INTRODUCTION

The Universal Declaration of Human rights guarantees internationally the right to life,[1] and the right to health of individuals, mothers and children,[2]  because  the latter is integral to the enjoyment of the former. Succeeding this declaration, Article 12(2) of the International Covenant on Economic, Social and Cultural Rights provides steps which should be adopted by States to realise this right.[3] The World Health Organisation’s (WHO)  Constitution in reaffirming the right to health expounds health to mean the  stability of the physical, mental and social well-being of a being, and not merely the absence of disease. This Constitution declares the essentiality of this right to the attainment of peace and security, and insists that its enjoyment must be devoid of discrimination as to race, religion, political belief, economic or social condition. Having underlined the significance of this right, it is no surprise that in 2015, the United Nations included as goal 3 of the Sustainable Development Goals (SDGs), ‘good health and well-being’. Of vitality to this work, is therefore  target 3.8 of the goal which promotes the establishment and sustenance  of Universal Health Coverage(UHC)[4]. 42 years since the Alma-Ata declaration[5], although considerable progress has been made,  400 million persons are reportedly still without basic health care,[6] half of the world population do not obtain health services required, and 100 million people are

*a final year law undergraduate of the University of Lagos.

[1] Article 3

[2] Article 25

[3] Article 12(2) lists these steps to be

  1. The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child;
  2. The improvement of all aspects of environmental and industrial hygiene;
  3. The prevention, treatment and control of epidemic, endemic, occupational and other diseases;
  4. The creation of conditions which would assure to all medical service and medical attention in the event of sickness.

[4] It states: achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all.

[5] where nations in 1978 at the International Conference on Primary Health Care, in tune with the mandate ‘Health for All’ pledged to the establishment of primary healthcare in the society for the promotion and protection of the people’s health.

[6]United Nations Development Programme “Goal 3: Good health and well-being” available at https://www.undp.org/content/undp/en/home/sustainable-development-goals/goal-3-good-health-and-well-being.html (accessed 15th October 2020)

catapulted into poverty for  financing healthcare.[7] This work reflects on the Nigerian situation, efforts taken to achieve UHC, ascertaining if progress has been made and proffering recommendations to improve them.

UNIVERSAL DECLARATION OF HUMAN RIGHTS (UHC)

The  58th World Health Assembly in 2005 ,adopted UHC  to develop both the  health-financing  systems and health care infrastructures of nations.[8]  Reinvigorating the commitment of member states resolution A/RES/67/81 was also passed by the United Nations (UN) in 2012 to encourage the collaboration of governments, civil society organisations and international organisations in promoting UHC, as a panacea to the impoverishment of citizens by health care expenditures. Annually, 12th of December is earmarked as UHC day, to denote its potential for life-preservation, increased life expectancy and stimulation of economic development.

This ubiquitous term ‘UHC’ is defined by WHO as the provision of essential health services to individuals and communities, so as to protect them from financial hardship. To WHO, UHC encompasses  the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.[9]  The three  clear-cut objectives of UHC are:

  1. Entrenchment of equity in health care,
  2. Improvement of quality of health services with a commensurate improvement in the health of service recipients,
  3. Protection of persons from financial harm resulting from direct payment for the services[10]

[7]World Health Organisation “Campaign essentials” available at www.who.int/camapigns/world-health-day/2019 (accessed 16th October 2020)

[8] UN Resolution WHA58.33

[9] World Health Organisation “Universal Health Coverage (UHC)” available at www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc) (accessed 14th October 2020)

[10] World Health Organisation “Health financing” available at www.who.int/health_financing/universal_coverage_definition/en/ (accessed 14th October 2020)

Aside from nations commitment, UHC has enjoyed support from organisations including but not restricted to   the World Bank[11], the United Nations Children’s Fund (UNICEF)[12], the United States Agency for International Development (USAID)[13] and a host of foundations such as the Rockefeller Foundation[14] and the Bill and Melinda Gates Foundation.[15]  It is however imperative to clearly state here  that UHC is not tantamount to limitless free coverage of financial bills. For as observed by the WHO, such is  impossible for any country of the world to sustain.[16] UHC simply strives to prevent death resulting from inability to fund health care or  the inaccessibility to the required health care.[17] And this ushers in primary health care, for UHC cannot be achieved without the placement of a quality and accessible primary health care.

Primary health care (PHC) is the preservation of a person’s  physical, social and mental well-being throughout the entirety of his/her lifetime, and not just treatment of a single disease.[18]   PHC embodies comprehensive health care reaching from promotion and prevention to treatment, rehabilitation and palliative care within  proximity to people.[19]  PHC is an equitable way to achieve UHC, and  on the 2019 World health day, the WHO recommended that quality and accessible primary health care should be put in place to achieve UHC.[20]

HEALTH FINANCING

[11] E.g. the World Bank has pronounced its (UHC) role in achieving the world bank group twin goals of ending extreme poverty, and increasing equity and shared prosperity.  See: The World Bank “Universal Health Coverage” available at www.worldbank.org/en/topic/universalhealthcoverage (accessed 14th October 2020)

[12] UNICEF works to strengthen primary health care in community with the aim of  achieving  UHC. See: UNICEF “Health” available at www.unicef.org/health (accessed 14th October 2020)

[13] USAID readily invests in sustainable health care. See: USAID “U.S investing $40 Million to support goal of Universal Health Coverage” available at www.usaid.gov/ethiopia/news-information/press-releases/us-investing-40-million-support-goal-universal-health (accessed 18th October 2020)

[14] In 2009, this Foundation launched a Transforming Health System Initiative to aid UHC. See: www.rockefellerfoundation.org/initiative/universal-health-coverage/ (accessed 18th October 2020)

[15] This foundation donates to improve health care around the world. E.g. see: PND by Candid “Gates Foundation Awards $145 Million for Global Healthcare Access” available at https://philanthropynewsdigest.org/news/gates-foundation-awards-14.5-million-for-global-healthcare-access (accessed 18th October 2020)

[16] Supra, note 9.

[17] World Health Organisation “Health is a fundamental human right” available at https://www.who.int/mediacentre/news/statements/fundamental-human-right/en/ (accessed 14th October 2020)

[18] Supra, note 7.

[19] World Health Organisation “Primary health care” available at https://www.who.int/news-room/fact-sheets/detail/primary-health-care (accessed 16th October 2020)

[20] Supra, note 7.

A central issue to our discussion thus far is health financing. This is because it is a major problem for governments as they try to subsidise or provide free health services to their populace. As such,  in 2010, a WHO report revealed that UHC is mostly encumbered by unavailability of resources, demand for direct payment of services, and the inefficient and inequitable disposal of the resources.[21] This report further commended Brazil, China, Chile, Thailand and Rwanda for resolving these problems, attributing it to stronger health-financing policies and strategies.

Health financing is  therefore vital to  UHC because it serves three important roles of: raising revenue, pooling of funds and purchasing of services.[22] But a good health system not only addresses the raising of money, but  also answers the questions:

  1. Who is asked to pay?
  2. The time at which they are to pay?
  • And the means by which money raised is spent?[23]

The WHO offers no uniform approach to UHC. Flowing from international documents, its constitution and resolutions, states are empowered to determine the best approach for their respective societies. As such nations have popularly employed either a National Health Insurance Scheme,[24] a Social Health Insurance Scheme,[25] or even a Community Based Health Insurance Scheme.[26] The hallmark of a good  health financing policy remains risk pooling; distributing the risk among persons to eliminate burdening just one person[27]

NIGERIA HEALTH SECTOR AND UHC

The 1999 Constitution of the Federal Republic of Nigeria adequately empowers all three tiers of government to ensure quality and stable health care for Nigerians. Section 17 for instance, directs States to steer its policies towards the safeguarding of the health and safety of workers, and the provision of medical facilities for all persons.  Item 17 of the Concurrent Legislative List in the

[21] World Health Organisation “World health report” available at https://www.who.int/whr/2010/en/ (accessed 14th October 2020)

[22] World Health Organisation “Health financing” available at https://www.who.int/health-topics/health-financing#tab=tab_1 (accessed 16th October 2020)

[23] Supra, note 21.

[24] Steered by the government

[25] For the working populace, which is financed by payroll taxes

[26] Popular in the informal sector, mostly organized within a small group of people. E.g. people in a community

[27] World Health Organisation “Pooling revenues and reducing fragmentation” available at https://www.who.int/activities/pooling (accessed 16th October 2020)

Second Schedule to this Constitution further enables the National Assembly to legislate on the health and safety of workers. Item 21 of the Exclusive Legislative List grants oversight of drug and poison to the National Assembly while paragraph 2 of the Fourth Schedule delineates the provision of health facilities to be a function of the local government. It is then pursuant to these powers, that a National Health Act was passed in 2014. This Act in section 1 established a national health system comprising both public and private health care providers. Therefore, as you would find, health care in Nigeria is both public and privately funded.  Sub-section 2 further lists agencies making up the national health system to include, a federal ministry of health, state ministries of health, local government health authorities etc.  Section 11 of this Act progresses to disburse 50% of the Basic Health Care Provision Fund to the National Insurance Scheme, 45% to primary health care, while the remaining 5% is to be reserved for emergency medical treatment.

At this juncture, it is worth to mention that Nigeria as a member of the United Nations is aligned to achieving UHC, the SDGs and a better world.  It is in demonstration of this that the government in 2004 created the National Health Insurance Scheme (NHIS) to provide social health insurance for Nigerians. This scheme is saddled  with the function of  financing health care from a common pool of funds, to improve health care, accessibility and affordability for everyone; thereby promoting universal health coverage.[28] Its scope ranges from the formal sector, to the informal sector (providing for tertiary institution social health insurance programmes, community based social health insurance programmes, public private partnership social health insurance programmes),  and vulnerable groups( which include: pregnant women, children under 5, prison inmates, retirees and the aged).[29]

However, since the launch of this scheme in 2005, there has been no substantial achievement. The realities for the Nigerian health sector is that in  a nation with an estimated population of over 207 million people,[30] the ratio of a doctor to a patient is at 1:3, 500.[31]  It is said that a move to satisfy the WHO recommended ratio 1:600 will warrant the employment of 300, 000 qualified medical

[28] NHIS “About Us” available at https://www.nhis.gov.ng/about-us/ (accessed 19th October 2020)

[29]NHIS “Programmes” available at https://www.nhis.gov.ng/our-services/ (accessed 19th October 2020)

[30] Worldometer “Nigeria Population (Live)” available at  https://www.worldmeters.info/world-population/nigeria-population/  (accessed 19th October 2020)

[31] Punch “Nigeria’s doctor-patient ratio is 1:3,500-NUC” available at https://www.google.com/amp/s/punchng.com/nigerias-doctor-patient-ratio-is-13500- (accessed 18th October 2020)

doctors.[32]    As for  health infrastructure, it was conceded by Boss Mustapha, the Chairman of the Presidential Taskforce on COVID-19 to be in a deplorable state.[33] This is evidenced by the lack of qualified personnel, the unavailability of equipment and of drugs, lack of financial investment, absence of technology application etc. More tragic for the health sector is the inability of the government to comply to the 2001 Abuja Declaration of apportioning at least 15% of its budget to the development of the healthcare sector.[34] Instead it  has witnessed  a reduction in the funds allocated. For instance, in 2020 only 8% of the budget totalling 46 billion naira was allocated to the health sector, a further reduction from 50.15 billion in 2019 and 71.1 billion naira in  2018.[35] Consistently,  the 2021 proposed budget ignores the AU benchmark by  allotting  N 547 billion; only 7% of the budget  for healthcare.[36] Working with a figure of 200 million persons, this figure is averaged to be N2, 735 per Nigerian.[37]  HIV/AIDS treatment continues to be financed at 90% by external donors, while the federal government’s contribution falls below 10%.[38] Nigeria’s catastrophic out-of-pocket health spending was calculated by the WHO to be 4.06% greater than 25% of total household expenditure or income.[39]  In 2019, households in the  urban areas spent 4.8 % of their annual expenditure on health, while those in the rural areas spent 7.3%.[40] Current health expenditure continues to be 3.76% of the GDP,[41] while out-of-pocket expenditure is 77.22% of

[32] Ibid.

[33] The Guardian “Need to check health sector in Nigeria” available at https://www.google.com/amp/s/guardian.ng/opinion/need-to-check-health-sector-in-nigeria/amp (accessed 18th October 2020)

[34] OAU/SPS/ABUJA/3

[35] “A breakdown of Nigeria’s 2020 budget for health” available at https://www.gogle.com/amp/www.healthnews.ng/a-breakdown-of-nigerias-2020-budget-for-health/%3famp_markup=1 (accessed 19th October 2020)

[36] Premium Times “2021 Budget: Again, Nigeria ignores AU benchmark for health funding” available at https://www.premiumtimesng.com/news/headlines/421129-2021-budget-again-nigeria-ignores-au-benchmark-for-health-funding.html (accessed 19th October 2020)

[37] Ibid.

[38]  Science “58 years of poor health services, outcomes” available at https://m.guardian.ng/features/science/58-years-of-poor-health-services-outcomes/ (accessed 19th October 2020)

[39] World Health Organisation “Catastrophic out-of=pocket health spending (SDG indicator 3.8.2 and regional indicators where available) Data by country” available at https://www.apps.who.int/gho/data/view.main.UHCFINANCIALPROTECTION1v?lang=en (accessed 19th October 2020)

[40] Statista “Expenditure of Nigerian Households on healthcare 2019, by area” available at https://www.statista.com/statistics/1126516/expenditure-of-nigerian-households-on-health-care/ (accessed 20th October 2020)

[41] The World Bank “Current health expenditure (% of GDP) – Nigeria” available at https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=NG (accessed 20th October 2020)

current health expenditures.[42] Nigeria’s death rate (not inclusive of the pandemic deaths) stands at 11.577 percent, its growth rate is at -1.650%[43] and the NHIS scheme has only been able to cover federal government officials making up 4% of total population.[44] Insurance coverage in Nigeria is severely low with only 1.4 percent of rural areas inhabitants with a health care insurance.[45]

PROPOSALS                         

The COVID-19 pandemic taking the country by surprise, further exposed the inadequacies of the health sector as it grappled with combating this virus. Asides from worsening infant mortality by increasing preterm birth among women[46], this pandemic made health facilities shut their doors to many  ailed because of their limited capacity and infrastructure. This worsened the already wobbling primary health care and impeded UHC. To remedy this and restore the country to fostering UHC, the following are proposed:

  1. Strengthening primary health care: for a while now, Nigeria has bypassed PHC to concentrate more on secondary and tertiary health centres. The result is that more and more persons, particularly in the rural sector have been denied basic health care. Due to unavailability of funds and affordable PHC, Nigerians take recourse to self-medication or treatment from quacks. A solution to this therefore is the establishment of fully furnished PHCs most importantly in the rural areas. Understanding however that the economy of the government is still struggling to recover from the effect of COVID-19, it is suggested that the government embraces private initiatives such as one proposed by ABCHealth to fund this.[47] The government can step in as a partner and also a regulatory body to curb abuses.

Reviewing Budget: in order to provide more funds for the health sector, the federal government is implored to adjust its proposed 2021 national budget. The allocation of N35.03 billion to Basic Health Care Provision fund is downright poor. While the allocation

[42] The World Bank “Out-of-pocket expenditure (% of current health expenditure) – Nigeria available at https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=NG (accessed 20th October 2020)

[43] Macrotrends “Nigeria Death Rate 1950-2020” available at https://www.macrotrends.net/countries/NGA/nigeria/death-rate (accessed 19th October 2020)

[44] Supra, note 38

[45] Supra, note 40

[46]Punch Healthwise “How COVID-19 worsens Nigeria’s high infant mortality rate” available at https://healthwise.punchng.com/how-covid-19-worsens-nigerias-high-infant-mortality-rate/

[47] African Review of Business and Technology “Transforming Nigeria’s primary health care sector” available at https://www.africanreview,com/finance/business/transforming-nigeria-s-primary-health-care-sector (accessed 20th October 2020)

  1. of N128.00 billion to the National Assembly is excessive, not to mention N227.02 billion to the Ministry of Interior. These are areas where adjustments can be made. It is essential that we prioritise our health not just because health is wealth but also because human capital is necessary for the nation to thrive.
  2. Improving Infrastructure: infrastructure deficit in the health sector has contributed to the crippling of the economy productivity and the average life expectancy of 54.3 years.[48] It is concluded that only the private sector can aid with the deployment of technology, equipment, and other necessaries for revamping the health sector.[49] And as such the government is advised to enact policies encouraging and incentivising such approach.
  3. Increased qualified medical practitioners: the health workforce is undoubtedly short-staffed with majority of practitioners migrating abroad because of better remuneration packages. The few left in the country are frustrated by the debilitated structure, the mass number of patients to attend to and worse still, the non-payment of salaries. The last factor has provoked countless number of protests demanding for better treatment for the practitioners, including an increase in the hazard allowance.[50] Nothing is thus more imperative for the government than an upward review of their salary and the creation of better working conditions. This would encourage the application of other experienced practitioners and stem the constant migration of their peers.
  4. Research and Improved Quality of Service: The Nigerian government must fund research within the country. Rather than be at the mercy of other nations for vaccines and drugs, pharmacists, universities should be deployed to examining botanical and chemical substances situated in the country for an ascertainment of possible usefulness to the country’s health sector. Quality service would be proportionally improved by the receipt of innovations, technological advancements and revitalised health workers.

A State Health Insurance Scheme: recognising the inability of the National Health Insurance Scheme to cater for the mass population, it has been recommended that a more

[48] Nairametrics “Funding Nigeria’s healthcare infrastructure gap” available at https://www.nairametrics.com/2020/07/21/funding-nigerias-healthcare-infrastructure-gap/ (accessed 20th October 2020)

[49] Ibid.

[50] This is currently at N5000

  1. realistic and efficient scheme should be undertaken by states.[51] The Autonomy of states in handling internal issues such as its budget and state ministries provides a perfect channel to insure the inhabitants of a state much better. As such, states can develop a state fund for the pooling of common resources, include the requirement of insurance as a precondition for something, or offer tax incentives to prompt registration etc. This approach is arguably more inclusive and persons-capturing than the national scheme as it is less burdened by catering for one set of persons other than the national health insurance scheme which attempts to pull everyone together. A small scale approach like this is expected to yield greater progress than an overladen one.

CONCLUSION:

UHC is applauded for its rise to the forefront of the global health agenda in the past few years, as reflected by donor pledges, international declarations, and high profile publications”[52] but while nations profess commitment, an analysis of their health sector  development is essential to determine their alignment with the 2030 agenda to create a ‘better  and sustainable world’. An analysis of the Nigerian health sector has revealed that it lacks basic infrastructure and primary health care to deliver coverage to its citizens. Although a national health insurance was created, it has grossly proved inactive and inefficient to deliver coverage, with households funding over 70% of their healthcare. This deplorable state is worsened by the pandemic overwhelming the health sector, regressing economic growth and producing financial constraints. If UHC is overlooked, good health, life preservation, peace, security and economic development is jeopardised. It is therefore in cognisance and the evasion of such terrible outcomes, that this work has offered measures that can be implemented to entrenching UHC.

[51]  Arnold Ikedichi Okpani and Seye Abimbola, “Operationalizing universal health coverage in Nigeria through social health insurance” (2015) 56(5) Nigerian Medical Journal: Journal of the Nigeria Medical Association, 305. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698843/#!po=12.2222 (accessed 14th October 2020)

[52] Jesse B. Bump, The Long Road to Universal Health Coverage: A Century of Lessons for Development Strategy (Rockefeller Foundation, 2010)

 

N. Assumpta Nwaogwugwu, ACIArb (UK),is a law student of the University of Lagos. She is an associate of the Chartered Institute of Arbitrators, Director 1 of the Good health and well-being committee of YSDC 2021. She is also a serving Director of JCIN, UNILAG CHAPTER. She has a keen interest in international law, Arbitration and Energy law. Assumpta is committed to the 2030 Agenda and the vital roles of youths in the achievement of the Agenda.