Can rural West African communities be custodians of their own health?
Most western and high-income countries have functional healthcare systems predicated on citizen protection from catastrophic costs which often arise (for the average working class person and below) when health care has to be paid for out of pocket. Based on the World Health Organisation's (WHO) definition, catastrophic costs are health expenditures 40% above a household's capacity to pay. In real terms, any expenditure that jeopardises a household's ability to meet its subsistence needs is frankly catastrophic; not to mention the incalculable emotional and physical strain it puts on the infirm and their families. It is obvious that poorer households are at greater risk and will more often face catastrophic costs. To put this in perspective, consider the impact of paying out of pocket for an emergency appendectomy for a successful lawyer versus a teacher versus a subsistence farmer. Night and day effects for uppermost and lowermost socio-economic strata indeed.
According to WHO, 800 million people spend greater than 10% of their household income on healthcare and 100 million every year descend into extreme poverty as a result of healthcare spending, living on $1.90 or less per day (NGN 689.70). To curb this, healthcare systems must be designed to be equitable with healthcare funding based on prepayment and pooling of risk and resources in order to reduce individual cost and prevent people paying out of pocket for health. This is undoubtedly the best means of achieving financial protection for any population and only by this can universal health coverage be achieved.
The Nigerian situation: Nigeria has little by way of a functioning health insurance system that safeguards its poorest. Of course there is the Nigerian National Health Insurance Scheme (NHIS) which is underpinned by capitation; however this means that the nation's poor who do not have regular salaried jobs or even bank accounts are excluded from the scheme when ironically, they are the most in need of financial protection. It is not clear if the government has a unique strategy to address this major gap in health and equity. One solution would be entitlement to free health care or substantial subsidy for households below a certain income line, paid for from the nation's revenue pot. However, this does not happen routinely (if at all) in Nigeria. The issue is not lack of revenue as Nigeria is by no means a poor country; the failure to prioritise health and to recognise the link between health and national productivity, much more so. The Maria-Nina Foundation's recent activities in a rural district in the heart of Abuja FCT unmasked several deficiencies in the health system. A needs assessment revealed that achieving universal health coverage in this district is very far off as the current situation stands; and proffering viable and sustainable solutions is a matter of urgency.
This provokes the question "Can rural West African communities be custodians of their own health and should they be?" Should people hovering around or living below the poverty line throw up their hands in exasperation and abandon themselves to fate, praying to be dealt luckier cards in another life? Or, can they (should they) come together in communities and take charge as much as possible of their circumstances, simultaneously raising their voices to the government? Is it possible for rural dwellers to operate on a micro level, the pooling of risk and finances, led by their chieftains or female leaders? Many are not unfamiliar to "contributions" as a way of raising funds for projects. Can a "contributions-based" form of health insurance be practised in rural settings, so that those without salaries and bank accounts can hand in their monthly contributions to a locally vetted and appointed rural official and in times of distress, get their health bills paid up to an agreed amount? This is theoretically possible but its success will be based on honesty, trust and cohesive efforts on health promotion and disease prevention, to reduce drastically, costs that would otherwise be incurred from treating preventable conditions. Food for thought now; the feasibility for safe experimentation will be explored.
In a move to help a rural community achieve universal health coverage (UHC), The Maria-Nina Foundation (MANIF) has established its first community health post in the Guzape district of Abuja, where some essential UHC services will be provided. For now, prevention and treatment of hypertension and diabetes, HIV and hepatitis screening and facilitation of treatment pathways are in place. The aim is to include reproductive, maternal, newborn and child health, cervical cancer screening and smoking cessation services in the near future.