HEALTHSCAPE: Universal Health Coverage – the right thing, the smart thing

Dr. Muhammad Shakir Balogun

One cold evening in 2005 I was with my cousin in Grays, a quiet town in Essex County some 35 km east of London. Glued to the computer screen as I was wont to for several hours every day, I was utterly oblivious to my surroundings until I began to hear a barely audible, almost musical sound, emanating from someone’s chest. I turned around – my cousin’s first son who had come visiting from London was having an asthmatic attack, having left his inhaler behind at Peckham. The wheezes quickly got louder and his breathing more difficult so his dad dialed 999. Within a few minutes, as if by magic, the medical emergency guys were in our flat on the 6th floor to attend to him.

After stabilizing him they took him in the ambulance to Thurrock Hospital where they carried out a battery of investigations to further evaluate him. I went along and spent the night at the hospital as he was being observed. The next day, my cousin who had spent the night at work, came to take us home. All the while no payment was made for any of the services. It would have been the same whether my cousin was employed or not. So, who paid for all the medications, tests and other services? The National Health Service (NHS), I was told. Few institutions in the world epitomize the concept of universal coverage like the NHS.

Universal Health Coverage (UHC), also known as Universal Coverage (UC), is a global health policy and agenda borne out of several historical, economic, social, and moral imperatives. According to a recent report, The New Global Health Agenda: Universal Health Coverage, the implementation of the UHC idea could be traced to 19th century Germany when Otto von Bismarck introduced a comprehensive medical care that covered large segments of blue-collar workers.

As a global health agenda, it is a logical consequence of the WHO constitution of 1948, which declares health a fundamental human right. It was driven home by the Health for All agenda set by the Alma-Ata Declaration of 1978 and is also at the core of the healh-related Millennium Development Goals.

But what is Universal Coverage? As the name implies, it means a system where the health needs of everybody – not only the well-to-do – are duly met. The World Health Organization (WHO) defines it as ensuring that all people can use the promotive, preventive, curative and rehabilitative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition of an ideal scenario implies that all who need a particular health service can utilize it whether they can afford it at the time or not. This means that a poor farmer in the village with end-stage renal disease can have dialysis, expensive as it is, rather than left to die as is often the case in Nigeria today. An unemployed youth involved in a car crash and requiring an urgent CT-scan or MRI can have it immediately. A hypertensive and diabetic pensioner can have access to good quality care that would otherwise have wiped out her pensions or savings. It means the child of a poor bus conductor can have that surgical procedure required to close the life-threatening hole in his heart – without the parent being driven to beggary or further into penury.

Now, there’s no free meal anywhere – someone has to pay for it. Since billions of people the world over often cannot afford the healthcare they need, even where and when available, who pays for them? Are they to be allowed to wallow in disease and die? It becomes obvious that, at the heart of Universal Coverage is the question of healthcare financing. Since healthcare utilization, for billions, is often attended by the risk of bankruptcy, it is also a question of risk bearing.

The cost of healthcare is usually met out-of-pocket or through a prepaid mechanism, or a combination of the two. Out-of-pocket cost-bearing, except for an infinitesimal minority of mankind, is not a viable option toward achieving UHC. According to a World Report, over 60 million people in India were forced below the poverty line by healthcare costs 2011. A vicious circle between ill-health and poverty has long been recognized. A poor man cannot pay for healthcare, a sick man cannot work or be productive, and an unproductive man cannot maintain his health. As for the pre-paid, whence comes the payment?

The United Kingdom, one of the earliest countries to take a concrete step towards achieving UHC, launched the National Health Service in 1948. The system is overwhelmingly funded by tax-generated revenues. So, it’s a social system of re-distribution of wealth to take care of the health needs of people in an equitable way. The healthcare system in Spain and Portugal, as in Denmark and Sweden, is similarly driven largely by taxes. It’s the ‘single-payer’ model.

The single-payer model is in place in Cuba as well but in a communist economic system. But in Germany, Japan and France, Switzerland and many European countries it’s a mixture of public and private contributions. Importantly, there is no UHC in the United States, which relies largely on private insurance funding that leaves out a lot of people. Recent attempts by the Obama government to address this lack of equity have met considerable resistance.

According to the International Labour Organization, by 2008 nearly 50 countries had achieved near universal coverage. A new wave of attempts at universal coverage has engulfed so many emerging economies from India and China in Asia to Ghana and Rwanda in sub-Saharan Africa. Success in implementing UHC seems to mirror economic success.

Where is Nigeria in this global picture? The National Health Insurance Scheme (NHIS) was established in to provide medical insurance. But the coverage has been very low. Only federal government workers and the organized private sector are covered. The vast majority of Nigerians are outside this system. Even those ‘covered’ still pay a lot out of pocket to meet a lot of health needs. As has been noticed in other countries, a lot of the resources pooled for medical needs through health insurance ends up in the pockets of providers and health management organizations (HMOs) rather than in direct benefits to the end users. NHIS has barely made a dent. The government has also launched a Community-Based Health Insurance Scheme (CBHIS) which is still at the pilot stage. In short, currently, we are nowhere near UHC.

I take the view that UHC is a matter of social, economic and moral priority. It resonates with one’s intrinsic sense of morality that every one, no matter their station in life, should have access to prompt quality healthcare without the risk of bankruptcy.

I am also convinced that the federal government collects generates revenue – from petroleum, customs, taxes etc – to fund a universal access to quality healthcare in Nigeria. The government should bear the risk, for its own sake. We hear about individuals misappropriating billions all the time. The point has been made by that government spending on health should be seen as investment rather than expenditure. Universal coverage is an economic issue, a development issue. Health is wealth. A sick population cannot be productive, a people impoverished by healthcare needs cannot contribute to the economy. It only makes economic sense to invest in health.

But, alas, there are enormous challenges and barriers to the implementation of UHC in this country. At the root are poor governance, weak systems, lack of accountability, and corruption. Universal coverage cannot be implemented in isolation. It is not attainable where infrastructure is poor; equipment is inadequate; technology is obsolete or grossly inefficient; governance is decadent; personnel are poorly trained, poorly motivated, and inadequate in numbers; communication is poor.

To provide UHC, the healthcare system needs a lot of engineering, a lot of strengthening. But we must not lose the tree for the forest; universal coverage is an attainable ideal exceedingly worth aiming at.
The people of Nigeria, with the enormous resources which abound in their country, deserve, among other fundamental things such as quality universal basic education, the right to health for which they must hold their leaders accountable.