The starting point for the reduction of inequality through economic and fiscal governance is the understanding of the concept of the minimum core state obligation in key social and economic issues. It is about the core values, entitlements and minimums embedded in each of the rights and services that the state renders to citizens. These core state obligations lead to the core content of each of the rights. The articulation of this core content is usually contextualised within the resources available in each country. In essence, we are adopting a rights based framework for the resolution of inequality rather than the basic needs approach. The beauty of this approach is that it creates identifiable rights holders and duty bearers and defines the contours of expectations on both sides.
For instance, in the right to health, preventive health care, public health education and primary health care are usually prioritised over costly curative care. Maternal, new born and child health, including immunisation for vaccine preventable diseases, also enjoy a priority. The state essentially defines the minimum package of healthcare services that it can guarantee to citizens. This is then costed per capita to arrive at the basic financial package needed to give everyone a meaningful access to qualitative healthcare. Provisions will then be made from various sources to finance this programme and the sources will include the normal pubic funding, special funds and earmarked taxes, health insurance, etc. The refusal of the present administration to provide funds for the Basic Health Care Provision Fund, asprovided in the National Health Act, is a vote for inequality. It is a vote for the continuation of the suffering and denial of the right to health of majority of the population.
In terms of public expenditure, it is not enough to increase the overall and per capita public expenditure on health. The increased expenditure must target marginalised and neglected groups who bear most of the disease burden and are left behind from reaping the benefits of scientific and economic progress. It must target the groups with the largest disparities, strengthen service delivery programmes and modalities, as well as create mechanisms for the recipients to hold service providers to account. Otherwise, increased public resources for health will become a slush fund for public officials who will not see themselves as beholden to the poor and marginalised.
In rural and remote areas where there is paucity of qualified health personnel, government can devise special bonuses and allowances to encourage qualified personnel to serve in those communities. And such service over a long period of time should qualify such personnel for special public honours and awards. The involvement of the communities in planning and rendering services is also a relevant process for reducing inequality. The idea of formulating policies, planning, executing projects on behalf of the poor and vulnerable is problematic on its own because it assumes that they have no contributions in the search for solutions to challenges that border on their intrinsic and inalienable rights. This paradigm of thinking needs to change for inequality to be reduced.
Funding the reduction of inequality will require wellarticulated programmes effectively communicated to all members of society – the rich, middle class, poor and the very poor. It needs charismatic leadership that effectively markets reform into the consciousness of all. Effecting marketing is about leadership which convinces through practical short, medium and long term action of the benefits from following a recommended course of action. When the leadership and senior members of the executive and legislature travel out of country to treat basic ailments, it is a vote of no confidence on the health system which they preside over. It is an admission that they have failed in their duty to respect, protect and fulfill the right to health of the citizens. This course of action heightens inequality because only the very rich can afford to be treated outside our shores.
For the very rich to pay more, experts have posited that an environment, which makes them to understand three things, is needed. They must perceive poverty and inequality as a threat to their continued good life and the basic dignity of all human beings in the country, including the associated risks of a revolt. This also includes an understanding that the rich will also increase their wealth if the purchasing power of the poor is increased. Thus, the ecosystem for increasing wealth is to create opportunities for others to partake in sharing the benefits of labour. They must also be made to get a sense of responsibility, not just corporate social responsibility but the responsibility of a shared humanity that purses a higher goal of nobility beyond the acquisition of ephemeral wealth. Finally, the system must convince those called upon to make sacrifices to believe that their efforts can actually reduce inequality. And that the resources they contribute will be properly managed and not stolen by some grass cutting bureaucrats.
The fact that several years after the Nigerian health insurance scheme came on board, less than five per cent of our population enjoys coverage speaks a lot about the management of the scheme. Proper management of the scheme would demand a reach out to both formal and informal sector workers. It would also demand a reach out to communities and tapping the community spirit found in most parts of Nigeria to organise a course of progressive action for health care reform. It is not about the aloofness of sitting in the highbrow polished offices of the scheme in Abuja and concentrating efforts at managing the little premiums that comes in. It requires the big picture of a leadership that dreams of the geometric increase in premiums hitting the 5-10 trillion mark; not just dreaming but drawing up strategies to actualize the dream.
Further, in situations where custom and religion have prevented groups like women from accessing effective health care; like in northern Nigeria where maternal and child health indicators are very poor, government needs to step in to prevent the continuation of this unfair state of affairs. First, we need more education for all members of society to move in the direction of reducing inequality in accessing good health care. Secondly, sanctions should be applied to individuals who seek to perpetuate the continued deaths of mothers and infants simply because it fits their whims and caprices. This is in line with the duty of the state to protect the right to health. Thus, the state has a basic obligation to prevent third parties from denying mothers and infants of their right to health and indeed their right to life under any pretext whatsoever. What has happened is that the state has been condoning murder which masquerades as lifestyles and culture. The easiest way of depriving women of reproductive age and infants of their life is the continued denial of life supporting healthcare to the point of abrogation.