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

1. Achieving UHC in Nigeria: Options for Federal, State and LGAs Professor Obinna Onwujekwe: MBBS, MSc, PhD (Health Economics) University of Nigeria, Enugu-Campus, Enugu, Nigeria March, 2014

2. 1.0 Objectives

3. Objectives • Highlight key UHC indicators in Nigeria • Share international experiences in UHC • Proffer options for Options for Federal, States and LGAs • Enumerate key action points for the implementation of UHC in Nigeria

4. 2.0 Background

5. 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 product • Out-of-pocket spending should not exceed 30-40% of total health expenditure • Over 90% of the population is covered by pre-payment and risk pooling schemes • Close to 100% coverage of population with social assistance and safety-net programmes

6. 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%

7. Nigeria is not on track to achieve UHC.. • High level of use of OOPS for healthcare • Minimal coverage with health insurance and other pre-payment mechanisms • States, LGAs and private sector unwilling to start mandatory health insurance scheme for their workers • Low level of access to healthcare services • Struggle to achieve MDGs

8. 3.0 Key Points

9. 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 reduced • Making health facilities work is more of a challenge than starting insurance and this should first be corrected • Concern about the governance and accountability system of the NHIS: lack of information to stakeholders at all levels about the activities of the scheme.

10. 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 protection • The depth of coverage: the range of essential services necessary to effectively address people’s health needs • The height of coverage: the portion of health-care costs covered through pooling and pre-payment mechanisms

11. International lessons (McIntyre, 2011) • Mandatory pre-payment: Core of UHC systems • Out-of-pocket payments do not allow for financial protection – minimise their role • Voluntary pre-payment: “It is impossible to achieve universal coverage through insurance schemes when enrolment is voluntary” (World Health Report 2010) – Largely a complementary funding mechanism • Way to ensure the widest cross-subsidies possible

12. Several common design features of UHC across countries (Giedion et al, 2013) • The coexistence of UHC schemes • Heterogeneity in design and organisation • Widespread effort to include the poor in the schemes • Prevalence of mixed financing sources (contributions plus taxes)

13. 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

14. 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

15. 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

16. 4.0 Implications and Relevance for Nigeria

17. Options for Federal, States and LGAs - the innovative imperative Conceptual framework • Universal 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

18. Implications and Relevance for Nigeria The Foundation “UHC can only be achieved when the health system is strong” - (WHO, 2010)

19. Four international lessons with UHC (Giedion et al, 2013). • Affordabilityis important but may not be enough • Target the poor, but keep an eye on the non-poor • Benefits should be closely linked to target populations' needs • Highly focused interventions can be a useful initial step toward UHC

20. 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

21. 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

22. 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

23. Option 4: Community-based health insurance scheme for people • For people employed in the informal sector • For 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

24. 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.

25. 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

26. 5.0 Recommended Actions

27. 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 Nigeria • Information Education and Communication to the strategic decision makers, and to the general public

28. 6.0 References

29. References • AFHEA. Toward universal health coverage in Africa: Key issues. AfHEA 2nd Conference – 2011. Palm Beach Hotel, Saly – Sénégal: 15th - 17th March 2011 • CBHI Nigeria Brief rev UN CPG 052912 • Chua HT and Chah JCH (2012). Financing Universal coverage in Malaysia: a case study. BMC Public Health, 12(Suppl 1) S7:S7 • Di McIntyre. Conceptual issues related to universal coverage. AHPSR Proposal Development Workshop. Cape Town, 22 March, 2011. • More Health for the Money CPG rev UN 052912 • More Money for Health Nigeria Brief RG CPG rev UN 052912 • National 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.

30. 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.1365-3156.2011.02836 • National 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 assessment • National Population Commission and ICF Macro (2009): Nigeria Demographic and Health Survey 2008. • WORLD HEALTH STATISTICS 2006