Opinion: It's time to channel household expenditures into health insurance in Nigeria

Ten years ago, our first child, Yagazie, was born, her Igbo name meaning “it is well.” She weighed 3.5 kilograms at birth and was a bubbly child. As new parents, my wife and I were elated. Yagazie’s grandparents were joyous about meeting their first grandchild. As the days progressed, however, we noticed things were not well with her. Yagazie was not feeding properly, and she was losing weight and crying irritably. She turned blue most times and was short of breath.

When Yagazie was 6 weeks old, she was diagnosed with four different congenital heart defects. The most serious of the defects was transposition of the great arteries, meaning that two major blood vessels in the heart arose from opposite sides. Our world collapsed. We were afraid and upset, and we also did not know how to pay over $12,000 for Yagazie’s open-heart surgery and treatment.

Millions of Nigerians are similarly unsure of how to cover the high cost of medical bills. The reality is that catastrophic health expenditures like the one we faced can push many families into poverty who weren’t there before, because our health care system is not working the way it should. We need to look to local resource mobilization to sustain health care financing rather than continue with the current system of high international donor support.

The 2010-2016 national health accounts study, which explores the total health expenditure and who pays for health care, reveals that in 2016, total health expenditure was above $10 billion. Out-of-pocket expenditure by households in the same year was $7.7 billion — 75% of total health expenditure. Combined federal, state, and local government expenditure was $1.4 billion, while international donors’ support was $1.1 billion. Households in Nigeria spent $2.6 billion at chemists and pharmacies. In comparison, out-of-pocket expenditure was 7.75%, 11%, 15%, and 38.8% in South Africa, the U.K., the U.S., and Ghana, respectively.

Mandatory state health insurance schemes are gaining momentum, and household health expenditure should be leveraged to shore up the number of Nigerians with health insurance. Despite the huge amount households pay for health care in Nigeria, health indices are still very poor.

Every year, a total of 58,000 women die during pregnancy, childbirth, and the 42 days after birth, and 714,188 children die before their fifth birthday. So, Nigerians pay a great amount for what is still poor-quality health care. According to a report by The Lancet, 5 million people die every year because of poor-quality health care in low- and middle-income countries, compared to 3.6 million who die due to poor access. This has to change.

Another reason the shift is needed is that there is donor fatigue due to competing needs globally and a renewed call for local resource mobilization to sustain health care financing. Indeed, now is the time to harness the power of the people and ensure the sustainability of health care financing in Nigeria by channeling household expenditures into health insurance. The current status quo is simply not working. These are three ways to achieve the sustainability we are lacking.

First, pre-qualify all public and private health facilities to ensure quality health care is delivered. The National Health Act, a law that defines a health system for Nigeria, empowers the minister of health to ensure that no person, entity, government, or organization shall be eligible to establish or run a health facility without the possession of a certificate of standards. The international Dutch NGO PharmAccess Foundation is leading the way through its SafeCare Initiative to improve quality health care in Nigeria. The organization already supports private and public health facilities. Its efforts should be taken to scale to reach other health facilities in Nigeria.

Second, achieving equity in health care depends on equity in health education. Therefore, government, civil society organizations, and the private sector must consistently educate Nigerians to invest in health insurance, especially after all health facilities must have acquired a certificate of standards. This initiative should be led by the minister of health.

Third, ensure chemists and pharmacies also have a certificate of standards and incorporate these outlets in the provision of quality health care. The 2010-2016 national health accounts study shows that Nigerians spent $2.8 billion at chemists and pharmacies, which was three times the international donor support to the country. Further, the 2011 National Malaria Control Programme implementation guide permits private patent medicine vendors to provide rapid diagnostic testing before prescribing an antimalarial drug.

To be sure, these actions will take time and require the highest political will, and they would need to be delivered with consistent advocacy to the Nigerian people. However, to ensure sustainable health care financing and wean Nigeria off international donor support, this is a road the nation must travel.

My wife and I were able to pay for open-heart surgery for Yagazie because of loans from our employers and, thankfully, she lived. But like so many, we were pushed into poverty because it took years to repay the loans. No Nigerian family should go through such a harrowing experience. They shouldn’t have to if sustainable health care financing is established in Nigeria and household expenditures on health are channeled appropriately.