By guest contributors Omokhudu Idogho, Kenneth Okoineme, Yusuf H. Wada, Isibhakhomen Y. Ikhimuikor, Moghonjubade Adesulure and Jennifer Anyanti
In 2020, the Minister of Health unveiled Nigeria’s Health Sector Roadmap, guided by the President’s 2019 Health Sector Next Level Agenda. One of the key elements of the program includes the implementation mandatory universal health insurance in collaboration with state governments and the administration of the Federal Capital Territory (FCT).
Fast forward to May 2022, when the President signed into law the National Health Insurance Authority (NHIA) Act which provides the framework for a health insurance plan that commits states to establishing health insurance for all. Stakeholders, donors, partners and other civil society organizations (CSOs) have commended the government for taking steps towards universal health coverage – particularly in the context of a report that 8 in 10 Nigerians do not have access to health insurance.
The new law makes it compulsory for every Nigerian to be covered by health insurance and provides for collaboration between the NHIA and state governments, especially in the accreditation of primary and secondary healthcare facilities. It prioritizes access to the most vulnerable population with the establishment of a “vulnerable groups fund” to be financed by the Basic Health Care Provision Fund (BHCPF), which are insurance levies to finance the premiums of the most vulnerable.
Moreover, it leaves room for cautious optimism; the reality of health insurance delivery must be understood in the context of broader health system challenges in the country. The Vulnerable Groups Fund, as envisaged in the design of the scheme at the moment, seems to assume that part of the population will require intervention from this pot. The reality is that almost 50% of Nigerians live in rural areas according to the World Bank, and a vast and growing urban poor population still has a relatively limited ability to pay for insurance on an ongoing basis.
Concerns are that the new law may not significantly expand the reach beyond the formal sector as was the limitation of the old regime. At best, it will only lead to a socialization of private health insurance schemes which work relatively well with the public scheme. Whose net gain is not clear at the moment with regard to our national ambition in terms of UHC. Moreover, the literature published by Adewole et al. and Okpani et al. suggests that the bottlenecks to achieving universal health coverage are less a problem of the formal sector, but more of expanding the use of health insurance in the informal sector and rural areas. The statutes as portrayed now are unlikely to fundamentally alter this narrative in the foreseeable future.
The proposed financing of the Vulnerable Fund as contemplated by law includes the Basic Health Care Provision Fund (BHCPF) which draws a 1% allocation from the Consolidated Revenue Fund and a counterpart mobilized by the States, premiums paid for by registrants and other sources. It is likely that the BHCPF will be the tripod on which the fund will operate. This is worrying as the BHCPF fund itself is already constrained by declining government revenue mobilization which is undermined by debt obligations. However, during the presentation of the Medium Term Fiscal Framework/Fiscal Strategy Paper 2023-2025 by the Federal Government (FG), the highlight was that FG’s undistributed revenue for the period was N1.63 trillion and debt service was 1.94 naira. trillion in the first quarter of 2022. The FG and most states are also facing extreme fiscal pressure, indicating how unlikely the new law is to change the realities and health outcomes of Nigerians, in particularly in the informal sector and in rural areas. Many of them are poor, vulnerable and in desperate need of the ambition set out in the law.
Each situation offers its own opportunity, and this could be the time to think about innovative and sustainable financing approaches for the fund. One such approach would be to wind down the “sugar tax” and earmark it exclusively to fund the Vulnerable Pooled Fund. A structured review of alcohol, tobacco and other related items should be implemented and the possibility of ring-fencing elements of taxes imposed on them and directed to funds should also be considered.
Designing service delivery channels and getting the bulk of resources to the point of service are the other two critical points of reflection, even as the law is rolled out. PHC is the main foundation and entry point into the health system, especially in rural areas. The report suggests that less than 50% of these public PHC facilities in the country are fully functional, even after 3 cycles of BHCPF investment. Therefore, it is not surprising that 75% of first point of care and PHC service utilization is provided by informal health service providers such as patent medicine vendors (PPMVs) and community pharmacists. (CP). Bold thinking and creative action are needed to improve citizens’ interface with the health sector in light of this worrying situation.
Finally, policy makers must recognize the centrality of the social contract between the citizen and the government, and do everything possible to ensure that it is effectively implemented. We also hope that the celebration announcing the enactment of this law will result in real change in the health outcomes of Nigerians, especially the poorest, and will accelerate Nigeria’s achievement of the Sustainable Development Goals (SDGs) related to health and the universal health agenda. 2030.
About the authors:
Dr Omokhudu Idogho is the Chief Executive Officer of the Society for Family Health (SFH), Nigeria, one of Nigeria’s leading non-governmental organizations, with over twenty-five years of leadership experience in developing and leading major development interventions at national and multi-country levels. Prior to joining SFH, he worked with ActionAid International in South Africa as the International HIV and AIDS Program Coordinator, overseeing ActionAid’s work in 22 countries in Africa, Asia and Latin America. He has also worked as a policy adviser with the ActionAid Alliance in Belgium, focusing on policy development within the institutions of the European Union.
Kenneth Okoineme is the health governance and public policy specialist for the Society for Family Health, with over 15 years of experience in the areas of governance and public policy engagement. Much of his work has focused on approaches to influencing public policy processes and outcomes in public finance, public service delivery, governance and democratic development.
He is passionate about effective civil society organizing and empowering communities to build alternatives and take action to demand, claim and defend rights to responsive public services, engagement with governance institutions, processes development policies and initiatives to improve their effectiveness towards people-centred development results and social impact. .
Yusuf H. Wada is a pharmacist and currently works as an executive assistant and health policy intern at the Society for Family Health. He is a member of the International AIDS Society’s HIV Cure Academy and has published several research papers, presented at local and international conferences and written for numerous blogs.
Isibachomen Y. Ikhimuikor is a program associated with the Society for Family Health. Previously, she worked with the Women’s International League for Peace and Freedom (WILPF Nigeria) where she oversaw the process of presenting a shadow report to the CEDAW Committee and the implementation of several other activities on peace and women’s safety. She holds a bachelor’s degree in pure and applied mathematics from the Federal University of Technology in Minna. She is passionate about public health and is committed to ensuring that every Nigerian receives basic health services.
Moghonjubade Adesulure is currently the National Digital Media and Communications Coordinator on the Society for Family Health’s DISC Project, where she leads a wide range of campaigning and communications activities in Nigeria. She is a media enthusiast with considerable experience in media and communications, with a current focus on health communications. She holds an MA in Mass Communication from the University of Lagos and a BA in Communication and Language Arts from the University of Ibadan.
Dr. Jennifer Anyanti is currently Deputy Chief Executive Officer (Strategy and Technical) of the Society for Family Health, one of Nigeria’s leading non-governmental organizations, and a Fellow of the West African Academy of Public Health. She is a medical graduate from Obafemi Awolowo University, Nigeria, and a public health expert with over two decades of experience in health promotion, research and public health-related programming funded by a range of international donors. She is a well-published author/co-author of over 50 peer-reviewed articles, and beyond her professional accomplishments, she is a mentor, results-oriented manager and board member of a number of national and international health-focused organizations.
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