Some Little Thoughts on Universal Health Coverage (UHC) in Nigeria

Having served in the Health System Strengthening sub-sector for some years before I recently had to step aside to take charge of Public-Private Partnership in my new station, I warmly welcomed the gentle thoughts about healthcare delivery that greeted my mind early this morning. 

How could we have expected to have ‘Health for All by the Year 2000’ in Nigeria with insufficient and dysfunctional Primary Health Care Centres? How can we expect to have available, accessible, and affordable healthcare when agencies charged with the mandate of ensuring physical access and financial access to healthcare are under-performing? How can we expect to have Universal Health Coverage (UHC) with the absence of synergy between the National Primary Health Care Development Agency (NPHCDA) and the National Health Insurance Scheme (NHIS)? How can we expect to have Universal Health Coverage with weak collaborations and partnerships between the national and sub-national levels, between the public sector and private sector (for-profit and not-for-profit), between Governments and communities, and between the health sector and other sectors? Even with UHC, how can we expect to have good health outcomes on a sustainable basis with little attention being paid to preventive health through provision of good water, sanitation, environment, nutrition, education, roads, etc?

Based on the 1988, 2004, and 2016 National Health Policy Documents, primary health care remains the bedrock and central focus of Nigeria’s healthcare system development. Important agencies such as the NPHCDA and the NHIS that are crucial for physical and financial access to health care are certainly due for reform. Some questions should begin to agitate our minds towards reforms that will enable things to be done differently to achieve different sets of better results: Do we really need Health Maintenance Organizations (HMOs) for our health insurance? Can we copy and adapt the health insurance models of some countries – especially Asian countries – that are not built around HMOs but have (almost) achieved Universal Health Coverage? How about a hybrid system whereby we still retain HMOs for secondary and tertiary care but remove primary care from the hands of HMOs? Or can we have social HMOs joining hands with and consolidating social healthcare providers?

Going down memory lane and reflecting on the current unwholesome situation of the nation’s healthcare with particular reference to the two agencies (NHIS and NPHCDA), one would observe that the situation is not acceptable. For instance, according to the National Health Policy (2016), “Less than 5% of the Nigerian population is currently covered by any form of prepayment schemes, such as health insurance. Only Federal Government workers are currently enrolled in social health insurance and civil servants from most states are yet to be enrolled.”

I believe that well-meaning leaders and individuals are capable of taking remedial actions and stopping predators in and around the agencies who can never change their carnivorous nature and who have been devouring all kinds of preys in the public sector jungles. We need as a matter of urgency to salvage our health care system, particularly the NHIS, from the claws of the predators and ambulance it out of the jungle. NOW is the auspicious period to do so, knowing that 50% of the Basic Health Care Provision Fund (BHCPF) from the Federal Government’s Consolidated Revenue Fund, international donor contributions, and other sources has been set aside by law for the NHIS to administer. The efforts of health sector stakeholders, the leadership of the Federal Ministry of Health (FMOH), as well as decision-makers in the executive and legislature which led to the enactment and signing into law of the National Health Act 2014 have been severally commended and still remains commendable. The Act prescribes, among others, the establishment of the Basic Health Care Provision Fund, 50% of which goes to the NHIS, 45% to the NPHCDA, and 5% for emergency medical treatment to be administered by a Committee which shall be appointed by the National Council on Health.

However, I am of the view that there is a need for urgent amendment of the National Health Act 2014 with respect to the disbursement of the Basic Health Care Provision Fund. Against the background of the fact that majority of Nigerians that are currently not covered by health insurance are informal sector employers, employees, and others who are largely rural dwellers, we need to tweak the Act to accommodate the private sector as major beneficiaries through dedication of a certain percentage of the Fund as soft loans to new and existing private-for-profit rural healthcare providers. These private providers may opt to go it alone or enter into public-private partnership agreements. Private-not-for-profit organizations such as Non-Governmental Organizations (NGOs), Community-Based Organizations (CBOs), Faith-Based Organizations (FBOs), Philanthropies, and Foundations should also be encouraged to establish and provide rural healthcare services on their own or through public-private partnerships (PPP). The private sector is undoubtedly stricter in management of men, money, materials, and methods than the public sector. The common incidence of absentee health workers and a number of other sharp practices in public health facilities, especially those in rural and hard-to-reach areas, cannot be condoned by the private sector. The sector has some values which government institutions at all levels can leverage on through partnerships. With public-private partnership arrangements, Government and partners should be able to balance their social and profit objectives to deliver effective, efficient, accessible, equitable, affordable, acceptable, and quality health care services.

In addition to the extant provision in the Act for disbursement of NPHCDA’s 45% share of the BHCPF exclusively to eligible States, Federal Capital Territory, Local Government and Area Council Health Authorities, all of which are public sector institutions, there should be an amendment to the Act to the effect that the NPHCDA and the NHIS will enter into a tripartite agreement with the Bank of Industry (BOI) through which eligible private sector operators with commercial orientation can access a certain percentage of the 45% that may be set aside. The BOI has the expertise, experience, and pedigree for effective and efficient management of venture capital funds. The NHIS will be expected to provide ‘health insurance lives’ and capitation to eligible and duly-accredited providers that are delivering rural healthcare services under this arrangement.

We really need to bring health care closer to the people and promote utilization of same. We must build and strengthen a new regime of shared goals, joint actions, and collective responsibilities between the NHIS and the NPHCDA towards achieving UHC. Both agencies cannot afford to operate in silos. What exactly is the benefit of new and existing pool of funds accruable and available to the NHIS for the provision of basic minimum package of health services to citizens if health care providers and services are not available and accessible within easy reach? What precisely is the benefit of health care facilities, equipment, personnel, drugs, consumables, and services made available to the public if the majority that are poor, weak and vulnerable do not have the means and the safety nets to access and utilize them? What indeed is the benefit of an elephant that is available for meat and protein without the availability of knife to cut it up and fire to cook or roast the meat, other than its carcass will become food for carnivorous animals and vultures? And as far as the public space is concerned, there are such ‘animals’ and ‘vultures’ around the corner.

Here now is a clarion call to the Presidency, the National Assembly, the FMOH, the NHIS, the NPHCDA, and other stakeholders: Let us all work together cooperatively, collaboratively, and patriotically to bring about necessary reforms towards achieving Universal Health Coverage in Nigeria!

Mobolaji Lateef OLADEJO