Nigeria: National Health Dialogue - 'Nine Reasons Nigeria May Not Achieve Universal Health Coverage By 2030'

A panel discussion at the National Health Dialogue
16 October 2019

A former Executive Secretary of the NHIS, Nigeria's health insurance agency has listed nine impediments to the quest for achieving Universal Health Coverage (UHC) in Africa's most populous nation.

While delivering his keynote speech at the national health dialogue which commenced on Tuesday, Muhammad Dogo said Nigeria is "already off track" in its quest to attain UHC by 2030.

He however, made recommendations which can make the country achieve the target.

The two-day health dialogue, now in its second edition, arose from the need for home-grown solutions, innovations and political commitments to bridge funding gaps in achieving UHC in Nigeria.

The annual event is organised by PREMIUM TIMES, the PTCIJ and their partners.

Even though Nigeria is among African nation's that subscribed to achieving UHC by 2030, about 145 women of childbearing age and 2,300 children under 5 years of age die daily in the country.

UHC which entails providing effective access -- including financial risk protection -- to at least essential healthcare for even the poorest and the most vulnerable population, is key to achieving the world's Sustainable Development Goals (SDG).

It is the central target of the SDG 3, one of the 17 goals set by the United Nations General Assembly in 2015 for the year 2030.

Achieving Targets of SDG 3 includes ending preventable deaths of newborns and children under five years of age by 2030.

'Nigeria is off track'

In his keynote address, the former NHIS boss listed the nine constraints to attaining UHC by 2030

· Constitutional Bottlenecks

Mr Dogo said the three tiers of governance in the country pose a serious bottleneck for the easy "cascading of policies and interventions" that will drive UHC.

He said the Nigerian constitution was not specific on who is directly responsible for health in the three tiers of government.

Under the Nigerian constitution, education is on the concurrent legislative list where both the federal and state governments share legislative powers.

There have been arguments between federal and state government over who is directly responsible for healthcare.

"Until recently when agencies of government at the federal level are having their state counterparts working in synergy, we may not achieve UHC," Mr Dogo said.

He said the legal provisions that should guide the various health policies and interventions have to be reviewed.

"In particular the Nigeria Constitution does not define the place of health in either concurrent or the exclusive list. Thus, the issues of health are not having strong constitutional backing.

"This gives way to the 3 tiers of government not adhering to declarations relating to the 2001 Abuja Declaration for the allocation of 15 per cent of the annual budget to health which has never been attained eighteen years after. Even the annual budgetary allocations for health across the 3 tiers of government are inadequately cash-backed."

· Weak Funding Model

The health expert said the funding models, as they are now, have failed to give support to the health system that could "work for us".

"Thus, the health system has remained very weak over the years. Currently Out-of-Pocket (OOP) contributes around 72.8 per cent with attendant consequences to households as in many cases it pushes families into poverty. Budgetary allocations as earlier discussed are inadequate ie the federal government allocated only 3.8 per cent to health in 2018.

"The health insurance which should collect contributions, pool, and purchase services stands at around 5 per cent. Another model being donations from international development partners are unpredictable, uncoordinated and there is high administrative cost. Additionally, there is donor fatigue."

· Population Overgrowth

Several estimates, including of the National Population Commission pitched Nigeria's population at about 200 million, a number expected to double in less than 25 years.

Mr Dogo identified population overgrowth as a major impairment to the country's economic growth and inability to provide achieve UHC.

He said this is among reasons for the country's grim health indices, including high maternal and child deaths and HIV/AIDS prevalence.

Family planning (FP), which according to health experts is the only watershed to slow down the bulge is frustrated by several other issues, poor funding.

· Unreliable, inadequate data

The health expert said the large informal sector which constitutes 80 per cent of the population is not properly captured statistically.

"It is the sector with the highest disease burden, low financial capacity; it lacks basic social amenities and low literacy rate," he noted.

· High leadership turnover

Mr Dogo said the high turnover of leadership in the country does not allow for development of programs and polices initiated.

He used the NHIS to cite as an example of a critical agency in the health sector with high leadership turnover.

The NHIS leadership seat appears too hot for anyone to sit on since the inception of the scheme almost a decade and a half ago.

Between 2012 when Mr Dogo left the scheme and 2019, the NHIS has had seven executive secretaries - both acting and substantive heads - with the new appointee being the eighth.

· Corruption

The health expert said corruption is the common denominator that is not just stifling the country's quest for UHC but a cankerworm disrupting "our journey as a nation towards greatness."

· Poor policy Implementation

He also said various policies and programs that would have helped in achieving UHC is mostly are not being implemented.

· Industrial strikes

"Skewed remunerations and professional rivalry over the years have dealt a serious blow to the quality of healthcare in most of our public health facilities in particular and has eroded the confidence of our people.

"Even though the country is churning out large numbers of health professionals, the hostile health environment has encouraged brain drain of the needed human resource for health with its attendant consequences.

"For the few privileged ones amongst us who have the financial muscle to flex, have resorted to health tourism to other countries in the Middle East, Indian subcontinent and Europe or the Americas," he noted.

· Poor/weak intra- and inter-ministerial collaborations

Mr Dogo said this is another area that requires serious attention.

"There are many areas in governance that have direct or indirect relationship with health issues. Let us look at the Ministry of Water Resources and Sanitation. Diarrheal diseases are 60 per cent water-born or all helminthic infestations related with soil.

"Proper drainage of water will address the breeding place of mosquitoes. Proper disposal of domestic (human) and industrial waste could drastically crush the incidence of many communicable diseases or poisoning.

"The Ministry of Finance and National Budget Planning must know the importance of ensuring timely release budgeted monies for the health ministry. Ministry of Agriculture and Rural Development should know what the nutritional requirements of the nation."

'Hope'

Despite these challenges, the former official, however, expressed optimism that Nigeria can still, achieve UHC by 2030 "with the right commitment".

Jonathan Eke, a representative of NHIS executive secretary would later allude to Mr Dogo's expression of hope.

He also said despite the myriad of setbacks bedeviling the health sector, Nigeria can still, achieve UHC even in the next five years with the right political commitment.

"The template is already there with us in the NHIS," he said. "What is needed is a strong political commitment."

Mr Dogo also made nine recommendations on how that can be achieved.

Recommendations

1) Repeal the current NHIS Act 1999 and enact the NHIC Act 2019.

2) Political will/commitment

3) Increase funding by attaining 15 per cent budgetary allocation by the three tiers of government, earmark mobile phone levy and other innovative ways of financing

4) Stabilise the leadership sourcing of CEOs through Due Process

5) Create more public awareness

6) Strengthen the health system through upgrading facilities, improving the welfare of human resource for health

7) Improve the purchasing power of the populace through human capital development and entrepreneurship.

8) Look at other non-health issues that have bearing on health through improving intra- and inter-ministerial collaboration

9) Monitoring and Evaluation to capture quality data for health and assess the impact of interventions and outcomes.

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