At a forum to x-ray the crisis bedeviling the health sector, stakeholders say nothing will improve if Nigeria fails to actualise the dream of Universal Healthcare Coverage (UHC) for its citizens, reports Moses Emorinken
It was promoted to spark a lively debate among citizens on how to achieve the dream of Universal Healthcare Coverage (UHC) in the country, and the gathering lived up to its billing.
At the national health dialogue organised by Premium Times with the theme: “Universal health coverage: The role of state and non-state actors in healthcare funding and support”, stakeholders agreed that no nation could attain greatness or prosperity if it did not prioritise health.
According to the World Health Organisation (WHO), UHC means that all people and communities can access promotive, preventive, curative, rehabilitative and palliative health services they need in sufficient quality without being exposed to financial hardships. The target for the provision of UHC for everyone is 2030. With the majority of Nigerians, especially the vulnerable and underserved, unable to access and afford qualitative healthcare services without huge impact on their personal finances, is the target date feasible?
Fifty years after independence, WHO still ranks Nigeria as 187th out of 191 countries in health efficiency, only ahead of Democratic Republic of Congo, Central Africa Republic, Myanmar and Sierra Leone. Is Nigeria going to walk the road of unfulfilled health targets like the case of the ‘health for all around the globe by 2000,’ which Nigeria also committed to in 1978? Or the Millennium Development Goals (MDGs) that equally proved elusive? Or the now more elaborate Sustainable Development Goals (SDGs) by 2030?
Sadly, the National Health Insurance Scheme (NHIS) has not been able to cover more than 70 per cent of Nigerians. In many parts of the world, health insurance has become a vehicle for expanding access with financial protection and improving the quality of care with efficiency. That was the dream when NHIS was launched in Nigeria in 2005, with a mandate for the scheme to achieve UHC within a space of 10 years. However, 14 years after, the country is still struggling with around five per cent coverage. Critics blame the failure of NHIS on the clause that failed to make enrolment mandatory. Can the citizens still trust NHIS to take them to the promise land of achieving UHC by 2030?
According to NHIS Executive Secretary (ES), Prof. Muhammed Sambo, the scheme is set to achieve the dream. “I don’t just believe that UHC is achievable in 2030; I believe we can achieve it in the next five years because we have got the structure on ground. What we have in the data base now is well between three and four million. Within the last two years, we were almost getting two million extra people covered under health insurance from the states. Delta State is almost 650,000 within a space of two years; Kano is over 370,000 and so on. It means that the future of UHC through insurance lies with the states. For this to happen, we need political commitment at the level of the states, though we are still talking of the formal sector,” he said.
Represented by Dr. Jonathan Eke, the NHIS boss explained that the scheme has decentralised implementation of health insurance to states because the constitution of Nigeria has not placed a priority on health, since the NHIS law, which is supposed to be the driver towards achieving UHC, is essentially voluntary.
“We see the high informality of the economy. Looking at that, we realise that it is impossible for NHIS to sit and say we can achieve UHC. To tap into those weaknesses, we had to go to the states. So, in 2015, we were able to midwife the creation of what we call state health insurance initiatives. What we want to attain is for them to drive that UHC vision of NHIS. NHIS has started to do what we call integration, regulatory, and the function of promoting health insurance, while the states will be the implementers of health insurance in the country.”
How it was done in Ghana
Explaining how Ghana leveraged domestic sources to fund UHC, National Health Insurance Scheme of Ghana Chief Eexcutive Officer, Dr. Lydia Dsane-Selby, said domestic funding through taxation played a pivotal role to the delivery of healthcare to many Ghanaians.
“Ghanaians were so agitated to get health coverage that it was easy for the government to introduce a small levy to pay for it, which was statutory earmarked. The government put 2.5 per cent value added tax (VAT) on all goods and services. Ghanaians were told that if they agreed to this, they would not have to pay in the hospitals, and the country agreed.
“The health insurance law was passed. That levy accounts for 70 to 75 per cent of the funding. The rest comes from 2.5 per cent on the pension contributions of formal sector workers, which accounts for 20 per cent of our funding. The rest comes from premiums from the informal sector. The premiums are not actually determined; it is a token just for people to have a sense of responsibility towards the scheme. The bulk of the funding for health is tax-based. We have changed the law. It isn’t even a levy on VAT, but a straight tax, which has increased the funding, and Ghanaians have accepted it because they know they don’t have to pay at the point of service.”
According to her, enforcement is usually a challenge to improve coverage, even in Ghana. To this extent, the Ghanaian government made it compulsory to have an active NHIS card before being admitted to school. “We have also leveraged mobile technology to help people renew their health insurance cards and also help us capture the number of people in the scheme; this way, we also know their demographical characteristics. We need to find a way to make health a primary investment for our politicians and government. We must continue to demand this,” she said.
The poor state of things
According to the former ES of NHIS, Dr. Waziri Dogo Mohammed, health-related SDGs item number three, which seeks to achieve good health and well-being for all, is difficult to achieve in Nigeria by 2030. He cited the targets and indicators.
“By 2030, maternal mortality should be reduced to less than 70 per 100,000 live births. Nigeria has 580 deaths per 100,000 live births. The country loses 145 women of child bearing age daily. By 2030, under five mortality should be 25 per 1,000 live births. In 2013, it was 128 deaths per 1000 live births. The country loses 2,300 under five daily.
“Malaria poses a serious health challenge with 60 per cent of outpatient attendance to health facilities and is responsible for 30 per cent of childhood mortality and 11 per cent of maternal deaths. The life expectancy of the country is 55 as compared to 64 and 72 for Ghana and Egypt. Immunisation coverage, which should be 100 per cent, is only 25 per cent.
“By 2030, to achieve UHC, including financial risk protection, access to quality healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all, is necessary. We don’t know the percentage coverage of the population. The health insurance coverage is less than five per cent. With such abysmal statistics, which are worse than the sub-Saharan Africa average, Nigeria is already off track towards achieving the health-related SDG number three. However, as the target date of 2030 is the same for the attainment of SDG goal and UHC, Nigeria has to brace up and pursue the attainment of UHC.”
What all this means, observers say, is that attainment of UHC in Nigeria by 2030 is near impossible.
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