Crossing the quality chasm: Nigeria’s long walk to universal health coverage

In a recently published blog, my friend Dr Abiodun Awosusi narrated this very touching story: “I walked into the paediatric unit of a teaching hospital in Nigeria a few years ago to review a patient. On the first bed was a lifeless child. He was brought in dead a few minutes earlier by his parents. His mother, “Bisi”, wept uncontrollably. While in tears, she recounted how difficult it was for them to borrow money to get to the hospital. Although they got some money from a chief in the community, the two-year-old baby died before they got to the hospital”.

Many households such as this one have been pushed into poverty, debt, and financial hardship as a result of seeking health care. In Nigeria, data from the 2017 National Health Accounts show that out-of-pocket payment for healthcare accounts for 76.6% of total expenditure on health. The poor are the ones affected the most. They have become disillusioned and dissatisfied with the general low quality of health care provided by the public health system, care that they must also struggle to pay for out of their own meagre pockets. Therefore, achieving universal health coverage (UHC) through pre-payment mechanisms and improved access to healthcare is an inevitable policy direction that Nigeria must vigorously pursue. Reaching UHC will ensure a fair distribution of the burden of paying for health services, protect households against the risk of catastrophic levels of expenditure on health, and reduce barriers to health service use while promoting equitable distribution of public expenditures.

With these UHC goals in mind, Nigeria established the National Health Insurance Scheme via a decree in 1999. However, a 2017 report found that 18 years after the launch of the NHIS in Nigeria, coverage was still limited to less than 5%  of the population. Those who were covered by the NHIS were mostly federal government employees for whom enrolment is mandatory and a handful of private sector employees. This narrow coverage has led to various attempts to expand coverage, including decentralization of social health insurance to states and ear marking of 1% of the consolidated revenue fund of the country to provide basic healthcare for the vulnerable.

Unfortunately, the emphasis on expansion to cover more people has paid little or no attention to the quality of healthcare under the Nigerian NHIS. Complaints in the public media suggest widespread variability in, and stakeholders’ dissatisfaction with, the quality of care for those already covered under the various health insurance programs in the NHIS. No detailed analysis of these grievances has been conducted and as a result it is uncertain if poor service quality remains a causative factor in the poor coverage of the NHIS and consequently a barrier to the attainment of UHC in Nigeria.

There is clearly a need for massive scale up and expansion of the current national health insurance program to include more groups of people, especially the poor and other vulnerable groups. At the same time, there must also be systems and processes in place to ensure that quality healthcare is provided at all levels for the nation to make tangible movement towards UHC. The WHO’s Director-General, Dr Tedros Adhanom Ghebreyesus, has argued that without quality, UHC remains an empty promise, as poor care not only jeopardises the health of individuals, it erodes trust and puts entire health systems and populations at risk.

The Lancet Global Health Commission on High Quality Health Systems in the SDG Era showed that quality of care is worst for vulnerable groups, including the poor, the less educated, adolescents, those with stigmatised conditions, and those at the edges of health systems, such as people in prisons. According to the commission, poor quality care is now a bigger barrier to reducing mortality than insufficient access. The commission estimated that about 60% of deaths from conditions amenable to health care are due to poor quality care, whereas the remaining deaths result from non-utilisation of the health system.

As part of my Global Health Policy Fellowship in the Center for Policy Impact in Global Health at Duke University, I led a research project on “Achieving Universal Health Coverage in Nigeria? Does Quality of Care under the Nigeria National Health Insurance Scheme matter?” The research focused on understanding how the push for expanding coverage to Social Health Insurance has paid attention to the quality of healthcare under the Nigerian NHIS. It also described the overall quality of care received by patients under the NHIS and identified provider and patient characteristics associated with measured differences in the quality of care. In addition, my study helped to determine if there is a difference in the quality of care between patients covered under the NHIS and those who are not. The overall goal is for the research to guide health policy formulation, diffusion and utilization in Nigeria in order to expand coverage with Social Health Insurance in Nigeria. The full study will be published soon.

My study indicates that, generally, quality of healthcare  is an issue of concern for both insured and uninsured patients. The key difference is that insured patients expressed great dissatisfaction in the area of availability of drugs, difficulty in getting a referral, delayed enrolment to care under the NHIS, as well as over payment for drugs and other services. Among the non-insured patients, the major quality of care concerns were the cost of healthcare services, long waiting times and inadequacy of resources and services, specifically doctors, drugs and equipment. Therefore, perceived quality of care is an important variable affecting utilization of healthcare services.  As a result, it is imperative for the NHIS to develop strategies to ensure the provision of high quality, equitable services in order to make progress towards UHC.

For the NHIS to improve the quality of care for enrolees of the scheme, it needs to harness and use data for decision making, establishing a system that is anchored on solid information technology as a tool for making healthcare safer, cheaper and more accountable. In addition, the scheme needs to reform its payment system from the present volume driven capitation and fee for service-based models to a value based payment system that emphasizes outcomes rather than volume. A much broader spectrum of approaches is needed within the whole health system to promote a culture of innovation and reward for hard work and performance. This spectrum should be complemented by strong monitoring and evaluation capacities that facilitate rapid dissemination of lessons and scale up of successful strategies.

Thankfully, a new leadership in the NHIS is making conscious efforts to reform and reposition the scheme into a result-oriented organization for effective service delivery. Based on all facts on ground, Nigeria may not be able to achieve UHC by 2030 but if we begin to act on these recommendations, we will significantly improve access to healthcare for many Nigerians. Only then stories like the one of Bisi’s family will become a thing of the past.

About the Author:

Kurfi Abubakar Muhammed, MD, MPH, MBA (tweets @abukurfi) is the Head International Collaborations Divisions in the National Health Insurance Scheme in Nigeria.

All views expressed here are entirely the author’s and not those of the National Health Insurance Scheme