Professor Eyitayo Lambo, a health economist and health systems expert, was Nigeria’s Minister of Health from 2003 to 2007. In this interview, he x-rays bottlenecks to increasing health insurance coverage for Nigerians, the progress made towards achieving Universal Health Coverage and areas of concern in the country’s health system. Excerpts:
Daily Trust: You are one of those pushing for Universal Health Coverage (UHC) in the country, what does it mean and how does it affect access to health services?
Professor Eyitayo Lambo: There are many definitions of universal health coverage but the standard one is the one provided by the World Health Organization (WHO) which says ‘UHC means that all people and communities can use promotional, preventive, curative, rehabilitative and palliative health services they need of efficient quality to be effective, while also ensuring that services do not expose their user to financial hardship.’
This definition embodies three related objectives: equity in access to health services (everyone who needs services should get them, not only those who can pay for them); the quality of health services should be good enough to improve the health of those receiving services; and people should be protected against financial risk, that is ensuring that the cost of using services does not put people at financial risk.
DT: Can you tell us about the journey of health insurance in Nigeria and the grey areas in establishing a national health insurance scheme?
Prof. Lambo: Attempts to establish a health insurance scheme was made by Nigeria’s first Health Minister, Dr. Moses Majekodunmi in 1962 but the bill which was introduced in parliament was defeated. Renewed efforts were made in 1984 by the then health minister, Admiral Patrick Koshoni, and by Professor Olikoye Ransome-Kuti who was health minister from 1985 to 1992. Their efforts led to establishing the desirability and feasibility of health insurance in Nigeria and the development of the template for establishing a national health insurance scheme in Nigeria respectively. The National Health Insurance Scheme (NHIS) Act of 1999 had some deficiencies, and includes making health insurance voluntary instead of mandatory. It provided the legislative framework for establishing and implementing NHIS in Nigeria.
There was, however, slow or non-implementation of the Act until during President Olusegun Obasanjo’s second tenure when the formal sector programme of NHIS was launched on June 6, 2005 to cover federal civil servants and with a presidential mandate to NHIS to achieve Universal Health Coverage by 2015. As part of the Health Sector Reform Programme from 2004-2007, I as the minister of health then set up a committee to look into how to restructure NHIS and make it more effective. But the recommendations of the committee could not be implemented then for many reasons, including the focus on the launching of the former sector programme of the NHIS.
There were attempts to revise the faulty 1999 NHIS Act such as the sponsorship of a private Bill for an Act to amend the 1999 Act by Hon. Christopher S. Ita in 2010, the sponsorship of a more comprehensive private bill by Hon. Ndudi Godwin Elumelu in 2011 to deal with the shortcomings of the 1999 National Health Act, and the sponsorship of yet another private bill in 2017 by Senator Lanre Tejuosho whose bill passed first and second readings and indeed received public hearings. However, the current status of this last effort is not known. So, for almost 20 years after the defective 1999 NHIS Act was enacted, it is yet to be amended in spite of the fact that its limitations have been recognized even from the beginning. Such limitations have contributed greatly to the slow and poor implementation of national health insurance in Nigeria, and that no country has been able to achieve UHC with voluntary health insurance scheme is common knowledge.
Some of the grey areas in the implementation of health insurance in Nigeria include but are not limited to the following: How to cover the people outside the formal sector as well as the poor, the vulnerable, retirees and the elderly; how to ensure effective regulation of the operators in the health insurance market, and how to generate adequate and sustainable funding to ensure that all Nigerians are covered by prepayment and risk-pooling schemes.
DT: Where are we today with regard to Universal Health Coverage (UHC)?
Prof. Lambo: I will apply the globally selected indicators for monitoring progress towards UHC by any country to objectively answer your question. One of the indicators is that a country’s Total Health Expenditure (THE) must be at least between 4 and 5% of its Gross Domestic Product (GDP) with public spending being at least 3% of the 4-5%.
Whilst Nigeria’s total health expenditure as a percentage of GDP has consistently been between 4 and 5%, the public spending component has been below 1% which is grossly inadequate. Another indicator is that Out of Pocket Expenses (OOPE) should not be more than 30-40 percent of the Total Health Expenditure (THE). For Nigeria, OOPE has constituted between 62 and 72% over the years! Another indicator is that at least 90% of the Total Health Expenditure (THE) should be through prepayment and risk-pooling schemes. The highest coverage level with prepayment and risk-pooling schemes that Nigeria has ever achieved was 7%.
The fourth indicator is that close to 100% of the poor and vulnerable must be covered by social assistance and safety-net programmes. Whilst Nigeria’s achievement is not exactly known, a generous guess will be less than 25%. Another indicator is that at least 80 percent of the poorest 40 percent of the population should have effective coverage with quality health services. Nigeria’s current performance with this indicator is certainly very low in view of the longstanding and widespread problem of low quality of health services.
Lastly on the Abuja target of spending at least 15% of Total Government Expenditure (TGE) on health by all levels of government, the best performance that we have ever achieved was less than 9%. It is as low as less than 5% currently. From these scores, it is clear that Nigeria is yet to seriously start the journey towards Universal Health Coverage.
DT: What is the way forward?
Prof. Lambo: The most important way forward is to develop and sustain political leadership and commitment to universal health coverage which is virtually non-existent currently. This will require decision leaders to use their power, influence and personal involvement to ensure that universal health coverage receives the visibility, leadership, resources and political support that is required to undertake all necessary steps to achieve it.
The political leadership and commitment would need to be expressed or demonstrated by making universal health coverage a political goal and putting it on the nation’s agenda. It involves making universal health coverage explicit in party policies, manifestoes and regarding it as a political campaign issue. It also includes ensuring that the leadership and the commitment to universal health coverage from the office of the president at the federal level and the office of the governors at the state level. Others include formulating a clear vision for universal health coverage, developing and implementing all necessary policies, plans, laws and regulations to attain the vision. It also requires allocating adequate and sustainable domestic resources to health by all levels of government, mobilizing domestic and external resources and using such resources efficiently, equitably and effectively. It can also be demonstrated by according first priority to covering the poor and vulnerable groups with public funds, setting up a multi-sectoral organ to coordinate the efforts of all stakeholders involved in the production of health, not health services; setting up a political monitoring process to track the use of allocated resources and concrete progress made as well as working closely with civil society organizations (CSOs) to sustain political support.
Other measures to take as a way forward are: strengthening the national health system with emphasis on revitalizing the primary health care system to make it effective and efficient, having adequate and appropriately distributed health infrastructure and staffing, removal of financial barriers through the acceleration of the implementation of prepayment and risk-pooling schemes and provision and financing of essential health services package.
DT: You have been involved in the country’s healthcare system for long, what really gives you concerns about it now?
Prof. Lambo: My concerns now remain almost the same as they have been for years. They include but are not limited to the lack of political commitment to health, inadequate health funding by government and inefficiencies including fraud and corruption in the use of the limited resources available, and inequitable access to services. My other concerns are poor quality of health services, public loss of confidence in our health system and thus increased outbound medical tourism. I am concerned about health policy somersaults and lack of policy continuity, professional rivalries and incessant strikes by medical and health personnel, and poor health system performance. Many less resource-endowed countries than Nigeria have been able to make significant progress in addressing these concerns.