Dr. E. Charles Ezuma-Ngwu is a Health Finance Expert and Budget Analysis and Strategic Performance leader, with a proven track record of over two decades. In this interview with SADE OGUNTOLA, he explains the benefits of healthcare providers’ capitation payment method and what needs to be done to ensure Nigerians enjoy universal health for all.
C AN you elaborate on your study and why the study was done?
Leaving my parents in Nigeria so many years ago, I did not know that my heart stayed back in Nigeria. My background in health care consulting services and experience working at the US premier research institution, NIH, and the Substance Abuse and Mental Health Services Administration continued to prepare me to focus on an area that will assist the reforms. I chose to embark on this six-year journey when I visited a newly constructed hospital in Lagos, Nigeria, and found that the emergency area was empty with all the brand-new equipment and services. When we asked the MD of the Hospital, he said that only the oil companies other higher-income persons could afford their services. My initial research indicated as is the case in the US and other developed economies that provided universal health care, access to the impoverished population remained elusive. Against the advice of my dissertation panel and an abundance of credible research data in the United States, I decided to explore the causes of this health care inequality in Nigeria. This research was highly rewarding, satisfying, and energising as I sought to contribute to the country I truly love.
What were your findings in this study?
The study explored universal health care in Nigeria with a focus on Lagos by triangulating multiple data points, including the USAID, SHOPS sponsored census of all private outpatient clinics in Lagos, which revealed a general clustering of clinics in metropolitan Lagos, paucity of disease-reporting, and scarcity of clinics and HMOs in the outskirts of the urban areas and other lower-income locations. The study concludes by delivering geospatial maps and other analyses as a template for transitioning from a predominantly FFS-based health care payment system to a more productive environment for private health care providers and patients to deliver and receive quality health outcomes and reach the lower-income population. Incentivising qualified private outpatient medical clinics with direct location-based capitation payments can attract clinics away from urban cities into outskirts and rural areas to meet the health care needs of the undeserved communities. There are strategies for quickly ramping up enrollments in these communities to meet the average number of patients per health care provider.
Your book focuses on the vulnerable population in Nigeria and how to deliver health care to them. Which population is vulnerable, and how should health care be delivered to them?
The informal sector bears the highest incidence of catastrophic health care expenditure, and they are the focus of universal health care. We have to tackle health care access to this sector. In Chapter 1 of my book, I stated that private health care providers (primary health care providers) are positioned to play a significant role in improving access to health care in contrast to large public health care systems. The private medical centers are numerous and are closer to the informal population. There are clinics in many more areas than public or regional hospitals. We need to incentivise them to come into the universal health care arena. We also need to develop systems that will attract them to impoverished communities both in the urban areas, suburban and rural areas. My research book provides a solution to this problem by analysing a location-based capitation system. Granted, it is resource-intensive, but it is also one of the most cost-effective systems of providing health care. Now that the governor of Lagos State has announced mandatory health insurance registration, incentivising qualified outpatient medical centers to participate as providers will speed access to all the citizens of Lagos and serve as a surveillance mechanism for reporting disease outbreaks and other epidemiological issues propping up within segments and areas of the state.
From your study, which should be prioritised, funding or human infrastructure in the health sector to make the system work better?
My study indicates that funding and “political will” are the two essential ingredients to a successful universal health care implementation. Studies in many developing economies have shown that unless the resources and sustained political will are present, full and successful implementation of universal health care will remain elusive. We continue to churn out medical and nursing school graduates without employment opportunities for them. As we all know, these essential groups are leaving the country in droves. This has been happening for over 40 years in Nigeria. As we see in China and Asia, health care takes off if the funding and political will are present. Currently, in Nigeria, there are over 20,000 health care structures in all 36 states that are dormant. More are being built without a sustained effort to staff and supply and maintain the necessary equipment and materials.
The national health insurance is yet to fully take off. What will you suggest to ensure that in the shortest time from now, Nigeria attains universal health for all?
In concert with HMOs, I suggest that we initiate a location-based direct capitation system for providers that will attract them to many rural and impoverished communities in Nigeria. The real incentive will pay qualified providers in an urban area a nominal capitation payment for primary care services to determine patient panel size and pay providers who wish to locate in the outskirts of the city and other rural areas a higher capitation. We will also need to incentivize the HMOs who successfully assist the health care providers to maintain successful operations in the areas where the HMOs are licensed to operate. In return for higher capitated payments to the health care provider, the providers are trained and required to input disease data into a national system.
Are there strategies that you will suggest to be implemented to convey trust in the quality of the health care system been delivered to Nigerians?
Trust is built through transparency. We have systems for tracking enrollees, including their insurance number, National Identification Number, mobile phone number. These can be used to track patients and ensure the delivery of services. In addition, tracking services delivered should be reportable on a real-time basis, using available technology while ensuring patient privacy. Tracking services delivered can gradually generate trust and make available additional funding from our international partners.
A big issue in the health sector is the professional rivalry. What is the way out?
The availability of sustained political will and resources peels away at rivalry. Rivalry occurs when few resources are available. Lagos State health care experts operate at a more professional level, and large international organisations recognise it. Political will has been sustained in Lagos State for many years. There are other states that also have experienced sustained political will in the allocation of resources for health care. Strategically assembling health care experts to solve the myriad of problems in health care in a resource-intensive government with recognition of efforts is our wayout.
What are the lessons from the private health sector that can be applied to the public sector to make it better?
My research was exclusively in the private health care sector. There are several best practices that can be incorporated from an operational standpoint that will ensure alignment of services from the gate attendants to the cleaners to reception areas, other health staff, and nurses, and doctors to ensure improvement of the quality goals and objectives of the public health care facilities. During my certificate program at Harvard X, we studied measurement metrics among many other topics, and I understand that surveys are important in evaluating the performance of these public hospitals. By implementing a direct capitation payment system, we stand a chance to incorporate controls and require certain levels of performance to receive capitation.
With the hindsight of knowing how health service is run in developed countries, what should be done differently to make Nigeria’s health care system run at par with those in these countries?
With maternal mortality deaths at 12 percent for a country representing two percent of the world population, we cannot keep a blind eye to the problems related to inadequate UHC. Nigeria’s tax to GDP ratio is the lowest in Africa, according to USAID. The 2018 estimated OOP for Nigeria was 76.6%, while South Africa and Sierra-Leon were 7.72% and 44.78%. We need to come close to 44% (World Bank).Nigeria Health Expenditure as a percent of GDP is 3.89%, while South Africa spends 8.25%, Sierra-Leon 16%. While Nigeria Out of Pocket Expense (OOP) is as high as 76.6%, the United States OOP is 10.81%, and the United Kingdom’s OOP is 16 as of 2018. Quite frankly, Nigeria has a long way to go in comparison to developing economies. The crucial needs are sustained political will that transcends several Presidential Administrations. We need resources and a motivated citizenry toward good health care.
Most importantly, in addition to Sin Tax, Nigerians need a UHC tax that will be implemented to include citizens as stakeholders in UHC, and the tax revenue can be generated from local markets and at each ground transportation association (Okada, Molo, Uber, Bolt, etc.)
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