Universal Health Care:Nigeria tackles polio, but other challenges linger

The eradication of polio in Nigeria is arguably the best health story out of the country since the turn of the millennium. It deserved to be. But, as Onyedimmakachukwu Obiukwu reports, after this victory, Nigeria should now give it’s full attention to defeating another protracted epidemic – its lack of universal quality healthcare.

Nineteen years since Nigeria missed her first Polio eradication deadline, the country has now gone three years without a case of wild poliovirus. “More than 200,000 volunteers across the country repeatedly immunized more than 45 million children under the age of 5, to ensure that no child would suffer from this paralysing disease,” the Global Polio Eradication Initiative (GPEI), the public-private partnership leading the effort to eradicate polio on the planet, said. Global consulting firm, McKinsey and Company, called the effort “the largest global health intervention ever attempted.”

But, while Polio may be finally down in Africa’s largest country, the absence of universal healthcare coverage is ending Nigerian lives faster than any epidemic the country has ever faced.

The top ten causes of death in Nigeria – among them, Malaria, diarrheal diseases and lower respiratory infections – are illnesses that should be preventable, treatable and manageable; but the absence of universal healthcare coverage has made these illnesses endemic. Three hundred thousand Nigerians die from malaria every year, six times this number lose their lives to diarrheal diseases and, according to the fact sheet of the Centre for Disease Control, one child dies every 20 seconds from a disease that could have been prevented by a vaccine.

Nigeria’s infant mortality rate is also abysmal. At 67 deaths per 1000 live births, the country is not only among the worst places for a child to be born, it is 10 times worse than Mauritius, which provides universal health coverage to all its citizens. This is not to say that Nigeria has not made significant strides in healthcare coverage, quite the opposite. The improvements in health outcomes that the country has experienced over the past two decades lend just as much credence to the need for universal quality healthcare.

State of Progress

Looking back twenty years, it is impossible not to appreciate the improvements that Nigeria has achieved in health care, no matter how limited such progress may have been. Since the turn of the millennium, the country’s under 5 mortality rate, which averaged around 250 deaths per 1000 kids in the year 2000, has halved. So too deaths from malaria and other non-communicable diseases.

Also, between the years 2000 and 2015, the maternal mortality rate has reduced by more than thirty percent from 1,170 deaths to 814 deaths per 100,000 live births, according to the World Health Organisation. Access to health services has also increased; vaccines now prevent an estimated 2.5 million deaths among children under 5 five years of age, and overall, Nigeria’s Health Access and Quality index has risen from 28.9 percent in the year 2000 to 41.9 percent in 2016.

There has also been, over the past 19 years, the steady, even if extremely slow, uptake of health insurance in Nigeria. This began with the establishment of the National Health Insurance in 1999 as a public-private partnership to pool health risk and provide greater financial protection to households seeking healthcare.

While the goal of the NHIS was to eventually provide every Nigerian everywhere with health care coverage, as of 2016, less than five percent of the population was covered – predominantly federal government civil servants and their dependents. The other bulk of health insurance coverage is provided by private-run Health Maintenance Organizations (HMOs) almost entirely to the corporate sector, both as a result of pricing and access to services.

However, despite the existence of the NHIS and the private HMOs, as at 2016, only three percent of healthcare expenditure in Nigeria was paid for using health insurance, according to professional services firm PWC. Worse still, the informal sector, comprising most Nigerians – including the poorest and sickest individuals – “are left to either forgo care when they fall ill or pay out-of-pocket for their health care expenditures,” according to the World Bank in its 2018 Nigeria Health Financing System Assessment Report.

With out of pocket healthcare costs too expensive for most Nigerians, or indeed anyone, and quality healthcare largely out of reach for Nigeria’s urban poor and rural inhabitants – who make up the majority of Nigeria’s population – only a comprehensive healthcare strategy, developed and executed in collaboration with the public sector, private sector partners and intergovernmental institutions, can provide most Nigerians with universal healthcare coverage.

Achieving Universal Healthcare Coverage

“It will be almost impossible for Nigeria to achieve Universal Health Coverage (UHC) by 2030 if the Primary Health Care (PHC) system is not improved and if health insurance remains voluntary,” journalist Ebuka Onyeji wrote in Premium Times, reporting on a panel on Nigeria’s progress towards achieving Universal Healthcare Coverage.

“It [primary health care] has to be a top priority for the federal and state governments,” Paul Basinga, Country Director, Bill and Melinda Gates Foundation, was quoted as saying during the event. “There is a need for reform so as to have a viable PHC system with enough finance flowing down to the facilities that will be located in the right places with adequate human resources, equipment and drugs,” he added.

Primary Healthcare Centres were designed to be the base of Nigeria’s healthcare system; it is the first point of contact for most people in the country and has the closest proximity to communities, especially in rural and semi-urban areas. Essentially, if you wanted to deliver quality healthcare to every Nigerian, anywhere they are in the country, you have to do it via the PHCs.

The problem is, the PHCs are the most under-equipped and under-funded of Nigeria’s healthcare arms. “With 5% level of funding, Primary Health Care services are bedevilled by 80% disease burden as against 15% and 5% in Secondary and Tertiary Health Care Services, which are having 15% and 80% funding capacity respectively,” said the Civil Society Legislative Advocacy Centre (CISLAC) in its report on Increasing Legislative Oversight on Primary Health Care in Nigeria.

“The Gates foundation is working with the government to implement the Basic Health Care Provision Fund (BHCPF) to boost service delivery in PHCs. As a matter of fact, we have provided money for it,” Mr Basinga was also quoted as saying at the panel. “We are the first donor to put money in BHCPF. We put two million dollars on the table to really allow government to speed up implementation and then we think that it’s a long term strategy which will allow money to flow from the CBN account down to the facilities.”

However, the challenge with building an efficient primary healthcare system in Nigeria, and by extension, achieving universal healthcare coverage, goes beyond funding. It is also about effective strategy and efficient management; and this is where, again, there are things to learn from Nigeria’s campaign to eradicate polio.

The fight against polio, even though it cost over a billion dollars, has always been more than just about funding. It demanded, at the high level, a strong and long term commitment from the public sector and international organisations, as well as close coordination between all stakeholders around one clear strategic goal. On the ground, the effort demanded skilled and well trained experts working together and with communities, constantly tracking, handling and measuring progress in the battle to eradicate polio.

If Nigeria’s bid for universal healthcare is to be successful, by 2030, or ever, the country needs the same kind of vigour and consistency as it had in the war against Polio.

The public sector must show greater commitment to the cause through government funding and accountability, whilst its partners in the private sector and NGOs have to lend more support in manpower and expertise. Ultimately, everyone passionate about Nigeria and its people must become active champions for universal health care, viewing it not just as a futuristic goal, but as a present necessity to bring an end to the wanton and preventable deaths and suffering of millions of Nigerians.