The general elections in Nigeria are long behind us, following postponements, pronouncements and postulation from the different political parties. Now, Nigerians are waiting with bated breath to hear who will be appointed/ re-appointed to the top jobs at the federal ministries. Health being one of them, following the end of Honourable Professor Isaac Adewole’s tenure. Besides the new appointments at the various ministries, two key health parastatals, National Health Insurance Scheme (NHIS) and National Agency for the Control of AIDS (NACA) now have new leaders. The revolving door of leadership at NHIS has finally stopped at the feet of Professor Mohammed Nasir Sambo, our new NHIS Executive Secretary and Dr. Gambo Aliyu, our new Director General at NACA.
Who will now steer the NHIS forward?
Professor Mohammed Nasir Sambo, the new Executive Secretary of NHIS is not new to the NHIS having spent many years of his early career years working there. He started off as the Principal Manager, rising to the position of Assistant General Manager in the NHIS, and was the first Zonal Coordinator in the NHIS South West zonal office based in Lagos. He was seconded to the National Primary Healthcare Development Agency (NPHCDA) where he was the Assistant Director and Zonal Coordinator for the North West in 2000, based in Kaduna. He was then recalled to NHIS to set up the community health insurance programme. He left the NHIS in 2004 for academia, starting from the Department of Community Medicine at the Ahmadu Bello Teaching Hospital in Zaria, where he rose to the rank of Professor and Head of Department. He was then called to be the Provost of the new Kaduna State University where he served until his recent appointment.
Professor Mohammed Nasir Sambo has also played many other supportive roles over the past 20 years in the Nigerian health sector. He was part of the first set of supervisors of the Nigeria Field Epidemiology Training Programme (NFELTP) and has remained on the Scientific Advisory Committee since then. His primary interests are in health financing, as a subset of Health Policy and Management. He has also played an advisory role to the Federal Ministry of Health, where he worked as a consultant on health financing and health sector policies. In 2017, he was the guest speaker at the annual National Council on Health meeting which focused on collaboration in the health sector — a theme that he will have to bring to reality in his new role.
A mixed history of leaders at the helm of the NHIS
Since its launch in 2005, NHIS has had quite a number of executive secretaries. Long before his appointment as the National Commissioner for the Independent National Electoral Commission (INEC) in 2015, Dr Muhammed Mustafa Lecky, led the NHIS. He was suspended by then President Olusegun Obasanjo in July 2006. Dr Lecky was succeeded by Mr Dogo-Muhammad in March 2007, who then served the agency for five years. The first Community-Based Social Health Insurance Programme under the NHIS was said to have been launched in 2011 under Mr. Dogo’s tenure. Between March 2012 and November 2013, Dr Abdulrahman Sambo was the NHIS’ Acting Executive Secretary, handing over to Dr Femi Thomas. Dr Thomas was relieved of his appointment by then President Goodluck Jonathan in April 2015, leaving Mr. Olufemi Akingbade as the Acting Head. Dr. Thomas, however, challenged his sack by suing the Attorney-General of the Federation and the NHIS. The appointment of Professor Usman Yusuf in 2016 was said to have been a breath of fresh air as many believed he would clean out the existent corruption in the health insurance sector and fulfill the mandate of the agency. During his talk at the 2017 Nigeria Health Watch Forum, he said “There is a new sheriff in town…It is not going to be business as usual”.
Of all the executive secretaries that have served the agency, one thing seems to be common, many have alleged cases of corruption and fraud. Could the issue of high turnover of executive secretaries be a major factor in the failures the agency has experienced since its 14 years of existence? The dismissal of Professor Usman Yusuf has now paved the way for the appointment of Professor Sambo.
What now for the NHIS?
We have written on several occasions about the complex organisation that is the NHIS — the battles between the previous Executive Secretary, Professor Usman Yusuf, sections of the staff of the agency, Health Maintenance Organisations (HMOs), the Minister of Health and finally with the Board of the agency. A critical National Health Insurance Bill that would have repealed and replaced the National Health Insurance Scheme passed third reading at the Senate in April 2019, however by midnight on the 29th May 2019, President Muhammadu Buhari had not assented to the bill. One of the key amendments in the bill would have made health insurance compulsory in Nigeria. As a result of this setback, the process will have to re-started by the 9th National Assembly with the new Senate Committee on Health.
Nigerians have argued for a long time that the dual functions of the NHIS, managing funds and regulating the health insurance sector should either be separated or at the very least sequestered in two parts of the organisation that are managed independently, without any undue influence on either side. Resolving this issue will be critical to the success of Professor Sambo’s tenure in his new role. However, the rapid growth of State Health Insurance Schemes has been one of the bright lights in the sector, inspired by the introduction of the Basic Health Care Provision Fund (BHCPF), successfully implemented under the leadership of the Chairman, Senate Committee on Health and former Minister of Health.
Not enough Nigerians have access to healthcare
Professor Sambo certainly has his work cut out for him, a review of some of his previous publications and lectures provides some insight into his thoughts on health financing. At a public lecture at the Bayero University Kano in 2017, he called an innovative approach termed “a basket collection”- a financial contribution from philanthropists, individual savings accounts, where every salary earner contributes 4 percent of his/her salary to a healthcare fund.
At present, less than 1% of Nigerians are covered under the NHIS, even this figure is still an estimate and the true number is still unknown. This could be one of the key tasks that Prof. Sambo takes on when he starts his tenure as was done when the HIV prevalence rate was redefined. Now is the time to bring life back into one of the most challenged parastatals in the Nigerian health sector, but also one of the biggest opportunities to transform the health insurance market.
“The most important reform for the health insurance industry is TRANSPARENCY, supported by the adoption of technology for identification and validation of access to healthcare for patients. Standards for pricing and quality of care must be urgently defined for sustainability in the sector, so all parties — patients, providers and payers — are clear what to expect from health insurance” — Obinnia Abajue, Chief Executive Officer, Hygeia HMO Limited.
Charting a future path for Nigeria’s HIV/AIDS response
As if to pre-test the leadership and scientific skills that would be required for his new appointment as the Director General of NACA, Dr Gambo Aliyu successfully led the implementation team of the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), the largest population-based single country HIV prevalence survey in the world, delivered in Nigeria in February 2019.
Dr Gambo Aliyu is a graduate of the Ahmadu Bello University, Zaria where he obtained his MBBS in 1995 and finally a Postdoctoral in Pharmaco-Epidemiology from the University of Manitoba, Winnipeg, Canada in 2015. He returned to Nigeria in 2017, working as a Research Associate at the Institute of Human Virology (IHV) at the University of Maryland School of Medicine (UMSOM), the institution selected to lead the $100 million NAIIS to measure the reach and impact of HIV programs in Nigeria. The landmark study, completed in a record 9 months showed that the HIV prevalence is 1.5% among people aged 15–64 years old. The result of the survey has also redefined the HIV epidemic in Nigeria and will shape its response into the future. Dr Gambo Aliyu will have to forge new alliances, try new approaches and strengthen strategies to reduce the burden of HIV in Nigeria, among our growing population.
In addition to his recent engagement as part of the NAIIS team, Dr Gambo Aliyu has a long history of engagement with HIV prevention in Nigeria, conducting research on critical issues that confront the HIV epidemic, from counselling and testing of hard to reach populations, through vaccine trial preparedness to the impact of acutely infected patients on transmission. This level of depth of understanding of the complexity of the HIV epidemic in Nigeria, puts Dr Gambo Aliyu in a strong position to carry on with the great work started by Dr Sani Aliyu, the previous Director General of NACA.
A history of great leaders
NACA has had a series of leaders who have taken the agency through various phases of the evolution of the HIV epidemic in Nigeria.Prof Ibironke Akinsete,was the pioneer Chairperson of the predecessor committee to the current NACA — the National Action Committee on AIDS (NACA), a multi-sectoral committee set up by President Obasanjo as the first serious act of political leadership to confront the HIV epidemic in Nigeria. Professor Babatunde Osotimehin took over the leadership of NACA in 2002 and led it through its transformation into an agency in March 2007. He went on to serve as Minister of Health, and Executive Director of the United Nations Population Fund (UNFPA), before sadly passing away on June 4, 2017. In March 2009, Professor John Idoko was appointed as the Director General of NACA and was reappointed for a second term in 2013 by President Goodluck Jonathan. He led NACA until the appointment of Dr Sani Aliyu in July 2016. Dr Aliyu led the agency until his resignation recently to pursue other professional interests and is widely credited for his successful delivery on his objectives as the Director General of NACA. Dr Gambo Aliyu is definitely following a path of health sector leaders that have shaped Nigeria’s response to one of the largest public health challenges of our time.
“Dr Gambo Aliyu is an excellent choice to continue the work that Nigeria has started with the NAIIS survey. He is best placed to use the findings to guide the HIV/AIDS response in Nigeria”- Former DG of NACA, Dr. Sani Aliyu
The beginning of HIV treatment in Nigeria
Since the first AIDS cases were diagnosed in 1985, this led to a flury of activity in Nigeria. The first decade of the HIV response was marked by initial hopefulness for a vaccine that never came. This was followed by despair due to the non-availability and high cost of treatment for millions of patients in African countries. The denial of HIV by governments in African countries had exacerbated access to treatment at the time. The turning point was the XIII International AIDS Conference, held in Durban in 2000, helped by a strong turnout of activists who drove home the issue of the glaring inequality in access to HIV treatment.Following the global push for more access to lifesaving antiretroviral therapy (ART), Nigeria was one of the first countries to order ARTs for 10,000 adults and 5,000 children in 2001.
A complex epidemic
Nigeria continues to face unique challenges that amplify the risks of HIV. We have a large and rapidly growing population, while at the same time facing serious challenges in financing our current healthcare needs. This means that despite the lower HIV prevalence figures, the absolute number of those infected and who require treatment is still very high. Our large young population and challenging socio-economic indicators mean that things can get worse very quickly. The NAIIS results also showed that the epidemic is very diverse and complex, with some parts of the country affected more than others and so impacting the requirements of the differentiated response rates.
Why are all these issues important? Leadership of the NHIS and NACA will not only require health financing and scientific leadership, but will also require a clear understanding of the political economy of global health, as well as advocacy at the grassroots to drive change. However, one of the most important attributes that will be needed by both leaders as they take up their new positions, at the helm of the NHIS and NACA will be compassion for the people they have been called to serve — we the Nigerian people. They will also need a resilient “can-do” attitude that is anchored on a spirit of collaboration with all stakeholders in the health sector.
The team at Nigeria Health Watch wish them well and we look forward to seeing them deliver on their mandates for the Nigerian health sector.