A Vision for Nigeria Health System in 2030

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Consolidating its position as Africa’s largest economy, and 10 years after it has been admitted into the Global 20 Club – Nigeria’s place as a significant economic power house is no longer in doubt.

The economy is now more diversified and the tax base is healthy, although government still relies heavily on oil and gas revenues. Like Agriculture that fully transformed itself from subsistence level to a growth sector in the decade that ended in 2020, the Health sector has also emerged from its ‘cocoon’ where it has undergone metamorphosis from its ‘pupal’ social service status to become one of the ‘real’ sectors of the economy. The key drivers are (i) the over USD 10 Billion annual spend on pharmaceuticals (drugs and medicines); (ii) commoditisation of healthcare that is no longer differentiated from personal care, as several medical goods and services loose their unique medical function and become readily available at the marketplace; and (iii) a massive middle class that demand for quality care and are willing to pay for better services.

And while there has been no rational re-design of the delivery system – health services are delivered through diverse approaches. Ranging from home-based care, mobile clinics, and provision from the regular government owned and operated primary health care centres and General Hospitals, to privately run specialist medical centres – there is near universal access to a broad-range of healthcare services. But the vast majority are ‘Stand-alone Facilities’ and Independent Practitioners using very basic to high-end specialised equipment that are responding to consumer demand for quick and reliable diagnosis and treatment of common and not too common health problems. In the rural and semi-urban areas, many of these are health extenders – not the conventional Community Health Extension Workers (CHEWs) usually employed by the LGAs, but ‘Paid Volunteer Health Workers’ linked to specific health programmes such as immunisation, maternal and child health, malaria, nutrition, TB, HIV/AIDS etc. And the PHC health facilities from where these cadres of health workers are supervised have taken on a new role – that of coordinators of inputs of these health interventions and the expected health outcomes for a given population.

There is still some bit of medical tourism as the proportion of citizens that is older (with associated chronic medical conditions) and richer (with huge disposable incomes) accounts for about a fifth of the population. But the destinations are now more widespread. Rather than India, the United Arab Emirates, Dubai in particular now receives the largest number of medical tourists from Nigeria. The United Kingdom and South Africa with strong historical and continental trading ties respectively also have reasonable share of this extended Nigeria healthcare market. Interestingly, these external medical suppliers are linked to local network of providers that feed the international markets, as well as maintain some level of continuity of care when the medical visitors return home.

In terms of financial access and funding for health services, the so called National Health Insurance Scheme is still faltering. Due to ‘vested interests’ the programme fails to take on a national outlook, as it has not been reformed within the context of a federal country; and thus not able to expand beyond its initial coverage of workers in the employment of the Federal government. Several State governments also attempted to institute state-based health insurance or similar pre-payment schemes, but these too have ran into similar difficulties as they were prone to capture by entrenched interests – politicians, civil servants and professional groups. And there has been serious tensions between State Primary Health Care Development Agencies (or Boards) on one hand, and the National Health Insurance Scheme, alongside the National Primary Health Care Development Agency and the Federal Ministry of Health, with respect to control of the Primary Health Care Fund that is incorporated with the National Health Act. Consequently, PHC Agencies in several States are only in name as they have not been funded by their State governments and the hope of accessing the national PHC Fund has not materialised. Only in States such as Zamfara and others that have adopted a ‘basket-fund’ arrangement where ‘pooled funding’ for PHC activities from State, LGAs and Donors exist – are State PHC Agencies or Boards seen to be viable with related improvement in access to services and health outcomes.

Notwithstanding, as a market for health care emerges, driven by high consumer demand and spending power, individuals and households still account for the largest proportion (over 70%) of total health expenditure in the country. But curiously, direct out-of pocket payments are now very low (about 10 to 15% of total health expenditure), due to the myriads of private pre-payment medical schemes and innovative market-based health care payment mechanisms that facilitate financial access to health care across the country. Learning from how multi-national companies – from manufactures of household goods to mobile telephone operators and digital television service providers – have converted the millions at the bottom of the income pyramid into effective consumers, smart healthcare enterprises are offering ‘financial access packages’ to healthcare tailored to the needs and aspirations of each and every segment of the population.

In this health care scenario, Donors or Development Partners as they prefer to be called, struggle to find a new role for themselves. Government officials still make the right noises about being committed to the Post-2015 Agenda, but it is business as usual as donors especially those with global mandates continue to carry out their small projects in limited number of LGAs while pretending to be supporting national programmes for this and that disease or strengthening national health systems. Nevertheless, donor-supported programmes, more like ‘research pilots’ provide good evidence for continuously improving health care service delivery and the management systems that support it in Nigeria. For example, our knowledge about the effectiveness of Community Health Volunteers as health extenders came from experience gathered from two donor-funded projects: an Australia Aid (AUSAID) funded Community Mental Health Programme in South East Nigeria that was managed by CBM Australia; and a Nutrition Programme in Northern Nigeria, which was jointly overseen by Unicef, Save the Children, and Action Against Hunger, but funded by UK Department for International Development (DFID). However, we also learnt from these projects that to be sustainable, Community Health Volunteers have to be paid – no matter how small.

And as per Health Care Professional Unions – the Doctors, Nurses, Pharmacists and the rest – they have become very unpopular with the average consumer of healthcare services. Tired of their constant bickering over professional supremacy, and their collective neglect of the interests and concerns of the consumer over the years – Nigeria healthcare consumers have used their new found influence expressed in ‘healthcare purchasing power ‘ to set new measures for healthcare delivery performance, partly based on mutual accountability among healthcare professionals. Although cost of care is important, consumers now value choice and trusting relationships with doctors and provider-teams who routinely spend considerable time learning about each consumer’s medical history and needs and provide each consumer with a feeling of empathy, security and respect.

With respect to the overall performance of the health system, there have been fundamental changes that are more aligned with the overall economic growth and development agenda of the country as an advancing economy, than with technically perceived unproven ideals. While the United Nations (UN) and its agencies fret about lack of progress by Africa’s largest economy in meeting the Post-2015 Agenda targets, the ‘leapfrogged’ changes at both macro and micro levels have set Nigeria’s health system on a path to sustainable development. And this transformation has started to lead to: (i) better health outcomes – for all demographic and socio-economic groups; (ii) improved individual satisfaction and experience – with health activities and interventions; and (iii) enhanced financial sustainability – for both individuals and the economy as a whole.

Nigeria Health Sector in 2015

Healthcare Nigeria

With the singing of the National Health Bill at the twilight of 2014, stakeholders in the Nigeria health sector naturally appear to be gearing up to actively participate in what they anticipate would be the beginning of a ‘new dawn’ for health care delivery in the country.

Theoretically, the National Health Bill now an Act of the National Assembly (Parliament) creates a huge opportunity that would help the country chart a path towards achieving Universal Health Coverage (UHC) in the very near future. Specifically, as this law makes provision for financing Primary Health Care (PHC) from the Federation Account, outside the regular monthly allocations to the 36 States (that is not mandated for any goods or services); it is expected that the in-built mechanism of using this as a ‘challenge fund’ would leverage additional resources from the States for PHC. And there is therefore the assumption that the potential increased funding for PHC would by and large provide vital health services at the community level, as well as secure financial risk protection for ordinary Nigerians when they use such services.

But this futuristic glance of the coming year – 2015, advise the exercise of caution in balancing optimism with a tinge realism.

Here is why ‘fundamental health system change’ that leads to: (i) better health outcomes – for all demographic and socio-economic groups; (ii) improved individual satisfaction and experience – with health activities and interventions; and (iii) enhanced financial sustainability – for both individuals and the economy as a whole – may not happen (or begin to happen) in 2015.

First – 2015 is election year in Nigeria. Though the elections will definitely come and go, and there will be winners and losers for sure. But as most things in Nigeria depend on government, the period of electioneering and the outcome of this significant national event will influence what happens generally in the country for the whole year. The May 29th ‘transition date’ somewhat divides the year into two halves. The first part of the year, overshadowed by ‘election fever’ will create uncertainly as stakeholders within the health sector may not fully engage with government as they are not sure of who they may be dealing with after the elections. The second half, the transition period will be equally unsettling as political officer holders – who are either new to office or consolidating their mandates – would either be finding their bearing or trying new approaches to doing things based on their previous experience.

Second – as technical capacity at all levels of government (Local, State and Federal) within the health sector remains weak; 2015 is not the year when suddenly technocrats in Nigeria are able to translate policies into plans and get them implemented. Moreover, as they are known to be territorial and clandestine in their dealings; this may not be the year when they become more transparent and agree to openly work collaboratively with all stakeholders in the health sector.

Third – Nigeria is an emerging economy (despite income inequalities) with all the trappings of affluence, and a growing middle class. But the International Donor Community (aka Development Partners) remain pretentious about delivering International Aid in the health sector based on conventional ideas of helping a poor country. In 2015, Development Aid to Nigeria in the health sector will continue to be ineffective as the interventions of Donor organisations will continue to be seen as projects of the respective agencies (including those with global mandates); and not national health programmes since they will fail to make the connection of engaging with a country in transition.

However, all hope is not lost for the Nigeria health sector in 2015. Based on the ‘drivers of change’ analysis – we are aware that while actors make outcomes possible their capacity to act is ultimately set by the structural context which they find themselves. Notwithstanding, in 2015, change may still come through collective action by actors who are able to overcome such structural obstacles by re-making of institutions – modifying the way actors relate with each other and with the structures. As previously demonstrated by the ‘Nollywood Paradigm’, the group that got the National Health Bill passed and signed through sustained advocacy – the Health Sector Coalition of Nigeria – will continue to ensure that the National Health Act begin to provide benefits for all Nigerians as intended and not hijacked by vested interests. But fundamentally, as the market-based Nigerian economy powers on (irrespective of low oil prices, which will only affect government revenue), the health sector will most likely follow the approach of the multi-national companies serving Nigerians (even the very poor) with good and services – by converting them into effective consumers rather than being patronising in their dealings.

On this note, stakeholders in the Nigeria health sector should look forward to a 2015 that will not only engage their energies, but also their mental faculties as they ‘navigate’ the ‘treacherous waters’ of re-vitalising the health system, especially primary health care delivery.

Ebola Crisis – Mass Health Behaviour Modification as Churches begin to serve ‘Holy Communion’ using disposable cups

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“We are one body…because we eat from one loaf of bread…and drink from one cup…” Not anymore.

The practice of Holy Communion whereby Christians like to enact the ‘Last Supper’ said to have been rites performed by the founder of their religion – Jesus Christ, during the last meal he had with his disciples before he was crucified, is well known.

In its original form, after serving bread (usually strips of Wafers) that represent the ‘body of Christ’ from a plate, a sip of wine symbolizing the ‘blood of Christ’ is taken from a special cup known as the Chalice. This is done in turn by members of the congregation, passing the cup from one member to the other or its movement facilitated by officiating Ministers of the Church.

But with the knowledge of the transmission of Ebola Virus, where contact with body fluids including saliva is one of the routes; sharing of one cup for whatever reason including religious may no longer be tenable. Moreover, as responsibility for personal protection in this matter has been passed to each individual, people are bound to act in ways that would secure themselves. And so, if people have to associate even for religious reasons, alternative means of doing so have to be found that while satisfying such spiritual needs does not compromise the personal well-being of individuals.

One church in particular, Christ Church, Port Harcourt is said to have done just that. An eye witness account of events of Sunday the 7th of September, 2014 noted that ‘plastic disposable cups’ were used to serve the ‘holy communion wine’ instead of the ubiquitous Chalice as it was the tradition. The source of this report narrated that prior to announcement of this modified mode of Holy Communion; there were a lot of apprehension among members with an assumed large number deciding not to partake in the ceremony. But with ‘personalized communion cups’, reassured members of the congregation were observed to have responded to fulfilling their spiritual obligations; as well as resulting to a successful Holy Communion service on this Sunday.

A sample of commentaries following the exercise is believed to have suggested an indefinite continuation of this approach with respect to Holy Communion even after the Ebola virus disease has been contained. If this happens, then it marks the start of how a public health emergency can drastically change human behaviour on a massive scale. And this experience should provide some insight into how we manage public health matters in large societies such as Nigeria.

The ‘Nollywood Paradigm’ still presents the best model to drive Africa’s growth

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Nollywood is Nigeria’s answer to Hollywood, Bollywood and all the woods of this world. Thanks to rare ‘native intelligence’ combined with common sense.

The fact that doing any type of business in an emerging economy such as Nigeria is a daunting task needs not to be over emphasized. Apart from lack of basic infrastructure – reliable power supply, good roads and transport facilities etc; there is wide spread corruption and bureaucratic incompetence. Although Nigeria with its over 150 million people could be the largest market in Sub-Saharan and indeed the biggest economy with the recent rebasing of the Gross Domestic Product (GDP), the vast majority (over 60%) of this population is said to live at the bottom of the income pyramid. So, how do you create and grow an industry for home movies in such a difficult environment?

This was the sort of ‘stupid question’ asked by Nigerian artists, directors, financiers and other supporters two decades ago. At some point, the French Cultural Centre in Nigeria actually brought French movie makers to study their methods – and they asked similar ‘foolish questions’: How on earth can you make a movie in seven days, at low cost, enjoyed by over half the population of your continent and still get noticed by the world? And Yes at a huge profit too.

Knowing that fixing all the socioeconomic problems to create an environment conducive for film making may never happen – those who insisted on making a living from this way of life have to ‘re-think’ how things are done in this industry. More over there was demand for home (local) content films that could tell stories viewers can relate to. And since making films was their core focus, they set out to combine ‘raw talent’ with ‘amateur technology’ and improvised all the way. They borrowed, begged but they did not steal. Instead of building studios they used people’s homes that were already ‘in set’. Most of the productions were financed by individuals, families and friends – there were no institutional investors or government guarantees. They latched onto the already existing commercial distribution system for everything, to distribute and market their products. Films that were already released carried the advertisements of those in the pipeline. And several other innovative approaches that were used to by-pass critical constraints.

From the perspective of individual film makers or film production, the major challenges they faced were centered on the cost of production and project management. The lack of adequate financial backing meant that individual film makers had to rely heavily on ‘bootstrapping’ all along the way, as well as employing plenty of ‘sweat equity’. These were apart from using up all personal savings and all they could borrow from friends and relatives. In addition, there was plenty of ‘asset parsimony’ – begging for things they should borrow; borrowing what they should buy; buying old equipment rather than new; use of assets in return for acknowledgement of the owners; and other creative means of acquiring the use of assets. As much as possible, the financial burden of the cost of fixed assets was kept to the barest minimum.

Similarly, because no single organisation had the capacity to pull all the resources required to fund and manage a complex project such as film making – production management was organised as ‘collaborative networks’ or ‘strategic alliances’. This on its own presented another level of complexity in an environment where managerial culture was poor. Nonetheless, ‘social capital’ – specific forms of social relationships, which act as individual or group resources (actual or virtual) that facilitate collective action for mutual benefit – said to be entrenched in African settings proved useful in getting participants to work together towards a common purpose. Key elements of social capital, such as mutual trust, knowledge of each other’s values and discipline, and a sense of belonging were noted to be critical in holding such networks together to produce results.

Initially, the quality of the films were not very good, compared to what people were already used to – mainly due to the level of technology applied.  But the artistry skills displayed by the actors and actresses were remarkable – and thus provided increase patronage. By learning from their mistakes; listening to audience reviews; and an expanded market across Sub-Saharan Africa and Africans in the diaspora, which help to generate more revenues – major improvements were made. This led to an increase in business confidence of both participants and supporters, as demonstrated by the high content of Nigerian films carried by major cable satellite networks.

Although figures are hard to come by, there is strong indication to conclude that the Nigerian home movie industry is profitable and has created several thousands of sustainable jobs. There is now a ‘celebrity culture’, where popular actors and actresses can be seen mixing with the high and mighty of society. Gone are the days when artists reign on TV shows and then fade away – and sometimes live hungry for the later part of their lives. There are also national and regional awards that encourage competition, as well as influence young and talented persons to consider this industry as a worthwhile career or business.

The lesson from this story is that irrespective of the business environment in Nigeria: it is feasible to grow and prosper, by creatively re-writing the institutional rules that govern any industry. The fact that the home movie industry in Nigeria has grown to be one of the bright spots in the nation’s economy, is a demonstration that it is possible to make progress even in the face of non-existent economic opportunities. But is this a replicable model?

Many commentators have noted that the Nigerian music industry, although a related creative sector, has achieved huge success by adopting similar approaches. Apart from this, on the basis of the concept of ‘jumping fences’ or ‘leap frogging’ – creatively re-engineering how things are done in difficult situations, while remaining profitable – one could identify several other examples of what one could call ‘nollywood paradigm moments’. Here are two examples to illustrate this point.

First is sachet water – popularly known as ‘pure water’ – commercially produced and distributed can be found everywhere in Nigeria – from the Atlantic shores of Lagos to the fringes of the Sahara desert in Sokoto. With no marketing or branding, just an essential commodity made available in a form that is acceptable to consumers. And significantly, sachet water is said to have helped to reduce diarrheal diseases; more than all the bore holes that have been sunk by both government and donors in the past 20 years.

And second, multi-national companies ranging from manufacturers of beverages, soap and toothpaste to mobile telephone operators – have converted the millions at the bottom of the income pyramid into effective consumers. By offering their products and services packaged in smaller and affordable sizes, many low earners now have access to a wide range of consumer goods and services that hitherto were only available to the upper classes.

Therefore for wider application to all sectors in Nigeria and indeed Africa: the message is simple – look for ‘nollywood paradigm moments’ that are taking place or create some, and scale them up to achieve and even surpass the results of the Nigeria film industry.

Absence of Health Insurance Markets will impede Universal Health Coverage

Irrespective of the scale of operation or model adopted, unless a market for health insurance is well established – it would be very difficult for health insurance to take proper root in Sub-Saharan Africa (SSA) as a viable financing mechanism for healthcare. A health insurance market occurs when individuals and insurance companies communicate with each other to buy and sell health insurance. On the demand side – individuals who wish to buy health insurance do so in order to maximize their ‘utility’; while on the supply side – insurance companies who wish to sell health insurance do so to maximize their ‘profits’ (or ‘surplus’). And both sides communicate with each other through the medium of health insurance premiums.

The failure to allow this basic arrangement to happen in SSA has given rise to all sorts of programmes and projects that have never left their pilot stages. Meanwhile, as countries continue to explore the promise of health insurance as a significant alternative source of funds for health care, many have been led to undertake schemes that do not take this very perception into account.

Contrary to common knowledge, health insurance is ‘not a health intervention’, rather it is a ‘financial instrument’ that allows easy access to health care. Part of this misunderstanding stems from the influence of donor agencies that are largely averse to using ‘market-based solutions’ in resolving critical development problems; but the main reason for not encouraging countries in SSA to develop health insurance markets is because of the notion of wide spread poverty in the sub region. Nevertheless, we know that even for poor people, market-based solutions have proved to be delivering much better value to them than traditional approaches. Manufacturers of fast moving consumer goods and Mobile Telephone companies in SSA who are already profiting from this knowledge have managed to turn this group into effective consumers for their products and services ◊◊◊

Health Insurance: making the Informal Formal

Consumers

In his book Africa Rising, Vijah Mahajan portrayed the African economy as the 10th largest in the world, but often underestimated due to the large size of the informal economy. More like a parallel economy (almost 50% of GDP), the International labour Organisation in Geneva, estimated that the informal sector also accounts for over 70% of employment in Africa.

Over the years, policy makers and practitioners have had great challenges in making health insurance services available to this group – either as a means of financial protection against the risk of unexpected and expensive illness; or as a form of savings set aside to cover relatively predictable contingencies such as annual medical check-up or even treatment for acute malaria for example.

Past attempts at providing health insurance coverage for those working in the informal sector and their families through community-based or micro-health insurance schemes were seen to have not achieved their desired impact. This was largely attributed to the realisation that irrespective of the scale of operation or population segment that is covered, financing healthcare through insurance requires the same level of managerial and technical sophistication necessary to deliver real value to clients while remaining viable.

Therefore, in the era of Universal Health Coverage, there needs to be creative redesign of workable business models away from traditional approaches that are not scalable. Going by the Africa Rising script, one could propose that the challenge of expanding health insurance to the informal sector is similar to the problems of distribution of products to reach those at the bottom of the income pyramid being faced by manufacturers in Africa. And their experience in overcoming these difficulties appear to be the paradigm shift required for making health insurance products available to this group. It has been noted that by understanding local consumers and the small unorganised retailers, using computer routing to find the best path through a complex and fragmented retail network; many multinational companies such as Unilever and Coca Cola were able to bring the informal sector within their sphere of influence to join the mainstream of consumers of their products.

Learning from this model, the task in Africa for health insurance organisations (for-profit or non-profit) especially Health Maintenance Organisations and Health Insurance Companies is to organise health insurance for the informal economy in a manner that strategically aims at bringing this group into a ‘single pool’ of contributors and beneficiaries, along with their formal sector counterparts. This would require the use of creative means as outlined above to ensure that while offering the full range of services to this population, their premium contributions are fair enough for them to remain consumers of health insurance products and services. No doubt, there would be linkages with other aspects of the emerging market for health insurance in Africa including premium subsidies by government or other bodies, as well as incentives for insurers and providers to specifically target the informal sector population ◊◊◊

Universal Health Coverage: how health insurance may help

In as much as health insurance shows great promise in improving financial access to healthcare, its ability to promote fairness (equity) is limited by the economic capacity of the population. For this reason, national health insurance programmes in many sub-Saharan African counties have only succeeded in reaching a relatively small formal sector, while community-based pre-payment schemes targeting rural and urban low-income households are yet to be scaled-up for impact.

Theoretically, there is an assumption that it is possible to attain universal health coverage (UHC) by making health insurance coverage mandatory. While this is yet to be fully tested even with the ongoing experiments in the United States of America with ‘Obamacare’, and several tiers of coverage in Indonesia – there is great anticipation for such a policy to be true and thus a high demand for it even in Nigeria. But as health insurance systems involve a highly complex combination of incentives to providers, consumers and third-party fund holders; mandatory health insurance coverage will necessarily require a ‘market for health insurance with some regulation’. This is to ensure that while the beneficial effects of universal access to care are being extracted, the unintended detrimental consequences of lack of equity and inefficiency are modulated.

And critical to success, is to ensure that access to health insurance is not dependent on income, by identifying those for whom premiums need to be fully paid for or subsidised. Apart from having local government agencies or community-based organisations to be well organised and have the skills to implement prospective means tests of the population, there needs to be a proper role re-definition of public sector (government) away from direct implementation to oversight of the system. While guarding against corruption and rent-seeking for example in Nigeria, this role could entail: defining a cost-effective package of standard minimum benefits that must be covered in all insurance plans; supplying information to consumers regarding their choices; subsidising (or fully paying) the premiums of low-income groups; and regulating the activities of health insurance companies or agencies which may be for-profit or non-profit. The market for mobile telephoning that is accessible to all socio-economic and demographic groups, where the Nigerian Communications Commission plays this public sector role effectively provides a good model for practice ◊◊◊

Universal Health Coverage: more of a managerial challenge than policy reform

 

Managerial Challenge - managing the pateint experience

International health development has had its fair share of fads and slogans that in most instances tend to divert attention from what is really important. As the post-2015 debate and consultations on the replacement Millennium Development Goals continue; there appears to be a common understanding that irrespective of the goals that emerge, the targets should aim towards achieving universal health coverage rather than assumed proportions of the population.  

But universal health coverage (UHC) is not a new concept or development. Previously, the WHO has massively promoted this idea in the 1980s through the ‘Health for All’ by the year 2000 agenda that came to be popularly known as the Alma Ata Declaration. And the era of health sector reforms that followed this campaign in the 1990s consequent upon the macro-economic adjustment programmes of the IMF and World Bank in many developing countries; also aimed at achieving better healthcare for all. While the debate on how to reach this goal globally has largely focused on further reforms of health systems, especially funding healthcare; little attention is paid to what really matters – outcomes.

No doubt policies on improving financial access to healthcare for everyone that could contribute to improved health status are essential; they are not sufficient on their own to achieve better physical and mental health outcomes across all demographic and socio-economic groups. Experience elsewhere (and even in Nigeria) has shown that to get to this level of change within the health sector, managerial capacity, which provides the link between defined policies and their implementation is crucial.

In the particular context of Nigeria, other than concerns about the ability of individuals and agencies responsible for leadership, planning and evaluation, decision-making and regulation of the health sector; the prevailing political-economy of Nigeria being a federal country (even just in concept), and other factors outside the health sector such as macro-economic performance, infrastructural development, educational levels and cultural norms impose added managerial challenges. Therefore, as the summits, conferences, workshops and seminars in support of universal health coverage rage on, it is important that significant attention is paid to this point. And may be, it is also time to make the complex very simple ◊◊◊