The Federal Government has just released its Economic Sustainability Plan. The plan is expected to be a stopgap measure for the next 12 months, to tidy Nigeria over the period of the pandemic, to when it develops a successor plan to the Economic Recovery and Growth Plan. This discourse reviews the content of the ESP on health and to raise and respond to the poser- whether the recommendations will concretely improve health services in Nigeria.
The objective of the ESP’s intervention in the health sector is to develop a robust health system with the capacity to withstand shocks. The guiding principle is to ensure resilience in the health sector systems. The project elements are: To create a single national pool of resources for the purchasing of a defined package of health services to foster broader risk sharing and reduce duplication of effort; expand Universal Health Insurance to cover the poorest and most vulnerable by linking the National Health Insurance Scheme to the National Social Register; accelerate implementation of the Basic Health Care Provision Fund to achieve at least a 65% increase in the share of the population covered by primary healthcare by 2023. Others are for the NSITF to launch insurance scheme for health workers to cover exposure to COVID-19 and other infectious diseases; ensure access to power for health clinics through stand-alone systems or micro-grids (where necessary) and establish a favourable tariff regime to support domestic pharmaceutical companies and allied manufacturers. Furthermore, it is to support domestic pharmaceutical companies to meet the WHO prequalification criteria, and overcome a major challenge to production for export; mobilise private sector resources to contribute to various health funds and services such as the National Emergency Health Fund or BHCPF, health infrastructure development and granting incentives like tax exemptions and support local research and development efforts aimed at production of medical and pharmaceutical resources including vaccines and consumables.
The project elements have a vote of N198.9bn over a period of 12 months. The background is that Nigeria records an out-of-pocket health expenditure of 72% of total health expenditure and has the largest number of poor people in the world and the number of the poor will be increasing as a result of the economic crisis occasioned by the COVID-19 pandemic. This implies that N198.9bn is grossly inadequate for the task ahead. For the first set of project elements, how do you create a single national pool of resources for the purchasing of a defined package of health services to foster broader risk sharing and reduce duplication of effort? It is a matter of common knowledge that health is not on the Exclusive Legislative List. The Federal Government and states are at liberty to legislate on health issues. Indeed, they have been doing so and while the FGN set up the National Health Insurance Scheme, many state governments have set up their state level health insurance schemes. Both the federal and state level schemes combined cover less than five per cent of Nigerians and when the private health insurance schemes are added, less than seven per cent of Nigerians have health insurance. There is nothing in the plan to indicate that the federal and state governments will work out a harmonised system of health insurance that pools all resources together. Nigerians who have been canvassing improved federalism will kick against this. A constitution amendment and framework legislation will be required to achieve this single national pool of resources. This will require a lot of political horse trading with its attendant intrigues required to get the National Assembly to pass the requisite bill. Twenty-four state legislatures will need to concur before it comes back for presidential assent. This may not be achieved in 12 months if the Nigerian experience is anything to go by. Effective health insurance which reduces the burden of out of pocket expenditure must be universal and compulsory.
Linking the National Health Insurance Scheme to the National Social Register to cover the poorest and most vulnerable will require increased public funding. Do we have the resources at the federal, state and local government levels to pay for this? Actualising this will only be possible if we reorder our priorities in a positive way, for instance, by channelling a good chunk of security votes or constituency project funds to health insurance premiums for the poor.
Accelerating implementation of the BHCPF to achieve at least a 65% increase in the share of the population covered by primary healthcare by 2023 will also imply increasing the resources available under the Fund. The current meagre sum available to the Fund cannot upscale primary healthcare to 65% of the population. This will call for increased appropriation because the National Health Act states that it should attract not less than one per cent of the consolidated revenue fund of the Federal Government. This is the minimum and not the maximum. The other component is to increasingly mobilise private sector resources to contribute to various health funds and services such as the National Emergency Health Fund or the BHCPF, health infrastructure development and granting incentives like tax exemptions. These financial incentives like tax exemptions need to be operationalised under an enabling law and this also needs legislative attention. Considering the declining consumer purchasing power and strong economic headwinds buffeting the private sector, the possibility of private sector operatives having the resources to make the required commitments in the next twelve months is seriously in doubt.
Ensuring that the Nigeria Social Insurance Trust Fund insures health workers is routine and should have been the practice long ago as prescribed by law. Implementing a system which ensures access to power for health clinics through stand-alone systems or micro-grids (where necessary) will be a very welcome development. However, this cannot be untied from the overall health and sustainability of the power sector, a sector which is facing so many challenges. Stand alone or micro grids will require substantial capital investments over the short term. The source of funding these grids is very much unclear.
It took COVID-19 and countries in the Western World and the Middle East closing their borders on medical tourism for us to begin to think of these rudimentary steps. But these closures will not last forever. Pray, if the opportunity for medical tourism is reopened tomorrow, will the Nigerian political elite go ahead with these planned activities? Will they not jet out for their health challenges and abandon the majority of citizens as was the practice before COVID-19? The provisions of the ESP on health will gather dust on the shelves if critical pressure is not mounted on the federal authorities. This is not the first time a plan has been drawn up and it will not be the last. The critical difference would be for the plan to be implemented in its letter and spirit.
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