Recently, I found myself stupefied by a statement by Dr Femi Thomas, the Executive Director of the NHIS on the amounts spent on health versus the amounts needed for universal health coverage in Nigeria. Currently we expend about 2.5 trillion naira, which includes premiums for national health plans, monies spent out of pockets and various governments spending on health. What does this sum get us? A system in which millions of Nigerians lack access to basic health care. Yet, a significantly 1.8 trillion naira would get us universal health coverage, where a much larger number of population would have basic health care. It is clear that we need a different strategy to attain universal health coverage in Nigeria.
What is Universal Health Coverage? To some, it could be argued to be just a more recent “trendy” way of defining the same thing that lawyers like me have tried to analyse and dissect as “the right to health.” To others it captures the essence of what governments should be striving to accomplish, providing basic health care for the widest numbers of a country’s population possible. The World Health Organisation describes the goal of universal health coverage as being the goal of ensuring that all people obtain the health services they need without suffering financial hardship when paying for them. This concept of universal health has been adopted by the government as an important goal for Nigeria. The Presidential Summit on Universal Health Coverage in 2014 affirmed health as a fundamental right of Nigerians.
The National Health Act contains various key provisions that will, if appropriately implemented, help provide universal health coverage. The provisions are aimed at increasing health coverage, affordability, and accessibility. These include the Basic Minimum Package; the Basic Health Care Fund; Referrals; and Emergency Care. There are also sections on quality without which coverage of any kind does not really achieve anything, for instance, provisions on Certificate of Standards. As Olumide Okunola, Senior Health Specialist at the IFC (which provides technical and financial support in health in Nigeria) has observed, these sections can be used to increase coverage through the addition of innovative approaches like the use of incentives to health providers to work in rural areas, as an example.
Urgently needed, therefore, is the implementation of these provisions. I believe an appropriate place to start would be with defining the basic minimum package provided under Section 3 of the Act. This is also in line with the recommendation of the Presidential Summit on Universal Health Coverage which stated that a standard benefit package of essential health services that address priority health care needs of all Nigerians should be defined.
Section 3(4) of the Act provides in part that “… all Nigerians shall be entitled to a guaranteed minimum package of services.” This appears to solve the problem of the right to access basic health care debated ad nauseam in human rights jurisprudence. However, the Act does not define the basic minimum package. At first glance, this appears to leave one of the most important provisions of this Act without force, lacking teeth. Certainly an argument can be made that such an important definition or description should have been articulated in the Act. This way, it is clear what the package is and it is clear that every Nigerian is legally entitled to it. The next best thing, however, would be that the Minister under powers conferred upon her by the Act defines the basic minimum package in regulations drawn up under the Act. This will give it the legal effect, since the regulations would be regarded as subsidiary legislation with all the attendant consequences. Given the fluidity of economic realities, disease burdens and changing technologies, this definition would include the Minister’s power to amend the regulations based on certain conditions.
To help chart a course for this important definition here, I will focus here on attempting to provide a roadmap to establishing this package. As noted by a WHO paper, essential or basic health packages in resource constrained countries, usually identify what is included, while basic health packages in richer countries tend to focus on what is excluded. Designing such packages should usually take into account what is needed – health services required, but also what is affordable, what is culturally acceptable, and what is politically feasible.
In terms of the latter, that is political feasibility, our federal system makes this imperatively, if often unfortunately, so. A certain level of political commitment and ownership are necessary to ensure practical implementation. A package that does not take into account what states can afford in a system where states and local governments have responsibilities and financial input, is bound to fail. Yet a system that does not attempt at least to provide the same basic care in Zamfara as in Lagos is bound to be inequitable with the resulting negative effect on national health indices, development and the economy.
But besides political feasibility, it is important to articulate a clear goal – theenunciation of a basic minimum package comprising ideally essential, cost effective interventions, to which every Nigerian must be entitled by law regardless of income, class, ethnic group, health status, gender, or location. The package should, at a minimum, contain primary health care services, children’s health services (in particular, immunisation, services for common illnesses such as malaria, diarrhea, pneumonia), maternal care, family planning, and health education. Some chronic illnesses, in my view, should be considered on the basis of prevalence, the existence of alternatives for sufferers, and other important criteria. I would, for instance, argue that certain mental health challenges be included within a primary health care services framework.
The design of this package, the scope and content, the manner of delivery, are critical to universal health coverage. The design must articulate what it is hoped to achieve. I believe it must be a mid-way between the utopian ideal for Nigerians’ basic health needs and the realistic goals that can be achieved today. This way we are not stuck with a package which cannot be delivered because it is not practical and sustainable, or a design which is so restrictive as to deliver in essence nothing.
An implementation strategy must be developed as an integral part of the design of the package. This strategy must demonstrate how delivery will occur and how the funds will be provided. In terms of delivery, the design must take into account the role of public and private providers in achieving the stated objectives. Accreditation of facilities and HMOs, as required under the National Health Act, the NHIS Act respectively, and other relevant legislation must take into account the capacity to deliver the basic minimum package. In terms of funding, the Basic Health Care Fund to be disbursed by the NHIS and the NPHCDA is a starting point, but we will have to think of other funding sources. It is also crucial to state how the services will be delivered – through free health services as some states currently have or via health insurance schemes. For reasons that I cannot go into here for lack of space, the latter is preferable.
The design should allow room for updating and expansion as economies generally do not stay static and as one hopes that not only will our economy in Nigeria improve but that political commitment to health and therefore government expenditure on health will improve, including through innovative approaches. Disease burdens may also change as will technologies for health care delivery. It should thus include a statement on how often the package will be reviewed and possibly updated – perhaps every two years.
The basic minimum package will operate within existing health financing frameworks and the frameworks now established by the National Health Act. These include institutional frameworks, including institutions like the National Health Insurance Scheme (NHIS) and the National Primary Health Care Development Agency (NPHCDA). These two agencies are primary agents for the purposes of developing the basic minimum package. Both agencies have previously each developed some form of essential health package. They will now have to harmonise these and take into account what I have described here and other considerations.
It will be crucial for other health financing, law, and policy experts to be part of this conversation to fashion out a lawful, suitable and practical and not overly restrictive package that provides reasonable and sustainable coverage that can be implemented throughout the country. The recommendations will then be provided to the Minister for input and development of regulations.
In closing, let me emphasise that to achieve the promise of universal health coverage, we must begin to flesh out and give teeth to many of the provisions of the Act such as the basic minimum package. It is understood that this could not have been done earlier, given the intense politicisation that accompanied the decade long path to enacting the National Health Act 2014. Now that we have the Act, the provisions must be thoughtfully implemented. This process of defining critical matters should ideally be sooner rather than later to allow effective operationalization and implementation of the potentially beneficial provisions of the Act.
Dr. Cheluchi Onyemelukwe-Onuobia
Executive Director, CHELD