- All protocols duly observed. Permit me to start by thanking the organizers of this event – Center for Global Health Security of the prestigious Royal Institute of International Affairs also known as Chatham House, for inviting me to be part of this important and high profile occasion dedicated to advancing the cause of Universal Health Coverage (UHC) and health security in Nigeria. I bring you good tidings form the President of the 8th Senate who co-incidentally is a medical doctor and one of the proponents of Nigeria’s UHC agenda as you will hear in the course of this talk.
- I will use this opportunity to share with you ongoing efforts geared towards moving Nigeria closer towards its Universal Health Coverage goals and mostly from a legislative standpoint. The unique opportunity to have medical practitioners at the helm of affairs at this point in time in the Nigerian legislature is a health policy makers dream and one we are determined to make good use of.
- The Nigerian legislature expectedly, has been very instrumental to Nigeria’s UHC aspirations and I must acknowledge the achievement of the 7th Assembly in passing the 2014National Health Act which provides legal framework for health system strengthening in the country and established an earmarked fund called Basic HealthCare Provision Find (BHCPF) which is aimed at providing additional statutory resources from the Federal Government to fund the provision and delivery of a Basic Minimum Package of Health services. The implementation of the Basic Health Care Provision Fund is the first test for the legislature in super charging the momentum to UHC. Let me spend some time in explaining the rationale for the BHCPF.
- RATIONALE FOR BHCPF: Low prioritization of health in public expenditure by previous governments has been compounded by a complex fiscally decentralized system which has resulted in a huge out of pocket expenditures and impoverishments for millions of Nigerians. In 2014, government health expenditure was 0.9% as a share of GDP and 2.2% as share of government expenditure, amounting to just US$29.5 per capita; this spending level accounts for about 25.1% of total health expenditure, far below Government expenditure as a share of total health expenditure in conflict-affected countries like Afghanistan, Eritrea, Mali, Niger, Chad and Central African Republic4,[1]. Further worsening the health financing situation is the fact that States and local government are given the responsibility of service delivery (secondary and primary care) without adequate capacity to raise funds nor fund it. The BHCPF of the National Health Act is supposed to be funded from one per cent of the consolidated Revenue of the Federal Government. The BHCPF effectively does three things. It provides additional funding for the health sector on top of the budgetary allocation. It funds a set of prioritized service through the Basic Minimum Package of Services and lastly it serves as a conditional Inter Governmental Fiscal Transfer (IGFT) which will incentivize States and Local Government to commit more resources into the health sector, thus increasing the overall public expenditure on health, in addition to addressing the inefficiencies at the sub-national level if efficiency performance indicators are leveraged as conditions. Clearly the BHCPF remains a veritable legislative tool which my committee is using as a key tool to leverage in moving the UHC agenda. The National Assembly is yet unable to appropriate for the BHCPF since the 2014 that it was signed into law as budget proposals from the executive never contained it. Therein lies the challenge. However, we are determined that going forward, the 2018 appropriation whether this is proposed or not the National Assembly will appropriate for the BHCPF as required by Law.
- REVIEW OF NHIS ACT: The National Assembly is in the process of amending the law that set up the National Health Insurance Scheme. My committee is already in advanced stages of this legislative review. The following principles will guide the review – Making health insurance mandatory for all Nigerians, Subsidizing premiums payments for those who cannot afford it, reflecting more strongly the 2014 National Health Act in the current implementation of the NHIS, guaranteeing a basic minimum package of services in the current implementation of the NHIS, specifying the role of states in the implementation of the NHIS, introducing telemedicine and telehealth as part of the package, paying more attention to delivery of service at the primary health centers and finally, expanding the regulatory powers of the NHIS to effectively carry out its functions. You can be rest assured that this review will be passed into law within the next few months.
- ESTABLISHMENT OF STATE SUPPORTED HEALTH INSURANCE SCHEMES: To leapfrog health insurance coverage in the country, State lawmakers in Nigeria have passed into law or are in the process of passing into law state Health Insurance Scheme legal framework which will ensure the decentralization of national level efforts. Equally Many State Houses of Assembly have also passed into law, legal frameworks setting up State Primary Health Development agencies which is pivotal to actualization of the Primary Health Care Under One Roof (PHCUOR) policy thrust.
- LEGISLATIVE ADVOCACY FOR UHC IN NIGERIA: The Senate committee on Health under my leadership has successfully established the Legislative Network on UHC in Nigeria. The network was officially launched by the President of Nigerian Senate, Distinguished Senator Dr. Abubakar Bukola Saraki on the 25th of July 2017. The occasion attracted participation of more than 200 lawmakers from federal and more than 30 states of the country. It was the largest gathering of lawmakers ever dedicated to advancing the cause of UHC in Nigeria. The consensus building forum signaled a turning point in the history of lawmakers’ involvement in health system strengthening in Nigeria as the communique of action jointly agreed upon at the forum will serve as reference for deploying legislative functions towards improved health care delivery in Nigeria. With the birth of the Legislative Network on UHC, the Nigeria legislature at both the Federal and state levels is now better repositioned to face the numerous challenges that constitute clog on the wheel of Nigeria’s UHC progress.
- EFFICIENCY OF SPENDING IN NIGERIA: I am not naïve to assume that additional funding alone as advocated through the BHCPF or through the review of the NHIS Act will lead Nigeria to improved health outcomes. There is a need for a concerted effort to make the best out of available public & private resources. We must embark on a new agenda for health financing to make the best out of available resources and ensure sustainability of spending. My committee is already on the lookout for improved geographic targeting that will disproportionately increase spending gaps between rural and urban areas and we will bias spending towards rural areas and the most impoverished Nigerians; we are already changing the allocation of spending across care levels – the current practice of allocating more resources to teaching hospitals and specialist hospitals will be a thing of the past. UHC is about prioritizing available resources to the populations that need it the most.
- OPPORTUNITIES FOR WORKING MORE EFFECTIVELY WITH THE PRIVATE SECTOR: As a medical practitioner who spent all his life in private practice and a second-generation proprietor of a successful medical practice (My father established the first industrial hospital in Nigeria) – I am amazed at the lack of a successful engagement between the public and private health sector in Nigeria. Let us make no mistake – Nigeria like most other African countries will not be successful in their UHC aspirations if they do not recognize and harness the potential of the private health sector as a key partner in improving health outcomes and making private expenditures more equitable. Subsequently my committee has proposed that the private health sector in Nigeria is incorporated to deliver the Basic Minimum Package of Health Services in the BHCPF implementation especially through the NHIS gateway.
- ADVOCACY TO ADDRESS MALNUTRITION IN NIGERIA: In December 2016, My committee hosted a high-level policy dialogue to address the rerising issue of Malnutrition in Nigeria As you know, nutrition is a key driver of development. However, malnutrition remains a serious public health challenge in Nigeria, one third (33 percent) of children in Nigeria under five years of age suffer from chronic malnutrition or stunting. Stunting is even more prevalent among the poorest. This negatively impacts not only health but also economic development in our country with economic consequences representing almost losses of 11 percent of GDP. Yet on the flip side, investing in nutrition can yield permanent and inalienable benefits in our UHC journey. Our strong advocacy efforts have led to the commitment of a sum of 350M USD to accelerate Nutrition results in the most affected states in Nigeria.
- ADVOCACY TO SUPPORT NIGERIA TO HARNESS THE DEMOGRAPHIC DIVIDEND: You are all aware that Nigeria is on a dangerous demographic trajectory a scenario which presents risks to Nigeria’s economy and society. However, the current situation can be turned into a great opportunity and the potential gains from change are dramatic. I was privileged to attend the last FP 2020 summit here in London a few months ago, and my colleagues and I are poised to support a number of policy interventions which can ensure that Nigeria begins a transition to a more productive population structure – one with a larger share of workers and a smaller share of child dependents. Such a change can provide the opportunity for massive gains in terms of GDP growth, poverty reduction and improved human development outcomes. Our UHC efforts needs to support the scaling up of Family planning efforts, addressing Girl child education & support to out of school girls whilst we also engage our faith and religious leaders.
- VIEWS ON GLOBAL PARTNERSHIPS: For sustainable health solutions in Nigeria, as regards global partnerships, our partners should help us think NIGERIA FIRST. Donations must be planned to make us develop the capacity to continue with the service or product delivery after the donations stop coming. For example, we are grateful to GAVI for donations of much needed vaccines to Nigeria over the years. We have now been notified of the cessation of these donations in another three years or so. Meanwhile, we are yet to manufacture this in Nigeria. Likewise, UNICEF, we are grateful, have also been donating replacement therapy for malnutrition of our children for years, all imported into Nigeria. We appeal to these our friends and partners to patronize only International companies that show evidence of immediate plan to situate manufacturing plants in Nigeria. The world bank is also appealed to, to fund only projects that have plans to develop the capacity of Nigeria to be self sustainable. This must be very easy to do because our partners greatly love Nigeria to have been donating this much over the years.
- PERSONNEL CAPACITY: It is a known fact that the exploits of Nigerian Doctors and Nurses is positively legendary in the developed world. The health system in the United Kingdom or the United States of America may probably collapse if the Nigerian Government withdraws its citizens from both Nations. It is quite a paradox that the health system of this same Nigeria, is begging for more qualitative personnel in its health sector. As soon as our medical doctors or Nurses qualify in Nigeria, they are consumed by these developed nations and we even lack enough lecturers to teach the new medical/nursing students. Hundreds of new medical doctors seek non existent house officer jobs that is mandatory before eligibility for employment. Can’t these developed nations, who are our friends and donors, device a solution to send our doctors back home at intervals to assist in the reversal of the health practitioners deficit we are presently battling in Nigeria? This can be for our mutual benefit. This means they donate these our trained doctors instead of the products they presently give us yearly. If this is done, the donations needed would drastically reduce as the much needed services of qualitative medical personnel will upscale preventive medicine rather than the curative that is now the bane.
- CONCLUSION: The quest for Universal Health Coverage spans beyond speeches but is one that needs to be characterized by concrete actions – I have shared with you several actions we are taking in Nigeria which no doubt will move us closer towards our UHC goals. Undoubtedly there is a need to explore mechanisms to improve relationships between the executive and parliament – it is not a relationship that should be defined by the annual budget cycles but one that is holistic and driven by a UHC agenda. Indeed, I would like to commend the renewed global interest geared towards galvanizing support for Nigeria’s UHC quest as progress made by Nigeria on the path of UHC has a multiplier effect on other African countries especially the West Africa sub region. Our efforts need to be situated within the ensuing global partnerships dedicated to advancing the UHC cause in Nigeria and I call on all our partners to support our efforts through collaborations and capacity building and knowledge exchange and learning. I thank you all for the opportunity to share with you a few thoughts on our UHC aspirations in Nigeria.
Thank you.
Senator Dr. Olanrewaju Tejuoso
Chairman Senate Committee on Health Nigeria
[1] Dieleman et al. National spending on health by source for 184 countries between 2013 and 2040, Lancet 2016; 387: 2521–35
PUBLIC HEALTH AFRICA POLICY FORUM, Primary Healthcare Policy, Universal Health Coverage & Health Security in Nigeria: Optimizing Global Opportunities and Partnerships for Success. A Keynote Address by Senator Dr. Olanrewaju Tejuoso, Chairman, Nigeria Senate Committee on Health on 22nd September 2017, Chatham House, London
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