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UNIVERSAL HEALTH COVERAGE IN NIGERIA: A MEDICAL STUDENTS’ PERSPECTIVE

INTRODUCTION

Health as defined by the World Health Organization is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.  Everyone has the right to be in good health and good medical services irrespective of their class in the economy. The aim of the universal health coverage is to secure access to adequate healthcare for all at an affordable price. What is Universal Health Coverage?

Universal Health Coverage is a health care system that provides health care and financial protection to all citizens of a country. It is organized around providing a specified package of benefits to all members of a society with the end goal of providing financial risk protection, improved access to health services, and improved health outcomes.

 

Universal health coverage is one of the set goals for Sustainable Development Goals (SDGs) that Africa and other countries pledged to achieve by 2030.To monitor the progress of Universal Health Coverage, the focus should be on

  1. The proportion of a population that can access essential quality health services.
  2. The proportion of the population that spends a large amount of household income on health.

World Health Organisation uses 16 essential health services in 4 categories as indicators of the level of achievement of coverage in countries. The 4 categories have different services under them. These include

CATEGORY I: Reproductive, maternal, new born and child health:

  1. Family planning
  2. Antenatal and delivery care
  3. Full child immunization
  4. Health-seeking behaviour for pneumonia.

CATEGORY II: Infectious diseases:

  1. Tuberculosis treatment
  2. HIV antiretroviral treatment
  3. Hepatitis treatment
  4. Use of insecticide-treated bed nets for malaria prevention

CATEGORY III: Non-communicable diseases:

  1. Prevention and treatment of raised blood pressure
  2. Prevention and treatment of raised blood glucose
  3. Cervical cancer screening
  4. Tobacco (non-)smoking.

CATEGORY IV: Service capacity and access:

  1. Basic hospital access
  2. Health worker density
  3. Access to essential medicines
  4. Health security: compliance with the International Health Regulations.

Universal Health Coverage is Sustainable Development Goal 3 and it should not be achieved alone. It must be achieved with other Sustainable Development Goals.

UNIVERSAL HEALTH COVERAGE AS AN SDG

Sustainable Development Goals(SDGs) or Global Goals for Sustainable Development are a collection of 17 global goals set by the United Nations(UN) in 2015. The 17 goals are further broken down into 169 targets. Accomplishing these targets means achieving the 17 goals. The SDGs covers social and economic development issues including poverty, education, gender equity, urbanisation, health, hunger, climate change, environment and social justice.

The SDGs was developed to replace the Millennium Development Goals (MDGs). The MDGs had 8 goals, and it categorised the countries into developed and developing countries. The reason for introducing the SDGs is that countries would use it as a template or a road map for development. The SDGs do not categorise the countries, as all countries are undergoing different degrees of transformation. Thus, even the developed is still developing.

Universal Health Coverage as an SDG focuses on the good health and well-being of citizens of a country.  Progress has been made in the last 25 years before the commencement of SDGs, as preventable child death reduced by almost more than half.

 

UNIVERSAL HEALTH COVERAGE IN THE WORLD

Some countries in the world have started providing health services for their citizens even before the World Health Organisation was established. One of the ways these countries achieved this by providing health insurance schemes for their citizens. For example, Luxemburg in 1901 established compulsory health insurance for manufacturing and industrial workers. Universal Health Coverage does not involve health insurance alone. Germany has a good healthcare system and Nigeria can learn a lot from their success

GERMANY: The German health care system is divided into three major areas. These include the outpatient care, the inpatient care and rehabilitation facilities. The health care system in Germany are based on four basic principles which are

  1. Compulsory insurance: Every citizen must have a statutory health insurance provided that their gross earning is within a fixed limit. Anyone who earns more than the fixed limit can choose to be on private insurance.
  2. Funding through insurance premium: Insured employers and employees pay insurance premium. This premium is also supported by tax revenue surplus.
  • Principle of solidarity: In statutory insurance, citizens pay according to their income. According to the principle of solidarity, the rich that pay more support the poor that pay less so that at the end of the day, everyone receives the same quality of health care service.
  1. Principle of self-governance: The German government set rules and standard for medical care, but further organisation and financing of individual medical services is the responsibility of self-governing bodies which are composed of physicians, nurses, pharmacist and physiotherapist within the health care system

 

UNIVERSAL HEALTH COVERAGE IN AFRICA

Africa is developing and has a lot of problems. Africa has 12 years to achieve these goals and the current look of things, a lot still must be done. Some countries in Africa have recorded improvement, for example, Kenya ministry of health claimed to have recorded a decline in the death of children below five years from 74 per 1000 live births to 52 per 1000 live births and decline in infant death from 52 per 1000 live birth to 39 per 1000 live births since 2013. This is just the result of one of the indicators to measure progress of universal health coverage.

Rwanda has moved ahead as the country allotted 13.1% of her annual national budget to health in 2015. This is close to the prescribed 15% by the AU. Since 2015, there have been a decline in the percentage allotted to health in Rwanda, but it is still greater than that allotted to health in Nigeria.

Figure shows percentage of annual budget allocated to health in Rwanda

 

UNIVERSAL HEALTH COVERAGE IN NIGERIA

Nigeria, with a population of over 170 million needs strategic plans to achieve universal health coverage. To provide affordable health service for everyone in Nigeria, there is need to have at least a standard primary health care facility in every ward in Nigeria. According to the minister of health, this would sum up to about 10,000 primary health care facilities in the country within 12 years. There would also be needing to revitalise the secondary and tertiary healthcare facilities. These are nice mouth-watering feats to achieve. Every patriotic Nigerian would love to live to see the day all these would be achieved.

There is no hard and fast rule on how to achieve these goals, but it must be systematically broken down to achievable goals to encourage and facilitate their actualization. Attaining universal health coverage would involve identifying the problems that have plagued the healthcare system, providing a solution to those problems and improving on the achieved feats.

Figure showing the 2017 WHO summary of the Nigerian health system

 

PROBLEMS OF THE NIGERIA HEATHCARE SYSTEM

Some of the problems facing the healthcare systems are highlighted below

1. INADEQUATE FUNDING

The Nigerian health care system is poorly funded. The funds that are allocated favour the secondary and tertiary healthcare facility more than the primary health care facility. Though the secondary and tertiary healthcare facility provide relatively cheap health services compared to the private health facilities scattered around the country, the capacity of these healthcare facilities is small and must be augmented by adequate primary healthcare facility to cater for the population. Heads of state of members of the African Union (AU) agreed to AU health funding commitment which requires member countries to assign 15% of their annual budget to improving the health sector. This agreement was reached in 2001 at Abuja, but till date the highest Nigeria have ever allocated to health was 5.95% in 2012. The percentage allotted to health in the 2018 annual national budget is 3.9%; this is lower than that assigned in 2016 and 2017 which are 4.23% and 4.16% respectively

2. INADEQUATE STAFFING

Health facilities would not just be provided without having adequate workforce in the facilities. It is not news that even the tertiary health facilities are short staffed, not to mention the primary healthcare facility.According to the Medical and Dental Consultant Association of Nigeria (MDCAN), the current ratio of doctors to patient is 1:6000, that is to every 6000 patients, there is only one doctor. The MDCAN recommended that the acceptable ratio of doctor to patient should be 1:600.

3. INADEQUATE INSURANCE SCHEMES

The high rate of poverty in the country has only added to the problem of the country. The desire of a man that lives less than a dollar per day would be that he would be able to confidently walk into any healthcare facility and receive adequate healthcare services without having to pay too much out of pocket. Health insurance should be made compulsory for every citizen of the country. The health insurance scheme isineffective, and a lot of changes still must be made. Using university of Ibadan as an example, a matriculated student of university of Ibadan have access to affordable health service at the university clinic but medical student that cross to the university teaching hospital to continue their training usually must run down to the university clinic to access medical services when there is a teaching hospital in their immediate environment. If health coverage organised by a university in inadequate, what would we say of the country. Moreover, health insurance usually covers more of the formal populace that is the civil servants and other educated people that work for good private companies. The informal populace which forms majority of the Nigerian population know little or nothing about insurance scheme.

4. INADEQUATE KNOWLEDGE OF THE HEALTH SCHEME: Most people in Nigeria do not know about universal health coverage. A survey was carried out among the medical students in the University ofIbadan to verify this assumption. It is surprising that most of them do not know about the Universal Health Coverage. The statistics are thus

 

 

If medical students are not on health insurance and do not know much about health insurance, it can be inferred that a large percentage of the Nigerian population do not know about it.

 

PROPOSED SOLUTION TO THE PROBLEMS IN NIGERIAN HEALTHCARE SYSTEM

The problems of the Nigerian healthcare system have so far been identified, providing adequate and long-lasting solutions to them should be the focus. Some of the proposed solutions are

1. CAMPAIGN AND GRASSROOT ENLIGHTENMENT: Medical students have a big role to play in enlightening the people in the immediate environment about the universal health coverage but from the data gathered, medical students needs to be educated and enlightened first before they can enlighten others. Community funded health insurance could be adopted wherein members of the community pool resources to support their primary health care facility. For example, if the members of the university college hospital Ibadan community can have access to health insurance, it would be easier to communicate it to other people. Rwanda for example has used this method successfully. In Rwanda, every leader in each community is responsible for enrolling members of the community. He is also responsible for collecting or pooling funds within the community and allotting them to the primary healthcare facility in the community. This has resulted in 75% health coverage for people in Rwanda. This method of pooling resources is called Community Based Health Insurances (CBHI). Nigeria can adopt this method too. Imagine if every community in Nigeria could adopt this; sit would take little time to increase the percentage of people that are reached by the Universal Health Coverage.

2. REGULAR FUNDING: Government should be committed to funding the available healthcare facilities in the country. There should be increase in funds allotted to the secondary and tertiary healthcare facilities though the primary healthcare facilities should be the major focus as this would provide immediate easy accessibility to health service in every community. Funds would be primarily provided by government and should be augmented by funds from international donors and innovative financing schemes. Much of funds should go more to primary healthcare unit. Plans should be made on how the funding would be regular and consistent. There are different methods through which the government can use to make funds available for the health system. For example, Earmarking taxes on some goods: Taxes on goods like tobacco and alcohol should be set aside to fund the health system. Philippines for examples earmark 85% of the taxes on tobacco and alcohol to their healthcare system. These funds are used to enrol the poor into insurance scheme and to improve their primary health facilities.

Nigeria can also adopt this method to generate regular supply of funds to the primary healthcare facilities.

3. ADEQUATE STAFFFING OF HEALTHCARE FACILITIES

This should be addressed adequately especially in the primary healthcare facilities. There should be massive recruitment, training and support of rural-based health workers. There should be incentives and special benefits to encourage workers to stay in primary healthcare facilities in rural areas. Workshops could be provided to educate health assistance workers so that people in the rural areas can be informed. There could also be a law that mandates it for medical student to have their elective postings in primary healthcare centres in the country to augment the manpower available in the primary healthcare facilities.

4. AMENDMENT OF HEALTH INSURANCE SCHEME

Health insurance should be made compulsory for everyone in the country. There should be intensified campaigns to create awareness on the importance of insurance. Only a few numbers of people are currently on insurance schemes in Nigeria. Nigeria can learn and adopt Germany’s method where there is statutory insurance by being a citizen of the country. This will make it easy for those in the informal setting that is those that are not civil servants to benefit from the insurance scheme. Insurance should also be made compulsory. If insurance were to be voluntary, people with low health risk and people that can pay out of pocket without adverse effect on their standard of living would have no reason to reason to register. Those that would register would be people with high health risk and the effect would be that there would be insufficient funds to cover their health management thus making it ineffective.

5. INCREASED PUBLIC-PRIVATE PARTNERSHIP

Government should encourage partnership with private investors. Private investors would want to make gain and as such make health services more effective. Partnership encourages effective management of scarce resources. This would strengthen the health system and bring about cost effectiveness in the health sector. Government should make private partners invest more in primary healthcare as much more people can be reached though improvement of the primary healthcare services.

 

CONCLUSION

The aim of Universal Health Coverage is to provide good affordable healthcare services for every citizen of a country. Africa as well as Nigeria still has a long way to go in achieving and fulfilling the aims of Universal Health Coverage. Everyone deserves access to good health services without much financial hardship, but someone must pay for these services. This then calls for the active involvement of the Government, non-governmental organisations, private companies and individuals in promoting and sponsoring quality health services.

 

REFERENCES

  1. Oreh, A. (2017). Universal Health Coverage – Is Leaving No One Behind in Nigeria a Pipe Dream? [online] Pubs.sciepub.com. Available at: http://pubs.sciepub.com/ajphr/5/5/4/ [Accessed 22 July. 2018].
  2. Seye, A. and Arnold, I. (2015). Operationalizing universal health coverage in Nigeria through social health insurance. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698843/ [Accessed 20 July. 2018].
  3. (2017). Adewole: Nigeria is committed to Universal Health Coverage – THISDAYLIVE. [online] Available at: https://www.thisdaylive.com/index.php/2017/12/13/adewole-nigeria-is-committed-to-universal-health-coverage-2/[Accessed 25 July. 2018].
  4. org. (2017). [online] Available at: https://www.unicef.org/esaro/UNICEF_Rwanda_–_2017_–_Health_Budget_Brief.pdf [Accessed 23 July. 2018].
  5. World Health organization. (2018). Frequently asked questions. [online] Available at: who.int\suggestions\faq\en  [Accessed  27 July. 2018]
  6. World Health Organisation. (2017). Universal health coverage (UHC).[online] Available at: http://www.who.int/en/news-room/fact-sheets/detail/universal-health-coverage-(uhc)  [Accessed 26 July.2018]

 

Author: Moses Bamigboye

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WORLD HEART DAY: THE IMPORTANCE, CARDIOVASCULAR DISEASE BURDEN, FAMSA’S ROLE AND THE ROLE OF THE GOVERNMENT.

THE HEART

The heart has been described over the years as the engine of life. From the moment it is created in a foetus, it continues to beat till the last moment of life. The heart being a muscular chamber, supplies blood and is the pump which controls the circulatory system. It is estimated that every day, the heart pumps blood through 90,000 kilometres of blood vessels.

 

WORLD HEART DAY

World Heart Day is a World Health Organization (WHO) recognized day that has been set aside to inform people around the globe about Cardiovascular Disease, the world’s leading cause of death which claims about 17.5million lives each year. World Heart Day is celebrated on 29 September each year.

 

WHY MARK WORLD HEART DAY?

 

World Heart Day being an initiative of the World Heart Federation aims at

  • Creating awareness about Cardiovascular Disease (CVD) which include stroke, heart failure, coronary heart disease and hypertensive heart disease.
  • Educating people on the need for controlling risk factors such as tobacco use, unhealthy diet, excessive alcohol intake, physical inactivity and obesity which help in preventing at least 80% of premature deaths from CVD.

It is estimated that 90% of CVD is preventable. Risk factor such as tobacco has been identified. Approximately 10% of CVD is attributed to tobacco smoking. Within two years of stopping smoking, the risk of coronary heart disease being a form of CVD has been found out to be significantly reduced. However, people who quit smoking by age 30 have almost as low a risk of death as never smokers.

High dietary intake of saturated fat, trans-fats and salt, and low intake of fruits and vegetables have been found out to be associated with increased risk of CVD. The World Health Organization attributes approximately 1.7million premature deaths from CVD to low fruit and vegetable consumption. Reducing intake of saturated fat has been found out to reduce the risk of CVD by 17%.

 

BURDEN OF CARDIOVASCULAR DISEASE

Cardiovascular disease remains the leading cause of death and disability worldwide accounting for about 17.5million deaths every year. CVD resulted in about 17.9 million deaths (32.1%) in 2015, up from 12.3 million (25.8%) in 1990. Of the 57 million global deaths in 2008, 36 million (63%) were due to Non Communicable Diseases (NCDs) and 17.3 million (30%) were due to CVDs. Nearly 80% of NCD deaths occur in Low – and middle – income countries (LMICs). Coronary artery disease and stroke account for 80% of CVD deaths in males and 75% of CVD death in females. Most CVD affects older adults. In the United States, 11% of people between 20 and 40 have CVD, while 37% between 40 and 60, 71% of people between 60 and 80, and 85% of people over 80 have CVD.

Cardiovascular is among the top three causes of death in Sub-Saharan Africa with about 210 daily deaths from CVD in South Africa. The challenge is that the prevalence of major risk factors has increased in the last 10 years.  Hypertension has been identified as the biggest single risk factor in Sub-Saharan Africa. The African region has the highest prevalence rate, 46% of adults aged 25 and above. The prevalence has been suggested to be increasing rapidly. The number of adults with hypertension in 2025 is predicted to increase by about 60% to a total of 1.56billion, with a disproportionate prevalence developing countries including Sub-Saharan Africa. 1 in 3 South African adults have hypertension and about 10% of the population over 15 years of age are pre-hypertensive. In the Sub-Saharan African region, 30% of adults over the age of 18 suffer from hypertension. In contrast with other CVD risks such as high BMI, the burden of hypertension is greater in lower income countries than higher income settings. Multiple risk factors positively interact to exacerbate CVD risks. Hypertension, for example, combined with unhealthy diets (high sodium and excessive alcohol intake) and lack of physical activity has a multiplicative negative effect on CVD mortality and disability-adjusted life-years (DALYs). In Sub-Saharan Africa, the prevention, detection, management and control of hypertension should now be regarded as a high priority. It is estimated that if the 10 – 20 million people who are believed to have hypertension in Sub-Saharan Africa were treated effectively, about 250,000 deaths would be prevented annually.

 

FAMSA’S OBJECTIVES

Federation of African Medical Students’ Associations (FAMSA) is a Non Governmental Body which has contributing towards the improvement of health in Africa as one of her objectives.

Having identified the rise in incidence of CVD in Africa, in marking this year’s World Heart Day, FAMSA aims at

  • Creating an awareness about CVD related deaths via various media platforms

The social media being a vital tool in disseminating information is being employed by FAMSA in staging a world class online campaign on the need to have a healthy heart. In line with this year’s theme of “My Heart, Your Heart”, the social media messages will preach sharing power via various ways. Other plans include gathering medical students together to display the need for a healthy heart by snapping with campaign posters and also forming a heart shape.

  • Educating the African populace about the possibility of reducing the risk of CVD

Studies have proven that about 80% of CVD risk can be reduced by lifestyle changes. FAMSA hopes to use the various campaign media to educate the African man on the need to engage in daily exercise, stop tobacco smoking, promote healthy diet and check his blood pressure regularly.

  • Identifying the risk factors of CVD and how they can be prevented

This campaign will aim at identifying risk factors with high prevalence in our community. In so doing, people who are at high risk are identified and educated about the need to put a stop to the identified risk factors or ensure adequate control as seen in diabetes mellitus.

 

ROLE OF GOVERNMENT IN REDUCING THE RISK OF CVD

The burden of CVD in Africa can be reduced if the African Government rises up to the increasing rate of CVD related deaths. Various measures that should be put in place include:

  • Creating a surveillance system to monitor CVD deaths and identifying those at risk of having CVD
  • Implementation of stringent tobacco control policy
  • The prevention, early detection, management and control of hypertension should be regarded as high priority.
  • Ensuring availability of diets that promote healthy heart and putting in place measures that limit the availability of diet high in fat, sugar and salt.
  • Putting in place strategies that control excessive consumption of alcohol
  • Promoting physical activity among the populace by creating an awareness on the need for it
  • Equipping the healthcare services available and provision of new and effective ones.
  • Making available healthy diet for school children.

 

CONCLUSION

Healthy heart is essential for healthy living. Ensuring a healthy heart begins with you as an individual. The risk of CVD related death can be reduced and it begins with you. The African government should rise up to the increasing rate of CVD related death. The message of ensuring a healthy heart should be preached to every individual. You and I should make a promise towards a healthy heart!

 

REFERENCES

Cooper RS, Rotimi C, Kaufman JS, et al.(1998) “Hypertension treatment and control in Sub-Saharan Africa: the epidemiological basis for policy. Br med J. ; 312:614-617. doi: 10.1136/bmj.316.7131.614 (Accessed 28th September, 2018)

Francesco PC, Michelle AM. (2016) “Cardiovascular disease and hypertension in Sub-Saharan Africa: burden, risk and interventions”. Intern Emerg Med.; 11: 299 – 305. doi: 10.1007/s11739-016-1423-9 (Accessed 28th September, 2018)

GBD 2013 Mortality and Causes of Death, Collaborators (2014). “Global, regional, national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990 – 2013: a systemic analysis for the Global Burden of Disease Study 2013”. Lancet. 385 (9963): 117 – 71. PMC 4340604. PMID 25530442. doi:10.1016/S0140-6736(14)61682-2. (Accessed 28th September, 2018)

Ibrahim MM, Damasceno A. (2012) “Hypertension in developing countries”. Lancet; 380:611 – 619. doi: 10.1016/S0140 – 6736 (12) 60861 – 7 (Accessed 28th September, 2018)

Kearney PM, Whelton M, Reynolds K, et al (2005). “Global burden of hypertension: analysis of worldwide data”. Lancet ; 365:217 – 223.doi:10.1016/S0140 -6736(05)70151-3 (Accessed 28th September, 2018)

Liesl Zuhlke (2016). “Why heart disease is on the rise in South Africa”. The Conversation Africa (Accessed 28th September, 2018)

Lim SS, Vos T, Flaxman AD, et al.(2010) “A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990 – 2010: a systematic analysis for the Global Burden of Disease Study 2010”. Lancet. 2012;380:2224 – 2260. doi: 10.1016/S0140-6736(12)61766-8. (Accessed 28th September, 2018)

McGill HC, McMahan CA, Gidding SS (2008) “Preventing heart disease in the 21st century: implications of the Pathobiological Determinants of Atherosclerosis in Youth (PDAY) study”. Circulation. 117 (9): 1216 – 27. PMID 18316498. doi:10.1161/CIRCULATIONAHA.107.717033 (Accessed 28th September, 2018)

Seedat YK (2004). “Recommendations for hypertension in Sub-Saharan Africa”. Cardiovasc J S Afr. 15:157 – 158. (Accessed 28th September, 2018)

 

Authors: Odedara A. M. and Ogunfolu A. A.

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