The global community in 2015 adopted the Sustainable Development Goals (SGD), which sets the course of action for improving the lives of everyone in the world by 2030. Goal 3 of what is also known as the global goals focusses on universal health coverage, based on ‘equity, quality, and affordability’ of heath care for all citizens by 2030, to be achieved through the implementation of ‘promotive, preventive, curative and rehabilitative health services’
The World Health Organisation WHO listed six essentials of universal health coverage which are health financing for universal coverage, adequate health workforce, essential medicines and health supplies, effective health statistics and information and systems, adoption of national health policies, efficient service delivery and safety.
The ongoing strike by Joint Health Sector Unions (JOHESU) has sharply brought into national focus Nigeria’s health system challenges. In Nigeria, poor conditions of service and debilitating health infrastructure often triggered incessant strikes by medical professionals, which in turn worsened health service delivery. Another sore issue is the politicisation of the appointment of Medical Officers for Specialists and General Hospitals resulting in mismanagement; poor drug supply chain management, and lack of proper coordination of the health sector with other related sector like water supply, large-scale corruption by custodians of the Nigerian economy also have negative multiplier effects on health service delivery. Also, there is high level of brain drain due to poor working conditions. Essential drugs are adulterated, health information is not updated, national health strategy documents are not implemented, and service delivery is appalling.
Other sectoral challenges are inequality of access, poor quality of health services, unaffordability of health services, poor performance of health systems, shortage of qualified medical personnel, increased incidence of deaths from affordable diseases and medical tourism to India, South Africa and other foreign countries by affluent Nigerians in search of high quality health services that are not available locally.
The question may, therefore, be asked what is the way forward? How have other countries particularly in the developing world been able to overcome health challenges? Cuba, a developing country that has achieved almost universal health coverage is one of such countries Nigeria could learn lessons from.
Cuba and Nigeria are two developing countries at two extremes of the ideological polarity. Cuba is widely perceived to be an authoritarian socialist country, while Nigeria runs a presidential democracy. Both countries have adopted completely different variants of health systems to achieve universal coverage. While Cuba has a unified, centralised mainly preventive health system, Nigeria has a decentralised, partly privatized and mainly curative health system.
Cuba, located on the Caribbean Island, with a population of about 11 million has a better health profile compared to Nigeria, Africa’s most populous nation, with about 182million. UNDP’s Human Development Index 2016 indicators on health outcomes, rated Cuba 67th with high human development and Nigeria 152nd with low human development; while the World Health Report, 2000 ranked Cuba 36th out of 191, and Nigeria 187th of the 191-member nations for its health systems performance. Life expectancy at birth (years) is 79.1% in Cuba and 47.7 in Nigeria, also skilled health professionals’ density (per 10 000 population) was 157: 8 in Cuba and 20: 1 in Nigeria between 2005-2013.
Compared to Nigeria, there is a strong political will in Cuba to prioritize health care and achieve universal health coverage despite the imperfections of the political system. Would Cuban universal health care have been possible without the Cuban revolution.? The answer is a definite no, as political considerations dictate the nature of health policy adopted by the national governments
In Cuba, Committees for the Defence of the Revolution were established since 1960s to mobilise systems in support of public health programmes. Also, curtailment of civil liberties ensured that public health policies were quickly implemented through simple governmental decision while dissenting voices were either subdued or forced to emigrate to other countries. In the early 60s for instance, over 3000 health professionals emigrated to United States, representing about 50 percent of Cuban physicians due to poor wages and restriction of civil liberties. This led to a shortfall in health personnel that put immense work load on the remaining professionals in the country, though the Cuban government tried to address this challenge by retraining health professionals to fill the gap. The cases in both countries show that powerful socio-economic forces and interplay of class interest shaped their health policies, making it a profoundly political process
Cuba adopted a unified Primary Health care in line with its political ideology of socialising essential services. Preventive health care was expanded with the development of family doctors, one allocated to every block. This, however, had its own challenges as family doctors are expected to defend the revolution rather than make (even constructive) criticisms of health service and may bear the brunt of the frustrations of service users.
Nigeria’s health sector strategy development has suffered from policy somersault in correlation to the ideological somersault on the political landscape. In the 1980s where there was an oil boom and the military government implemented social welfare policies, the government through the third National Development Plan 1975- 1980 adopted Basic Health Service Scheme (BHSS) for the promotion of preventive medicine with emphasis on immunisation, family planning, environmental improvement, child and maternal health.
However, the neo liberal civilian government of the 1990s and 2000s, in the face of declining oil revenue relegated preventive medicine to the secondary and embarked on privatisation of health services. Not surprisingly, the beautiful policy strategies encapsulated in past documents such as the National Health Policy, Health Financing Policy, National Health Bill and National Strategic Health Development Plan (2010-2015) have failed to improve Nigeria’s health performance.
Unarguably, the challenges of inequality, poor quality, and unaffordability of health services would not be successfully addressed unless a right-based approach is adopted to the provision of health services. Cuba approached this by recognising health as a human right in its Constitution. Its article 50 states: “Everyone has the right to health attention and protection” though critics argue that this right is limited by the restriction of civil liberties, associated with the Cuban authoritarian regimes.
Nigeria does not have an express constitutional provision on the right to health, its constitution Section 17 (c) merely states that government shall ensure ‘the health, safety and welfare of all persons in employment are safeguarded and not endangered or abused’
Another reason that has been adduced for Nigeria’s poor health performance is the low priority accorded to health funding as evidenced by low financial capital allocation and actual expenditure of development plans in Nigeria between 1960 till 1980.
The adequacy of health financing is critical to achieving universal health coverage, while Cubans health system is 100% funded by government through taxes, in Nigeria, health is poorly financed through various sources-out of pocket 69%, Federal Ministry of Health 7%, Local Government 7%, State Governments 5%; Private Health Insurance less than 1%; and Community Based Health Insurance (CBHI) for rural areas. In Cuba, where health is financed by the state, the economic recession has limited resource allocation. Substantial number of health professions emigrated to greener pastures because of better wages compared to the $30 per month wage in Cuba.
Babalobi writes from Lagos via [email protected]