5.1. Challenges of HRH militating against the attainment of UHC in Nigeria
Currently, the official record of Nigeria’s FMOH shows that the country’s formal sector (public and organized private sectors) constitutes approximately 12.8% of Nigeria’s 211.5 million population while non-vulnerable informal sector constitutes 36.6%. The vulnerable population accounts for the remaining 50.6% comprising informal pregnant women – 4%; children under 5–15.0%; the elderly (above 64 years) – 3.0%; and the indigents – 28.6%.[2] As leaders/policymakers, we admit that the requisite HRH is inadequate to deliver UHC to the growing population; resulting in weak performance and the resultant deficits in work values, attitudes and practices over the years.[10]
At the top management level of HRH in Nigeria, quality workforce is required for managing direct and indirect healthcare provisions (products and services). Nigeria is unfortunately faced with scarcity of senior management officers across different zones and states to cover the country’s landmass. Accordingly, the NHIS itself lacks top management level officers to massively advance SHIP across the 36 states of Nigeria. Currently, more than 40% of NHIS staff are in the top/senior management level, which makes the scheme ‘top heavy’. The consequence is scarcity of medium level managers to lend executive services for the coverage of the increasing population.
The Executive/Medium management level of HRH in Nigeria comprises medical practitioners closest to the population seeking healthcare services. These comprise physicians, nurses and midwives, pharmacists, community and social healthcare workers, among others. Currently, there is a dearth of HRH with the requisite qualifications and skills to cover the required ratio of patients to one healthcare personnel. This challenge is worsened by the constant emigration of Nigerian medical workers to other country in search of greener pastures due to poor remuneration and working conditions.[3] As a matter of fact, available reports in the Federal Ministry of Health (FMoH) reveals that Nigeria produces about 3000 medical doctors annually. Unpublished reports made available to the Director, Department of Planning, Research and Statistics, FMOH revealed that about 5000 Nigerian medical doctors left their positions across the country in August 2021 alone. The NHIS also suffers similar scarcity of HRH at all management levels; its headquarters, zones and states.
There is also a lack of consideration for specialisation in workforce recruitment and deployment within the NHIS.[11] Consequently, the scheme is hindered by scarcity and unbalanced distribution of specialists in Health Planning, Health Economics, Statistics/Data Analytics, Actuary/Insurance, ICT and Data Security, Research, Monitoring and Evaluation, etc.
Furthermore, the study observed cases of poor management practices in the NHIS. These include poor accountability, lack of transparency, poorly articulated job schedules, appropriation of responsibilities or absconding from duties at intervals, delays in approval of memos for activities, lack of staff training on civil service rules targeted at value reorientation, field activities driven by material gains, weak appraisal system or delay in the upgrade of staff, porous security systems and lack of appropriate identification check-in and checkout procedures for all staff and visitors. The major reasons for these challenges can be traced to weak loyalty to the organisation by staff and healthcare providers.
The impact of ethno-cultural and religious characteristics of Nigiera, having about 300 ethnic nationalities, is also immense. The need to reduce ethnic tension among Nigerians resulted in the policy drafting of ‘Federal Character’ and ‘quota system’ in 1979 for a fair representation of all ethnic groups in managing Nigeria’s affairs; healthcare provision inclusive. This political interference is extended to the training and employment of HRH, resulting in the recruitment of individuals who may neither be passionate about advancing healthcare accessibility to Nigerians nor owe commitment to healthcare administrators.
Nigeria’s ethnic nationalities are further divided along religious lines (Christians dominating the south, Muslims dominating the north, with African traditional religions across the country), which influence healthcare coverage through unchecked/unsupervised religious preaching and practices.[12, 13, 14] Consequently, a number of Nigerians belong to certain ethno-cultural or religious groups who detest certain or all medical services. It is therefore flawed that HRH lacks requisite professionals in language/public communication, and social psychologists, to advance massive sensitisation of Nigerians on the need to cue into discussions towards enhancing acceptability and accessibility to medical services.
furthermore, we admit that supervision in healthcare delivery to Nigerians is poor. Reasons are attributed to flaws in the recruitment process due to the political policies of federal character and quota system, as well as politically/ethnically/religiously induced/influenced appointments. Consequently, there is poor supervision of HRH in health administration, including the NHIS. Equally, allegations of witch-hunt are leveled against supervisors who supervise staff that do not share similar ethno-cultural, religious or political affiliations with them.
5.2. Policy considerations for mitigating the challenges of HRH towards achieving UHC in Nigeria
Various technical meetings of stakeholders in Nigeria’s health ministry have yielded several considerations for managing HRH in Nigeria. They are discussed below.
5.2.1. Conducting health workforce skills gap analysis
As policymakers, we acknowledge the urgency to strengthen the management of HRH for enhancing the NHIS and the overall healthcare system’s efficiency for the expansion of SHIP aimed at reducing OOPE and achieving UHC in Nigeria. In the NHIS, we acknowledge the absence of scale for assessing the skills mix and distribution of staff. The first step therefore requires the conduct of HR diagnostics of skills gap in the NHIS to help determine the specific skills and competencies required, which creates proper foundation for employing and distributing administrative and executive staff at all levels of the scheme/organisation. It will also engineer the decentralisation of NHIS headquarters, zonal and state offices to ensure rapid spread of SHIP to the nooks and crannies where Nigerians can be accessed.
5.2.2. Policy considerations towards strengthening healthcare administrative and executive positions
There is need to ensure that the best hands are promoted to healthcare administrative positions. Consequently, considerations are being made to develop a succession plan into administrative/top management positions to help make more staff available for deployment into executive/middle management positions for advancing SHIP into the hinterlands of Nigeria, which is one of the surest indications of progress towards achieving UHC. Importantly, also, there is need to halt the continuous mass emigration of Nigerian doctors, nurses and other health workers by increasing health budgetary allocations for enhancing better welfare and working conditions of healthcare workers.
5.2.3. Policy considerations towards employing the roles of language and communication experts
We observed that one of the greatest solutions for strengthening HRH is halting the ever-existing information/communication deficit between Provider-HMO-NHIS and Nigerians. Language and public communication experts are essential in health policy communication for developing and engineering effective public messages in various linguistic mediums and channels in order to massively enlighten the people about SHIP, and the roles of HRH at their disposal. Thus, proper linguistic engineering and orientation/re-orientation is needed to emancipate many Nigerians from their ethno-religious beliefs that dissuade them from accessing medical healthcare services.
These communication professionals are also charged with educating SHIP enrolees about their rights and benefit packages, to understand the processes of holding healthcare providers, HMOs and other stakeholders accountable. They are also to develop and plan consultations/sensitisation meetings, media campaigns, health consumers' forums, etc. for enrolees, develop procedure for healthcare providers to popularise patients’ bill of rights, grievances/redress policies, guidelines and procedure for enrolees to make and resolve complaints within 48 hours in order to keep HRH on their toes for an effective system.
5.2.4. Policy considerations towards promoting synergy of HRH across health organisations
To further enhance synergy among HRH, there is need to strengthen technical management forum that enhance synergy in the Provider-HMO-NHIS mechanism in Nigeria. We therefore consider the introduction of an annual Provider-HMO-NHIS meeting in each state of the federation to discuss and handle issues relating to compliance and maintenance of quality standards by HRH, who will also improve in delivering 30 days maximum payment of claims to healthcare providers, increase responsiveness to health consumer needs, strengthen the supervisory level of SHIP across health organisations, zones and states. Well-trained and honest supervisors and auditors devoid of political, ethno-cultural and religious sentiments and influences should be properly mobilised within the system to promote accountability among the HRH in SHIP and healthcare system generally.