A Vision for Nigeria Health System in 2030

Frog_leapfrogging

Consolidating its position as Africa’s largest economy, and 10 years after it has been admitted into the Global 20 Club – Nigeria’s place as a significant economic power house is no longer in doubt.

The economy is now more diversified and the tax base is healthy, although government still relies heavily on oil and gas revenues. Like Agriculture that fully transformed itself from subsistence level to a growth sector in the decade that ended in 2020, the Health sector has also emerged from its ‘cocoon’ where it has undergone metamorphosis from its ‘pupal’ social service status to become one of the ‘real’ sectors of the economy. The key drivers are (i) the over USD 10 Billion annual spend on pharmaceuticals (drugs and medicines); (ii) commoditisation of healthcare that is no longer differentiated from personal care, as several medical goods and services loose their unique medical function and become readily available at the marketplace; and (iii) a massive middle class that demand for quality care and are willing to pay for better services.

And while there has been no rational re-design of the delivery system – health services are delivered through diverse approaches. Ranging from home-based care, mobile clinics, and provision from the regular government owned and operated primary health care centres and General Hospitals, to privately run specialist medical centres – there is near universal access to a broad-range of healthcare services. But the vast majority are ‘Stand-alone Facilities’ and Independent Practitioners using very basic to high-end specialised equipment that are responding to consumer demand for quick and reliable diagnosis and treatment of common and not too common health problems. In the rural and semi-urban areas, many of these are health extenders – not the conventional Community Health Extension Workers (CHEWs) usually employed by the LGAs, but ‘Paid Volunteer Health Workers’ linked to specific health programmes such as immunisation, maternal and child health, malaria, nutrition, TB, HIV/AIDS etc. And the PHC health facilities from where these cadres of health workers are supervised have taken on a new role – that of coordinators of inputs of these health interventions and the expected health outcomes for a given population.

There is still some bit of medical tourism as the proportion of citizens that is older (with associated chronic medical conditions) and richer (with huge disposable incomes) accounts for about a fifth of the population. But the destinations are now more widespread. Rather than India, the United Arab Emirates, Dubai in particular now receives the largest number of medical tourists from Nigeria. The United Kingdom and South Africa with strong historical and continental trading ties respectively also have reasonable share of this extended Nigeria healthcare market. Interestingly, these external medical suppliers are linked to local network of providers that feed the international markets, as well as maintain some level of continuity of care when the medical visitors return home.

In terms of financial access and funding for health services, the so called National Health Insurance Scheme is still faltering. Due to ‘vested interests’ the programme fails to take on a national outlook, as it has not been reformed within the context of a federal country; and thus not able to expand beyond its initial coverage of workers in the employment of the Federal government. Several State governments also attempted to institute state-based health insurance or similar pre-payment schemes, but these too have ran into similar difficulties as they were prone to capture by entrenched interests – politicians, civil servants and professional groups. And there has been serious tensions between State Primary Health Care Development Agencies (or Boards) on one hand, and the National Health Insurance Scheme, alongside the National Primary Health Care Development Agency and the Federal Ministry of Health, with respect to control of the Primary Health Care Fund that is incorporated with the National Health Act. Consequently, PHC Agencies in several States are only in name as they have not been funded by their State governments and the hope of accessing the national PHC Fund has not materialised. Only in States such as Zamfara and others that have adopted a ‘basket-fund’ arrangement where ‘pooled funding’ for PHC activities from State, LGAs and Donors exist – are State PHC Agencies or Boards seen to be viable with related improvement in access to services and health outcomes.

Notwithstanding, as a market for health care emerges, driven by high consumer demand and spending power, individuals and households still account for the largest proportion (over 70%) of total health expenditure in the country. But curiously, direct out-of pocket payments are now very low (about 10 to 15% of total health expenditure), due to the myriads of private pre-payment medical schemes and innovative market-based health care payment mechanisms that facilitate financial access to health care across the country. Learning from how multi-national companies – from manufactures of household goods to mobile telephone operators and digital television service providers – have converted the millions at the bottom of the income pyramid into effective consumers, smart healthcare enterprises are offering ‘financial access packages’ to healthcare tailored to the needs and aspirations of each and every segment of the population.

In this health care scenario, Donors or Development Partners as they prefer to be called, struggle to find a new role for themselves. Government officials still make the right noises about being committed to the Post-2015 Agenda, but it is business as usual as donors especially those with global mandates continue to carry out their small projects in limited number of LGAs while pretending to be supporting national programmes for this and that disease or strengthening national health systems. Nevertheless, donor-supported programmes, more like ‘research pilots’ provide good evidence for continuously improving health care service delivery and the management systems that support it in Nigeria. For example, our knowledge about the effectiveness of Community Health Volunteers as health extenders came from experience gathered from two donor-funded projects: an Australia Aid (AUSAID) funded Community Mental Health Programme in South East Nigeria that was managed by CBM Australia; and a Nutrition Programme in Northern Nigeria, which was jointly overseen by Unicef, Save the Children, and Action Against Hunger, but funded by UK Department for International Development (DFID). However, we also learnt from these projects that to be sustainable, Community Health Volunteers have to be paid – no matter how small.

And as per Health Care Professional Unions – the Doctors, Nurses, Pharmacists and the rest – they have become very unpopular with the average consumer of healthcare services. Tired of their constant bickering over professional supremacy, and their collective neglect of the interests and concerns of the consumer over the years – Nigeria healthcare consumers have used their new found influence expressed in ‘healthcare purchasing power ‘ to set new measures for healthcare delivery performance, partly based on mutual accountability among healthcare professionals. Although cost of care is important, consumers now value choice and trusting relationships with doctors and provider-teams who routinely spend considerable time learning about each consumer’s medical history and needs and provide each consumer with a feeling of empathy, security and respect.

With respect to the overall performance of the health system, there have been fundamental changes that are more aligned with the overall economic growth and development agenda of the country as an advancing economy, than with technically perceived unproven ideals. While the United Nations (UN) and its agencies fret about lack of progress by Africa’s largest economy in meeting the Post-2015 Agenda targets, the ‘leapfrogged’ changes at both macro and micro levels have set Nigeria’s health system on a path to sustainable development. And this transformation has started to lead to: (i) better health outcomes – for all demographic and socio-economic groups; (ii) improved individual satisfaction and experience – with health activities and interventions; and (iii) enhanced financial sustainability – for both individuals and the economy as a whole.

Nigeria Health Sector in 2015

Healthcare Nigeria

With the singing of the National Health Bill at the twilight of 2014, stakeholders in the Nigeria health sector naturally appear to be gearing up to actively participate in what they anticipate would be the beginning of a ‘new dawn’ for health care delivery in the country.

Theoretically, the National Health Bill now an Act of the National Assembly (Parliament) creates a huge opportunity that would help the country chart a path towards achieving Universal Health Coverage (UHC) in the very near future. Specifically, as this law makes provision for financing Primary Health Care (PHC) from the Federation Account, outside the regular monthly allocations to the 36 States (that is not mandated for any goods or services); it is expected that the in-built mechanism of using this as a ‘challenge fund’ would leverage additional resources from the States for PHC. And there is therefore the assumption that the potential increased funding for PHC would by and large provide vital health services at the community level, as well as secure financial risk protection for ordinary Nigerians when they use such services.

But this futuristic glance of the coming year – 2015, advise the exercise of caution in balancing optimism with a tinge realism.

Here is why ‘fundamental health system change’ that leads to: (i) better health outcomes – for all demographic and socio-economic groups; (ii) improved individual satisfaction and experience – with health activities and interventions; and (iii) enhanced financial sustainability – for both individuals and the economy as a whole – may not happen (or begin to happen) in 2015.

First – 2015 is election year in Nigeria. Though the elections will definitely come and go, and there will be winners and losers for sure. But as most things in Nigeria depend on government, the period of electioneering and the outcome of this significant national event will influence what happens generally in the country for the whole year. The May 29th ‘transition date’ somewhat divides the year into two halves. The first part of the year, overshadowed by ‘election fever’ will create uncertainly as stakeholders within the health sector may not fully engage with government as they are not sure of who they may be dealing with after the elections. The second half, the transition period will be equally unsettling as political officer holders – who are either new to office or consolidating their mandates – would either be finding their bearing or trying new approaches to doing things based on their previous experience.

Second – as technical capacity at all levels of government (Local, State and Federal) within the health sector remains weak; 2015 is not the year when suddenly technocrats in Nigeria are able to translate policies into plans and get them implemented. Moreover, as they are known to be territorial and clandestine in their dealings; this may not be the year when they become more transparent and agree to openly work collaboratively with all stakeholders in the health sector.

Third – Nigeria is an emerging economy (despite income inequalities) with all the trappings of affluence, and a growing middle class. But the International Donor Community (aka Development Partners) remain pretentious about delivering International Aid in the health sector based on conventional ideas of helping a poor country. In 2015, Development Aid to Nigeria in the health sector will continue to be ineffective as the interventions of Donor organisations will continue to be seen as projects of the respective agencies (including those with global mandates); and not national health programmes since they will fail to make the connection of engaging with a country in transition.

However, all hope is not lost for the Nigeria health sector in 2015. Based on the ‘drivers of change’ analysis – we are aware that while actors make outcomes possible their capacity to act is ultimately set by the structural context which they find themselves. Notwithstanding, in 2015, change may still come through collective action by actors who are able to overcome such structural obstacles by re-making of institutions – modifying the way actors relate with each other and with the structures. As previously demonstrated by the ‘Nollywood Paradigm’, the group that got the National Health Bill passed and signed through sustained advocacy – the Health Sector Coalition of Nigeria – will continue to ensure that the National Health Act begin to provide benefits for all Nigerians as intended and not hijacked by vested interests. But fundamentally, as the market-based Nigerian economy powers on (irrespective of low oil prices, which will only affect government revenue), the health sector will most likely follow the approach of the multi-national companies serving Nigerians (even the very poor) with good and services – by converting them into effective consumers rather than being patronising in their dealings.

On this note, stakeholders in the Nigeria health sector should look forward to a 2015 that will not only engage their energies, but also their mental faculties as they ‘navigate’ the ‘treacherous waters’ of re-vitalising the health system, especially primary health care delivery.