By Felix Abrahams Obi
After ten years in the making, a harmonised National Health Bill has just been sent to the President for signing. We invited Felix Obi to take us through its history. It’s been ten years – so this blog is inevitably longer than usual…but it is important that you know! You can download the Bill HERE.
Nigerians often reminisce about the days of Prof. Olikoye Ransome Kuti as Minister of Health when the health outcomes were better and Primary Health Care was promoted vigorously as the major thrust of the National Health Policy enacted in 1988. But with the 1990s came the southward spiral of our health indices when an Army General and Military Head of State famously tagged our Teaching Hospitals as ‘mere consulting clinics’. By the turn of the Millennium, WHO’s 2000 World Health Report ranked Nigeria as 187th out of 191 countries in the Health Development Index in the world. We were ahead of only four countries that happened to be either at war or just emerging out of war. We were all shamed and it was obvious something had to be done to turn things around
The anthropologist, Margaret Mead famously said “Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” In similar vein, a concept paper written by Prof. Eyitayo Lambo after his retirement as the Senior Health Economist of WHO African Region was to spark a new beginning in Nigeria’s health sector. That concept paper was presented to the Nigeria Country Office of the UK Department for International Development (DfID), and birthed the Change Agents Programme (CAP) in 2001 through which 30 reform-minded Nigerians were selected as Change Agents. Through action learning, capacity building and study tours to other developing countries with better functioning health systems such as Ghana, South Africa, Egypt, Tanzania, Zambia, Uganda, and Cambodia; these change agents were challenged to do something to change and reform Nigeria’s health sector.
As these Change Agents reflected on their experiences and exposure to other countries’ health systems, they critically-reviewed the Nigerian health system and observed that although the 1988 Health Policy prescribed that the 3-tiers of government each have responsibilities for providing healthcare, however, the 1999 Constitution inadequately addressed the provision of health to Nigerians. Out of the 68 items in the Constitution’s Exclusive Legislative list, there was no mention of health, except for a mention of Drugs and Poisons as item 21. Similarly, in the Concurrent list which has 30 items, health is only mentioned in relation to industrial safety. To remedy this lacuna, the Change Agents felt it was imperative to have a legal framework for the provision and management of healthcare in Nigeria. Thus was the idea of the National Health Bill conceived in 2004 and thus began the long and tortuous journey of its abortion, still births, and uncertain but lengthy gestation, with no certain expected date of delivery in sight.
The “Bill For An Act To Provide A Framework For The Regulation, Development And Management Of A National Health System And Set Standards For Rendering Health Services In The Federation, And Other Matters Connected Therewith, 2014” otherwise called the National Health Bill (NHB) was first drafted in 2003/4 by the Change Agents who had reviewed and revised the National Health Policy as part of the Health Sector Reform Agenda of 2004-2007. With the appointment of the CAP Director, Professor Eyitayo Lambo as the Minister of Health in July 2003, the Change Agents found a useful ally in him. Coincidentally, some of the Change Agents occupied senior management positions at the Ministry, and so the idea of a National Health Bill received favourable attention by the Top Management Committee, who approved the draft and presented it as an actionable memo at the National Council on Health where it was approved and adopted.
Expectations were high that the Bill would be passed before the Christmas of 2005, but these were dashed by the delay in sending the Bill to the National Assembly by the Executive arm before the end of 2005. By 2006, the late Senator Yellowe-led Senate Committee on Health held the first Public Hearing on the bill. . During that same year 2006, the National Council of State and the National Economic Council approved the Bill considering that the provisions of the Bill were to be financed by 2% of the Consolidated Revenue of the Federal Account.
By 2007, the House of Representatives passed the Bill, but the Senate Health Committee cohort of 2004-2007 did not complete its work on the bill so there was no harmonized bill by the end of President Olusegun Obasanjo’s second tenure in May 2007. In 2008, the Bill was dusted all over again and the review process restarted. With Senator Iyabo Obasanjo as Chair, the Senate Committee on Health held the much-publicized and controversial workshop on the Bill in Ghana which was sponsored and facilitated by HERFON and Partnership for Transforming Health Systems (PATHS); both organizations funded by DfID (add link). The House of Reps also reviewed the bill in 2008 and by 2009, both the Senate and House of Reps passed the Bill. However the Legal Department of the National Assembly (NASS) referred it back to both chambers of NASS to rectify conflicts with existing legal regulations.
It was also alleged that the Federal Ministry of Health (FMOH) had controversially inserted into the House of Reps version, a provision through which the FMOH will get 5% stake of the Fund for ‘emergency preparedness’ and another 10% for human resource development. These clauses were later expunged. And by 2010 the Senate and House of Reps reviewed the Bill to reflect the suggested amendments by the Legal Department of NASS. But for no plausible reasons, the harmonized version was not passed in the first quarter of 2011.
By May 2011 anxieties heightened as the tenure of the 2007-2011 cohort of legislators was nearing the end, . Following a demonstration by the Market Women Association at the National Assembly on May 18th 2011, the Senate passed the Harmonized Bill in a matter of days. This gladdened the hearts of the numerous advocates of the Bill who looked forward to the assent by Mr. President within the stipulated 30 days following its official transmission.
That was when the real drama started with the dissenting voices of the opponents rising higher with some alleging that the Bill was designed to sustain the so-called “hegemony of doctors” over other health professionals. Some religious organizations like the Catholic Church and Jama’atu Nasril Islam (JNI) were opposed to certain provisions of the Bill, and the fiduciary aspects of the Bill also had implications for the yearly budgeting process which was of interest to the Federal Ministry of Finance. The cacophony of dissenting voices swayed the President to withhold assent to the Bill. And all the efforts went down the drain and we were back to ‘square one’ again!
By August 2011, the Health Sector Reform Coalition hosted a Stakeholders’ forum at the Sheraton Hotel in Abuja with health professional groups with the aim of understanding their objections to certain provisions of the Bill. Subsequent consultations were held in Obudu and Ibadan to address these issues and secure the commitment of critical stakeholders towards supporting the bill. With Senator Iyabo Obasanjo not re-elected, Senator Gyang Dalyop Dantong became the chair of the Senate Committee on Health, and resurrected the process with the 1st and 2nd reading of the bill at the Senate Plenary in 2012.
The tragic death of Senator Dantong in July 2012 due to the community crises in Jos dealt a major blow to the Bill. Senator Ifeanyi Okowa would later take over as chairman of the Senate Health Committee and helped to facilitate the public hearing of the Bill by the Senate in 2013, which culminated in the passage of the Bill by the Senate on February 19, 2014. With sustained advocacy and push by the core group of the Health Sector Reform Coalition, the House of Reps passed the Bill on July 8th before the annual recess and transmitted it to the Senate for concurrence.
The passage of the bill stirred up the ‘roforofo’ fights once again with vociferous individuals and organizations (including the Catholic Church) objecting to some provisions of the bill. Realizing that most opponents of the Bill had premised their arguments on the 2011 version of the bill, the HSRC held workshops in Lagos with top media representatives to help educate Nigerians on the provisions of the bill and to galvanize support using the media. The Senate Committee on Health also held consultations with the representatives of the Catholic Church to resolve seemingly outstanding gray areas of the bill. With most issues settled, , the need to fast-track the process became imperative and the HSRC continued its advocacy and lobby to key members of the NASS.
Following a meeting by the health committees of both chambers on the 16th September a harmonized version of the Conference Report,was produced with the House of Reps and the Senate eventually adopting the harmonized copy of the Bill by October. With all the legislative processes now completed, the Harmonized Bill was officially transmitted to the President for assent on October 28th 2014. Expectations are high that the Bill will finally be signed into law, considering that the President has previously committed to expanding the provision of universal health to Nigerians.
Essentially, the bill is set to provide a platform for efficient coordination of the Health System and the delivery of a Minimum Package of Essential Health Services; It also makes provision for social inclusion, addresses the issue of equity in Health and seeks to protect families from catastrophic health expenditure and impoverishment due to high cost of healthcare, accelerating Nigeria’s progress towards Universal Health Care. Some health economics experts project that implementation of the provisions of the bill can help save 3,131,510 lives of mothers, newborns and under 5s by 2022; thus helping to reverse the poor health indices in Nigeria as well as providing a better legal basis to address conflicts among health professionals in Nigeria.
As we look back from 2014 to the beginnings in 2004, we are confronted by the political realities that make Nigeria unique, and are appalled at how much resources and opportunities have been wasted to reform and strengthen our health system and improve the really poor health outcomes for which Nigeria has been known globally. We hope the Bill will indeed be signed into law this time and more importantly, help change the way healthcare is provided and managed in Nigeria!
One day we will count how many lives could have been saved in those 10 years.
Health Sector Reform Foundation of Nigeria is made of the following core group members, HERFON, PATHS2, Save the Children International, and Evidence for Action. Others include the Federation of Women Lawyers (FIDA), Federation of Muslim Women Association of Nigeria (FOMWAN), Advocacy Nigeria, Nigerian Urban Reproductive Health Initiative (NURHI), Civil Society for HIV&AIDS in Nigeria (CISHAN), National Association of Women Journalists (NAWOJ), White Ribbon Alliance, Nigeria, Wellbeing Foundation, Medical Women Association of Nigeria (MWAN), National Council of Women Societies, Medicial and Dental Council of Nigeria (MDCN), Nigerian Medical Association (NMA), Allied Health Professional Associations, Market Women Association, UNICEF etc.