11th February, 2016
Healthcare and the struggling economy
In these days of economic gloom it may appear wildly optimistic to say that there is a lot of money that could be made immediately available for use in the Nigerian healthcare sector. It may seem unrealistic to expect that a government currently superintending a bare treasury could somehow source billions of naira to inject into the health sector in states across the nation without crippling other sectors in the process. But I know it to be true and I believe it is especially urgent in these straitened times to get the money working for health in this country.
Our economic downturn has been frustrating for Nigerians looking forward eagerly to the change promised by General Buhari. It seems an unfair twist of fate to be gifted an honest leader who is determined to move Nigeria forward only for his administration to be starved of the funds to do the job. However, in the Health sector there is hope.
Hope for health?
We stand to benefit from a culmination of a series of public health events that began decades ago: A groundswell of opinion, policy changes, technical advances and an international public health community, impatient at our abject failure to improve our healthcare system, that is ready to back a big idea that might do the trick. We now have a clear route to our desired destination and resource mobilisation by Government and partners has provided significant financing; the only missing ingredient is political will. The right actions taken now will precipitate a cascade of changes that could create a revolution in the equitable delivery of quality healthcare services to our citizens.
Universal Health Coverage – the target
It is a long and winding path that has brought us to this promising take-off point. As far back as 1978, the objective – if not the roadmap – was clearly laid out in the Alma Ata declaration – Primary Health Care delivery is the key. Years rolled by and in spite of its evangelism by one of our most lauded Health Ministers, Prof Olikoye Ransome-Kuti, (and ample proof that he was right) effective sustained PHC services remained a pipedream: we still had not solved the how. Health for all by the year 2000 came and went, Primary Healthcare, Now More than Ever was the title of the 2008 World Health Report, urging us (ie those in the developing world who needed encouragement) forwards. And now we have the refrain of Universal Health Coverage (UHC), growing ever louder. UHC can be defined as all people having access to the health services they need, of appropriate quality, without suffering financial hardship. In principle the same message was there in 1978: get affordable equitable healthcare to the grassroots.
Unfortunately, building clinics and a multiplicity of vertical programmes has got us nowhere and we have been wondering just how to tackle the complexity of developing a healthcare system that can deliver. This is clearly illustrated by the length of time we have been talking about, and spending money on, ‘health system strengthening’ without even partly achieving it. Money has been a big part of the problem, not only the amount but the question of how and where it flows.
How to get to the UHC target
Now however, as enshrined recently in the Sustainable Development Goals, and before that – in Nigeria – at the 2014 Presidential Summit on Universal Health Coverage, the roadmap has more detail and a more promising route – Social Health Insurance is seen as the route to sustainable success. It has been pioneered in Kwara, Ogun and Lagos States, still on a relatively modest scale but enough to convince observers that this may just be the How that we have been waiting for.
Calling a well-designed scheme health insurance is somewhat of a misnomer. It is like calling a car an engine. The word hints at power and motion but does no justice the the complex interaction of the many parts of the system. An effective State-supported Health Insurance Scheme (SSHIS) doesn’t just help the insured pay their bills. It must embrace the finance (including government subsidy to make premiums affordable and the scheme sustainable), the quality of the services and a mechanism for their continuous improvement, provision of preventive services, the administration of the system (including some decentralisation), the involvement of the communities in its running, and partnership with the private sector. Importantly the schemes must be based on baseline research that will enable customisation to each locality. It is much more than health insurance – it is re-engineering the health system starting from the obvious place, the bottom of the pyramid. It addresses both sides of the equation in detail: the demand for, and the supply of, quality affordable healthcare services.
The National Council on Health, the highest decision making body in Nigerian Healthcare, has adopted the idea as policy and mandated the National Health Insurance Scheme to support the setting up of SSHISs around the nation. This is a welcome recognition of the importance of a decentralised approach to health system strengthening that will prove crucial to success.
Where is the money to fund affordable healthcare?
So now that we have a national and international consensus on the need to aim for Universal Health Coverage and agreement that Social Health Insurance is the best route, we need the finance to start work – where is it?
During the tenure of Prof Chukwu as Minister of Health, Dr Muhammad Ali Pate was Minster of State (2011-2013) and during that time he championed an idea which has become known as SOML. In full – The Saving One Million Lives Initiative – Programme for Results. The programme aims to increase access to high impact, evidence-based interventions in maternal and child health through a results-based financing (RBF) scheme. RBF is an effective funding method in which you pay more for better results. Most importantly, the Government negotiated a $500 million IDA credit with the World Bank.
The initiative provides for an initial grant of $2m each to 29 states and $1m to the remainder (using criteria based upon baseline statistics). The initial grant is awarded on receipt of a detailed work plan which outlines interventions and targets. It is not competitive, nor are there any stringent criteria – just submit a workplan. States were informed early in 2105 and responding quickly to the promise of this ‘manna’ from Abuja, most states submitted plans. All the plans have been approved and the World Bank funds have been made available to the Federal Government. At the time of writing, however, the money has not yet been released to the states.
After the initial grant, further disbursements will be performance-based. Although $500m, will go a long way, divided amongst the states it might suddenly look a lot less like the grounds for the great optimism I have expressed so far – but there is more.
How to double the Federal grant money
As mentioned, UHC is now part of national policy and is even enshrined in the National Health Bill passed in 2014. The National Health Insurance Scheme (NHIS) has a significant pool of funds that are to be dedicated to initiating State Supported Health Insurance Schemes (SSHIS) in furtherance of the implementation of this national policy. The NHIS began engaging states, and continues to do so, making it clear that states could be given a subsidy to the tune of hundreds of millions of Naira to help to pay premiums for enrolees in vulnerable groups into state schemes. Put another way, if states set up their insurance schemes, the NHIS will almost guarantee their early and successful take-off by helping to pay subsidies, thus making it free for pregnant women and children.
The criteria to access these funds includes the states committing to match the funds and setting up appropriate institutional structures.
If you have been paying attention, you may have just noticed something that was not lost upon some state ministries: those finding it hard to raise the matching funds to unlock the NHIS money, could easily and legitimately get it from the take-off grant being provided by SOML – because it is also targeted at women and children. Federal grant money is right now available to states to help unlock the conditional NHIS money!
And there is even more . . .
The final piece of the financial jigsaw is the state insurance scheme itself. The schemes take basic healthcare to the grassroots in return for a modest premium, set at a level that is affordable by even low income earners in the public, private or informal sectors. Even a modestly sized scheme with relatively low premiums could make additional hundreds of millions of naira available to primary healthcare budgets – larger schemes could, once they get momentum, raise billions to swell the State Health Insurance Agencies that will channel payments to the primary health facilities and some secondary providers. Meanwhile, the SOML design, (including the PBF incentive) which extends until the end of 2019 has the flexibility to be highly complementary to efforts to entrench Social Health Insurance programmes.
It’s time to let the money flow!
From the foregoing, it should be clear that in the health sector there is much that we can be getting on with. The heart of my message is that none of the above sources relies on the depleted Nigerian treasury, it is all additional to government budgets. In these financially lean times any if money is available to be injected to the health sector, getting it moving should be seen as a priority. This money can, in addition to directly benefiting grassroots healthcare, unlock even more funds. That latent multiplier effect makes it in my view an emergency.
We need some good news and I believe that good news can come from the health sector. Ultimately the cascade of events that SOML grants can trigger will add billions of Naira directly to the primary healthcare budget of every state in the country – that will save more than a million lives and put millions of smiles on the faces of Nigerians. The Buhari Government will be able to deliver on its promise to get decent basic healthcare to the people and deliver real change to the healthcare system.
Dr Olaokun Soyinka
February 2016. (Dr Soyinka was Commissioner for Health, Ogun State, 2011-2015)