HealthCare System In Nigeria: Obstacles and Challenges 

-African Development Bank Group

Nigeria is projected to become one of the most populous countries in the world, and is rightly taking its place on the world stage. Despite being Africa’s largest economy and most populous country, Nigeria’s healthcare outcomes compare dismally to its West African neighbours. With a dysfunctional focus on curative care, the Nigerian health system is ill-prepared to deal with the increased prominence of non-communicable diseases and surge in deaths due to metabolic risk factors that the country has witnessed over the past two decades.

Coverage and quality of healthcare services in Nigeria is unevenly distributed and compares poorly to other West African nations. Government spending on healthcare in Nigeria  Africa’s largest economy falls short of the average across the Sub-Saharan region, and a reliance on out-of-pocket spending puts healthcare out of reach for the poorest Nigerians.

Healthcare in Nigeria is a concurrent responsibility of the three tiers of government in the country. The Federal Government is largely responsible for providing policy guidance, planning, and technical assistance, and coordinating the state-level implementation of the National Health Policy, and establishing health management information systems. The Federal government is responsible for disease surveillance, drug regulation, vaccine management, and training health professionals. The Federal Government is also responsible for the management of teaching, psychiatric and orthopaedic
hospitals and also runs some medical centers. Health facilities in Nigeria are all classified based on their management or the services they render. Under management classification, there are private hospitals and government hospitals. On the other hand, if they are classified by the services rendered, Government Hospitals are classified the same as those in the FBO and private sectors since they all operate under the same regulations and standardizations. The 2014 National Health Act classifications of health services are Primary health care, Secondary healthcare, and Tertiary health care.

The responsibility for the management of public health facilities and programs is shared by the State Ministries of Health, State Hospital Management Boards, and the Local Government Areas (LGAs). Faith-based and private health facilities play an important role in the provision of health services in Nigeria. The faith-based health response in Nigeria is being implemented at two levels. The first level is at the health facilities involving the direct provision of health and medical services. Here it is estimated that FBO and the private sector contribute up to 70 % of the total health services provision in the rural areas and the hard-to-reach places in Nigeria. The second level is a non-facility response where the health response focuses mainly on advocacy, community mobilization, prevention, care, and support services. At this level, the impact of FBOs has also been significant. They have been a critical part of the multi-sectoral response to HIV/AIDS through their network of community systems. FBOs are an integral part of the community and their leaders strong voices in influencing policies, calling for justice, addressing stigma and discrimination, and
mobilizing their members and the community at large to take up testing, prevention, and treatment
services. Private providers of healthcare have a visible role to play in healthcare delivery. The use of traditional medicine (TM) and complementary and alternative medicine (CAM) has increased significantly over the past few years.

Healthcare delivery in Nigeria has experienced progressive deterioration as a result of weakened political will on the part of successive governments to effectively solve several problems that have existed in the sector over many years. This directly impacts the productivity of citizens and Nigeria’s economic growth by extension. Over half of Nigeria’s population lives on less than $1.90 a day (‘Poverty Head-count’), making them one of the poorest populations in the world. As of February 2018, the country was ranked 187 out of 191 countries in the world in assessing the level of compliance with Universal Health Coverage (UHC), as very little of the populace is health insured, whereas even government provision for health is insignificant. Out-of-pocket payments for health causes households to incur huge expenditures. Private expenditure on health as a percentage of total health expenditure is 74.85%.

The implication of this is that government expenditure for health is only 25.15 percent of all the money spent on health across the nation. Of the percentage spent on health by the citizens (74.85%), about 70% is spent as out-of-pocket expenditure to pay for access to health services in both government and private facilities. Most of the remaining money spent by citizens on their health is spent on procuring ‘alternatives’ which cost a lot. Nigeria has better health personnel than most other African countries. However, considering its size and population, there are fewer health workers per unit population than are required to provide effective health services to the entire nation. Sadly, the most commonly advertised reason is the brain drain of health professionals in other countries, especially in Europe and America.

Health infrastructure

The federal government’s role is mostly limited to coordinating the affairs of the university teaching hospitals, Federal Medical Centres (tertiary healthcare) while the state government manages the various general hospitals (secondary healthcare) and the local government focuses on dispensaries (primary healthcare), which are regulated by the federal government through the NPHCDA.

The total expenditure on healthcare as a percentage of GDP is 4.6, while the percentage of federal government expenditure on healthcare is about 1.5%. A long-run indicator of the ability of the country to provide food sustenance and avoid malnutrition is the rate of growth of per capita food production; from 1970 to 1990, the rate for Nigeria was 0.25%.Though small, the positive rate per capita may be due to Nigeria’s importing of food products.

Health insurance

Historically, health insurance in Nigeria could be applied to a few instances: free health care provided and financed for all citizens, health care provided by the government through a special health insurance scheme for government employees and private firms entering contracts with private health care providers. However, there are few people who fall within the three instances; as of 2015 less than 5% of Nigerians have health insurance coverage.

In May 1999, the government created the National Health Insurance Scheme, encompassing government employees, the organized private sector and the informal sector. Legislatively the scheme also covers children under five, permanently disabled persons and prison inmates. In 2004, the administration of President Olusegun Obasanjo gave more legislative powers to the scheme with positive amendments to the original 1999 legislative act. 1.5 percent of Nigerians have been covered by the National Health Insurance Scheme since its establishment. In 2017, the House of Representatives Committee on Health Care Services in Abuja, organized a two-day investigative hearing; where the Minister of Health Isaac Folorunsho Adewole said that the sum of N351 billion had been expended on health management organizations so far without commensurate result.

There is immense private sector participation in the scheme with HMOs like Health Partners HMO, Total Health Trust, Police HMO, Clearline HMO, Multi Shield Nigeria, Expatcare Health International, Oceanic Health Management and Zuma Health Trust.

1. Health Care Services Financing
The federal government, the state government, and the local governments respectively are responsible for all financial aspects, including personnel costs, consumables, running costs, and capital investment in the public health sector. The federal and state governments are under obligation to allocate not less than 15% of the state budget to health services. This has however not happened since 2001. The government has not been able to even meet the 6% mark. High priority is given to primary health care services with particular focus to the fewer privileged areas and groups. Community and financial sector resources are mobilized in the spirit of self-help and self- reliance.

Unlike the public health systems with regular funding streams, financing of the faith-based health care sector in Nigeria is primarily 70% from service charges, 20% from church donations and offerings through the health departments while 10% comes from philanthropists, government or other donors.
Donations from the government to faith-based health facilities are common in the Nigeria Middle belt, South West and South East regions where there are large groups of inhabitants from a particular faith. Government support comes in the form of ambulances, construction of patient wards, laboratory or road construction, drug donations, hospital equipment, or even joint ventures between the Government and the facility.

In Nigeria, public funding accounts for about 25% of total health spending while the private sector (largely faith-based) provides 75% of the funding, with household out-of-pocket expenditure accounting for 95% of the private sector expenditure. Another existing major health financing mechanism in Nigeria is the Formal Sector Health Insurance Programme (FSSHIP), which is run by the National Health Insurance Scheme (NHIS). It is a mandatory scheme for employees in the formal sector. Most private/FBO health facilities run the NHIS program in Nigeria for both government and private sector workforce. The NHIS contracts private, for-profit Health Maintenance Organizations (HMOs) to administer the purchasing system and channel resources to providers. Healthcare providers receive capitation payments for primary healthcare services and fee-for-service for secondary services.

2. Availability of Human Resources for Health
The exact number of health workers in the Nigerian health system is not well documented, especially those working in the faith-based sector. There is currently no consolidated database of faith-based health care workers, although CHAN is working on developing one. However, Nigeria has the largest human resource for health in Africa. As of 2007, there were 52,408 registered medical practitioners in Nigeria but only 14,000 applied for registration to practice. There were also 128,918 nurses, and 90,489 midwives registered, which translates into about 35 doctors and 86 nurses per 100,000 population respectively. As is found in most African countries, many qualified medical practitioners work in or are located mostly in urban areas. About 60 % of the states in Nigeria provide incentives to health workers that volunteer to serve in rural areas, while others make rural service a condition for certain promotions.

3. Training Health and Medical Workers
Health workers receive training in designated health /medical training institutions. Presently, these institutions are poorly distributed in favor of the southern parts of the country. Furthermore, nursing and midwifery schools have limited the enrollment of new students to 50 per annum to ensure that standards are maintained.
Health workers are trained at various professional levels including certificate, diploma, graduate, and postgraduate. A major constraint on the number of trained health workers is the acute shortage of intern posts for doctors, dentists, pharmacists, and laboratory scientists as well as a shortage of residency posts for doctors and dentists. There is also no school of public health in Nigeria, although most medical schools have small departments of community health, mainly for undergraduate training. The lack of public health schools focused on postgraduate professional education, leadership, and research severely limits the professional health workforce. Also, the lack of bachelors and masters-level public health programs, and service management training, results in a weak capacity to promote public health programs and to lead health services and systems more effectively. Some of the problems of the health workforce in Nigeria include low salaries, health worker shortages, particularly in rural and remote areas, skill-mix imbalances characterized by a curative care bias, poor distribution of specialists, poor working environment, a weak evidence base, the challenge of HIV/AIDS,
out-migration, and inadequate investment in the health sector.