Monday, January 14, 2013

0 Universal health coverage and our children

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IT is hard to believe, but a child’s future can be determined years before they even reach their fifth birthday.

A child’s potential can be greatly enhanced or just as equally limited, within the first five years of their life. These years comprise the most fragile years and are the gateway to the formative years of a child’s life. Securing the future for our children, and indeed our country, requires that extra attention be paid to these formative years. It also means that we as young people must take up a role in advocating for the healthcare and other needs of these children, as the future of all our efforts is theirs to hold and cherish.

According to the UN Inter-agency Group for Child Mortality Estimation, some 80 per cent of the world’s under-five deaths in 2011 occurred in only 25 countries, and about half in only five countries: India, Nigeria, Democratic Republic of the Congo, Pakistan and China. India (24 per cent) and Nigeria (11 per cent) together, account for more than a third of under-five deaths worldwide.

Under-five mortality rate is defined as the probability of dying by age five expressed as the total number of such deaths per 1000 live births. It is strictly speaking, not a rate but a probability of death derived from a life table. It is a leading indicator of the level of child health and overall development in countries. It is also a Millennium Development Goal indicator. According to the World Health Statistics 2012, Nigeria has a rate of 143 per 1000 live births, Ghana 74, DR Congo 170 and a rate of less than 20 across most of Europe.

The Federal Minister for Health listed achievements in the health sector, in a Guardian article on 13 September, 2012, most of which were hugely underwhelming as there were not enough short or long term benefits to the health and healthcare of our children, lacing these achievements. They mostly comprised the adoption of a National Strategic Health Development Plan, promises of a Health Sector Performance Report in the coming months and numerous committees, task forces and on-paper strategies.

However, some concrete improvements can so far be appreciated and the Federal Ministry of Health must be given due credit for these milestones. Some of these achievements include doubling the funding of Polio Eradication activities to N4.7 billion, compared to 2011, the introduction of the new Cerebrospinal Meningitis vaccine, the new trauma centres in University of Abuja Teaching Hospital and the National Hospital nearing completion, modernisation of some Federal Teaching Hospitals to apparently international standards (Sokoto and Kano are inaugurated, Ile-Ife and Benin are completed, Nnewi and Calabar are at advanced stages), introducing the National Centre for Disease Control (NCDC) and a few others.

New and or improved health facilities, and increased investment and effort in immunisation schemes, are remarkable steps towards improving our health and the health of our children and should be applauded.

Having taken a look at some of the achievements in the Nigerian health sector today, some key issues arise on how these achievements are affecting people at the grassroots, how it is contributing to a guaranteed future for our children and our country and if the most relevant issues are being addressed in ensuring the health of our children.

An in-depth analysis of the health and socio-economic designs of our country will most likely show that the biggest killer of our people, and especially our children, is the really small matter of universal health coverage or a lack of it.

Universal health coverage is defined as: ensuring that all people have access to needed health services – prevention, promotion, treatment and rehabilitation – without facing financial ruin because of the need to pay for them.

If parents cannot afford to pay for health care, or will go broke from accessing health care for these children, then the battle for childhood survival, within our circumstances, appear to already be lost.

According to the World Health Organisation, three fundamental, interrelated problems restrict countries from moving closer to universal coverage. Firstly, the availability of resources, as no country, no matter how rich, has been able to ensure that everyone has immediate access to every technology and intervention that may improve his health or prolong his life. Secondly, an over-reliance on direct payments at the time people need care, which include over-the-counter payments for medicines and fees for consultations and procedures – whether that payment is made on a formal or informal (under the table) basis. Thirdly, the inefficient and inequitable use of resources, as at a conservative estimate according to the WHO, 20–40 per cent of health resources, is being wasted.

The World Health Assembly resolution 58.33 from 2005 says everyone should be able to access health services and not be subject to financial hardship in doing so. The data on the extent of financial catastrophe and impoverishment associated with direct out-of-pocket payments for health estimates that each year up to 10 per cent of the population in many countries suffer financial catastrophe, with up to 4 per cent pushed under the poverty line, due to healthcare related payments simply because they use health services for which they are forced to pay out of their own pockets.

Imagine having total savings of N100,000, and a family of two kids of primary school age. An acute illness requiring hospital admission for a week, drugs and laboratory investigations for one child, could cost as much as N50,000 in a federal hospital. How much then of one’s savings are left?

Without financial risk protection in health – the assurance that they will not suffer severe financial problems if they need to use health services – people will defer seeking care or not seek it at all.

The bottom line then is that, even if adequate services are provided to safeguard the health of our children, the fear of financial hardship from seeking healthcare will consistently deter parents from seeking healthcare for these children. If these children cannot get healthcare, then our future as a nation is not secure.

What then can we do to help these children and to safeguard their parents from the financial risks of seeking healthcare?

Health financing is one of the eight priority areas of the Nigerian National Strategic Health Development Plan, rubber stamped by President Goodluck Jonathan. The National Health Insurance Scheme (NHIS) is very central to health care delivery in the country and the health ministry has supposedly put a lot of effort to upscale coverage.    There is the community health insurance scheme, and the Voluntary Contributory Health Insurance, all aligning to reduce out-of-pocket payments, which account for 62 per cent of total health spending in Nigeria (World Health Statistics, 2012).

However, the government has failed to deal with or do enough in certain core areas, surrounding making health care affordable to our children and their parents.

With very low level of funding, we cannot ensure universal access to even a very limited set of health services. On the other hand, higher levels of funding might not translate into better service coverage or improved health outcomes if the resources are not used efficiently or equitably.

The National Health bill, not necessarily a perfect document, will definitely change the direction of health and health care in Nigeria, if implemented. It guarantees financial commitment from the Federal Government, commitment to essential health pillars, limitation of resource wasting and engagement of the grassroots in subsequent health policymaking.

The bill specifically promises to provide all Nigerians with a basic minimum package of health services and pledges to develop a national health policy that includes N60 billion (about US$380 million) devoted to primary health care each year, provision of essential drugs, and comprehensive vaccination programs for expectant mothers and children younger than five years.

A former health minister, Professor Adenike Grange, said four years ago and I quote “....the absence of a National Health Act to back up the National Health Policy has been a fundamental weakness which needs to be tackled frontally. This weakness means that there is no health legislation describing the national health system and defining the roles and responsibilities of the three tiers of government and other stakeholders in the system. This has led to confusion, duplication of functions and sometimes lapses in the performance of essential public health functions.”

While National Assembly debated the bill from 2003 – 2011, the Nigerian Medical Association estimated that seven million children and 385,000 mothers died in the interim. The bill has been on the desk of the President since May 2011 and remains unsigned, with no explanations provided to the public. How many more children will die before the bill gets signed, is anyone’s guess.

Several additional funding approaches for health care are being used by many countries including Robin-hood taxes, taxes on mobile phone ownership/airtime usage or mobile money, increased value added taxes, excise taxes on tobacco and alcohol, and/or insurance premiums and other exemplary schemes. These prepayment approaches, with subsequent pooling of available financial resources spread the risk across the population, and help to ensure that people can use health services without fear of financial risks.

This basic concept behind health insurance needs to be explained at great length and effort to the public, to win them over and get them to subscribe. The people will have to take on a paradigm shift that ensures looking out for one another through risk sharing and crowd pooling of resources for health needs. The government will, however, need to educate people, as well as be the role model in this desired paradigm shift.

In Nigeria, as in every country, a proportion of the population is too poor to contribute via income taxes or insurance premiums. They will need to be subsidised from pooled funds, generally government revenues.

The health ministry is putting some effort into this already. However, there is still a huge gap that needs filling. Ultimately, universal coverage requires a commitment to covering 100 per cent of the population, and plans to this end need to be developed from the outset even if the objective will not be achieved immediately.

Universal coverage with needed health services maintains and improves health. Good health allows children to learn and adults to earn. It helps people escape from poverty and provides the basis for long-term economic development. At the same time, financial risk protection in health prevents people from being pushed into poverty because unexpected illness requires them to use up their life’s savings, sell assets, or borrow – destroying their own future and often that of children.

“No one in need of health care, whether curative or preventive, should risk financial ruin as a result” – Margaret Chan, WHO Director General.

If Nigeria as a country would like to guarantee its future, we must seek to promote and protect our health and most especially, the health of our children.

We as a people, have to become and remain accountable to this country’s children. A first step is to ensure that they can access healthcare without the deterrent posed by out-of-pocket payments.

• Chijioke Kaduru is a medical doctor

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