Health for all? Or health for those who can afford it?

A stethoscope on top of rifled out 100 dollar bills to illustrate health care costs

In view of the current events, it feels more vital than ever to revisit discussions that were held in 1974. Then, the UN adopted the “Declaration on the Establishment of a New International Economic Order”, which was meant to support the struggle against neo-colonialism and imperialism and to correct global inequalities and injustice. Against this backdrop, the Declaration of Alma-Ata on Primary Health Care was assented a few years later in 1978, emphasising the need for social and economic development in order to attain “health for all”. At that point in time, a more equitable distribution of power and resources across the world was seen as an integral part of efforts targeted at improving people’s health status

Today, a few months into the COVID-19 pandemic, the long-standing debate of whether healthcare should be a public good or allow for private profit in a “bottom-of-the pyramid” business model has once more reignited. In mid-March, the Spanish Government announced the temporary nationalisation of private hospitals. Also, the UK Government plans to make use of private healthcare facilities – however, the National Health Service will need to pay for these additional beds made available for the treatment of COVID-19 patients. 

Further South, in Nigeria, where access to healthcare remains largely tied to a household’s ability to pay, the role of the private sector in providing healthcare – including unlicensed medicine vendors and low quality providers – is substantial (not to mention the Nigerian elite that commonly seeks healthcare abroad). Yet, while private sector involvement is often promoted by the International Financial Institutions, the discriminatory effects of a growing presence of private actors in health delivery raised concerns amongst African leaders.

After the arrival of COVID-19 on the continent, discussions emerged on whether African countries’ public healthcare system will have the capacity to absorb the potential number of COVID-19 patients alongside continuing their day-to-day operations. Many African Governments can draw from their vast experiences of dealing with infectious diseases and it is imprudent to jump to any conclusion about a general capacity and aptitude of “Africa” to contain the spread of COVID-19 (rather, other places in the world could be encouraged to learn from some of the existing best practices). Nonetheless, public healthcare systems across the world, including in Africa – and most definitely in Nigeria – have been chronically underfunded for many years. 

While after independence, many African Governments introduced social policies as part of their nation-building efforts, public health budgets were cut with the ascendency of neo-liberal ideology in the 1980s and under the pressure of the International Financial Institutions, as these promoted structural adjustment programming and pro-market reforms. Since then, the scope of social policy has narrowed, and public services have become increasingly commodified and financialised. Individuals bear responsibility to cater for their own welfare and the “Alma-Ata understanding” of universal primary healthcare has been watered down to take the form of a basic minimum package, reserved for the few.

Nigeria’s healthcare system has been a subject of global debate and domestic contestations for many years. When, in 2000, the World Health Organisation published a report evaluating the world’s health systems, Nigeria ranked 187th out of 191 countries, representing one of the worst-performing healthcare systems in the world. Unfortunately, since then, the situation has failed to improve substantially. Today, maternal and child mortality rates remain high and surpass national and international benchmarks. 

Decision-makers recognise the underfunding of the Nigerian healthcare system and in 2014, a new National Health Act was signed into law, introducing a novel health financing mechanism. The Basic Health Care Provision Fund (BHCPF) is expected to pave the way to Universal Health Coverage and is seen as an instrument to ease the burden of families. Still, with only US$ 17.5 million disbursed via the BHCPF as of today, 6 years after the enactment of the law, there is an urgent need to ensure that the Government’s promise to increase funding for health does not amount to lip service

Nigeria’s situation, distinctive in many ways, is not unique. In today’s world, “development” is often understood as poverty alleviation, while concerns relating to broader structural social and economic transformation receive limited attention. Social sectors in many African countries appear segmented and focus is put – frequently, on recommendation of multi- and bilateral donors – on narrowly conceived social assistance programmes, such as cash transfers schemes targeted at “the poorest”. At the same time, inadequate levels of resources are made available to fund more comprehensive welfare regimes, which may make the difference in responding to a health crisis as the world is experiencing it now. 

The on-going pandemic, and the threats of an unfolding global economic crisis, seem to offer a good opportunity for us to re-emphasise the need for a “new international economic order” and to campaign for the return to a wider vision of social policy!

  • Julia Ngozi Chukwuma is a PhD Candidate in the Department of Economics. Her PhD research seeks to generate novel insights into how social policy, here in the context of health, has taken form in Nigeria.

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