Out of pocket payment and health delivery in Nigeria

Out of pocket payment and health delivery in Nigeria by Sylva Ifedigbo

The first wealth of a nation is the health of her citizens. Nowhere does this globally accepted fact make more sense than in developing countries like Nigeria.

Empirical evidence abound, littered in countless bound copies of reports and web databases of global and local health institutions, that the health of a nation significantly enhances its economic development, and vice-versa. Malaria, HIV-AIDS, grave maternal mortality rates, etc, have and continue to increase poverty and overwhelm the economies of developing countries.

However, while poor healthcare delivery is evidence of an equally unhealthy economy, we cannot put off the desire to acquire good health until the economy improves. None of us might be alive to behold that day. Our health, is therefore so important that measures to improve its access and delivery must be accorded priority at all times for this has a direct positive impact on economic growth.

Critical to the delivery of efficient healthcare is the way a country finances its health care system and how her citizens pay to access health services. Currently, healthcare in Nigeria is financed by a combination of government funding, out-of-pocket payments, donor funding, and health insurance. Because government’s investment in healthcare, as seen in annual budgetary expenditure, is abysmally low, it has resulted in a situation in which the system is characterised by extensive out-of-pocket payments by already impoverished patients, limited insurance coverage, and low donor funding, most of which end up being spent on the high costs of maintaining foreign expatriates.

The above scenario is compounded by limited institutional capacity, endemic corruption, unstable economic and political landscape; and with the endless squabbles among the various health professions, are all factors that contribute to ensuring that brief illness continues to ravage our people and make us die cheap.

Out of pocket a payment, and the evil of it, is the crux of this piece. That in this age, out of pocket expenditure as a percentage of private expenditure on health in Nigeria stands at an unbelievable 95.4% (according to 2012 WHO figures) should be a national embarrassment. The gravity of the situation becomes even more glaring when we remember that majority of our people, over 70% of the population, is officially poor by accepted standards and unemployment is in double digits.

What this means is that when you are sick here, you have to pray to God to have the money at that moment to pay and if you don’t, if you are broke, if salaries are delayed, if you are unemployed, if the ailment costs more than your pockets can carry, you die. Simple. Sad.

Alternatively, most of our people resort to street begging and public appeals, including crowd sourcing on social media. In recent times we have been inundated by series of passionate viral messages to save various individuals who need urgent Medicare. That our people should resort to this strategy, which is effective for only but a handful, is unacceptable especially considering the fact that we are rich enough in material and human resources to have a robust, organised and well managed national health insurance policy scheme.

It’s not like we have nothing currently in place in that light. The federal government established the National Health Insurance Scheme (NHIS) under Act 35 of 1999 with the aim of improving access to health care and reducing the financial burden of out-of-pocket payment for health care services. The NHIS became fully operational in 2005. It was not long before we found that the scheme was not comprehensive enough. A World Bank survey in 2008 reported that about 0.8% of the population was covered by NHIS. The poor coverage and the fact that the Act that set it up made it optional ensured many Nigerians were left out. It became apparent that we needed to review the scheme and make it more efficient and effective.

The bill for an act to repeal the National Health Insurance Scheme (NHIS), and enact the National Health Insurance Commission and to ensure a more effective implementation of a health insurance policy that enhances greater access to health care services by all Nigerians is currently sitting in the National Assembly. Alongside is the National Health Bill which pledges a budget of N60 billion ($380 million) for primary healthcare each year, and promises to ensure the provision of free medical care for the most vulnerable.

The bill, which has been languishing in the National Assembly, promises to establish minimum guarantees of basic healthcare services for select groups – such as children below the age of five, pregnant women, adults above the age of 65 and people with disabilities – and help extend primary healthcare to 60% of Nigerians living in hard-to-reach rural communities.

The importance of the passage of these two bills cannot be overemphasised if I may use these overworked lines. Our lawmakers, most of whom (by the grace of our collective patrimony) can get off to Europe or Asia to treat the slightest of aliments owe it to us as a duty to enact those laws for the protection of our health and the guarantee of the health of generations to come. We demand a system that ensures that everyone who requires health care services is able to access them and not denied due to inability to pay. We urgently need to use what we have to take care of our people and de-emphasise dependence on donor funds.

The time has come for health care financing to be seen by the Nigerian government as an investment, which certainly requires an effective management and attendant political commitment for it to be profitable. Other factors such as lack of awareness, corruption, and unstable economy that have undermined health care financing in Nigeria need to be addressed exigently. In addition, there is the need for all the various professions under the health discipline to overcome whatever differences they habour and work in unison towards the enthronement of a truly efficient health care delivery system in the country.