Rethinking Nigerians Healthcare Financing

By 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. 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 huge potentials abound in the sector to the economy.

Although there are numerous angles to the problem bedevilling Nigeria’s fragile health sector, including the collapse of the primary health care system, poor infrastructure, inter-professional rivalry, poor accountability, and an inefficient and limited health insurance coverage among others, 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. What many Nigerians see in other countries that offer healthcare services almost free of charge to their citizens are actually products of either heavy government subsidies, strict universal taxation regimes or compulsory insurance programs. Governments in Nigeria have over the years got caught up with this delusion that they can offer free healthcare to their citizens from the little they generate either interal and external without any sustainable framework in place 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 many are very expensive to use and manage. For example, we have specialists across all the various surgical specialties with the necessary skills to perform highly technical surgical procedures like kidney transplant, open heart surgery and complex brain surgeries but the system is so designed that it cannot accommodate their expertise due to the unavailability of resources to sustain such programs. This leaves so many Nigerian patients cumulatively spending billions on such medical procedures abroad at a great economic loss to the country.

Primary healthcare, the most important segment of any serious health system is virtually non-existent in the country. This is not due to the absence of the structures as in building, but largely due to ‘internal’ brain-drain within the levels of the existing health system. With the primary healthcare centres largely under the care of the local governments, most of whom cannot afford to employ the minimum required number of qualified doctors, nurses and other health workers who by extension are being pulled by better-paying jobs available at higher levels of the system.

Currently, the vast majority of Nigeria’s primary health centres are manned by Community Health Extension Workers with very limited skills and expertise.

The National Health Insurance Scheme (NHIS) that by design is supposed to be the main driver of universal health coverage in the country is, as it is currently structured, largely running far below par largely due to the poorly regulated profit-driven model upon which 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, it is only evident that only a meagre sum of money can be generated in the insurance pool.

This, coupled with the profit-only motive that drives the Health Management Organisations (HMOs), one can only expect that the system cannot cover fully, the comprehensive health needs of its enrollees talk less of 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 foregoing, it can then be deduced that sustainable financing is the critical element that is missing in our health sector, improving which I think should be the focal point of any meaningful health sector reform in the country. The current model whereby health financing largely depends on what the government generate from their dwindling revenue or from 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 growing population.

Accordingly, this high profile committee set up by Mr President should find ways of developing a comprehensive, sustainable and transparent healthcare financing model that would cover the most basic health needs of every Nigerian. It should consider a complete overhaul of the country’s healthcare financing by the development of a composite 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 social-economic class.

This should be supplemented by a comprehensive reform of the NHIS 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, to cover for specialised healthcare across our tertiary and specialist hospitals, both public and private and the same time broadening the insurance industry to include ethical health insurance systems like the takaful system in order to increase inclusivity across the various demographics of the country.

The committee should also encourage the creation of windows for community-based contributory health safety nets to tap into the national health insurance pool to enable citizens from lower socioeconomic access specialised healthcare at our tertiary health institutions.

To address the issue of funding for specalised healthcare services and preventive health, special funds can be set aside annually from the NHIS fund pool for research and development in our tertiary health institutions . This should be enough to cover for the provision of all the available infrastructure needed to procure, support and maintain modern diagnostic and therapeutic equipment.

Hopefully, the committee, headed by the VP Prof Osinbajo with qualified, world-class technocrats as members and the Bill and Melinda Gates Foundation, Vesta healthcare partners, and WHO as observers, would painstakingly develop a sustainable blueprint for health financing as the bedrock of their important task of development and implementation of the needed reforms in Nigeria’s fragile health sector.