THISDAY Summit: Road to Expanding Frontiers for Healthcare Financing

It is no longer news that Nigeria spends less on the health of its citizens than nearly every other country of the world, resulting in the poor health indices and high mortality rates currently recorded. Martins Ifijeh writes on the issues and why THISDAY Summit on Healthcare Financing Policy Dialogue will change the narrative

When health indices are discussed on global stages on a country-by-country basis, Nigeria often emerges one of the countries with the worst indices among key global health issues. The country sits comfortably among the 10 worst countries in the world with disease burdens.

For instance, Nigeria has the highest burden of malaria globally, with about 40 per cent of global malaria deaths occurring in the country and Democratic Republic of Congo alone. Not only that 90 per cent of Nigerians are at risk of it, it kills over 300,000 of them yearly, with 11 per cent of maternal deaths linked to it.

Nigeria is rated as the second worst country with maternal and child deaths globally, just second to India. In specifics, about 15 per cent of global maternal deaths occur in Nigeria alone, and the deaths of newborn babies in the country represents a quarter of the total number of deaths of children under five worldwide. In fact, a woman’s chance of dying from pregnancy or childbirth in Nigeria stands at one ratio 13, if indices from the World Health Organisation (WHO) is referenced.

Also, among other areas, Nigeria is the second worst recipient of malnutrition burden globally, just second to India.

A recent interview with THISDAY by the Chairman, Senate Committee on Health, Senator Lanre Tejuoso showed that about 11 million Nigerian children are stunted, with an estimated 2,000 of them dying every day due to the public health issue. Ironically, despite this high malnutrition burden, Nigeria ranks 37th among countries making efforts to end hunger and malnutrition, according to indications by Hunger and Nutrition Commitment Index – Africa (HANCI-Africa).

But while persons not-in-the-know may worry why Nigeria has such high healthcare issues despite the rich human and natural resources in the country, the reasons for the indexes are not far fetched. One of such is that the Nigerian government does not allocate enough resources to funding the health sector.

Low government spending on healthcare of Nigerians

The Nigerian government in fact allocates to healthcare one of the lowest amounts from its yearly budget compared to other sectors. This is despite the fact that no other sector can thrive in a country if the citizens are unhealthy.

The under-prioritisation of the health sector is so alarming that in 2016, total government health expenditure was N588 billion (US$2.2 billion) or 0.6 per cent of the Gross Domestic Product (GDP). This abysmally low figures translate to just $11 per capita which is well below regional and lower middle-income averages and a far cry from the recommended US$86 per capita required to deliver a limited set of key health services in a low and middle-income country like Nigeria.

But while the Nigerian government may be quick to say the current dwindling revenue from oil sales has significantly contributed to the deteriorating level of healthcare spending, history has shown that even when the country had a good economic time, investments in healthcare remained low, compared to other countries of similar economic status.

A statement by THISDAY Newspapers Board of Directors during the announcement of the Health Summit noted that Abuja in April 2001 hosted the Heads of State of member countries of the African Union, where they resolved to allocate 15 per cent of their annual budgets to improving their countries’ health sectors. But over the years, the Nigerian government has failed to meet its part of the declaration, resulting majorly in the poor health indices currently being experienced.

“The highest health allocation for Nigeria since the ‘Declaration’ was in 2012 where 5.95 per cent was allotted. In 2014 it allocated N216.40 billion to healthcare, representing 4.4 per cent. In 2015 it was N237 billion, which represents 5.5 per cent of the entire budget. Same with 2016 (4.23 per cent) and 2017 (4.16 per cent).”

“Already the trend has continued in the proposed 2018 annual budget of N8.6 trillion, with only N340.45 billion allocated to healthcare, representing 3.9 per cent,” the Board says.

Weak governance and poor accountability in the health sector

Apart from the low allocation to the health sector by the Nigerian government, another reason for the poor healthcare indices is because the health sector has continued to suffer from weak governance and poor accountability, across levels of governance.

Findings suggest the lower levels of governments in the country are not doing enough for the health sector: According to the 1999 constitution, health is on the concurrent list and as such all levels of government are meant to finance healthcare but this does not happen in reality rather most health spending happens at the federal level.

Latest data in the Nigeria National Health Accounts shows that 67 per cent, 26 per cent, and seven per cent of government health spending took place at the federal, state, and local levels respectively in 2016. Furthermore, unrealistic revenue projections and perennial delays in the approval of the budget at all levels of government further undermine the efficient allocation and implementation of the health sector budget.

The truth is that healthcare spending in Nigeria has been skewed towards curative care. The stated responsibilities of the three tiers of government in service delivery largely determines where health spending occurs rather than any national strategic health priorities and it is not unusual for most of the financing to be focused on secondary and tertiary hospital settings, with little focus on low-cost high-impact areas of prevention, public health, and primary health care.

Also, there is a glaring lack of ability to coordinate and consolidate information on health resources, the cost and use of health services, at all levels of government and across the various ministries, departments, and agencies (MDAs) responsible for the delivery of health services.

While the sector recognises the National Council on Health as a coordinating policy body, it only has an advisory role even then the ability of the Federal Ministry of Health to effectively oversee the sector as a whole is questionable in the absence of the right incentives and leverage mechanisms in a federation like Nigeria where states make their laws and policies.

Absence of public health financing dominated by out-of-pocket expenditure

In Nigeria, Out-Of-Pocket spending by Nigerians account for 75.2 per cent of total health expenditure – among the highest in the world.

In order to address this, the Nigerian government in 1999 established the National Health Insurance Scheme (NHIS) to complement government health financing, pool health risk, and provide greater financial protection to households. However, as of 2016, only 7.9 million people (about 4.2 per cent of the population) were covered – predominantly federal government civil servants and their dependents.

The way the NHIS is currently implemented reinforces existing regional fiscal and health outcome imbalances, failing to provide adequate financial risk protection to the poorest and sickest households.

Private sectors not fully harnessed to support health financial initiatives

The private sector is an important provider of healthcare in Nigeria with data showing that use of private providers for healthcare is high even among the poor. The Nigerian organised private sector can also be a huge source of support for the health sector. Until recently there was little opportunity to benefit from both the potential of the private health sector for service delivery or for the organised private sector. However this has changed with the emergence of the Healthcare Federation of Nigeria and the private sector Health Alliance of Nigeria.

Drop in development assistance for health

Nigeria’s strong economic growth a few years ago which led to the country being classified as a LMIC has resulted in Nigeria losing its eligibility criteria to benefit from funds that have supported the financing of several of Nigeria’s health financing activities including vaccines. The implication is that Nigeria’s future access to preferential terms for grants, concessional loans and debt relief will be severely limited.

Way forward

The above situations represent major reasons why health financing in Nigeria has remained a challenge, but with a policy dialogue between major healthcare stakeholders and the political class, the country can find a working model for resetting the healthcare system, which by extension will not only improve the health of the citizens, but will reduce mortality rate and increase life expectancy for Nigerians.

It is for this reason that THISDAY Newspapers is holding its first Summit on Healthcare Financing at the Musa Yar’Adua Conference Centre in Abuja this Tuesday by 10am, where major healthcare organisations/individuals and the political class in the country will meet under one roof to chart a way forward for a more improved healthcare financing model for a sustained investment in the provision of quality healthcare to the over 180 million Nigerians, especially in the area of highly cost effective interventions.

High powered members of the World Bank Group, Senate President Bukola Saraki, the Minister of Health, Professor Isaac Adewole; Chairman, Senate Committee on Health, Senator Lanre Tejuoso; Chair of Global Alliance for Vaccine and Immunisation (GAVI) & former Minister of Finance, Ngozi Okonjo Iweala, are among stakeholders expected to grace the Summit.

Among the World Bank chiefs expected at the summit are the Director, Health Nutrition Population of the World Bank Group, Washington, Olusoji Adeyi; the Country Director, World Bank Nigeria, Rachid Benmassoud; and CEO GAVI, Seth Berkley.

Others expected at the summit are the Chairman, Senate Committee on Health, Lanre Tejuosho; Managing Director, Shell Petroleum Development Company, Osagie Okunbor; President, Global Development Programme, Bill & Melinda Gates Foundation, Chris Elias; Minister of Health (State), Dr Osagie Ehanire; Chairman Senate Committee on Finance, Senator John Owan Enoh; Chairman House Committee on Primary healthcare Services, Hon Chike Okafor; and Chairman House Committee on Health institutions, Hon Jocelyn Betty Apiafi; among others.

The summit, themed “Moving Nigeria towards Universal Health Coverage through Appropriate Financing” aims to galvanise discussions on why the country should prioritise financing of the health sector as a bastion of human capital development critical for the achievement of the Economic and Growth Recovery Plan.