Profile of University of Lomé Students in Togo: Significant Health Requirements, But Challenges for Healthcare Access

When considering the Sustainable Development Goals, the health of young people emerges as a significant concern for the countries of sub-Saharan Africa. This region, which hosts the world’s largest population of young people, faces the most acute health challenges for its young population. Nevertheless, our understanding of their healthcare-seeking behavior, both curative and preventive, and their health requirements, remains limited.[1] In this “Insights” article, we delve into the situation of students in Togo[2] to better understand the nature of these challenges.

Health in Togo

In 2011, Togo introduced a National Health Insurance Scheme (RNAM) managed by the Institut National d’Assurance Maladie (INAM), primarily targeting active and retired public and para-public employees, and their dependents. This scheme extends coverage to 4% of the Togolese population (CARES, 2019). The funding of the RNAM comes from contributions equivalent to 7% of the employee’s salary, with the cost split between the employer and the employee. Additionally, a health insurance program for disadvantaged students was launched in 2019, covering approximately 1% of students at the University of Lomé, Togo. Private insurance, which used to cover 2% of the population, has declined due to the impact of COVID-19. Mutual Health Insurances, a form of community-based health insurance, cover 1.6% of the population (CARES, 2019). In total, in 2019, 7.6% of the Togolese population had some form of health insurance.

The government has introduced initiatives offering free healthcare to specific vulnerable groups, including schoolchildren and pregnant women, through the School Assur program and the Wezou program (Togolese Republic, 2020).

Togo is intensifying its efforts to achieve universal health coverage. In October 2021, the Togolese government passed legislation to establish Universal Health Insurance. The goal is “ to ensure access to high-quality healthcare for all segments of the population, through a mechanism of risk pooling and solidarity in financing”.[3] This initiative is currently in the process of implementation.

These advances are highly promising, and in this context, it has become imperative to gain a deeper understanding of the healthcare needs and behaviors of populations that have been relatively little studied. Based on a survey of 760 students at the University of Lomé,[4] we have identified six characteristics that demonstrate the importance of focusing on the healthcare requirements of students.

The majority of students report having a poor health status

A majority of students perceive their health as subpar, revealing notable gender disparities: 68% of women compared to 58% of men report a general health status perceived as very poor, poor, or average.

An additional concerning statistic is that 22% of students claim to have a chronic illness (with variations between men and women), and half of them experience adverse effects on their daily lives, including a lack of ongoing care or treatment.

Students with limited safeguards against the financial risks associated with illness

A mere 11% of the surveyed students assert that they have health insurance, a figure that is more or less in line with the data for the overall population in Togo.

The majority of students (51%) benefit from insurance coverage through their parents’ affiliation to the National Health Insurance Scheme. In 9% of cases, coverage is secured through private insurance, whereas 2% of students are beneficiaries of the National Health Insurance Institute’s pilot program specifically designed for students (the vast majority of these beneficiaries are women).

Most students do not seek healthcare due to financial constraints

When students are questioned about their actions the last time they felt the need to consult a doctor for a health issue, 72% admit to not seeking medical care. Foregoing care can encompass two scenarios: either resorting to self-medication, as is the case for 54% of them, or neglecting treatment entirely, which applies to 46% of them.

In both instances, the repercussions can be significant, both in the short term and in the longer term, such as the progression of illnesses or the requirement for more complex treatments, increased reliance of emergency services or higher healthcare expenses. Self-medication poses considerable risks to users: misdiagnosis, inappropriate therapy choice, severe side effects and, potentially, death. The over-use of self-medication contributes to the rise of antimicrobial resistance: a significant challenge, as projections suggest that an additional 24 million people worldwide could be pushed into extreme poverty due to antimicrobial resistance by 2030. Additionally, the issue of counterfeit drugs plagues many developing countries.

Students mainly attribute their decision to forgo healthcare to financial constraints. The absence of insurance coverage appears to encourage them to not seek medical attention. Reducing the financial barrier to healthcare access for students is therefore a critical challenge, and underscores the case for extending the dedicated pilot program for students.

Students encounter exorbitant healthcare expenses

When students incur healthcare expenses, it has a detrimental impact on their quality of life. In fact, in the month preceding the survey, half of the students experienced high healthcare expenses: i.e., the healthcare costs comprising at least 40% of their ability to pay. These high healthcare expenses exacerbate the already precarious financial situation of students. The literature indicates that the presence of high leads to reductions in consumer spending, and can push individuals below the poverty line. Again, this underscores the need for wider health insurance coverage.

Students with various unmet health needs

In this context, students face ‘unmet needs’ as demonstrated by the following statistics:

• 35% of students report insufficient food intake.
• 41% of students believe they require glasses or contact lenses but do not possess them.
• 66% of respondents express the need to consult a healthcare professional within the last 6 months.
• 75% of students express a desire to consult a healthcare professional in the coming weeks if given the opportunity.
• Most women would prefer to consult a general practitioner, gynecologist, ophthalmologist, or dermatologist.
• Most men would prefer to see a GP, ophthalmologist, nurse, or dentist.

Emphasis on Women’s Healthcare

One in four female students indicate that they have consulted a gynecologist or healthcare professional for intimate or contraception-related matters within the past 12 months. Despite the low utilization rate, there appears to be a demand, because 73% of respondents express a desire to consult a gynecologist or health professional for these reasons in the coming weeks if given the opportunity.

Respondents cite various reasons for not utilizing this type of care, with the primary reason being financial constraints (64%). To a lesser extent, lack of perceived need (16%) is also a factor. Other reasons, such as time constraints, fear of such consultations or examinations, unfamiliarity with professionals providing this care, or apprehension about discovering illnesses, are mentioned to a lesser degree.

Regarding contraception, 56% of students, who were willing to answer this sensitive question, state that they do not use any contraception, primarily due to concerns about side effects (28%) or lack of financial means (26%). 10% of female students use the pill and 8% use spermicide. It is worth noting that the vast majority of both male and female students (89%) claim to be well-informed about the risks associated with unprotected sexual activity.

Conclusion

The health of students, and young people in general, is a significant concern for developing nations. As they stand on the threshold of the job market, students represent the future workforce and  entrepreneurs. Their health status and health-related behaviors are likely to influence their life choices, entrepreneurial potential, and their access to economic opportunities. For women, in particular, health plays a role in emancipation, fostering autonomy and impacting their future prospects.

Extending health insurance coverage represents one avenue for enhancing students’ access to healthcare by lowering the financial barrier that constrains their choices. However, it is not only on the demand side that action is required; the supply must also meet the demand, particularly on university campuses where only 7% of students, who seek medical attention, visit the university medical center.