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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 29  |  Issue : 3  |  Page : 351-361

Universal healthcare coverage and medical tourism: Challenges and best practice options to access quality healthcare and reduce outward medical tourism in Nigeria


1 Past President, National Postgraduate Medical College of Nigeria, Lagos, Nigeria
2 Senate and Governing Board Affairs (SGBA), National Postgraduate Medical College of Nigeria, Lagos, Nigeria

Date of Submission09-May-2020
Date of Decision17-May-2020
Date of Acceptance17-Jun-2020
Date of Web Publication18-Sep-2020

Correspondence Address:
Dr. Salami Suberu Sule
National Postgraduate Medical College of Nigeria, Km 26, Lagos-Badagry Expressway, Ijanikin, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJM.NJM_67_20

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  Abstract 


Background: Universal healthcare coverage (UHC) leads to access to quality healthcare. Improved quality healthcare can stem outward medical tourism (MT). This review examined challenges and best practice policy options to implement UHC and how it can reduce outward MT in Nigeria. Methodology: The designed search terms used were “universal health coverage,” “quality healthcare” “medical tourism,” “access to healthcare,” “primary health care,” “healthcare financing,” “private health insurance,” “social health insurance,” and “Nigeria healthcare system.” Peer-reviewed research articles and institutional reports published between January 2000 and March 2020 were searched using four databases: PubMed, National Library of Medicine, Web of Science, and Library of Congress. EndNote X9 software and Google search engine were used to access these databases and documents, and 124 publications were retrieved and 106 were reviewed. Results: Majority of publications reviewed emphasized building health infrastructure, developing skills and human resources for health, and funding for equipment and drugs. Expanding healthcare coverage through social health insurance, developing a financial system to protect the poor, access to quality healthcare, and reinvigoration of primary healthcare (PHC) were common themes. About 50% of the studies identified unavailability of quality healthcare services, inequalities in the supply side of healthcare services, issue of human resources, and health sector implementation shortfall as challenges to UHC. Another 50% of the studies reviewed identified poverty and poorly funded PHC as a barrier to UHC. Almost all the studies (100%) identified cost-effectiveness, safety, and quality of healthcare services as drivers of MT in all countries. Conclusion: Improving the quality of healthcare delivery, increasing accessibility, affordability, and timeliness of access by the population through UHC can stem MT.

Keywords: Financing, medical tourism, Nigeria, quality, SHI, universal healthcare coverage


How to cite this article:
da Lilly-Tariah OB, Sule SS. Universal healthcare coverage and medical tourism: Challenges and best practice options to access quality healthcare and reduce outward medical tourism in Nigeria. Niger J Med 2020;29:351-61

How to cite this URL:
da Lilly-Tariah OB, Sule SS. Universal healthcare coverage and medical tourism: Challenges and best practice options to access quality healthcare and reduce outward medical tourism in Nigeria. Niger J Med [serial online] 2020 [cited 2020 Oct 24];29:351-61. Available from: http://www.njmonline.org/text.asp?2020/29/3/351/295301




  Introduction Top


Nigeria accounts for 20% of the population of Sub-Saharan Africa (SSA) and is projected to be the third most populous country in the world, with over 400 million people by 2040.[1] Nigeria citizens face a lot of challenges in accessing quality healthcare. This has led to poor health indices and a driver for seeking healthcare outside Nigeria.[2] Preventable and low-cost treatable communicable diseases still cause significant morbidity and mortality, and this is compounded by the increasing burden of non-communicable diseases.[3]

For most Nigerians, expending money for healthcare during other competing interests and needs can be severely challenging. The consequences of this situation can be catastrophic.[4],[5],[6] Healthcare should be a socio-economic investment.[7] Economic productivity is increased with a healthy population as lost hours to ill health is reduced and absence from work is reduced. The role of healthcare in development was stated in the United Nations (UN) Sustainable Development Goals (SDGs) 2030 as “ensure healthy lives and promote well-being for all at all ages,” and one of the targets is to “achieve universal healthcare coverage (UHC), including financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.”[8]

Life expectancy in Nigeria is 54.3 years, and the share of Nigeria's population living in extreme poverty is 42.8% in 2016 and this will rise to 45.0% by 2030, which represents about 120 million people living on < US$1.90 per day.[1],[9],[10] The UN Human Development Index ranking of Nigeria is 158 out of 189 countries in 2018.[10] The World Bank defined extreme poverty as people living on < US$1.90 per day. People living in extreme poverty are characterized by severe deprivation of basic human needs, such as food, safe drinking water, sanitation facilities, health, shelter, education, and information. Extreme poverty condition does not depend only on income but also on access to services including healthcare services.[11] The Nigerian total expenditure by the federal and state government and private sector on health as a percentage of Gross Domestic Product (GDP) is 3.6% in 2016. Private expenditure on health as a percentage of total expenditure on health is 76.7% (mainly out of pocket [OOP] expenditures) in 2016; the general government expenditure on health as a percentage of GDP is 0.47% and the total government expenditure as a percentage of the national budget is 5.01% in 2016.[12] The Nigerian health indices are poor, for example, the neonatal mortality rate of 23/1000 live births and under-five mortality rate of 76/1000 were reported in 2018, while the maternal mortality ratio of 917/100,000 live births was reported in 2017.[13],[14] The physician density per 10,000 was 3 in 2018;[15] births attended by skilled health workers were 43.4% in 2018; the crude birth rate per 1000 was 38 in 2017; and the fertility rate was 5.5 per woman in 2017.[14]

The percentage of Nigerians covered by the National Health Insurance Scheme (NHIS) is about 3%;[16] there are about 74,543 medical doctors, of which 3035 are specialists in the country as of 2018.[15] Nigeria needs to achieve a ratio of one doctor to a thousand patients (the WHO prescribes 1:600), for a projected population of 200 million. This situation is no different for nurses, pharmacists, laboratory scientists, etc., Health workers are vital to SDGs and UHC.[17] Health infrastructure and social support are less than satisfactory.[18] The spate of strikes by doctors and other healthcare professionals is another disturbing phenomenon, often spurred by the perceived neglect of their welfare and inadequate working environment.[19] Paucity of funding of healthcare services by the various tiers of government in Nigeria (Local, State and Federal)[20] leads to increased out of pocket payments (OPPs) and many poor Nigerians cannot pay for these services. This results in them being turned away by healthcare providers if they are unable to pay, forcing them to patronize quacks or resort to self-medication, both of which could worsen their ailments.[21]

Nigeria has been reported to have about 160,000 hospital beds as of 2015, a low ratio of bed per thousand population of 0.9 (<1) in comparison to countries such as South Africa at 2.29 and Japan at 13.32. The number of hospital beds has grown below the population growth rates over the last 5 years, which is coupled with obsolete healthcare infrastructures, equipment, and lack of requisite infrastructure to expand/deepen medical specialization.[18] Budgetary allocations and internally generated funds cannot equip and maintain the hospitals with state-of-the-art equipment. Attempts at public–private partnership (PPP) is still at a low level.[22] This makes a compelling case for Nigeria to adopt a compulsory SHI system to cater for the poor and those who cannot afford medical expenses at the grassroots.[23],[24] There is a need to examine the healthcare financial option in Nigeria and the implementation of progressive tax policy that will increase the fund availability for providing healthcare services.[25],[26] This will increase the capacity of the healthcare system to be able to deliver quality healthcare services affordable to all.[27] Will implementing UHC through progressive tax system and compulsory SHI be a vehicle to improve funding for health and improve quality of health and affordability to the populace? Will improve quality of health, affordability, and accessibility be a driver to reduce outward medical tourism (MT) in Nigeria? These are the questions that this review is set to answer. Therefore, the aim of this review is to determine issues, challenges, and best practice policy options for implementing UHC and stemming medical tourism (MT) in Nigeria.


  Methodology Top


Search strategy

The literature review design involved the search for peer-reviewed research articles and institutional reports on UHC and MT that were published between January 2000 and March 2020. Four databases were used: PubMed; National Library of Medicine; Web of Science; and Library of Congress. EndNote X9 software and Google search engine were used to access these databases and documents. The following search terms were used, “universal health coverage,” “quality healthcare” “medical tourism,” “access to healthcare,” “primary healthcare,” “healthcare financing,” “private health insurance,” “social health insurance,” and “Nigeria healthcare system.” Africa, Sub-Saharan, developing countries, and Nigeria were also used as keywords. The literature search was divided into seven major parts: UHC globally; UHC in developing countries; UHC in Africa: UHC in Nigeria: medical tourism (MT) globally; MT in developing countries; and MT in Nigeria.

Inclusion and exclusion criteria

The inclusion criteria for the studies selected for this review are: empirical studies that were related to at least one of the seven aspects of UHC and MT that provided clear and full information of research design and methods; reports of institutions such as WHO, World Bank, and UNICEF; online Nigeria news reports on UHC and MT in Nigeria; and publications that occurred between January 2000 and March 2020. The exclusion criteria for this review were: studies before 2000 on UHC and MT; and the remaining publications were screened to exclude those that do not meet the inclusion criteria. One hundred and twenty-four publications were retrieved for all the categories and 106 publications were reviewed.


  Results Top


Research question 1

Determination of the issues, best practice options, and challenges of implementing UHC in Nigeria are shown in [Table 1]. The reports and studies included in this review showed consistent results of strengthening the healthcare system to be efficient and effective, developing financial system to protect the poor and access to quality healthcare by the populace. Majority of review reports and studies emphasize building health infrastructure, developing skills, increasing the number of human resources for health, and the funding of drug and equipment acquisition. Expanding healthcare coverage through SHI and reinvigoration of primary healthcare (PHC) was a common theme and that moving toward UCH is gradual or incremental and should be either medium-term or long-term period for implementation.
Table 1: Issues and best practice policy options for Nigeria to achieving universal healthcare coverage

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Research question 2

Determination of challenges facing implementing UHC in countries is shown in [Table 2]. Studies reviewed were from SSA and Asian countries. The majority of studies reviewed identified accessibility and availability of barriers to UHC. Political issues and policy implementation toward UHC were also observed. About 50% of the studies reviewed identified availability of quality healthcare, inequalities in the supply side of healthcare services, issue of human resources, and health sector implementation shortfall. Another 50% of the studies reviewed identified poverty and poorly funded PHC as a barrier to UHC.
Table 2: Challenges of implementing universal healthcare coverage in various countries

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Research question 3

What are the drivers of MT in various countries to determine how to stem it and use it as an advantage to develop healthcare system, improve the health of the population, and attract foreign exchange earnings? This is shown in [Table 3]. Reviewed studies identified the different drivers of MT in both developed and developing countries including SSA countries. Almost all the studies (100%) identified cost-effectiveness, safety, and quality of health services as a driver of MT in all countries. About 50% of the studies identified development of healthcare systems including infrastructure and human resources for health skills as a driver. In Nigeria, improving the quality of healthcare delivery and increasing accessibility, affordability, and timeliness of access to the population were identified as factors that can stem MT. Drivers of circumvention tourism are shown in [Table 4]. Healthcare opportunities and access to medical services that are legal in the destination country but illegal in the home country are the main drivers globally.
Table 3: Drivers of Medical Tourism in Various Countries

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Table 4: Drivers of circumvention tourism globally

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  Discussion Top


Substantial gaps exist in healthcare systems and access to Millennium Development Goals (MDGs)-related health interventions in Nigeria. There is a need for sound policies and plans with clear direction for strengthening Nigerian health systems and addressing the social determinants of health.[28] Universal Health Coverage (UHC) is guaranteeing that all people use the needed promotive, preventive, curative, rehabilitative, and palliative health services of adequate quality and effective and that their use does not cause financial hardship and impoverishment due to healthcare costs.[29] These should be pursued with SDGs and WHO's General Program of Work 2019–2023[33] in an integrated way is shown in [Figure 1].[66] Countries that progress toward UHC will make progress toward the other health-related targets and toward the other goals.[27]
Figure 1: Set of interconnected strategic priorities – WHO's General Program of Work 2019–2023

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Adequate government investments in healthcare reduce financial impoverishment as a result of catastrophic cost by shifting cost away from OOP expenditures.[67],[68],[69] Nigeria should develop an adaptive health system with solid institutional foundations and governance, with an engaged civil society that demands accountability and transparency.[70] All stakeholders should be made to understand that to achieve UHC as shown in [Figure 2] is a journey of progressive realization. The emphasis at all times should be that the quality of healthcare services is good enough to improve the health of the people.[71] This also entails building health worker's capacity, good governance, and sound systems of procurement; supply of medicines and health technologies and well-functioning health information systems are other critical elements.[27]
Figure 2: Taking action – A roadmap to achieving universal health coverage for all by 2030

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The WHO and World Bank developed a framework to track the progress of UHC and used 16 essential health services in four categories as indicators of the level and equity of coverage in countries.[27] The road map to achieve UHC[72] and what the Nigerian government and all stakeholders can do was clearly articulated at the Presidential Summit on UHC with the theme “UHC… A Vehicle for Sustainable Growth and Development” and documented in 2014.[34] One of the outcomes is to make SHI compulsory for all Nigerians. However, after 6 years, Nigeria is still not implementing compulsory health insurance to drive UHC, due to the lack of political will. To achieve UHC using health financing as the strategy, there is a dire need to review the system of financing healthcare[73] and to adopt primary healthcare as the fulcrum for moving Nigeria ahead toward UHC and the attainment of the health-related sustainable development goals.[74] The NHIS Act was enacted in 1999 with objectives[75] that are in line with the recommendations of the WHO and World Bank on the implementation and achievement of UHC; however, despite these laudable objectives, the implementation in Nigeria is very poor and coverage is very low due to lack of political will.

PHC is an approach to health and well-being centered on the needs and circumstances of individuals, families, and communities that is needed for UHC.[27] It is about providing whole-person care for health needs throughout life in the most efficient and cost-effective way to achieve UHC in Nigeria.[74] A country like Thailand had made a major stride to achieve UHC using PHC as an intervention.[76] It is practically impossible for Nigeria to achieve UHC by 2030 if the PHC system is not improved and if SHI through NHIS and state governments remains voluntary.[77]

The consequence of looking for money for the treatment can result in catastrophic expenditure which forms majority of healthcare expenditure in Nigeria,[78] with patients being driven into abject poverty or even death. OOP payment is a direct payment made by individuals to healthcare providers at the time of service use. Statistics have shown that the level of OOP expenditure as a share of total health expenditure in Nigeria is still placed at 72%, the highest on the continent and one of the highest in the world.[79] This problem can be solved by compulsory SHI through NHIS, by pooling funds to take care of treatment by an individual when needed. The NHIS should be improved through policies that include closer integration of the informal and formal sectors under the existing NHIS with improvements in communication and education, higher public and private healthcare funding, and targeted financial assistance.[80]

In Nigeria, private health insurance is still limited in its scope, and even in countries where it has taken root, insurance beneficiaries still have limitation to the utilization of healthcare services and may not ensure financial protection.[81] Funding of healthcare from the general health budget is still poor in Nigeria. The current allocations are in the region of 4% of the budgets,[12] with erratic and none release of the allocated budgets.[73] The law establishing the NHIS did not make contribution by all citizens compulsory, and state governments have exercised their discretion to enroll or not. A few states have joined the scheme. The organized private sector has also not joined. Only federal government employees and their households are covered by NHIS.[82],[83] States in Nigeria should setup and manage their own insurance schemes as a unique opportunity for rapidly scaling up SHI for Nigerians. The Nigerian three-tier governance structure should be leveraged to help states establish and manage their own insurance funds while encouraging integration with the NHIS.[20] Nigeria must make health insurance compulsory to achieve UHC.[84]

There should be an effective regulatory regimen to guide behaviors of all institutions and stakeholders involved in SHI toward undesirable business practices.[82],[85],[86] Which should also include identifying the role of research?[87] The Nigerian government should drive a creative policy to raise the necessary funds to capture all its citizens in the provision of basic healthcare. It must ensure adequate and equitable distribution of good quality healthcare infrastructure and human resources for health so that the insurer will receive equitable and good quality health services.[20],[32],[73] Nigeria can learn from a country like Thailand which was able to achieve UHC in 2001 started with government employees and dependents and extend mandatory social insurance scheme for formal private employees and later all others citizens under a single fund financed by general tax revenue.[88] Similarly, from an island country of Fiji, which healthcare system has achieved a degree of vertical equity in financing (taxes paid increase with the amount of earned income), therefore, the poor receive a higher share of benefits from government health spending and bear a lower share of the financing burden than wealthier groups.[89]

Taxes that can fund UHC, for example, increasing domestic tax revenues by encouraging progressive tax and discouraging consumption tax, should be integral to achieve UHC, and emphasis should also be on pro-poor taxes on profits and capital gains.[90] International health development agencies can assist Nigeria to make this transition to financing its health systems publicly.[25] Pooled public financing is far greater at ensuring better access to healthcare services and health outcomes than out of pockets (OOPs) expenditure or private voluntary insurance which are associated with higher mortality rates.[91]n financing UHC, collecting taxes, improving tax administration, and expanding the tax base in Nigeria are more achievable.[26]

There is a need to establish a Commission on UHC in Nigeria with legislative power enacted by the National Assembly and headed by a Public Health Physician as Czar with direct reporting to the President of Nigeria. The Commission should be given extra-ministerial power to cut out bureaucratic bottleneck and have access to national resources such as fund locked up in legislation like the National Health Bill of 2014. The Commission should coordinate with government health insurance scheme and PHC bodies as well. The Commission should have direct supervision of the NHIS, the National Primary Healthcare Development Agency, and the Nigeria PPP Commission.

The derivative from all the potential mechanisms to fund UHC and finance healthcare systems to reach the twin goals of effective quality healthcare services and financial protection for the poor and vulnerable is shown in [Figure 3].
Figure 3: Healthcare financing system hierarchy for universal healthcare coverage

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Nigeria should adopt the hybrid healthcare financing system option. It should incorporate progressive tax revenues from profits, capital gain, and income, as well as some indirect taxes (for example, on luxury goods) and other indirect taxes that might help improve health outcomes (for example, taxes on tobacco and alcohol).[90]

MT has been described as “travel across international borders with the intention of receiving some form of medical treatment. This treatment may span the full range of medical services but most commonly includes dental care, cosmetic surgery, elective surgery, and fertility treatment.”[92] MT has also been described as combination of “the two of the fastest growing industries in the world; healthcare and tourism.” There is a paradigm shift in MT from wealthy patients from developing countries traveling to developed countries to seek healthcare services to take advantage of their technologically most advanced medical facilities. The current prevailing pattern is that less wealthy patients from developed countries seeking expert healthcare services at most affordable rates and quick response in the developing countries[93] and mostly in the Asia-Pacific region of the world.[94]

The failure of Nigeria's health system is responsible for the thriving foreign MT as a result of poor quality and service delivery, poor funding, inadequate human resource for health capacity, poor infrastructure, and inadequate specialist services, among other flaws [Figure 4]. MT in Nigeria is largely net outflow of patients seeking better quality healthcare outside Nigeria which has led to a net outflow of scarce foreign currency. A significant number of Nigerians travel abroad every year for MT, and estimates showed that Nigeria may be losing about $1.3 billion yearly as a result which places a burden on the Nigerian economy.[95] This is often facilitated by MT facilitators that market healthcare services over the internet and social media.[59] There is a need to regulate MT agencies and physicians and to invest more resources into Nigeria's healthcare.[60]
Figure 4: Factors responsible for increase outflow for medical tourism in Nigeria

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The MT sector has a lot of potentials to grow but is also confronted with many challenges that need to be tackled.[96],[97]

MT presents a new and challenging health ethics frontier, being largely unregulated as shown in [Figure 5].[98] Patient autonomy and informed consent, obtaining honest information, quality of care in destination facilities, limited health literacy, and risks of seeking healthcare in another country are some of these ethical issues.[99]
Figure 5: Challenges with medical tourism

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Improving the quality of healthcare delivery in Nigeria can solve the problems facing healthcare systems.[61] Nigeria can learn from many countries that are destinations for MT in the Asia-Pacific region.[62] There is need for massive investment in the healthcare industry in Nigeria both by the government and by the private investors either by Nigerians or foreigners[9] by investing in infrastructures, human resources for health, technology, hospital/medical supplies, and drugs for higher coverage as well as improving public health services.[100] Encouraging medical doctors in the diaspora to provide rare disease treatment and advanced medical services in Nigeria, enhancement of private hospitals with excellent services to provide more services,[48] etc., can also help. However, the drawback will be cost and access issues because of the high prevalence of poverty in Nigeria. This can be addressed by compulsory social health insurance (SHI) programme and progressive tax on income.

PPPs are on-going long-term agreements and collaboration between government and private sector organizations. Each participate in the decision-making, sharing of risks, responsibilities, rewards, and production of a public good or service that has traditionally been provided by the public sector.[101] Evidence supports PPPs as a strategy for improving healthcare infrastructure and operations.[22],[102] This is a win–win situation for both the public and private sector players in healthcare as well as the general population,[18],[103] by developing human resources for health capacity and improving quality of healthcare services.[104] There is quicker market entry and guaranteed revenue streams as well as an increased ability to attract more patients with higher purchase power.[105]

With UHC, access to healthcare is easier and diseases are treated well before they are advanced.[27] The medical infrastructure will be better developed due to increased funding from the public budget, compulsory health insurance, and the private sector. More human resources for health capacity will be available. This will lead to the development of confidence of Nigerians in the quality and variety of healthcare services available at an affordable cost to them. The attainment of such a level of development in the Nigerian healthcare system will stem an outward flow of Nigerians for medical treatment abroad and foreigners will flock to Nigeria for MT. Nigeria will be saving and earning foreign currency through inward flow MT just like as it is in Thailand.[106]

Recommendations

Political will at the federal and state government levels of Nigeria to implement UHC through the hybrid health financing systems that mix compulsory SHI contributions and general taxation revenues (double progressive tax on incomes) and encourage private investments in healthcare. Nigeria needs to commit massive resources to the health sector. Health system operators should focus more on improving the quality of services to improve public confidence.


  Conclusion Top


Improving the quality of healthcare delivery and increasing accessibility, affordability, and timeliness of access to the population through UHC can stem MT. Exploring funding options that ensure access to healthcare for all and revitalization of PHC in Nigeria are necessary to achieve UHC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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