In 2009, our first daughter appeared healthy at birth, lively, and unspeakably cute. However, just four weeks later, her health was failing. She could not nurse and was rapidly losing weight. She cried inconsolably. An echocardiogram revealed the cause. She had congenital heart defects and needed open heart surgery, immediately. But this was not an option in Nigeria. And although my wife and I were both employed — and I worked as a medical doctor for an international nonprofit — we did not have the savings to pay for our daughter’s surgery in India. We suddenly faced both a health crisis and a financial disaster.
Millions of Africans face such catastrophic health emergencies on a daily basis. Usually, however, the cause is preventable or at least easily treatable, if people have the money and the access to health care. But many never get the help they need. As a result, 145 women of childbearing age and 2,300 children under 5 years of age die daily in Nigeria. Women die in childbirth, children die of malnutrition, malaria, diarrhea, and pneumonia.
International funders spend billions on improving health care in Africa. But only through universal health coverage programs can the continent lock in progress. In Nigeria, Africa’s most populous country, the government and its partners should be leading the way by setting up a system to protect people against out-of-pocket payments that can represent a one-way ticket to poverty.
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My wife and I were lucky. Our employers provided loans, and at reasonable terms, to cover the cost of our travel to India and our daughter’s surgery. But for most Nigerians, a health crisis that does not kill them pushes them more deeply into poverty. Today, nearly 72 percent of Nigerians’ total health expenditures are paid for out of pocket, forcing people to choose between their health, housing, education, and even food for their children. With 70 percent of the population already living in absolute poverty, Nigeria can ill afford to maintain this status quo.
The government acknowledged this 12 years ago, when it established the National Health Insurance Scheme to provide health care to all Nigerians through various prepayment systems. But today, only 1 percent of Nigerians have health insurance.
Several factors are responsible for this: Leadership of the NHIS has been unstable; demand is low as few Nigerians know that national health insurance is available; and health insurance companies sometimes fail to remit NHIS funds to hospitals in a timely manner.
Universal health coverage, which entails providing effective access — including financial risk protection — to at least essential health care, is key to achieving the world’s Sustainable Development Goals. Spurred by these goals, momentum towards UHC is growing.
It takes political will for countries to implement UHC. And several African countries, including Botswana, Rwanda, and Ghana are demonstrating that will and finding innovative ways to fund UHC.
Ghana charges informal sector subscribers small premiums that average just $6.1 per year. In addition, it has implemented a value added tax, made National Health Insurance Fund investments and mandated social security deductions to individual’s income. Through these combined sources, the government of Ghana currently provides health insurance for about 40 percent of its population.
Nigeria, with a population of 186 million, is a much bigger deal. With the majority of Nigerians working in the informal sector, taxation has not been a realistic option for public financing of health. Therefore, Nigeria has required that one percent of the government’s total revenue and all donor funds earmarked for health care delivery be dedicated to a Basic Healthcare Provision Fund, which in turn finances the NHIS, the National Primary Health Care Development Agency, and emergency health care. This core funding is then supplemented by additional prepayment plans, all at a fraction of the cost of out-of-pocket expenditures paid by Nigerians.
Of course, the NHIS cannot pay for all health care expenses. But it should make basic health services much more affordable for the majority of Nigerians, especially the poorest. A functional, fully funded NHIS, combined with other prepayment plans, such as health insurance, would save countless lives as people receive the care they need, and prevent financial crises.
How do we ensure that no Nigerian family suffers the kind of catastrophic health expenditure that risked driving my family into poverty? To be sure, there are major challenges ahead in implementing UHC. But after 12 years of inaction, it is time to recommit to the principle of health for all. Recently, the Bill & Melinda Gates Foundation and the World Bank partnered with the Nigerian Federal Ministry of Health for a phased implementation of the Basic Healthcare Provision Fund in three Nigerian states. This implementation is projected to provide a basic package of health services to 8 million beneficiaries in rural communities in Abia, Niger, and Osun States.
Other international partners should contribute to this phased implementation, which could ultimately lead to UHC for all Nigerians.
Over the years, the development community has done much to improve the health in Nigeria. However, projects that insist on a siloed approach to treating specific health problems will never get to the root causes of continent-wide problems, including high rates of maternal and child mortality. The global push for universal health coverage can help Nigeria to turn the corner. And if Nigeria can help to show the way, real progress on African health will follow.
