REMOVING THE ROAD BLOCKS ON THE WAY TO ATTAINING GOOD QUALITY UNIVERSAL HEALTHCARE (UHC) IN NIGERIA
– A review of Senator Lanre Tejuosho’s Keynote Address, delivered at the Nigeria Health Summit on 27th April, 2018.
By Dr Femi Olugbile
On Thursday 27th April, 2018, an event that was tagged the Nigeria Health Summit took place in Lagos. Among the invitees were the Minister of Health for the Federal Republic (who was represented), and the Honourable Commissioner for Health for Lagos State. There were other major figures from Government and the Private Sector, including the leaders of major Health Maintenance Organisations (HMOs), the General Manager of the National Health Insurance System, CEOs of some major health facilities, and IT stakeholders, including IQVIA and iDokita.
The theme of the Health Summit was ‘Embrace the power of change to transform Health’.
The key discussion points included
• Closing the Health IT Gap: What does success look like?
• The collaborative partnership model to support the changing healthcare landscape
• How to improve the value and use of data to make informed healthcare decisions and
• The Missing Conversations: what Healthcare leaders should be discussing.
The atmosphere was set by the Chairman’s keynote speech which came midway through the proceedings. The Chairman was Senator (Dr) Lanre Tejuosho – the Chairman of the Senate Committee on Health.
By the end of his delivery, virtually everyone in the room was convinced that disruptive, epochal changes were about to happen in Nigerian Health, and it would no longer be business as usual.
Of course, as in all things Nigerian, between a stated commitment, even from the most powerful quarters, and the actual implementation of the desired end lay many unknowns and confounding variables. Still, the clear-headed identification of critical bottlenecks, and the apparent readiness to make major, necessary change happen struck a powerful cord. It was most unusual. It also provided justification for a close examination of a number of issues raised in his speech.
The Senator starts off his piece by reeling off some of the all-too-familiar doom-and-gloom statistics that reflect the parlous state of Health in Nigerian society.
• Little progress has been made in reducing Maternal and Child Mortality in the nation.
• Nigeria is the greatest contributor to maternal deaths worldwide.
• The rate of stunted growth among the children has increased from 42% in 2003 to 44% in 2016.
There is a state of emergency in health in Nigeria, he avers. And Nigeria cannot achieve the economic progress it aspires to without significantly improving the health of its people. The country spends less on Health as a percentage of GDP than most other LAMI (Lower and Middle Income) nations.
As its own contribution towards jump-starting the required transformation in Nigerian Health, the Senate, he says, will activate the implementation of the National Health Act by creating a budget provision for the Basic Healthcare Provision Fund (BHCPF) in the 2018 Budget. This is in furtherance of the implementation of the National Health Act which was signed into law in 2014, but which has not been substantially implemented to date.
The law requires that not less than 1% of the nation’s Consolidated Revenue Fund be allocated for the purpose of driving activities which are geared towards the provision of Universal Health Coverage (UHC).
UHC guarantees quality healthcare which is affordable and accessible for all citizens irrespective of their economic status. The present situation whereby access to healthcare is for most Nigerians (about seventy percent of cases) comes from out-of-pocket spending, and where many people are not able to afford the cost at the time they need the service, represents the very antithesis to the concept of UHC.
Continuing his pitch, Dr. Tejuosho indicated that the Senate is going to move to change the existing National Health Insurance (NHIS) legislation to make the possession of health insurance by citizens not voluntary but compulsory going forward. From the example of other nations that have achieved success in that area, Health Insurance only helps to achieve Universal Health Coverage if it is mandatory.
The Senator’s third game-changer is a simple tweak of the basic logic that has guided government funding of health services to date. A substantial part of government health expenditure is spent on government Health
Facilities – primary and tertiary for the federal government, secondary mostly for the States. In these establishments, the government pays for the inputs – the buildings, the staff, the equipment, the drugs and consumables. Suppose – instead of paying for inputs, the government chose instead to pay for outputs and outcomes – that is UCH, LUTH, or LASUTH, instead of getting ‘subventions’ in the current fashion, is funded by ‘reimbursement’ based on the services it has rendered over a unit time (number of Surgeries, Procedures, Consultations etc). Suppose also that government, instead of trying so hard and with so little success to provide most services by itself, turns itself into an enabler of service provision, encouraging the private sector to thrive and to move in where services are sparse, and ‘buying’ services from them on behalf of the citizenry under Insurance or some other arrangement?
To round up his list of game- changers, the Senator reveals that the current regulatory law for Pharmacy in Nigeria which makes it impossible for non-pharmacists to invest substantially in retail pharmacy in the country will be repealed and a new one put in its place. This will make possible the injection of private sector capital to expand the pharmaceutical value chain. The logic, according to Tejuosho, is that Universal Health Coverage is unattainable without ready access of the masses to good quality affordable drugs.
The general logic and socially progressive merit of the Senator’s presentation is hard to fault in any one of the crucial areas where his committee has chosen to tweak the system.
However, because this is Nigeria, things may not be as straightforward as they may appear on first inspection.
The language of the legislation on Health Insurance, and the proposed changes to it, may suggest that it is an area of exclusive interest for the ‘federal’ government. However, some states – such as Lagos, Oyo, and Delta, have already passed laws establishing a system of Basic Health Insurance that is intended to cover all their citizens. At least on paper, the Lagos system is meant to be mandatory, already.
There are also already in existence several Health Management Organisations offering Social Health Insurance directly to the public, or to corporate bodies.
In the past even such exercises as running pilots of Community Based Health Insurance have been politicized and bastardised. Exercises have been run by ‘federal’ authorities in states without the State health authorities being fully in the picture, and have in the past been conduits for dispensing political favour by the party in ‘federal’ power.
The present structure and operations of the National Health Insurance Service itself will need to be substantially changed if it is to serve a useful regulatory role in an expanded mandatory health insurance system. The dangers of having a regulatory body that is also a custodian and dispenser of a huge treasure trove of money have become obvious from the recent dramatic events at the NHIS. The Legislature will need to move to create a separate, independent structure for the control of Insurance funds if the proposed system is to have any chance of working for the Universal Health Coverage for long-suffering Nigerian citizens. If this is not done, the organization will be an even more powerful magnet for carpetbaggers who will be inexorably drawn to it as ants are drawn to sugar.
The allocation of money for the Basic Healthcare (BHCPF) is clearly a welcome development. But it is not a panacea, and it brings with it its own challenges. Assuming that the Senate surmounts the howls of ‘Budget Padding’ that are bound to be raised once people discover that the N50 billion allocated for the purpose was not in the budget submitted to the Senate, the next issue would be how to ‘protect’ the Fund, and to ensure it serves the purpose for which it was meant – ie UHC – especially for the most vulnerable Nigerians?
By the provisions of the National Health Act, 50% of the fund should go to the NHIS, for the purpose of providing Basic Health Insurance for Nigerian. The exact mechanism and criteria are not spelt out. Will they be running ‘in parallel’ with the States, thereby wasting resources, or synchronizing with them? (the Act says:
‘50% of the Fund shall be used for the provision of basic minimum package of health services to citizens in eligible primary and secondary health care facilities through the National Health Insurance Scheme (NHIS)’.
Problematic loopholes for subjective choices such as ‘eligible primary and secondary health care facilities’ are already lying there, waiting to be exploited by mischievous administrators. Who decides? Where do the states come in?
Going further down the fractions, 20% of the fund is to be used for ‘essential drugs, vaccines and consumable for eligible primary health care facilities’.
This is to be disbursed by the National Primary Care Development Agency (NPHCDA), as is the 10% to be used for development of human resources for Primary Care.
Although the Act says the above funds are to be disbursed ‘through State…Primary Healthcare Boards for distribution to Local Government and Area Council Health Authorities’, the experience from the past is of an overweening bureaucracy trying to control and micro-manage everything out of Abuja.
The paradigm shift of beginning to focus on rewarding outputs and outcomes by paying ‘reimbursement’ instead of ‘subvention’ to government health facilities is an attractive notion. However, given the ‘civil service’ nature of recruitment, deployment and organization of human resources in virtually all of these government facilities, it will be a very hard sell indeed, and will be emphatically resisted by interest groups – including the professional Unions. What appears natural and guaranteed to maximize efficiency and quality in a private sector environment is almost unworkable in the ambience of a government facility.
Two things stand out from this quandary. The first is that even in the most deeply entrenched public health facility structure, an effort can still be made by government to introduce a funding system that is a mixture of subvention (at least to guarantee salaries!) and reimbursement.
The second point is that government more and more should see itself as a regulator and enabler, and should be less directly involved in the actual provision of services. It should encourage the private sector to have a presence everywhere, including currently underserved areas, instead of building ‘white elephant’ ‘hospitals it cannot man. It can then regulate the practice of these entities, and ‘buy’ services from them as and when needed for the generality of the public, whether this is through Insurance or ‘Direct Commissioning’. Incidentally, it is interesting to think how the morale of the public would be boosted if the government suddenly announced that, using a fraction of the money sitting idle in NHIS coffers in Abuja today, it would buy, through ‘Direct Commissioning’ two hundred kidney transplants from St Nicholas Hospital, five hundred Open Heart surgeries from LASUTH, five hundred each hip and knee surgeries from Enugu and Igbobi – all for clinically appropriate ‘indigent’ Nigerian citizens from all across the land. The medical, psychological and financial effects would be great – not only for the patients, but even more for the hospitals and specialists!
The logic of loosening the stranglehold of professionals over the business aspect of their professions in order to allow the ‘business’ side of healthcare to grow and thrive emphatically supports the Senate’s plan to allow more private money to be brought into Pharmacies. The same thinking should apply to hospitals, laboratories and diagnostic centres.
In conclusion, it is obvious that there are good developments afoot, and the sentiment of the generality of the healthcare stakeholders in Nigeria should be a guarded optimism in an area where, for too long, there has been little cause for cheer.
However, as is evident from the issues raised here, victory in this battle may only be the beginning of new battles that have to be fought, and won, in order to put in place for our long-suffering people a genuine and sustainable Universal Healthcare Coverage.
About the Author:
Dr Femi Olugbile FRCPsych FNIM
Former Permanent Secretary Lagos State Ministry of Health).
CMD LASUTH 2001-2010
CEO, SYNTHESIZ CONSULTANTS.
Chairman of IQVIA HCP Space Advisory Board.