As part of the debate on health systems in West Africa, WATHI met with Dr Francis Ohanyido, President of the West African Academy of Public Health, to discuss the challenges of health systems in West Africa and specially in Nigeria. In this first part of the interview, we discuss about the implementation of universal health coverage (UHC) in the region.
- Recently several African countries have embarked on the project of providing universal health coverage to their citizens with varying degrees of success. How do you analyze it?
The movement to universal health coverage (UHC) in West Africa is possible, but the varying degrees of successes that you have mentioned are largely as a result of the level of strategic visioning and political will of the country’s leadership to the implementation of their UHC roadmap. UHC is more of an initiative that provides political investment and implementation opportunity for West Africa to improve accessible and equitable health care.
That said, it is common knowledge that most West African nations have duly incorporated UHC as a goal in their national health strategies but none has truly attained UHC. However, evidence suggests that executing these strategies and their underlining commitments so that there is first an expanded level of domestic resource mobilised in country have not been quite successful. Secondly, there are also issues of effective use of available external development assistance that still plagues most of these countries due to general lack of transparency and accountability. Lastly, the peak of our UHC odyssey is to finally achieve significant equitable and quality health care with improved financial protection for citizens, but this has largely remained in the realm of our national dreams.
I always caution that we need to always remember that countries are coming along the UHC road with different national peculiarities that define their political economies, which then determine how their commitments to goals are affected. So therefore, it means that there is no one-size approach to it that fits-all all countries for achieving UHC, because it must ride on home-grown understanding of national circumstance and how stakeholders and the state dialogue around making it happen. It is only the stewards of the state that truly can make this happen, so political commitment remains the key.
- What are the common challenges that you identify among the West African countries that have implemented this project?
Even though I have cautioned about lumping countries into one UHC model, it is obvious that despite their unique circumstances, one can look at some critical evidence to list what could be seen as commonalities that challenge West African countries on the journey. This is just an off the cuff list that come to mind.
First, most countries are yet to meet the Abuja target of 15% allocated and expended on health from their annual national budget. A year after that commitment, it was only Gambia that met that mark. Almost two decades later, meeting up with that commitment has challenged almost all the countries of the region. Nigeria which has the largest population target to cover and an economic engine room in the region has barely done more than 5% of its budget in terms of allocation with even less than that expanded over the years. So in other words meeting a health financing bulwark for UHC has been a major challenge across board.
Secondly, generally, across the region, service delivery capacity has expanded, but so has the population grown. There is an attendant gap of lower density of health workers than required, thus the overall capacity to deliver health services suffers a persistent bottleneck to achieving UHC. We would probably require about one million skilled health professionals (doctors, nurses, and midwives) to meet the sustainable development goal three (SDG-3) in West Africa Health Organisation (WAHO) countries. Recollect that the 2013 SDG Index threshold of 4.45 physicians, nurses and midwives per 1000 population showed that sub-Saharan Africa was struggling with a shortfall of about 2.7 million professionals to meet the required capacity towards attainment of the SDG 3 which UHC (SDG 3 target 8) forms the cornerstone.
There is no one-size approach to it that fits-all all countries for achieving UHC
Third, out of pocket spending by citizens of West Africa is still rising in the face of region-wise commitment to UHC. Empirical evidence from household surveys between 1990 and 2014 shows that for 25 years, millions of households reported suffering impoverishment from catastrophic health spending.
This is despite the fact that many countries of West Africa attempted to attain the millennium development goals within a significant part of that period. Evidence suggests that across the region, household health expenditure as percentage of total health expenditure (%) ranges from 35% in Burkina Faso (a low-income country) to as high as 72% in Nigeria (a lower middle-income country).
Fourth, in countries where social health insurance programmes have gained traction, the tendency has been to inadvertently perpetuate inequity by focusing more on formal sector while the informal sector with more at the bottom of the social pyramid suffer. The private health insurance segment tends to focus more on targeting the rich, so adds only little in rapidly in supporting the overall coverage.
Meanwhile, attempts at driving community based health insurance programmes wholly owned and run by communities have not be largely successful, mostly because their voluntary contribution structure tends to challenge sustainability. Ghana’s government had to take over paying the salaries of the staff of such community-based structures.
Five, the status of Essential Public Health Functions (EPHF) in the region is generally still weak as many of the countries are not adequately prepared for public health emergencies despite the 2014 devastating Ebola pandemic in some of the countries of the region. Nigeria is currently battling a Lassa Fever epidemic which seems to have become almost an annual cycle. The region currently looks with trepidation as the 2019 Novel Coronavirus runs a fast-paced pandemic course globally with Wuhan as its epicenter.
Why will it not? Many countries are only just waking up to the realization that epidemic preparedness is very important and failure to do so can mar the gains even in an otherwise thriving health system. This ultimately would impact on the goal of achieving quality UHC. The Academy would love to see an EPHF peer review system for West Africa that strengthens the regional health security which strongly involves the civil society.
The private health insurance segment tends to focus more on targeting the rich, so adds only little in rapidly in supporting the overall coverage
Six, many West Africans do not have access to affordable, safe and quality essential medicines and technologies which has not only challenged the individual citizen, but also the performance of the health system. Fake and adulterated drugs as well as inappropriate use of drugs are still major sources of concern. There is also significant entry into the system of substandard equipment and fake equipment due to poor regulation by authorities. These have significant impact on the journey to quality UHC.
There are many other challenges. These are by no means exhaustive.
- How to solve these challenges?
I will speak generally so that it touches the challenges I have listed and others not included here. Fundamentally, it still comes back to issues of stewardship and larger health system accountability. At the West African Academy of Public Health (WAAPH) and Institute, we have a saying that “Leaders must commit and walk the talk of their political will”. Of course, the solutions will also have to be driven by the peculiarities of each country so that that it can achieve UHC targets by 2030.
Our national governments as a necessity should continually reform the health system to pursue improved and more-equitable coverage for our population, and the path to leaving no one behind needs to advance over time as population requirements and health burdens change.
The Academy would love to see an EPHF peer review system for West Africa that strengthens the regional health security which strongly involves the civil society
There is need to finance health better by meeting the Abuja target of 15% of annual budget and also ensure accountability and transparency to certify that citizens get more health for the money spent and this includes development aid assistance for health. Domestic resourcing to boost health care through innovative and pro-poor options and expanded pre-payment systems are very central to this, since the demands and needs of health systems will change with time. Mechanisms for sustainable health insurance should consider a mandatory system that improves on what exists and backed by necessary statutes.
The people should be at the center of the design and execution of any country’s roadmap to UHC and the roadmap should be equity-driven and partnership friendly so as to eliminate avertable maternal and child deaths, improve resilience to public health emergencies, tackle the human resource for health gap, reduce financial hardship associated with illness, and intensify the groundworks for enduring economic growth.
The institutional and political building blocks of UHC should be crafted around the fact that it should be performance-benchmarked to ensure that no one is left behind in terms of access to information and data on UHC, ensuring value for money processes and enabling platforms for social, voice and accountability should be established to engender dialogue and cross fertilisation of ideas with feedback loops in the system.
Leaders must commit and walk the talk of their political will
If we learnt anything at all from the last Ebola epidemic in the region, it is the fact that we need to invest more in epidemic preparedness and response capacity and have clear national action plans in case of health security threats, as epidemics have the potential to destabilise economies and health systems.
- What are the other challenges of public health policies in Nigeria?
In my opinion, Nigeria as a case study does not lack strong realistically framed health policies. We can look at the challenges of public health policy from the points of design, political will, institutional arrangements/coordination and implementation ownership. For me implementation-related challenges are the main problems.Public health policy design process has its own problems. How it is done matters because it needs to speak to the needs and idiosyncratic side of Nigeria or any other country.
In the course of health sector reforms in Nigeria, most major public health policies have been often donor-supported. There has always been the risk that an agenda which may sometimes be at variance with strategic national interest of the country may be at play. However, the country has made effort over time to be in the driving seat of such actions, but sometimes indigenous capacity is lacking so external professionals need to be procured.
Many times, in the past, public health policy could be described as ‘copy and paste’ and the design may not necessarily fit the peculiarities of the country, so such policies suffered. People used to sit in distant countries and design development assistance around health policies in countries they know close to nothing about like something akin to a ‘field trial’. These days, the health sector has begun approaching policy from a human-centered design approach.
Political will is the clasp of successful policy strategy and execution. Poor political will challenges public health policies when the political class gives little emphasis to health for all sorts of reasons which I will not attempt to analyse here. This mindset, thus also affects the will to effectively finance public health policy development and implementations. For instance, it took ten years of tortuous work for Nigeria to pass its National Health Act within which is embedded a catalytic fund for repositioning primary health care called the Basic Health Care Provision Fund (BHCPF), that mandates first line charge from the consolidated revenue of the federation of not less than 1% to be devoted to it annually, outside the normal federal budget for health and that of the states and local governments.
There is need to finance health better by meeting the Abuja target of 15% of annual budget and also ensure accountability and transparency
Despite the passage of the Act, it took the Nigerian government almost another four years for the BHCPF to become funded, despite the existence of the law that mandates it to do so. The funding only happened with the intervention of the legislature due to intense pressure from campaigns and evidence-based advocacies from civil societies under the Health Sector Reform Coalition (HSRC) that spearheaded it. The Academy was a key factor in the process, because it believes the UHC focused law is something the region and the world could learn from its implementation.
In terms of institutional arrangements, the fact that Nigeria is a federation with three-tiered architecture of which health is on its concurrent list sometimes challenges the processes, structures and expected outcomes of public health policies. For example, still using the National Health Act as a case study, one can see that not all the states have met some of the requisite enabling environment in line with the guidelines expected to enable the BHCPF to be implemented in their states.
Sometime, public health policies are brought to play without giving thought to the framework for effective coordination by assessing the institutional arrangements. Because of years of military governance with unitary approach to governance, the tendency for top-down approach from the national government to sub-national structures is still generally common. However, efforts to at least engage the states more in health policy process is more or less the norm now.
Bureaucracy is also a major challenge that affects public health policy, especially at intersectoral or interagency levels in Nigeria, sometimes worsened by conflict of roles among some government parastatal.
The fact that Nigeria is a federation with three-tiered architecture of which health is on its concurrent list sometimes challenges the processes, structures and expected outcomes of public health policies
The ground zero of programme implementation is at the local or community level which is subnational and even lower than regions or states. At this level, you find that the actors are often not carried along in the process of policymaking and are frequently not educated about such policies and so there is tendency for lack of ownership, implementation malalignment and in some cases, no implementation at all. In other cases, by the time such policies are finally accessible at the downstream of the system, some of them are already obsolete.
There is often no sense of ownership of such policies. Another implementation related challenge has to do with monitoring and scoring public health policy performances, so as to feedback and learn for the next iteration. Implementation is also characterized by poor or inconsistent funding, which is not the same for polylateral programmes.
Crédit photo : Elombah News