Understanding the context of health coverage in Nigeria and progress towards effective UHC / HealthChoice

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uh good morning everybody and welcome again um to all of those who put in some hard work yesterday including some of you in the afternoon and evening um and for those of us those people joining us um for this as a webinar uh very welcome um so we've got some very interesting and i think enlightening presentations that we'll just be uh listening to and we'll run through those presentations um in sequence without um questions

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immediately after the presentation so if people could just keep a note of their um the question they want to ask we'll have some time for questions at the end of the session if you want to write your question into the chat function of zoom please do that and we'll have facilitators who will who will be looking out for those questions um or as we approach the question and answer session begin to put your hand up so that we can identify people who want to ask a question in the final

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piece of the first session um we had some interesting discussions yesterday there's clearly lots of work to do in this arena of um universal health coverage um for somebody like me who is much less familiar with nigeria the there was clear recognition of some of the realities of achieving uhc um but it was fantastic to be with a um a community that displays all the optimism and enthusiasm and energy that um everybody did yesterday in which i've

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come to associate with at least my work also in in east africa so our focus really by the end of this morning is to come up with some high-level aims um that we all feel we can share and endorse um and for that reason we'll have some breakouts um get feedback from the breakout groups and yesterday have some more discussion but to in further inform those discussions we'll start off with the presentations um and as i said we've got five of those

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um so if we're ready it'd be great to welcome robert yates who's executive director of the center for universal health chatham house in london a think tank i think many of you all um know and he's going to talk to us about um how can nigeria finance universal health coverage so everybody's ready we'll go for um robert great thank you very much indeed mike and and greetings from chatham house well that's actually my study in wandsworth of course because we're in lockdown still at the moment partial lockdown in london

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um but yes i'd like to talk to you about uh health financing for 10 minutes a topic that came up quite a lot in yesterday's discussions and if i just uh try and share my screen hopefully uh you are seeing some slides now okay nods yeah right with that so um yes how can nigeria finance universal health coverage uh a huge topic and one that i'm sure is exercising a lot of you and first of all i think it is important to define what we mean by universal health

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coverage this is that you know the simple definition that all people receive quality health services they need without suffering financial hardship notice there's nothing about insurance in here you know people often associate uhc with health insurance but it's all about people just having financial protection from um when they access health services and of course everyone being covered this is very important because i think that uhc

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is really fundamentally about rights and equity it's being universal it means that literally nobody is left behind and you know of course we're seeing in the covid crisis how important it is for public health that sectors of the communities like refugees aren't left behind so it means everyone secondly that services are allocated according to need we're not saying that everyone gets the same amount of health care but some people objectively need more

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health services than others so young children and pregnant women and disabled people and people say requiring palliative care they need more health care so they should get it thirdly it's about a health system which is financed according to people's ability to pay if you're having a situation that everyone gets the health services they need well then clearly you need a financing system where richer people pay more than poorer people otherwise only rich people will get the health

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services and so that already boils down to this idea of healthy wealthy people cross-subsidizing services for the sick and the poor now what does this mean therefore for what are the best financing mechanisms to reach uhc and here it is actually pretty straightforward and very clear now um i'd say about 20 30 years ago there were big debates about the private financing and public financing and you even had the likes of the the world bank and imf about 20 or 30 years ago

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saying that it was legitimate to charge healthcare user fees but all this has changed now and there is this realization around the world that a market driven privately financed system people buying and selling health services will never result in universal health coverage and quite simply that's because you won't get across subsidies if you want to have a situation that the healthy wealthy subsidise the sick and the poor the state has to force people to do that

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now this has implications for different types of financing mechanisms because obviously user fees which is the you know the way that you trade health services is the worst way to finance a health system and you have w.h.o in this pandemic now encouraging countries to scrap all healthcare user fees now interesting private voluntary insurance is not really that much better because the rich will always try and sort of opt out of subsidizing the poor and um there are only one or two countries that are really heavily

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reliant on private voluntary insurance united states and south africa really and clearly that type of system is very inefficient uh it's ineffective it doesn't reach universal health coverage and it's fundamentally inequitable because the poor tend to get left out so really that means that public financing is the only way to reach universal health coverage and there your two main mechanisms are financing out of general taxation like we have here in the uk and a good

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number of countries around the world and also social health insurance contributions but it has to be compulsory and progressive you know the rich must be made to pay more in and because it is compulsory like that it's basically a public financing mechanism so you know social health insurance and taxation actually aren't that different and most countries mix them anyway so i think it's it's simpler really to just refer to public financing and this was a point that grow harlan

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brooklyn made last year at the uh un high level meeting on uhc that if there's one lesson the world has learned is you can only reach uhc through public financing and i think you know that this is the consensus now all the big agencies are saying the same thing and so the issue in nigeria is how do you publicly finance the health system because looking at the situation in nigeria you can see that you know if the idea is about reducing out-of-pocket spending which we

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know is the worst um and really public spending is what you you require to do that these are all the countries in africa in 2016 and you can see you know the situation in nigeria is that you know it's pretty much the lowest public health spend as a share of gdp and the highest out of pocket spending we heard this repeatedly said yesterday and of course in a situation like this you're looking at a lot of people being excluded um from from the health system so the trick is

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how do you move down that curve and really you need uh public financing to do that and this really does i think demonstrates as well um you know that nigeria over recent years hasn't been fulfilling its commitment you know whereas you know many of its competitors you know they have been increasing their public spending in nigeria it's been sort of going down and there's only about half a percent of gdp which i think is the second lowest in the world i think south sudan is is

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is lower so it's only up from here you know that you know this is the opportunity to to increase public spending now now how do you do that and um i think there's this recognition that given the magnitude of the task and often leading ministries of finance to to come up with the money you need to go for the politics it's politicians and heads of state uh we heard um former governor mimiko um from ondo yesterday saying that you know how he had introduced

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universal free healthcare it's politicians who make the difference and so dr tedros is very much working with politicians to encourage them to increase financing and it's interesting you know that country this is a thailand um wasn't doing particularly well when its gdp was similar to nigeria's today prime minister taksin came in after the asian financial crisis introduced publicly finance uhc and thailand has some of the best uh health systems

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in in southeast asia now and it's coping very well indeed with the kovic 19 crisis another country that is showing um inclinations like this is kenya where president kenyette kenyatta announced about three years ago that he was making uhc a priority and wh sho is advising um president kenyatta and in fact they've started off with piloting universal free services in four counties scrapping user fees largely not not taking health insurance

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contributions but going for a tax financed approach so the big question is you know sort of in the midst of you know covid19 is this the appropriate time to be having this conversation with president buhari and say state governors in in nigeria and i would say yes it definitely is you might think counter-intuitively that that's in the middle of a massive crisis that's battering public financing this will be the last thing that politicians want to hear but surprisingly and interestingly

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this is the best time because this is a crisis a health crisis requiring immediate action from the head of state particularly around giving people access to health services and giving them financial protection um often to protect their jobs and their livelihoods and there is this demand from the population that everyone is included no one's going to be want to say you get left out when an effective vaccine comes along and there's great pressure to act quickly

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look around the world politicians really talking up what they're doing and acting quickly and again there's a real precedent for this in in in china after the sars epidemic in the early 2000s the the chinese realized that they'd allow their health financing system if you look at the graph on the right here to become dominated by private spending and this had resulted in a very weak health system that hadn't coped with the crisis and so this was the catalyst for rapid

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resocialization of the health financing system in china um and that um you know involved i think it's involved about 600 billion dollars of tax financing each year now to reach 96 coverage in in china south africa is a country in this crisis where president ramaphosa is saying that he's going to launch the the national health insurance reforms in in uh south africa off the back of the covid crisis

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it's going to be tax financed and you know it's going to cover the entire population and we're seeing leaders all around the world taking similar actions the big question is it going to happen in the united states uh where of course this is going to be such a hot issue in the upcoming presidential election and in a recent town hall meeting hillary clinton actually use these words you know don't let this crisis go to waste and encouraging joe biden to basically run on a uhc ticket

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and and fast track the united states towards universal health coverage so the big question is you know will this be the time for nigeria to go from that very low public spending to accelerate uhc reforms and i i think you know that the opportunity is right and it's all a matter of you know how do we get the messages to the right people at the right time so just to conclude um yes we are obviously the biggest health crisis in over a century and people are desperate they're fearful

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they want their leaders to take action um particularly around giving people access to health services and financial protection so i would say learning from history including the history of the uk i mean our nhs came out of the rubble of the second world war the same with the japanese health system so in the middle of a crisis now is the time to be pitching uhc to political leaders in nigeria and we at chatham house and as part of the lefier consortium are very very keen to support all of you in

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that process so if you want us to talk to any politicians about the merits of this strategy do please get in touch thank you very much great thank you very much robert and um as i said we won't have now but there was lots of information in there and i'm sure people were willing to come back to it so please keep your questions put them in the chat write them down and we'll get to you later um and thank you also robert for sticking to time um and i'll be having to interrupt

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the panelists talks if they do run on but we'll move straight on now to dr neko orgy who's a senior health economist with the federal ministry of health in nigeria and who's going to talk to us about accelerating uhc in nigeria and and what perhaps what the ministry sees as opportunities and challenges so over to you dr necker yes so good morning everyone sorry a couple of minutes i'm trying

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a um screen okay so just to confirm is it showing now yep it's sharing right okay so thank you very much and um good morning everybody um so we're going to be discussing um issues around accelerating universal health coverage in nigeria um what are the current challenges and the opportunities sorry excuse me doctor

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if you're able to put it into full screen that might help people thank you right right better now perfect thank you right so um we'll be talking about accelerating universal health coverage in nigeria what challenges we've encountered and what are the possible opportunities that um we see and so um this outline will guide the

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discussion as we move on so just as a bit of background we found out that in the last 20 years or more nigeria has made several efforts to accelerate or implement universal health coverage interventions by either committing to uhc goals or signing on to uhc pact or even protocols both at the national regional and global level so um just a couple of um

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the interventions that we have tried to implement in nigeria um working towards uhc the mdgs currently were on the sdgs we also have the uh phc under one roof um initiative phc revitalization and the 71 million live project which has just um come to a close we also have the rim project which which is around nutrition and in the past we've had the nhis mcch intervention

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and several others and as a strategic document we also have um the strategic health development plan currently we have the second strategic plan which is going to be um reviewed as uh you know going on mid-term um implementation that document is anchored on the national health policy which was also um discussed yesterday which is focused on

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15 key priorities and most recently we have we had the national health act which also contains the basic health care provision fund which um was also mentioned yesterday and most importantly in 2018 nigeria joined the uhc partnership which supports the development and implementation of sector uhc communication strategies in line with country priority and country agenda

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so you agree with me that um we have walked around um and yet we're still where we are um so just to have a peep at um the current um uhc indicators in nigeria looking at the global standard and just opposing that with what currently obtains in nigeria so looking at the general government health expenditure as a percentage of the gdp um so the global benchmark is five percent

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but um nigeria is still at zero point seven percent um looking at the abuja declaration not minding that this declaration was uh made in nigeria uh and abuja precisely nigeria is still doing um very badly at six point six percent as against the fifteen percent which is the standard um out of pocket health expenditure is not enviable um the global standard is around 30 to 45 percent

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but sorry 30 to 40 percent but nigeria is as a 2017 national health account report um we are at 77.5 and just to say that um um the preliminary reports that we have from the 2018 health account study is even giving us a higher fee goal um and then for the um per capita spending on health nigeria has not done well at all

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so we continue to have the inverted pyramid where we spend more on curative rather than focusing on um preventive care or primary health care which is um the main strategy for us to um fast-track uhc again when you look at the phc spending so you find out that um most of the spending on phc services would even happen outside the phc system whereas we have

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low spending uh of on phc services within the phc and centers or phd system so we have a huge gap of 84 percent to deal with so um that means we're not prioritizing primary health care as a strategy for advancing uhc and then if you look at um holistically you know financing um healthcare in nigeria you see that out of pocket is stopping the least this um data was drawn from um the national

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health account as a 2017 like i said the preliminary report from the 2018 analysis is even higher so it's showing us that even the health insurance coverage which you know some people have argued could um help us leapfrog um our aspirations as a country we've also not done um well um in that regard so if you look at see the oop is growing fat whereas public financing is growing very thin

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at 18 that is not very good for us as a country so um we've been able to going through all of this we've been able to um identify key issues that you know um is actually impeding our accelerating uhc in nigeria so topmost um amongst our findings is the fact that uhc has not been made a prior political priority this resonates with you know all of the suggestions and um discussions that had happened

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both yesterday and from um robert's presentation this morning so we've not made um um health a political priority it's not topping the political agenda we have inefficient financial flows um our financial flow system is erratic and um unpredictable and this does not tell well with uh it doesn't go down well with financing our health system again the high out of pocket and then the way

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our health budget is the design it's like it's in silo is in isolation not looking at other um systems that could impact on the health system and also having to deal with the complexity of our health system which is fashion around our political governance system it's really very complex um to deal with then the current national health insurance status is also not good for the system um so

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in the last few years and i'm still obtainable we've noticed that there is a low absorptive capacity and this is the reason why i put inadequate financing um you know below the lease so for me i don't think inadequate financing is the problem because if we have a low absorptive capacity we shouldn't be talking about inadequate um financing we're not using um there is huge inefficiency within the system and we're not using what we have for us to say there is

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inadequate and financing now um donors and other foreign implementing agencies they've played massive roles you know in our health system so most times they are their roles and their priorities are not aligning with country focus so for us that's a big issue that um should be talked about more deeply um accountability um um focal accountability and frameworks and strategies

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are not adequately um um um they're not targeted and they're not you know that they're just not working you know and then the um private sector is one area that we have failed to tap from what it has to offer so looking at all of this the question is can nigeria actually reverse the trend with the oop growing fat and public financing um growing tina so

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um well let's see what how that goes so so we were able to outline a few opportunities you know for us to move uhc forward in nigeria but few things we must um take into consideration is that uhc is entirely aspirational and that is what it is there's no hard and fast rule about uhc so uh and the fact that it's one of the core targets of the sdgs so that will mean that uhc is not a standalone it's also hinged

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on some other multi-sectoral strategies that um health people will need to look at and work more closely um to achieve so uhc we should understand it's not just about financing although financing is critical but we must look beyond financing if we have to uh um achieve uhc there are other health system and even outside the health system bottlenecks which needs to be looked at uhc is a political choice

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and we need to recognize that and push for it to be top on the political agenda with that um we may be able to galvanize political commitment as well as um increase the financing and do that efficiently um so we also need to look at all the political dimensions of uhc um the relationship of government with other um stakeholders within the system that's why i said we must have open start having open discussion with the private sector

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players there's huge huge huge mistrust between government and the private sector we need to address that by having open discussion and we this was um mentioned yesterday and i think robots mentioned it again but i think more specifically nigeria needs to start looking at policies for um cross-subsidization if we really need to work on the level of our oop and not just that um there are people that were making these decisions for

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they are citizens of this country and they are never you know on the table for uh where these discussions are happening so citizens must be made part of the discussion if we need to move forward i'm trying to conclude i want to say that the gold standard for uhc must be public financing not just public financing but it has to be efficient public financing strategy and our donors need to be guided to align with country needs and country focus

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so the discussion and the relationship between government countries and donors needs to change and going forward we need to start building targeted partnerships for uhc um to move forward especially when it has to do with the multi-sectoral approach that we are talking about um again citizens and beneficiaries need to come to the table where discussions are happening and we need to start educating people that

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oop is a huge high oop not just all people catastrophic oop is a huge huge barrier to advancing um uhc in nigeria um so not just at the federal level but we need to drill down to actors at the state and the local government level to provide that support and technical assistance that is missing there to help them redefine and realign their uhc readiness and uac focus such that they are able to take charge

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of the health of their people the discussion that happened yesterday it was mentioned that some commissioners of health some governors don't even know what is written inside the state strategic their state strategic plan so um i think going forward we need to address that by providing that support and um guidance for them to understand um the content of the plan and their roles in making sure that those plans are um well implemented um so we can't run away from

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this within the health system within the uh space there's a huge power play you know amongst different stakeholders i think that needs to be strategically addressed as well and accountability strategies and focuses focus should be open and collectively defined as well again i say there must be mutual accountability between donors and the government of nigeria another critical point is to ensure that

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um roles and responsibilities of different actors within the health system they're very critical they are supposed to be clearly defined i don't want to go into it but we learnt lots of lessons from implementing um the the basic healthcare provision fund um we also need to clearly outline uh strategies for strategic purchasing and who is purchasing what who is regulating what and all of that um well

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and clearly articulated laws and policies are imperative lots of lessons from implementing the basic health care provision fund so um i don't want to um continue to take our time but i think the key points here is to say that awareness creation at all levels for different stakeholders very important the political support dr necker please this is very important rush through this slide yes

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yes i'm just finishing so we need a national uhc strategy and framework very important for us to move forward and um also for csos to um take ownership and provide that available the necessary knowledge for government to do the right thing mainstreaming health in all sectors like i said a multi-sectoral approach is what is needed at this point health system reforms to strengthen all the building blocks of the health system

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very very very important thank you very much for listening and thank you for your time great thanks very much dr nekker um i'm always hesitant to interrupt somebody from a federal government um but lots of important messages there um the name is i might be a little less polite um as we've eaten in a little bit to our question time um so it would be great to have some questions so i will keep the next speakers um to 10 minutes or a bit under if you

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can manage it and you can post questions in the q a part of the zoom platform that you can probably see in your task bar at the bottom but let me um now hand over to professor oyo gorenji who's professor of psychiatry and i think everybody on this call probably knows him um and he's director of the who collaborating center for research and training and mental health in ibadan but over to you can my slide the same

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yes we can see them okay thank you very much mike uh good morning everyone uh many thanks for the opportunity to contribute to this important topic my intention over the next 10 minutes or so is to highlight some of the barriers to the achievements of the of uhc um i will be focusing specifically on supply side barriers um even though i do realize that demand

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side barriers are also quite important um especially in the context of mental health care which is what i'm going to be particularly paying attention to these barriers are not by any means of course limited to mental health care alone avoid most areas of health need but mental health probably you know best exemplifies the the impact of these

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barriers mental health is actually one of the most neglected areas of public health as can be seen on this slide even though more than 28 percent of years live with disability is attributable to mental neurological and substance use disorder many of the major disorders of mental health disorders

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do not person suffering from them do not receive adequate adequate care in fact sometimes not care at all and you can see on that uh com on the on the side of that slide that a large proportion of patients receive of suffering from these conditions do not receive treatment around the world of course with the most [Music] astonishing rate of treatment gap being found in low and middle income countries

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i'm trying to see where i can change the slide all right so things are changing though um there is now increasing acknowledgment that uh there's no health without mental health uh and that's a global developmental goals cannot be achieved without adequate attention to mental health care and this is reflected in the fact that the sdgs now have specific targets

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for mental health service including promotion of mental health prevention and treatment of substance abuse and what we've been talking about in the last idea or so which universal head coverage which of course covers mental health care as well but this uh enthusiasm or commitment around the world is not so much reflected in what is happening in nigeria and these are the barriers which i i said i

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was going to focus on the these supply side barriers are the ones that um constitute the main problems uh and i define barrier disparities are the ones that restrict access to adequate care many examples of them again we've gone through some of these in various presentations in the last day or so lack of policy or poor implementation of policy for funding and that's also been reflected in what's been described mentioned this morning the scarcity of

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specialists and even though that might not be a problem but there is the problem that you then have in efficient primary care we are known specialists in abundance and then of course pervasive stigma the policy environment is a particularly um disappointing one in nigeria this the nigeria the current nigeria uh mental health policy which was adopted uh at the 56th meeting of the national

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council of health in 2013 has not been has not been implemented the one before that which was adopted in 1991 was equally not implemented so that's a policy but it's not even complemented by a program of uh or a strategic plan about how to uh how to bring about the achievement of the various aspirations in the policy we're still using laws that were handed over by

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colonialists and insanity laws they are called these are laws that are really out of step with the modern mental health care even though several attempts have been made in the country to have modern era mental health over the past 20 years we've been making an attempt to get new laws to be passed but this has not succeeded meanwhile really really embarrassing human rights abuses

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of persons with mental health and persist in our country poor funding both robert and nick at this morning have also mentioned issue about crowdfunding inadequate which of course translated to uh payment out of pocket and for mental health conditions uh which often require long-term care and this often means that families are driven into poverty uh because

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of the need to provide or to provide care for their for the members of the family who may have a disorder because we do not have any uh coverage for those who are unable to afford care scarcity of specialists nigeria has about 250 psychiatrists and even fewer specialists in other areas this is of course mean it means that

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they can rely on specialists to provide care but that's actually not probably not a problem if we had an efficient primary care setting or primary healthcare service where we can draw on the skill of of the non-specialist there about the lack proportion of primary care clinics in nigeria is not functional and providers in them are hardly able to identify or treat mental health conditions even though we do have experience and

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research evidence to support it that these frontline providers can in fact be trained to deliver effective and quality care and for most common mental health conditions pervasive stigma runs across the community and unfortunately also its thrive among the health care providers the doctors and health workers in various at various levels of course policy makers also very much

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affected by this really high level of stigmatizing attitude to mental health care and so discrimination is common and and this of course results in neglect of mental health issues at all levels of the of health care in the country all of this translates to a huge treatment gap almost 80 percent of persons suffering from various mental health conditions in the country

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do not receive any care in any 12-month period among those who do only about 10 percent of them receive what might be described as minimally adequate treatment which means appropriate treatment for the conditions they have so you're not giving analgesics for depression or vitamins for depression uh and even those who do get treatment and don't get it in good time there's a really long period before the the access care

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all of this is happening in the context of a global move to ensure that governments provide better care for their populations this mental health action plan by the who list out for objectives that if implemented will help countries to uh to improve their health service to mental health service and and and and get care to those who need who need care uh in fact the the who has

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uh devised this pyramid and i think nate has mentioned something about that in her presentation about which she was talking about the inverted pyramid here it's about the provision of care which of course is that uh tax shifting should form the um the tenant of uh expanding care and delivering universal health care uh especially for patients with mental health conditions in fact for all conditions uh with primary care at the close to the

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base of that pyramid and this requires well-trained primary healthcare providers and as i've mentioned we already we have experienced that these people can be trained and to deliver service in fact the wh also provided uh so oh yeah i need you to finish in a minute please yeah that's right they provided a tool for for countries to be able to achieve this and we have also demonstrated in the country that this

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can be used in fact nigeria was one of the first countries to demonstrate the utility of this again this was adopted by the national health council in 2013 again it has not been any implementation of this this is in spite of the fact that we have evidence that we can do all of this that there's very strong evidence randomized control trials and for various conditions about low cost treatment and that this treatments are actually quite uh cost effective and we have research

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evidence to show that others can scale up the packages of care at a very cost effective level so the promise of uhc uh which is to leave no one behind uh is only likely to be achieved in nigeria if we have increased policy attention uh implement existing policy pass legislation to protect the right of

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people with mental health conditions made adequate adequate improve financial provision for care and train prima primary care providers uh to be able to deliver the service and we cannot rely on specialists and we don't in fact need to do that but also we need to include mental health indicators in our health information system so that we can track changes and improvement in the service thank you very much thank you very much oyer we will move

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straight on so again questions please in the chat or the q a function um we're going to move on to dr modupe olodipe who's the lead for health strategy delivery foundation based in lagos um and she's going to talk to us about approving access to quality healthcare through private provider networks which is obviously highly relevant um to nigeria and other settings over so off you off you go please dr olody good morning everyone can you hear me yes okay and you can see my slides yes

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we can thank you thank you very much so um doctor paul you depe and um i'll be sharing some learnings from work done by the health strategy and delivery foundation to improve access to quality health care through private sector networks um the health strategy and delivery foundation that's hsdf is a not-for-profit organization incorporated in 2013 with a mission to improve the quality of decision making and execution in the

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health sector we do this through substantive engagement with our stakeholders by providing analytical support and driving innovation we work with all chairs of government that's federal state and local as well as healthcare leadership and frontline service providers we do this to improve the effectiveness of health service delivery to strengthen the performance of the health system and to ensure a focus on results and outcomes within nigeria we work across different states that represent the nation's

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different health market archetypes so in 2013 we conducted a national level health system assessment and the results highlighted barriers to the sustained achievement of um desired health outcomes demand and supply-side barriers inadequate strategic frameworks to operationalize relevant policies like we've heard you know that is if the policies existed and then limited engagement of the country's private sector that has also been pointed out you know

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these were some of the drivers for the consistent dismal health outcomes reported despite efforts by government and other stakeholders and we have talked about nigeria being a mixed health system you know with um health funding by the private sector up to 77 and we're saying that for that to be managed for uhc goals the private sector must be engaged the private sector contributes 38 of health facility ownership nationally

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and higher in some states such as lagos where private sector ownership is 89 the private sector employs 45 percent of the health workforce nationally and about 63 percent in lagos state they also provide as much as 60 of health services in many states across the country in addition to the aforementioned contributions the private sector is also well positioned to offer you know quality products and services to scale up innovation such as digital

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solutions that can facilitate the uhd goals to scale up innovative business models that can do same to incorporate uhc principles in core business models and objectives to contribute to financing efforts to achieve uhc to build capacity for relevant policy dialogues and partnerships with stakeholders including government and of course apart from employing the private sector can also build the capacity of the health workforce so the hsdf 2013 diagnostic that i mentioned

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you know identified pivotal issues plaguing the private sector that needed to be addressed for an effective engagement um i would like to you know point out that there were other issues but these particular engagements and this particular um issues that i'm going to be calling out were highlighted as foundational for our engagement objectives and these issues are poor and variable quality of care driven by known supply side factors low engagement in public health

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priorities evidenced by limited visibility of the private sector on the national database that's the nhis2 and fragmentation and what do i mean by this that's hundreds of small and independent sole proprietorships that experience barriers to growth and expansion such as lack of access to capital so hsdf put together a program to engage the private sector for public health goals specifically the goal of quality essential you know health services for all which

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is one of the uhc goals we set out to implement a program and take learnings you know to improve further and future engagements we didn't set out to conduct an experimental research and to address the issues of quality and data we deployed specific interventions to standardize and improve the quality of care being given at the facilities as well as interventions um to enhance data reporting to foster sustainability and this is one

48:41

of the key things you know when implementing partners work you must make sure that there is a system for sustainability to foster that after the program ends we also developed and deployed interventions to strengthen the financial management systems in these facilities and then to address the issue of fragmentation and operational inefficiencies we deployed the network model and because of the way you know the private sector is organized or not organized as you can see you know with hundreds of small and independent

49:13

sole proprietorships it is quite difficult to engage at scale in that format so we designed and deployed the private sector networks which are geography based networks that is facilities are aggregated according to their locations and these networks are not social networks but learning and improvement collaboratives that facilitate information sharing peer-to-peer learning and collaboration the network model also enables at-scale interactions and

49:43

support synergies so a theory of change was based on the premise you know that um facility level interventions that improve quality enhance data reporting systems and strengthen financial management systems when these are coupled with network level engagements they would result in networks of sustainable healthcare businesses that drive the uhd goal of quality essential health services for

50:17

all and so we armed ourselves with the lego state local council development authority map so that's the lcd map we initiated conversations with the association of general and private medical practitioners of nigeria that's the agpnd we identified lcds we could work in we got letters of introduction from the agp mpm and we approached the facility owners it was important to us you know that the facilities were willing to work with you know our engaged

50:50

had a current um practice license from the state regulatory agency that's her family um our first engagement was in april 2014 and the second was in november 2018. we deployed the interventions as earlier stated at both facility and network levels and for each strategic intervention conducted the baseline to know each facility's starting point to identify gaps that inform their specific interventions and to also address you know variability

51:21

objectively at the network level we also conducted post-intervention assessments to ascertain the level of improvement you know or otherwise and for both sets of facilities engaged like i said in 2014 and 2018 individual facility and network level scores post intervention improved across all intervention areas namely quality of care quality of data reported onto the dhis2 and financial management

51:52

systems one of the key activities under improving quality of care was to work with the facilities to improve their adherence to national guidelines for three of the commonest conditions for hospital utilization and even though network level scores had not hit the expected national guideline targets there were significant improvements in adherence to protocol and similarly for both sets you know of facilities engaged the private um provider networks were established

52:26

in conclusion without a doubt for our nation to achieve universal health coverage and to leave no one behind in the attainment of this quest the private sector must be engaged and engaged effectively and through a number of programs hsdf has engaged the private sector to facilitate the loadable goal of quality essential healthcare for all our work with the private sector has shown us that the private providers are

52:59

willing to improve their quality of care and data quality if equipped with appropriate information skills and supports and this is an area where state governments you know can look into state facility regulatory agencies you know we believe they should develop and deploy a robust framework to strengthen clinical governance at the facility and we've been talking about you know non-existent frameworks since yesterday and we're saying this needs to be in place they should also provide

53:30

supportive supervision during periodic monitoring and evaluation visits to the facilities our work has also shown that private providers are open to engagement and collaboration through effective structures like the network model like i i had mentioned earlier on this um our model it's a geography-based provider network model that we rolled out you know and it infuses features of a learning and improvement collaborative and this model can be further explored

54:01

as an enabler in engaging the private sector to achieve universal health coverage and other public health goals so we're saying government and uhd stakeholders should conduct cost-benefit analysis to inform the possibility of adopting provider network as a viable engagement model you know for the attainment of public health goals including uhc thirdly the private providers were willing to adapt and apply innovative solutions that would foster the delivery of uhc

54:32

please don't forget like i had mentioned earlier on these private providers are small single doctor-led sole proprietorships but they were willing to deploy technological solutions such as electronic medical record systems and drug inventory management systems you know to foster the delivery of quality essential health services for all government and uhd stakeholders can develop a framework to sensitize and inform solution providers on the opportunities for at-scale interactions

55:01

you know you know in the private sector supported for example by tax reductions and financing options cost savings can be passed on to the care providers who can in turn pass this on to the care users thereby forging a win-win situations for the care providers the solution providers government and the care users thank you um thank you very much dr ulodipe um we will have to move straight on

55:32

um so our final presenter is um and she's country director of the farm access foundation which i know operates in many countries and she's also going to talk to us about the role of the private sector in accelerating uhc um and i welcome you to give your presentation dr ngd we can see your slides thank you so much i was trying to mute myself so uh good morning and again it's uh fantastic to speak to the audience i'm leaving my video off so you can hear

56:08

me properly i'm having a bit of network issues uh today um i i think the beauty of uh speaking last is that quite a number of things uh have been said a lot of issues similar issues have been accommodated from practical examples of what we've done uh integrating private sector into the vision of uac and accelerating uhc so i'll start with um just showing the fundamentals

56:38

of how we operate as farm access we try to identify the key pillars towards a successful uhc achievement or accelerating uhc one is a demand side supply side the governance structures and of course the responsibility of the patient and how we can also try to change behavioral or health seeking behavior but fundamental to all of this is the issue of trust the fact that trust is still very low

57:09

and there has to be a way to improve the trust in the system if a patient is going to prepay for health care they have to have the confidence that when they actually seek the care that they're going to get good quality care in the system of course the governance structure being available and the people having the capacity within those uh institutions to properly monitor uh um and track what is happening within the system so this is a framework uh through which we operate and

57:40

what is a unique approach is that we actually intervene at different uh stages through out all the pillars so we have interventions in the demand side uh governance supply and the patient uh behavioral change activities so some of this the uhc position of nigeria has been talked about so i'm not going to go in depth into this but it's important to kind of stratify the different areas the

58:12

fact that you have you know operational challenges you have policy challenges and then the environmental challenges also including the economics within the country the poverty rate and so on so it's very key to have this in the back of the mind uh to while we try to tackle what the barriers are uh with uhc now the private sector plays a very critical role uh whether we would like to acknowledge and acknowledge it or not uh over 70 percent uh based on the data

58:43

that we've collected of care is provided in private sector uh of course the patient doctor ratio is you know significantly below what it should be and who is filling that gap so uh in some of the discussions yesterday there was mention of the community pharmacies and patent medicine vendors even being the front line in terms of providing care again this is private sector and we need to look at how they are properly uh um you know oversight regulated and integrated or even their

59:14

roles recognizing in terms of delivery government has quite a number of primary health care centers but because of our you know the information that we have so far quite a number of them are non-functional so what can be done to increase the functionality of some of these uhcs and of course we've talked a lot about the high out of pocket payment uh for nigerian seeking care so having this at the back of our minds how do we then bring in private sector to work uh um in a kind of collaboration

59:45

or ppp with uh with government uh it's important to emphasize that government always has to take leadership which is why the political will is forefront you know but there are significant uh uh roles that can be played by each for government you know they have the policy they actually have the patience because as we know a lot of states in nigeria 30 years at the last count if not more by now have mandatory health insurance laws uh trying to accelerate uac so in a

01:00:16

sense it's the state governments that really should uh enforce or uh motivate uh the the citizens to you know tap into the uhc uh laws or infrastructure that has been put in place again the government has the structures and infrastructure around the primary healthcare centers which is key to uhc so in a sense how can you bring in private sector and on this slide you can see how we try to delineate um the roles each side can play private

01:00:48

sector can of course bring in the efficiency and their funding as well as quality but working in partnership with uh government uh to make that happen now if i go to uh this next slide which i showed before i just wanted to show how uh farm access is really uh uh intervening so i need to work with government to um implement their health insurance programs and i'll talk a bit more about that on research and advocacy we try to showcase what we've done

01:01:19

uh through impact evaluations just to show what works and what doesn't work on the patient's side the promotion of technology including mobile technology uh to enable access then on the supply side we are you know promoting loans uh access to finance for healthcare facilities so that they can improve their quality even in ppps uh we are putting in a lot of money there quality standards through our safe care methodology and in some instances uh equity within the supply we have to

01:01:49

improve the supply side for demand side to have trust in the health care quality coming out of it so running very quickly into specific examples what we do with state governments um of course a lot of states are different stages of implementation of their of their laws their mandatory health insurance laws these are just to give some examples of the processes that we have identified that are critical to successful implementation and i won't go through all of this but again these are some of the

01:02:21

involvement that we have through partnerships uh with the state governments to make this uh to be able to implement uh the mandatory health insurance programs um now i wanted to highlight this uh because it has been discussed for many many years uh the acquire state health insurance uh community health insurance program which started as a ppp in 2007. at the time that we started this program there were a lot of uh skeptics and a lot of uh push

01:02:52

but again to emphasize that it was a pilot and it was from the learnings from this scheme uh that really catalyzed the need uh for insurance being mandatory so that you have risk pools the involvement of government and the fact that government has a role to play by you know taking care of or designating a percentage of their consolidated revenue to pay for the indigents or those who can pay and they need to bring in private sector providers so this is just to give you a snapshot and all the details are in there of what was

01:03:24

accomplished at some point it was the largest ppp community health insurance scheme in sub-saharan africa but at the time farm access was in the lead so we had to reverse uh um you know the structure so that the state government takes ownership and i'm happy to say that after so many years of stopping we stopped the program in 2016. tomorrow uh the scheme is going to be re-launched by the government and it's important to note this transition that the government now took the leadership the reason why

01:03:54

it took so long for it to be restarted was that we decided to take a back seat then we transferred all the learnings to the government even though we were still supporting from the back but this is your program it is your budget we can support with structures and and you know best practices but it is your program to run and you have to take ownership so the scheme you know a big congratulations even the fact that they transition governments opposing parties it will be relaunched again uh tomorrow by the new administration so i think that is

01:04:26

a key learning uh political will and what can be achieved through uhc then the role of technology also very important to note that uh whether we like it or not that technology has a role to play especially with uh aggregation of funds okay uh combining financial flows even provider and individual empowerment law and transaction costs without technology it is almost impossible to achieve uhc so i think that this needs to be at the back of all the skin designs

01:04:57

and all the different uh benefits needs to be factored in for uh yet to be accomplished i i really needed to highlight this then just quickly i'm just going to flash through some of the uh interventions that we've done uh on the supply side um again talking about our interventions we try to uh not only implement some of uh some pilots to prove a hypothesis but we actually embed ourselves within uh the governance structures or the

01:05:28

regulatory framework to build capacity uh okay so this is an example of um this is an example of how we've structured ourselves we are providing technical assistance to federal and tertiary institutions such as fmca bhutan which has been in the news lately federal ministry of health uh the peace pharmacy council of nigeria and so on and so forth so again it's important that even as we're implementing at the state levels we need to find a way to build capacity

01:05:59

uh with the regulator um this is just to show some of the the different areas covered by the standards just to help improve quality on the supply side this is just a bit more detail about what we're doing with the farmer which is the regulatory boding lagos pharmacy council of nigeria in terms of capacity building helping develop standards and so on now using lagos as a case study we're really embedded in lagos both on

01:06:30

the supply side demand side uh helping to even paying for some indigenous just to test the system to make sure that it works and you can see the details of what is going on right now and i can say that as of today there's over 200 000 civil servants the governor has paid for the premiums of the civil servants and there's a bit of momentum in the system in terms of uh traction towards uhc on the supply side we also try to put our money where our mouth is

01:07:01

to help catalyze investment in the healthcare sector because i think in on the supply side because i think that in order for you to improve quality there has to be some kind of access to finance and we know that you know with the fragmentation in the system the sole proprietorship of the the healthcare smes it's almost impossible for them uh to get loans to improve uh either scale or scope of their facilities now uh yesterday we talked i talked a bit about what is happening in

01:07:31

and delta state this is a picture uh just to uh uh highlight if you can wind up in a minute please yes yes so to show that a public phc can be run by private sector and get it functional so this is another example um you know i wanted to show then you know there's also involvement in the tertiary facilities because again a lot of patients are going to the tertiary because the primary is not that functional how can we you know improve the system throughout

01:08:03

um then rushing through also capacity building the fact that we've embedded healthcare training within the health lagos business school just to build capacity because it's key for healthcare practitioners to understand how to run a healthcare business then my final slide is just to show that you can actually divert or integrate vertical programs into uh supporting a state uh uh journey towards uhc so we're involved in so many different projects but in all those

01:08:35

states we try to channel the funds towards the central achievement of uac so this is just a mind map of some of the activities that we're doing so in a nutshell all this has been talked about let's the importance of private sector the mapping roles and responsibilities use of technology and i'll end with that thank you very much thank you very much dr angelic um back to you the close of the presentations we've been allowed a small

01:09:06

extension in time so we've got maybe a little bit over 10 minutes for questions um so if people do have questions can they please raise their hand and you'll be identified by one of the facilitators and we've got a couple of questions um in the chat um so i might if i call your name i hope somebody can unmute you and may then maybe you can um give your question verbally and one of the presenters can um can respond so the first and i know

01:09:38

there's been a response in the chat but um from obiama there was an interesting question to robert our first presenter um but i don't know whether you want to ask your question um in person to get robert to respond over yeah thank you very much mike um i was trying to express my appreciation to the presentation by robot when i highlighted the comment he made about the inefficiency of community-based

01:10:13

health insurance schemes i was thinking that in its place does he think that a mix of fair tax-based financing strategies can work better and i was thinking that options like earmarking telephone and sick taxes could actually be a saving grace realizing that the poverty rate in the country is very very high and getting premium from such unstructured tax administration group can be very very difficult so i was thinking that an alternative

01:10:44

approach can be picked from a key recommendation of participants of senior executive course 41 of nips national institute for policy and athletic studies in 2019 one of the key recommendations they made was if nigerians could if nigeria can create a law that allows one kubo per minute of call from nigerians we will raise substantial revenue to the tune of about 216 billion naira from 1 million

01:11:16

100 million active lines if this money can be picked together and earmarked for health financing or for health care in addition to seeing taxes like alcohol and um and tobacco so much so much can accrue in the basic healthcare provision fund which was created for that kind of purpose i think it will work and i think from his answer is a way to go and we have to explore this

01:11:47

explore this truth for that research thank you hey thank you robert if you can keep your answer short that'd be great sure absolutely yeah and to keep the first part very short yes community-based voluntary community-based health insurance unfortunately it doesn't work i mean there's been decades of experiments with this but tends to have very low coverage doesn't cover the massive uh people in the informal sector and um you know that we need to move on from this and that public financing is is the only way and there you are looking at a mixture of tax financing mechanisms looking at the

01:12:19

structure of the economy with that enormous informal sector in nigeria payroll taxes are not likely to be massive uh for the for the time being so looking at progressive ways that you can tax both wealth and the wealthy and their incomes through through uh things like you're mentioning are excellent ideas but i i come back to what i said yesterday don't forget you know perhaps the greatest resource is the oil revenues in nigeria you know you have natural resources which you know if you

01:12:51

renegotiate your contracts with the likes of shell and people like that and they pay sensible amounts of taxation is likely to be much much better and effective at covering the entire population so i would go for natural resources more than anything thanks very much robert um there were a couple of questions which i think are linked from dr babalola um in the q a so dr babalola if you want to ask those questions i think you had two targets for them over

01:13:33

hello hello good morning okay yeah good morning thank you so much for the presentations um uh coming from the point of view of pharmacists i'm interested in the role of access to quality medicines in achieving the uuhc coverage the uhc in nigeria we do suffer from a lot of poor

01:14:05

supply chain and i always wonder if we can achieve uhc without quality medicines and to doctor and she didn't just spoke i was interested in the farmer access and their roles and i'm asking whether she mentioned the patent medicine dealers they should be trained and all of that i do know that in australia the government empowered um pharmacies to be

01:14:37

spread to rural places and another country too that i've read if they are giving some incentives we can have skilled professionals providing quality medicines in rural places i wonder whether these are the areas we can look into as we're looking at uhc uhcn and primary healthcare thank you so thank you for that question let me answer really quickly based on uh the work that we're doing with pharmacy council of

01:15:08

nigeria uh currently there is a project uh called uh integrate e which is funded by msd for mothers and bill amelie the gates foundation but basically it is to find a way uh to have the pharmacy council of nigeria uh regulate the activities of the peter metzen vendors in a structured manner uh some of you may know that um you know there's a huge gap uh with availability

01:15:40

of community pharmacies and patent medicine vendors such that you know there's a proliferation of uh peter merton vendors especially in the rural areas when they can't access healthcare proper healthcare facilities or licensed community pharmacies so what is happening is that we are trying to develop a framework in partnership with the pharmacy council of nigeria where there's an hobby spoke model with community pharmacies

01:16:10

overseeing the activities of some of these patent medicine vendors such that the supply chain is guaranteed there's training provided to the patent medicine vendors but again under the supervision of community pharmacies and the regulator uh the pharmacy council of nigeria we feel that no matter the care that you're providing if the quality medicines are not available then you know there's there's a break in the system so we have to look at it uh from an end to end uh perspective so yes uh there there

01:16:40

is a role a huge role for pharmacists and the patent medicine vendors in the in achieving uhc and i'd quickly like to add to that um mike if that's just please do okay yeah um definitely there is a rule for um strong supply chain systems you know for us to achieve quality we can't talk about quality healthcare you know without um the supply chain being strengthened and um even in the work we did you

01:17:13

you would have heard me mention the drug inventory the management system so we ensured that our facilities came together and even did the pulled procurement you know of drugs one of the cost-saving mechanisms that we had so just to quickly ride on that what ng also said just to back that up that we cannot you know be talking about quality essential healthcare for all without you know strong supply chain

01:17:44

systems being put in place and this is end to end you know from the manufacturers to the users so it's the whole length of it you know that we need to strengthen it's it's a whole lot but just to add to the the conversation that he needs also to be in place and strengthened thank you thank you very much um there's a question um from um dan on yeah good morning all uh thank you so very

01:18:25

much to all the presenters i learned a great deal from all the high quality uh presentation made this morning thank you very much for that um i want to learn more particularly from robert yates uh he keep on mentioning that south africa is not a good model to follow but i do know this [Music] long before they covered a pandemic

01:18:56

south africa had the lowest out of pocket expenditure per cap in in africa and they made a conscious political decision to move to a one-payer system last year in fact a good friend of mine nicholas crisp was appointed head of the national health insurance fund and the south african government made a commitment to be uh paying or expending at least

01:19:28

over 2 billion dollars u.s dollars per annum to cater for the poor in the new system so as a developmental process i would say that south africa actually did quite well uh so why is it a priority where a development as a developmental model for others to follow um can you please elaborate thank you yeah yeah very good question dan and i know nicholas very well and and the the

01:19:59

the um i think it is a great model the nhi model in south africa the problem is they haven't implemented it yet you know the the the previous system or the current system that hasn't really changed is phenomenally inequitable you you have about half the health expenditure going on about 16 of the population who are in private very inefficient health insurance schemes the other half of the population sorry 84 of the population are are having to sort of cope with very underfunded public services

01:20:32

so the attempt by the nhi is to bring these two together into a national system um it's been piloted for about the last 12 15 years but hasn't really taken off yet but there is very high expectations and hopes that coming out of this crisis that the government is going to fast-track this so i would say that the nhi model is is excellent the problem is it hasn't been implemented yet but watch this space because i think with uh particularly with uh president ramaphosa taking charge of it now he's brought it

01:21:04

all into his office into a war room there is this potential for this to happen so uh very much look out for what happens in south africa great thank you very much robert and we've just got a minute or so left and i'd like to give the final words to dr nekker um as a representative of the federal ministry of health so over to you dr nekker right thank you very much um so i was just going to check in a few insights um concerning what dr

01:21:34

obioma had um suggested about the telecom tax so just to share a bit of experience so it's a very good model wonderful model but just to share some experience when the national health act came into being so we went ahead to do um a bit of um work on looking at aviation tax telecom tax and all of that i don't have the numbers you know um clearly now but um we were able to turn out

01:22:05

you know great numbers which looked very um interesting and very promising but we also looked at other health systems issues that was why um during my presentation i made mention of the fact that look uac's strategy should be country tailored what works for you in your country that's the strategies that you should adopt to move forward so we looked at the taxing system how it is um operated within an insurance system so somebody makes laws on the taxes

01:22:37

somebody does the remittance somebody does the collection all of this has nothing to do with the health system or the leadership of the health system and then somebody decides um from the entire collection what goes to health what goes to education so remember the fact that you are advancing that course asking for that does not mean that you're going to get a fair share of the total outcome of the telecom tax there are other competing needs and that's why i i mentioned the fact that

01:23:09

um it's an opportunity for us to look at a multi-sectoral approach such that we we don't continue competing where and there isn't any need for competition so just to say that yes telecom tax or some but we need to be careful where we look at other um health systems issue that um may not make it very workable for us um within the health system thank you great thank you very much um and i think we will have to close it there i'm sure we could have had much more

01:23:41

discussion for some great presentations and i'd like to thank all the presenters um for uh for really giving us great deal of insight from their personal um professional perspectives um we are going to go straight on now to the break breakout group sessions and so i'll be handing over the chair now to friday um but thanks again everybody for your questions and engagement over to you friday

01:24:16

thank you mike for that great session is everybody hearing me yeah good morning ladies and gentlemen and it's my pleasure to now lead you to the breakdown breakout groups reporting back and you also know yesterday we had three groups that met in paradise sessions and today over the next couple of minutes we'll be asking the group to report back to us plenary and they will have about another

01:24:49

10 minutes to discuss the recommendations we've made we have three groups one is the policy group another is a research group then the third one is the multi-sectoral group it's now my privilege and people like to invite dr chima onoka to present for over 10 minutes about what the policy group decided yesterday so otochima please

01:25:16

make your presentation 10 minutes please thank you very much i'll be sharing my screen okay can my screen be seen yes visible okay thank you so we had very robust discussions and it was a very good participation well you know many stakeholders were there we focused on the policy aspects

01:26:03

of of our discussion over these two days on understanding the context of coverage and the progress so we try to tease out a number of things of course whether there's a vision and that vision where it is and then the strategies that are encapsulated in it and as well as you know going further to look at the barriers and challenges um and then we try to bring out points around um points for action

01:26:36

um so first of all you know starting with that vision um participants felt strongly that a policy direction exists and this is reflected in the national surgical development plan the national health policy and the act but there are huge challenges with awareness and there isn't a clear system of accountability that is effective and that implementation is weak

01:27:06

um i'll speak a bit more about that in in the subsequent slides and the strategies that have been you know that need to be brought forward to you know to move things forward you know including include them um having stronger stakeholder engagement um clearly defining who the stakeholders are bringing them on board to the conversations and that the vision actually really needs to be shared

01:27:37

with all stakeholders issues around accountability for those at the political level um clearly electability in nigeria to positions of authority especially at the state level isn't connected to issues like universal health coverage but this can be strengthened if you know there are things like um competition you have things like competition and the sub national levels um amongst governors whatever could be

01:28:09

will be you know can be done to stimulate competition at that level will be useful in um stirring up political will at that level and of course at the national level and also at the local government level um a clear communication strategy so there are lots of things that are on ground um but they need a clear communication plan they need to be packaged first of all um and then there's a clear

01:28:40

communication plan through which that information the information around uh can get to the leaders and the lead to enable them to take the right action and there's a need for usc policy champions um people who are influential being drafted you know um to the discourse and then they can drive a lot of the advocacy that is needed because advocacy is needed at the top level in the government houses

01:29:10

um and of course that the focus should be on trying to think about what the minimum standards are at the national level but the specifics will really be tailored to the states and then these things can be tracked adapted and implemented and the incentives to motivate right action can also be clear at those levels um current efforts and the successes and learnings from it i think a number of them

01:29:41

have also come out you know from some of the speakers um there are quite a lot of usc related initiatives that have happened related i mean even if they are not connected to your to an overall plan um but it's been clear that success has been linked to political leadership where a political leader is interested success is possible when they are not interested it is difficult technique technocrats

01:30:11

bureaucrats will just be reviewing policies and writing new ones and editing and turning the papers until there is a political window and this is in line with evidence that is also out there when political windows of you know meet um ready um meet um technical guidance that has been packaged those opportunities lead to real quick differences so

01:30:42

stakeholder engagement citizen education is poor it's still not something that the citizens in nigeria are actually aware of and um ready to even support or to help drive alignment is needed and so discussions like what we are having um this kind of meetings there are lots of stakeholders who actually drive a lot of process that we will take steps to start them engaging more deliberately the nshdp has been developed but like

01:31:13

has been said even commissioners and even people at the national level still don't even know the content and we are already like two years plus into its implementation and it will be over in the time for it will pass in another two years and then the issue of partners have been spoken about um the basic aircraft provision fund of course has been talked about as well it is very small

01:31:44

compared to the need and so there is that risk of phone displacement even before its implementation hasn't really started there is already a risk of fund displacement at the state levels people saying you know governors and decision makers saying basic healthcare provision fund money is already coming why are you asking for this kind of budget for health again at the state level the national health insurance scheme we've talked about it um not being mandatory but there are

01:32:17

concerns with even saying that it needs to be compulsory but those decisions have to be made um then you know it also needs to be more comprehensive um all the evidence that is available points to the fact that it's actually somewhere around two point something percent of nigerians that are covered there is yet no evidence that suggests that it's up to five percent um we hope that something like that can come out it's still somewhere around 2.5

01:32:46

percent and um until some real information comes out the issues with accountability and that hinders engagement with that level with that platform political leadership needs to understand the subject matter so there is a lot of work to be done to redirect and focus leaders and for them to also see that there are clear timelines and is a stepwise process not that people wake up and they want to achieve everything during their tenure

01:33:18

and because of it it turns them towards vertical programs um they need to agree that others can continue from where they stopped and then the agenda needs to be connected to accountability like we've said and have real political leadership not just technocrats designing the policies without an interest from political leaders and then at the end of the day that's never implemented private sector contribution has been raised and i will

01:33:50

say more about that so the barriers and challenges that have been out there critically the poor appetite for system building is very critical it's a key issue that came out of that conversation there's a poor appetite for that amongst those leading at all levels um not just political leaders but even at the ministries and all that for system building and so that leaves a lot of vertical programs

01:34:20

which because people want to achieve them during their own tenure which may be two years four years it makes them to rest on those vertical programs fragmented approach to coordination which needs to change um and also the issues of you know financing which has been raised as well um and then that the organizations within the health sector and outside it haven't yet been oriented towards a usc

01:34:52

agenda and the changes that need to happen in those organizations haven't started so are there mechanisms that we've identified yes um i think i've spoken about a number of them already bringing a clarity to the discussion at this level usa being embedded um you know in every sense of of the world and then engaging the private sector then policies pushing for implementation

01:35:23

of the policies that are in the nshdp already and financing through um more innovative mechanisms and contextualizing the models of uhc um and then that it's not just about financing but there are things that involve the communities and involve you know individuals groups that nigerians use as social systems as well and then regulators and

01:35:53

all that need to be separated from the providers and to take advantage of you know the polio the kovi 19 pandemic opportu opportunity towards building a resilient system key priorities for going forward and that's to bring this to a wrap the health system we need to focus on that um building that up and then learn from other countries that are trying to take advantage of the covered opportunity what they are

01:36:25

doing and that can help us move forward address other areas like hunger poverty alongside and then raise awareness up to what we call in nigeria the grassroot until it becomes a grassroots movement and there are lots of discussions about strategic purchasing to improve the efficiency of an effectiveness of funds that are being pushed down the line to even increase the trust in the system that

01:36:56

will allow you know more funding to go into health and of course to improve the political and you know um technical interface and strengthen the practices around procurement and supply chain issues have also been raised during this um discussion this morning and to also be sure who the stakeholders are and to engage them deliberately um i think finally we have a list of you know various strict

01:37:28

stakeholders from the conversation that happened yesterday for further engagement and i think that's where we got to and thank you very much i think the comments can follow for auditions and whatever i may have missed thank you back to you thank you thank you dr noka for keeping your time and we will keep the question and comments to the three presentations i'll be completed so it's now my pleasure to invite

01:37:59

dr taya merchant to present the findings from the research group dr taya please thank you so much friday can you see my screen and can you hear my voice yes perfect thank you so much and so um following on from chima's presentation here i'm representing the group that met yesterday to talk about research priorities in advancing the uhc agenda from nigeria and i want to thank the group very much for very constructive and

01:38:38

interesting conversation and i hope that you're going to find that some of the issues that we highlighted overlap with those from the policy group but we have a very specific uh lens that we've applied given that we were targeting this from the perspective of of researchers similar to chima i'm going to follow a structure whereby i'll have three slides highlighting three priority strategies that we identified one slide on a set of barriers that we

01:39:11

thought were preventing us from doing our best work and then two slides highlighting priorities going forwards so before we even get started on the first of the three strategies just to underline something that was really um universal between us and i think for all of us as a group which is that whatever the vision of uhc uhc is for nigeria we must systematically

01:39:43

prioritize equity and high quality care so whatever the package of care that's included in universal health coverage so the national strategic plan too has laid out what the um components of uhc look like for nigeria they have to be delivered equitably and they have to be delivered at the highest possible quality if we are to achieve health gain which is i mean the thing that nigeria is is perfectly poised to do so we thought of three strategies that

01:40:15

will help to operationalize this and the first of these is a common theme political leadership and governance that uhc really still needs to become uh prioritizing the political agenda a very cool theme for us it ran through all of our discussions was the need to consider actions and solutions at both national and state levels so we placed quite a high uh premium

01:40:46

on the need to have to take account of the very varied context between states and that when federal level makes recommendations and has strategic goals and and and policies actually the majority of the work takes place by the group of actors who are in states who have their own leaderships and their own competing demands and priorities so all of our strategies need to take special attention special attention on both the

01:41:18

national and the state level response and we thought that at the national level of course there's a role for accountability and and there's some research perspective there's some promise in the strategy of benchmarking uh between states it's certainly been something that's been shown to be quite effective in the role of immunization it's being used increasingly maternally born in child health care and i'm sure across other domains of healthcare delivery

01:41:51

but that there needs to be a drive towards accountability within states for their individual implementation and performance one of the things that we think limits this strategy that we would want to promote as a strategy is to promote the importance of health as of concept so when talking about economic development development of the country as the whole we feel that there is still a need to promote

01:42:23

health as a top priority for the country and that there's a an interesting and important conversation to be had about the strategies that would help to drive that it should include mobilizing communities using community voice more effectively to exert political pressure and of course we'll need to make use of champions to help drive messages through so political leadership and governance

01:42:53

is our first overarching strategy and our second one is really focusing in on the primary health care system as the bedrock for uhc of course the different elements of health that are being delivered through uhc might include and and have to include secondary and tertiary health care but if we can't get the primary health system right including engaging community right from the bottom

01:43:24

up then we feel like we are struggling to even really get out of the gold blocks with uhc so we would like to see a revisitation of the structures and the systems for healthcare delivery at the state level in primary healthcare what is working how is it working why is it working where the primary healthcare system is not working why is that what do we understand so a theme also that arose for us from a research perspective is can we move from describing

01:43:55

the many problems that we know to exist and start to focus our agenda much more around strategizing around solutions reflecting on the issue of quality i think it's really crucial that we're very thoughtful about what the quality that phds can provide so primary health care is delivering promotive and preventive and curative health care and all of those dimensions have quality

01:44:26

issues around them so what is it that phds are doing well where are they providing good quality care what needs to be improved where are the gaps inevitably there was a large discussion around finances as i mean it's a theme across this whole workshop of course so um when it comes to conceiving of phds is the bedrock are we sure that we have the right funding flows do we have the right investment in the

01:44:58

right areas do we have an appropriate accountability system system for the allocation of funds and sometimes it's not only allocation but actually release of funds do we have the accountability for release of funds within states we've touched on the national health insurance scheme and we talked about that too we talked about the need for research that would help to strengthen that that exists but clearly there's a need for research that

01:45:29

helps to develop mechanisms for financial risk protection for people outside of that scheme for the poorest in the rural areas and then research that would help potentially with prioritization so there was discussion yesterday in the plenary about incremental steps to uhc and in our group we uh talked about progressive uhc so where there's some prioritization in a stepwise process whereby we want to achieve

01:46:00

given levels of population coverage across the gamut of services being provided through uhc and maybe we can't do that all at the same time as having our eye on full service coverage and financial protection but we need to have a road map to make sure all three are being tackled and then finally our third priority strategy is around community involvement and this links again to this concept of governance

01:46:30

accountability and also to promoting the primary health care model we feel that i mean populations vote with their feet demand is insufficient in nigeria and part of that is because people know that the quality of care is not always available to them but also people do not always know what their rights are to health care they don't have adequate information about a type of care that they should be receiving and we feel that there's an opportunity

01:47:02

for research to contribute by representing and highlighting community voices and integrating that then into policy dialogue and so our research responses need to be fit for purpose to address community needs and crucially our research communications need to be very thoughtful and address communities when we're um when we're discussing our findings there's an additional point there when we think about strategies that can promote primary health care which is

01:47:36

that nigeria now has adopted the community health influences promoters and services the chips initiative there's an obvious opportunity there to use that initiative to effectively promote the uhc in the short term because let's face it we do need to identify actions that we can take immediately as well as actions that might take a little longer to instill so thinking about barriers why are we not currently doing the things that we wish that we would do

01:48:06

and we had three main areas here the first is that we felt that research was not always designed with research uptake in mind and that there was discussion around the research culture which i think is true for nigeria it's true beyond also so that as researchers we must be more um proactive and thoughtful about mapping and involving a broad range of stakeholders from the outset who is it who we want to take action from any of

01:48:39

the research evidence that we generate and our activities mustn't just stop at planning and involving people at the outset but our we must be thoughtful all the way through to effective communication to those different audiences at the end of research activities making sure that we target different audiences with appropriate messages and products the second issue was more of a domestic issue and that's around research not always being allocated sufficient

01:49:13

funding within nigeria so i think we would all agree that uh research is most effective when there's country ownership but most research currently is externally driven and that really is perceived to limit research uptake and actionability so if it is a barrier currently that there's not enough research investment in nigeria i'm not entirely sure how we would address that but it's something that we would like to see more of

01:49:45

and and particularly because we saw a need for more effective communities of practice more uh collaboration and coordination between research activities in nigeria for more opportunity for research uptake and then finally there's a barrier that we identified around fragmentation of the concept of health so i mentioned and the the first slide in governance around the the needs to have the topic of health embedded in the discourse around

01:50:16

economic development for the country and some of the reasons we thought that this is is is challenged is because there's a multiplicity of vertical health programs in nigeria so we sometimes just talk about malaria or we just talk about hiv or we just talk about immunizations without necessarily linking it to the concept of a person's holistic health and then of course there are weaknesses across the health system that um just exaggerate that fragmentation

01:50:49

so finally priorities for action and i've divided these into two topics that we need yeah thank you i will so two groups here the first is around topics for research so research that aims to optimize the primary health system identifying which health system building blocks need to be strengthened and how research that purposely tries to understand the end users so that's targeted on

01:51:22

community um community targeted research and then there were three areas of research that we thought were really crucial around financing so around efficiencies in health financing around effectiveness of resource allocation but also around improving financial risk protection for communities but then there were a group of research priorities that were more cross-cutting so the first of those is around this issue of collaboration

01:51:55

and coordination so uhc needs a large type of data it needs diverse methods to be applied we can't all do everything what can we do to help build a stronger community of practice we must push ourselves to go beyond descriptive research and be much more thoughtful and focused on evidence-based solutions definitely to learn from other countries about how they've responded to kobe 19 to inform potential strategies for uhc but

01:52:29

not forgetting that whatever research agendas we develop going forward they must take account of the state driven action and the differences in context so thank you very much to the group again and thank you for this opportunity thank you taya great presentation alive because of time we have to invite professor john idoko to present the recommendations from the merch to satiriya group

01:52:57

john plays johnny docker 10 minutes do you see my slides i'm seeing it now thank you okay great thank you very much so uh first to thank the members of the group for the very lively discussion yesterday and i hope that i'm representing you know what uh we all came to us our final thoughts i'm sure that i would

01:53:45

have missed a couple of things i i guess that in the last five minutes that is allocated during the discussion that that can come up so um in terms of the strategies again there's a lot of overlap but our main focus was on multicentral uh collaboration engagement of government at all levels to bring attention to the need of ufc is critical in ensuring sustainable funding and

01:54:15

encouraging communication between the federal government and the states and non-state actors we heard over and over from various speakers about the lack of political will and the lack of political commitment so and the gap between the politicians and the technical class and also the gap that exists in terms of uh collaboration between governmental choice and non-government so that's uh political agreement is a critical

01:54:45

component of what we believe humidification for uac developing a policy framework to strengthen collaboration we heard from uh dr rj this morning some of the power plays that happened between you know the ministry of health and the non-health actors and unless we're able to have a framework to be able to bring them together with a vision for uac we're not gonna make much progress and when you go down the line

01:55:16

even with the gaps that we see between the federal government the state government and the local government because of the concurrent nature of our you know health system that's we need some frameworks there that bring people together we've had how difficult it is to operate at phc because of the gap between you know the supply side and the demand side these are all issues that require a very thorough you know framework to bring about the synergy that is required to see this

01:55:48

vision we've also had the lack of community involvement those are things that need to be addressed in terms of this framework and i'm happy that we're just looking at that you know the result issue even multi-sectoral collaboration requires a lot of data to look at the various gaps you know in terms of the planning implementation monitoring etc so these are all things that you need to look at in terms of strategies current efforts and substances and

01:56:24

lengths we've heard about the successes from polio high came about the insights into how to address the various issues the competition that you know was engendered between the states to be able to you know advance the uh goal of you know um eradicating problem in nigeria we believe that such can be brought to be you know not only in maternal services but even the old vision of the uac we had you know in a

01:56:58

group yesterday uh how you know community-based health insurance system can be very very important in driving you know services to the community and therefore helping to improve the uptake of services so those are some of the things that we believe are extremely important funding availability in the primary healthcare setting was shown uh to increase access to medicines we had that

01:57:29

that was a major strategy that was used by the national primary healthcare development agency we also learned about the successes from the mtg component of the nhis which run and was implemented in about 14 states was stopped as soon as the mdgs you know uh came to an end wasn't sustained so the question is can we come back to use the same system to take up and focus on ufc this is this is a

01:58:00

success story and something that we can look back and learn the lessons from and take the tools now and you know to uh so this is something that uh our group also discussed yesterday next now the current efforts strategies and learnings the additional points that we had you all have this morning the presentation from ninja day where you know uh private there was a public private partnership

01:58:31

in running various uh you know health facilities from the phc to tertiary uh institutions so those are things and strategies that we should be thinking about you know as we look forward to ensuring you know that we move along the goals of us uhc and then because this ensures that people had both insurance and access to facilities she also talked at lead about the success of the phd services in kara

01:59:03

state which was like one of our first community-based health insurance schemes uh and we believe that in that group that this is something that we need to replicate in many of the states particularly that ministers are now coming up with their you know health insurance schemes and in one example that was given tbs had been financially incentivized 200 mother to people britannica and post natal care into phd to overcome the lack

01:59:33

of mothers using uh phd firstly this is not the first time that there is certain incentives but those are things that can sort of stimulate you know the uptake of services which is a bigger acquired ph given the lack of trust and confidence that communities have in all these facilities the broad taking away of all these states need to experimentally what learning should be shared so that successful approaches can be replicated

02:00:05

you know as we move on now what are the barriers and the challenges that were discussed of course the lack of senior government engagement and the ufc's champion which has resonated in all the presentations and lack of senior government me engagement start from the president to the governors to the chairman of the liberal governments and we all know in this country that once those are not if we can't carry those along

02:00:37

the uh programs are not going to receive government attention they're not going to receive government funds i think one of the things that we must go along you know to convince the politicians is how important health is and also getting you know communities to ask questions and ensure that during elections that people are not talking about roads only and bridges but also the human capital the health of the human capital

02:01:09

and you know the education of the human culture those become very very important things that you know we need to start looking at because these are the major barriers there's a lack of clarity as to the responsibility of the nhis and we're not surprised after over 10 years of its inception nhis has now gone up to fight and as we all know it's only the government of the country that is you know are paying capitations on behalf of the workers so these are things that we need to look

02:01:40

at and see you know how we can reform the nhis and ensure that it has a strong collaboration with um with the states so that state health insurance schemes can be made you know to become effective and efficient particularly that many of them are stages where they are almost taking up the other form that was discussed was that if you look at

02:02:10

the insurance providers their key performance indicators focus rather on profiles and you know the lives of people to be safe these are things again uh this is bad because most of them or things are looked at the vertical form and the question is how do you use like the presentation we heard from today how can we use those vertical uh programs to sort of leverage on you know the global vision that we are seeing or the

02:02:42

national vision that we have seen for for years you should now communication please stand up okay low level of awareness about uhc in the community and the lack of clerics of current strategies and kps next forming as an issue anytime is not working to ensure good use of funding we've told been told about the issues of accountability and the integrity access is variable between states i

02:03:12

think that we must therefore learn to be flexible in our implementation to adapt to the context resources is the problem many phds you know are far from the communities it takes time and money these are some of the barriers next and the feedback look of awareness sometimes uh are there possible mechanisms yes uh it's an agenda that should be on the forum for discussion by politicians governors

02:03:43

the national assembly the national council of health etc gathering data to highlight the gaps in delivering you know the burial services encouraging our stakeholder from senior government officials right through to the communities so that we can you know sustainable sustainable foreign develop services that are right for the locality and ensuring that access to them the issue of champions has been you know uh

02:04:14

mentioned several times and here the nigerian academy of science support from organizations like ams and many local foundations can help to support and bring to be a professional civil society and others to jointly advocate you know and to hold you know a government account for uh you know um the um universal health coverage next what are our priorities what priorities were discussed

02:04:46

focus on states rather than you know the center because you know we learn from the issues of polio that if we look at the states that is a lot easier to manage and we know that there are different levels and they can compete build an alliance for private sector on uac leverage on the experience of polio covet and then list champions you know uh who can re-engage stakeholders at all levels they live for years coordinate activities between all stakeholders and

02:05:17

enjoy sustainable fund and very importantly continue to gather data to bring insight and actions you know to use thank you very much thank you john for that great presentation um i don't think we're having a lot of time to discuss but i think we'll have time for about three to five questions i'll ask alice because there's a question in the chat bots to present those questions allow them to those who have put some questions on the chatbot to ask

02:05:53

themselves alex please okay uh so we had a question from sorry i'm just going down there um amazigo hang on i'll allow you to talk please ask your question you're able to talk if you unmute yourself can you hear me now alex yes sorry then uh for the delay um now doctor no khan the policy group mentioned that citizens uh lack knowledge and i agree completely

02:06:49

with them there is total lack of knowledge of the citizens in fact their perception their voice on phd and particularly on uhc is extremely poor and i'm wondering whether this group this panelist could give us two three points on how to improve engaging the citizens at all levels so that at least they understand uh and have a little knowledge about what

02:07:21

we are talking about so far what we have had yesterday and today we have had only from us professionals we don't know what the people want we've never asked them in this country in a large scale we have pockets of research about people's perceptions but i do know that um if you can google the uh world health organization report which i shared with um professor o'connor for yesterday

02:07:50

a study we did for 10 countries in in sub-saharan africa in 2012 about their perception of health systems in africa very interesting of what people in rural areas think about health systems in africa that sort of study could be replicated here in nigeria because for me in nigerian though nigeria is a multi-country so if we do pockets of research and then we build our decisions on on

02:08:23

those pockets of research research done in lagos research done in kwara elsewhere they are not representative of nigeria so uh my question to this group if it is communication if it is um focusing on states how do we how do we get to listen to nigerians so that at least they can understand what we are talking about on uhc thank you

02:08:54

i think we should keep the questions and then later on uh alice do you have more questions so that the presenters will answer at the end yep uh dan dan you should be able to speak now okay thank you so very much uh to the group coordinators i was a member of the policy group so my uh interest is actually on the uh presentations by the other two groups

02:09:28

for the research group um in terms of funding the central bank of nigeria recently made available 100 billion naira for research that's over 250 million us dollars for research related to the kovi pandemic so there's an opportunity there is a question of us you know finding a mechanism to make sure that this is sustained

02:10:00

uh beyond the central bank uh but i have a specific question for the multi-sectoral group um my thinking is that do you know maybe you did discuss this but i didn't see it in the in the uh presentation made what is the health sector uh going to do in collaboration with specific sectors like education in terms of developing human capital

02:10:32

or ministry of finance in terms of financing health and improving the public finance financial management system i i don't know whether your group looked at those two aspects of multi sectoral collaboration thank you very much thank you unless do you have any questions otherwise we asked do you have any questions in the chat room uh no other

02:11:05

questions okay so i will invite uh let's start with chimajima can you start with any questions that you want to answer you have a question to answer you don't we'll pass on to john or taya let's talk very well i i do okay let's chill on please and thanks doctor myself that was you know a very brilliant comment around it you know when i got to my workplace this morning i saw two women

02:11:38

over 30 fighting and people gathered they couldn't even touch them they were just fighting and i mean the fuel prices we had is increased and then the electricity prices went up on first of september i felt they wanted to express themselves they wanted to give their voice out but they can't speak to the government and it was they were not expressing their frustrations between themselves and that was poor you know if they end up in the hospital

02:12:09

there's there's not much that can be done for them and i i think really people people's voices need to be heard politicians political leaders most of them don't have an incentive to create the opportunities for questioning and that's sort of why that's one point secondly when a lot of these things are being discussed it happens in abuja and those who have access are also politicians appointees of government and ngos that

02:12:41

can afford an office in abuja that float in abuja but the usa movement can only happen if it is driven at state level states and lgas government should be about funding especially where is the money and how can we make it easier and how can we provide technical support to states but it has to happen at states and states that is where it's a lot more possible to hear the voices of people who are

02:13:11

real citizens of nigeria at that level not up in abuja but there's a lot of circulation and that's where a lot of the documents happen so at those state levels i i think just like what you know like the conversation we're having at the nigeria academy stepping up along with such institutions that appear independent that can help in creating the opportunity for the leaders to you know meet with the citizens wear

02:13:42

such voices you know it appears neutral i i want to focus more on that aspect to say that those are the kind of things that we need to create and is at that level where people's voices can really be heard and um you know that's the comment i i'm going to make you know um in response to that i i think i've also been given an opportunity to you know you know just a comment or question for you know what has come out of the other groups

02:14:13

i i think the from the research it will be interesting to hear really what is it about we had the national help a national policy on health research is it and i've seen so many times there have been all the research agenda articulated it's not funded and in ministries and departments there's always a department of research it's not connected to that research policy is also not connected to research

02:14:43

funding is usc research funding of research to support uhc how will that flow what would be our recommendations is it a cbn thing like was mentioned for covid does the treasury of u.s drive research is it equivalent to what we have as any nih and even in the uk why will cbn be the one driving

02:15:14

funding for research why will he not be domiciled somewhere why will he not be nima why will he not be the national institute of medical research why will he not be an n high nih type system that understands the issues why do we accept everything that comes like that is that how we will drive uhc research it would be good to hear our thoughts on it or are we comfortable with just the fact that there's a third fund can the 2 million 3

02:15:46

million drive uh c related research and our academic institutions really really seen local academic institutions as platforms through which re uhc research can be commissioned because like he said where your treasure is your heart to be dead if government's funding does for you heads it does not go to nigerian government funding does not go

02:16:15

to nigerian academic institutions to drive uhc research happened so we made a very important point of our funding to think about it thank you thank you um can i call taya to make to respond to some of the questions she was asked yeah i will thank you and i won't try to add to tumer's point because as a non-nigerian i wouldn't dare to try to ask why it's accepted tumor but what i would say is that i really hear your frustration

02:16:49

and i understand why that frustration exists and it came up in the group yesterday and i feel it myself as a as a a privileged guest to conduct research in nigeria that there is such an opportu there's so much capability there's so much capacity in research but there's so much fragmentation and and that there's a there's a real need for some

02:17:18

um networks building capabilities enhancing coordination having a greater voice academic institutions having a greater voice in the country and i can't pretend to be able to say how that should be achieved and there might be others who were on my on the research group who could chip in more but i i see that it's an incredibly an opportunity full of potential and maybe this covey 19 drive is part of that maybe

02:17:52

covert 19 the spotlight of it the spotlight on the need for data to address a health emergency can be used to the effect of enhancing the need for networks and investment in research institutes in nigeria and the network of research institutes somebody yesterday in the plenary talked about he wished that somebody put a comment that he wished that um there was a a project in every tertiary institution in nigeria

02:18:23

that would take control for one aspect of uhc and i mean i think thinking to uchi's point about how do we hear community voices i think we hear community voices as you said yourself chima through state driven action i think it's too actually it's not enough to just talk about states because we need to go beyond the states that's kind of the if you think about the macro the miso and the micro with the federal being the macro the state being the miso the micro the actual voices are coming from

02:18:56

communities so our window into communities are yes lga but in fact war development committees are becoming increasingly important in driving improvements in primary health care so i think that there is a real opportunity there to bring more development committees not just lgas into this conversation but i think yes capturing nigerian voices uses using embedded research institutions in states but having

02:19:26

networks of institutions so that there is an opportunity to build capacity and to share learning across different networks is a really crucial part of the agenda going forward and all i would say to dan if you've had 100 billion naira released for research in the light of covid welcome to my world i'm in the uk we've had 10 years of austerity and all of a sudden we've got all the money in the world to spend although we haven't yet seen the tax rises

02:19:57

thank you taya can i invite professor ridoku to make the final statement please and thank you for that very very uh important question actually it came up as a presentation that was not so much discussed but you know i think the answer to it is just to reflect back and see what happened to us when you know we're dealing with hiv it was a merely health sector but each of the relevant sectors in

02:20:29

in the in the the government had held this and from this you know uh they they they had capacities built they had their programs that would promote you know issues of prevention treatment issues of hiv prevention and awareness and then you know this happened not only at the federal ministry of health but was replicated at the state level and even at the local government and once you have this

02:20:59

if we're going to move forward with ufc this is the way we must go to help to ensure that finance has a depth for uhc education has a desk for ufc information has it there for use et cetera et cetera all the relevant sectors and one of the things that i believe happened with hiv and polio which is now also happening with kobe is that in the various committees policy committees

02:21:30

guideline committees you know implementation committees some of these very relevant non-health sectors are brought in so that you know there's uh a semblance of one team working towards one goal and one vision thank you professor for that summary feedback i think we are coming to the end now i'm sorry i have a little code this money i would like to because much of what has been discussed

02:22:00

today in this session i focus on government and israel and i know that uh as a consequence of this workshop the nigeria academy of science will be ready will be willing and in collaboration with the uk academy of science to begin to mobilize transform our advocacy and knowledge during activity in attempts to address usc nigeria so i would like to bring in uh would like to bring neck at this stage she's a representative of the federal administrative head to talk about the potentials without our

02:22:32

collaboration and whether she thinks i'll be important for the nigerian academy of science to play a role in trying to get government to do some of the things that i'll be raised here today his next day please can you please help us about the last few minutes to talk about that right um thank you prof um thank you very much for the opportunity to speak um i think we've had very interesting sessions and very interesting discussions um just to say that um i think you knew

02:23:05

i was thinking along that that line maybe that's why you asked me to speak so it's also good now that uh i'm bringing it to so um before now um we were planning on um a policy dialogue um which will culminate into a uhc summit you know sometime this year and after most of the discussions yesterday um i muted it to um professor

02:23:36

or ob who is um the chairman of the health financing twg it's a national technical working group so that technical working group would usually provide guidance um for that policy dialogue and for the uhc submit i said hey come on i think it will be nice and very enriching if we could partner um with the academy to um you know to um host the uac submits because um some of the

02:24:09

things that are coming out from this discussion from the um conference that we're having could be um you know brought to the table at the policy dialogue and partnering with them we could take a deeper dive into some of the issues that we have highlighted here and also drawing on from the lessons that we've articulated from um this engagement i mean for me it would be a very good strategy to um closely and deeply engage with um

02:24:42

the leadership of the ministry of health as well as um other um high-level stakeholders within the health nigeria's health system because usually at the policy dialogue and the submit who would usually bring all of those um key stakeholders to the table and um he was like yes that would work well that um he told me was going to speak to somebody somebody i don't know i said okay it would be nice to have that feedback such that um um i can put it as part of

02:25:14

the concept we're just trying to finalize the concept for the policy dialogue and the uhc submit and um yeah so it will also be an opportunity to get some support from the academy in trying to articulate the concept no such that it captures everything you know that we've talked about and what we plan to do and what the country should also be driving up so i think for me as the health financing lead in the

02:25:45

ministry i think the partnership is already established it's just for us to draw out how to move it forward and i'll take that to my principles thank you thank you very much necker and claire that promoting usc will be one of the most important follow-up activities of the national criminal science going forward because i know that we have our members very strategically pleased throughout

02:26:16

the country to play this type of role and ensure that the policy framework become right and appropriate for delivery of usc in terms of what we've described and apart from just policy dialogue i also believe that we need to be very active ensure that whatever dialogue will come up are implemented and i think kuche a magical professor amazing who is also a fellow of the academy has also pointed the fact that the academy can lead in coordinating

02:26:47

research institutions and also mobilizing funds in terms of funding i want to say that since we are talking about multidisciplinary or multi-sector approach i don't think there's anything wrong with anybody providing funds i think all sectors including banks really private sectors should be encouraged to provide funds and i don't think we could we should unnecessarily because we also have funding from canada you know organizations so i i don't think unnecessarily but i think the academy of science has a

02:27:19

very important role to help to try and see how it can build capacity for people to obtain these fronts hello this slide summarizes a lot of what you're saying at the moment yeah thank you those are the final areas and i they will circulate this in due course what i'm saying is that the academy of science and in agreeing to co-host this particular workshop uh was you know i was actually convinced that usc is an important area

02:27:58

and right now the uh the academic science is interested in ensuring that it chooses scientific mentors to enable nigeria indeed african region to attend the sustainable development goals and since access to hurt is one of these goals i'm very sure that working with the president and fellows will be able to prioritize some of these activities going forward i want to on behalf of this meeting now stop this session and thank everybody for being part of it

02:28:29

this particular session breakout groups reporting back and to say that uh we have opportunity to continue to talk about this i have i'm gonna say a very highly loved enriched manola has been reached in so many ways and going forward have been motivated and i do all of you are motivated to work on this area after you leave this conference so it's my pleasure to end this session to thank you all for participating mike i think i handled it will be parting to you now great thank you friday um so i think

02:29:04

um the slide i hope everybody can see [Music] was an initial attempt to summarize what appeared to come because we a few people had access to the present group presentations that um you all saw earlier so this is very much a draft um and if you are familiar with the expression a straw man something to get people to think and critique um so

02:29:34

um but if the idea was to try and draw together some key high-level issues that have come out of this two-day meeting um partly as a way of identifying issues to carry forwards while we've heard a lot of detail um we obviously need to have a reasonably focused uh agenda um for any activities that might come out of this so alex i don't know whether we've got um five or i know we're

02:30:05

we're in theory at the end of our time have we got five or ten minutes for anybody to make any quick responses to these um issues here yep we have until 11 40. great so um i think it's just while people gather their thoughts and maybe want to put their hand up again or put a question in the q a so again this set of um seven points is not it cannot fully represent the rich discussions we've had um but the idea is that

02:30:38

we do have something reasonably concise to take forward and it's recognized that in each of these um each of these seven elements they often overlap or intersect so clearly the role the private sector is you know you could may span all of the other points the issues we've just heard about in terms of um trying to coordinate research that may be across um different universities and the point was made about

02:31:10

not just doing studies in one or two states so initial thoughts would be very welcome and i think the first um the first question uh was from uche so uche please uh give us your immediate reflections over meet yourself jay and then you can speak can you hear me alex yep yes okay great i'm sorry now um just looking at the seven points uh priority areas i still think

02:31:54

that we are after 30 years of phc and even more we have still left in this priority seven points we have left the people behind and out of it completely so i would plead that we find a a point where we will emphasize if possible the role the importance of engaging the people and bringing them on board now after 30 years so that we can reset

02:32:25

uh the mistakes of the we have made in the last 30 years i don't see the people in these seven points maybe it's hidden but there should be one of the key points that everybody should see engaging citizens and informing them about what are learning from them what they think uhc should be uh and and you know communicating with them the the uhc and phc this is missing from the seven points in

02:32:57

my opinion thank you mike thank you i think that's a fantastic point um and i think the intention was there and i think we can that would be easy to work into this wording and i think we'll circulate these slides um again so people have a bit more of a chance to comment but the most obvious place would be policy and public or community engagement and that yes making sure that they're as you're suggesting it's not just

02:33:28

pushing communication out to them but giving they what they think is happening and what's what they need um so thank you for that um are there any other mic yeah can we have a subgroup it's called community engagement i'm sure that's fine yes yes because it's a very important point uh because i also know that we are there's something with there's a discussion we've not had about communities in all our discourse on

02:34:02

on usc and that is the role of cultural ad harmful cultural practices and beliefs which can actually serve as barriers to people assessing services the role of beliefs and i think that that's where education city communities and other accounts they have contradicting opinions about traditional versus others or to those who care and it is by engaging communities that will be able to know how that interferes with universal health coverage yes i think that

02:34:33

that's an excellent point friday alex um maybe this is just a time to just give people a minute um of of how people might be involved in looking at any draft and document that comes out or or even earlier than that um commenting on perhaps this this list how can how would you manage that over so we get offer um opportunity we can share this after the meeting in our wrap-up and uh with all the participants and anybody can send through further thoughts

02:35:05

um we have three people with their hands up as well uh cara was first are you happy for me sir please if you can see who's got hands up please just work through them thank you cara you should be able to speak now good morning everybody thanks for a great set of presentations and discussions one of the things that doesn't come through in these areas is the whole area of service delivery so you know we often focus uhc discussions about where the money is going to come from should it be tax should it be insurance what mix of

02:35:35

public sources but i am kind of increasingly persuaded that what's really important is to get the service delivery side right and then to pull the resources through rather than thinking about how to allocate more at the top we've talked about all the sort of bottlenecks in terms of absorptive capacity so i'd quite like to see something in terms of priority areas around really looking at the service delivery model and and uh and picking up on dr uchi's point about primary health care and primary health care is the kind of engine

02:36:06

of uhc and they need to explore new ways of delivering those services so that they can absorb additional funds appropriately we have also have francis next so i'll allow him through you should be able to talk now francis okay thank you very much i i very much appreciate these priorities that have been presented which are very useful so i'm looking at priority number two that talks about agreement of core aims and priorities for universal health coverage in our policy

02:36:40

group discussion yesterday we all agreed that these agreements aims and priorities are are very much in existence and very very well articulated what is missing um however is the clear communication strategy of clear and appropriate communication um to those who have the responsibility for their implementation and of course clear communication to the community members in the languages they

02:37:11

understand so that they will be able to hold those who are responsible accountable to their implementation so that's what we are identified as the clear gap here um and and of course um it talks about um um a coordinated approach um to that implementation so for me i will ask that we rephrase this um in terms of in terms of um getting a clear communication of the aims and priorities of

02:37:43

existing policies and strategies on universal health coverage as against um the agreement of it as he's put here thank you very much over thank you thank you francis and then there's also neca would also like to talk so i'll allow her through there we have everybody becca you could i mute yourself and then you can speak yes yes thank you very much um so um i have two comments um first of all to i'd like to allude to what uchi

02:38:19

had mentioned that um it appears that um one of the things that has resonated in all of our discussions in the past two days appears to be missing here which is around the citizens engagement because they are critical stakeholder stakeholders in their entire uhc discourse but thinking back again i'm looking at four when you talk about policy engagement so i'm just thinking engaging the

02:38:49

citizens could they be embedded within that policy engagement because when you're doing policy engagement you're engaging with several stakeholders um that's just my suggestion i don't know we could look at that and probably recouch that policy engagement to um be able to capture um the citizens aspect of it otherwise we could create a separate bullet for um citizens engagement now to my main point which is around the data

02:39:20

so for me i think um we can expand further on this because it should be around um data generation data interpretation and data use for the different levels of stakeholders within the uhc space not just the political class the policy makers the executive and of government and even the people they are all embedded within this um data generation aspect so i think we

02:39:55

could go further um to broaden the definition of or i don't know couching this point i think it should be around data um generation data interpretation because that's also very clear we need to generate this data and make it interpretable for um the critical people who will need to look at it understand it and make decisions using the data going forward thank you very much

02:40:30

thank you so i'm alex i'm presuming that the quest the people who wanted to make comments or questions at this um point have been given an opportunity yeah okay um thank you very much everybody as mentioned this was very much um this put something up there so that people could could comment and we've had fantastic comments even in that few minutes um so i'm sure the secretariat led by alex and the team will be inviting people to make further

02:41:02

comments um both on perhaps this if you like key messages um but also then for some for those people who've been involved or want to be more involved perhaps on a draft document that will be um prepared with um with with friday and the nigerian team at the academy there um i think we ought to wrap up now and try and keep to schedule we've done a uh we're pretty pretty

02:41:32

much on time at least for anything that i've chaired before um so i i just like to say a big thank you to to everybody um we obviously there were people who have been involved for some months in trying to prepare this um prepare for this meeting um led by friday in the nigerian um team but with the support of the academy medical sciences team um so i i won't be able to thank everybody in person

02:42:03

but a big thank you to that organizing committee who put in uh put in very valuable time to get us ready for this um obviously a great thanks to the presenters that we had yesterday and today um who i think have really given us great insights and certainly from me who's much less familiar with west africa um into the very real challenges of implementing uhc um we've had great support from our group chairs um who after the

02:42:34

meeting yesterday with some of the secretariat um developed um the presentations you heard earlier today um and and then presented to you so you could get some feedback um so and then obviously to the secretariat themselves who've been behind the scenes technically making this work and i think you'll agree with me it's actually worked remarkably well i hope everybody's internet connection

02:43:05

has allowed them to participate as much as they wanted to um from my perspective it's it's gone very well um just a couple of closing remarks um the i think everybody was aware that um all of these sessions have been recorded and certainly the initial sessions and initial presentations will be available on youtube and the secretary will circulate links to that so that you can share that with your students your colleagues

02:43:36

or whoever you want to in case they want to have a look um the whole purpose of this two-day meeting was to really try and catalyze a conversation um i feel we've been successful in that obviously what we're hoping is that it's not a sort of bright burn for 24 or 48 hours and then it completely fizzles out but it it was very uh exciting to hear from dr nekker about the idea for a summit perhaps later this year that

02:44:07

and i hope our nigerian colleagues will take full opportunity to participate in that um so in one sense part part of the job has been achieved in these last two days and i'm grateful for everybody's input to that um just one small thing on behalf of the academy i think many people on this call will be aware but if you're not the academy does offer networking grants um so to have a look out for those um they're not they're they're reasonably generous they

02:44:38

are specifically for networking they're not big research project grants but um and they're not by no means limited to networking amongst the people on this call so it's a very open call um so please um if you're interested have a look at have a look at those um and i basically think that's all from me so maybe i'll just pass over to friday to give the final concluding remarks but it's been a great pleasure to meet you all online and i wish you all a very pleasant rest of your day

02:45:10

thank you mike for that closing remarks i i want to also deeply appreciate the academy of medical sciences in uk for actually bringing this initiative to us they actually started it in informed nigerian academy of science and then we followed up from there so i also know that perhaps this is the first type of interaction between the academy of medical sciences and angela clinical science

02:45:41

i want to on behalf of the president and of the academy thank the criminal science for bringing this to us you know at the beginning we thought it was going to be a west african discourse we thought we were involved countries in west africa but nigeria as you know has 50 70 percent of the problems of west africa so i'm happy we're able to convince you you can see now that in terms of universal high coverage nigeria are some of the most what are called donkey problems in our region so concentrating your resources

02:46:12

on air force on nigeria and if nigeria wins this battle then i'm sure many countries in africa will also win the battle so i thank you and i do look forward what is particular what i know about discourses and workshops of this nature is not just writing a report and then forgetting about the entire concept thereafter we look forward to continuing collaboration to ensure that in two or three years time this university becomes a public policy comes into public

02:46:44

policy agenda and our politicians become more unwanted and willing to do something about universal high coverage so i think that is i i would work with the academic science to ensure that they privatize this as part of their work plan over the next for three years and also to and hope that the academy of medical science will join us we will be working out a number of uh concert papers some of our proposals to ensure that uh there's therapy optic nigerian academy of science

02:47:15

uh is a frontline organization in nigeria and it's quite in french in terms of its members and i think you can bring the influence to bear on promoting universal high coverage during advocacy and public health education those two things are important for us and for us who are here and nigerians listening i want to thank you i want to particularly kind of thank his excellency dr lucia minico who was there yesterday and is still here today listening to me now on the thank you because he's been the champion

02:47:46

of uh universal high coverage if you are looking for champions of universal high coverage i think mimiko is an exemplar and i know of several others i remember when i was an advisor to president new segment passenger on head he was very very concerned this was in 2006 about universal coverage and did so many things for universal coverage so people like that can still be brought on board and we can just for us to inform them to let them know what's going on many policymakers in this country

02:48:17

don't know many many things about it when i walked to ambassador that's when i first knew that what he wanted to know was more about heads and once he knew he was willing to do something about it so on that note i want to thank everybody for listening and for being present and the academy of medical science uk for pointing this very important program to us and i assure you that will not stop until issues are resolved thank you very much

Understanding the context of health coverage in Nigeria and progress towards effective UHC

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