In recent years, government policies in the Health sector (especially since 2018) have shown apparent commitment to revamping that sector. Such policies have included the launch of the Basic Health Care Provision Fund (BHCPF) through the allocation of 1% of the Consolidated Revenue Fund (CRF) in order to improve access to Primary Health Care (PHC), especially for low-income and vulnerable Nigerians; the Finance Act of 2021 which was introduced in early 2022 and imposes a ₦10 tax on each litre of sugar-sweetened beverages (from which, if the government consents to the yearnings of some civil society organisations, some funds are expected to go towards health financing); the establishment of the National Health Insurance Authority (NHIA) through the NHIA Act of 2022 which makes health insurance mandatory for all citizens and legal residents and the National Mental Health Act 2021 (signed into law in January 2023), which redefines mental health and addresses discrimination against mental health patients.
Will the 2023 health budget make any difference?
More recently, allocation to Health in the 2023 budget proposal has been lauded as the biggest yet in the history of the nation, with N1.17 trillion (5.75%) earmarked for the sector out of a total budget of N20.5 trillion for the fiscal year. This is a remarkable increase from the N547 billion and N826.9 billion allocated to it in 2021 and 2022 respectively. Although the 5.75% allocated to health in the proposed budget is an increase from the 4.7% allocated in 2022, advocacy groups have claimed this does not call for much applause.
First, it does not meet the 15% target agreed in the Abuja Declaration -meeting in Abuja in April 2021, African heads of state and governments under the aegis of African Union (AU) had committed to dedicating a minimum of 15% of their annual national budgets to the health sector. This was meant to address the deficient health systems in most African countries. While countries like Rwanda and South Africa have been able to commit 15% of their total budgets to health, Nigeria has been unable to achieve this target in the past 15 years.
Second, it has been argued that the Nigerian government cannot afford to finance its 2023 budget at this time and may have to borrow, a step which might worsen the fiscal health of the nation.
Third, going by precedents, actual spending may be a far cry from the 1.17 trillion proposed for the health sector, as funds could be delayed and remain unutilized. For instance, in 2021, the sum of N137 billion was allocated to the health capital budget, but N90 billion (66% of the allocation) was eventually released and only N54 billion was utilized from the released fund.
In the past 11 years, 72% of budgets in the health sector was spent to pay salaries and run offices. According to available statistics from the Budget Office , the Federal Government had allocated N3.5 trillion (N3,545,594,778,327) to the sector within that period, from which the Federal Ministry of Health got N2.9 trillion (N2,905,050,442,117) for recurrent expenditure and N640 billion (N640,544,336,209) for capital expenditure. While recurrent expenditure refers to funds for salaries, training of employees and the running of offices, capital expenditure is spent on physical projects, such as building and equipping new offices and other procurements.
Meanwhile, the Federal Ministry of Health’s capital budget for the period was approximately19% of its total budget. Yet, despite earmarking nearly 19% (N640,544,336,209), of the budget to capital projects, the government eventually released less than 80% of the capital funds.
In a recent publication, The Lancet sees public sector corruption in Nigeria as a concern which can affect the health of any nation and lead to brain drain. Quoting data from Transparency International, the publication states that Nigeria ranks 150 in a list of 180 countries culpable for public sector corruption (Transparency International’s recent data report shows that 44% of public service users in Nigeria paid a bribe in the previous 12 months).
The health sector is not healthy
It is against this backdrop that one can better understand the parlous state of many public-run health facilities in the country. Back in 2016, the then Minister of Health, Isaac Adewole, shocked many when he disclosed that no cancer machine worked in any of the nation’s hospitals. However, the situation may have improved slightly in recent times with the procurement of five cancer machines for some of the nation’s teaching hospitals and the National Hospital, Abuja, thereby bringing the total number of cancer treatment machines in the country to 13 (including machines owned by some private medical facilities).
Sadly, in a recent PUNCH interview, President of the Nigerian Cancer Society (NCS), Dr. Adamu Umar, revealed that many of the cancer treatment machines in government-owned facilities were either not functioning or did not have trained professionals to operate them. According to the PUNCH interview, Globocan (an online monitor of cancer incidence around the world) reported Nigeria had 211,052 cases of breast, prostate, cervical, colorectum, and Non-Hodgkin lymphoma cancers as at 2018.
The foregoing state of affairs also underscores the mass exodus of professionals in the health sector from Nigeria. According to reports, Nigeria lost an estimated 9,000 of its doctors to the United Kingdom, Canada and other countries between 2016 and 2018. Also, according to the General Medical Council, a public body which maintains the official register of medical practitioners within the United Kingdom, at least 3 Nigerian-trained doctors were licensed per day in the United Kingdom, from February 2 to March 15, 2023. In other words, 162 Nigerian-trained doctors were licensed to practise in the United Kingdom within 42 days, increasing the population of Nigerian-trained doctors practising in the UK from 10,824 to 10,986, in 6 weeks.
Regrettably, the dearth of quality healthcare in Nigeria is largely due to the aforementioned factors (especially the lack of top-notch health infrastructure and a continuous depletion of medical specialists, due to emigration). To some extent and among other reasons, this can be adduced for the upsurge in medical tourism from Nigeria. The balance of payment report released by the CBN in March 2022 recorded data showing that Nigerians spent $11.01 billion on health-related services, in foreign countries, between 2010 and 2020.
While some elite Nigerians can afford to embrace medical tourism, most Nigerians in the middle class patronize private medical facilities, while the options usually available to millions of poor Nigerians include government-owned medical facilities (where they are available) or self-medication. Many Nigerians do not have access to affordable quality healthcare. This explains the rise in the incidence of maternal and infant mortality in the country. Nigeria’s maternal mortality rate has been estimated at 34% of global maternal deaths, according to WHO. Nigeria has about 512 maternal mortalities per 100,000 births. Five of 1000 Nigerian women die while delivering their babies, while current Infant Mortality statistics according to the United Nations reveal an average of 54 newborns die for every 1,000 live births.
The need for effective health insurance implementation
Ultimately, while it seems there has been a re-awakening of political will to improve the health sector, there are still enough reasons for critics to be dissatisfied with the quantum of advances made in health policymaking. Effective policy implementation remains a major determinant to ensuring the success of health reforms in Nigeria. A major yardstick to measure the success of health reforms is in the accessibility of quality and affordable healthcare to millions at the Bottom of Pyramid (BoP) –the teeming numbers of Nigerians leaving below and at the curve of the minimum wage. This is where the Nigeria Health Insurance Authority (NHIA) and other stakeholders can make a difference in the implementation of the National Health Insurance Scheme (NHIS).
Health Insurance is one of the mechanisms for providing financial protection from the costs of healthcare services. This is a key driver of universal health coverage
The NHIA Act, which supersedes the previous NHIS legislation, was signed into law by President Muhammadu Buhari on Thursday, May 19, 2022. It mandates the National Health Insurance Agency (NHIA) to ensure that health insurance is made compulsory for every Nigerian and legal resident; to promote, regulate and integrate health insurance schemes in the country and improve and harness private sector participation in the provision of health care services. The ultimate goal of the NHIA act is to achieve Universal Health Coverage (UHC) for all Nigerians.
To achieve optimum coverage by bringing most Nigerians into the health insurance net, the NHIA has effectively delineated the scheme into three programmes: the Formal Sector Social Health Insurance Programme (FSSHIP) which consists mainly of employees in the organized private sector and public sector and their dependants (others include constituencies, retirees and NYSC members); health insurance programme for the Informal Sector Group which includes social health insurance for tertiary institutions and communities; and the Vulnerable Group Social Health Insurance Programme which is targeted at physically-challenged persons, prison inmates, pregnant women, children under the age of 5 and the aged.
Health insurance has been existing for 15 years in Nigeria and prior to the enactment of the NHIA act. However, its uptake still remains at a dismal low. According to available information, uptake of the NHIS is currently below 5%, while health insurance penetration in Ghana was estimated at 68.6% in 2021 and Rwanda is estimated to have 90% of its population enrolled in health insurance.
In Nigeria, most of those currently insured are either employees of institutions in the organized private sector and the federal government. This is the formal sector. Comparative uptake within the informal sector remains critically low and this could be due to a number of factors. First, awareness within that sector is low. Second, payment of requisite premium is a choice many low-income earners in Nigeria would rather not make, considering its opportunity cost, especially in a depressed economy where inflation is high and disposable income is low.
In order to increase uptake of the NHIS, the NHIA and other stakeholders must consider innovative approaches in the implementation process. These include
a.) Strengthening the mandate of NHIA by making health insurance a prerequisite to accessing certain public services and amenities (for instance, the National Identification Number has become a compulsory requirement for accessing many public services in Nigeria). This may require some policy adjustments such as an executive order.
b.) Enhancing more inter-agency collaborations such as partnering with the National Orientation Agency (NOA) to enlighten key segments and opinion leaders in the informal sector about the importance and benefits of health insurance –interest groups such as trade unions, professional groups, religious bodies and community associations can be co-opted into a campaign to increase participation in health insurance programmes tailored for the informal sector (including the Community-based Social Health Insurance Programme).
c.) Determining how technology can be leveraged in the deployment of health insurance in the country. This will require multi-sectoral engagement with the private sector, especially techpreneurs in finance, telecommunications, health, etc and may also require some interface with the Nigerian Communications Commission (NCC), the National Information Technology Development Agency (NITDA) and the Central Bank of Nigeria (CBN), among others
d.) Ensuring continuous inter-government interaction with state governments which have already established State Social Health Insurance Agencies (SSHIAs) in their states and non-government organizations (NGOs). NGOs can be partnered to share knowledge on what has been learnt so far, embark on further research to determine needs and gaps and co-create with current users and intended users of health insurance. Co-creation of field implementation programmes with current users and intended users will determine what exactly they want and when, where and how they can easily access it. After all, long-held assumptions on the dynamics of health insurance delivery for Nigerians may not be valid any more, due to recent sweeping changes in their socio-economic realities.
The proposed National Health Insurance Summit planned by NHIA for December 2022, but which was postponed for unknown reasons, may yet be a first step towards providing veritable opportunities for the agency to interact with stakeholders and kick-start formidable partnerships. Such partnerships will help actualize the objectives of the agency and ensure resounding outcomes of the NHIS.
Image Credits: Bryan Christensen & BBC / Anne Wittenberg & UNFPA / NHIA