Lambo: Only Political Will Can Address Universal Health Coverage

Thirteen years after Nigeria launched its National Health Insurance Scheme, only four per cent of its populace has been enrolled under the scheme. Martins Ifijeh ran into a former Minister of Health, Prof. Eyitayo Lambo who birthed the scheme in 2005. In this exclusive interview, he spoke on how the absence of political will is fast killing universal health coverage in the country, among other sundry issues

We heard you were very pivotal to the commencement of NHIS in Nigeria. How did you make this a reality?
The first time health insurance was discussed in Nigeria was in 1962 during the tenure of Dr. Moses Majekodunmi as Health Minister. He introduced a bill in parliament for Health Insurance in Lagos and the bill failed. Nothing happened since then until 1984 when Patrick Koshoni was the Health Minister. Koshoni set up a committee to look at the feasibility of Health Insurance, and it recommended that it was desirable and visible. Again, nothing happened afterwards until Dr. Ransome Kuti became Health Minister in 1992. He again set up a committee that did a kind of research. A renowned economist, Prof. Abraham Smith of blessed memory was part of that research. They came up with a template for the scheme. Again, nothing happened. Then Kuti left. One of the problems we have in this country is lack of continuity.

At that time, I was almost rounding up my appointment at the World Health Organisation. That was when Abdulsalami Abubakar came into power. At that point, the legal framework (NHIS Act) came into existence in 1999. So we can say NHIS started in 1999.
When I came back, I saw people making noise concerning the scheme. They were doing all manners of launching, which I called jamboree. When I was in the regional office of WHO for 10 years, one of the things I was doing was providing technical support to member states to develop their health insurance and health support scheme. So, I knew we were just making noise. And really, nothing concrete happened until former President Olusegun Obasanjo’s second term in 2003, I never knew I will be minister because I don’t like politics. When I became the Minister of Health, I carefully listed 13 things that I will like to do. Number one was the establishment of NHIS. I didn’t know how long I was going to be minister. I told Baba the 13 things listed were my priority. He told me he has approved all, but I told him what I needed was beyond approval, that I needed his support. He assured me of that, and particularly mentioned the number one on the list, which was NHIS. A number of things happened and he helped me to overcome them. On June 6, 2005, we launched the formal sector in the scheme. We kicked off June 6th, 2005.
Nigeria’s NHIS started 13 years ago, yet we are still on 4%. What is the issue?
When I gave my speech during the launch 13 years ago, I told them if we get our acts together and there is continuity of ideas, by 2025 we will achieve Universal Health Coverage (UHC). In 2007, we piloted with federal civil servants. We were enrolling but it was difficult to enroll everybody at once. Before we left office, we had enrolled about seven per cent of the population. Immediately we left office, it started declining, and now it is between three to four per cent.

How do you feel seeing the NHIS you helped get coverage of up to 7 % is now on 4% when it should be moving towards 100%?
I have told myself that after this interview I will not talk about NHIS anymore. I have spoken all the grammar I know but nothing is changing. It is very disturbing and depressing that our vision for NHIS is not what we are seeing now. Ghana for example, started a cooperative based scheme in 2004, and today they have coverage of about 41 per cent. Rwanda that went through genocide, developed their own law in 1999, and today, they have 91 per cent coverage.

So what is the actual problem with our own scheme, why is it not growing?
There are a number of problems and the major one is the lack of political will and commitment to address the scheme. We only saw some commitments during the second tenure of Obasanjo. It was during that tenure that the federal government health allocation went up to 8.5 per cent. Don’t forget the Abuja Declaration by all Heads of States in 2001 targeted 15 per cent, yet the highest we have had was 8.5 per cent. Last year, we had 4.2 per cent, so there are many things wrong with us.

Back to the scheme, a number of factors are responsible for the slow growth. Number one, is the Act of 1999. When I read it, I knew we have missed our way, because they made the scheme voluntary. There is no country in the world that has achieved UHC without making it mandatory. Number two, is that if states refuse to buy into the scheme it may not work. Thirdly, which is important, is that many people don’t know health insurance is supposed to be contributory. Even the one we piloted showed that the employer, which is federal government, will contribute 10 per cent of people’s salaries and the people will contribute five per cent. So what we have now is not contributory health insurance because it is only the government that is contributing 10 per cent, which was to be reviewed after two years. But the two years coincided with when we left office.

As former Minister of Health who oversaw 54 parastatals, you went back to become board chairman of NHIS, one of the parastatals. Isn’t that a form of demotion, or were you trying to make NHIS work at all cost?
That is to show how passionate I was on the scheme. When we left office, I made sure the person I appointed as the Executive Secretary of NHIS was always getting updates from me. Every month I would invite him to my office to know his plans and I will give him my advice because I saw it as my child. He knew I was interested in it and was the one who put him there, so when they were going to reconstitute the NHIS Board in 2010, he came to me to inform me. We had a lot of discussion, and he told me he wanted me to chair the board. I told him in Yoruba land we don’t go backwards. I told him as former minister for four years, if I take up the chairmanship position, it would mean I will start reporting to the minister, forgetting that when I was minister, I had 54 parastatals under me, and NHIS was part of them. I rejected it, until he said I should not let the baby I conceived, nursed and delivered, die while I am still alive. That touched me and I accepted the offer.

For the period of two years before they dissolved the board, I singlehandedly revised the Act six times. We made corrections and then presented it to the board which was approved. We heard a House of Representative member was sponsoring a private bill to amend the Act. Our bill was modified in such a way that states were to benefit and easily buy into it. At the end, nothing happened. There was just lack of political will to carry it through.

Why didn’t the bill you put together again scale through. Is it that it was not comprehensive enough?
It couldn’t have been more comprehensive than that. Even the bill the present Chairman, Senate Committee on Health, Senator Lanre Tejuso is putting together can’t be compared with the one the House of Representative member, Ndudi Elumelu was trying to push through then. What is simply happening is that we lack political will.

The National Health Bill, now National Health Act was part of my reform agenda. That was to be the mother of all health legislations, which we drafted the first time and took to the council. You know when someone says there is no form of responsibilities on the three tiers of government, we tackled that. The basic healthcare we are talking about now was in the bill. The area where they said we couldn’t legislate for states was revised. And by the end of 2004, it had gone to the National Assembly, yet nothing happened until we left in 2007.

Another process started again as a private bill, but when it got to the president, it wasn’t signed. In 2012, it was withdrawn and they worked on it again as a private bill. This time it took about seven months before it was finally signed in December 2014. We are in 2018, yet it is not operational. What do you call that if not lack of political will?
What should Nigeria do to achieve UHC?
There are major indicators if a country must achieve UHC. First, government must drive Total Health Expenditure (THE) towards four to five per cent of Gross Domestic Product (GDP). The THE comes from both the public and private. That of public must be at least three per cent. In Nigeria, we are around four per cent GDP in total, but government part is less than one per cent, which means we have not started. Secondly, out of pocket payment must not be less than 30 per cent of the THE, but in Nigeria, it has been between 62 per cent and 70 per cent. Thirdly, payment and health insurance scheme must constitute at least zero per cent of the THE, but in Nigeria today, it is three per cent. The fourth indicator, is that at least 80 per cent of the poorest 40 per cent must have access to quality health services. But can we even say that five per cent of Nigerians have access to quality health services.

All these things can be achieved through political commitment. Election is next year; if we don’t get our politicians to put health on their agenda then we may still continue to clamour for political commitment until 2023 when we continue the same cycle. The only reason we are where we are is because we are not giving healthcare the needed priority. If we continue like this we won’t achieve Sustainable Development Goals. Election year is around the corner, so if we don’t put our leaders to task, it means nothing in the next four years. What that means is that we will only have seven more years to meet the target. It took someone like Bill Gates to tell us that our priorities are misplaced. Do we need him to come and tell us if we really have political will to tackle what we have been clamouring about? In many countries, they have taken UHC overage as a political issue

Specifically what is the way forward in achieving UHC for Nigeria?
Number one is political commitment. Number two is political commitment. Number three is political commitment. Then we can talk of other strategies the government must put in place to achieve UHC. One key way is revitalisation of our primary healthcare centres.

The basic healthcare provisions fund, ideally, is to tackle primary healthcare. The amount earmarked this year (N57.17 billion) is nothing compared to what is really needed. A study has just been done which showed that amount won’t be enough. The two per cent we were asking for won’t have even been enough. What the Act says is that that one per cent will be used to provide basic health package to all Nigerians. If we are able to do that and address PHC, at least there will be UHC in a way. Remember, the minimum package does not contain everything, but at least we will be able to say every Nigerian has access to that minimum.

As we have more money, we will be adding to that BHCPF so that eventually it becomes comprehensive. That is the way many countries started.
If the political leadership and commitment is there, so many things will be settled in our healthcare space. When health is in our political agenda, we will budget more for health. If PHC sub system is working effectively and efficiently, it can address 80 per cent of the healthcare issues in Nigeria. 20 per cent will then go to secondary care, while about five or three per cent will go to tertiary. PHC is the basic; it is the one that reaches everywhere. An example of a country that has used this model is Costa Rica. They achieved UHC through strengthening of PHCs.
We need to strengthen the health system as a whole. There should be good referral system from primary to tertiary. When you go to outpatient department of teaching hospitals, you will see people who have malaria, who normally should access PHCs.

Offering of minimum package of service is another very important area. Government has to find a way of financing or adding to the minimum package so that everybody will be covered. Also, government at all levels has to provide money that will be used in covering vulnerable and the poor. Unfortunately, none of these is receiving serious attention.

Have you tabled these ideas with the Minister of Health?
The minister is very close to me. When am talking about political commitment, it is not the minister am talking about. I played a key role in developing health policy for this government. The minister worked closely with me when I was minister. He represented me in two or three places when I was minister. I am getting tired, what will he do, political commitment is beyond the minister. We are talking about the president for federal, the governors for states and the chairmen for local governments.

Specifically, are you saying our president is not giving political backing to addressing health issues?
I presented a paper in Spain because I was invited to share my secret on how I was able to convince the federal government to put more money into health during my time. I told them God see my heart, I never went to Obasanjo to ask he put more money into health. Baba himself knew health must be prioritised. We were one of three sectors that contributed to the NEEDS strategy. Also, Dr. Ngozi Okonjo-Iweala was Minister of Finance. She is an economist. Any economist who knows his or her onion will see health not as consumption good, but as an investment good. So you have the president committed to health, you have the Minister of Finance committed to health, and then we had the Minister of Health, which is me, and I am an economist also. And then there was debt relief which was mandated to be channeled to health and some other sectors. Health got the highest, 21 per cent, while education got 18 per cent.
Over the period 2006 to 2012, health got an average of 27 per cent in the debt relief. In summary, I am saying this minister is helpless.

If you were in the minister’s shoe what would you do?
That is a billion dollar question. There is nothing much you can do unless the man at the top recognises the issue. For instance, in those days if I had any problem as minister, I will go straight to the president. If he knows he can’t see me immediately, he will give me time to see him. There was nothing important I took to him that he never approved.

I give you an example; for us to kick start NHIS June 6 2005, there were things Obasanjo did which surprised me. I didn’t complain to him about stumbling blocks, yet he removed people. He will always tell me, ‘Eyitayo you didn’t tell me but I know. This thing must be done.’ That was the man I was dealing with. I don’t know what obtains now.

Outside the issues you have raised, will the tension between NHIS and HMOs allow the scheme soar successfully?
I try not to talk about the current NHIS administration, but the way I can address what you are saying is this; the initial Act we are still running today makes NHIS more of an implementer instead of a regulator.
The revision I made in the Act was supposed to make NHIS a regulator. So if NHIS has the capacity to regulate effectively, this problem from Health Management Organisations (HMO) won’t be there. What has happened is that NHIS has failed in its duty as a regulator because the Act is not too strong on that. Functions of HMOs and NHIS are not well clearly defined.
There must be a way to ensure HMOs do their jobs which is not the case now. NHIS has its problem, and HMOs probably took advantage of the weakness of NHIS. So that’s the problem, and we seem not to be getting out of this. I have decided to now look away. When I am passionate about something, and I have made several efforts, I get disappointed. Sometimes I don’t want to hear about this anymore. If anybody comes to me now, just like Dogo came to me eight years ago to tell me my baby (NHIS) was dying, I will tell him go and bring a hoe and I will dig where it will be buried because I am tired. I have written so many papers, not only on UHC. The recent UHC paper I delivered in the last NMA conference took me almost a month to work on. Imagine you do this four times a year, it means you have probably spent four months working on papers, yet you can’t see the results.
I sat down recently and I told myself, I will no longer honour any invitation to deliver papers again. So even when NMA came in January to tell me they wanted me to be the key note speaker for their conference, I told them I am no longer interested. But one of them, a lady consultant said ‘Sir please’. I then told them I will do this for the last time and it will be my valedictory speech. All these recommendations we keep making can be sorted out, all that is needed is political will, and it is not fair because these vulnerable and poor people cannot go abroad for treatment like our leaders; so strengthen primary healthcare, finance minimum health package, among others.

Just take a look at Ghana, they have about 41 per cent coverage, yet we started about the same time. Nigeria is on three per cent. We must force this to be an issue in the political agenda next year. If anybody is campaigning, ask the person to explain the meaning of UHC. It should be the beginning, because some of them are just hearing UHC and they don’t know what it is. Tell them all over the world what is being talked about is UHC, and that they should share their thoughts on this. It is their answer to the question that will make you know whether they have interest in it or not. After their explanation, ask what they would do about it over the next four years because we have just 12 years until the target date.
This is becoming more and more important because of what our leaders do. They are sick today, the next day they are flown out, not even with their money but with ours, and yet for the poor person to finance treatment, he will have to give out his 12-year-old daughter in marriage to finance treatment. Or he will have to sell his cocoa farm to finance treatment.

If anything changes today, will Nigeria meet UHC target of 2030?
No, we won’t meet it. We have wasted 12 years just to get to four per cent. Don’t forget we are trying to get up to 100 per cent. We moved from seven to four. Another reason I said no, is because in Nigeria there is always policy summersault. Leaders come, leaders go, and not too many of the leaders build on what their predecessors have done.

Baba, in our time made health one of the top four sectors. Then he chose his successor, Musa Yar’Adua, who reverted all the policies made by Obasanjo. This was a man not healthy enough, yet his seven point agenda did not include health initially. It was when some of us made noise that they changed the education he listed to human capital. It will be miraculous if we achieve it because a lot of damage has been done. Trying to meet that achievement should not make us look ridiculous to the outside world. We need sustainable political commitment. It is not enough for the president to be committed to it in the next four years. Presidents, governors, and local government chairmen must be committed to it (I didn’t say ministers), I mean the very decision maker.

There are a lot of countries that made UHC a political agenda. They won election on the basis of that. In some parts of the world, UHC is a vote catcher.

As an economist, how did you become a Health Minister when the unwritten rule in Nigeria is that you must be a medical doctor to head the ministry?
During a discussion with Obasanjo before sending names to the National Assembly for approval, he told me he wanted me to be in the economy sector, but I told him I will like to work where I have a comparative advantage, and he said that is why he will either post me to Commerce and Industry, Budget and Planning or Finance. I told him I would prefer the Ministry of Health, and he said I’m neither a doctor nor a nurse. I then told him, what you need is a Minister of Health, and not a minister of medicine; someone who has knowledge of health system, not health services.

During the NMA Conference, I told them I am not a doctor or a pharmacist or so. We didn’t have a day of strike for four years when I was minister. It wasn’t magic; they knew I was very objective. I am not a nurse, they know I wasn’t siding health workers, neither am I a medical doctor. I was a health system specialist, and I was ready to listen to everybody.