By Tunde Ipinmisho
Ahead of its Annual General and Scientific Conference in Abuja on May 3, 2018, the Nigerian Medical Association (NMA) was determined that the gathering would not go down on just another talk shop that would not have the desired impact on the nation’s health system.
To achieve that purpose, it picked the theme: “Quality Healthcare Delivery: An Indicator of Good Governance”. It said the theme was chosen because the NMA wanted to, ahead of next year’s general elections; position itself appropriately, to ensure that health issues feature prominently in the manifestoes of the political parties, campaigns and debate sessions with the overall goal of the attainment of Universal Health Coverage (UHC) in Nigeria.
The NMA also said the choice of the theme was informed by the need to raise the consciousness among the populace that efficient and effective healthcare delivery was a measurable indicator that could be used to assess the performance of administrations at all levels of governance.
Having outlined its objectives, the association needed somebody to help it meet the goal and no other personality readily came to mind than the former Minister of Health, Professor Eyitato Lambo, who, the NMA in the letter inviting him to be the theme speaker, described as a front-row health advocate, thought leader on healthcare delivery issues and an exemplary leader in the area of institutional reforms.
They could not have made a better choice and, to demonstrate that, Lambo arrived at the venue with a 75 slide presentation. He was initially expected to speak for 20 minutes but when Lambo commenced his delivery, not even the organisers could stop him until 60 minutes later when he was done.
In the presentation titled: Universal Health Coverage in Nigeria: The Challenges of Leadership and Political Commitment the former Minister took his audience through an overview of UHC, its major benefits, facilitating factors and the steps to UHC. He also reviewed Nigeria’s UHC report card which he deemed abysmal, identified the factors responsible for the nation’s poor performance and explained what leadership and political commitment could do to hasten the country’s attainment of UHC. He closed the presentation with recommendations towards getting greater political commitment to UHC in 2019 and beyond.
Quoting the World Health Organisation, Lambo said “UHC means that all people and communities can use promotional, preventive, curative, rehabilitative and palliative health services they need of efficient quality to be effective, while also ensuring that services do not expose their user to financial hardship”.
That definition, according to him, embodied three related objectives: equity in access to health services (everyone who needs services should get them, not only those who can pay for them); the quality of health services should be good enough to improve the health of those receiving services; and people should be protected against financial risk, ensuring that the cost of using services does not put people at financial risk.
The World Health Assembly, he noted, at its 58th session in 2005 adopted Resolution 58.33 (WHA 58.33) on “Sustainable health financing, universal health coverage and social health insurance” which among other things, urged member states (including Nigeria) to: ensure that health financing systems include a method of pre-payment of financial contributions to healthcare with a view to sharing risk among the population and avoid catastrophic healthcare expenditure and the impoverishment of individuals as a result of seeking care; ensure adequate and equitable distribution of good quality healthcare infrastructure and human resources for health so that the insures will receive equitable and good quality health services according to the benefits package and establish the transition to UHC of their citizens.
The third of the Sustainable Development Goals (SDGs), to be achieved by the year 2030, Lambo noted, was on health with nine targets. Target 3.8, he pointed out, relates specifically to UHC and “Achieve Universal Health Courage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” According to him, it is believed that achieving that SDG target on UHC would automatically achieve majority of the other eight targets dealing with different diseases, population groups and health system reforms. He listed the major indicators for monitoring progress towards UHC to include: The Total health Expenditure (THE) which should be at least 4-5 percent of the Gross Domestic Product with the public component to be at least 3 percent; out of pocket expenditure (OOPE) on health should not be more than 30-40 percent of the THE; over 90 percent of the population to be covered by pre-payment and risk pooling schemes; and close to 100 percent of vulnerable groups covered by social assistance and safety-net programmes.
Others are: at least 80 percent of the poorest 40 percent of the population to have effective coverage with quality health services; meet the Abuja target of government spending which must be at least 15 percent of total government expenditure on health at all levels of government; and have a strong and efficient health system especially a primary healthcare system that produces comprehensive, efficient and quality health services with good referral system to other levels of healthcare.
Lambo said Nigeria effectively commenced the implementation of the 1999 National Health Insurance Act on June 6, 2005 with the formal launch of the Formal Sector Programme of the NHIS Act to cover federal civil servants. President Olusegun Obasanjo who inaugurated the programme gave the NHIS a Presidential mandate of UHC by 2015.
Examining Nigeria’s report card, using the main indicators for UHC, Lambo lamented that the country scored less than four percent of the Total Health Expenditure which should be at least 4-5 percent of GDP. More importantly however, he said, the public contribution to Nigeria’s THE is less than 1 percent.
On the Out of Pocket Expenses (OOPE) which should not be more than 30-40 percent of the Total Health Expenditure, the former Minister said Nigeria had consistently scored over 60 percent. The country’s score of seven percent in the coverage by pre-payment and risk pooling was far below the recommended 90 percent. Nigeria’s score is also “very negligible” on vulnerable groups covered by social assistance and safety-net programmes as against the 90 percent recommended.
On another indicator for measuring progress towards UHC: at least 80 percent of the poorest 40 percent of the population should have effective coverage with quality health services, Lambo said Nigeria’s score was not really known but concluded that “certainly we are not there yet.”
He also noted that Nigeria’s primary health care system remained weak and was yet to experience effective re-vitalization whereas an important indicator of progress towards UHC is the presence of strong and efficient primary health services with good referral system to other levels of care.
Lambo, said the only years when Nigeria had some noticeable improvement in public health expenditure were 2004-2008 which covered Obasanjo’s second term as President.
With these abysmal results, the former Minister expressed regret that Nigeria was yet to start the journey towards UHC, noting also that although there had been numerous pronouncements by Nigerian leaders affirming the country’s commitment to UHC, her progress did not support such statements. On the other hand, he pointed out that less endowed African countries such as Burkina Faso, Ethiopia, The Gambia, Ghana, Kenya, Lesotho, Liberia, Rwanda, Uganda and Tanzania had achieved greater strides towards UHC than Nigeria.
He blamed Nigeria’s abysmally slow progress towards UHC on many factors including politics, political leadership and commitment; financial constraints, heavy reliance on out-of-pocket payments for health services and inefficiencies in public health spending. Others are poor governance including corruption and fraud, lack of essential health package financed and provided by government for the population, especially the poor and vulnerable, economy related challenges such as poverty and unemployment and weak health system. The former Minister identified politics, political leadership and commitment as the most important factor that had played an important role in other countries such as the United Kingdom, Japan, South Korea, Brazil, Mexico, Thailand, China, Ghana and Rwanda which had achieved or were on the fast lane to achieving UHC.
Beyond identifying the failures and challenges to Nigeria attaining UHC, he proffered solutions which he said would ensure greater political commitment to the goal in 2019 and beyond. He implored the NMA and other medical/health professional associations to make UHC their rallying cry over the next 12 months and beyond. Rather than the notorious professional rivalries that had plagued the nation’s health sector, he said professionals in the sector should be united in their demand that political parties and their candidates for the 2019 elections should show unquestionable commitment to putting UHC high in their manifestos. Lambo also counseled the NMA and other medical/health professional associations to form an alliance with well-meaning civil society organisations and individual activists to educate the populace about how UHC affects their lives, adding that Nigerians should be advised against trading off the benefits of UHC for monetary inducement to vote for parties (and individuals) which do not place priority on UHC.
The NMA and other medical/health professional associations, he said, should also form an alliance with media to drum into the ears of the leaders of the political parties that they should not campaign anywhere without making firm promises to pay the highest premium to UHC. He called on the political parties to state clearly in their manifestos, their commitment to UHC and to spell out in concrete terms what they would do from 2019-2022, to ensure that Nigeria attains UHC coverage of at least 50 percent.
On their part, Lambo urged the general public to pay close attention to the manifestos of each political party as well as their aspirants, particularly for Presidential and gubernatorial positions, on issues related to UHC and take keen interest in understanding how each party stands on UHC related issues. They are also to take aspirants to task on their promises on UHC issues in order to ascertain their level of seriousness about the commitments they make..
Although a standing ovation greeted Lambo after his delivery of the presentation, the look on the faces of members of the NMA and other health professionals, top government officials and members of civil society organisations present at the International Conference Centre, Abuja, venue of the conference indicated that both the theme speaker and those who invited him achieved their desire to adequately prick the conscience of all on the issue of Universal Health Coverage in the country.
Ipinmisho, who lives in Abuja is a former Editor of the Sunday Times