In the push for global health reforms, no initiative has been as uniting as the call for Universal Health Coverage (UHC). Governments view UHC as a means to gain political favour and through advocacy, citizens are being educated about their right to quality, accessible and affordable healthcare.
In spite of the ongoing advocacy and sensitisation efforts, knowledge gaps, which can only be breached by effective communication, still exist. Because UHC is context specific, communication strategies must also be tailored to fit the context. Nigeria’s journey to achieving UHC has been long and eventful. The country’s first attempt at building a healthcare system was made in 1962 (Medical World, 2015), when the then Federal Minister of Health, Dr. M. A. Majekodunmi, presented a bill in parliament for its enactment in Lagos, but it was rejected. In 1988, the then Minister of Health commissioned a committee that recommended the template for the present-day National Health Insurance Scheme (NHIS). The law was signed in May 1999, but became operational in 2005.
Today, Nigeria is at a critical inflection point in its effort to expand access to healthcare and to move toward UHC. Nigeria’s UHC Declaration was adopted at the Presidential Summit on UHC in 2014. In October 2014, the National Health Act (NHA) was signed into law, providing a legal framework for the provision of healthcare services to Nigerians and for the organization and management of the health system. The Nigerian Federal Ministry of Health (FMoH) with its key stakeholders is now in a crucial position to develop a comprehensive strategic communication plan to support the emerging UHC strategic plan.
To address the need for explicit guidance on strategic communication for UHC, the United States Agency for International Development’s (USAID) Health Finance and Governance Project (HFG) partnered with the Joint Learning Network for Universal Health Coverage (JLN) to bring together an eight-country delegation to co-produce a Practical Guide to Strategic Communication for UHC and accompanying Planning Tool. These resources are intended for adaption to meet local needs, associated with strategic communications planning.
At the workshop, participants broke into groups to identify key UHC messaging for target audiences. Photo credit: Nigeria Health Watch
Nigeria is piloting the Practical Guide and accompanying Planning Tool to develop its strategic communication strategy. The FMoH is working with USAID, Health, Finance and Governance (HFG), Results For Development (R4D) and Nigeria Health Watch (NHW) to develop the UHC strategy. In order to better understand what Nigerians know about UHC, the Federal Ministry of Health commissioned stakeholder mapping and a data collection and analysis survey, which was carried out by Nigeria Health Watch, in the three states where the Basic Health Care Provision Fund (BHCPF) is going to be piloted – Abia, Osun, and Niger States – as well as in the Federal Capital Territory (FCT). Following the survey, a stakeholder forum held to discuss the results of the survey, after which a validation survey and social media poll was also conducted.
Themes and sub-themes of stakeholder survey:
| S/N | THEME | SUB-THEMES |
| 1 | Level of Awareness of UHC | |
| 2 | Universal Health Coverage, a Right or Privilege. | |
| 3 | How Can UHC be achieved in Nigeria? |
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| 4 | Benefits of UHC in Nigeria | |
| 5 | Financing UHC in Nigeria | |
| 6 | UHC Opposition in Nigeria |
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| 7 | Government Policies or initiatives on UHC | |
| 8 | Knowledge, beliefs and behaviour that influence UHC in Nigeria. | |
| 9 | Desire for UHC | |
| 10 | Communicating UHC to a child |
Table 5: Thematic framework
Survey participants were asked to explain what Universal Health Coverage meant to them. One participant responded:
“Universal Health Coverage; It’s like an insurance, in the sense that, for a premium you want a certain amount of access to health care for everybody, not for everything anyway, but at least people should be covered per say to some extent in terms of health care, where the coverage prevents them or stop them from paying from their pockets when they receive the care because it would have been paid for previously either through premium or some other means.” Media, Abuja.
Participants were asked if UHC was a right or a priviledge. One respondent summarized it this way:
“It should be a right, considering chapter 2 of the Nigerian constitution, which makes healthcare as part of the primary responsibility of the government…It appears to be right, but the caveat is that it is not justiciable, in the sense that you cannot even sue the government for not doing that but in reality, it is a right.” CBO, Abia State.
When asked what benefits UHC would have on the nation, one participant said,
“So many things will change. I will give you an example in my area where I live, a girl that used to come to my house, because of diarrhea we lost her. Just because of 3 thousand naira, we lost a grown-up girl. They said they should bring, 3 thousand naira, they couldn’t, and they lost that girl. Now by the time these things are accessible she would just run to any clinic.” Indigenous NGO, Niger State.
The survey asked participants for their knowledge of government initiatives to achieve UHC. A majority of respondents had heard mainly about the NHIS.
Another respondent mentioned that:
“Honestly speaking I know that there is National Health Insurance Scheme but I know that the coverage of National Health Insurance Scheme is abysmally low, very low, and its actually covering the people who you would think have an advantage, because its covering the Federal Government workers so the vulnerable are not covered for the most part by National Health Insurance Scheme but I also know that some states are setting up their own health insurance schemes that go beyond those in the formal employment sector, and trying to figure out how you will cover petty traders, and casual workers, women and children and all that.” CBO, Abuja.
Finally, participants were asked how they would explain UHC to a 10-year-old child. One participant responded:
“The basic line I believe they should hear is for them to know that you, boy or girl, you are a bonafide citizen of this country. It is your right to live a healthy life and it is your right that whenever you are sick government comes in to treat you. It is your right that when you go to the hospital your parents don’t need to worry about where they will get money to treat you.” Armed Forces, Abia State.
Some participants at the Strategic Communication for UHC workshop. Photo credit: Nigeria Health Watch
On July 19, the Federal Ministry of Health(FMoH) and its partners held the UHC Stakeholders’ Forum to discuss and design messaging for the strategic communication document. This document will lay the foundation for the government’s efforts at crafting a communications framework for Universal Health Coverage across Nigeria. The meeting was attended by representatives from government and development partners, including federal and state ministries of health, USAID, UNFPA, NHIS, HFG, R4D, WHO, and the Media. Participants analysed the stakeholder survey and its findings and made key observations. Target audiences in need of UHC communication were expanded to include political parties, traditional and religious leaders, youth groups, vulnerable communities and the agricultural sector. Participants broke into groups to identify key UHC messaging for different target audiences. After the Forum, a validation survey was sent out to over 18,000 health professionals to further validate the key messaging for target audiences.
At the Stakeholder Forum messaging was developed for four target audiences; Traditional and Religious Leaders. Youth, Market and Pregnant Women, and Vulnerable Communities. Participants agreed that key messaging that traditional and religious leaders need to hear is, “Universal Health Coverage will help you reduce out of pocket payments and protect you, your family, and your livelihood.” For youth, key messaging they need to hear is, “Good health enables you to have a good social life, and helps you achieve your dreams and passions. This is not a privilege, it is your right and you deserve it.” One of the key messages that market women and pregnant women need to hear is “UHC will save cost. It is free for you and your household. UHC is free healthcare for all;” while key messaging for unreached and vulnerable communities to hear is “healthcare is a right of every Nigerian, no matter where you are.”
“It is great to know that Nigeria has been doing all the necessary things,” Elaine Baruwa, Abt Associates. Photo credit: Nigeria Health Watch
At the closing of the stakeholder forum, Elaine Baruwa of Abt Associates (HFG) expressed pleasure at the fact that Nigeria has been at the forefront in implementing Universal Health Coverage. “It is great to know that Nigeria has been doing all the necessary things,” she said. She spoke of the need to change the trajectory of politicians’ mindsets to one where they make promises that are tangible for the health sector. “We are going to require them to put health on the agenda…It’s not just that they say, it’s that the whole group of stakeholders actually hears what is being said and holds them accountable,” she said.
As the Federal Ministry of Health works towards developing an effective strategy to ensure that Nigerians fully understand and can appreciate the need for Universal Health Coverage, it is important that health advocates continue to raise awareness at both the Federal and state levels, that the buzz around UHC does not become a passing fad but we begin to take realistic albeit incremental steps towards actualizing UHC in Nigeria.
Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (WHO 2017).
This definition of UHC embodies three related objectives and constraints:
1 Equity in access to health services – everyone who needs services should get them, not only those who can pay for them;
2 The quality of health services should be good enough to improve the health of those receiving services; and
3 People should be protected against financial-risk, ensuring that the cost of using services does not put people at risk of financial harm.
Constraints:
▪ Robust and reliable technical infrastructure
▪ Value-based service model
Its success and effectiveness is directly related to a robust technical infrastructure designed to track performance metrics, prevent abuse of service ie Stark Law, and other fraudulent gaps. Babies crawl before they can walk; one size does not fit all; UHC is not plug-and-play; nations should prove they are able to provide quality care before implementing UHC. Nigeria has yet to prove that. What most of these UHC advocates fail to realize is how contradictory their messages/stand are; thanks to social/electronic media for easy and effective information tracking.
As we are all aware, Insurance is a process of transferring Risk. What insurance company will be willing to insure the present quality of care in Nigeria? Till date (August 23, 2018), a nationally owned hospital at the federal capital does not have the basic infrastructure (including catheter, digital patient medical report – hand-written, etc) to effectively provide quality care resulting to loss of lives to wrongly and/undiagnosed conditions.
If you fail to plan, you plan to fail.
Universal Health Coverage (UHC) is a key step for humankind towards overcoming selfishness.
The major challenge of present human civilizations would be to have the government by the haves to be convinced that UHC is in its best interest.
The haves don’t need it and the have nots cannot get any coverage without the consent of the haves. The alternative would be for the have nots who are the vast majority to seize government power and implement it without waiting on the haves.