sdg3 Akuche
sdg3 Akuche
sdg3 Akuche
Andre Ben Moses Akuche (Madonna University, Nigeria), Kennedy Nsan (Obafemi Awolowo
University), and Precious Tariela Ebikabowei Victor (Madonna University, Nigeria)
Abstract
The Ministry of Health have vast potential to facilitate the realization of universal health coverage
(UHC) and health system development in Nigeria. Until now, significant gaps exist and threaten
its sustainability in many low-income and middle-income countries. Therefore, this study
examined nurses’ knowledge of UHC for inclusive and sustainable development in healthcare
professional practice. This study was a cross-sectional survey. A convenience sample of 125
currently practicing auxiliary, pediatric and critical-care nurses was recruited. Respondents
completed a questionnaire which was based on the perception, evaluation, implementation
strategies advocated by the WHO Global Forum for nursing officers. Questions covered the
government initiative, healthcare financing policy, human resources policy, and the respondents’
perception of importance and contribution of nurses in achieving UHC. The results of the study
revealed that the effect of nurses’ knowledge on UHC on perception of development of healthcare
services was significant (β = .38; F= 23.29; p < .00). Also, the contribution of the role of nurses in
Nigeria was significant to the improvement in the perception of the universal health services for
health workers [β = .39; F = 32.77; p < .00] and the challenges faced by nurses was statistically
significant to the decline in achievement recorded in the universal health coverage [β=.42; F =
27.19; p < .00]. In addition, nurses in both clinical practice and management perceived themselves
as having more contribution and importance than those in education. They were relatively
indifferent to healthcare policy and politics. The study concluded that the survey uncovered a
considerable knowledge gap in nurses’ knowledge of UHC in healthcare professional practice
and shed light on the need for nurses to be more attuned to healthcare policy towards achieving
the UN SDGs Goal 3. The educational curriculum for nurses should be strengthened to include
studies in public policy and advocacy. Nurses can make a difference through their participation in
the development and implementation of UHC in healthcare services.
Introduction
The international community has vast potential to facilitate the realization of universal health
coverage (UHC) and health system development. Until now, significant gaps exist and threaten
its sustainability in many low-income and middle-income countries (Sachs, 2013). People
worldwide still lack access to basic healthcare. In response to this challenge, the United Nations
General Assembly passed a resolution unanimously in December 2012. It called on all countries
Why It Matters
to plan or pursue the transition of their health systems toward universal coverage (United Nations
General Assembly Resolution on Global Health and Foreign Policy, 2013).
The World Health Organization, (2012), sets its objective to ensure that all people obtain the
health services they need without suffering financial hardship when paying for them. According to
the WHO Director-General, Universal Health Coverage is the single most powerful concept that
public health has to offer (Chan, 2013). This consensus has arisen as a mounting body of
evidence shows that Universal Health Coverage can deliver significant benefits: for individuals, in
terms of access to health services and protection from financial ruin caused by ill health; for
countries, in terms of population health and contribution to economic growth (Global Health
Strategies, 2013).
However, Nigeria faces challenges that delay the progress toward the attainment of the national
government declared goal of universal health coverage. One such challenge is system-wide
inequalities resulting from lack of financial protection for the healthcare needs of most Nigerians
(Okolo, Nwankwo, Okoli and Obikeze, 2019). This paper aims to synthesize the research
evidence on Universal Health Coverage and challenges as it affects health workers perception
as well as present policy recommendations in an accessible way to stakeholders and
policymakers who might not have a technical background in the plight of health workers.
Universal health coverage (UHC) is defined as the entire spectrum of health services, ranging
from health promotion, disease prevention, acute care and treatment, rehabilitation, to palliative
care, and it should be financially affordable and geographically accessible to everyone in need
(Awojumobi, Remilekun and Okpara, 2017). The definition embraces two key concepts,
inclusiveness of the coverage and the sustainable development of the services provided. The
former being, how the coverage is representative of the people and how far-reaching are its
policies as well as sustaining consistency in effectiveness in accomplishing aims, while the latter
portends the how plans, policies are integrated into local and international programmes and what
strategies to adopt in other accomplish long and short-term objectives (Awojumobi et al., 2017).
The multifaceted quest for sustainable health and development, communities represent a unique
and potent resource. Communities that are healthy, empowered, and prosperous are the
grassroots drivers of national and regional development (Woodward, Smart, Benavides-Vaello,
2015). Without communities as partners and leaders, all our aspirations for health and
development will amount to little more than rhetoric (Iwu, Ekeh and Austin-Evelyn, 2017).
Community health workers who come from the communities they serve, are answerable to these
communities, and receive training that is shorter than that required for doctors, nurses or other
health professionals represent the essential missing gap, between broad societal yearnings and
the communities who both need assistance the most and serve as essential vehicles for progress
(Woodward et al., 2015). Few, if any, of our health and development tools match the potential of
community health workers to drive gains on multiple fronts. A substantial body of evidence
demonstrates that community health workers increase uptake of health services, reduce health
inequalities, provide a high quality of services, and improve overall health outcomes (Iwu et al.,
2017).
Why It Matters
The World Health Organization has been advocating UHC over the past few decades to ensure
all human beings are able to seek health services and are not deprived of services because of
financial hardship (Willmann, 2012). The elderly population is one of the most vulnerable groups
that require extra effort to achieve UHC. This is partly because of the loss of gainful employment
and partly because of the increased incidence of co-morbidity in this group of people (Willmann,
2012). As expected, demands for health and social care will increase by many folds due to the
trending rise in the aging population. Thus, the rights of elderly in accessing healthcare may face
unprecedented levels of threat; Nigeria is no exception (Department of Health, 2015).
In Nigeria, the healthcare system, including elderly services, relies on both public sector and
private sector. While 88%of the secondary and tertiary healthcare services were provided by the
public sector, nearly 70% of the primary healthcare services were provided by the private sector
(Chimezie and Faloye, 2014). All Nigeria citizens are eligible to seek medical services from the
public sector at an extremely low fee. This fee may also be waived if the person covered by the
comprehensive social security scheme (Chimezie and Faloye, 2014).
The development of the nursing profession in Nigeria is considered relatively more mature than
in many African countries, yet the level of nurses’ participation in politics was reported to be low
(Tajudeen, Ifeanyi and Owoeye, 2015). Often, nurses were perceived to be apathetic to political
decisions, even if they were healthcare related (Nwanfor, Ogoribuno and Nza, 2018). Heavy
workloads, a sense of powerlessness, gender bias, lack of understanding of the political and
policy making process, and ethical conflicts between professional and political values may
account for this. Nurses, as one of the major healthcare providers, are the key members in the
provision of quality healthcare services, and advocate for health choices and health policies
(Tajudeen et al, 2015). It is important for them to be knowledgeable of the implementation
strategies for UHC, even if they do not fully understand.
Healthcare services for impoverished in Nigeria are far from adequate, despite many new
initiatives have been implemented (Nwanfor et al., 2018). Many institutions, such as day centers,
skilled nursing facilities and infirmaries want to support the initiatives; however, they cannot find
enough nurses to do so. The goal of achieving UHC for public healthcare services is moving
farther away. The situation does not appear to have any impact on nurses. This is rather unusual,
as nurses have been very devoted to vulnerable people in Nigeria (Kayode and Ossai, 2018).
Hence, this paper focuses on fundamental challenges of health workers in the purview of the
UHC.
Now, a vast proportion of health policy debate is focused on realizing the 2030 Sustainable
Development Agenda, a milestone which places specific importance on universal health coverage
(UHC) a concept which supports a collective credence that all people should have access to the
health services they need without risk of financial ruin or impoverishment (World Health
Organization,2012). However, considering the present inequalities within countries, achieving
Why It Matters
UHC in Africa and particularly Nigeria, will require inclusive participation between health systems
and the citizens across primary, secondary, and tertiary levels (Smith, 2004; Adongo, Phillips and
Aikins, 2014). As a result, community health system performance has become increasingly
relevant to both high-income countries and low-income and middle-income countries (London,
2008).
One of the fundamental problems associated with UHC is healthcare consolidation, funding, and
investment (Adongo et al., 2014). While the case for investment in health is clear, it is less
straightforward to determine whether investments in health are more beneficial than those in
areas such as education or infrastructure. Also, the strength of the case for investing in health
varies among countries. The return on investment is likely to be highest for emerging economies;
they can obtain significant improvements in health outcomes (e.g., life expectancy) through
modest increases in health expenditure. However, higher income countries might already be at a
level of expenditure where the marginal return, in economic and health terms, for increased
investment would be relatively small (Adongo et al., 2014).
Where policymakers have decided to make transformative investments in health, there are further
choices to be made, such as how to allocate resources between improving health services and
addressing the social determinants of health. Improving water quality and sanitation, or funding
girls’ education, may be as effective at improving health outcomes as spending on health services.
However, given that strengthening health systems is vital to improving health outcomes, Universal
Health Coverage is a highly effective way for countries to deliver significant health, economic and
political benefits.
The empirical evidence from various regions mostly supports the theoretical expectations
described above. Several evaluations of a national health insurance program in Nigeria, for
example, find positive impacts on health care utilization. Nwanfor, Ogoribuno and Nza, (2018) for
example measure the subsidized regime component of the program finding the intervention to
greatly increase utilization of medical care among poor and previously uninsured individuals
Giedion et al. (2017).
In a recent study, King et al. (2019) examine the impact of the randomly assigned Mexican
universal health insurance program Seguro Popular. The phased rollout of the program provides
an experimental design for a study of a program aimed at reaching 50 million uninsured Mexicans.
This study, however, shows Seguro Popular to have no significant impact on the use of medical
services but it is important to note that the study is based on a time span of only 10 months.
Galarraga et al. (2010) found that in Seguro Popular there was a reduction of catastrophic health
expenditures of 49 percent for the experimental evaluation database (the same used by King et
al. but using a different method) and 54 percent for the whole country based on a DHS-like survey.
In addition, the authors found a reduction of out-of-pocket health expenditures for most types of
services.
Why It Matters
Findings in Asia are mostly positive. Chen et al. (2007) find that one year after the establishment
of Taiwan’s National Health Insurance scheme, previously uninsured elderly people increased
their use of outpatient care by nearly 28 percent. Previously insured elderly people increased their
use by over 13 percent leaving a chance of nearly 15 percent which can be solely attributed to
the National Health Insurance scheme. In a study of a national rural health insurance scheme in
China, Wagstaff et al. (2017) find that the scheme increased utilization of both inpatient and
outpatient care by 20-30 percent but that the scheme had no impact on utilization among the poor.
Yip et al. 2008) find that the China health insurance program increased utilization by 70 percent.
Wagstaff and Moreno-Serra (2017) investigate the impact of the introduction of social health
insurance in 14 countries in Central and Eastern Europe and Central Asia and find an increase in
acute in-patient admissions.
There are few impact evaluations of health insurance in African countries and those that do exist
demonstrate a weaker methodology than the articles reviewed above. One example is Smith and
Sulzbach (2018) which examines the impact of health insurance in three African countries. The
authors find a correlation between health insurance and use of maternal health services but
highlight that the inclusion of maternal health care in the benefits package of the insurance is key.
In Jutting (2003), the author finds in a study of community-based health insurance in Senegal an
increase in utilization of hospitalization services but a failure of the program to address the needs
of the poorest of the poor. In addition to impacts on health care utilization, health insurance is
expected to provide financial protection because it reduces the financial risk associated with
falling ill. Financial risk in the absence of health insurance is equal to the out-of-pocket
expenditures because of illness.
Additional financial risk includes lost income due to the inability to work. There is little rigorous
empirical evidence measuring the impact of health insurance in its ability to provide financial
protection. The existing literature examines the impact of health insurance on out-of-pocket
expenditures for health care measured in either absolute or in terms relative to income
(expenditures are labeled catastrophic if they exceed a certain threshold). King et al. (2009) in
their study of the Mexican universal health insurance program Seguro Popular find reductions in
the proportion of households that suffer from catastrophic expenditures and a reduction in out-of-
pocket expenditures for in- and out-patient medical care (though no effect on spending for
medication and medical devices).
Wagstaff et al. (2007) find no impact on out-of-pocket health expenditures in rural China which
contrasts with Wagstaff and Yu (2007) who find reduced out-of-pocket. Achieving universal health
coverage in Nigeria one state at a time may involve payments, lower incidence of catastrophic
spending and less impoverishment due to health expenditures. By contrast, in a later study,
Wagstaff and Lindelow (2018) find health insurance in rural China to increase the risk of high and
catastrophic spending. The authors define high spending as spending that exceeds a threshold
of local average income and catastrophic spending is defined as exceeding a certain percentage
of the household’s own per capita income. This finding contradicts the hypothesis that health
insurance always will reduce financial risk.
Why It Matters
The above mentioned Wagstaff and Moreno-Serra (2017) study of Central and Eastern Europe
and Central Asia finds an increase in government spending per capita on health but not in private
health spending, while a switch to fee-for-service does increase private health spending. They
find negative effects of social health insurance on overall employment levels but positive effects
on average gross wages in the informal sector. Since it is difficult to measure the impact of
improvements in quality per se, and because few insurance interventions explicitly address the
supply-side, the literature is unclear about the separate impact of quality improvements of the
supply of care versus making health insurance available and affordable.
Theoretical Explanation
The necessary elements to ensure a functioning health system are: financing (risk pools and
prepayment); administrative systems; health care providers such as clinics and hospitals,
medication and laboratories; and the client/patient relationship. The demand (financing) side and
the supply (delivery) side should be aligned and managed to deliver care to the patient, who will
therefore be willing to prepay to ensure the availability of quality services when needed. An
alternative model is a public-private partnership community-based health insurance model (PPP-
CBHI). This model has the potential to contribute to the achievement of UHC by addressing many
of the constraints described in the previous section. The PPP-CBHI model is based on three main
pillars:
1. Building on existing local public and private institutions and informal networks;
Achieving universal health coverage in nigeria one state at a time. In this model, donor funds can
be used to catalyze the development of a more sustainable health system by stimulating
investment and risk pooling mechanisms. In this way both the demand and supply-side are
addressed. In developed countries, public institutions facilitate economic exchange in society by
reducing risk and moral hazard. Public and social goods like health care, water, sanitation and
education are effectively organized by the state through public or semi-public institutions.
However, in low and middle-income countries like Nigeria the limited functioning of the state and
its institutions hampers economic development and the rendering of public goods and services.
Informal institutions often take the place of public institutions and transactions within those
institutions are commonly enforced by social pressure and other social norms. Interventions
therefore, that build on existing local and often informal institutions for which there may be greater
trust, are more likely to succeed.
This can be achieved by, for example, leveraging social capital of communities and their local
leaders, and their existing ties with private providers. In this model, groups such as microcredit
Why It Matters
members, farmers, or market women are targeted to build on the existing social capital present
in the group. Also, contributing to the strengthening of formal institutions (e.g. quality
standards/accreditation, investment funds for social infrastructure), through involvement of the
private sector in the delivery of essential public, semi-public and social goods, is a logical step.
In many developing countries, the private sector is an important provider of health care, including
for its poor who pay for these private services largely out-of-pocket. Increasingly, many of the
facilitating functions for healthcare information, quality certification, technology support, human
resources are also provided by the private sector. This makes the private sector an important
partner to reach the primary beneficiaries, namely, low-income groups, and facilitate systemic
change in a bottom-up approach.
Harnessing the out-of-pocket expenditures into prepaid systems rather than crowding them out
with public health funding is another important element of this model. Another important element
is the leveraging of donor funding to mobilize private capital.
Ownership by and empowerment of clients and the communities they belong to is of crucial
importance for the approach to succeed. A client-oriented approach requires knowledge about
what clients want and need and what they can afford and are willing to (pre) pay. It implies the
importance of delivering good quality care to the clients/patients, which requires building a strong
health care supply chain: without good quality supply the willingness to prepay is likely to be low
(Ogungbe and Eche-Gilbert, 2019).
Based on these three main pillars, a multi-pronged approach for an alternative insurance model
was developed by the Health Insurance Fund (HIF), a Dutch foundation set up in 2005 to increase
access to quality basic health care and to provide financial protection through the provision of
private community-based health insurance to low-income Africans. On the demand side, existing
private resources for health care are used more efficiently to realize solidarity (based on health
risk) and protect scheme members from unexpected financial shocks due to ill health. At the same
time, the health insurance schemes generate financial resources to build up an efficient supply
chain and empower members to insist on high-quality care, creating a snowball effect. People
who can pay are induced to pay into risk pools, thereby creating stable health care demand.
Improved efficiency in the supply chain lowers costs and raises quality, increasing peoples’
willingness to pay. As more people buy health insurance, schemes grow, resulting in larger cross-
subsidization, which enhances equity.
Through volume effects, the costs and premiums can be further reduced. These schemes do not
compete with government programs but complement them. Beneficiaries are involved in
Why It Matters
determining who has access to the schemes, the design of the benefits package, the level of
premiums, and the costs to be covered.
The supply side is strengthened through facilitating private investments, both debt and equity
capital. Supply-chain upgrading is undertaken through quality-improvement programs with
rigorous monitoring and control, preferably in cooperation with international accreditation
organizations. Where regulatory capacity of the government is weak, enforcement of quality
standards to ensure adequate delivery of care can be a task for the private sector. Output-based
contractual agreements provide a good opportunity to do this while achieving universal health
coverage in Nigeria is possible in one state at a time (Ogungbe and Eche-Gilbert, 2019).
Donor funds are used to subsidize the community-based health insurance schemes’ premiums.
Disease-specific donor programs such as for HIV/AIDS, malaria, tuberculosis support the
insurance schemes through a risk-equalization arrangement built into the programs. These long-
term donor commitments are made with the solvency of the insurance funds serving as collateral,
which lowers the investment risk and makes investments in the health care supply chain feasible.
Limited donor funding is also used to upgrade the supply chain. Finally, donor funding is used as
a lever to mobilize additional private capital to scale up the interventions.
In 2006, Health Insurance Fund (HIF) received a £100 million grant from the Dutch Ministry of
Foreign Affairs to launch, together with its implementing partner, community-based insurance
programs in four African countries, including Nigeria. In this public-private partnership model of
community-based health insurance, donor funds are linked to African health maintenance
organizations (HMOs), insurance companies, or third party administrators. These organizations
are responsible for the execution of HIF’s insurance programs and for contracting a network of
public and private providers where scheme members can get their health services. Payment of
insurers and providers is performance-based, measured as the medical care delivered and the
number of enrollees. Insurers’ prices and profit margins are contractually fixed.
The insurance package consists of primary and limited secondary care, including treatment for
malaria, testing for HIV/Aids and TB. The programs are always complementary to regular public
sector health programs. The programs create stable healthcare demand by subsidizing insurance
premiums for target groups of African workers that enroll with the HMOs.
The program covers groups with at least some income, who must pay part of the (reduced)
premium themselves. HIF’s resources are also used to upgrade medical and administrative
capacity of the insurers and health providers contracted under the program. Quality and efficiency
are further pursued by strictly enforcing medical and administrative standards through
independent audits. This reinforces the output-based approach: payment only takes place if the
patient has received treatment that meets the agreed quality requirements. The quality
improvement activities of health care providers under the HIF program are formalized and put
under the aegis of an independent quality improvement and evaluation body called SafeCare.
Why It Matters
This organization acts as the custodian of internationally recognized standards covering the
spectrum of basic health care for providers in resource-restricted countries.
To date, HIF programs have been established for market women and farmers in Lagos, Nigeria,
coffee growers in Tanzania and for groups of dairy and tea farmers in Kenya. Currently, a total of
121,000 people are enrolled. The expansion of the program to other African countries is currently
under discussion.
Conceptual Review
This study reviewed several literature concerning to the following areas such as; identifying and
categorizing prospects and challenges for health workers especially nurse’s perception towards
Universal Health Coverage within the Nigerian polity as well as theoretical framework that
explains specific areas of this study. The health and well-being of Africans are fundamental to
Africa’s future. To ensure a healthier, more secure future, Africa has embarked on a historic effort
to lay the foundation for sustainable health and development for all.
In this multifaceted quest for sustainable health and development, communities represent a
unique and potent resource. Communities that are healthy, empowered and prosperous are the
grassroots drivers of national and regional development. Without communities as partners and
leaders, all of our aspirations for health and development will amount to little more than rhetoric.
Community health workers who come from the communities they serve, are answerable to these
communities, and receive training that is shorter than that required for doctors, nurses or other
health professionals represent the essential “missing link” between broad societal yearnings and
the communities who both need assistance the most and serve as essential vehicles for progress.
Few, if any, of our health and development tools match the potential of community health workers
to drive gains on multiple fronts (Chizaram and Uchenna, 2017).
A substantial body of evidence demonstrates that community health workers increase uptake of
health services, reduce health inequalities, provide a high quality of services and improve overall
health outcomes (Chizaram and Uchenna, 2017). Community health worker programmes also
represent good jobs, bolster national and local economies and increase productivity by improving
health and well-being. Investments in community health workers will also enable Africa to turn the
projected near-doubling in the youth population through 2050 from a potentially perilous “youth
bulge” into a dynamic “demographic dividend” that drives economic growth and improves living
standards. Indeed, investments in community health workers represent an ideal opportunity to
Why It Matters
tackle one of the most vexing problems in Africa, the perilously high levels of unemployment
among young people.
A broad range of risk-pooling mechanisms or insurance schemes are increasingly being utilized
across the developing world to increase access and reduce the financial burden of health. The
number of evaluations of such efforts is growing and while findings are mixed, the overall findings
on impacts are encouraging. In theory, we expect health insurance to contribute to achievement
of UHC because it increases access and utilization by lowering the price of health care. Individuals
will have better health if they utilize preventive and curative health care when needed and in a
timely manner (UNDP, 2011).
Several studies that evaluate the impacts of programs ranging from NHI and SHI to CBHI on
health care utilization and financial protection (Usoroh, 2012; Sachs, 2013). Broader definition of
UHC given the lack of agreement on the specific systems that might be utilized to achieve it and
because we argue that a national system may not be the only answer to achieving universal
coverage. A systematic review of the impacts of health insurance on health status in low and
middle-income countries can be found in Giedion et al. (2013).
Nigeria, with its population of around 162.5 million and a population growth rate of 2.5 percent, is
the most populous country in Africa and the 8th most populous country in world (Iwu, et al., 2017).
The country’s tumultuous history is reflected in its abundance of states beginning with only three
states at the time of Nigeria’s independence from the United Kingdom in 1960 and now with 36
states and the Federal Capital Territory (FCT), where the capital Abuja is located. This highlights
the potential challenges of managing such a heterogeneous country.
Nigeria is ranked as one of the fastest growing economies in the world with a growth rate of 6.4
percent in 2007 and 7.4 percent in 2011 (Dutta and Hongoro, 2013). Nigeria’s GDP per capita in
PPP adjusted dollars is $1,500 according to World Bank estimates from 2011. One of the main
issues facing the country is balancing oil sector revenues and government spending. Over the
last few years, the accrued oil revenues have not led to improvements in the welfare of most of
the population (Dutta and Hongoro, 2013).
Poverty incidence has varied but remained high over the past decade. In 2004, the poverty rate
was 54.4 percent., it rose to 62.6 percent in 2010 and dropped back down to 54.4 percent in 2011
(Kayode and Ossai, 2018). There are great regional disparities, reflected in a contrast between
rural areas with a poverty rate of 69.0 percent and 51.2 percent in the urban sector. The poorest
zones of the country are those in the North while the South East zone has the lowest incidence
of poverty. Inequality, as measured by the Gini coefficient, rose steadily since 1985, save for a
slight decline in 1992 (Kramer, Osagbemi, Tanović and Gustafsson-Wright, 2013).
Why It Matters
As of 2011, the total population inequality is back at the only slightly better 1992-levels with a Gini
coefficient of 0.397. Human development indicators are staggeringly low considering the country’s
GDP per capita. Nigeria ranks 156th out of 173 countries with data on the Human Development
Index (HDI) (Okolo et al., 2019).
Nigeria’s health indicators have either stagnated or worsened during the past decade despite the
federal government’s efforts to improve healthcare delivery. Life expectancy at 52 years is below
the African average, while the numbers on child mortality are astounding partly because of the
country’s size. Annually, one million Nigerian children die before the age of five due mostly to
neonatal causes followed by malaria and pneumonia (Smith and Sulzbach, 2018).
Maternal mortality is 630 per 100,000 live births which is comparable to low-income countries
such as Lesotho and Cameroon. An estimated 3.3 million Nigerians are infected with HIV and
access to prevention, care and treatment is minimal. Nigeria also continues to combat the double
burden of both communicable and non-communicable diseases (Smith and Sulzbach, 2018).
Policymakers and political leaders face tough choices and trade-offs when considering where to
allocate the limited resources at their disposal. Competing priorities make such decisions very
hard, and political dynamics often have a bigger role in determining the answers than evidence-
based evaluations of value for money. In this opening chapter we seek to briefly make the case
for investment in UHC (Giedion and Díaz, 2010).
The benefits of investing in health are significant and not limited to improving the health of the
population: there can be significant economic returns and social benefits. A recent report by the
Lancet Commission on Investing in Health lays out the channels by which health improvements
have a direct impact on GDP: productivity (healthy people are more productive and less likely to
take sick days); education (healthier children are more likely to go to school); investment (people
are more likely to save when life expectancy is longer); access to natural resources (can be
affected positively by a reduced risk from endemic diseases); temporary impact on ratio of
working-age to dependent people (Tajudeen, Ifeanyi and Owoeye, 2015). It showed that
reductions in mortality accounted for about 11 percent of recent economic growth in low- and
middle-income countries, or even 24 percent of growth if the value of added life years is used to
calculate a country’s ‘full income’ (Smith and Sulzbach, 2018).
While the case for investment in health is clear, it is less straightforward to determine whether
investments in health are more beneficial than those in areas such as education or infrastructure.
Also, the strength of the case for investing in health varies among countries (Gertler and Gruber,
2002). The return on investment is likely to be highest for emerging economies: they can obtain
significant improvements in health outcomes (e.g., life expectancy) through modest increases in
health expenditure (Takian and Akbari-Sari, 2016). However, higher income countries might
already be at a level of expenditure where the marginal return, in economic and health terms, for
Why It Matters
increased investment would be relatively small (Preker, Lindner, Chernichovsky and Schellekens,
2013).
Where policymakers have decided to make transformative investments in health, there are further
choices to be made, such as how to allocate resources between improving health services and
addressing the social determinants of health (Davig, Eric and Leeper, 2018). Improving water
quality and sanitation, or funding girls’ education, may be as effective at improving health
outcomes as spending on health services (Gerdtham and Magnus, 2020). However, given that
strengthening health systems is vital to improving health outcomes, UHC is a highly effective way
for countries to deliver significant health, economic and political benefits:
a. Health: There is now significant evidence that UHC brings health improvements to the
population of countries that implement it. Researchers using data from 153 countries
concluded in The Lancet that “broader health coverage generally leads to better access
to necessary care and improved population health, with the largest gains accruing to
poorer people”.8 A recent review study9 found that UHC reforms have been a powerful
driver for improving women’s health in a number of low- and middle-income countries
including Afghanistan, Mexico, Rwanda and Thailand.
b. Economic: Apart from delivering the aforementioned economic benefits deriving from
improved health, UHC can be an effective policy to reduce inequalities and poverty levels.
The financial protection it provides can have further beneficial effects, for example helping
reduce excessively high savings rates in families concerned about unpredictable
healthcare costs as has been the case in China. UHC systems can help generate and
support significant employment in the health and life sciences sectors.
c. Political: The debate around the Affordable Care Act in the United States shows that the
politics of UHC can be highly controversial. However, introducing UHC in a country with
limited healthcare coverage for the majority of the population can provide significant
benefits for politicians. The most recent example of this has been President Joko Widodo
(Jokowi) of Indonesia, whose focus on improving healthcare coverage has been an
important driver in his political rise from city mayor, to Governor of Jakarta, to head of
state. Politicians have also recognized the power of UHC to maintain social order and
reduce the scope for conflict. Reporting on the decision of the Chinese Government to
launch massive public health reforms in 2009, the then Minister of Health Chen Zhu said
that the government’s primary motivation was to ensure a harmonious society (Gerdtham
& Magnus, 2020).
Nigeria has a federally funded National Health Insurance Scheme (NHIS), designed to facilitate
fair financing of health care costs through risk pooling and cost-sharing arrangements for
individuals. Since its launch in 2005 the scheme claims to have issued 5 million identity cards,
covering about 3 percent of the population (Nyandekwe, Nzeribe and Kakoma, 2018). Under the
Why It Matters
National Health Insurance Act 2008, the national health insurance started a Rural Community-
Based Social Health Insurance Program (RCSHIP) in 2012. The majority of the enrollees,
however, are individuals working in the formal sector and the community scheme still leaves large
gaps among the poor and informally employed (Nyandekwe et al., 2018).
Several proposals are currently in the works to expand the reach of NHIS. One such proposal is
to make registration mandatory for federal government employees. The creation of a “health fund”
collecting an earmarked “health tax” of 2 percent on the value of luxury goods was proposed
(Opatunde & Zachariah, 2019). This fund would be used for the health insurance of specified
groups of Nigerian citizens, including: children under five, physically challenged or disabled
individuals, senior citizens above 65, prison inmates, pregnant women requiring maternity care,
and indigent persons. At a broader level, the National Health Bill which was first proposed in 2006
to improve its poor health sector by allocating at least 2 percent of the federal government’s
revenue to the health sector is still not signed into law (Opatunde & Zachariah, 2019).
According to Omehi and Azubuike, (2018) the constraints to achieving UHC in Nigeria are
numerous and complex. Factors limiting Nigeria’s health outcomes are both demand and supply-
side including inadequate financing, weak governance and enforcement, inadequate
infrastructure and poor service quality, weak governance and enforcement, household poverty
and insufficient risk pooling.
Dehinde & Osagie (2019) postulated that there are four main sources of public funding for the
public (non-federal) health sector: state governments, local governments, direct allocations from
the federal government, and private individuals and organizations, including non-governmental
organizations and international donors in some states. The federal government and some state
governments have increased funding to public health care (PHC) over the past decade, with a
dramatic increase between 2005 and 2007 (Dehinde & Osagie, 2019).
Achieving universal health coverage in Nigeria one state at a time 7 increase in health sector
allocations jumped from 31.4 percent to 86.2 percent. Nonetheless, Nigeria spends a mere 5.3
percent of its GDP,) or $139 (PPP) per capita on health care. This is extremely low, in particular
when compared to other African countries such as Burkina Faso (6.7 percent) and the Democratic
Republic of Congo (7.9 percent), which have considerably lower GDP per capita (Dehinde &
Osagie, 2019).
The government contributes only 36.7 percent of the country’s total spending on health. In order
to achieve effective access and financial protection, the government must begin by making a more
serious commitment to spend on health. The absence of institutionalized National Health
Accounts (NHA), however, contributes to the challenge of reassessing health spending in the
country. Finally, low levels of external health financing reflect an unwillingness to invest in the
Why It Matters
country. Just 9.2 percent of spending is donor funded, which is very low compared to, for example,
Ghana with 16.9 percent, which has a comparable GDP per capita (Alhassan & Okonji, 2019).
The existing legislative structure for budget allocations to social sectors as well as weak
governance and institutions leads to inefficient spending and lack of trust in the system. State
governments in Nigeria have substantial autonomy and exercise considerable authority over the
allocation and utilization of their resources. This arrangement constrains the leverage that the
federal government has over state and local governments in terms of getting them to invest in the
health sector (Alli and Uwaji, 2018).
Low government spending combined with weak institutions and lack of enforcement lead to
inadequate health infrastructure and poor service quality. Due to the unwillingness to invest in
health or prepay for health care, predictable revenue flow is unavailable for health providers to
improve the supply chain leaving much of the country’s health infrastructure in a dismal state
(Tangcharoensathien, Oyeneye & Jafarudeen, 2019). Many health facilities lack access to clean
water and a reliable supply of electricity, face shortages of medical equipment, and are missing
necessary medications or blood to treat their patients.
Gap in Literature
The essence of this study is to fill the existing gap in knowledge where focus on the Nigeria’s
quest towards achieving the Universal Health Coverage in line with Goal 3 of the United Nations
Why It Matters
Development Goals is being challenged by pragmatic policy focus because of lack of knowledge
of the UHC for inclusive and sustainable development in healthcare professional practice.
Methodology
A cross-sectional survey was conducted in June and July of 2021.The study made use of primary
source of data collection. Through the administration of pencil-paper questionnaire to elicit
responses from nurses. A list of potential respondents was generated from a pool of nurses who
had experience interacting with the researcher and her research team. The respondents were
informed about the purpose of the study and how the details of the study would help improve
nursing practice.
This research considered the eligibility of the nurses who volunteered to participate in the study.
Having obtained their consent to participate, the research team continued the exercise by giving
out questionnaires to the (nurses) respondents electronically. Phone calls were sent to them two
and four weeks after the initial distribution of the questionnaire. Names were not collected, to
ensure anonymity of the respondents.
Data analysis was conducted using the version 20 of the Statistical Package for Social Sciences,
version 20 and to ensure ecological validity, the research team developed a demographic profile
section and 4 questions initially based on the implementation biographical information as
recommended by the WHO Global Forum for the Governmental Chief Nursing Officers and
Midwives (GCNOMs).
Apart from the demographic profile, there were two parts in the final version of the questionnaire,
namely, knowledge of inclusiveness of UHC and the perceived contribution to sustainable
development of UHC. Inclusiveness of UHC was composed of the government initiative (Q3),
healthcare insurance and financing policy (Q1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12), and human
resources policy (Q13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 and 27. Respondents
were asked to indicate how they evaluate the importance of contribution of Nurses in Nigeria to
their level of knowledge of UHC. For sustainable development of UHC, respondents were asked
to rate their perceived contribution (Q28, 29, 30, 31, 32, 33, 34, 35, and 36) and perceived
importance of nurses (Q37, 38 and 39, 40, 41, 42, 43 and 44).
Split half reliability was performed using Spearman’s coefficient which was satisfactory at 0.881.
With the unique function of the Likert-type questionnaire system, the respondents’ answers were
automatically compiled in a table format. Descriptive and inferential statistics were then computed
and a comparison was performed by years of experience, job title, nature of one’s role, and their
qualifications.
Data Interpretation
The study considered the analysis of data generated from the research study in relation to the
responses obtained through questionnaire administration. A total of one hundred and thirty-one
Why It Matters
(131) questionnaires were initially distributed, however, only one hundred and twenty-five (125)
were retrieved. Three (3) healthcare facilities were engaged for this study namely; Federal
Medical Centre, Airport Road, Jabi Federal Capital Territory, Abuja and Save-A-Life Mission
Hospital Stadium Road, Port-Harcourt, Rivers State, Nigeria, as well as, New General Central
Hospital GRA, Asaba, Delta State, Nigeria. Respondents (Nurses) at the Federal Medical Centre,
Airport Road, Jabi FCT, Abuja were sixty-nine, 69 making a total of 55%, of the entire population
of the study. Nurses from the Save-A-Life Mission Hospital Stadium Road, Port-Harcourt, Rivers
State Nigeria were forty-one 41 making a total of 33% respondents and the nurses who
participated in this study, from New General Central Hospital GRA, Asaba, Delta State, Nigeria
were fifteen 15 making a total of just 12%. The responses or data retrieved from the questionnaire
administration formed the basis of the following results.
Table 3.1: Showing the Categories of Nurses (Respondents) from the 3 Hospitals that
Participated in the Study
From the result 3.1., categories of Nurses that participated in the study from the three hospitals
used in the study suggest that auxiliary nurses had the highest population with 56(44%), closely
followed by Pediatric Nurses who were 41(32.8%) of the entire population and the least category
were critical care nurses who were 28(22.4%) of the entire population.
Table 3.2: Showing the Age Distribution Information of Nurses from the 3 Hospitals that
Participated in the Hospital
From the result Table 3.2., revealed that age distribution of nurses with an average age of 34.56
and the majority of respondents where within the age bracket of 17-30 (53%), closely followed
Why It Matters
respondents within the age bracket of 31-50 (29%), and age bracket of 51 and above was 18.2%
of the entire population of the study. Thus it can be inferred that the respondents of the study
were knowledgeable enough to provide informed consent pertaining to the questions asked in the
questionnaire regarding customer satisfaction.
Table 3.3: Table Showing the Gender Distribution of Respondents from the 3 Hospitals that
Participated in the Study
The descriptive analysis in Table 3.3 indicated the gender distribution of respondents in this study.
The analysis demonstrated that gender of respondents was representative the differences in the
number of male and female respondents. Result showed that female respondents were the
majority with 77 (61.6%) and male respondents were the least with 48 (38.4%), indicating that
majority of the respondents were female. This implies that there are more females than males in
the study.
Table 3.4: Showing Educational Qualification Obtained by Each of the Respondents from
the 3 Hospitals
From the Table 3.4 majority of respondents had reportedly obtained bachelor’s degree, 66
(58.2%), followed by respondents who had obtained Senior Secondary School Certification
31(24.8%), this is followed by respondents with a Master’s degree 23 (18.4%), however, only 3
respondents indicated that the highest qualification was Doctorate Degree making up 5(4%) of
the total population. Thus, it can be inferred that the majority of the respondents of the study had
university education, this indicates that the respondents who were educated were more likely to
report perceptions of universal health coverage is required to form opinion and responses on the
items of the questionnaires.
Why It Matters
Table 3.5: Showing Religious Belief as Indicated by Each of the Respondents from the 3
Hospitals
From the Table 3.5 majority of respondents indicated that they were Christians, 75 (58.2%),
followed by respondents who reported that they were Muslims 41(18.4%), and the least category
of respondents with other beliefs 9(18.4%). Thus, it can be inferred that the majority of the
respondents of the study had been Christians.
This section presents the results obtained from the study analysis in tabular formats where
inferences were drawn. The study considered the analysis of data generated from the research
study in relation to the responses obtained from the questionnaire administration. A total of one
hundred and twenty-five (125) were retrieved. Respondents (Nurses) at the Federal Medical
Centre, Airport Road, Jabi FCT, Abuja were sixty-nine, 69 making a total of 55%, of the entire
population of the study. Nurses from the Save-A-Life Mission Hospital Stadium Road, Port-
Harcourt, Rivers State Nigeria were forty-one 41 making a total of 33% respondents and the
nurses who participated in this study, from New General Central Hospital GRA, Asaba, Delta
State, Nigeria were fifteen 15 making a total of just 12%. The responses or data retrieved from
the questionnaire administration formed the basis of the following results. The responses or data
retrieved from the questionnaire administration formed the basis of the following results.
Testing of Results
Nurses’ knowledge of Universal Health Coverage (UHC) for inclusive and sustainable
development would not significantly influence the perception of development of healthcare
services in Nigeria. Below is the regression analysis for the test of hypotheses.
Why It Matters
Table 4.1: Regression Analysis on Nurses’ Knowledge of Universal Health Coverage (UHC)
on Perception of Development of Healthcare Services in Nigeria
Model Statistics
R .455
R2 .717
Adjusted R2 .219
Standard Error Estimate 3.331
F Statistic 23.291
Level of Significance .000
DW statistics 1.390
The regression analysis above showed that the nurses’ knowledge on UHC was statistically
significant on perception of development of healthcare services in Nigeria. The overall effect of
nurses’ knowledge on UHC on perception of development of healthcare services was significant
(β = .38; F= 23.29; p < .00). Therefore, the null hypothesis 1 was rejected. This result implies that
nurses’ knowledge on UHC is a significant contributor to the perception of development of
healthcare services, such that, when increased level of nurses’ knowledge on universal health
coverage, this increases the tendency for nurses to perceive development of healthcare services.
The result further revealed R2 of .71, implying that the contribution of facets of customer service
contributed 71% to the overall variance on customer satisfaction. This suggests that other
variables not considered in this study may account for more than 29% of the total variance
observed in the study.
The contribution of the role of nurses in Nigeria would not lead to significant improvement in the
perception of the universal health coverage for health workers.
Why It Matters
Table 4.2: Regression Analysis Showing the Contribution of the Role of Nurses in Nigeria
to Perception of the Universal Health Coverage for Health Workers
Model Statistics
R .356
R2 .632
Adjusted R2 .341
Standard Error Estimate 1663
F Statistic 31.08
Level of Significance .000
DW statistics 3.111
From the results above, the regression analysis above showed that there is a contribution of the
role of nurses in Nigeria was significant to the improvement in the perception of the universal
health services for health workers [β = .39; F = 32.77; p < .00]. The overall contribution of the role
of nurses in Nigeria was significant to the improvement in the perception of the universal health
coverage. Therefore, the null hypothesis two was rejected. This result implies that technological
innovation is a significant contributor to customer satisfaction, such that, technological innovation
increases, the higher the perception of customer satisfaction.
The challenges faced by nurses in Nigeria will not lead to a decline in achievement recorded in
the universal health coverage. The result is presented in Table 4.3.
Table 4.2.: Regression Analysis Showing the Relationship Between Challenges Faced by
Nurses Would Decline in Achievement Recorded in the Universal Health Coverage
Model Statistics
R .344
R2 .502
Adjusted R2 .513
Standard Error Estimate 2.44
F Statistic 27.19
Level of Significance .000
DW statistics 1.299
The regression analysis above showed that the challenges faced by nurses was statistically
significant to the decline in achievement recorded in the universal health coverage [β=.42; F =
27.19; p < .00], therefore, null hypothesis 3 was rejected. The overall challenges faced by nurses
to the decline in achievement recorded in the universal health coverage was significant. This
result implied that the overall challenges faced by nurses in assessing universal health coverage
is significant contributor to perception of the decline of universal health coverage, such that
decrease in the overall challenges faced by nurses leads to high perception of the decline in
achievement recorded in the universal health coverage. The result signifies that the nurses’
knowledge of universal health coverage, the contribution of the role of nurses, as well as, when
pulled together yield a multiple R of .34 and R2 of .50 [ F = (2, 125) = 27.19, p < 0.01].
Summary
This study revealed that nurses showed low political involvement and powerlessness in the
process of policy making, which was consistent with the findings from previous studies (Boswell,
Cannon & Miller, 2019). Focusing on the difference between Auxiliary Nurses (AN’s) and Pediatric
Nurses (PN’s), majority of the former believed that it was important for nurses to develop
evidence-based policy for managing the nursing workforce, and to ensure the continuity of the
health care system, pressure groups should be lobbied, while of the latter agreed that it was the
nurse’s role and they should help support educational institutions in developing/implementing
training programmes to meet the changing quantitative demand of healthcare delivery.
This may reflect the importance of training and education in fostering nurses’ political sense,
particularly their understanding of the policy making process. From the core competencies
Why It Matters
stipulated by The Nursing Council of Nigeria, AN’s are only required to practice in accordance
with policies while PNs and Critical-Care Nurses (CCNs) are expected to understand the process
of developing health care policies. However, attention was suggested for teaching health care
policies in the curriculum for nursing education. The inadequacy of policy studies in nursing
education can be reflected in the answers of the respondents to the questions about the perceived
contribution to evidence-based policy making. Only ANs and PNs, respectively, claimed that they
had more contribution in the development of evidence-based policy. This finding suggests that
the majority of nurses feel powerless and remote from policy-making related to healthcare
services.
As a result, they are indifferent to the political process leading to UHC for healthcare workers to
access healthcare services in Nigeria. This phenomenon warrants the immediate attention of the
nursing profession. It may be timely and appropriate to reconsider the long standing suggestion
to incorporate political education in the education of nurses.
From the findings of this study, nurses with higher academic qualifications, such as the master’s
degree and higher, perceived a significantly higher level of importance in helping to
develop/strengthen policies to improve the quality of nursing education. In recent years, the
Government has proposed several major changes in elderly care policy in response to the
challenges evolving from our rapidly aging society, such as strengthening primary care,
emphasizing aging in place, and a voluntary health insurance scheme. Understandably, these
changes mean increasing demand for both ANs and PNs at the community level.
The question is, will nurses be able to meet the demand, or an even better question may be, have
nurses been prepared for it? Unfortunately, with the present ANs, PNs and CCNs mix, the answer
is negative. The findings of this study reaffirmed this. It is crucial, therefore, to involve nurses in
policy-making, particularly when a major change is expected to occur. To ensure nurses are
competent in the political process, the professional body such as The Nursing Council of Nigeria
should consider revising nursing curriculum to increase nurses’ knowledge on the universal health
coverage.
Conclusion
Universal health care evolves from the ‘Health for All’ movement advocated by the WHO in the
1970s. Since then, the Nigerian government has launched many initiatives in order to achieve
UHC, particularly for inclusive and sustainable healthcare services for healthcare workers such
as nurses. Although the outcomes of these initiatives are yet to be seen, the researcher and her
supervisor considered it to be appropriate to conduct the reported survey to identify nurses’
knowledge of and involvement in the process, including policy-making and implementation. It was
hoped that the findings would inform major stakeholders of some issues which may possibly affect
the success of these initiatives.
The survey has revealed some knowledge gaps among nurses. Their knowledge of healthcare
financing, including health insurance, drug-dispensing, and human resource policy needs to be
Why It Matters
enhanced. The low perceived importance and contribution to the sustainable development of
elderly healthcare services are deterrents to their possible involvement in the initiatives. After all,
nurses constitute a major work force in healthcare. They should be better prepared to participate
with policy-making knowledge for the benefit of the population that they serve.
Recommendations
Since the demand for healthcare services will increase in the future. To meet the escalating
demand, the government needs to allocate additional resources, be they human or financial, to
prepare the society. The nurses constitute the major healthcare workforce in Nigeria. There is no
reason for nurses to have such low level knowledge of the universal health coverage and to be
unprepared for this forthcoming challenge. Based on the findings, the following recommendations
were made for this study.
2. Since nurse educators are responsible for nurturing the future generation of nurses, they
should be role models for their students, and should equip themselves well in this area.
There is an urgent need to involve more nurse educators in the political process leading
to decision-making.
3. The survey uncovered a considerable knowledge gap in nurses’ knowledge of UHC, but
care must be taken in interpreting the findings from such a non-random sample. Having
collected the data on nurses’ perceived contribution and importance to policy-making
across clinical, management and education sectors, the research team believes that, with
the increase of the aged population, regulatory bodies such as the Nursing Council of
Nigeria could do more to enhance their capacity at various fronts to support the
government’s initiatives to provide UHC for nurses and other healthcare workers.
4. To ensure that more knowledge with regards to universal health coverage for nurses in
Nigeria, the National Health Insurance Scheme (NHIS), National Primary Healthcare
Development Agency (NPHCDA) as well as, the Hospital/Healthcare Management Boards
(HMO’s) under the auspices of Ministry of Health are encouraged to reform the healthcare
policy mandate nurses and other allied healthcare workers are to attend and actively
participate in seminars, conferences and workshops on universal health coverage so as
to assuage and increase knowledge regarding universal health coverage as it concerns
health workers especially nurses in Nigeria.
Why It Matters
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