How to achieve universal health coverage, reduce brain drain, by Oloriegbe

Dr. Ibrahim Yahaya Oloriegbe is Chairman, Senate Committee on Health. In this interview with CHUKWUMA MUANYA, he speaks on efforts to ensure Universal Health Coverage (UHC) in Nigeria.

What is your assessment of Delta State’s model for attaining universal health coverage?
I think it’s innovative. There are lessons to be learnt for scale up applications. Of course, as a health system person, I have had opportunity of studying options like this. What came to my mind is what I saw in Cambodia, in 2006, but that one was donor driven, what they call contracting-in and contracting-out system. So, it is a similar thing. What you see here is government trying to provide healthcare for its people, particularly, those that are hard to reach or do not have access to normal health services. They know that the normal government system cannot provide that, so, they make use of private sector. Government owns the facilities and guarantees the filings and also creates business opportunities for them through insurance enablement.

The key challenges I see there is, if it has to be in urban area, there will be resistance from the unions, because it means they are handing over facilities where you have doctors, nurses, all health workers recruited by government and they will move them out of these places. But if they give it to the private sector, they may not retain those staff or the staff may not want to be retained under the condition of the private sector services because of pensions and other things. But it is something that can be replicated for areas that are hard to reach or are unattractive to regular government workers, by so doing, reach the unreachable and be able to bring them on board those people into the main healthcare services.

DSCHC said it has reached 25 per cent of the state’s population and the National Health Insurance Authority (NHIA), which used to be National Health Insurance Scheme (NIHS) has not been able to reach more than five per cent of Nigerians. Are there plans of replicating the DSCHC model on a national scale?
It is not through this alone that they reached the 25 per cent. What they are saying is that their entire state health insurance activities have reached that, including the formal sector and informal, where one pays N7,000 and gets covered. There are many states that have keyed into that. What we need to understand about NHIS is that it was optional. That’s why we changed the law to make it mandatory.

It covered only federally employed personnel; whether you are in the civil service or in the security outfits such as the Police, Army and other security agencies. When it started, there was no contribution by even the employee. It was purely to encourage buy-ins; the labour union resisted deducting money from their salaries as part of their contribution. But with time now, the medical allowances paid were converted into the premium. It has now been changed to employee’s and employer’s contribution. So, that was one of the reason that one did not go beyond five per cent in total. But with what we have done now, making health insurance mandatory for every resident in Nigeria, it means everybody, whether you are employed by the state, federal, private sector, local government, you must enroll. If you are not in any of these, and you are in the formal sector; you must also get that. This current law, properly implemented, would expand it to everywhere.

But this one you are talking about Delta and other states, they will now be captured. So, while we have the NHIA as regulator, the state will be implementing it. When we said is mandatory, it means the basic, because we also have what we call the add-ons can still exist, which is private. The basic is that you have a basic healthcare, which is determined through a guideline but it does not mean you cannot pay extra premium to have add-ons.

This programme claims to have tackled and is tackling the issue of brain drain, that most doctors are being retained and they may not have to travel abroad because they are being taken good care of. Is government at the federal going to copy the model?
This model cannot solve the problem of brain drain because the issue is systemic. The health workers payment is within the general system, they cannot increase salary of doctors, nurses and other health workers beyond what National Wages and Salaries Commission has fixed. It is a law of demand and supply, basic economics. The demand is very high all over the world with good pay and here we cannot meet that demand, so, the supply will be less. There will be migration until when we reach equilibrium.

This DSCHC programme cannot solve the challenge of brain drain. What can solve it, as I had said, are two things: We have to pay appropriate wages for work done, that is, it should be based on not only your output, but on what you are contributing. What I am saying is that, where they are migrating to, is because health workers are better paid compared to this place. So, health workers should be better paid here just like you hear university lecturers demanding that they should be paid, specially.

What the DSCHC programme has done is to reduce brain drain, not that it has eliminated it, because they get guarantee for their payment. The way they say it is that they go for two weeks medical intervention into the creeks and hard to reach areas, and they come out. It means that they are paying the health workers a little bit higher than what they will get in normal government services. So, if government can remunerate appropriately, then they will retain more people.