Will Nigeria still achieve Universal Health Coverage (UHC) by 2030?
This is one big question hundreds of participants from Nigeria and abroad took away with them after two days of spirited discussion of the future of health care in Africa’s most populous nation.
At the 2019 National Health Dialogue, the call for Nigeria to reinvigorate its quest for UHC rang out from the conference hall of Nicon Luxury Hotel in Abuja, where the annual event took place last Tuesday and Wednesday.
The dialogue was organised by PREMIUM TIMES, PTCIJ, dRPC-PACFaH@Scale, Nigerian Sovereign Investment Authority (NSIA), International Society for Media in Public Health (ISMPH), Project Pink Blue and the Nigerian Governors’ Forum (NGF).
The event witnessed “high and low moments” that will have implications on health delivery in Nigeria.
The highest moment perhaps was when Nigeria’s health minister, Osagie Ehanire, responded to a touching story of the painful battle against cancer shared by Serah Shimenenge Yugh, a breast cancer survivor.
The minister touched hearts when he announced a plan to institute a cancer treatment fund to reduce the financial burden of treating the terminal disease.
However, a long shadow loomed when Muhammad Dogo, the former Executive Secretary of the NHIS – Nigeria’s health insurance agency, in his keynote speech said the country is “already off track” in its quest to attain UHC by 2030.
At that moment, the upbeat mood was immediately interrupted by the urgency of seeking ways to tackle the numerous drawbacks to meeting the 2030 target.
The Quest for UHC by 2030
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 SDG 3, one of the 17 goals set by the United Nations General Assembly in 2015 for the year 2030.
Targets of SDG 3 includes ending preventable deaths of newborns and children under five years of age by 2030.
Even though Nigeria is among African nations that committed to achieving UHC by 2030, about 145 women of childbearing age and 2,300 children under 5 years of age still die daily in the country.
The 2019 National Health Dialogue arose from the need for home-grown solutions, innovations and political commitments to bridge funding gaps in achieving UHC in Nigeria.
It could not have come at a better time than the week after President Muhammadu Buhari presented the 2020 budget proposal to the National Assembly for consideration.
From an aggregate expenditure of N10.33 trillion, President Buhari proposed N46 billion for health – almost six times less than N262 billion for Works and Housing for capital expenditure.
President Buhari’s latest spending plan for the health sector fell short of the N71.1 billion and N51.1billion proposed in 2018 and 2019 for capital expenditure.
More worrisome, however, is whether the funds will be released on time.
Health experts have repeatedly decried the late or non-release of the paltry allocations for health, a situation they blamed for Nigeria’s grim health indices.
They asked the National Assembly to ensure early passage and release of the 2020 budgetary allocation.
Unfortunately, lawmakers were conspicuously absent at the dialogue even though they were invited.
Here are some of the talking points at the dialogue.
‘Nigeria is off-track’
“Nigeria is already off track”, Mr Dogo had told the audience while giving his keynote address on Tuesday.
He then listed nine constraints to attaining UHC by 2030.
They include constitutional bottlenecks; population overgrowth; unreliable, inadequate data; high leadership turnover; poor policy implementation; corruption; poor/weak intra- and inter-ministerial collaborations; industrial strikes and; weak funding model.
The former NHIS boss said until President Buhari’s signs the 2019 NHIS bill, UHC might continue to be a “mirage”.
Mr Buhari, who had acknowledged the need to address Nigeria’s gross out-of-pocket spending on health, is yet to sign a bill proposing to make health insurance compulsory.
The bill has been on his table since June after the 8th National Assembly passed it.
A mandatory health insurance programme will rescue Nigerians from out-of-pocket spending on healthcare.
Over 70 per cent of Nigerians still pay out-of-pocket for care and this negates the principles of UHC.
Special honours for Stella Adadevoh
In his welcome address, the frontline journalist said her heroic deed should be emulated in the drive towards UHC in Nigeria.
Mrs Adadevoh was the lead consultant physician and endocrinologist at a private hospital in Lagos when an Ebola patient arrived in the country from Liberia.
The medic and three of her colleagues contracted the dreaded virus while treating the patient, and ensuring he did not leave the hospital.
Their efforts helped stop the virus from spreading in heavily populated Lagos.
Mr Olorunyomi said her birthday is October 21 and charged Nigerian to celebrate her.
He said an online petition had started in honour of Ms Adadevoh. He said PREMIUM TIMES has subscribed to the petition, urging everyone to do so too.
Presenting a paper, Chiedo Nwankwo saw a bright light in Nigeria’s gloomy health sector in the heroic sacrifices of health workers such as Ms Adadevoh.
A short video documentary was also presented in honour of the late medic.
Health Insurance: Learning from Successes and Failures of other African Countries
One country’s success story is another’s gain, just as one country’s loss is another’s lesson.
The dialogue heard both setbacks and success stories in the implementation of health insurance – a major driver for UHC – from officials from Ghana and Kenya.
Nigeria and Ghana both launched health insurance, NHIS, in 2005.
While Ghana’s scheme has covered over 50 per cent of its population, Nigeria has achieved five per cent coverage of mostly the informal sector – civil servants and corporate workers in the private sector.
Lydia Dsane-Selby, the CEO of Ghana NHIS, shared how her country introduced a Mobile-based Renewal Application System for the scheme in June.
The system allows enrollees to renew their membership from anywhere with the aid of mobile wallet-enabled phones.
She said the Ghanian government introduced a biometric ID card which is used to identify active members of the scheme.
The official said the enrolment card enables users to access public services.
Mrs Dsane-Selby also explained how the West African country has been raising domestic resources for UHC for the past decade.
“Everybody in Ghana should enrol. That is our plan but coverage is still a challenge we are facing”, she noted.
The official said a majority of enrollees can access their plan through their mobile phones at home. She, however, said authentication and verification is also another challenge.
She alluded to funding challenges, a situation she said “is tempting her scheme to dip hands into the ‘government’s pot’.”
Inadequate data remains one of the universal challenges of health insurance, according to Beatrice Gatumia, the UHC lead, AMREF in Kenya.
She said the situation is frustrating the drive for coverage of health insurance in the informal sector of the East African country.
She said the right data will empower people more to demand adequate health services.
“With data, you will know how deep is the insurance coverage and what you can obtain when you are covered.”
Mrs Gatumia stressed the need for leveraging alternative sources of funds and leveraging technology.
She said Rwanda set a good example with their community health model by leveraging on technology to drive health insurance in rural areas.
Peculiarities in implementation of state health insurance
The health dialogue also presented an opportunity for states to share the peculiarities in the implementation of their various health insurance programme.
Heads of health insurance agencies in Anambra; Osun; Delta; Bauchi and Kano sat on the panel to discuss their experiences and challenges in implementation.
The failure of the NHIS to deliver heralded the quest for the establishment of State Health Insurance Schemes (SHIS).
Experts believe SHIS offers each state a more feasible platform to take health insurance to the last citizen.
One peculiarity in the setup of SHIS in different states is the premium to be paid by enrollees.
In Lagos for instance, a single enrollee will pay N8,500, but in Niger state, a beneficiary is billed N7,200 annually for the informal sector. In the formal sector, 25 per cent of the monthly salary will be deducted at source.
The SHIS Executive Secretary in Anambra, Simeon Onyemachi, said the state is using “the adoption model”, which encourages philanthropists to pay for the health of their community members and relations.
“As I speak to you, a philanthropist in Anambra has made payments covering 1,000 people in his community,” Mr Onyemeachi said.
He said the law guiding the scheme makes health insurance mandatory in the state because 90 per cent of the citizens are in the informal sector where the use of the “adoption model” boosted coverage.
“Just in less than 10 months, over 70,000 people have already keyed into Anambra state health insurance scheme,” he said.
Others took turns to share the experiences of their states.
In sum, however, the officials alluded to the need for nationwide awareness, especially in the informal sector.
‘Rays of Hope’ for UHC 2030
Despite the long shadow cast by a multitude of challenges on the health sector, the national health dialogue saw ‘rays of hope’ in the quest for UHC by 2030.
“With the right commitment, Nigeria can still, achieve UHC by 2030”, said Mr Dogo, the former NHIS boss.
Jonathan Eke, a representative of NHIS executive secretary, said despite the setbacks to the health sector – especially. the NHIS, Nigeria can even achieve UHC 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.
They among others include a repeal of the current NHIS Act with the NHIC Act 2019 and improved political will and commitment.
The Managing Director, Nigeria Sovereign Investment Authority (NSIA), Uche Orji, in his presentation, also said UHC is still achievable in Nigeria. He, however, stressed that government and private individuals need to work together to revive the health sector.
Impact: Hope for Cancer patients
The panel on “Cancer control in Nigeria” was arguably the most impactful out of the eight in the two days of the dialogue.
This was largely spurred by the touching story of a painful battle against cancer.
Ms Yugh, a breast cancer survivor, shared how she battled with the debilitating ailment without even a free or subsidized cancer screening.
She said many cancer sufferers die needlessly because their conditions were mostly not diagnosed on time.
Over 40, 000 Nigerians die yearly from cancer, according to the World Health Organisation.
Ms Yugh appealed to the government to at least make cancer screening free.
Responding, the health minister said the government will soon roll out a cancer treatment fund to reduce the cost burden of treatment on sufferers.
“There will be a creation of a fund, either a cancer treatment fund or whatever we decide to call it. It is important and can be driven by investment or donation,” the minister said.
“It can be driven by any method that takes you beyond the point where health insurance cannot cover any more in your treatment.”
Conversations in this panel also resonated advocacies for free cancer screening and inclusion of cancer treatment in the BHCPF.
Even before the National Health Dialogue ended, everyone was already looking towards how to advance the conversations initiated.
On behalf of the organisers, Tobi Oluwatola presented a rough draft of the communique from the event which was intended to be shared with the National Assembly.
There are 15 recommendations in the communique. They include:
1. Increased budgetary allocation to healthcare with the intent of attaining UHC by 2030.
2. Decentralization of the NHIS to improve its functionality and bridge inequality in access to healthcare.
3. Additional funding for the Implementation of the Basic Healthcare Provision Fund (BHCPF) to also cover cancer.
4. Increased capacity building health workers in identifying simple cancer signs and symptoms in other to attend to patients.
5. Free cancer screening and subsidized rates for cancer drugs and treatment such that even the poor can afford without any financial implication.
6. Create advocacy around the causes of cancer and the Basic Health Care fund provisions to cancer patients.
Indeed, the 2019 National Health Dialogue did not just set the stage, it raised the standard for pursuing Nigeria’s UHC goal and everybody has a role to play.