Implementing universal health coverage in Nigeria

Isaac Eranga, CNS Correspondent, Nigeria
Universal health coverage (UHC) means that every person, everywhere, has access to quality health care without suffering financial hardships. Unfortunately, each year 1 billion people cannot afford a doctor, cannot pay for medicines and/or cannot access other essential healthcare services without risking impoverishment.

In Nigeria, accessing healthcare service still remains a very big problem for many, particularly those living in the rural areas.  As the World Health Organization (WHO) sees it, countries need networks of primary-care providers close to the grassroots, backed up by specialized institutions to provide advanced care; a comprehensive package of benefits that ensure people’s needs are met; standards to ensure access to high-quality care; and mechanisms to ensure that health providers are accountable and consumers have a voice in their care.

Some specific issues include:

Efficiency- Are there bottlenecks in the network of health-care institutions, and if so where do they occur? Is there a network of grass-roots health-care facilities that can provide basic or primary care, so that a small number of regional referral hospitals can take the more complex cases that require specialized care? The answer unfortunately is No. This is a classic example of system failure.

Quality- What standards exist to ensure quality of care in various institutions? Are standards enforced, and if not, why? In many cases, health workers have to deal with overwhelming workloads; and focus on health workers’ bad behaviour without explaining their great stress is like missing an important part of the story.

Patients’ rights- If people seeking treatment are not satisfied with their care, what recourse do they have?

Sub-Saharan Africa has just 1.3% of the world’s healthcare workers, but accounts for 25% of the global disease burden. Africa has 2.3 health workers per 1,000 people – about one-tenth the figure in the Americas. Some 57 countries face critical shortages of health-care workers – an estimated shortage of 2.4 million doctors, nurses and midwives.

Recently, the USAID, through its SHOPS project, conducted a survey of six Nigerian states, assessing the private health sector’s capacity, geographic distribution, and services offered. Key findings of the survey revealed that:

•The ratio of private health facilities to total population is substantially higher in Lagos than in other states.
• Existing lists of private health facilities maintained by government agencies are incomplete and inaccurate.
• Private facilities have excess capacity to deliver family planning services.
• Prescribing practices of private facilities related to malaria and pediatric diarrhea need improvement.
• Facilities that do not offer family planning cited lack of demand and inadequate skills, but not lack of finance, as key barriers to offering family planning.
• Private sector is a major provider of family planning and other health services in Nigeria with 60% of all family planning visits being to a private sector provider.

Policy Implications

Findings of this survey reveal several ways in which the private sector may be better used to increase access to family planning specifically, and to increase the quality of overall health care. Firstly, accurate lists of private health facilities are essential for governments to understand the capacity of the private doctors and design appropriate strategies for working with them. The current census may provide a one-time boost to maintain the accuracy of these lists but the government needs to devise ways to keep them accurate in the future too. The most logical method would be to use the lists of private facilities that currently have operating licenses. Ideally, the government could provide some benefits to those who relicense their facilities annually (like giving them access to free government commodities) and some threats for those who do not (like threat of closure).

Secondly, a large number of private facilities offer several methods for family planning services. Yet, family planning clients make up only a small proportion of their overall patient numbers. The findings suggest that private facilities have unused capacity to deliver family planning services and that targeted demand creation efforts could increase use of family planning services.

Thirdly, many private facilities state that they plan to offer additional family planning methods, like implants, in the future. Clinical training on implant insertion and removal may help speed the rate at which private facilities offer this service to their patients.

Lastly, many private facilities do not follow recommended guidelines for treating malaria and pediatric diarrhea. Greater effort should be made to educate providers on correct prescribing practices for these common diseases through interventions such as training and mass media campaigns. Data should be collected on an ongoing basis to monitor progress against these diseases.

Health is a human right and a cornerstone of sustainable development and global security. The way that health care is financed and delivered must change, so that it becomes more equitable and effective. Because no one should go bankrupt when they get sick.

•  Lack of affordable, quality health care traps families and nations in poverty.
•  1 billion people lack basic health care, and 100 million fall into poverty every year trying to access needed services.
•  ~1/3 of all households in Africa and Southeast Asia borrow money or sell assets to pay for health care.

The poorest and most marginalized populations bear the brunt of preventable maternal deaths and diseases like HIV/AIDS, TB and non-communicable diseases (like cancer and heart disease). The Ebola crisis clearly demonstrates the urgent need to strengthen health systems everywhere.

WHO affirms that the enjoyment of the highest attainable standard of health is a fundamental human right, and not a privilege and can transform communities, economies and nations. Access to quality health care should not depend on the race, gender, age, geographical location and/or financial status of a person. Every $1 invested in health can produce $9-$20 in full-income growth by 2035. UHC policies create resilient health systems with two major benefits: in times of distress they mitigate shocks to people’s lives and livelihoods and in times of calm they improve a community’s social cohesion and economic productivity.

Realizing the benefits of universal health coverage (by way of healthier communities and stronger economies), more than 80 countries, including 30 of the world’s poorest, have taken steps towards implementing it. There is no “one-size-fits-all” approach to universal health coverage. Countries will have to design their own unique pathways toward health for all and exchange lessons learned on the ground.

Isaac Eranga, Citizen News Service - CNS
2 January 2015