Guest Column By Olaokun Soyinka
The sight of an old lady wailing and rolling in the harmattan dust at my feet, was one of the more unusual hospital welcomes I experienced as a commissioner. This was in 2011, and I was visiting one of the busiest government maternity hospitals in Abeokuta. The lady concerned, it transpired, should have been celebrating as she had just become a grandmother (again). The cause of her distress was that her daughter, who had just had a Caesarian operation could not pay her bill and was thus ‘detained’ in hospital. She would be discharged when her bill was paid or, as in this case, until she could attract the attention of the visiting commissioner and hope for a reprieve. I helped her to her feet and enquired about the case from the discomfited Medical Director beside me. Naturally, I directed that the new mother be released.
The Solution to Health Inequity
It gave me little satisfaction because it was a gesture which may have solved one family’s immediate problem but would make no difference to the thousands who would suffer similar or worse indignity across my state and across the nation. Most detained relatives do pay eventually – the technique is cruelly effective. I also have no doubt that most relatives who disappear for a day or two, and then turn up to hand over the amount owed, have spent days and nights begging, selling possessions, or taking loans, raiding their savings, desperately doing whatever it takes to raise the money. This is the sad reality of the level of health inequity in our country today.
Achieving Universal Health Coverage (UHC) is how we stop this kind of thing happening. A basic definition of the term is ‘all people having access to the health services they need, of appropriate quality, without suffering financial hardship’. Since it is estimated that about two thirds of health expenditure in this country is ‘out-of-pocket’ we can only imagine the scale of financial hardship that is being caused by ill health.
Achieving UHC will also ameliorate a host of secondary problems that thrive where there are poor and desperate customers: quacks, greedy for profit, who harm or even kill. Makers and purveyors of cheap fake, drugs, traditional and not so traditional practitioners who wreck livers and kidneys. There is also a high level of dangerous self medication going on. And do not forget that there are many people who just suffer or die at home, who never become visible to the health system.
Getting to ‘U’
Getting affordable health services universally available to Nigerians will be a massive task. We don’t just have to scale up, we have to redesign our health system at the same time. Our current structure is dysfunctional and its design is too flawed to do the job. Simply pumping money into it in the hope of expanding coverage will be like buying a bigger basket to carry more water. To succeed, we have to change our system from ‘basket’ to ‘bucket’.
The characterisation of our health system as ‘mere consulting clinics’ appeared in 1984 as the military took over. We know that since then we have had numerous ideas, plans and strategies to improve healthcare and plenty of smart and dedicated people to put them into practice. We have to ask why they have failed. The answer is simple – there has been no money to back up the plans.
If we are to implement a plan to achieve UHC, it makes sense for us to embrace an idea which focuses on providing a predictable stream of finance. This is why many people like myself are excited about the potential of State Supported Health Insurance (SSHIS) as a means to finally break the cycle of decline in primary health care, with knock-on effects that will ripple through all tiers of the health system.
What is Exciting about Insurance?
When we were in the planning stages of such a scheme in Ogun State (called the Araya scheme) and I was doing my bit to whip up support for the idea, I was disturbed that people did not understand why I was getting so excited. To the lay person, the idea sounded so ‘dry’ and boring and anyway, insurance was certainly not new. How could this be the long awaited key to bringing healthcare to the masses?
I changed my tactics and instead emphasised the ‘free’ and ‘affordable’ aspect and its benefits for those on low incomes, I explained how our massive informal sector would also be able to access the benefits currently only available to the formally employed. I enthused about how powerful the idea was, of communities joining hands with government to take ownership of the primary healthcare problem, contributing financially and helping to revolutionise the system from the ground up. I think this way I managed to get a few more converts.
How State Supported Health Insurance Works
State-supported Health Insurance works by individuals (via payment of an insurance premium) and other stakeholders (Federal and State Government, donors, philanthropists, charities etc) contributing regularly to a large health fund that is devoted exclusively to funding basic healthcare for participants in the scheme – this is the ‘bucket’ I referred to and it can be designed not to leak. As long as you have done your calculations right, the few (relatively) who access healthcare will be easily covered by the fund created by the many. The state contribution, or subsidy, is key to keeping the scheme affordable and the participants only need to pay a modest premium – say N4,000 per year. Specific categories of people, pregnant women or the very poor, for example, can be exempt from premium payments. The ailments covered or ‘benefit package’ is also limited to the basic common medical problems.
Furthermore, unlike other schemes, in SSHIS, scaling up creates strength rather than being a challenge because the more people participating the bigger the pool of funds becomes – this is called risk-pooling. Insurance schemes turn all participants, who access healthcare into paying customers and that is what enables the participating facilities to thrive.
Providing basic health care services relies more on the steadiness of the flow of funds than the absolute amount. Predictable finance even if modest, brings facilities, the ability to plan and to invest, which encourages the private sector into the game as well. Regular insurance funds flow can enable our previously cash starved centres to operate as small businesses, investing in assets that improve the quality of service which in turn brings more income. This is a key part of well-designed schemes – a built in engine for quality improvement. The wave of free healthcare will be accompanied by a steady improvement in levels of infrastructure, staffing, training, equipment and supplies: the mere consulting clinics will evolve into proper PHCs.
Learning from the Early Movers
In Ogun State, the Araya scheme was planned as a holistic financing scheme that would give the communities a say in how money was used at the facility level and encourage them to help in marketing the scheme, getting families to sign up and discouraging fraudsters. The state provided the investment to develop an IT system to facilitate the administration of the entire scheme and government embarked on development of legislation and the institutional structures to protect and distribute the funds appropriately.
The Araya scheme, since its launch in 2013, has unearthed enormous latent community resources, showing how important it is for government to decentralise and make use of our widespread human capacity. Araya has proved to be an effective umbrella framework that can synergise with other programmes and it provides transparent operations that encourage philanthropic largesse.
Kwara State, however, is the pioneer in Nigeria and has been running a scheme for rural communities since 2007. Pharmaccess, a Dutch NGO (which is also assisting operations in Ogun State) and the Dutch Government, joined forces with Hygeia an indigenous Health Maintenance Organisation, to implement the scheme, which eventually expanded to over 120,000 participants. It has demonstrated the potential for great impact on health and is popular with the communities. Particularly impressive is the way in which the steady flow of money has enabled facilities to continuously upgrade the quality of services. It has shown that the smallest, most far-flung facility can operate to modern standards.
I am not ignoring the many difficulties that lie along the path to implementation of these schemes – I have seen them first hand. What I have learned is that we have little choice but to get moving and to optimise the operations by systematic evaluation over time. The facilitating role of the Federal Government particularly for resource mobilisation will be critical for these schemes.
Federal Government as a Catalyst
Worryingly, with the economic downturn, the Kwara and Ogun schemes have slowed their progress because of the knock-on effect of the economy on the ability of the state government to pay for take-off operations and premium subsidies. In an earlier article I explained how the Federal Government could trigger a cascade of funds that do not rely on the treasury, but takes advantage of an existing World Bank facility for the Saving One Million Lives initiative added to money set aside by the NHIS. This would do the pump-priming to help states take-off with their State-supported Health Insurance Schemes – in effect getting everyone to gather at the starting line for the race to UHC. In addition, I believe that since the Ogun and Kwara programmes can yield up valuable lessons for the rest of the country, some funds should also be set aside for operational research on what works best in these pilot programmes. They have gone far up the learning curve and can shorten our journey to UHC as other states leverage the gained experience.
Protecting the Gains – the National Health Act
If the Federal Government embraces its role as catalyst and releases funds to stimulate the re-engineering of Primary Healthcare across the nation, the states will heave a sigh of relief as stagnated, crumbling PHCs across Nigeria splutter back to life. But with that will come the need for money to sustain the new, expanded system. Even with billions of naira being raised via the health insurance premiums, the surge in people with access to healthcare will require a sustained and additional increase in funding. This is where the National Health Act comes in.
The act had suffered a tortuous 10-year gestation. Expectation had escalated until the bill took on a magical aura, as if when enacted it would cure the health system just by existing. If not magical, the impact if implemented will surely be significant because, at last, all states in Nigeria will have a protected flow of funds for healthcare. One of its clauses established a Basic Healthcare Provision Fund which is to be financed from a Federal Government annual grant of not less than one per cent of its Consolidated Revenue Fund. The Act should offer a reassurance to State Governments that having embarked upon SSHIS, they will have a major portion of the necessary funding dealt with.
With SSHIS providing a transparent and effective framework for the money to flow through, to the grassroots, and with the addition of state and community contributions via premiums, we can at last dare to believe that we are at the end of the era of plans without finance.
Following the Money
The Federal Ministries of Finance and Health need to collaborate and get the existing healthcare funds moving. The NHIS needs to revisit its criteria for assisting states; currently few states will be able to meet the existing financial criteria for NHIS assistance and it is important that more states get started on implementing the schemes that will move us closer to UHC.
This is not the time to be nervous about releasing resources for healthcare. What we need to do differently is devise a solid means for monitoring what the money is achieving. The money can then be released in instalments based upon on adequate performance,
Our politicians must seize the moment. We are failing in our duty of care. Unlike the grandmother who rolled before me in the dirt, thousands of our low income citizens who are not lucky enough to find a benefactor are plunged into deeper poverty. Others suffer a worse fate and lose much more, often life itself. This is unbecoming of a nation of our status, unjust and entirely preventable.
· Dr Soyinka was Commissioner for Health in Ogun State from 2011-2015