Improving health financing in Nigeria

Medical experts have made recommendations on how to improve health financing and ensure the efficiency of existing spending in Nigeria.

The team, in their report titled “The Lancet Nigeria Commission: investing in health and future of the nation”, called for ‘One Nation, One Health.’

The Lancet Nigeria Commission is a multidisciplinary group of Nigerian academics based in Nigeria and around the world, working in close collaboration with University College London’s (UCL’s) Institute for Global Health and policymakers, over a two-year period, reviewed existing disease burden, and opportunities to improve health.

The landmark UCL -led report studying health inequality in Nigeria has called for urgent action by policymakers to prevent diseases before they occur and to urgently increase access to health care for all.

The Lancet Nigeria Commission report, inaugurated March 16 by the Vice President, Prof. Yemi Osinbajo, found that health outcomes remain poor in Nigeria, despite higher expenditure since 2001.

The report recommended that the Federal Government (FG) should lead efforts to improve health financing (that is, revenue mobilisation, pooling and management of funds, and purchase of services), aligning the investment case with political incentives, levers of accountability, and the rhetorical appeal of “health for wealth” among the Nigerian population.

To achieve these improvements, the Commission said the government should:
•Establish legally ring-fenced predetermined health budgets outside of the electoral cycle, which occurs every four years to ensure sustainable funding and strategic planning, building on the Basic Health Care Provision Fund (BHCPF), and using the third National Strategic Health Development Plan (NSHDP) to reach the goal of 15 per cent of the yearly budget allocated to health
• Establish structural reforms to withdraw inequitable subsidies towards financing health and social services building on lessons from the Presidential Task Force on COVID-19 (example, N1·5 trillion in petroleum subsidy can free up fiscal space to be redirected towards health)

• Fund health insurance coverage to all Nigerians by paying the estimated N15,000 per capita yearly premium for 83 million least wealthy individuals (approximately 40 per cent of the population) with revenue raised through the Basic Healthcare Provision Fund, taxation, and levies, and each state to fund residents through their state health insurance scheme supported by a national mechanism to assure quality; today, it would cost N1.2 trillion or nine per cent of the current budget to cover individuals who cannot afford to pay current premiums in National and State Health Insurance Schemes

• Improve the efficiency of systems for pooling and purchasing of health finances by establishing national and state purchasing organisations with oversight for allocation of funds, raised through revenues generated from taxation, levies, or donors, and the payer at each level should use strategic health purchasing to provide more health services using available resources.

• Increase the national fiscal space for health through more efficient tax collection (company profit tax, and capital gains) and through innovative health financing such as levies on commercial services (example, mobile phone use, financial transactions, and air travel) to reach the existing goal of reducing the proportion of out-of-pocket expenditure to below 30 per cent by the end of NSHDP III and improve health outcomes.

• The FG should anticipate donor transition and prepare for post-aid status in which technical assistance, knowledge, and learning are more relevant than donor projects, which will require domesticating financing of health, research, and development, to achieve health independence and decolonise the Nigerian health space. Local institutions must be prepared to step up.

The National Institute funded the report for Health Research (NIHR), the Bill & Melinda Gates Foundation, the UK Medical Research Council, the UK Department of Health, and the Wellcome Trust.

The team found that while Nigeria is Africa’s largest economy and most populous country – projected to become the world’s third most populated country by 2050 – its dismal health outcomes are holding back progress and threatening the future of an otherwise dynamic nation.

In the accompanying Lancet paper, the group also examined population health outcomes in Nigeria between 1998 and 2019, compared with 15 other West African countries. They analysed by gender patterns of mortality, years of life lost, years lived with disability, life expectancy, healthy life expectancy, and health system coverage. The authors concluded that Nigeria compares less favourably than similar nations in West Africa, despite recent improvements.

The authors of the report include: Ibrahim Abubakar, Professor in Infectious Disease Epidemiology at University College London and director of the UCL Institute for Global Health; Dr. Chikwe Ihekweazu, assistant Director-General of World Health Organisation (WHO); Dr. Sani Aliyu, coordinator of the COVID-19 Task Force and the director of the Nigeria Centre for Disease Control (NCDC); Prof. Obinna Onwujekwe, Obinna Emmanuel Onwujekwe is Professor of Health Economics and Policy and Pharmacoeconomics in the Departments of Health Administration & Management and Pharmacology and Therapeutics, College of Medicine, based in University of Nigeria; Prof. Iruka N. Okeke is a Professor of Pharmaceutical Microbiology at the University of Ibadan; Prof. Gambo Aliyu, Director-General of the National Agency for the Control of AIDS (NACA); Vivianne Ihekweazu, Managing Director of Nigeria Health Watch; Prof. Muhammad Ali Pate, Global Director, Health, Nutrition and Population (HNP) Global Practice of the World Bank and the Director of Global Financing Facility for Women, Children and Adolescents (GFF), based in Washington DC.; Prof. Babatunde L. Salako, Director General, Nigerian Institute for Medical Research (NIMR) Yaba; Dr. Faisal Shuaib, Executive Director, National Primary Health Care Development Agency (NPHCDA); Prof. Mohammed Sambo, Executive Secretary, National Health Insurance Scheme (NHIS); Dr. Ifedayo Adetifa, Director General, NCDC, among others.

Prof. Ibrahim Abubakar of UCL Institute for Global Health, who led the Commission, said: “Nigeria urgently needs to improve access to health care by improving health financing and the efficiency of existing spending. Our report offers specific recommendations on innovation financing and specific interventions to improve healthcare staffing, information systems and access to care for all.

“Given that the vast majority of factors that influence health lie outside the healthcare sector, health should be at the heart of all policies. This will require a re-think of governance for health with the establishment of inter-sectoral governance mechanisms that enable measurement of the health impact of different policies to hold all sectors accountable.

“This includes addressing poor access to water and sanitation; improving access to healthy foods addressing the double burden of malnutrition due to underweight and overweight, and tackling the scourge of air pollution. Explicit consideration of equity in the implementation of programmes and provision of social welfare, education and employment opportunities should be paramount.”

Yet the report presents a positive outlook that Nigeria can deliver equitable and optimal health outcomes. It identifies bold recommendations for action in collaboration with policymakers, contributing to sustainable change on health policy and programming, national health outcomes and global health goals.

The team said measures could be taken to substantially improve population health, including targeted interventions to tackle unsafe water sources, poor sanitation, malnutrition, and exposure to the health impacts of climate change, including air pollution.

The team said an urgent goal of the Nigerian government should be to rebalance prevention and curative care to improve the health of young people.

Priorities include improving access to water and sanitation and to education – particularly for women and girls – as well as adopting policies to promote environmental sustainability to reduce air pollution and to create a healthier built environment.

They called for re-positioning future policy to achieve Universal Health Coverage (UHC).

Abubakar added: “Health is a unique political lever, which to date has been under-utilised as a mechanism to rally populations. Good health can be at the core of the rebirth of a patriotic national identity and sense of belonging.

“A commitment to a ‘One Nation, One Health’ policy would prioritise the attainment of Universal Health Coverage for all, particularly for the most vulnerable Nigerians, who bear an unacceptably high disease burden.”

The report combined analysis of demographic dynamics, disease burden and future projections based on data available from the Global Burden of Disease study, the Nigerian National Bureau of Statistics, and the Nigeria Centre for Disease Control.

The report noted: “We outline options for improving health financing and ensuring better accountability and distribution of resources. The rationalised governance schemes we have proposed should improve the efficient use of existing resources devoted to health. Ultimately, the proportion of spending allocated to the health needs to be increased. We envision a future of Nigeria’s health without foreign aid. This will require a substantial increase in domestic investments.

Foreign aid (multilateral, bilateral, and philanthropic) has led to fragmentation of the already complex health development landscape, with huge asymmetries in legitimacy between foreign actors and the Nigerian state as well as weak accountability. Defragmenting and decolonizing the Nigerian health landscape requires domesticating health financing.

“We recommend a whole system assessment of the investment needs in Nigeria’s health security. The COVID-19 pandemic has exposed the weaknesses of Nigeria’s health security system. Nigeria needs a better manufacturing capacity for essential health products, medicines and vaccines, the provision of diagnostics, surveillance and preventive public health measures in health facilities and community settings, as well as other preventive and curative measures.

“We call on the Federal Government, working with state governments, to fund and lead the development of standards for the digitisation of health records and better data collection, registration and quality assurance systems. A National Medical Research Council with two per cent of the health budget and central government funding to award competitive peer-reviewed grants will support high-quality evidence and innovation.

“Governance and prioritisation of health are the first places to start
We call for the thoughtful use of existing institutions as an approach to achieve better governance and prioritisation of health. Although corruption has undermined the Nigerian health system, we can harness existing institutions for the benefit of population health. All levels of Government in Nigeria (federal, state, and local), traditional leadership structures, civil society, the private sector, religious organisations, and communities, influence health.

“Efforts towards a balance between centralisation and localisation should focus on common policies, standards, and accountability. Concurrently, there is an equal need for localisation of implementation, meaning actual community and local government ownership of health service delivery. All three levels of Government are crucial, and we provide recommendations for each level. Differences in regional needs and context must also dictate programmes and interventions. What is needed in the northeast, in a context of ongoing insecurity and a crisis of internally displaced persons, is quite different from needs in wealthier, more secure urban centres, or in the face of the different levels of insecurity found in oil-producing areas in the Niger Delta.

“Prioritisation of health requires additional funds. We have provided a clear investment case on health to convince politicians and governments that improved population health will reap political, demographic, and economic dividends. Our call for a whole-of-government approach to health will allow the delivery of multisectoral policies to address the social determinants of health, prioritise health-care expenditure to major causes of burden of diseases, and substantially increase healthy and productive lifespans.”

This Commission was written in the context of the COVID-19 pandemic, which has laid bare the inability of the public health system to confront new pathogens with threats to human health. However, despite a history of weak surveillance and diagnostic infrastructure, the scale-up of COVID-19 diagnostics suggests that it is possible to rapidly improve other areas with sufficient local effort and resources.

The Lancet Nigeria Commission aims to reposition future health policy in Nigeria to achieve universal health coverage and better health for all. This Commission presents analysis and evidence to support a positive and realistic future for Nigeria. The Commission addresses historically intractable challenges with a new narrative. Nigeria’s path to greater prosperity lies through investment in the social determinants of health and the health system.

A viable health system requires dedicated, efficient, and equitable health financing mechanisms, complemented by optional health insurance. Countries with systems comparable with Nigeria’s, such as Ethiopia and Indonesia, have planned or implemented ambitious programmes to deliver health insurance coverage.

Nigeria’s public health system should be supported by a comprehensive health insurance system for all people, funded using through both contributions and taxation, with trials underway in states such as Anambra. Access to health insurance for society’s most vulnerable people must be government-funded. Considerable political will is needed to bring a greater proportion of the informal sector accessed by most Nigerians under government governance mechanisms.

There is also a need to expand the fiscal space by increasing overall government revenue, which will lead to higher health funding, allowing health and the determinants of health to be addressed. Achieving these financing goals will require an optimistic political economy approach, considering the current context, alongside future steps. A starting point could be an explicit declaration by governments at all tiers that the achievement of universal health coverage is a priority goal.

Nigeria is a country with so much wealth in terms of human talent and potential, but also beset by challenges, including inadequate provisions for optimal healthcare delivery and well being of its people. For Nigeria to fulfil its potential the leaders and people alike must embrace the implications of what they know already—that health is wealth.

Other partners include the University of Ibadan, University of Nigeria, Bayero University Kano/Aminu Kano Teaching Hospital, and Ondo State University of Medical Sciences.