As part of its corporate social responsibility to help Nigeria focus on challenges of financing its health sector, THISDAY recently held a healthcare financing policy dialogue, which attracted huge participants. Iyobosa Uwugiaren captures the event

In spite of the four-day notice for the event, over 500 participants, including senior officials from government, private health sector, domestic and international public health institutions, as well as non-governmental organisations (NGOs), were at the recent THISDAY Policy Dialogue/Summit.

THISDAY, the nation’s leading newspaper of record, as part of its corporate social responsibility efforts to help Nigeria focus on the challenges of financing its health sector and finding sustainable solutions to them, held the policy dialogue, with technical support from The World Bank.

The huge interest/concern by the participants, including some critical segments of the international community, could be seen in the finding of the Chief of Health, Nutrition and Population of The World Bank, Dr. Benjamin Loevinsohn.

Giving reasons why the World Bank was involved in the summit, which was held at the Musa Yar’Adua Conference Centre, Abuja, the World Bank expert said Nigeria spends less on healthcare than almost any other country in the world, resulting in poor Nigerians paying out-of-pocket for their health
He noted that most poor Nigerians were unable to afford adequate healthcare.

“This government’s low spending also means the country is unable to spend adequately for health services and facilities. For instance, only about 10 per cent of Nigerian children are immunised, whereas in Chad and Niger, about 30 per cent and 50 per cent are immunised, respectively’’, Dr. Loevinsohn stated.

“In addition, Nigeria is pretty much the worst place in West Africa to be a poor child or a poor mother. Again, this outcome is worse than in Lake Chad and in Niger. This is a real problem we can’t wish away. That is why we are involved.”

Research findings also show that Nigeria is one of the developing countries faced with the “double burden” of persisting high prevalence of communicable diseases and rising prevalence of non-communicable diseases.
Key health indicators such as maternal and infant mortality are worse than the Sub-Saharan African average, and Nigeria is not on track to tackling the challenges, including malaria – Nigeria’s most important public health challenge that is responsible for 60 per cent of outpatient visits to health facilities , 30 per cent of childhood deaths and 11 per cent of maternal deaths.

Experts are of the few that over 90 per cent of Nigerians are at risk of malaria with o ver 100 million cases per year and about 300,000 deaths. Even the Federal Ministry of Health estimates a financial loss of approximately USD8.4 million.

These frightening revelations are perhaps, what informed different experts and speakers drawn from the public and private health sector, who emotionally canvassed for a legal framework to finance the sector at the policy dialogue/summit, stressing that the framework should be robust enough to support the delivery of a set of high impact interventions.

The participants equally harped on the need for increased public investment in the health sector if Nigeria is to achieve Universal Health Coverage (UHC). They noted that it would require encouraging state governments to increase public funding, as more than two-thirds of public sector funding for healthcare currently comes from the federal government.

In a communiqué issued at the end of the THISDAY Health Financing Policy Dialogue, the participants observed that although investment in health leads to economic growth, Nigeria had invested too little and wastefully in the health sector, spending less than nearly every country in the world.

In the lively, robust dialogue, moderated by Dr. Olumide Okunola, Senior Health Specialist, IFC/World Bank l MIGA- Investment Climate – Health in Africa Initiative (HiA), which attracted a huge audience, it was agreed that the country’s development partners should also support the federal government’s efforts at improving primary healthcare delivery, using the Basic Health Care Provision Fund (BHCPF) as the vehicle. That credible metrics and effective health planning, monitoring and evaluation, by federal and state ministries of health, according to the participants, were required to encourage confidence.
They also agreed that the BHCPF should be funded without further delay in order to unleash the cycle of better health, economic and sustained development.

Setting the tone for the conversation – while welcoming participants to the dialogue, the Chairman/Editor-in-Chief of THISDAY and ARISE NEWS CHANNEL, Mr. Nduka Obaigbena, assured the audience that the media group would pay special attention to the health sector of the country for the next 12 months.

“We at THISDAY have focused a lot on the economy and politics, but I believe as the election year draws near, we will be focusing more on the health issues. So, in the next 12 months, we would be focusing more on health and education,” he said.

He also informed the audience that the forthcoming THISDAY Awards will target the health sector rather than governors and other politicians.

He explained that health was critical to the overall development, peace and security of the country, adding that it helps to improve three key areas of national lives, namely: living standards, poverty and inequality.
“Inequality is a problem because the country is faced with a great economic chasm between the rich and the poor,” he stated, while stressing that even the state of insecurity Nigeria is currently grappling with, was rooted in inequality.

Mr. Obiagbena added, “To bridge this inequality gap will be through a special focus on health and education. But we have found out that government alone cannot tackle our healthcare challenges. So, the question is, how do we finance the health sector? How do we get the rich to finance the health sector?”

The Director, Health Nutrition Population, the World Bank Group, Dr. Adeyi, while giving the keynote address at the policy dialogue, expressed concern that public health spending, as a share of total health spending in Nigeria, was low at 22 per cent compared to 36 per cent for Lower-Middle-Income Countries (LMICs) and 57 per cent for Upper-Middle-Income (UMICs).

He added that in the fight against out-of-pocket expenditure, which is being experienced by most Nigerians in accessing basic healthcare, the National Health Act has the capacity to be of benefit to eight million Nigerians by the end of 2018, if captured and implemented in the 2018 budget of the federal government.

The World Bank expert said now was the time to unleash the National Health Act, adding that it would lift Nigerians out of poverty and misery, judging from the fact that Nigeria spends less on healthcare compared to any country in the world.

He put the country’s spending on the health sector at 0.6 per cent of Gross Domestic Product (GDP), saying the current out-of-pocket expenditure was unacceptable and that Nigeria was prone to a poverty trap if the government fails in the provision of basic healthcare.

While emphasising that universal health coverage was achievable in Nigeria, he explained that public accountability for basic healthcare services, credible budgeting of public funds and effective/sustained planning would tackle the challenges enveloping the universal health coverage in the country.

According to him, “Nigeria is the second country living in poverty after India. The National Health Act will lift Nigerians out of poverty. At 0.6 per cent of GDP, Nigeria spends less on health compared to any country in the world, which is poor and below the middle and lower income average compared to other African countries.
“Out-of-pocket expenditure is very unacceptable, which is 75.2 per cent of the total expenditure and the highest in the world, and projects Nigeria as having the weakest health revenue in the world. All states must receive equal share of funding based on population.”

On his part, the Minister of Health, Professor Isaac Adewole, who actively participated in the conversation throughout the dialogue, said President Muhammadu Buhari-led federal government recognises that the country’s future success depends on its capability to transform non-renewable natural capital into productive wealth by investing more in human capital.

He said as the most populous country in Africa that has yet to complete its demographic transition, its human capital potential was substantial. “Yet, slow progress on poverty reduction, health outcomes, literacy, and governance challenges threaten further development. Our country is home to the second largest number of people living in extreme poverty, after India at 86 million in 2013, a 69 per cent increase from 1990’’, he stated.

He confessed that the country significantly underperforms in key health outcomes such as life expectancy, maternal mortality, and child health compared to regional and lower to middle income averages.

The Minister of Health agreed with the World Bank director that Nigeria spends less on health than nearly every country in the world, adding that for Nigeria to accelerate progress to universal health coverage, the federal and state governments would need to significantly invest more in health.

He continued, “In 2016, government health spending was 0.6 per cent as a share of GDP or just $11 per capita. This is below the regional and the lower to middle-income averages and the recommended $86 per capita for low and middle-income country benchmark needed to deliver a limited set of key health services.”

Describing the dialogue as unique, the minister commended the management of THISDAY for the initiative, promising that the federal government would ensure that the outcome of the dialogue is promoted.

He shared the popular view by the participants that although investment in health leads to economic growth, Nigeria invests too little and inefficiently in the health sector, spending less than nearly every country in the world.
Explaining the importance of a sound, healthy environment, Adewole noted that without an educated, healthy workforce, the nation would not be able to build the necessary infrastructure, saying it was important that the narrative is changed with a proper accountability framework.

Continuing, the minister wondered why the state governments and their health ministries were not doing enough to deliver improved healthcare services to the people, saying funds needed to be spent judiciously.

“We must spend these monies judiciously, we must account for it and we must justify increased allocations. I believe that this meeting will help us to articulate further what we need to do. And the media has a role. “This is my third year as a minister. When there’s disease outbreak in Calabar, there is diarrhoea in Kano, they say it’s the Minister of Health’s problem. Where are the Commissioners of Health? We should not assume that they do not have any role to play and everything is on the Federal Ministry of Health; that is wrong.

“The states have a role to play, they have responsibilities, there are people in those states who need to be taken care of. But everything is for the federal government to resolve. Maybe, when oil prices were high and there was a lot of money, the federal government could take on everything.

“But let the states rise up to the challenge, the states are not improving their health workforce; they are not employing nurses, they are not employing doctors, they are not even paying their salaries. At the state level, a consultant in the state earns close to what the most junior doctor at the federal level will earn.

“That is where we have a problem. So, we need to work together and I must thank THISDAY. This is unique, this is unprecedented and I want to assure you that we will partner with you,” he stated.

In his intervention, the Chairman, Senate Committee on Health, Senator Olarenwaju Tejuoso, said the Senate was working on modalities to see how N200 per 100 million Nigerians, which will translate to N20 billion per month, will solve the challenge of attaining the objectives of the National Health Act.

“The minimum expectation for Nigeria to have a functional health system is 15 per cent of the budget, as captured by the Abuja Declaration, but 16 years after, this is still not feasible”, the senator added.

He declared on his behalf and that of the minister that if the 2018 budget does not make any difference in the lives of Nigerians as it relates to health, then he would have no option than to change his portfolio in the Senate.

“The Senate Committee on Health is proposing to amend the Health Insurance Scheme. The private sector will take responsibility for funding the private sector. With N200 per 100 million Nigerians, which will translate to N20 billion per month, the health challenges in Nigeria will be a bygone issue,” the senator further added.

“If you can’t implement it, what is the need of having it on paper? If the budget won’t make any difference, let’s change portfolio. It will be best if I am taken to a place like the labour committee,” he said.
One of the panellists, Chairman of the Senate Committee on Finance, Senator John Eno, however, said that the issue was not about budgeting but efficiency in the implementation of the budget.

For instance, he explained that the revenue framework submitted by the executive did not include the national health fund in the 2018 budget, hoping, however, that it will be done.

“But then, when it is done how efficient are we going to be? But answering straightforward, the National Assembly is working to ensure the fund is included in the national budget of 2018 before it is passed,” he added.
Another parliamentarian, Chairman of the House of Representatives Committee on Health, Hon. Betty Apiafia, agreed with her colleague, Senator Eno, saying: “We need to improve on the budgeting for the health sector, and of course the efficiency of the funds budgeted.”

Also, the acting Director-General of the Infrastructure Concession Regulatory Commission (ICRC), Mr. Chidi Izuwa, while contributing to the panel discussion, said financing for universal health care coverage was not an issue, pointing out that the world is awash with funds.

However, he said lenders would not give money when they are not sure about the investment climate, adding that the problem with Nigeria’s healthcare was not just funding, but quality and access.

On his part, the Chief Executive Officer of the Nigerian Sovereign Investment Authority (NSIA), Mr. Uche Orji, said healthcare should be recognised as an investable sector, while making the case for training of personnel in the sector.

The Chairman, House Committee on Primary Healthcare Services, Hon. Chika Okafor, also called for a neutral regulator that would observe what the HMOs are doing and taking impartial decisions.

Meanwhile, the communiqué, which was read out by the Managing Director of THISDAY Newspaper, Mr. Eniola Bello, at the end of the policy dialogue, said: “Participants observed that although investment in health leads to economic growth, Nigeria invests too little and inefficiently in the health sector, spending less than nearly every country in the world.”

It added: “Where political leadership has rallied stakeholders behind investments in the health sector, significant improvements have been possible.

“The National Health Act passed in 2014, charts the way forward for increased investments in health and provides a legal framework for achieving Universal Health Coverage (UHC).”

Part of the recommendations from the policy dialogue, the communiqué noted included: Improved transparency and accountability in public financial management;

• Legal framework for financing the health sector should be robust enough to support the delivery of a set of high impact interventions;

• Increased public investment is important if Nigeria is to achieve Universal Health Coverage (UHC);
• Development assistance should only support government policy;

• State governments should increase public funding as more than two-thirds of public sector funding currently comes from the federal government;

• The public should take more interest in government policy and funding of the health sector and should demand greater accountability and transparency;

• The Basic Health Care Provision Fund (BHCPF) should be funded without further delay, in order to unleash the cycle of better health, and sustained economic development;

• Development partners to support the federal government’s efforts to improve primary care delivery using the BHCPF as the vehicle;
• Credible metrics and effective health planning, monitoring and evaluation by the Federal and State Ministries of Health is required to engender confidence;

• Reduction in out-of-pocket payments at point of service delivery through better and improved public investments in health;

• Efficient use of the private sector for supply chains and clinical delivery;

• Development of institutions to perform core public health functions;

• Health Insurance should be made compulsory;

• Channelling civil society activism and emerging accountability paradigm; and

• FMoH and NSIA should quicken the delivery of the centres of excellence in existing teaching hospitals.
The issues raised by the participants at the dialogue is a strong verdict that Nigeria has consistently ignored the commitment it made alongside other African countries 16 years ago on funding of health care services for its citizens.

Nigeria hosted the Heads of State of member countries of the African Union (AU) in 2001, which made the “Abuja Declaration” under which the leaders pledged to commit at least 15 percent of their annual budgets to improving their health sector.

Since the declaration, Nigeria has refused to attain the pledged funding benchmark as the federal government has refused to vote more than six per cent of its annual budget to the health sector. The highest since the declaration was in 2012 when 5.95% of the budget was allotted to health.

In the 2018 Budget proposal Buhari presented to the National Assembly, he allocated a mere N340.45 billion — about 3.9 per cent of the N8.6 trillion expenditure plan to the health sector.
The budgetary allocation is less than the 4.16 per cent and 4.23 per cent made to the health sector by the administration in the 2017 and 2016 budgets.

Nigeria again hosted over 50 African Heads of State in a special summit that was tagged ‘The Abuja +12 meeting” in 2011, which reviewed the progress made on the promise of the Abuja Declaration on health funding.
The implication of low funding of the health sector is that Nigerians spend estimated N359.2 billion on medical tourism annually.

Experts believe that the country’s health situation is of mounting worry especially in the insurgency shrunken North Eastern region where access to medical care has reduced. Several data also show that Nigeria has one of the worst health care delivery records in the world. The World Health Organization in its recent report rated Nigeria 187th out of 191 countries in terms of health care delivery.

The world health body said one-third of more than 700 health facilities had been destroyed in Nigeria and about 3.7 million people are in need of health assistance, placing Nigeria at third highest in infant mortality rate in the world.

Medical experts have also described as troublesome data released by international agencies, which put Nigeria’s maternal mortality rate at 68,000, showing that Nigeria recorded the second highest maternal death rate in the world recently.