MEMORANDUM BY THE NIGERIA LABOUR CONGRESS (NLC) TO THE COMMITTEE ON NATIONAL HEALTHCARE REFORM
We appreciate the opportunity to present to this august committee the position and recommendations of the Nigeria Labour Congress to the ongoing quest to reform public healthcare in Nigeria. The interest of the Nigeria Labour Congress in this very important reform initiative of government is informed by its centrality to the welfare and wellbeing of Nigerian workers, their families, and the ordinary citizens of our country.
Healthcare is a fundamental human right which is indispensable to the enjoyment of other rights. Article 25 of the United Nations Universal Declaration on Human Rights (1948) strongly depicts the ‘rights’ element on healthcare with these words:
“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
The right to effective and affordable healthcare was further reinforced in the International Covenant on Social Economic and Cultural Rights (CSECR), a multilateral treaty adopted by the United Nations General Assembly on 16th December 1966. Article 12 of the CSECR recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The CSECR also depicted healthcare not just as a right to be healthy, but as a right to control one’s own health and body and be free from interferences. The CSCER mandates States on their obligation to protect this right by ensuring that everyone within their jurisdiction has access to the underlying determinants of health, such as clean water, sanitation, food, nutrition, and housing, and through a comprehensive system of healthcare, which is available to everyone without discrimination, and economically accessible to all.
The mandates espoused by the Universal Declaration on Human Rights and the International Covenant on Social Economic and Cultural Rights on the role of the State in ensuring effective and affordable public health was further buttressed by the Abuja Declaration on Health which mandated all the African countries to devote 15 percent of their budgetary allocation to improving healthcare. This marching mandate is only in tandem with the provisions of Section 17 of the 1999 Constitution which stipulates that government must ensure that there are adequate medical and health facilities for all persons.
The universal obligations on States on healthcare was recently highlighted by the 2022 International Labour Conference of the International Labour Organization (ILO) which adopted two ILO Conventions on Occupational Health and Safety as fundamental labour standards.
Therefore, from the foregoing, the right to health for all people means that everyone should have access to the health services they need, when and where they need them, without suffering financial hardship. The World Health Organisation (WHO) also stipulates that no one should get sick and die just because they are poor, or because they cannot access the health services they need. The WHO further states that good health is determined by other basic human rights such as access to safe drinking water and sanitation, nutritious foods, adequate housing, education, and safe working conditions. Safeguarding of these rights is in State purview.
A Scary Public Healthcare Scorecard
The current health indices in Nigeria shows very serious deficits in terms of government commitment to effective public healthcare. According to World Health Organisation Global Observatory Report (2017), maternal mortality ratio is 814 per 100000 persons. Mortality rate for infants and children under five years is 70 and 104 per 1000 live births respectively. Malaria still constitutes about 27% of the disease burden in Nigeria.
The WHO Report also posits that tuberculosis prevalence is at 323 per 100000 persons while HIV/AIDS prevalence is estimated at 3.2 percent. Malnutrition is said to be common with stunting rate at 43.6 per cent. While guinea worm transmission was interrupted in 2013, and the last Wild Polio Virus was reported in September 2016, yet the country is increasingly coming under the onslaught of Non-Communicable Diseases (NCDs) including hypertension, diabetes, psychiatric and neurological disorders which are all on the rise. Mortality attributed to household and ambient air pollution is at 99 per 100000 of the population.
Nigeria experiences multiple public health emergencies perennially, with most infectious in nature. Currently, the country has two WHO graded emergencies: Grade three North East humanitarian crisis and Lassa fever outbreak. A significant disparity in health status exists across States and geopolitical zones as well as across rural/urban divide, education & social status. Achieving SDGs remains a challenge with poverty still pervasive.
The efforts by the Nigerian government to reform public healthcare should be benchmarked by the aspiration of the United Nations Sustainable Development Goal 3 on healthcare which has delineated key targets for the actualization of health for all. The targets include the following:
- Maternal Health – Aims at reducing maternal mortality ratio to less than 70 per 100000 live births by year 2030.
- Neonatal Health – Aims at ending preventable deaths of newborns and children under 5 years by year 2030 with a commitment by every country to reduce neonatal mortality to at least 12 per 1000 live birth.
- Infectious Diseases – End epidemics of AIDS, tuberculosis, malaria etc.
- Non-Communicable Diseases – Aims at reducing mortality from non-communicable diseases through prevention and treatment.
- Substance Abuse – Strengthen prevention of substance abuse
- Road Traffic – Halve the injuries and deaths from road accidents.
- Sexual and Reproductive Health (SRH) – Access to SRH.
- Universal Health Coverage (UHC) – A UHC with financial risk protection, access to quality healthcare services, access to effective, quality, and affordable essential medicines and vaccines for all.
- Environmental Health – Reduce deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination.
Healthcare Services and Healthcare Reforms in Nigeria
The history of health care services in Nigeria has evolved from traditional medical and herbal practice in pre-colonial era to an organised system of healthcare service. For us in Nigeria the organized healthcare system has gone through series of transformation and modification though characterized by short-term planning they all nevertheless aim to provide universal health care service that is affordable, accessible and available.
There have been at least five major healthcare reforms in Nigeria spanning from the colonial era in the 1940s. After Nigeria’s independence, the healthcare system was reformed along the emerging regional governments which operated an independent healthcare system different from the national government. Later, given the evolution of a unitary form of government, public healthcare was reformed along this line. Much later, primary healthcare system and the universal health coverage systems were institutionalized at different levels of government with varying results.
The National Health Act policy is the legislative guideline for the provision of products and services in the health sector. For us in the labour force, the key essential of this act is the ‘Basic HealthCare Provision Fund’ which has been consistently underfunded and therefore unable to achieve affordable quality health care service for majority of Nigerians.
The importance of a functional health system is in the measure of human capital development and the level of productivity of a country. It easily goes to say therefore that sustainable development is driven by people oriented purposeful governance for which human health must be factored as not only key but integrated human rights of prime importance.
According to the World Health Organisation, Nigeria healthcare system ranks 187th, while life expectancy at 61 ranks 178th below Rwanda, Kenya, and South Africa. Despite being the largest economy in Africa, a Health Index Sustainability Index Report released earlier in the year ranks Nigeria 14th out of 18 countries with poorest health system in Africa (WHO, 2019). Nigeria has consistently ranked one of the highest in perinatal mortality, infant mortality and maternal mortality in Africa in the last two decades.
Despite series of policy reforms, the average annual budgetary allocation of 5 percent is the lowest in Africa and is a far cry from the African Union (AU) recommendation of 15 percent budgetary allocation to healthcare. Despite the intervention from the private sector, the health system in Nigeria remains dreary, infrastructure poor yet expensive, exclusive and elusive.
The Challenge of the state of Health in Nigeria
The primary challenge of the health sector in Nigeria is that it is yet to be prioritized as a key requirement for human capital development which should be a stimulant for growth in productivity and national income. Therefore, the persistent low budget allocation which averages 5 percent of the national budget and constitutes about 3 percent of the GDP is a far cry from the AU and WHO recommendation of 15 percent (Budgit 2021). Indeed, with the largest population and biggest economy in Africa, Nigeria’s performance in the health sector has implications for the economy specifically in respect to its external reserve, employment, capacity development and of course its internal security.
So, even as there is free entry and exit for private sector in health service provision at all levels, the high cost and general poor facilities in the private sector, the push for profit as against quality provision of services, the inability of the private sector to invest sufficient resources, the prevalence of mass poverty and inequality across all sector and location, the growing poverty among the working class all these and more make a holistic privatization of the health sector inhuman, provocative, insensitive and against the provision of Nigeria’s 1999 Constitution (as amended).
As it has become the tradition with every neo-liberal policy implementation, we know well that this will lead to a further cut in the already lean budget allocation to the health sector, loss of jobs, more poverty, inequality, and more social crises.
Indeed, this has been the trend with every policy on privatization in the last three decades, this is clearly the hall mark of the dictators of neo-liberal policy, and this is another level of engineering social destruction of the people and the country.
Private Sector and Health Care Provision in Nigeria
While the private sector participation in health service delivery is mostly in the provision of nursing, primary health care, laboratory, drugs, diagnostics, vaccines, and ancillary services; despite their overwhelming number at 70 percent, their service negates the spirit of affordability and accessibility, they are also commonly known to be expensive, exclusive, elusive and therefore driven more by profit than the quality provision of service. Indeed, their degree of quality service is driven by cost.
In a country where over 60 percent of the population is poor earning less than $1 per day, spending an average of 6 percent of their income on health service with more than 80 percent going to the private sector a full privatization will only worsen poverty and widen the inequality gap which is currently one of the lowest in the world with all the attendant ripple effect.
In the light of the current economic indicators; high level of inflation, devalued minimum wage, food and nutrition crises, endangered external reserve etc, a privatization of the health sector will mean a return to the age of dependence on traditional practice and increased self-help, for the majority on the one hand and persistent corruption and health sector leakages.
The Proposed Health Sector Reform Program
The current proposed health sector reform which has been formulated by a US indigenous firm in partnership with the Bureau for Public Enterprises and the Federal Ministry of Health is essentially a mission of holistic commercialization and privatization of the health sector across its value chain.
Its core policy recommendation is a private partnership reform program that aims to increase private sector investment to fill in the N2.9trillion required to upscale and modernize the tertiary health sector in Nigeria, while government gradually withdraws and tilts its strength towards primary health care provision. This is coming even when the findings of the contracted firm acknowledge the acceptance that health is a social service.
By alluding that the government lacks the financial capacity to fund quality health care, the report summarizes its reform plan thus “…Conversely, the local private sector and foreign investors possess the funds required, and are very likely to opt to fund hospital modernization projects that offer acceptable returns on investments. Hence, a Public Private Partnership is a suitable financing mechanism that would enable … A win-win situation … where the government achieves its objective of providing modern, well- equipped tertiary care facilities for Nigerians in a cost-effective manner, while the private sector earns a profit for the risks borne”. (Health Sector Reform Program, 2021)
The proposed policy reform further tasks the government to increase budget allocation to the health Sector from the current average of 5 percent to 6 percent while expanding Health insurance coverage and access. It acknowledges that in the UK, France, Germany and South Africa, government is the biggest spender with ownership and control of the health sector. The core of the reform seeks control of teaching hospitals through a ‘hospital modernization’ program with an initial pilot of six teaching hospitals spread across the geopolitical zones.
While we are aware that the wave of changes in the global development paradigm is being reflected in local socio-economic indices and we agree that consequent to the changing social reality, it behooves on the government that rules, regulation and policies must reflect the evolving pattern. However, we are of the strong conviction that human beings are at the center of whatever makes meaning to life and must therefore be the core consideration of policies and action to which they are beneficiaries.
This means that changes or development of policies and programs that are expected to be beneficial to people must undergo critical impact analysis such that it leads to a progressive outcome rather than a tendency to further deepen the social inequality divide and poverty.
Therefore, with much appreciation of the desire to make health services accessible and available to all we are concerned that:
• the timing of the plan for the implementation of a New Health Sector Reform Programme for the country comes at a time when the current administration has less than eight months to conclude and bearing in mind the legislative and administrative process that is required to conclude any policy that must pass through universal standard test
• the possibility to rush through the process before the expiration of the current government will very likely exclude key stakeholder consultation and impact analysis as is evidenced in the gap from the terms of reference and the poor stakeholder consultation.
• the seeming exclusivity of the process counters the claim of this government to policy of due process, transparency, accountability, and good governance which should precede the birth of a new policy especially one that affects human wellbeing with implication for human capital development.
• the diagnostic report developed by Vesta Healthcare which is basically advocating for privatization of the tertiary health facilities and services which provides the guiding principle for the envisaged reformed has neither been made public nor shared with stakeholders for proper interrogation.
• that the published call for memoranda is not sufficient without a direct request sent to all critical stakeholders in the health sector since some important stakeholders may have missed the published call for Memoranda, including relevant MDAs at the state and National level.
Health sector allocation and socio-economic indices in select African countries
S/No Country Poverty rate % GDP per Capita Life Expectancy Budget allocation %
- Nigeria 45 2,097.09 61 4.3
- Burundi 64.9 274.01 62 7.99
- Guinea Bissau 69.30 727.52 60 8.4
- Madagascar 70.7 495.49 67 7.2
- South Africa 55.5 1,512.77 64 7.7
Compiled 3-year (2019-2021) average country national data: WHO
From the above comparative data analysis, it is clear that Nigeria’s position as the biggest economy in Africa can be ridiculed when smaller economies, with higher rate of poverty place more premium on health as human capital than Nigeria.
Our mandate here on behalf of the workers and the working class is to emphasize our total and unreserved rejection of the privatization of the health sector. We are not against providing the private sector with more space to participate in the provision of health service delivery in Nigeria, but we are emphatically opposed to the sale of government facilities to either local or foreign investors because health is life and life should not be a commodity to be subjected to the vagaries of the market.
We debunk the lies being persistently told to Nigerians and the master profiteers of privatization that the government lacks resources to modernize the health sector and provide quality health care service to Nigerians. This can only be a ploy to further exploit Nigerians while increasing the wealth of a few.
Evidence from the comprehensive study, an OXFAM report released in 2019 which shows that between 1960 and 2005, about $20trillion was stolen from public accounts by public office holders including army and civilian governments strengthens our position that the government has sufficient resources to adequately fund the health sector
Indeed, this fact of government capacity to fund the health sector is further provided by the National Bureau of Statistics. In its 2020 report on Social Statistics in Nigeria shows that; about $32.1m and N179b were recovered from stolen public funds between 2017 and 2019. Between 2020 and 2022, more than N200billion have been stolen and all these publicized thefts are a fraction of the leakage that is daily going on in the oil and gas sectors.
Corporate evasion of taxes and the high cost of governance particularly its legislative arm. So, ironically though Nigeria is a rich country, almost half of its population is living in poverty and unable to afford quality health care services.
This is the core of the problem in Nigeria’s successive governance system and rather than confront the sources of leakage and corruption which have rendered our health sector weak, typical of this system is to take the burden of additional cost to the workers and citizens.
A key manifestation of the economic crises in the country today is the prevalence of diseases and major sicknesses that require a holistic and comprehensive integrated intervention policy. This means that there is the need for addressing the poverty, food insecurity, and access to water for the 57 million who lack access to safe water and the 130 million that lack access to sanitation, the lack of decent livelihood all of which establish the condition for sickness.
Victims/patients of major diseases and sicknesses cut across class and gender, however while the few rich can afford a good living and subsequently quality health care, that the poor and workers who generally earn low wages, the retirees and aged are not excluded from access to quality health care.
It is therefore the primary responsibility of the government as contained in Chapter 2 of the federal constitution (1999 as amended), to ensure “that suitable and adequate shelter, suitable and adequate food, reasonable national minimum living wage, old age care and pensions, and unemployment, sick benefits and welfare of the disabled are provided for all citizens”. Section 17 of the same chapter further adds the provision of “adequate medical and health facilities for all persons”. All of these are essentially captured in the national health policy provision of factors that enables accessibility and affordability.
On the challenge of paucity of funds which incidentally is not peculiar to the health sector alone, the government needs to be sincere, willing, and decisive in addressing corruption and leakages in the system. Health and Education are critical human resources that facilitate development and which performance is key indicator of a responsive and responsible government that is accountable to its citizen.
The sincerity of a reform process that can deliver on the above objectives should therefore focus on the following: Governance, financing, Health work force, Health information, medicine and technology.
Our Prayers and Demands
We will wish to work with the government in the design and implementation of a public private participation in the health services delivery in such a way that the workers and their families are able to access and afford available health care service from primary to tertiary health care with human dignity.
We will therefore need to examine the existing National Health Act and other policies and programs to enable us steer towards solutions that are workable with implementation strategies.
- Public Healthcare Privatization is not an Option
It would be tantamount to mass suicide to attempt to privatize public healthcare in Nigeria especially in light of our foregoing submissions. We therefore demand a halt to the idea of a health sector reform that allows for free entry and exit into the health sector yet compromising government’s responsibility to provide health services to its citizens and especially the 87 million Nigerians who are living under $2 per day.
- Upgrade the Tertiary Healthcare Sub-sector
The tertiary health sub-sector should be upgraded to enable it carry out the function of providing healthcare, producing skilled personnel, and carrying out research that can add social and economic value to Nigeria.
- Overhaul the National Health Insurance Scheme
The National Health Insurance coverage needs to be overhauled first to expand the coverage to capture more people especially women in the informal sector and all retirees above the age of 60 years should continue to have access to the NHIS. We demand that quality health care delivery to be legislated as a right of citizens and not an exclusive preserve of the rich.
- Ensure Adequate Financing for the Health Sector
a. We align with the constitutional provision that the fundamental responsibility of government is the welfare of its citizens, and for us the core of this is in the quality of health enjoyed by the citizens.
b. We believe that Nigeria is endowed with sufficient resources to adequately fund the health sector, which must be affordable, accessible, and available from the rhetoric of the policy texts.
c. While we are not averse to the participation of the private sector in the provision of health service, we are mindful of the fact private sector is most likely to be motivated by profit and will therefore price health services out of the reach of the common citizens.
d. We demand that government’s presence in the health sector should be a social responsibility towards its citizens to aim at reducing poverty and inequality. Thus, we recommend a national development reform of the public financial management system aimed at strengthening budget design, allocation, and spending.
e. We also demand that government should increase funding to health sector to at least 15% in line with Abuja Declaration on Health starting with annual increment of 2%. The increased funding should specifically target trainings and skilled personnel development; health information; medicine and technology. More resources can be freed from blocking leakages and corruption in the health sector.
f. Given the role of healthcare in increased productivity and income cum poverty alleviation, we demand that additional sources of funding to health should come from special 0.5% tax on individuals who earn a minimum of N60million annual income and 0.1% for business/corporation that earns a minimum of $1billion Naira after tax profit.
g. We need to prioritize health as a core of human capital which affects and is affected by other socio-economic indices. We would therefore need to strengthen program based budget spending and allocation to the health sector to align with national development priorities.
h. We demand the participation of stakeholders in the health sector including workers to be empowered to engage in budget design, monitoring and evaluation. This process will strengthen transparency, accountability and consequently increase resource efficiency.
- Round Pegs in Round Holes
We demand that qualified professional health administrators be selected from across different medical specialties to run tertiary and secondary health institutions in Nigeria. This is the practice in many countries with verifiable results in effective and efficient public health outcomes.
We acknowledge that health systems are dynamic necessitating constant change to respond to emerging challenges. However, any meaningful reform should prioritize making healthcare affordable, accessible, and available across class, gender, and location. This change process to improve service delivery and the quality of health often referred to as Health System Reform must be broadly available in coverage, inclusive in access and easily affordable especially to workers and their family, pensioners and the 87million Nigerians living in poverty.
We make this humble submission on behalf of over 10 million members of Nigerian trade unions and their families, the 97 percent who lack access to health insurance, the over 50 million Nigerian women who sleep hungry and wake up to poverty, the 47 percent of Nigerians who are either unemployed or underemployed and citizens who expect that government should take care of their social capital needs but are currently hopeless and frustrated.
Let us be guided by the saying that “health is wealth” which goes for the individual as much for the nation. Let us be guided by the primary responsibility of governance as enshrined in the 1999 Constitution of the Federal Republic of Nigeria (as amended), that the security and wellbeing of Nigerians is the primary responsibility of government. Let us also be reminded that the security and development of a nation is premised on the quality of its human capital ditto education and health. None of which should be priced out of the reach of the ordinary citizen.
We therefore appeal to the presidential task force on health reform to strongly consider our submission, the submission from the Joint Health Sector and the silent submission of Nigerian citizens who may not have access to be here today or tomorrow, but whose voices resonate through our submission with hope for a better life and a stronger country.
We thank you for giving us this opportunity. We also look forward to collaborating with the government, legislature, and other stakeholders to ensure a healthy population for a healthy and safe economy.
Comrade Ayuba Wabba mni
President, Nigeria Labour Congress
16th August 2022