Financing Universal Health Coverage in Africa: Nigeria’s comparative experience

The Partnership for Advocacy in Child & Family Health at Scale, PACFaH@Scale (PAS), is a social accountability project which aims to strengthen the capacity of Nigerian Civil Society Organisations at the national and state levels. The project aims to hold decision-makers (in the executive and legislature) to account to comply with commitments in child and family health, policies (laws); financial obligations and to bring down regulatory and administrative barriers to effective and efficient service delivery. PAS is anchored by the development Research and Projects Centre (dRPC) and implemented by a coalition of 23 indigenous health NGOs and professional associations. The project is also supported by 2 government partners working to develop champions with the executive and legislature.

This panel is moderated by veteran journalist, Moji Makanjuola.

Veteran journalist, Moji Makanjuola

She explained that the panel would be discussing various factors Nigeria can leverage on to improve and sustain the drive for UHC.

Speaking first, Emmanuel Meribole from the department of planning, research and statistics at the health ministry said there is a need to tap into funds from sources other than the annual budget.

Emmanuel Meribole

Such sources, he said include the Basic Health Care Provision Fund (BHCPF).

The official, however, decries the poor monitoring of health indices in the country saying it is a major constraint to UHC.

Mrs Makanjuola introduces Garba Buluma, an official of the National Primary Health Care Development Agency (NPHCDA).

Given his background, the moderator expresses delight in having Mr Buluma in the panel because “he was once an Almajiri but went ahead to become a medical doctor”.

He said Mr Buluma’s story is that of hope that should inspire “our kids in the streets”.

Speaking, Mr Buluma said for Nigeria to achieve UHC there should be good governors.

“If governance is fixed, there will be 80 per cent success in the health sector,” he notes.

“Everything revolves around good governance and finding a way to maximise the funds available.

He speaks about the federal government’s Primary Health Care Under One Roof.

PHCUOR Policy

The PHCUOR policy was brought on board as a watershed to reduce bottlenecks in the delivery of Primary Health Care (PHC) services by integrating all PHC services under one single authority – the State Primary Health Care Board (SPHCB).

But for shortfalls in implementation and execution, there was no shortage of ideas when the policy was approved by the National Council on Health in 2011 and later backed by the National Health Act (2014).

It mandates every state to create SPHCB as a single management body to control all PHC services and resources especially funding, staff enrollment, payment of salaries and maintenance.

Every year, a scorecard exercise is concurrently done across the 36 states where the policy is being implemented to continuously review successes and identify the shortfalls in applying PHCUOR.

The assessment conducted by the NPHCDA in collaboration with the Development Research and Project Centre (DRPC), covers the State Ministry of Health, SPHCB, three selected Local Government Health Authorities (LGHAs) and one PHC in each of the three selected LGHAs in the State.

Meanwhile, Mr Buluma advocates for robust and holistic implementation of the program.

Garba Buluma, an official of the National Primary Health Care Development Agency (NPHCDA) describes PHCUOR as a one way ticket to solve challenges facing PHCs across the country.

Mohammed Ube is on this panel to represent NIPSS, Nigeria’s foremost think-thank organisation.

He starts by giving a brief background of NIPSS and how it operates.

About NIPSS

NIPSS – National Institute for Policy and Strategic Studies (NIPSS) based in Kuru, Jos, North Central Nigeria is a policy formation center for bureaucrats, private sector leaders, Army officers, and medium-rank and senior civil servants, which was founded in 1979.

Most policymakers in Nigeria have attended the NIPSS. Notable graduates of the NIPSS include Ibrahim Babangida, the former Nigerian Head of State, and Nuhu Ribadu, the anti-corruption campaigner.

Each year, the institute develops a policy plan for the country. It reports directly to the office of the president and is being supervised by the vice president.

This year, NIPPS has a mandate of charting a roadmap that will help the country achieve UHC through better funding mechanism.

Meanwhile, Mr Ube said the NIPSS has undertaken several study tours to ascertain the various challenges to funding UHC in Nigeria.

Mohammed Ube on the Panel

PREMIUM TIMES reported earlier in the year how NIPSS undertook a study tour of PHCs in selected states in the country.

The captain said the study encountered three major challenges – the need for more money, more health, and more professional hands.

He said the institution looked at the challenges from three different dimensions –
1) Who is to be covered?
2) How to finance UHC?
3) How to implement UHC?

On who is to be covered, he said the institute encountered a challenge of getting accurate data and statistics of the country’s population, health indices, health facilities, “how many pregnant women we have among others”.

On raising funds, Mr Ube said the government is confronted with so many competing demands other than health.

On how to implement, he says the constitution appears to be silent on specific roles of different actors.

He gave several examples where the state and federal actors are not working in sync, saying it is a major impediment to UHC.

Lydia Dsane-Selby, the CEO, NHIS in Ghana is now speaking.

NHIS in Ghana

Lydia Dsane-Selby

Ghana introduced a Mobile-based Renewal Application System for the country’s NHIS in June.

The system allows enrollees to renew their membership from the comfort of their homes with the aid of mobile wallet-enabled phones.

The system has boosted enrollment, the Ghanaian authorities said.

The West African country has covered more than 50 per cent of its population.

Meanwhile, Mrs Dsane-Selby said her country has been raising domestic resources for UHC for the past decade.

“Fee were introduced after we had an economic downturn. There was a special levy of two and a half per cent VAT on all goods and services.

“These monies were gathered and put in the pool of funds for health insurance. 20 per cent of the funding was also raised from premiums of 39 cedes max.

“Stray tax has also increased funding,” she explains.

She also explains how the Ghanian government introduced a biometric ID card which is used to identify active members enrolled into the scheme.

The Ghanian official said the enrolment card is used as a benchmark of getting access to public services.

“If you want to stay on campus in the university, you must have a National Health Insurance Card.

Challenges

“Everybody in Ghana should enroll. That is our plan but coverage is still a challenge we are facing,’’ she notes.

The official said a majority of enrollees can access their plan through their mobile phones at home. She, however, said authentication and verification is also another challenge.

She also alludes to funding challenges, a situation Mrs Sebly said “is tempting her scheme to dip hands into the ‘government’s pot’.”

The moderator reaffirms her previous position that health should be seen as an investment and not an expenditure.

“it is a global issue and we need to find a way to make health a national issue. We have the money, what we need is action,” she adds.

 

Beatrice Gatuma, the UHC lead, AMREF Kenya is now speaking.

Dr. Beatrice Gatumia of Kenya

She explains how Kenya has been driving coverage of health insurance in the informal sector through alternative options.

She explained that their neighbour Rwanda had set a good example with their community health model. She said the East African country is leveraging on technology to drive health insurance in rural areas.

AHAIC 2019: Learning health insurance from Rwanda, Ethiopia and Kenya

Rwanda and Kenya were lauded for advancing UHC through various health financing mechanisms, during the Africa Health Agenda International Conference 2019 (AHAIC) held in Kigali.

In Rwanda, community-based insurance has provided “the modern social security we want for our people”, Rwanda’s Minister of State for Primary Health Care, Patrick Ndimubanzi had said.

Rwanda’s health insurance scheme is financed by both the national government and individuals through insurance and fees for services.

Members pay annual premiums at a flat rate based on their economic status, regardless of individual health risks, which can then be used for discounted treatments at community health centres.

Health insurance became mandatory for all individuals in 2008; in 2010 over 90 per cent of the Rwanda population was covered.

In 2012, only about four per cent was uninsured.

This scheme increased the number of women delivering in health facilities from 50 percent in 2010 to 90 percent in 2015, Mr Ndimubanzi noted.

In Kenya, the government appeared to have a larger plan of achieving UHC by 2022.

UHC hospital insurance pilot project is currently being tested in four regions troubled with high disease burdens.

Since the launch in December 2018, the government has offered free basic healthcare services to all citizens holding a UHC card — which required the presentation of national identification to register — and covers anyone in the household under 18.

“Today, 75 percent of all residents [in the pilot counties] have been registered and are holding a UHC card,” Rashid Abdi Aman, chief administrative secretary at the Kenya Ministry of Health, had said.

He explained that health programmes requiring registration may need to be adapted for those who lack identification papers.

Challenges

The official says inadequate data remains one of the universal challenges to health insurance.

She said the right data will empower people to demand adequate health services.

“With data you will know how deep is the insurance coverage and what you can obtain when you are covered?”

Solutions

Mrs Gatuma stresses the need for leveraging alternative sources of funds and leveraging on technology.

Mr Meribole harps on the need for inter-sectoral collaborations to drive funding for UHC and health insurance.

He also advocates for synchronisation of federal, state and local government levels to drive progress.

He says the issue of awareness for health insurance should be addressed. “People should begin to see health insurance as a major way to address out-of-pocket spending.”

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