achieving uhc in nigeria: options for federal, state and lgas

Federal Ministry of Health

Achieving UHC in Nigeria: Options for Federal, State and LGAs

March, 2014

Professor Obinna Onwujekwe: MBBS, MSc, PhD (Health Economics)University of Nigeria, Enugu-Campus, Enugu, Nigeria

1.0 Objectives


Objectives

Highlight key UHC indicators in NigeriaShare international experiences in UHCProffer options for Options for Federal, States and LGAsEnumerate key action points for the implementation of UHC in Nigeria

2.0 Background


Four target indicators proposed by WHO to M&E progress to achieving UHC…

Total health expenditure should be at least 4% - 5% of gross domestic productOut-of-pocket spending should not exceed 30-40% of total health expenditureOver 90% of the population is covered by pre-payment and risk pooling schemesClose to 100% coverage of population with social assistance and safety-net programmes


Is Nigeria on track to achieve UHC?

Total health expenditure was 6.7% of GDP in 2009 (more than the baseline of 4-5%)Out-of-pocket spending is more than 60% of total health expenditure instead of the recommended 30-40%Less than 5% the population is covered by pre-payment and risk pooling schemes instead of the recommended 90%Less than 2% coverage of population with social assistance and safety-net programmes instead of the recommended 100%


Nigeria is not on track to achieve UHC..

High level of use of OOPS for healthcareMinimal coverage with health insurance and other pre-payment mechanismsStates, LGAs and private sector unwilling to start mandatory health insurance scheme for their workersLow level of access to healthcare services Struggle to achieve MDGs

3.0 Key Points


Constraining Factors to Adoption of the formal sector social health insurance programme (FSSHIP) [Onoka, Onwujekwe et al, 2012]

States should have their own insurance schemes/HMOs and have the fund circulate within the state. It was unacceptable and inefficient the process of sending state contributions up to the NHIS, having the NHIS deduct 10% as administrative cost and having this money come back to the state again grossly reducedMaking health facilities work is more of a challenge than starting insurance and this should first be correctedConcern about the governance and accountability system of the NHIS: lack of information to stakeholders at all levels about the activities of the scheme.


International Experiences and Lessons for UHC in Nigeria

Moving towards UHC involves expansion of coverage in three ways (WHO, 2010) :The breadth of coverage: the proportion of the population that enjoy social health protectionThe depth of coverage: the range of essential services necessary to effectively address people’s health needsThe height of coverage: the portion of health-care costs covered through pooling and pre-payment mechanisms


International lessons (McIntyre, 2011)

Mandatory pre-payment: Core of UHC systemsOut-of-pocket payments do not allow for financial protection – minimise their roleVoluntary pre-payment: “It is impossible to achieve universal coverage through insurance schemes when enrolment is voluntary” (World Health Report 2010) – Largely a complementary funding mechanismWay to ensure the widest cross-subsidies possible


Several common design features of UHC across countries (Giedion et al, 2013)

The coexistence of UHC schemesHeterogeneity in design and organisationWidespread effort to include the poor in the schemesPrevalence of mixed financing sources (contributions plus taxes)


African and developing countries moving towards UFC – Case Studies

Ghana Has extended mandatory health insurance coverage

to more than 50% of the Ghanaian population

RWANDA About 90-95 percent of Rwandans in the informal sector

are enrolled in health insurance and are accessing health care.

During 2005–2011, deliveries at health facilities increased by 78 percent, new curative consultations by 51 percent, and family planning users by 209 percent


Case Studies (Cont’d)

Malaysia Total Health Expenditure (4.8% of GDP) Out-of-pocket expenditure as a % THE =30.7% Comprehensive safety nets for vulnerable groups Tax-based financing mechanism

South Africa 40% mandatory health insurance; 40% voluntary

pre-payment; 20% out-of-pocket


Case Studies (Cont’d)

Thailand Achieved Universal health coverage (100%):Used a variety of pre-payment mechanisms (75% mandatory health insurance and 25% other pre-payment mechanisms)

The 30 Baht scheme

4.0 Implications and Relevance for Nigeria


Options for Federal, States and LGAs - the innovative imperative

Conceptual frameworkUniversal health coverage depends on:

‒Enabling policies, legislation, strategic plans, capacity, advocacy, perceptions

‒More health for money (improved efficiency)‒More money for health (increased funding)‒Innovative health financing

Improve Equity

‒Better health indices, achieve MDGs and other goals


Implications and Relevance for NigeriaThe Foundation

“UHC can only be achieved when the health system is strong”

- (WHO, 2010)


Four international lessons with UHC (Giedion et al, 2013).

Affordability is important but may not be enoughTarget the poor, but keep an eye on the non-poorBenefits should be closely linked to target populations' needsHighly focused interventions can be a useful initial step toward UHC


Option 1: Mandatory Health Insurance

Mandatory health insurance for all federal, state and LGA public workers Exists at the Federal level only States and LGAs should start health insurance

schemes for their workers Workers must contribute a mutually agreed

proportion of basic salary at all levels Benefit package to be improved with increased

contribution Capitation payment to providers should be

increased


Option: Special Mandatory Health Insurance

Special mandatory health insurance for all children under 12 years and pregnant women Start with children under five years and pregnant

women All nursery and primary school children should be

enrolled (independent of their parents) Funding from federal, state and LGA government

budgets, special earmarked taxes and donors and other funding sources

Part funding from UBEC resources for school children


Options 3: Free services

For high priority life-saving public health services through increased use of government revenue:

Immunization services Prevention and treatment for HIV/AIDS Prevention and treatment of tuberculosis (TB) Prevention and treatment Malaria and some non-

communicable diseases Maternal, Neonatal and Child health services,

especially antenatal, child birth and postnatal services


Option 4: Community-based health insurance scheme for people

For people employed in the informal sectorFor secondary and tertiary school students

‒Existing free programmes can be the core of CBHI scheme

‒Motivating all telecom and oil producing companies to enrol their catchment communities in health insurance schemes

‒Government subsidy using general tax revenue


Option 5: Creating health safety nets for the poor and other vulnerable groups = equity funds

‒Harness the conditional cash transfers from SURE-P towards UHC‒Funding from local and international organisations‒Local earmarked taxes – proportion of VAT or some levy on tobacco, alcohol and airtime etc.‒Develop and implement strategic plans for mainstreaming ‘Health in all Policies’ (HiAP) ‒Funding from Sovereign Wealth Fund (through social investments), interests from unclaimed dividends, NHIS investments, etc.


Option 6: Private-sector involvement

Providing robust and enabling guidelines for the establishment and use of Private Voluntary Health Insurance Certain categories of the informal sector Formal private sector Others

5.0 Recommended Actions


Finally

Strive for more health for money (improved efficiency in use of available funds)Develop cost strategic plans for achieving UHC in Nigeria: develop and cost 38 plans (for the Federal, 36 states and the FCT)Continually generate and use evidence to improve the functioning of the UHC schemes in NigeriaInformation Education and Communication to the strategic decision makers, and to the general public

6.0 References


References

AFHEA. Toward universal health coverage in Africa: Key issues. AfHEA 2nd Conference – 2011. Palm Beach Hotel, Saly – Sénégal: 15th - 17th March 2011CBHI Nigeria Brief rev UN CPG 052912Chua HT and Chah JCH (2012). Financing Universal coverage in Malaysia: a case study. BMC Public Health, 12(Suppl 1) S7:S7Di McIntyre. Conceptual issues related to universal coverage. AHPSR Proposal Development Workshop. Cape Town, 22 March, 2011.More Health for the Money CPG rev UN 052912More Money for Health Nigeria Brief RG CPG rev UN 052912National Bureau of Statistics (NBS) 2007, Nigeria Multiple Indicator Cluster Survey 2007 Final Report. ABUJA NIGERIA.National Bureau of Statistics (2006). Obinna Onwujekwe & Benjamin Uzochukwu(2009). Benefit incidence analysis of priority public health services and financing incidence analysis of household payment for healthcare in Enugu and Anambra states, Nigeria. Obinna Onwujekwe, Ogo Ezeoke, Felix Obi and Benjamin Uzochukwu (2011). Situation analysis of financial health risk protection: Nigeria. Health Policy Research Group, College of Medicine, University of Nigeria and RESYST Consortium: London School of Hygiene and Tropical Medicine.


References

Onoka CA, Onwujekwe OE, Hanson K, Uzochukwu BS (2011). Examining catastrophic health expenditures at variable thresholds using household consumption expenditure diaries. Trop med int health doi: 10.1111/j.1365-3156.2011.02836National Bureau for Statistics (NBS), 2004. The 2004 National Living Standard Survey (NLSS). Abuja: NBS.Obinna Onwujekwe & Edit Velenyi: Feasibility of private voluntary health insurance in Nigeria: valuation of benefits and equity assessmentNational Population Commission and ICF Macro (2009): Nigeria Demographic and Health Survey 2008. WORLD HEALTH STATISTICS 2006

achieving uhc in nigeria: options for federal, state and lgas

Documents

portion of health

mdgsfederal ministry

uhctotal health expenditure

total health expenditureover

coverage of population

mandatory prepayment

implementation of uhc

universal coverage