ABSTRACT

Universal health coverage aims to increase equity in access to quality health care services and to reduce financial risk due to health care costs. It is a key component of international health agenda and has been a subject of worldwide debate. Despite differing views on its scope and pathways to reach it, there is a global consensus that all countries should work toward universal health coverage. The goal remains distant for many African countries, including Nigeria. This is mostly due to lack of political will and commitment among political actors and policymakers. Evidence from countries such as Ghana, Chile, Mexico, China, Thailand, Turkey, Rwanda, Vietnam and Indonesia, which have introduced at least some form of universal health coverage scheme, shows that political will and commitment are key to the adoption of new laws and regulations for reforming coverage. For Nigeria to improve people’s health, reduce poverty and achieve prosperity, universal health coverage must be vigorously pursued at all levels. Political will and commitment to these goals must be expressed in legal mandates and be translated into policies that ensure increased public health care financing for the benefit of all Nigerians. Nigeria, as part of a global system, cannot afford to lag behind in striving for this overarching health goal.

INTRODUCTION

Universal health coverage (UHC) arose as a visionary initiative by global health care leaders to address the challenges faced by many countries in providing increased access to quality health care services without creating financial hardship. It has been viewed from different perspectives.[¹1. Abiiro GA, De Allegri M. Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates. BMC Int Health Hum Rights. 2015 Jul 4;15:17.] According to the 2005 World Health Assembly resolution, UHC is “access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost thereby achieving equity in access.”[²2. World Health Organization [Internet]. Geneva: World Health Organization; c2017. Programmes. Document Center. Sustainable health financing, universal coverage and social health insurance; 2005 Apr 7 [cited 2016 Nov 10]. Available from: http://www.who.int/health_financing/documents/cov-wharesolution5833/en/
http://www.who.int/health_financing/docu... ] In 2010, WHO referred to UHC as a basic principle according to which everyone, regardless of ability to pay, has access to quality health care services without suffering financial hardship as a consequence.[³3. World Health Organization. The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization; 2010. 128 p.] UHC has also been defined as “necessary health care of good quality,”[⁴4. Kutzin J. Towards Universal Health Care Coverage: A Goal-oriented Framework for Policy Analysis. Washington, D.C.: The World Bank Group; Jul. 57 p.] while some scholars define it as providing all citizens with “adequate health care, regardless of their employment status or any other factors.”[⁵5. McIntyre D. Learning from experience: health care financing in low- and middle-income countries. Geneva: Global Forum for Health Research; 2007 Jun. 92 p.] In summary, UHC aims to increase equity in access to quality health care services and reduce associated financial risk.

UHC takes into account some foundational principles such as health as a human right and equity in health. Recognizing health as a human right entails that everyone has the right to the highest attainable standard of physical and mental health,[⁶6. National Economic and Social Rights Initiative [Internet]. New York: NESRI; c2017. Human Rights. What is the human right to health and health care?; [cited 2016 Nov 4]; [about 2 screens]. Available from: http://www.nesri.org/programs/what-is-the-human-right-to-health-and-health-care
http://www.nesri.org/programs/what-is-th... ] while equity in health implies the absence of unnecessary, avoidable, unfair and unjust differences in health across population subgroups, whether defined socially, economically, demographically or geographically.[⁷7. Whitehead M. The concepts and principles of equity in health. Int J Health Serv.1992;22(3):429–45.,⁸8. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003 Apr;57(4):254–8.] There is some controversy on how to measure countries’ progress towards UHC, and The World Health Report 2010 proposed nine indicators for this purpose.[³3. World Health Organization. The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization; 2010. 128 p.] In 2014, WHO and the World Bank proposed a framework for monitoring advances towards UHC focused on indicators and targets for service coverage including promotion, prevention, treatment, rehabilitation and palliation—with financial protection for all.[⁹9. World Health Organization, The World Bank Group. Monitoring progress towards universal health coverage at country and global levels. Framework measures and targets. Geneva: World Health Organization; 2014 May. 12 p.] In 2016, Wagstaff proposed a UHC progress metric with two components in service coverage: prevention and treatment, and financial protection against impoverishment and catastrophic health care spending. He used nationally representative household survey data to adjust population averages to capture inequalities between the poor and better off, allowing nonlinear trade-offs between and within the two dimensions of the UHC indexes.[¹⁰10. Wagstaff A, Cotlear D, Eozenou PH, Buisman LR. Measuring progress towards universal health coverage: with an application to 24 developing countries. Oxf Rev Econ Policy. 2016;32(1):147–89.] Population coverage of essential health services and financial protection against catastrophic health payments are considered important measures of progress toward UHC.

HEALTH IN NIGERIA

Nigeria is the most populous country in Africa, with a population of 182.2 million. Bordering Benin to the west, Chad and Cameroon to the East and Niger to the North, it is an oil-rich country with many natural resources and a GDP of $481.1 billion,[¹¹11. World Bank [Internet]. Washington, D.C.: World Bank; c2017. Countries. Nigeria: country at a glance; [cited 2016 Jun 14]; [about 2 screens]. Available from: http://www.worldbank.org/en/country/nigeria
http://www.worldbank.org/en/country/nige... ] but high levels of inequality between rich and poor and between urban and rural areas. Nigeria, like many African countries, has yet to achieve UHC. Table 1 shows health indicators and health data for Nigeria and four African countries that have initiated varying health financing reforms aimed at achieving UHC: Ghana, South Africa, Rwanda and Tanzania.[¹²12. World Health Organization. World Health Statistics 2015. Geneva: World Health Organization; 17. 2015. 161 p.,¹³13. United Nations Development Program. Human Development Report 2015: Work for Human Development. Statistical Annex [Internet]. New York: United Nations; c2015 [cited 2016 Jun14]. 73 p. Available from: http://hdr.undp.org/sites/default/files/hdr_2015_statistical_annex.pdf
http://hdr.undp.org/sites/default/files/... ] According to 2015 data, compared to those four countries Nigeria displays a worse life expectancy at birth, as well as neonatal, infant, maternal and under-five mortality, although three of the four have lower per capita gross domestic product (GDP) and gross national income (GNI: GDP minus income earned by foreign nationals, plus income earned by nationals abroad) than Nigeria. In Nigeria, public health expenditure is less than 4% of GDP and total tax revenue is barely 1.6% of GDP; the lowest in this group of countries for both indicators.

Despite the World Health Assembly’s 2005 resolution on UHC and health financing[²2. World Health Organization [Internet]. Geneva: World Health Organization; c2017. Programmes. Document Center. Sustainable health financing, universal coverage and social health insurance; 2005 Apr 7 [cited 2016 Nov 10]. Available from: http://www.who.int/health_financing/documents/cov-wharesolution5833/en/
http://www.who.int/health_financing/docu... ] and support for UHC in 2012 by both the UN[¹⁴14. United Nations. United Nations General Assembly Sixty Seventh Session: Global Health and Foreign Policy [Internet]. 2012 Dec 6 [cited 2016 Nov 4]. 6 p. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/67/L.36&referer=http://www.un.org/en/ga/info/draft/index.shtml&Lang=E
http://www.un.org/ga/search/view_doc.asp... ] and Ministers of Health and Finance in Africa,[¹⁵15. African Development Bank Group. Tunis Declaration on Value for Money, Sustainability and Accountability in the Health Sector [Internet]. Tunis: African Development Bank Group; 2012 Jul 5 [cited 2016 Nov 4]. 3 p. Available from: https://www.afdb.org/fileadmin/uploads/afdb/Documents/Generic-Documents/Tunis%20declaration%20english%20july%206%20%282%29.pdf
https://www.afdb.org/fileadmin/uploads/a... ] Nigeria still is far behind in moving toward UHC, according to progress metrics proposed by Wagstaff.[¹⁰10. Wagstaff A, Cotlear D, Eozenou PH, Buisman LR. Measuring progress towards universal health coverage: with an application to 24 developing countries. Oxf Rev Econ Policy. 2016;32(1):147–89.] According to WHO, countries such as Mexico, Thailand, Saudi Arabia, Oman, Costa Rica, Colombia, Cuba and Estonia already have “some form of” UHC while countries such as Rwanda, Ghana, China, Chile, Indonesia, Singapore and Tunisia have gradually made important strides toward it.[¹⁶16. Stuckler D, Feigl AB, Basu S, McKee M. The political economy of universal health coverage. Background paper for the global symposium on health systems research; 2010 Nov 16–19; Montreux, Switzerland. Geneva: World Health Organization; 2010 Nov. 40 p.,¹⁷17. Rodin J. Accelerating action towards universal health coverage by applying a gender lens. Bull World Health Organ. 2013 Sep 1;91(9):710-1.]

PROSPECTS FOR UHC IN NIGERIA

Political will and commitment are important in making headway toward UHC and must be expressed as a legal mandate and translated into policies that ensure increased public financing for health care for the benefit of all Nigerians. In my opinion, Nigerian political actors and policymakers lack the political will and commitment to make UHC a reality. Ghana, Chile, Mexico, China, Thailand, Turkey, Rwanda, Vietnam and Indonesia all adopted laws and regulations as steps toward implementing UHC reforms.[¹⁸18. Gupta V, Kerry VB, Goosby E, Yates R. Politics and Universal Health Coverage—The Post-2015 Global Health Agenda. N Engl J Med. 2015 Sep 24;373(13):1189–92.,¹⁹19. Obare V, Brolan CE, Hill PS. Indicators for Universal Health Coverage: can Kenya comply with the proposed post-2015 monitoring recommendations? Int J Equity Health. 2014 Dec 20;13:123.] Nigeria can learn from these experiences by providing a legal framework for UHC and health financing reforms.

According to the Nigeria Poverty Profile Report, about 70% of the Nigerian population lived in poverty in 2010.[²⁰20. National Bureau of Statistics (NG). Nigeria Poverty Profile Report 2010 [Internet]. Abuja: National Bureau of Statistics (NG); 2012 Jan [cited 2016 Jun 14]. 30 p. Available from: http://www.nigerianstat.gov.ng/pdfuploads/Nigeria%20Poverty%20Profile%202010.pdf
http://www.nigerianstat.gov.ng/pdfupload... ] WHO reported that in 2015, general government expenditure on health was 33.2% of total health expenditure and private expenditure 66.8%.[¹²12. World Health Organization. World Health Statistics 2015. Geneva: World Health Organization; 17. 2015. 161 p.] Alarmingly, out-of-pocket expenditure remains the major financial source for Nigeria’s health system, representing 95.5% of private health expenditure (or 63.8% of total), according to World Health Statistics 2015.[¹²12. World Health Organization. World Health Statistics 2015. Geneva: World Health Organization; 17. 2015. 161 p.] In 2010, WHO proposed targets for four indicators of progress toward UHC (Nigerian value in parentheses after each): total health expenditure 4%-5% of GDP (3.9%); out-of-pocket spending not exceeding 30%-40% of total health expenditure (72%); providing coverage through prepayment and risk pooling schemes to over 90% of the population (<10%); and close to 100% population coverage in social assistance and safety net programs (3.4%).[³3. World Health Organization. The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization; 2010. 128 p.,¹²12. World Health Organization. World Health Statistics 2015. Geneva: World Health Organization; 17. 2015. 161 p.,¹³13. United Nations Development Program. Human Development Report 2015: Work for Human Development. Statistical Annex [Internet]. New York: United Nations; c2015 [cited 2016 Jun14]. 73 p. Available from: http://hdr.undp.org/sites/default/files/hdr_2015_statistical_annex.pdf
http://hdr.undp.org/sites/default/files/... ,²¹21. The World Bank. The atlas of social protection: indicators of resilience and equity [Internet]. Washington, D.C.: The World Bank Group; [updated 2016 Jul 26; cited 2016 Jun 14]. Available from: http://data.worldbank.org/data-catalog/atlas_social_protection
http://data.worldbank.org/data-catalog/a...

22. Onoka CA, Onwujekwe OE, Uzochukwu BS, Ezumah NN. Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria. Health Res Policy Syst. 2013 Jun 13;11:20.-²³23. Uzochukwu B, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing in Nigeria: Implications for achieving universal health coverage. Niger J Clin Pract. 2015 Jul–Aug;18:437–44.] Nigeria falls short of these four target indicators and is unlikely to achieve UHC, unless there is a reduction in reliance on out-of-pocket payments. Some attempts were made to explore social health insurance and private health insurance with the establishment of the National Health Insurance Scheme (NHIS) under Act 35 of 1999 and its eventual launch in 2005 (delayed by political instability), as well as establishment of health maintenance organizations, but these did not translate into increased population health coverage.

A 2013 study suggested that <5% of the Nigerian population is covered by NHIS, mainly government employees. [²²22. Onoka CA, Onwujekwe OE, Uzochukwu BS, Ezumah NN. Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria. Health Res Policy Syst. 2013 Jun 13;11:20.] Most Nigerian states do not yet provide health insurance coverage to those in the formal sector of the economy covered by NHIS a decade since its inception.[²³23. Uzochukwu B, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing in Nigeria: Implications for achieving universal health coverage. Niger J Clin Pract. 2015 Jul–Aug;18:437–44.] A similar study in 2015 found <1% of the Nigerian population covered by private health insurance, which is voluntary[²³23. Uzochukwu B, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing in Nigeria: Implications for achieving universal health coverage. Niger J Clin Pract. 2015 Jul–Aug;18:437–44.] rather than legally mandated.[²⁴24. Sekhri N, Savedoff W. Private health insurance: implications for developing countries. Bull World Health Organ. 2005 Feb;83(2):127-34.] The law establishing NHIS does not mandate private companies to provide health insurance to their workers; not surprisingly, few do so. What’s more most people in the informal economy have no health insurance coverage.

Another obstacle to UHC is inefficient use of resources. Health spending has not translated into improved health status and better population health outcomes.[¹²12. World Health Organization. World Health Statistics 2015. Geneva: World Health Organization; 17. 2015. 161 p.,¹³13. United Nations Development Program. Human Development Report 2015: Work for Human Development. Statistical Annex [Internet]. New York: United Nations; c2015 [cited 2016 Jun14]. 73 p. Available from: http://hdr.undp.org/sites/default/files/hdr_2015_statistical_annex.pdf
http://hdr.undp.org/sites/default/files/... ] However, in Rwanda, a community-based health insurance scheme (CBHI) has proven to be a viable model for moving closer to UHC.[²⁵25. Lu C, Chin B, Lewandowski JL, Basinga P, Hirschhorn LR, Hill K, et al. Towards universal health coverage: an evaluation of Rwanda Mutuelles in its first eight years. PLoS One. 2012;7(6):e39282.] While Nigeria’s NHIS contains provisions for CBHI for poor communities (Community Based Social Health Insurance Programme, or CBSHI, part of the Informal Sector Social Health Insurance Programme), it has not provided financial protection for the vast majority of people in rural areas and the informal sector; I concur with other authors that it is due to poor leadership and lack of governance. [²⁶26. Odeyemi IA. Community-based health insurance programmes and the National Health Insurance Scheme of Nigeria: challenges to uptake and integration. Int J Equity Health. 2014 Feb 21;13:20.] In fact, one study shows that the CBHI in Nigeria has been associated with poor coverage, poor health care service delivery, high rates of attrition, high levels of poverty in rural areas, poor uptake, low awareness, lack of information, low client participation, lack of trust, lack of incentives for management teams, inadequate financial support, and issues concerning sustainability of subsidies paid by program managers.[²⁷27. Center for Public Policy Alternatives. 2014. Achieving Universal Health Coverage in Nigeria: Assessing the Community Based Health Insurance Scheme (CBHIS) in Lagos. A study report [Internet]. Lagos: Center for Public Policy Alternatives; 2014 Jul [cited 2016 Nov 4]. 18 p. Available from: http://www.cpparesearch.org/wp-content/uploads/2014/12/Community-Based-Health-Insurance.pdf
http://www.cpparesearch.org/wp-content/u... ] Once again, greater political will and commitment on the part of government is important to increase health investments, engender strong engagement, scale up CBHI across the country, provide the necessary leadership, improve governance, encourage community support, promote acceptance, build trust, and thus overcome most of the aforementioned shortcomings.

The right to health is a key component of UHC. The Nigerian constitution does not establish a fundamental right to health,[²⁸28. International Center for Nigerian Law [Internet]. Abuja: ICFNL; c2017. Constitution of the Republic of Nigeria; 1999 [cited 2016 Nov 4]. Available from: http://www.nigeria-law.org/ConstitutionOfThe FederalRepublicOfNigeria.htm
http://www.nigeria-law.org/ConstitutionO... ] which could help explain the lack of political will and commitment to UHC among Nigerian policymakers and political actors. Furthermore, health systems in low- and middle-income countries, including Nigeria, are weak,[²⁹29. Mills A. Health care systems in low-and-middle- income countries. N Engl J Med. 2014 Feb 6;370(6):552–7.] and there is evidence that UHC cannot be accomplished in weak health systems.[³⁰30. Meessen B, Malanda B. No universal health coverage without strong local health systems. Bull World Health Organ. 2014 Feb 1;92(2):78–78A.] Weak health systems have hindered achievement of the Millennium Development Goals, the success of disease-specific interventions, improvement in population health and health outcomes.[³¹31. Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet. 2004 Sep 4-10;364(9437):900–6.]

Health indicators displayed in Table 2 show that Nigeria falls short of the African continental average for health service delivery, health financing and health system organization. There are large health and health-related inequalities between the poor and the better-off in Nigeria. Most households and indi-viduals do not get the health care services they need, regardless of their ability to pay.[¹²12. World Health Organization. World Health Statistics 2015. Geneva: World Health Organization; 17. 2015. 161 p.,³²32. World Health Organization. Public financing for health in Africa: from Abuja to the SDGs. Geneva: World Health Organization; 2016. 92 p.] Table 3 shows health and access disparities by sex, sector (rural vs. urban), education and region in Nigeria. States in the South East, South West and South South regions of Nigeria have better health outcomes than states in the North Central, North West and North East regions.[¹²12. World Health Organization. World Health Statistics 2015. Geneva: World Health Organization; 17. 2015. 161 p.,³³33. National Population Commission (NG), ICF International. Nigeria Demographic and Health Survey 2013. Abuja: NPC; 2014 Jun. 538 p.] Furthermore, public and private health facilities demand upfront payment before a patient is treated even in an emergency. All these contribute to a substantial financial burden of out-of-pocket payment for health care among individuals and households; some 23% of Nigerian households experience catastrophic health expenditures (>10% of nonfood expenditure).[³⁴34. Ichoku HE, Fonta W, Onwujekwe OE. Incidence and intensity of catastrophic health care financing and impoverishment due to out-of-pocket payments in southeast Nigeria. J Insurance Risk Manag. 2009;4(4):47-59.]

THE WAY FORWARD

For Nigeria to improve people’s health, reduce poverty and achieve prosperity, UHC must be vigorously pursued at all levels. Although the World Health Report 2010 acknowledged that there is no single path to UHC,[³3. World Health Organization. The World Health Report 2010: Health Systems Financing: The Path to Universal Coverage. Geneva: World Health Organization; 2010. 128 p.] Many high- and middle-income countries have taken advantage of the benefi ts of UHC, and Nigeria, as part of a global system, cannot spare any efforts towards this overarching health goal. Inadequate health fi nuancing by political actors and policy makers is a major obstacle to UHC. Furthermore, health funding has not been judiciously utilized over decades, leading to concerns about effi ciency in resource use, which impedes progress toward UHC. [³⁵35. Olaniyan O, Lawanson AO. Health expenditure and health status in northern and southern Nigeria: a comparative analysis using national health account framework [Internet]. Paper presented at the 2010 CSAE Conference at St Catherine College, University of Oxford; 2010 Mar; Oxford, United Kingdom. Cape Town: Data First; 2010 [cited 2016 Oct 19]. 18 p. Available from: http://www.csae.ox.ac.uk/conferences/2010-EdiA/papers/451-Lawanson.pdf
http://www.csae.ox.ac.uk/conferences/201... ] Both developed and developing countries face challenges in fi nancing their health systems,[³⁶36. Kutzin J. Health financing policy: a guide for decision-makers [Internet]. Copenhagen: World Health Organization, Regional Office for Europe, Division of Country Health Systems; 2008 [cited 2016 Nov 4]. 26 p. Available from: http://www.euro.who.int/data/assets/pdf_file/0004/78871/E91422.pdf?ua=1
http://www.euro.who.int/data/assets/pdf_... ] but governments at all levels need to increase domestic tax revenue, a potential fi nancial source proven to be key to achieving UHC.[³⁷37. Reeves A, Gourtsoyannis Y, Basu S, McCoy D, McKee M, Stuckler D. Financing universal health coverage-effects of alternative tax structures on public health systems: cross-sectional modelling in 89 low-income and middle-income countries. Lancet. 2015 Jul 18;386(9990):274–80.] Domestic fi nancial support for UHC is crucial to its sustainability, both for countries that have achieved it and countries that are striving to move closer to it. Adequate government spending on health from domestic sources is an important indicator of a government’s commitment to the health of its people.[³⁸38. Lu C, Schneider MT, Gubbins P, Leach-Kemon K, Jamison D, Murray CJ. Public financing of health in developing countries: a crossnational systematic analysis. Lancet. 2010 Apr 17;375(9723):1375–87.]

Political actors and policy makers need to take steps toward UHC in Nigeria as a major Sustainable Development Goal. Legislation is needed to make governments at all levels responsible for the health of the population. Health must be seen as a fundamental right by political actors and decision makers if Nigeria is to comply with the 2001 Abuja Declaration (in which African countries pledged to allocate 15% of their budgets to improving health),[³⁹39. Organization of African Unity (OAU). Abuja declaration on HIV/AIDS, tuberculosis and other related infectious diseases [Internet]. Abuja: OAU; Apr 27 [cited 2016 Nov 10]. 7 p. Available from: http://www.un.org/ga/aids/pdf/abuja_declaration.pdf
http://www.un.org/ga/aids/pdf/abuja_decl... ] not to mention make good on the National Health Act’s promise to ensure Nigerians’ right to access to health services.[⁴⁰40. Government of the Federal Republic of Nigeria. 8th National Health Act. Official Gazette [Internet]. 2014 Oct 27 [cited 2016 Nov 4] ;101 (145): 139–72. Available from: http://www.nphcda.gov.ng/Reports%20and%20Publications/Official%20Gazette%20of%20the%20National%20Health%20Act.pdf
http://www.nphcda.gov.ng/Reports%20and%2... ] NHIS should be expanded to cover people in both the formal and informal sectors by making health insurance compulsory. The present health fi nancing system in Nigeria contributes to increasing poverty by impoverishing people with out-of-pocket payments; hence, Nigeria needs a deliberate health fi nuancing policy to protect the poor. Such a policy should provide an appropriate mix of fi nancing mechanisms with <10% out-of-pocket payment. Lack of political will and commitment helps explain why the NHIS is made optional for states to adopt. Because NHIS is not mandated by law, most state governments have not adopted it, leaving the majority of state employees uninsured.

CBHI has played a key role in moving Rwanda and Ghana closer to UHC.[²⁵25. Lu C, Chin B, Lewandowski JL, Basinga P, Hirschhorn LR, Hill K, et al. Towards universal health coverage: an evaluation of Rwanda Mutuelles in its first eight years. PLoS One. 2012;7(6):e39282.,⁴¹41. Gobah FK, Zhang L. The National Health Insurance Scheme in Ghana: prospects and challenges. A cross-sectional evidence. Global J Health Sci. 2011;3(2):90–101.,⁴²42. Nguyen HT, Rajkotia Y, Wang H. The Financial Protection Effect of Ghana National Health Insurance Scheme: evidence from a study in two rural districts. Int J Equity Health. 2011 Jan 19;10:4.] To make similar progress, the Nigerian government should scale up CBHI throughout the country to provide fi nancial risk protection to rural residents (over 60% of the population) and the informal sector in Nigeria, providing leadership and governance by NHIS management and decision makers. Compulsory enrolment of members of rural communities under CBHI will reduce out-of-pocket payments for health care services to the barest minimum. Governments at all levels have to ensure strong involvement in the program by subsidizing premiums for poor rural dwellers and delivering quality health care services, as well as enlisting community support in order to increase uptake, reduce attrition, and increase awareness and coverage.

CONCLUSION

UHC is the provision of access to quality health care services without creating financial hardship. There is a growing consensus worldwide that health is a basic human right, hence a legal framework for UHC should be instituted in Nigeria. Enhanced political will and commitment among Nigerian political actors and policymakers are critical to making UHC a core objective of the country’s Sustainable Development Goals.

REFERENCES

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