The Implication of the African Sustainability Index for the Nigerian Health Sector: Part 1

At the 2021 African Health Agenda International Conference (AHAIC), the FutureProofing Healthcare Initiative launched the Africa Sustainability index. The index is a data-driven policy tool that aims to measure the healthcare situation of 18 African Countries. These 18 countries were assessed based on 6 vital signs upon which a total score was obtained as well as an overall rank. The 6 vital signs examined are access, financing, health status, innovation, quality, and wider factors. Nigeria ranked 14 out of the 18 countries evaluated, with a total score of 41 over 100. South Africa, Tunisia, Morocco, Algeria, and Ghana were ranked in the top 5 while Nigeria, Cameroon, Angola, Sudan, and the Democratic Republic of Congo ranked in the bottom 5. All 18 countries were also ranked based on their performances in the respective vital signs. Nigeria’s best ranking was 6th under the Innovation vital sign, while the worst ranking was 17th under the vital sign Health quality. The general performance in the innovation vital sign was however poor as Nigeria ranked 6th with a score of 38.

Nigeria’s performance in the Sustainability index is not impressive and begs to question whether growth measures in Nigeria are merely quantitative. To put things in perspective, Nigeria has a GDP of USD 400 billion, the largest in Africa, but ranked among the least performers. Meanwhile, South Africa, Algeria, Morocco, and Ghana that ranked in the top 5 on the index are among the top 10 GDP in Africa, suggesting some correlation between GDP and performance in the African Sustainability index (or better still, healthcare infrastructure). However, Nigeria’s performance defies this intuition. How does a nation with such economic strength perform abysmally in a health index?

Many factors explain the distortion from GDP to poor healthcare delivery as captured in the health index. For instance, low health sector spending to GDP of less than 4% (global average is 8.8%); low budgetary allocation to the health sector to increase the supply of critical infrastructure or low health workers per capita amongst others are some of the challenges in the health sector. In the Abuja Declaration of 2001, heads of state of the African Union countries pledged to allocate 15% of their annual budget provisions to improve the health sector. According to a report by dRPC, in those 20 years, Nigeria allocated only 4.7%, on average, to the health sector – the highest allocation of 6.08% was in 2012. In 2020, allocation to the Ministry of health was 4.05% (from 3.83% in 2019) – a marginal increase despite the pandemic. Only Rwanda and South Africa have the 15% benchmark as of 2011; Nigeria is apparently off track at 4.52% in 2021.

The role of institutional factors constraining health sector performance can not be overlooked. Some institutional factors that stymie health sector performance directly and indirectly include:

  1. Weak Institutions: Over the years Nigeria has set up various institutions and reforms in the health care sector. For example, in 2004 the National Health Insurance Scheme (NHIS) was established to tackle the challenges to healthcare access and financing at the household level. Nigeria’s performance on the Financing vital sign implies that the NHIS has not been very effective. For instance, the NHIS is largely not mandatory; and that weakens its effectiveness especially in the informal sector. Consequently, insurance coverage in Nigeria is still at less than 5%. In 2018 76.6% of current health expenditure in Nigeria is still out-of-pocket. A robust scheme and implementation framework are necessary to ensure the effectiveness of institutions, policies, and reforms to achieve a far-reaching impact on society.
  2. Political instability: Insecurity, terrorism, and violence create an unsafe and tense environment for all sectors in an economy including health. Nigeria has an average score of -1.8 on the Political Stability index calculated from 1996 to 2019. The political Stability index range from -2.5(weak) to 2.5(strong). For comparison, South Africa and Tunisia have an average value of -0.15 and -0.27 respectively for that same period. With civil and political unrest, health infrastructures are destroyed. Qualified health care personnel are often discouraged or scared of providing services in conflict-prone areas. This creates a wide disparity in access to healthcare. Often, the international community intervenes with voluntary workers such as the Doctors without borders and Red Cross.
  3. Corruption: Transparency International defines corruption as the abuse of entrusted power for private gain. This means the misappropriation of funds and resources meant for a particular public good. Nigeria ranked 149/180 in the corruption perception index with a score of 25/100. For Comparison, South Africa and Tunisia both ranked 69/180 with a score of 44, while Cameroon and Angola ranked 15th and 16th in the African Sustainability index ranked 149/180 and 142/180 respectively in the corruption perception index. The NHIS is a regulator and an operator which is in contravention to the Act stipulating that it should function as a regulator with defined roles. Also, poor supervisory activities create leeway for the hospitals and Health Maintenance Organisations (HMOs) to exploit subscribers who, in most cases, have limited information about the workings of the system.

What does this situation mean for our race to Universal Health Coverage (UHC) by the year 2030? According to the World Health Organization (WHO), Universal Health Coverage is a situation where all individuals and communities receive the necessary healthcare and treatment at a rate affordable to them so they do not undergo financial hardship. This means that for a nation to achieve UHC, they have to ensure that quality healthcare is available to all individuals irrespective of economic class. This concept was mooted by the world health assembly in 2005 and adopted as the 8th target of the Sustainable Development Goals (SDG) goal 3.

The Sustainability Index provides a clear insight into Nigeria’s lapses, calling for urgent policy and action-driven responses. The six vital signs examined in the index exposes thematic policy areas that enable Nigeria to achieve UHC by 2030. This article is the first in a 3-paper series to address some thematic areas of healthcare based on the 6 vital signs captured in the index. For this purpose, the 6 vital signs will be grouped into two thematic areas namely, Healthcare Financing and Healthcare delivery/access. The subsequent series will examine broadly, the two groups.