UHC Forward: Towards Universal Health Coverage

Kunle’s story touched me deeply. I walked into a pediatric unit of a teaching hospital in Nigeria a few years ago to review a patient. On the first bed was a lifeless child. He was brought in dead, a few minutes earlier by his parents. His mother, Bisi, wept uncontrollably. While in tears, she recounted how difficult it was for them to borrow money to get to the hospital. Although, they got some money from a chief in the community, the two-year old baby died before they got to the hospital.

Kunle’s case typifies the plight of many poor people in the country and the rest of Sub-Saharan Africa. The financial burden of illness makes many families poorer. People are afraid to go to hospitals because they may not be able to afford the cost of the health services they need. They prefer to buy drugs over the counter or visit a local herbalist who will charge little or nothing to provide poor health service.

I believe Kunle had a right to be alive today but he is not. His case confirms the assertion of Dr. Paul Farmer, co-founder of Partners in Health, that “it seems to be poor means to be bereft of rights” in many parts of the world. This should not be so. Illness should not make families poorer. It is true as World Bank Economist Adam Wagstaff says that “the idea that people may fall into poverty by having to pay for something that will simply make them better offends our basic sense of fairness.”

Universal health coverage (UHC) is a useful approach to address this challenge. “UHC inherently promotes equity through the goal of health for all,” says Dr. Jonathan Quick, President of Management Sciences for Health “It’s most life-changing for those underserved by the status quo — those for whom the necessary services are unavailable or unaffordable.”

UHC guarantees access to preventive, curative, rehabilitative and palliative services the population needs. It reduces the financial burden of diseases by cutting out-of-pocket expenditure. The concept is supported by key stakeholders. The United Nations, World Bank and World Health Organization endorse it in strong terms. The conference of African Ministers of Health and Finance, and African civil society also see tremendous value in pursuing UHC.

In Nigeria, the journey towards universal coverage has also begun albeit at a slow pace. The level of universal financial coverage in the country is poor. Less than 7% of the population is covered by health insurance instead of at least 90% recommended by the WHO. Out-of-pocket spending is more than 60% of total health expenditure instead of 30-40% recommended by the WHO. Total health expenditure is 0.7% of Gross Domestic Product (GDP). Most of those covered by pre-payment mechanisms are in the formal sector. The informal sector where Bisi’s family belongs represents about 70% of the population; most of them are not protected by any viable pre-payment mechanism.

According to Simon Wright, Head of Child Survival, Save the Children UK, “Access to quality care based on need, not ability to pay, is a human right and the critical objective of the health system. And, it is the government’s responsibility to realize this right for all, starting with the most poor and vulnerable.” This is perhaps reason former President Olusegun Obasanjo directed in 2005 that universal coverage must be achieved in Nigeria by 2015. He facilitated the creation of the National Health Insurance Scheme to fulfill this mandate. It has been eight years since that declaration but less than 7% of Nigerians have health insurance.

What is limiting progress towards UHC in Nigeria? Leading Nigerian health economist, Professor Obinna Onwujekwe, argues that absence of lack of a health system backbone, lack of legal framework for equitable health financing, inadequate funding of health care at all levels, the three-tiered health system operated in Nigeria and inadequate human resources for primary health care are key culprits. Other factors are inadequate health information management system, poor inter-sectoral coordination and fragmentation of programs due to multiple partners.

Is it then possible to achieve UHC in Nigeria by 2015 in the face of these challenges? The answer is No. However, some efforts are being made to improve access to healthcare in the country. Primary healthcare is being strengthened. Workers within the federal civil service and the organized private sector are increasingly enrolled for health insurance. The National Health Insurance Scheme (NHIS) recently rolled out community-based health insurance (CBHI) in several communities to reach the poor and vulnerable. Lessons learnt from the success of CBHI in Rwanda and Ghana’s health insurance are adapted to local realities. There are also efforts to provide appropriate legal framework to fast-track the entire process.

In order to garner country-wide high-level political commitment for UHC, the Honorable Minister of Health, Prof. Chukwu Onyebuchi instituted a technical working group on July 10 for a proposed Presidential Summit on UHC. He says, “Achieving this goal goes beyond rhetoric and symbolic demonstrations but requires decisive action, especially providing adequate resources to finance healthcare for all.” A major outcome of the summit is a “cohesive, comprehensive, realistic and costed roadmap” to fast-track the achievement of UHC in the country.

It is impossible to achieve universal coverage in Nigeria by 2015 but there is need to intensify efforts to improve access to needed health services for all Nigerians including Bisi’s family. It is time to do more!

Dr. Abiodun is a health system consultant and universal health coverage advocate based in Nigeria. He writes a monthly blog for UHC Forward on Nigeria's movement toward universal health coverage. Dr. Abiodun currently works with Management Sciences for Health.