This week’s guest blog comes from Robert Yates, an internationally recognized expert on progressive health financing. He works for Chatham House, the international affairs “Think-tank” based in London. He was one of the speakers at the Future of Health Conference held on June 18 in Abuja.
Far from being a lame-duck, Barack Obama is having an extraordinarily successful second term as President of the United States, to the extent that he is being heralded as one of the most consequential Presidents in US history. A number of domestic and foreign policy successes have been responsible for this transformation, but one triumph appears to have singled him out for greatness – his universal health reforms.
“Obama Gains Vindication and Secures Legacy With Health Care Ruling” trumpeted the New York Times on June 25th after the US Supreme Court voted in favour of preserving the President’s pioneering health reforms. It is now widely recognized that President Obama will go down in history as a national hero for bringing healthcare to the uninsured in America.
But President Obama is not unique in this regard. Across the world countries venerate leaders who have brought healthcare to the masses. Other examples include President Mandela in South Africa, after he launched universal free health care for pregnant women and children in 1994. Tommy Douglas has been voted the greatest Canadian of all time for bringing healthcare to all and Anuerin Bevan has become a legend in the UK for launching the NHS in 1948. More recently, President Park in Korea in 1977, Prime Minister Thaksin of Thailand in 2002 and now President Jokowi of Indonesia became national heroes for bringing health care to the masses.
What these great leaders have recognized, is that achieving universal health coverage (ensuring all people receive the health services they need without suffering financial hardship) is hugely popular. Furthermore, they have realised that with genuine political commitment and increased public financing, it is possible to implement UHC reforms surprisingly quickly and benefit the entire population. This makes health reforms unusual, because they can generate national political returns quickly, as opposed to many economic and infrastructure investments that often take decades to deliver results. Rapid popular health reforms are therefore a proven vote-winner within the time frame of one presidential term. In fact, there is strong evidence to indicate that President Obama’s early health reforms were instrumental in securing his re-election in 2012.
Looking at world history, it is also noticeable how these great leaders often delivered UHC to their populations after major political transitions in their countries. This included the UK after the Second World War, Thailand after the Asian Economic Crisis in 1998 and South Africa after the end of apartheid. Many democratic governments elected in Latin America following the overthrow of corrupt dictatorships also launched UHC reforms as a quick political win. Bringing health services to everyone was one of the best ways to demonstrate that these new leaders cared about the people and that their governments represented a break with the past.
One of the main reasons to study history is to predict where the lessons from the past might be relevant today – in which case there surely can be no better example of a country ripe for UHC reforms than Nigeria.
This is for a number of reasons. Firstly, relative to its income level, Nigeria is performing extremely badly when it comes to health, with the country unlikely to achieve many of the health related MDGs. This is partly due to health coverage being so low with only around 5% of the population covered by any form of health insurance. Given this low baseline, there is therefore a tremendous opportunity for the new government to improve the performance of the health sector.
Secondly, Nigeria now has the domestic financial resources to reach UHC. In 2014, a by eminent health economists estimated that countries needed to raise a minimum of $86 per capita in public health spending in order to cover the costs of UHC. They also called on countries to allocate 5% of their GDP for this purpose. Nigeria currently only allocates 1.1% , but $86 per capita only represents 2.6% of GDP, which should be eminently affordable. Rwanda, for example, allocates 6.5% its GDP to public health spending. Furthermore it should be noted that Nigeria today is almost twice as wealthy as Thailand was in 2002, when it extended tax financed healthcare to the entire population.
One strategy Nigeria could employ to find the additional public financing for UHC would be to use savings made by reducing fuel subsidies. This is an approach being adopted by Iran and Indonesia, where leaders have recognized the importance of providing a popular social policy (free health services) to the population as they increase fuel prices. As levels of fuel subsidy spending in Nigeria have been as much as seven times the federal health budget, there would appear to be considerable scope to raise public health funding from this source.
But perhaps most significantly for the likelihood of UHC success, after the recent historic elections, the Nigerian people have now voted for a progressive leader who has committed himself to bringing healthcare to the people. Following his victory, President Buhari in an open letter to the people pledged that he would:
“Guarantee financial sustainability to the health sector and minimum basic health care for all.” [In other words achieve UHC]
As world history has shown, all the health and economic ingredients may be in place but it is the political catalyst that is the key to achieving UHC. Of course the President and his Government would need to plan and implement Nigeria’s own path to UHC, reflecting the country’s specific health, economic and political context. In particular, it will be vital to take into account Nigeria’s federal system to secure political buy-in at the state level and facilitate fiscal transfers to ensure that poorer regions receive their fair share of national resources. It will also be imperative that the President maintains genuine political commitment to overseeing the necessary health system reforms and that the population holds him to account on bringing effective coverage to everyone.
If President Buhari invests similar levels of political capital into UHC, as President Obama, there is every chance that in 5 years time the Nigerian media and people will be heralding him as one of the most consequential presidents in Nigerian history. Furthermore he would go down in world history as one of the great political leaders who recognized the importance of bringing universal health coverage to their people and who delivered on their promise.