Healthcare is a human right
On Wednesday, 15th July 2020, we stopped admitting patients to the Isolation Centre at the Landmark Village in Lagos. In line with our Memorandum of Understanding with the Lagos State Government to support the state response to COVID-19, the centre was set up by the Lagos Chapter of the Young Presidents Organisation (YPO) to be managed for a period of three months, after which the equipment would be transferred to the state for continued capacity building.
The centre was well equipped and was run as a cost-free service to the community. During the three months, I had been actively involved with the management of the centre and received daily calls from people seeking assistance and possible admission. When the three months were up, the calls continued, but all I could do was recommend some private hospitals that were accredited to be part of the effort as well as the government-run centres. Those looking for assistance came back to me with cries of woe on the amounts they had to deposit before they could receive treatment, but there was nothing I could do. Recalling my frustration at not being able to help, the following lyrics come to mind from the 1981 Adam And The Ants hit single: “stand and deliver, your money or your life.” While the lyrics refer to 18th-century English highwaymen, they also ring true for quality healthcare in Nigeria.
In 1948, the United Nations General Assembly enlisted the agreement of all Member States to the production of the Universal Declaration of Human Rights. This seminal document aligns the religious and philosophical discussion of the inalienable rights of the human being. Article 3 states that everyone has the right to life, liberty and security of the person. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition. Some 67 years later, in 2015, all UN Member States adopted 17 Sustainable Development Goals, which includes Goal 3, to ensure healthy lives and promote well-being for all at all ages.
In short, it is your right as a human being to be healthy. If you are ill, it is your human right to access the necessary healthcare services to get better. This places a responsibility on every government to at least strive for universal health coverage and ensure that healthcare is universal (available and acceptable to the people), of the right quality (safe, effective, people-centered, timely, equitable, integrated and efficient) and affordable, for all.
The challenge with this declaration is that someone has to pay for it. There is no such thing as free healthcare. This fundamental issue underpins the ongoing debate about healthcare reform in the United States with its high healthcare spend ($1.3 trillion in 2019–17% of its GDP) and relatively poor health outcomes. Some believe that healthcare is a privilege and not a right, as the government has no money of its own, which means that it cannot “give” anyone healthcare without first taking away something from someone else. The argument does further to state that healthcare for all is an unrealistic utopia as you cannot have accessible, affordable and quality healthcare for all. At best, you can only have two of the three. If healthcare is affordable and accessible, then the quality of the care will be poor, and if the quality is good, then it will not be affordable.
The pride of Britain, the National Health Service (NHS), suggests that the attainment of this ‘utopian’ dream is one of political will. The NHS was formed in 1948 on the three core principles; that it meets the needs of everyone, that it be free at the point of delivery and that it be based on clinical need and not the ability to pay. All UK citizens are eligible to use the NHS, and while there are many debates about the future of the service — that people are getting older and the burden of demand is increasing — the ‘utopian’ position has served the UK for many years and continues to evolve to make it work. The NHS is funded from general taxation and contributions from individual taxpayers. It is a central payment system, and although there are concerns over the cost burden with iterations being proposed and carried out by successive governments, the NHS remains the pride of England and is genuinely universal healthcare.
As lofty and as idealistic as this may sound, it is not impossible to make this utopian ideal a reality. Already, 32 countries have achieved universal healthcare in some form, and 11 of these countries are in Africa, including Burkina Faso, Rwanda and Ghana. To follow suit and meet the ideal of universal health coverage for all, the three legs of universal healthcare must be addressed simultaneously, these being universal accessibility, quality and affordability. There will inevitably be some necessary trade-offs to define the journey towards universal healthcare. For example, who are the people to be covered, what are the services to be covered and what proportion of the services to be covered? And, how will these services be financed? Will it be from general taxation or compulsory or voluntary insurance?
We must further consider the challenges associated with the economics of healthcare, which is not driven by conventional market economics of supply and demand. This is because third parties such as government and insurance companies are invested in outcomes and can influence patient purchasing decisions through scheme designs and regulatory considerations.
The people must have access to clinics that are safe and effective in treating their conditions in a timely manner and they must receive the right level of care. This ideal may be difficult to achieve within the constraints of limited healthcare budgets. Indeed, it requires political buy-in with a deliberate and intentional focus to drive most healthcare purchasing and infrastructure towards primary care, increasing the role of technology in healthcare and developing innovative financing models. Countries such as Thailand were able to achieve universal health coverage as far back as 2002 by focusing on task shifting from doctors to nurses and using paramedical personnel to solve the problem of staff shortages as well as building the required primary care infrastructure as the first point of call.
Health is essential for production, and a productive society will thrive to the benefit of all. It isn’t easy to define the return on investment for healthcare dollars in terms of national output because of the long term nature of health as well as the multivariate nature of the determinants of the outcomes. Still, the statement is intuitive enough to be compelling. We need to look into ways of making healthcare more affordable such as leveraging technology to expand access. Technology will be a crucial enabler of primary care by making healthcare more patient-centric and taking healthcare to the patient. The interface of remote monitoring and big data algorithms holds a lot of promise for community surveillance and chronic disease management, all of which will support primary care without the need for bricks and mortar clinics.
There is a lot of evidence that the burden of non-communicable diseases such as diabetes, heart disease and cancer can be reduced by a shift to the enhancement of wellness with dietary and lifestyle modification. We need to do better at driving the assurance of quality healthcare delivery through regulation and enforcement so that the healthcare dollars spent translate to real improvements in outcome. Innovative healthcare payment models that link the payment for healthcare to recharge card behaviour for air time are showing real promise in many African countries. Having said all of this, the real driver of change will be the political will to reduce the burden of poverty as well as the belief that quality, affordable and accessible healthcare is the right of everyone.
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