Presentation given on February 6, 2017, by Dr. Francis Nwachukwu Ukwuije at the Nigeria Healthcare Financing Workshop in Abuja, Nigeria.

1. Dr. Francis Nwachukwu Ukwuije
Snr. Health Economist
Healthcare Financing Equity & Investment,
HSS, DHPR&S FMOH
06 February, 2017
Federal Ministry of Health
Where is Nigeria on Universal Health Coverage (UHC)?

2.  World Health Assembly (WHA) Resolution
2005: urged countries to develop their
health financing systems to:
 Ensure all people have access
to needed key promotive,
preventive, curative and
rehabilitative health services
of good quality at an
affordable cost without the
risk of financial hardship linked
to paying for care.
Definition of Universal Health Coverage (UHC)

3. 3

4. 4
Dimensions of Universal Health Coverage (UHC)

5. 5
Who should be covered?
• 100% population coverage:
- All population groups and their families need to be covered:
- Formal sector employees, informal sector workers, self-employed, unemployed, students,
pensioners, …
Which services should be covered?
• Defined package of services
- Available resources: What can the country afford?
- Health service priorities
- Preferences for specific services
How much of the costs should be covered?
• Very high level of prepayment, not necessarily 100%
- Moral hazard, rational consumption of services
Dimensions of Universal Health Coverage (UHC)

6. 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 vulnerable population groups with social
assistance and safety-net programmes
At least, 80% of the poorest 40% of the population have effective coverage
to quality health services
Target Indicators To Monitor Progress Towards UHC

7. Total health expenditure
(THE) was 6.7% of GDP in
2009
(>4-5% Benchmark)
5-7% population
covered by pre-payment
and risk pooling schemes
(< 90% Benchmark )
< 2% coverage of
population with social
assistance and safety-net
progs
(100% Benchmark)
Out-of-pocket spending
>60% of total health
expenditure
(>30-40% Benchmark)
7
Is Nigeria on Track Towards UHC?`

8. Tunisia
Kenya
Tanzania
Cote d'Ivoire
Ghana
South Africa
Ethiopia
Senegal
Rwanda
Uganda
Georgia
Sri Lanka
Vietnam
Nigeria
LOW INCOME
LOWER
MIDDLE
INCOME
UPPER
MIDDLE
INCOME HIGH INCOME
15204060100
ShareofTHE(%)
250 500 1000 2500 10000 35000 100000
GNI per capita, US$
Source: World Delopment Indicators database
Note:Both y- and x-axes logged
Out of Pocket Spending
Household out of pocket health spending as share of total health
spending is among the worst.

9. 2015
100
89%
11%
2014
100
82%
18%
2013
106
74%
26%
24%
76%
2012
100
% of Federal Health Budget Allocated to Tertiary Care
Others
Tertiary Care
• Health ailments
treatable at
Primary Health
Care levels,
contribute 70%
of total disease
burden in
Nigeria
• Yet Federal
Government
allocates ~80%
of its resources
to tertiary care
• By increasing
allocative
efficiencies,
Nigeria could
increase
coverage of
health care
services.
Source: Budget Office, NDHS
3%
2%
Tuberculosis
Meningitis
3%
4%
Cancer
Malnutrition
3%
Stroke
Diarrheal 5%
Malaria
20%
LRTI
19%
9%
HIV
Nigeria’s Cost Efficiency is Low & Contributes to Poor Health
Outcomes

10. 10
8.2
9.7
9.8
60.1 58 61
32.6
35
36
41.8 39 38.1
20.1
35.4
38
31.4
41.4 42
0
10
20
30
40
50
60
70
2003 2008 2013
Modern Contraceptive Prevalence Rates Antenatal Care Coverage
Delivery in a Health Facility Skilled Birth Attendance
DPT3 Coverage Measles Coverage
Health Service Delivery Nigeria;1990-2013 (NDHS)

11. 100
75 69
201
157
128125
99.3
73.9
0
50
100
150
200
250
2003 2008 2013
IMR
U5MR
MDG4 Target
11
Source: Nigerian Demographic and Health Surveys - NPopC
IMR & U5MR from NDHS – some progress but not fast enough to accomplish mdg4

12. 12
0
50
100
150
200
250
300
2003 2008 2013
North Central
North East
North West
South East
South South
South West
U5MR by Geopolitical Zone 2003-2013 NDHS – North is Lagging

13. 13
48 40 37
52
35
31
112
88
64
0
50
100
150
200
2003 2008 2013
Child
Post-Neonatal
Neonatal
Post-Neonatal Mortality Accounts for 71% of U5MR in 2013 NDHS

14. 6 5.7 5.7
5.5
0
1
2
3
4
5
6
1990 2003 2008 2013
14
Total Fertility Rate – NDHS: Very Slow Progress

15. 15
0
1
2
3
4
5
6
7
8
2003 2008 2013
North Central
North East
North West
South East
South South
South West
TFR by Region 2003-2013 – NDHS Limited Progress Everywhere

16. 42
11
24
41
14
23
37
18
29
0
5
10
15
20
25
30
35
40
45
Stunting Wasting Weight for Age
2003
2008
2013
Source: NDHS 2003, 2008, 2013 16
Child Nutritional Status 2003-13: mixed results

17. 17
0
10
20
30
40
50
60
2003 2008 2013
North Central
North East
North West
South East
South South
South West
% of Children Stunted by Region 2003 to 2013 - NDHS

18. -50.0 0.0 50.0 100.0 150.0 200.0
Plateau
Benue
Ekiti
Sokoto
Yobe
Osun
Lagos
Imo
Abia
Cross River
Borno
Rivers
Ogun
Gombe
Kaduna
Jigawa
Niger
Adamawa
Enugu
Cumulative Difference
2008 - 2013
Congratulations to Enugu, Kwara,
Adamawa, Bayelsa, and Niger
Progress is Possible: Changes in 8 Key Maternal and Child Health Indicators 2008-2013

19. 19
0
20
40
60
80
100
120
140
160
180
200
Poorest 2nd 3rd 4th Richest
Child from the 2 poorest income quintiles has
2.6 times higher risk of dying in childhood
Poorest 40% of Population Accounts for 56% of all U5 Mortality

20. 20
0
10
20
30
40
50
60
Poorest 2nd 3rd 4th Richest
Stunting
Low Weight for Age
% of Children who are Malnourished by Income Quintile – 2013 NDHS

21. 7
24.6
5.7
0.9
79.5
94.5
85.3
23.4
0
10
20
30
40
50
60
70
80
90
100
DPT3/Penta3 Antenatal Care Skilled Birth
Attendance
Modern CPR
Poorest
Richest
21
Coverage of Key Health Interventions by Income Quintile – NDHS 2013

22. 83 83.9
86
50.6
46.4 46.5
12.8
27
24.9
40.2
54.8
62.2
0
10
20
30
40
50
60
70
80
90
100
2003 2008 2013
ANC
Rural
DPT3
Rural
DPT3 Urban
ANC
Urban
Source: NDHS 2003, 2008, 2013
22
Service Delivery 2003-13 in Urban and Rural Areas:

23. 23
Need for Clear & Strong
Government Leadership &
Commitment

24. 24
Presidential
Declaration on UHC;
March 10, 2014

25. I. Financial access
II. Physical access
III. Quality of services
Key Outputs from Presidential Summit
on UHC: March 10, 2014

26. Governments at all tiers should
declare that the achievement of
Universal Health Coverage in
Nigeria is a priority goal
Starting-point for achieving UHC

27. • Commitment by all tiers of government to ensure
every Nigerian has financial access to health
services through mandatory health insurance and
other financial risk protection mechanisms
• Fast-track the amendment of the NHIS Act to
ensure that all employers in formal, informal and
organized private sector cover their employees
with mandatory health insurance
Recommended Actions for improving financial access for UHC (1)

28. • Establish a Universal Health Coverage (UHC) fund with
innovative funding sources – general tax revenue with
budget line for UHC, Sin tax (alcohol, tobacco), air-
ticket levy, percentage of VAT, GSM contributions, etc.
• Governments (Federal and states) should ring-fence the
UHC fund for ensuring compulsory coverage for the
poor and vulnerable groups including, pregnant
women, children, those physically challenged, etc.
Recommended Actions for improving financial access (2)

29. • Governments at all levels should increase their
budgetary allocations to health to reach the
“Abuja Declaration”
• Establish mechanisms to ensure all government
workers pay the 1.75% salary contributions for
the Formal Sector Social Health Insurance
Programme of the National Health Insurance
Scheme.
Recommended Actions for improving financial access (3)

30. • Governments at all levels should ensure the presence of at
least one functional primary health care centre per ward and
one general hospital per LGA that can deliver the minimum
defined benefit package.
• All states should reactivate their Central Medical Stores to
conform to a minimum standard for the supply chain
management of health products
• Governments at all levels should ensure that their health
facilities have the availability of the minimum standards
(numbers and skill sets) defined for human resources for health
at each level
Recommended Actions for improving physical access

31. • Training institutions should ensure that there is
competency-based training of all health
professionals. around priority health needs
• The government should address mal-distribution
of health workers through policies and incentives
around retention
Recommended Actions for improving physical access

32. • Governments at all levels should conduct a health system
needs assessment for improvement of quality of services
• Governments should strengthen existing systems for
supervision and monitoring of quality of healthcare
provision and institutionalize monitoring and evaluation of
health system in Nigeria
• Governments should explore the use of an Independent
Health Quality System for issues relating to quality in
health services
Recommended Actions for improving quality of health services

33. • Strengthen existing consumer protection agencies
including SERVICOM and every hospital should have its
own SERVICOM desk
• Governments should establish a Clinical Governance
body or bodies to protect both providers and
consumers at all levels
• Governments at all levels should improve healthcare
infrastructure and equipment (including maintenance
strategy).
Recommended Actions for improving quality of health services

34. • Affordability is 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
(Giedion et al, 2013)
In implementing UHC interventions

35. • Strive for more health for money (improved
efficiency in use of available funds)
• Advocacy to decision makers and all Nigerians
to understand and be fully involved in
interventions to achieve UHC
• UHC will save millions of lives in Nigeria
In implementing UHC interventions

36. 36
OPPORTUNITIES

37. 37
THE NHAct 2014: VEHICLE FOR ACHIEVING UHC

38. 3 Main Sources
FG Grant at Least
1% of CRF
Donor Funding
Other Sources
including Private
Sector
BHCPF
Distribution
50% for BMHCP
through
Insurance
45% for
Primary
Healthcare
5% for
Emergency
Care
38
Basic Healthcare Provision Fund (BHCPF)

39. 1. Investment Case
2. Healthcare financing strategy
3. Joint financing for investment case
The Global Financing Facility (GFF)

40. And the SOML P4R Program
Code Disbursement Linked Indicator Means of Verification Indicative
Allocation ($m)
% of
Total
1A. Performance-based grants to States -
quantity
SMART Surveys 289 58
1B. Enhanced MNCH weeks SMART Surveys 16 3
2. Performance-based grants to States - quality Health Facility Surveys 54 11
3.1 Improving data collection Review by WB and IVA 35 7
3.2 &
3.3
Improving data utilisation Review by PMU 45 9
4. Encourage private sector innovations Third party verification 29 4
5. Increasing transparency, management &
budgeting for PHC
Review by WB and IVA 41 8
Total 500 100

41. • Achieve Universal Health
Coverage by ensuring 1
functional PHC per ward
in Nigeria
UNIVERSAL
HEALTH
COVERAGE
Responsive
ness
Greater
Equity
Improved
Health
Outcomes
Financial
protection
Efficient,
accountable
and
transparent
system
Increased
job
Reduction in
poverty
Greater
productivity
• Significant
resources are
required to
achieve the
goal.
• Government
thus needs to
determine a
financially
sustainable
mode of
financing
• To achieve UHC, Nigeria
will scale up the inputs
required for efficient
service delivery
• 10, 000 PHC facilities will
be revitalised over the
next 2 years.
• 100m Nigerians will have
access to qualitative
health care
The PHC revitalisation program will serve as the basis for
achieving Universal Health Coverage

42. And Health As an Investment that yields huge returns to the
National Economy
42

43. review policy to ensure efficient and effective
management of our health system with focus on
prevention
Ensure that no Nigerian will have any reason to go outside the
country for medical treatment
Guarantee financial sustainability to the health sector and minimum
basic healthcare for all
Review occupational health laws and immediately commence
enforcement of the provisions to reduce hazards in the work place
Partner with state Governments and development partners to ensure all
round implementation of our primary health plans by expanding access to
health insurance for rural communities
43
The President’s Pledge for Health

44. The Joint Learning Approach
1. Common
Problem
Identification 2. Collective
Problem Solving 3. Synthesis of
New Knowledge 4. Knowledge
Adapted Within
JLN Countries
5. Knowledge
Disseminated to
Other Countries
Key Benefits of the JLN Approach:
 Strong country ownership
 Relevance to country priorities
 Space to analyze root causes
 Builds trust, safe space, and community
 Results in practical tools/knowledge products that can be
used & shared
 Creates opportunities for responsive follow-up by partners
jointlearningnetwork.org 44
Using collaborative learning among practitioners to co-develop global knowledge on
the practical “how-to’s” of achieving UHC

45. How Do I Support My State Achieve
UHC?

46. Thank You
46