15 February 2014

NIGERIA accounts for a disproportionate share of global burden of disease; while Nigerians represent just 2 percent of the world population the country accounts for 13 percent of the under-five mortality globally according to the UN Inter-agency Group for Child Mortality Estimation ( 2013). In the same vein, Nigeria is ranked among 10 worst countries in terms of wellbeing of mothers by Save the Children 2013 State of the World’s Mothers publication. The abysmal health outcome statistics mirror poor coverage of essential health services and socioeconomic inequity in accessing basic care in the country. Available statistics show that women from high-income group in the country are ten times more likely to access skilled delivery service than women in the lowest income group while children from the lowest income group are three times more likely to die before their fifth birthday than children from highest income group. The aforementioned scenario reflects the dysfunctional state of the health system governance and financing in the country.

The suboptimal state of our health system also raises an important issue of inadequate government commitment to improving health care delivery in the country. Inadequate funding of health at the federal and state levels and lack of commitment to the principle of Universal Health Coverage ( UHC) at all levels is a clear demonstration of the commitment and responsiveness gap on the part of the government. Universal Health Coverage, whose goal is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them, is earnestly craving for attention in Nigeria.

In order to advance the cause of UHC in Nigeria, it’s imperative to articulate sound argument that will appeal to the diverse stakeholders that have important roles to play in health sector reform. The array of stakeholders and decision makers include but not limited to the politicians, civil society organizations, health policymakers and the economic policy chiefs. Therefore, a multidimensional justification for UHC including a social case, political case, economical case, and epidemiological case for UHC is presented here.

From social protection point of view, citizens have constitutional and moral right to be protected from any form of adversity by the government including adversity of disease and its inherent financial burden. Moreover, the concept of social contract between the government and the governed implies that government has obligation to develop the society and protect the citizen against any adverse condition including physical and financial misfortune from ill-health.

It is also important to advance an economic case for UHC as spending on health is erroneously seen as a mere expenditure instead of a virile investment. Investment on health contributes to economic development through poverty alleviation, economic growth and employment creation. Globally, more than 100 million people are pushed below poverty line as a result of high Out of Pocket health expenditure annually. Ill health also contributes to poverty by reducing productivity of citizens. Universal access to healthcare translates into improved productivity which in turn results in improved economic growth. Moreover, reduced Out Of Pocket expenditure means citizens have more disposable income which could boost consumer spending with a positive impact on the GDP. Poverty reduction effect of UHC increases the pool of taxable population thereby leading to increased revenue for the government. The health sector is a large employer of labor. Therefore, expansion of the sector to improve access of the populace to health services will invariably provide a significant magnitude of employment opportunity for the citizens.

The last dimension of justification for UHC is the epidemiological case for UHC. The aforementioned burden of disease and social and economic inequity in accessing desired health care services is an important justification for advancing the cause of UHC in the country. Moreover, epidemiological transition implies that there is an increase in prevalence of Non- Communicable Disease ( NCD) and the associated complications which are more expensive to manage with increased potential to throw many people into poverty. Therefore, epidemiological justification is another important consideration for UHC buy-in.

UHC is not achievable without reform in the health financing system. To reform the health financing system, three important functions of this building block of the health system require urgent attention. In practical terms, risk pooling is about how the healthy will share the financial burden of disease with the sick, how the rich will share the financial burden of the disease with the poor and lastly how the productive population will share the financial burden of disease of the less productive population e. g. the elderly, children and the unemployed.

Various health financing mechanisms exist for achieving improvement in the aforementioned three functions of health financing. Among various health financing mechanisms, use of general government revenue and various insurance schemes are the most important mechanisms for achieving wider health access with equity. Though various community financing mechanisms have shown potentials at pilot stages in the country, there is no robust body of evidence to reach a conclusion on this. External funding also plays an important role in the journey towards UHC, especially in terms of the much needed technical support required to design, implement and evaluate a UHC agenda or roadmap.

It is imperative to highlight various right steps that have been taken towards achieving UHC in Nigeria. The National Health Insurance Scheme is playing an important role of enrolling Nigerians for one health insurance scheme or the other, though the coverage is unacceptably low as only about 4% of Nigerians are enrolled to date.

Other steps in the right direction include the introduction of Free Maternal and Child Health ( FMCH) program by some states in the country like Kaduna, Jigawa, Enugu, Ondo and others. The aim of the FMCH program is to improve physical and financial access to maternal and child health services where this program is being implemented. The program has achieved varying degrees of success depending on the level of political commitment of the state governments. Another laudable step in the right direction is the proposed presidential summit on UHC which is a platform for evaluating progress and charting a course of action on UHC in Nigeria.

Dr. Gafar Alawode is the Program Director, DGI Consult, Abuja