How Out-of-pocket Medical Bills Render Sick Nigerians Poor

Is there a right to health in Nigeria? In other words, can an aggrieved party appear before a court in Nigeria, claiming that his right to health has been violated? Is there any legal basis for such a claim? The answer depends on whom one asks but for health and human rights scholars, the response to these questions is resoundingly affirmative and for very good reasons.
Aside from the domestication of the African Charter on Human and Peoples’ Rights by the National Assembly in 1983, the National Health Act (NHA) 2014, unequivocally affirms the right of all Nigerians to health.

But a large percentage of the Nigerian population remain astoundingly uncovered by the national and state health insurance schemes. “You have to make a deposit before we can treat the patient” is what many patients and their relatives are greeted with when they enter health-care facilities in Nigeria.

Hospitals – public or private, demand upfront payments. There is an over-reliance on out-of-pocket payments in Nigeria. About 70 per cent of Nigerians are living in poverty. Out-of-pocket payments can make households and individuals incur catastrophic health expenditure and this can exacerbate the level of poverty.

Studies published in the Lancet on Enugu and Anambra States showed that the incidence of catastrophic health expenditure among households (at a 40 per cent threshold of non-food expenditure) were 14·8 per cent and 27 per cent , respectively.

Such a source of health-care financing negatively affects people’s living standards and welfare. More than 90 per cent of the Nigerian population is uninsured in spite of the establishment of a National Health Insurance Scheme (NHIS), in 2006.

Just 5 per cent of Nigerians in the formal sector are covered by the NHIS. Only 3 per cent of people in the informal sector are covered by voluntary private health insurance.

Uninsured patients are at the mercy of a non-performing health system. Health indicators in Nigeria have not changed substantially due to the non-responsiveness of the health system to the needs and expectations of the population. Unfortunately, for many years, there has been no action taken by political actors and policy makers. Most people seem to have accepted life with this terrible situation since there is not much they can do to reverse it.
Today, the cost of medicine at community pharmacies has tripled. To treat malaria, one will need about N3000 and above. Last week, this writer bought a single packet of Amatem Forte Soft Gel for N2500 at a pharmacy in Gwarimpa. The pharmacist on duty recommended that I add a ciprofloxacin tablet costing another N1800 , plus a card of paracetamol to the dosage. But I wouldn’t afford all that on the spot.

All these negative indicators of the Nigerian healthcare system has inspired the Centre for Social Justice (CSJ) Nigeria with the support of the Strengthening Civic Advocacy and Local Engagement program of the United States Agency for International Development (USAID-SCALE) to execute a project titled “Improving the Realisation of the Right to Health in Nigeria”.

The project will be implemented in the Federal Capital Territory (FCT) and 6 focal states of Sokoto, Adamawa, Nasarawa, Imo, Ekiti and Rivers. The project’s goal is to contribute to improvements in the realization of the right to health in Nigeria through enhancing respect for extant laws and policies, reforming laws and policies as well as mainstreaming transparency and accountability in public health sector expenditure.

The programme will be implemented through four critical objectives for action vis: (a) Improve legal and governance frameworks of the health sector through legislative and implementation advocacy; (b) Enhance stakeholder participation to improve transparency and accountability in health budgeting; and (c) Increase awareness and sensitisation of rights and duties on the right to health and (d) Build the capacity of cluster members and critical civil society stakeholders to effectively intervene for the improvement of the right to health.

“Akin to any other human right, the right to health has close affinity to other human rights and is attainable only upon the realization of these other human rights, such as the rights to food, housing, work, education, human dignity, life, non-discrimination, equality. These are integral components of the right to health and must necessarily be protected by countries seriously committed to establishing the right to health in their respective jurisdictions,” said Dr Nnamuchi Obiajulu, an Associate Professor of Health Law at the University of Nigeria, Enugu Campus.

It is gratifying to note that the right of access to health has been recognized by the African Charter on Human and Peoples’ Rights, the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa (Maputo Protocol) and many other international human rights instruments that African states have ratified.

Chapter II of the 1999 Constitution, as did its predecessor, characterizes what ought to be the right to health care as one of the “Fundamental Objectives and Directive Principles of State Policy” (Directive Principles). And to further emasculate the right to health care, section 6(6) (c) of the Constitution precludes the courts’ jurisdiction with respect to matters enumerated in chapter II. In essence, codification as a Directive Principle means that the right to health care is not justiciable under the Constitution or, for that matter, any other law in Nigeria.

However, Nnamuchi said “legal formalisation is not a sine qua non [necessary condition] for the existence and enjoyment of human rights.” He said that projecting fundamental rights in isolation of complementary socio-economic rights leaves a gaping hole which seriously undermines the value and robustness of the former.
For him, to contend that an individual possesses the right to life in absence of ingredients necessary for its sustenance (such as health care) is, on many levels, vacuous. Enjoyment of the right to health is not only vital to all aspects of a person’s life and well-being, it is also crucial to actualization of all the other fundamental rights and freedoms.

Another study by Nnamuchi reveals that notwithstanding the provisions of section 6(6)(c), health care related interests may be justiciable if the National Assembly elects to exercise its legislative prerogative under the section 4 of the Constitution.

He suggested that item 60(a) means that the National Assembly may, by legislative sanction, arrogate justiciability status to the Directive Principles in chapter II of the Constitution. The effect of such a measure will be to nullify section 6 (6) (c), “thus allowing state organs to “conform to, observe and apply the provisions” thereof of the Directive Principles as stipulated in section.

The Nigerian situation obviously has been statutorily resolved through the enactment of the National Health Act 2014 (NHA). The Act contains various key provisions that will, if appropriately implemented, help provide universal health coverage. The provisions are aimed at increasing health coverage, affordability, and accessibility.

On this, Nnamuchi said that the right to health in Nigeria could be secured under the framework of the NHA as “the Act unequivocally affirms the right of all Nigerians to health.”

The NHA has now provided an enforcement mechanism for the enforcement of the right to health specified under the Act. The effect of this is that “citizens no longer need to go through the rigorous process of enforcing the right to health care in Nigeria under the African Charter or under the provisions of Chapter II of the Constitution.

The National Health Act represents a laudable effort on the part of the Government to use legislative measures to attain the goals specified by international obligations to health.

Aside from proclaiming, as one of the objectives of the national health system, to “protect, promote, and fulfil the rights of the people of Nigeria to have access to health care services,” the NHA specifically identifies means of reaching this goal, including the creation of a legal framework that will regulate the provision of health services in the country, whether by the Government or private providers, promotion of a spirit of cooperation and shared responsibility amongst all providers of health services in the country and any part thereof; ensuring that people living in Nigeria enjoy the best possible health services within the limits of available resources; setting out the rights and obligations of health care providers, health workers, health establishments and users.

Regarding the obligation to refrain from prohibiting or impeding traditional medicines, the response of the NHA is quite positive in that it specifically identifies traditional health care providers and alternative healthcare providers as integrated within the national health system. Even the composition of the Technical Committee on Health, which advises the National Council on Health, is inclusive of associations representing traditional medicine practitioners and alternative health care providers.

There are a myriad of reasons for Nigeria’s abysmal entries in health care indicators. As one way forward, there is a need to estimate the number of deaths associated with the non-responsiveness of the Nigerian health system.

Out-of-pocket payments for health-care services are a very big challenge in Nigeria. Governments and decision makers need to come up with policies to address this problem. NHIS needs to be expanded to cover people in both the formal and informal sectors. Private health insurance has to be made mandatory while the community-based health insurance scheme needs to be scaled up across the country. Out-of-pocket payments affect the ability of households and individuals to meet basic needs and push many below the poverty line.

International organisations concerned about poverty and universal-health coverage in low-income and middle-income countries, including Nigeria, need to assist in generating adequate resources for the improvement and strengthening of health systems performance.

The importance of the right to health underscores the need for the government and partners to engender a workable healthcare framework for its citizens.