User fees in Nigeria: Implications for equity and universal health coverage

In the 1980s, there was call for the introduction of user health care fees in African countries due to macroeconomic difficulties.[1] User fees are health payments charged at the point of accessing public health care services. Based on this call, most African countries and governments introduced user fees for public health care services. Nigeria introduced user fees within the framework of the Bamako Initiative Revolving Drug Fund.[2] 

The projected pros and cons of user fees

The argument of user fee proponents is that it will improve:

• consumption efficiency,
• quality of health services,
• access to care for the poor,
• demand rationing,
• equity and
• ensure better targeting.

However, there is overwhelming evidence that the effects of user fees have been negative.[3-4] User fees have instead:

• limited health care use,
• promoted inequity,
• contributed to inefficiency,
• led to impoverishment of households and
• had adverse effect on access to basic health services.

Making health care free in Africa

Although waivers and exemption policies are ways to deal with the negative impacts of user fees, governments find these difficult to implement [5]. What's more, waivers and exemptions are ineffective in protecting the poor.[6] This accounts for the advocacy for the removal of user fees in African public health facilities by some organisations, initiatives and governments.[3,7]

Evidence suggests that the removal of user fees for all publicly provided health care increased utilisation of health services in Uganda [8-9]. Studies conducted on user fees removal for some maternal and child health services in Zambia [10], South Africa [11] and Madagascar [12] also revealed that user fee removal led to increase in health care use. However, the increase in the utilisation has also placed a burden on the inadequate human resources and affected the quality of care [7].

The case of Nigeria

There is substantial evidence from the African context and consensus on the fact that user fees are not an appropriate health financing mechanism in developing countries. This change in policy position on user fees is also reinforced by the World Bank. However, governments at the national and sub-national levels in Nigeria have done little towards the removal of user fees for the treatment of some diseases. This is especially pertinent for children under five years of age, as well as pregnant women in the public sector [2]. In addition, health insurance coverage is less than 5% [13-15], while government health expenditure as a percentage of Gross Domestic Product (GDP) has consistently been less than 1%.[16] 

Equal access to health care

Equity in health care financing means that health care payments should be based on the ability to pay, in which households with unequal ability to pay make unequal payments for health care.[17] The poor and most vulnerable populations, which constitute a larger percentage of the Nigerian population and need health care the most. bear the negative consequences of user fees [18]. They do not seek the needed health care or delay seeking health care due to user fees [19].

The progressivity of out-of-pocket (OOP) payments in Nigeria [17] is due to the inability of the poor to use health care services rather than exemption of the poor from user fees at public health facilities. Therefore, user fee policy in Nigeria is an inequitable health financing mechanism because it does not disproportionately benefit the poor, vulnerable and non-poor informal sector populations.

Realising Universal Health Coverage: Recommendations

Universal Health Coverage (UHC) aims to increase equity in access to quality health care services without financial hardship.[20] Nigeria is unlikely to move towards or achieve UHC as a target of the Sustainable Development Goals (SDGs) without the elimination of user fees for public health services. This is not to say that the complete removal of user fees is the solution to the health financing challenges that Nigeria faces. Experts have suggested that user fee removal policy should be designed and implemented by governments as part of reforms towards UHC. This must be accopanied by preparation to avoid unintended consequences[4,18].

The health financing strategy of Nigeria must remove the financial burden of health care services on the poor, vulnerable and non-poor informal sector populations who are at the receiving end of inequities in access to health care and bare the burden of the high cost of health care. Policy makers and political actors, therefore, have to address the issue of user fees as a matter of urgent national importance. Removal of user fees will benefit from an evidence base on the topic within the Nigerian context.

The inequities in the allocation of public health sector resources, which benefit the rich more than the poor, should also be of great concern to decision makers. Making verbal commitments to UHC, without taking the necessary steps towards user fee removal and increasing public financing for public health services, will result in failure to achieve UHC as a target of the SDGs.

References

1. Akin, J, Birdsall, N and de Ferranti, D (1987). Financing health services in developing countries: an agenda for reform, World Bank Policy Study, Washington DC: the World Bank.
2. Onwujekwe, OE, Uzochukwu, BSC, Obikeze, EN, Okoronkwo, I, Ochonma, OG, Onoka, CA et al. (2010). Investigating determinants of out of pocket spending and strategies for coping with payments for health care in Southeast Nigeria, BMC Health Services Research;10(67): 1-10.
3. James, C D, Hanson, K, McPake, P, Balabanova, D, Gwatkin, D and Hopwood, I (2006). To retain or remove user fees? Reflections on the current debate in low- and middle-income countries, Applied Health Economics and Health Policy 2006; 5: 137–53.
4. McPake, B, Brikci, N, Cometto, G, Schmidt, A and Araujo, E (2011). Removing user fees: learning from international experience to support the process, Health Policy and Planning; 26:ii104–ii117. Accessible: doi:10.1093/heapol/czr064
5. Gilson, L and McIntyre, D (2005). "Removing user fees for primary care in Africa: the need for careful action", British Medical Journal; 331: 762-765.
6. Bitrán, R and Giedion, U (2003). Waivers and exemptions for health services in developing countries, Social Protection Discussion Paper Series No. 0308. Washington D.C.: The World Bank.
7. Yates, R (2009). Universal health care and the removal of user fees, The Lancet; 373(9680): 2078-2081.
8. Nabyonga, J, Desmet, M, Karamagi, H, Kadama, P Y, Omaswa, F G and Walker, O (2005). Abolition of cost-sharing is pro-poor: evidence from Uganda, Health Policy and Planning; 20(2):100-8.
9. Nabyonga, J, Mugisha, F, Kirunga, C, Macq, J and Criel, B (2011). Abolition of user fees: the Uganda paradox, Health Policy and Planning; 26:ii41–ii51 Accessible: doi:10.1093/heapol/czr065
10. Masiye, F, Chitah, B M, Chanda, P, Simeo, F (2008). Removal of user fees at Primary Health Care facilities in Zambia: A study of the effects on utilisation and quality of care, EQUINET Discussion Paper Series 57. EQUINET, UCT HEU: Harare.
11. Wilkinson, D, Gouws, E, Sach, M and Abdool Karim, S S (2001). Effect of removing user fees on attendance for curative and preventive primary healthcare services in rural South Africa, Bulletin of the World Health Organization; 79: 665–71.
12. Fafchamps, M and Minten, B (2007). "Public service provision, user fees, and political turmoil", Journal of African Economies; 16: 485–518.
13. Onoka, C A, Onwujekwe, O E, Uzochukwu, B S and Ezumah, N N (2013). Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria, Health Research Policy and Systems;11:20. Accessible: doi:10.1186/1478-4505-11-20.
14. McIntyre, D, Ranson, M K, Aulakh, B K, Honda, A (2013). Promoting universal financial protection: evidence from seven low-and-middle-income countries on factors facilitating or hindering progress, Health Research Policy and System; 11:36.
15. Okebukola, P O and Brieger, W R (2016). Providing universal health insurance coverage in Nigeria, Int Q Community Health Educ 2016;36(4):241–6.
16. World Health Organization (2016). Nigeria: Factsheets of health statistics 2016. Accessible: http://www.aho.afro.who.int/profiles_information/images/3/3b/Nigeria-Statistical_Factsheet.pdf (Accessed March 30, 2018).
17. Lawanson A O and Opeloyeru, O S (2016). E"quity in health care financing in Nigeria", Journal of Hospital Administration; 5(5): 53-59. Accessible: doi:10.5430/jha.v5n5p53
18. McIntyre, D, Gilson, L and Mutyambizi, V (2005). Promoting equitable health care financing in the African context: Current challenges and future prospects, Harare, Regional Network for Equity in Health in Southern Africa (EQUINET).
19. Nyonator, F and Kutzin, J (1999). Health for some? The effects of user fees in the Volta Region of Ghana, Health Policy and Planning; 14(4): 329-341.
20. Aregbeshola, B S (2017). "Enhancing political will for universal health coverage in Nigeria", MEDICC Review; 19(1): 42-46. Accessible: doi: 10.1590/medicc.2017.190100010