By Dr Abdulkareem Kabir Masokano
The announcement of a high profile committee by President Muhammadu Buhari on September 6, 2021, to be headed by his Vice President, Prof. Yemi Osinbajo, to oversee reforms in Nigeria’s health sector, is a laudable and timely one. However, like most sectors in Nigeria, the health sector is, to put it mildly, in a state of stagnation that, with the existing structure and organisation, is practically impossible to make any headway despite the enormous potentials abound in the sector to the economy.
There are numerous angles to the problem bedevilling Nigeria’s fragile health sector. They include the collapse of the primary health care system, poor infrastructure, inter-professional rivalry, poor accountability, inefficient, limited health insurance coverage, etc. However, the single most important factor causing the apparent none progress of the sector is the absence of a robust, patient-centred health financing model. Every single one of the problems can be directly attributable to this.
Contrary to what many think, modern healthcare is too expensive to be offered for free anywhere in the world. Nigerians think other countries provide healthcare services almost free of charge to their citizens. Actually, these are products of either heavy government subsidies, strict universal taxation regimes, or compulsory insurance programs. Over the years, governments in Nigeria have gotten caught up with this delusion that they can offer free healthcare to their citizens from the little they generate of their internal and external revenues without any sustainable framework to ensure steady financing of such an important yet expensive sector.
The result of this thinking is the current problem of underutilisation of highly trained healthcare professionals across various tertiary hospitals in the country because of the unavailability of modern diagnostics and therapeutic equipment – all of which are very expensive to use and manage. For example, we have specialists across various surgical specialities with the necessary skills to perform highly technical surgical procedures like kidney transplants, open heart surgery and complex brain surgeries. However, the system is so designed that it cannot accommodate their expertise due to the unavailability of resources to sustain such programs. This leaves many Nigerian patients cumulatively spending billions on such medical procedures abroad, and Nigeria loses money tremendously.
Primary healthcare, the essential segment of any serious health system, is virtually non-existent in the country. This is not due to the absence of the structures. It’s because of the ‘internal’ brain drain within the levels of the existing health system. The primary healthcare centres are primarily under the care of the local governments in the country. Unfortunately, most of them cannot afford to employ the minimum required number of qualified doctors, nurses and other health workers who, by extension, are pulled by better-paying jobs available at the higher levels of the system. As a result, most of Nigeria’s primary health centres are manned by Community Health Extension Workers with minimal skills and expertise.
The National Health Insurance Scheme (NHIS), which is supposed to be the primary driver of universal health coverage in the country, is essentially running far below par due to the poorly regulated profit-driven model it is structured. According to various statistical sources, the NHIS covers less than 5% of all Nigerians (out of over 200 million people!). As a result, the vast majority of Nigerians resort to paying out-of-pocket to access specialised healthcare. With that proportion, the insurance pool can only generate a meagre sum of money.
Coupled with the profit-only motive that drives the Health Management Organisations (HMOs), one can only expect that the system cannot cover the comprehensive health needs of its enrollees, not to mention driving any meaningful growth in the sector. The state-run contributory health systems are even worse! They are fraught with inefficiencies, lack of transparency and corruption. And as far as I am concerned, they ought not to have been created as their creation only serves to decrease the pool and reach of the National Scheme.
From the preceding, it is evident that sustainable financing is the critical element missing in our health sector; the focal point of any meaningful health sector reform in the country should include improving it. The current model whereby health financing largely depends on what the governments generate from their dwindling revenue or generous donor agencies is not sustainable and cannot move the sector even an inch from its current state. Therefore, it is about time Nigeria’s policymakers look for other alternatives to fund our increasing healthcare needs, given our explosive population growth rate.
Accordingly, this high profile committee set up by Mr President should look into developing a comprehensive, sustainable, and transparent healthcare financing model that would cover every Nigerian’s most basic health needs. It should consider a complete overhaul of the country’s healthcare financing by the development of a hybrid health financing system at various levels of the healthcare system with varying blends of public, private and public-private partnership, through the creation of a compulsory basic healthcare taxation system to cover for a comprehensive healthcare financing at the primary level for all Nigerians regardless of socioeconomic class.
A comprehensive reform of the NHIS should supplement this to enforce the enrolment of all workers in the formal sector of the economy (public and private), cooperative organisations of the various non-formal entities of the economy like farmers, artisans, transport workers, among others. This will cover specialised healthcare across our tertiary and specialist hospitals, both public and private and broadening the insurance industry to include ethical health insurance systems like the Takaful system to increase inclusivity across the various demographics of the country.
The committee should also encourage creating windows for community-based contributory health safety nets to tap into the national health insurance pool to enable citizens from lower socioeconomic access to specialised healthcare at our tertiary health institutions.
Special funds can be set aside annually from the NHIS fund pool for research and development in our tertiary health institutions regarding funding for specialised healthcare services and preventive health. This should be enough to cover all the available infrastructure needed to procure, support and maintain modern diagnostic and therapeutic equipment.
The committee has qualified, world-class technocrats as members. It also has the Bill and Melinda Gates Foundation, Vesta healthcare partners, and WHO as observers. Thus, we are optimistic that it will develop a sustainable blueprint for health financing as the bedrock of their essential task. May the government implement the committee’s recommendation for the needed reforms in Nigeria’s fragile health sector.
Dr Abdulkareem Kabir Masokano is a resident Surgeon, ABUTH, Zaria. He can be reached via abdulkareemmsk@gmail.com.