted standards and declarations particularly the 2000 Abuja Declaration which requires all African nations to allocate at least 15% of their budget on health; this will go a long way in expanding the health care space through the provision of funds needed to provide essential quality health care to the populace. The country must also show greater political commitment to the health sector by passing the National Health Bill which will serve as a viable framework to provide for the regulation, development and management of the national health system and set standards for rendering health services in the federation.
Health is a long sought-after developmental objective expressed in all known theories of social justice and equality. As a result it should be a right and not a privilege. This requires that health insurance is made compulsory at all levels of the federation. Even though it is germane to note that health insurance is not free. Indeed, it involves a pre-payment plan where participants pay a regular fixed amount. This money is pooled allowing the providers of insurance to pay all those needing care. In a country like Nigeria where over 70% of the populace still live below the poverty line per day, it becomes difficult for countless individuals to be able to meet up with the pre-payment plan of the scheme. This necessitates the need for devising effective poverty friendly health care plans that will cater for the majority of the populace.
The financial viability of the National Health Insurance Scheme is a crucial determinant of the sustainability or otherwise of the entire health insurance process. There is therefore the need for the scheme to look away from the present singular source of funding where it is totally reliant on contributions from the Federal government, to more sustainable and viable options of financing. However, for the scheme to be able to do this, there is need for the speedy passage of the revised bill National Health Insurance Commission Act, 2011. This will empower the scheme to serve as an independent agency capable of raising its own resources via innovative financing mechanisms. In addition, it will aid in overcoming the heavy administrative bottlenecks that exists with the current arrangement.
This fiscal space can be expanded through cost reductions, synergy effects and improvements in efficiency so as to minimize duplication and increase the cost effectiveness of services provided. Multiple pathways like the establishment of a Health Insurance Trust Fund, charging interests on dormant accounts in the banks; new borrowings from global financial institutions with friendly interest rates and an Airline levy can be explored as avenues for expanding the fiscal space among others. Other avenues include harnessing private sector contribution and maximizing donor aid effectively as well as the health Insurance lottery. For a country like ours where corruption is rampant, repatriation of looted funds into the health insurance fund to finance health care for all Nigerians may be another avenue of raising funds.
In addition, the national health insurance system in the country should be more inclusive; it should synergize with other actors not under its direct authority particularly the informal sector, civil society and the private health sector players. This will help to identify innovative ways to address bottlenecks that limit access to care for all Nigerians.
There is also the need for a much broader spectrum of approaches within the whole health system to promote a culture of innovation and reward for hard work and performance. This should be complemented by strong monitoring and evaluation capacities that facilitate rapid dissemination of lessons and scale up of successful strategies. It is clear that Nigeria cannot achieve UHC by 2015 but if we begin to take action on these recommendations, we will significantly improve access to healthcare for many Nigerians. Only then stories like the one of Bisi’s family will become a thing of the past.
Kurfi Abubakar Muhammed, MD, MPH is a medical doctor working with the National Health Insurance Scheme in the North West Zonal Office Kaduna
NB. All views expressed here are entirely mine and not that of the National Health Insurance Scheme
Grateful to Dr Biodun Awosusi and Dr Usman Sanusi Gwarzo for their review and inputs into this write up.