By Victor Okeke
Promoting and protecting health is essential to human welfare and sustained economic and social development. This was recognized more than 30 years ago by the Alma-Ata Declaration signatories, who noted that Health for All would contribute both to a better quality of life and also to global peace and security. Not surprisingly, people also rate health one of their highest priorities, in most countries behind only economic concerns, such as unemployment, low wages and a high cost of living. As a result, health frequently becomes a political issue as governments try to meet peoples’ expectations. There are many ways to promote and sustain health. Some lie outside the confines of the health sector. The “circumstances in which people grow, live, work, and age” strongly influence how people live and die. Education, housing, food and employment all impact on health. Redressing inequalities in these will reduce inequalities in health.
But timely access to health services – a mix of promotion, prevention, treatment and rehabilitation – is also critical. This cannot be achieved, except for a small minority of the population, without a well-functioning health financing system. It determines whether people can afford to use health services when they need them. It determines if the services exist. Recognizing this, Member States of the World Health Organization (WHO) committed in 2005 to develop their health financing systems so that all people have access to services and do not suffer financial hardship paying for them. This goal was defined as universal coverage, sometimes called universal health coverage.
In striving for this goal, governments face three fundamental questions: 1. How is such a health system to be financed? 2. How can they protect people from the financial consequences of ill-health and paying for health services? 3. How can they encourage the optimum use of available resources? Back in 2017, governments in many low- and middle-income countries including Nigeria were lagging behind in providing adequate health services to the population as committed in the SDG Target 3 and protecting the population from financial catastrophe and impoverishment due to out-of-pocket payment for health in the SDG Target 3. Translating these political commitments into reality is achievable though not straightforward. The inadequacy of PHC hampers access to services needed by all. The lack of pooled prepayment systems limits financial access to the services by the citizens. Most of the low-income countries rely on donor resources which focus on specific diseases rather than strengthening health systems. This is a result of the lack of fiscal space as measured by government revenue or tax as per cent of Gross Domestic Product (GDP), as well as inadequate fiscal space for health as measured by public expenditure on health as percent of total public expenditure. All of these challenges are rooted from lack of political and financial commitment by the governments.
The N1.58 trillion allocated to the health sector in 2023 is eight per cent of Nigeria’s total budget of N20.51 trillion, compared to 5.35 per cent for 2022. It means that Nigeria has again failed to meet the commitment made by African leaders under the 2001 Abuja Declaration to allocate at least 15 per cent of its annual spending to the sector. Not only is more money for health needed, but governments also need to gain more health for money through effective strategic purchasing. Greater efficiency can be achieved by applying health technology assessment to prioritize cost-effective interventions; using generic medicines; investing effectively in health promotion and disease prevention; energizing PHC with proper referral mechanisms to hospitals; and minimizing waste in hospitals from inappropriate admissions and lengths of stay, overuse of equipment, investigations and procedures, waste, corruption and fraud.
There is also the issue of inadequate health system capacity. An adequate number of committed and competent health workers, particularly in frontline service, are essential in ensuring well-functioning PHC. Government policy needs to scale up health worker training and ensure effective health worker retention in places where they are needed most. A political window of opportunity opens every general election; reformists and civil society organizations should seize this opportunity to encourage political parties to bring UHC into their political manifestos. This advocacy holds governments accountable to their political promises post-election. The Presidential candidate of the All Progressive Congress (APC), Senator Bola Tinubu, the Peoples Democratic Party with former Vice President Atiku Abubakar and the Labour Party with Peter Obi have all made commitments to UCH by increasing the number of persons enrolled under the health insurance scheme.
Success requires citizen ownership of UHC, ensuring fiscal sustainability and protecting it from political interference. Once citizens realize the benefits of UHC, they will protect UHC from political uncertainty and changes of government.Nigerians should approach UHC as the citizens’ rights and entitlement to health, through full subsidies for the poor and vulnerable. Again, a strong policy commitment can overcome the sources of inefficiency in health care coverage. For example, improve medical emergency services, quick medical laboratory services and even the use of telemedicine facilities. These will help healthcare providers to reduce prices, save time, and adapt to customer requirements more effectively.
The country can ensure quality of medicines through post-marketing surveillance to detect substandard and falsified medical products, and through legal actions, if necessary. Use of substandard and falsified antimicrobial drugs can cause antimicrobial resistance and increase mortality and health care costs. Separating the two functions of prescribing and dispensing can prevent potential financial conflicts of interest. The government needs to regulate pharmaceutical market promotional activities which influence physicians’ prescribing behaviours and increase costs for patients or insurance funds. Evidence shows that clinical audits of health care providers can result in better planning for an optimum hospital capacity, can take advantage of economies of scale and prevent low use of certain infrastructure. There is also a need for adequate and timely release of funds to the health sector to achieve the set goal of the NDP as related to health care. There is a need to revisit the investment plan proposed for the sector in the NDP as it is counterproductive to the health budget estimates.
There is also a need to ensure the timely publication of the health budget implementation report for accountability.
Therefore, enacting UHC legislation or making a political statement at global forums is not enough to bring about access to health services without financial hardship for all citizens. Deliberative efforts to overcome bottlenecks are required in the path towards UHC.
A few factors contribute to the effective implementation of UHC. Extensive geographical coverage of PHC facilitates access to and use of needed health services by all. Prepayment schemes facilitate access to services without financial hardship. Strategic cost containment, efficiency and equity. There is much to learn from various UHC pathfinder countries Algeria and Botswana, including both their positive and negative lessons.
Therefore, whoever emerges winner of the 2023 presidential election should implement the NHIA Act that makes health insurance mandatory for all residents in Nigeria. The imposition of an insurance levy on all residents of Nigeria will generate the required funds necessary to fund the health sector. The next president should also commit to allocating 15 per cent of the entire annual budget to health, in line with the Abuja Declaration of African leaders.
Okeke writes from the Centre for Social Justice (CSJ) Nigeria.