Editor’s Note: For UHC Day on December 12th, The Nigeria Health Watch team in partnership with Centre for Family Health Initiative (CFHI), held a Community UHC Forum in Jiwa, on the outskirts of Abuja’s Municipal Area Council. The goal was to learn what the community understood about the country’s Basic Health Care Provision Fund (BHCPF) that is enshrined in the National Health Act. The event was supported by the UHC2030 Coalition. Nigeria Health Watch’s Programme Analyst, Aloysius Chidiebere Ugwu, writes about key learnings from the forum, highlighting the importance of ensuring that communities are brought onboard and involved in the process, if Nigeria is indeed to achieve Universal Health Coverage and “leave no one behind.”
“I went to the facility with two of my kids to access free medical care, but on reaching there, I was told that we will all have to register to get treatment, and because I don’t have money to run the required tests for registration, we went back home”.
These were the words of Hajara Yahusa, a resident of Jiwa community in Abuja Municipal Area Council (AMAC), Federal Capital Territory (FCT), who wanted to access services from a health facility accredited by the government to deliver the minimum package of health services as laid out in the National Health Act. Unfortunately, Hajara’s story is not different from others in Jiwa and perhaps in neighboring communities. The mandate of Universal Health Coverage (UHC) is to “Leave no one behind” regardless of age, gender, ethnicity, and social status. This means that nothing should deprive anyone from accessing affordable and quality care.
The World Health Organisation (WHO), defines Universal Health Coverage as “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user the financial hardship.”
The minimum service package as provided in the National Health Act is expected to be funded from the Federal Government’s annual statutory transfer of not less than one percent of its Consolidated Revenue Fund (CRF), grants by donor partners and other sources. Services covered by the Fund include antenatal care, delivery and postnatal care for pregnant women; immunisation, treatment for malaria, pneumonia, measles and dysentery for children under 5; and malaria treatment, family planning, screening for hypertension and diabetes for all adults. An effective and efficient roll out of this fund could be a game changer for the achievement of UHC in Nigeria.
On the journey towards achieving UHC, it is important to bring UHC down from the conceptual cloud of political dialogue to the human face of communities who should be beneficiaries of this global initiative. A community hall forum organised by Nigeria Health Watch and Centre for Family Health Initiative to commemorate the 2019 UHC-Day was intended to help generate understanding, awareness and grassroots demand for UHC and motivate policies and investments that truly leave no one behind.
The Community Forum had representatives from the Emirate council, village leaders, health workers from the BHCPF accredited facility, and community groups. It was a townhall style event which allowed community members to air their opinions and concerns about the implementation of the BHCPF. It also allowed for fuller explanation of issues surrounding the BHCPF, including explaining the concept in the native language of the community, Hausa.
Key takeaways from the Community Forum include:
Understanding the Basic Health Care Provision Fund: It was learnt at the forum that the Jiwa community was properly sensitised on different occasions by civil society organisations and government agencies on the BHCPF and its’ benefit packages. Community members were knowledgeable of what the fund is and what it provides for them as beneficiaries. This is an encouraging step towards leaving no one behind. Still, there is need for continued sensitisation and support for community members to demand for the full implementation of the BHCPF. Continuous advocacy will stimulate the community to hold government accountable, especially at the local government level.
The BHCPF registration process: Despite the fact that Jiwa’s Primary Health Centre has been accredited by the National Primary Healthcare Development Agency (NPHCDA), community members pointed out during the forum that they had not been able to access services provided by the BHCPF, primarily due to registration issues. A number of community members said they were dissatisfied with the registration process, noting that the cost to register was prohibitive. The registration requirements include; a passport photograph, National Identification Card and Blood group test results. Community members said the blood test cost 200 naira per person. Community member Hauwa Tanko said “the poor turn out is due to the money attached to registration, for instance a mother of six or ten children will find it difficult to register all of them, that is why most people are not registering”. The Programme Manager of the BHCPF Secretariat, domiciled in the Federal Ministry of Health, was invited to be at the event, but was unable to send any representative.
Poor health seeking behaviour: When asked where people go first to seek for healthcare when they fall sick, Alhaji Ahmed Akwoshi, the Hakimi (Traditional Ruler) of Jiwa community said that most of his people prefer to patronise patent medicine vendors or private health facilities. He noted that this was because of the long waiting time in public healthcare facilities and the poor attitude of health workers towards patients. With the accreditation of the Jiwa PHC under the BHCPF, it is hoped that the quality of care at the facility will improve. Health worker attitudes to patients rank high as one of the reasons patients do not go to the health facility, and if Nigeria is to improve its health indices and move towards Universal Health Coverage, this is one area that is critical for the implementers of the BHCPF to take into consideration. If poor health seeking behaviour persists in local communities, many will be left behind.
From the conversations at the forum, it is clear that while the Jiwa community is aware of the BHCPF, implementation is yet to fully start. This can be attributed to the financial challenges in registering for the scheme as described by community members. Enrollment in the BHCPF is presumably free, so one solution may be for health facilities to be mandated to do the blood group tests for free, or perhaps the Local Government Health Authority should further sensitise the community on why the test fee is important, to enable registration to continue. The whole aim of Universal Health Coverage is to reduce financial burden on the citizens when accessing health care, and this aim could be missed if the cost of enrolment is prohibitive for certain communities, especially vulnerable populations earmarked to benefit from the fund.
Although community members are aware of the BHCPF and its benefit packages, there is still a lack of trust between community members and the healthcare system, due to their rather unpleasant experience with health workers. Adamu Tanko, who is 96 years old, narrated the unfair treatment meted out to him on several occasions at the Jiwa PHC, prompting him to start seeking care from a private facility. “When I go to the health facility, the health workers do not treat me with respect and sometimes I spend up to ten days just to access care,” he said.
Stories like this highlight the need for more sensitisation and education to regain the community’s trust. Also, there is need for training and retraining of health workers on patient-centered care to understand how to treat patients needs with respect and dignity. The government across the federal, state and local government levels should understand that to “keep the promise”, the epicenter of UHC is the community. They should consider the peculiarities and challenges of different communities as they work to roll out the BHCPF to all Nigerians.
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