Five priority health areas for the next Nigeria government — and how behavioral economics can help achieve them
Health is the base of every prosperous, economically productive nation yet it was not a prominent feature in the conversation leading up to the recent presidential election in Nigeria. Now, with campaigns largely behind us, the new leaders must set their priorities, setting forward the roadmap for the next four years. In this essay we briefly discuss five behaviorally informed health investment areas.
- Improve people’s attitude to health insurance
Access to quality health services is a fundamental human right. Increasing funding allocation to the health sector, prioritizing mandatory universal health coverage for the poor at primary healthcare levels, is therefore a priority. Leaders should encourage creativity and innovations that promote health inclusion to improve health coverage. For example, where both spouses are in gainful employment, there should be legislation to allow for the enrollment of extended family members as beneficiaries, instead of the same family benefiting from multiple coverages. This will easily expand the coverage net without the corresponding increase in cost.
People’s attitude and perception towards health insurance also needs to change because even though 63% or 133 million Nigerians are multidimensionally poor, 73% are satisfied with out-of-pocket (OOP) spending for health. This is not entirely surprising considering that OOP constitutes over 70% of total health and 90% of gross private health expenditure, and only 3% of Nigerians have health insurance coverage. Ever since the Abuja Declaration in 2001, the highest percentage allocation to health in Nigeria was 6.1% in 2012, against the pledged 15%, even when the figures have nominally increased over the years.
Even additional funding mechanisms such as the Basic Health Care Provision Fund (BHCPF), sugary drink tax; the Nigerian National Health Insurance Scheme, now National Health Insurance Agency (NHIA); subnational states and private investment in health; and support from local and foreign development partners remain inadequate. The people have directly and indirectly filled the void, either with their life savings or their lives. For example, maternal mortality is 576 per 100,000 live births, the fourth highest in the world.
2. Get people to access quality healthcare
Nigeria has 39,914 functional hospitals and clinics. 85% of these facilities are primary health centers (PHCs), a majority of which are underfunded and underequipped. As the government invests in health infrastructure, there is an even more urgent need to use behaviorally-informed strategies to reorient the populace on how, when and where to access health care to improve efficient and judicious use of health resources.
For example, patients with uncomplicated cases that can and should be handled by a primary health center (PHC) often present themselves first at a secondary or tertiary health center. This practice leads to the overcrowding of secondary and tertiary health centers, which make up 15% and 0.5% respectively of all hospitals and clinics in Nigeria. This disorganization and improper referral linkage leave our PHCs undersubscribed and underutilized — which, in the long term, worsens the neglect of the facilities since people do not frequent them.
3. Motivate and reorient health workers to provide quality care
New health professionals must be reoriented through behaviorally informed engagements to awaken their patriotism and sense of nationalism. However, success would depend on palpable investments in the welfare of health workers by the relevant stakeholders. The government and development partners must reorganize the human resources for health, starting from training, ensuring adequate training of the required cadres; placements, striving to achieve equitable distribution of health workers across rural-urban communities; and incentive structuring, affording health professionals adequate compensation and incentives edged against inflation.
Nigeria has just about 940,000 healthcare workers across all cadres, out of whom only 8% are physicians (generalists), and even fewer physicians are specialists (1%). Still, from these numbers, about half of the Nigerian-trained and registered physicians have relocated abroad, leaving behind the other unmotivated half to serve our poor and growing 200 million population.
About half of the Nigerian-trained physicians are practicing in the UK and elsewhere. Internally, many trained medical professionals continue to leave medical practice for more financially rewarding professions. Another dimension of the crisis is the uneven distribution of health workers in the country. Residents of rural settings — who make up nearly half of the population — have access to less than 20% of doctors and nurses. The community health workers — who constitute 12% of all health workers in the country and often fill the void in rural communities — remain underpaid, unmotivated, and unrecognized. The health implications of this trend are far-reaching, including a proliferation of quacks to fill the void.
4. Adopt the ‘prevention is better than cure’ attitude
Prevention is also cheaper and safer. We must continue to invest in pandemic preparedness and other disease preventive programmes, including sensitization and behavioral interventions that improve people’s adherence to public health advisories. Nigeria, like other African countries, are increasingly becoming doubly burdened by communicable and noncommunicable diseases (NCDs). NCDs like cancers, diabetes, and heart disease with the greatest burden in low- and middle-income countries could cost the global economy over USD47 trillion by 2030 if the status quo is maintained.
Infectious diseases like Ebola, and more recently COVID-19, have become a recurring nightmare, costing us human and economic losses. Nigeria was rated “Not Ready”, scoring 39%, in an assessment of countries’ readiness for the next pandemic in 2017. Since then, the national and subnational governments have made significant strides in strengthening our readiness. For example, every subnational state now has a functioning public health emergency operations center. The Nigeria Centre for Disease Control (NCDC) and other public health agencies have also become stronger. Still, we must not relent. Investing in preventive ventures such as manufacturing and promoting uptake of immunizations should be a priority.
5. Improve the culture of innovation in health technology
Research and development (R&D) is the backbone of innovation. We need to mobilize resources and invest in technological advancement in tools and pharmaceuticals, and promote telemedicine and e-pharmacy. The Lancet Nigeria Commission recommends a ‘National Medical Research Council with 2% of the health budget and central government funding…to support high-quality evidence and innovation.’ This has become even more cogent with the recent learnings from the COVID-19 pandemic when African countries received less priority in vaccine allocation.
Further, 87.6% of households in Nigeria own a mobile telephone while 34.6% of households have the internet. This is a revolutionary opportunity to equitably advance, democratize access to healthcare, and even decongest health facilities, by adopting telemedicine. With more than 70% of adult Nigerians being financially included, we can replicate similar templates in the health space to improve reach and access to information, services and prescription for uncomplicated health issues.
Luckily, the telemedicine and e-pharmacy innovations have picked up rapidly with a few telemedicine providers in Nigeria already providing health services at scale. There is equally a need to invest in programs that seek to change people’s attitudes and behaviors to improve receptiveness and uptake of these innovations.
