My headache with Universal Health Coverage
About 2 years ago I began my fifth year in medical school and was initiated into the public health/ healthcare impact/ universal health coverage cult. I was pumped about health for all at a cost that does not cause financial instability to the population (remember that definition?).
Quality, financial equity and appropriate service utility were all I spent all my reflective moments pondering. Oh I had so many ideas! Those ideas got me into fellowships, boot camps for young leaders and all that. But, a lot of them remained ideas. This was not for a lack of ability to implement. On the contrary I worked on and executed many other projects in this time. However, none of these that I worked on were related to actual health care delivery which is what I really wanted to do more than anything else.
Why? Well, thinking through the health service delivery models we have in Nigeria and trying to decide where I could fit in brought to light a lot of issues, not only with my ideas but also with the general healthcare landscape in the country. This is basically what I have been trying to figure out. I have come to you now, stumped, and with more questions than answers.
First of all, Universal Health coverage revolves around three major themes: access to health care, good quality of services, as well as financial protection and equity. Basically, everyone should be able to access and use health care facilities based on need and not how much they can afford to pay, the services being offered should be good and efficient, and the amount contributed by a person to financing this health system should be proportional to their income. This I have described is a perfect world- and we are not even close.
In Nigeria, many people have touted health insurance as the sure-fire way to moving a bit closer to UHC. Many private HMOs have arisen and even the government has the oh-so-magnificent NHIS for people in the civil service. Now the problem with this is that the people who are more likely to need health services are the poor and disadvantaged (due to their standard of living they face greater health risks). This same set of people are also more likely to be pushed into extreme (or more extreme than they already are) poverty by the cost of accessing health care. The private HMOs cannot cater for this disadvantaged group because they are businesses and must make profit. The NHIS scheme as well does not really have a proper structure for to address the informal sector where many of them fall.
Some others, having encountered these problems have proffered community based health insurance as a solution and a way to finance healthcare for poorer communities. This is basically that in a community, the households or individuals contribute some money monthly so that they can access basic healthcare whenever they need to. The rationale behind this is that it is easier to 1500 naira every month than to pay 30,000 naira at once. The big problem with CBHI is that it is usually voluntary. Those who are healthier would not normally be inclined to subscribe, while the people who have chronic health conditions for example are more likely to subscribe. Hence, the sicker people on the scheme end up using up more than they have contributed. Normally this deficit is supposed to be offset by healthier ones who are contributing to the pool of funds but don’t need the health services. But, because it is voluntary, there are fewer healthy people to balance out the funds and the scheme ends up with a large deficit. This is not financially sustainable.
The above models are somewhat forward thinking and try (even though they still fall short) to achieve some sort of responsibility for funding our own healthcare. However, probably the most rampant and unsustainable method is charity. Foreign aid, grants, non-governmental organisations, crowd funding, etc. Many well-meaning individuals try their very best to provide healthcare for Nigerians in one way or the other. From high ups like the Bill and Melinda Gates Foundation to the young NGO started by a young student to provide some semblance of health services to people; we have them all. However, aid is unstable. It leaves the people at the mercy of donors. It is also very easy for charity funding to be misappropriated (as we saw with the IDP camp debacle and many others) and some donors may even insist on a particular agenda regardless of whether or not that is the pressing need in the population at that time. On a national level, aid may be helpful if at the same time there is a concerted effort by the country to increase health spending and improve efficiency of the health system. However, Nigeria has not done this in all these years. Aid has become a crutch that may just be slowing down our development.
I guess the question now is what on earth can be done about all this? The average Nigerian millennial has been thoroughly schooled in the “don’t wait for the government” mentality. This mentality is completely valid in our unique environment as it has pushed young people to strive to see the difference they can make outside of our faulty systems. However, for health it seems to me that all the stand- alone efforts, although noble and praise worthy, are like pouring water in a basket-the basket is getting wet but that’s about it.
The life of one person is important and we may be encouraged that at least we made one person’s life better. Maybe this is true. But, if a bigger picture appeals to you, maybe you will understand why I have a headache. I wonder if it is enough. Is it enough to save ten thousand out of millions? Is it enough to help hundreds and still lose thousands? Can we replace an efficient primary health care system with health outreaches? Can we replace a national fund for health with scattered health insurance schemes and crowd funding accounts? Can we replace essential drugs and vaccines with health education and campaigns?
My twenty-first century young person training hates the very idea that maybe we might actually need the government. I hope this is not the only answer and would be glad to hear what you think. If you don’t have any answers and are in the healthcare space, maybe you would find these questions useful while thinking through your idea or current project.
