Debo Onifade


While I pray that Nigeria and indeed the rest of the world will overcome the COVID-10 plague soonest, I wish to address a more important issue today that electorates and politicians need to think about.  It is about universal free healthcare for all Nigerians.  Most of our traditional politicians may not care about this subject, butmajority of us in Nigeria care about it.


Many presidential aspirants in 2019 talked about increasing healthcare budget as a key solution to healthcare crisis in Nigeria.  My views are different because if the federal government budgets more funds to the ministry of health, government officials willconsequently steal more money.  From 1999, the federal government has spent billions of dollars in the healthcare sector and we have not seen much improvements.  A few days ago, I watched the National President of the Nigeria Medical Association (Dr. Francis Faduyile) say on Channels TV that over 70% of government-owned hospitals in Nigeria don’t have running tap water.  And if the simplest protection against Covid-19 is to wash hands with soap and water for about 20 seconds, and government hospitals don’t have running tap water, then we’re in big trouble.


The first thing the Nigeria government needs to focus on is how to ensure every Nigerian has health insurance.  I know there is a law to this effect, but the implementation has been very poor and there has been persistent massive corruption in the National Health Insurance Scheme (NHIS) and State Health Insurance Schemes (SHIS).  I am proposing some changes to the law in order to enhance effectiveness across Nigeria.  First, we need to find a way to convert NHIS to a public-private-partnership organization (as long as government has controlling shares and private owners include the most competent and credible Nigerian experts).  The fact that this organization will be profit-driven will certainly promote efficiency, speed up implementation across the country and reduce corruption.  The federal ministry of health will continue to regulate to protect the customers and ultimately create a buffer to provide free service to the poor.  Much as I strongly dislike the idea of letting private run our healthcare, I am extremely convinced that we will continue to dance around circles if we leave this very important institution to civil servants.


In his first tenure, President Buhari appointed a new NHIS boss (an accomplished Nigerian doctor from the US) who was supposed to be a credible man.  The new NHIS boss exposed a lot of corruption but himself reportedly got involved in corruption, and finally got sacked.  This has been the story since NHIS was created and it is time to inject private participation into this system to turn it around.  In Nigeria, it is a well-known fact that private organizations usually run more efficiently than government run organizations.So we need not fool ourselves that a new president or a new NHIS boss will successfully clean up the mess.


This revamped or privatized NHIS should continue to deal with ONLY government hospitals and be required by law to fund the hospitals.  The hospitals don’t need expensively run hospital boards any longer.  They just require management teams that will report directly to the ministry of health and these management teams will also relate directly with the NHIS to seek funding.  The regulator (federal ministry of health) should continue to manage and fund staffing, until the NHIS is big enough to take over this completely.  NHIS currently has good money and the law guarantees them steady income from the government in addition to the premiums from workers.  They must be required by law to fund the hospitals and should have powers to investigate corruption in all hospitals and recommend punitive measures to the regulator (federal ministry of health).  Let’s remember that this funding process will nolonger require any government appropriation process which is usually reportedly laden with corruption.  Projects will therefore be executed faster and hopefully cheaper.


Also, because the regulator will no longer be burdened with project execution, appropriation issues, politics related to board appointment,etc, they will have more time to properly regulate and ensure the NHIS, SHISs and private players are run properly.  Currently, it’s the ministry of health that’s managing and technically regulating itself.What I am describing will eventually look like the practice in the UK and Canada, except that our own NHIS will be managed through a more efficient private-public-partnership arrangement and will start with only government workers.  The UK NHS is crumbling and is significantly different from my proposal because they are 100% run by the government.


The next point is that it is obvious that many states are struggling with their state insurance schemes and they have been delaying a proper implementation for many years.  We need to allow state government workers to have the option of buying insurance from the NHIS and create competition across all 36 states and Abuja.  If ultimately a state cannot run his own system well, they should forget about it and let the NHIS run insurance in that state.  We should not continue to delay implementation and let state government workers suffer.


We also need to open up the NHIS to allow non-government workers buy insurance from it.  The premiums charged may be higher, but NHIS will benefit financially when the subscriber pool is widened.  I know the next question people will ask is ‘so what happens to the private insurance companies?’  The fact is that majority of lower middle-class to rich Nigerians will still always prefer to visit private hospitals, and there are far more private hospitals in Nigeria than government hospitals.  Since NHIS will not work with private hospitals, that market will remain huge for private insurance companies.  And we must ensure that the private insurance companies are fully consulted while coming up with the new changes.


What about poor people that cannot afford to buy health insurance?  This is actually the group I care mostly about, but if the NHIS is not better positioned to become rich enough to be able to create sizable financial buffer to take care of this group, we’ll just continue to bury our head in the sand like an ostrich.  First, if we quickly reposition the NHIS as I described above, they will get millions of subscribers within a short time and they will start earning a lot of money.  The regulator should ensure an agreed percentage of their income (not profit) is set aside to cater for this group.


What defines indigence? And given that many Nigerians will lie that they are poor in order to get free health insurance, who certifies indigence?  This is the toughest part of this subject and I fully agree that it is the most challenging part of my suggested reform.  I provided greater details and recommendation in my book – LIBERATING NIGERIA: A GUIDE TO WINNING ELECTIONS AND LIBERATING OUR COUNTRY.  I don’t have the space to fully explain here but the summary is that we should have state boards made up of respected religious, civil rights and traditional leaders in different states to determine who is genuinely indigent and qualifies for free health insurance.  This should be re-evaluated every year as is done in the United States Medicaid system.  We will not get it right immediately but we should have a 3-year target such that before the end of a new governments first-term, ALL poor people that cannot afford health insurance should have started getting free health insurance acceptable in all government hospitals across Nigeria.


Nigeria will surely prosper again!


Onifade is the author of “Liberating Nigeria: A Guide to Winning Elections and Reviving our Country”, and the founder of the Nigeria Politics Online Forum: Liberating Nigeria


deboonifade             @deboonifade

April 14, 2020

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