Nigeria on the Move towards Universal Health Coverage

Nigeria on the Move towards Universal Health Coverage

{Photo credit: MSH staff}Photo credit: MSH staff

Cross-posted with permission from UHC Forward.

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 story touched me deeply. Kunle’s case typifies the plight of many poor people in Nigeria 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 has 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 expenditures. 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 percent of the population is covered by health insurance---instead of the WHO recommended minimum of 90 percent. Out-of-pocket spending is more than 60 percent of total health expenditures, instead of 30 to 40 percent recommended by the WHO. Total health expenditure is 0.7 percent of the 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 percent 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 the reason that in 2005 former President Olusegun Obasanjo directed 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 percent of Nigerians have health insurance.

What is limiting progress towards UHC in Nigeria?

Leading Nigerian health economist, Professor Obinna Onwujekwe, argues that absence 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, 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.

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 Awosusi is a communications consultant for MSH Nigeria.


V. Tata
The concept of insurance is yet to be well understood by the laity in most African countries and many other developing countries. The concept has a murky understanding in city arenas, but is yet to be implemented fully or to a level that would spur non city dwellers to emulate. In most developing countries, car insurance is obligatory and as such most people purchase the very basic options that would keep police and other road safety officers off their back. To many, it is perceived to be yet another tax for owning a vehicle. The fact that it takes a long time, sometimes involving lawyers to get a claim from a major injury in a vehicle is deterrent enough for most people to shy away from purchasing health insurance. Having a sick person in the hospital and rather taking more time to run behind insurers to get a claim processed is agonizing to many. In rural areas, most people are so poor that asking them to chip in some money in an insurance fund with the hopes of getting help when they become ill is incomprehensible to many. Many worry about keeping all they can afford to make ends meet. Most people in rural areas of the developing world live in an agrarian economy of some sort. For healthcare finance to work in such areas, it needs to be fashioned like cooperative organizations where families/individuals would pool their produce for better bargaining power. When the produce is sold (with a better profit margin), it is easier for some of the profits to be routed to a group insurance fund that could later support the individuals/families in times of healthcare needs. For universal healthcare to succeed in developing nations, it is imperative to have massive education programs geared towards preventing ailments/epidemics. Once people understand and change their habits for the better, community health workers can then lead the way by implementing grassroots healthcare programs and communicating in local languages. UHC may sound foreign and abstract to rural dwellers, but could be modified and implemented in various settings using local tools and thrifty principles that already abound in such areas.
Abiodun Awosusi
Dear Tata, Many thanks for your thoughtful comments and suggestions on how universal coverage can be achieved in low- and middle-income countries. The knowledge of health insurance among people in Africa is generally low. There is need to popularize it—as you rightly pointed out—in a language people can understand. It is particularly important when we see that Africa has a double disease burden and widespread poverty. People need to know how risk pooling through health insurance can reduce out of pocket expenses that drive many to deeper levels of poverty. This is what Health for All campaign coordinated by Management Sciences for Health aims to achieve. It has started in Ethiopia and will soon be launched in Kenya and Nigeria. A country cannot achieve UHC without targeted schemes for the poor and vulnerable. Mutual health associations, a semblance of the cooperative you suggested, are also being formed in Nigeria to improve access to care through the community-based health insurance introduced by the government. Although the effectiveness of this initiative is yet to be reported in Nigeria, its success in Rwanda is well documented. I really appreciate your suggestion on role of community health workers in achieving UHC. Physical and financial barriers to healthcare limit universal coverage. While risk pooling through health insurance reduces the financial barrier, deployment of community health workers in Ethiopia, Rwanda, India and Bangladesh has significantly improved access to care especially for the poor and vulnerable in hard-to-reach areas. They need to be properly trained and supervised and well remunerated to ensure they deliver quality health services and remain committed to the program. We all need to embrace UHC, and explain its value to friends and colleagues. As the World Bank President Jim Yong Kim asserts, “we must be the generation that delivers universal health coverage.”
Foluso Ishola
In Nigeria ,where the private sector plays a significant role in health care provision, it is not surprising that about 69% of health financing is covered by out of pocket payments. This, of course, results in limited access to basic health care services for the poor . Reducing the reliance on out-of-pocket payments will undoubtedly lower the financial barriers to access and reduce the impoverishing impact of health payments. The government needs to give a higher priority to health in their budgets as domestic financial support is crucial for sustaining universal coverage in the long term. Sharing costs across the population could be a relevant way to provide and sustain UHC, however our taxation and insurance culture is very weak. The importance of UHC is yet to be fully registered in a lot of African countries where most people have no financial plans for health emergencies.
Charles Llewellyn
Another factor in Nigeria is the Federal System where primary health care is controlled and provided by the States. What program works in one state, may not work in a neighboring state. Nigeria is making progress, but painfully slow. The Nigeria Demographic and Health Survey (NDHS) 2013 Preliminary Report show health indicators, nationally, but especially in some of the northern states, to be some of the worst in Africa. (Immunization: all basic vaccinations in children aged 12 - 24 months 25.4% national, ranging from 1.4% in Sokoto to 62.4% in Imo state. But this depressing indicator is up from a national level of 13% nationally in 2003 NDHS and 23% in 2008 NDHS. Under-five mortality nationally is reported at 128 deaths per 1,000 live births (very high, but down from 201 in 2003 and 157 in 2008.) Modern methods contraceptive prevalence is at 10% nationally, unchanged from 2008. UHC has a long way to go in Nigeria!

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