AFOLABI GREAT.
Of late, social media is always filled with depressing posts of Nigerians trying to raise funds for siblings or relations who want a transplant or an expensive surgery outside the country. All across the country, tables of Chief Medical Directors (CMDs) are filled with requests for medical fee waivers in financial support for patients. Healthcare providers now prefer to inform their patients of their diagnosis and not their bill, because it is a worse sentence than the ailment they may be suffering from. While the illness may be bearing on only the patient, the bill impacts the entire community.
The current reality is that “you are only a sickness away from poverty”. This is a precarious situation because no one plans for sickness. It is not within anyone’s control to instruct their cells to behave and not become malignant. No one gives birth to a child hoping their heart is malformed so they would require a transplant. Yet these unpredictable diseases and illnesses are pushing more Nigerian households into poverty every day like our economic indices aren’t already bad enough.
Some may be tempted to think that hospitals are only trying to make a profit off others’ predicaments, but nothing could be farther from the truth. Healthcare is expensive. The cost of production, research and distribution of drugs are no measly cost. Neither is the equipment used to diagnose or perform procedures or the remuneration of health personnel (who are underpaid in Nigeria). All these culminate into the high cost of healthcare, a reality that’s lost on the Nigerian government.
In 2001, Nigeria signed a pledge to budget 15 per cent of its annual budget to the health sector, of which it has miserably failed. Within the current allocation, the majority is spent on recurrent expenditure and the building of new specialized centres, whose impact no one feels. Only about 5 per cent of the National healthcare budget goes to the National Health Insurance Scheme (NHIS) and Primary Health Care in form of the Basic Healthcare Fund, which is reserved mostly for public and civil servants. Of course, the coverage by the NHIS is very low despite being the largest health insurance scheme in the country.
Several private Health Maintenance Organisations (HMOs) have taken the opportunity to get into business. Yet, only 5 per cent of our estimated 200 million population are covered while 95 per cent of our population still pay for healthcare out-of-pocket. The ugly irony of health insurance in Nigeria is that it’s not available for those who need it the most. While a director in a federal ministry has to pay almost nothing to be treated for malaria, a family who lives on less than a dollar per day, have to spend a fortune to get less quality of care.
Despite the annual budgeted sum for healthcare, it has failed to reach those who need it the most. It tells that the problem isn’t how much is spent but the way it’s spent. Curiously, only 5per cent of our population are covered and only 5 per cent of the health budget is spent on insurance. Coincidence? I don’t think so. Among the several problems plaguing healthcare, out-of-pocket expenditure may be the most important. Foremost is because it affects health-seeking behaviour. A study in Nigeria by the Health Economics Review observed that economic status determined health-seeking behaviour. Those who were a part of the upper socio-economic class were more likely to present promptly at competent health facilities unlike those in the lower socio-economic class, who were more likely to watch and wait or visit unaccredited health givers.
Out-of-pocket expenditure also forces health providers to treat patients according to the size of their pocket. While Fairness, Justice and Equity are part of the core ethics of the medical profession, health providers have to face the dilemma between upholding this principle which means doing nothing or working with what’s available for their patients. Hence, those in lower socio-economic classes are prescribed affordable drugs of low quality while the upper levels are the ones privileged to get standard medication. Mind you, these illnesses have no respect for anyone’s account balance. Several times, patients have to delay interventional treatments while they go to raise money and by the time they return, it’s already too late and may need a more complicated and expensive treatment.
No one wins with out-of-pocket expenditure. Hospitals cannot charge the right fees for their services, so there is inadequate cash flow into the health economy and thus the vicious cycle of industrial strikes and dilapidated medical services in the country. For too long, the Nigerian government has paid attention to the wrong aspects of healthcare and the time to correct that is now. There has been more emphasis on subsidizing healthcare at public hospitals, which unfortunately is still too expensive for the average Nigerian. For instance, a Caesarean Section that could be required as emergency costs ₦30,000, way more than the minimum wage. If the Nigerian health sector will ever stand on its feet again, out-of-pocket expenditure must be eliminated by providing insurance for every citizen of the Federal Republic of Nigeria. Every level of government; federal, state and local must rise to this responsibility.
Several models suggest how this can be done. Examples of mass insurance being done on a federal scale is the National Health Scheme (NHS) in England and the Sistema Unico de Saude in Brazil. These two systems make sure that all citizens can access healthcare for free at any of the affiliated treatment centres. However, it isn’t free as they are funded by general taxation and contributions by the state. The schemes pay the hospitals whatever expenditure is spent on their citizens. A similar model can be replicated in Nigeria by expanding the NHIS scheme and creating a special taxation model to fund it. Fellow African countries like Tunisia, Rwanda, Egypt, and Mauritius have been able to cover above 80 per cent of their population.
But as the agitations for restructuring increase, states can begin to lead the way by insuring their residents. Already, about 19 states have begun implementation, but it needs to be treated as a matter of urgency with more aggressive campaigns to cover their citizens. Lagos State has taken the initiative through the Lagos State Health Management Agency (LASHMA) after the Lagos State Health Scheme Bill was passed in 2015. Its’ sources of funding include 1 per cent of the Consolidated Revenue Fund, premiums from the formal and informal sector, donations, Grants-in-aid and the National Health Act through the NHIS and NPHCDA. It provides different schemes to different cadres of the community including sportsmen, seniors, students and the public. More governors should emulate these schemes in their states, and citizens must also demand it.
There is still room for more players in the private sector to get a slice of the cake and achieve some social good while at it. They can take advantage of the sachet economy by providing small insurance packages for specific health issues e.g. Malaria, Maternal Health, etc. at small premiums. This will encourage more citizens to take on health insurance for themselves and their families. One problem existing HMOs have complained about are the data gaps between them and Healthcare providers, but technology can surmount this.
Already Nigerians are crowd-funding to pay for healthcare, what we need is to organise it better and create a larger pool that will be available for all citizens. The fact is that with our worsening economic indices, more Nigerians don’t even have pockets let alone affording out-of-pocket spending for healthcare. Health Insurance is a matter of urgency, any further delay could be disastrous but by taking the right steps, it is capable of transforming the economic story of our nation, anyway “Health is Wealth.”
Twitter- @Latid13
LinkedIn- Olatide Afolabi
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