Universal Health Coverage (UHC) – which simply means equitable access to needed quality healthcare services without the risk of financial catastrophe or impoverishment associated with obtaining care – is one of 169 targets of the Sustainable Development Goals (SDGs), more in particular target 3.8.  While there is evidence that a strong Primary Health Care (PHC) system contributes to improved access to healthcare, PHC can also produce a range of (health) economic benefits through its potential to improve health outcomes, health system efficiency and health equity.  Despite all this available evidence there has not been much debate on how best to organize or re-organize PHC within a country’s health system, mobilize resources to finance PHC and purchase PHC services to improve health system performance in the context of the global push for UHC.

A recent symposium  

It is in line with the above, that the Sophia University Institute for Human Security,  a Japanese institute committed to advancing and realizing human security through social science research, organized a two-hour mini-symposium on 5 November, titled Why Primary Health Care (PHC) is important in progress towards Universal Health Coverage (UHC) – perspectives from Asia and Africa. The 3 panellists for the symposium included Dr Viroj Tangcharoensathien, (well-known in global health circles); Dr Toru Honda (medical doctor and one of the founders of SHARE (Services for Health in Asian African Regions)); and Dr Kurfi Abubakar  (author of this blog).

The symposium started with a brief presentation on the definition of PHC, its evolution, components, principles, emerging trends and challenges of PHC in the context of UHC by Dr Honda.  Dr Honda also talked about the PHC system in Japan drawing on its preventive focus and how the policy makers have been able to balance demands and supplies with dexterous skills, controlling healthcare costs under the universal health insurance system.  Dr Viroj then gave an insight into Thailand’s experience of achieving UHC by establishing a strong PHC system. He also dwelled on the current research agenda to help strengthen policy for PHC and UHC, drawing on preliminary results from a seven-country study on the capacity of PHC to cope with public health problems involving non-communicable diseases . Dr Viroj also discussed the UHC status of countries in the East Asia and Pacific region, drawing lessons on how countries can learn from each other as they design their various trajectories towards UHC. For me, the takeaway from Dr Viroj’s lectures was that not all low catastrophic health expenditure is good, especially if there is high unmet need. Services must be available and accessible first, before we talk about how costly they are.

After these two gentlemen, I gave a talk on the ongoing health care financing reform in Nigeria; challenges and opportunities for strengthening PHC for UHC in the context of Nigeria. My presentation focused on how PHC is organized and financed in Nigeria; how NHIS purchases PHC for members; and the challenges for PHC under NHIS in the context of Nigeria.

A panel discussion was then facilitated by Prof Ayako Honda to further discuss the following key issues:

• Migration and PHC for UHC – As the numbers of people moving between countries are steadily increasing globally, the variety of motivations and conditions for mobility, as well as the socioeconomic context and political climate in which this mobility occurs, add to the complexity of responding to health challenges faced by migrants in their sending, transit and receiving countries. Conditions surrounding the migration process may exacerbate health vulnerabilities and risk behaviours, as is the case for a victim of sex trafficking through transnational networks. Conversely, it can be an enabler for achieving better health trajectories, see for example a newly arrived refugee as part of a humanitarian settlement programme accessing treatment for a chronic disease. Due to the lack of legal status, stigma, discrimination, language, cultural barriers and low-income levels, irregular migrants may be excluded from accessing primary health care services, vaccination campaigns and health-promotion interventions.   Panellists therefore agreed that equitable access for migrants to low cost PHC can reduce health expenditures, improve social cohesion and enable migrants to contribute substantially towards the development of their (new) nations. However, the relationship between migration and health is complex, and its impact varies considerably across migrant groups, and from person to person within such groups.
• Re-organization of PHC for UHC as a society changes – The well-known Alma-Ata Declaration established a standard of public commitment to making community-driven, quality health care accessible to all, both physically and financially. The world has made substantial progress on global health outcomes since then, even if the work is far from finished. Advancements happened as a result of the complex interplay of numerous factors which include demographic, technological, economic as well as environmental factors, among others. If we apply this insight to 21^st century Africa where we have rapid urbanization, increasing life expectancy, high fertility rates with a huge burden of young people, growing food security threats due to global warming and other man-made disasters, the need to reorganize and re-prioritize the delivery of PHC has never been more urgent and pertinent. Panellists agreed that PHC is not only a necessary tool for tackling these challenges, in fact, they stressed that UHC and the health related SDGs can only be sustainably achieved with a stronger PHC system. This PHC system should be able to adapt and respond to a complex and rapidly changing world.
• Links between policy makers, researchers and civil society – In order for PHC to serve as a veritable catalyst for UHC, numerous actors and players work together to strengthen the delivery of PHC. How these players affect and/or are affected by the system determines the success (or failure) of a nation’s push for a PHC-driven UHC. The symposium appreciated the need for more emphasis on the multisectoral nature of PHC, and emphasized the need for coordination of all the critical stakeholders working in the UHC space in order to avoid duplication of efforts, waste of scarce resources and to ensure complementarity of efforts.

UHC momentum in Nigeria

If I put this discussion on the “UHC space” in the Nigerian context, there has been a massive push lately towards expanding the fiscal space in the country through the introduction of the Basic Health Care Provision Fund (BHCPF). The BHCPF, which is made up of 1% of the consolidated revenue fund of the country, including other contributions from donors and implementing partners, is meant to be shared between the National Health Insurance Scheme (50%) for the purchase of a basic minimum package of health care services, while 45% of the funds is meant for the National Primary Healthcare Development Agency to provide infrastructure and other essential medicines and manpower to PHC. In addition, 5% of this fund is earmarked for the provision of medical emergencies and epidemics management .The BHCPF represents a very good avenue for the NHIS to provide the much needed coverage to the informal sector, especially the poor and the vulnerable.

In addition to the BHCPF, the Federal Government of Nigeria has also made a conscious effort to reposition the National Health Insurance Scheme (NHIS) in order for it to provide comprehensive and affordable quality healthcare services to all Nigerians. The new Executive Secretary of the NHIS, Prof Muhammad Nasir Sambo has developed a three-point agenda for repositioning the NHIS towards effectiveness and efficiency in service delivery. This agenda includes: value reorientation, ensuring transparency and accountability in the delivery of health insurance services in the country, as well accelerating the drive towards UHC.  Under the new Executive Secretary, the NHIS will be more inclusive, it will work in synergy with all actors and players who are directly or not directly under its authority, among others, the informal sector, civil society organizations, the private sector and the state and local government administrators. This will help it to identify innovative ways to address bottlenecks that limit access to care for all Nigerians.

I have great hope that the commitment of the Federal Government of Nigeria to provide additional resources for health, the zeal of the new Executive Secretary of the NHIS in accelerating UHC through a decentralized health insurance system and the active participation of all stakeholders in the health sector in Nigeria will galvanize Nigeria’s journey towards Universal Health Coverage.