Why medical tourism to foreign hospitals thrive

Recommend Better Funding, Equipping Of Health System

President Muhammadu Buhari had in April 2016 said the Federal Government would not provide funds to any government official to travel abroad for medical treatment unless the case cannot be handled in Nigeria.

He said: “While this administration will not deny anyone of his or her fundamental human rights, we will certainly not encourage expending Nigerian hard earned resources on any government official seeking medical care abroad, when such can be handled in Nigeria.” It was the Director, Media and Public Relations, Ministry of Health, Mrs. Boade Akinola, who relayed the statement to the media.

Unfortunately, Mr. President broke the promise barely a month later in early June 2016 when he was flown to London to be treated for an ear infection.

Minister of Health, Prof. Isaac Adewole, had in October 2016 told journalists in Lagos that medical tourism is a scam. He said that medical tourism to India is a racket and the country loses billions of naira yearly due to the fraud.

A racket is a service that is fraudulently offered to solve a problem.

But barely three months on, President Buhari is back to the UK for an extended medical vacation.

Why? What will it take to have Nigeria’s health facilitates updated to discourage top political office holders from sourcing health solution in foreign countries? What is the cost of the present situation to the country’s health system, beginning with the psychology of it?

It is estimated that Nigerians spent $2.5b (that is about N1.25t) on foreign medical trips yearly, most of which cases could be handled in Nigeria and were frivolous.

A breakdown shows that the global pharmaceutical market was rated to be $7 trillion as at 2014, with Nigeria contributing at least $2 billion to this huge market. At today’s exchange rate, that is at least N1 trillion worth of drugs in this health system. For a country that is still forced to depend on importation of over 70 per cent of its drug needs, this transcends to about $1.4b on drug imports or N700b in naira terms.

This is apart from what Nigerians who travel abroad to the UK, United States (U.S.), India, United Arab Emirates (U.A.E) spend on the medicine component of their treatment while outside this shores, which is estimated to be at least $250m or N125 billion. A summation of all of these factors suggests Nigeria must be losing at least $2.5 billion or N1.25 trillion to health tourism at today’s exchange rate to other nations.

Despite Nigeria being a major signatory to Abuja declaration of heads of government, which resolved to adopt a minimum of 15 per cent as national health budgets for all members, the country has never exceeded six per cent since that laudable step was taken in 2001.

Less than five per cent, about 4.15 per cent (N303 billion) of the proposed 2017 national budget of N7.29 trillion is for healthcare despite serious negative health indices, including the dishonour of being a major exporter of the oral poliovirus to other nations.

Also, the one per cent consolidated fund, which the National Health Act 2014 stipulates should be for health, especially for universal health coverage with health insurance and primary health care, has never been implemented since the Act became a valid Act of Parliament three years ago.

Imagine a situation where Aso Rock Clinic has substantial billions (about N3.8 billion) dedicated to it, when the so-called centres of excellence, 20 teaching and specialist hospitals, as well as, the 35 Federal Medical Centres (FMCs), receive far less as their yearly budgets.

Several studies have shown that if the 20 teaching hospitals spread across the six geo-political zones of the country are refurbished and made to function optimally, Nigerians will not need to travel abroad again for medical treatment and it will prevent brain drain in the health sector.

Also, the country would have been spared the embarrassment she got from flying its political office holders, including Mr. President and his Chief of Staff, Abba Kyari, to the UK for medical attention.

However, teaching hospitals in Nigeria have not been able to meet that mandate due to poor funding, dilapidated infrastructure and equipment, and incessant strikes by doctors and other healthcare providers.

Until now, teaching hospitals have been described as “mere consulting clinics”, ‘theatre of deaths”, and “final bus stop.”

In fact, over 600 members of the Association of Resident Doctors at the University College Hospital (UCH), Ibadan, Oyo State, penultimate week, staged a protest against what they termed poor working conditions, unpaid salaries and absence of basic facilities at the hospital.

President of National Postgraduate Medical College of Nigeria (NPMCN), Dr. Ademola Olaitan, had identified poor funding and frequent strike as the bane of the country’s teaching hospitals.

The Guardian had reported that Nigeria does not have enough cancer treatment machines, linear accelerator (LINAC), and the few in public, government-owned, hospitals are not working optimally, even as the centres do not have back-up plans.

Also, The Guardian investigation revealed that a LINAC costs about $5 million (over N1.5 billion) and the six that the Federal Government procured for six teaching hospitals have packed up.

The ministry of health recently confirmed to journalist that almost all cancer treatment machines, linear accelerators, have broken down and most patients are stranded.

Medical doctors under the aegis of the Nigerian Medical Association (NMA) and their affiliate association, National Association of Resident Doctors (NARD), have faulted President Buhari and other top politicians’ regular medical trips abroad even as they blamed the situation on the poor state of the country’s health institutions.

President of NMA, Dr. Mike O. Ogirima, told The Guardian that the poor working conditions in the country’s apex health institutions, which has led to the continuous patronage of foreign hospitals by top government officials and increasing medical tourism to hospitals overseas by affluent Nigerians is the major reason why the NMA backed the strike by NARD.

Ogirima said: “… You want to do away with the professionals that are not even sufficient considering the population they serve. If the system is so fantastic why do the president and top government officials still go abroad for medical checks and treatment?”

What is the solution? The NMA President said: “We need more funds and dedicated and prudent management with innovative instincts. I strongly advocate for sustainable costing of services rendered.”

Ogirima said the situation is heavily draining the countries external reserves as it involves about $2billion per annum.

He said the country needs a committed leadership with political will to address the issues of the health of the citizens. “Leadership must also show patriotism,” Ogirima said.

The consultant medical practitioner said the National Health Act (NHA) of 2014) sets out to improve the health of citizens through the various provisions. “It encourages universal health coverage, extra fund to care for the vulnerable in the society through basic health provision fund, setting up basic standards for our health facilities, minimizing the high maternal mortality and infant mortality among others. Only the government knows why the delay in the operation of the law before now,” he said.

Also, Vice President of Commonwealth Medical Association (CMA) and former President of NMA, Dr. Osahon Enabulele, had accused President Buhari of reneging on a promise to end “medical tourism” by seeking treatment in the UK.

He said Nigerian politicians were mostly treated by Nigerian doctors when they get to the UK.

Enabulele said it was a “national shame” that Mr Buhari went to the UK for treatment when Nigeria had more than 250 ear, nose and throat (ENT) specialists, as well as a National Ear Centre.

He said Buhari should lead by example, by using Nigerian doctors and facilities, and ensures government officials do not go abroad on “frivolous” medical trips.

Enabulele said the UK had more than 3,000 Nigerian-trained doctors, and the United States (U.S.) more than 5,000, accusing the government of failing to address the brain drain by improving working conditions and health centres.

“Records show that in last year alone, 637 medical doctors emigrated due largely to poor working conditions and health facilities, insecurity, unpredictability and poor funding, uncompetitive wages and job dissatisfaction,” he said.

On what it will take to have Nigeria’s health facilities updated to discourage top political office holders from sourcing health solution in foreign countries, President, Pharmaceutical Society of Nigeria (PSN), Ahmed Yakasai, told The Guardian that it will take high intention, big commitment, sheer determination and huge investment to update and upgrade Nigeria’s current health facilities to world class standard so that all Nigerians, whether top political office holders or an infant born in a remote village in any part of the country that need optimum healthcare will be properly taken care of.

Yakasai further explained: “In addition, we also need to invest in health care personnel training and re-training, technology and put competent administrators to run our tertiary and secondary hospitals across the country. It is also pertinent to boost the morale and motivation of the healthcare providers in order for the country to stop losing some of our best brains to other countries of the world and for those currently practicing abroad to be able to come home and join the team. I believe with the above multifaceted approach, if applied, within a decade we can revamp our healthcare system and become the healthcare destination for sub-Saharan Africa.”

What is the cost of the present situation on the health system, beginning with the psychology of it? The PSN President said the cost is huge and the psychology of average Nigerians is that the healthcare system is nothing to write home about. Paradoxically, Yakasai said, Nigerian medical doctors, pharmacists, nurses and other healthcare providers are some of the best brains in Europe, America, and the Middle East.

He, therefore, said Nigeria does not lack the talents needed to give Nigerians optimum care, what the country lacks is the political will, the mindset, acting on the existing health policies and providing the enabling environment to turn around the health care services for the best.

Yakasai said Nigerians also needed to start trusting the professionals more and provide the right technology, infrastructure and motivation for them to blossom.

The PSN President said for citizens to have confidence in Nigeria’s health infrastructure, it has to begin with the leadership. He explained: “Leaders lead by example. Until political, business, religious and community leaders have trust in our healthcare delivering system in the country, many Nigerians would not. The confidence in Nigeria’s health infrastructure and service delivery must start top down through the social stratification in the country.”

On the provisions of the 2014 Health Act, Yakasai said it provides the legal framework for the regulation, management and development of the Nigeria health system, setting models for the rendering of health care services in the country.

He further explained: “Translating and implementing the provisions of the Act to achieve qualitative, cost-effective and accessible healthcare for all Nigerians will require a sheer commitment from the Federal government and the various levels of the healthcare delivery system working in synergy. This is yet to be done.

“The 2014 National Health Act encompasses the legal provisions required to regulate and ensure effective, efficient and quality of healthcare delivery in Nigeria. In collaboration with an efficient health financing system, the ensured quality health service becomes accessible, beneficial and cost-effective with the citizens of Nigeria becoming the ultimate beneficiaries.”

The PSN President said the Health Act has clearly define a role and relationship for and between the three ties of government in the country, knowing fully well that healthcare load is bottom-heavy with over 75 per cent of Nigerians accessing care at the primary level, the National Health Act had provided for the establishment of Basic Health Care Provision Fund of at least one per cent of the consolidated Revenue Fund at the Federal level, with counterpart funds from both the States and Local Governments.

Yakasai said if well implemented, the National Health Act can significantly improve the quality, affordability and accessibility of health services for all Nigerians in the country. “The onus is on the Federal government, the other tiers of government and other relevant stakeholders to key into the National Health Act and get it working as soon as possible,” he said.

Immediate past President of PSN, Olumide Akintayo, told The Guardian: “Not too much if you ask me. This is just an attitude problem, which our leaders need to work on. Let me submit that Nigeria has an array of experts who will rub shoulders with the very best in care provisioning across the borders in the various professions, including pharmacy, laboratory sciences, medicine, physiotherapy and others.”

Akintayo said the major drawbacks are the extremely wretched funding, the refusal to embrace comprehensive reforms in healthcare and our refusal to embrace research and development.

Akintayo said the way forward is to fund healthcare through a myriad of options known to all providers and health administration for optimal outcomes. “We must embrace comprehensive health reforms, which must oust or review some obnoxious health laws, in particular the irresponsible decree 10 of 1985 (now cap 463 LFN 2004), which institutionalizes a peculiar mode of Nigerian healthcare practice by imposing one profession on all others. When you cede headship of health institutions to doctors, zone 80 per cent of board membership to only one profession and refuse other key health workers from getting to the apogee of their careers in Federal Health Institutions, what you get is the poor output we continue to record, which places our health system 187 out of 191 in a recent survey by the World Health Organisation,” he said.

The former PSN President said if government properly funds the health system and equip the hospitals with modern gadgetry to aid proper diagnosis, which is backed by safe, affordable and efficacious medicines, public officers will not have a basis to continue to fritter away scarce financial resources.

Akintayo appealed to government to fund research and development in the sector. He said the National Institute for Pharmaceutical Research and Development (NIPRD), Abuja, and Nigerian Institute of Medical Research (NIMR), Yaba, Lagos, should be supported in the quest to boost local production of vaccines and essential medicines. The pharmacist said NIPRD and a well-nourished local pharmaceutical industry can become a veritable source of Internally Generated Revenue (IGR), which ultimately boosts National Gross Domestic Product (NGDP), especially if government leads the way by building viable petrochemical plants.

Akintayo said the impression the average Nigerian gets is that healthcare services around here is substandard, which is the motivation for leaders to patronize health facilities abroad. “In a country where people often times tend to do what their leaders do, senior government officials must patronize Nigerian facilities to inspire confidence in our local health facilities,” he said.

How can the situation be addressed? Akintayo recommended: “Like I said earlier, the 2014 National Health Act prescribes a compulsory one per cent consolidated fund to the health system. Section 10 of the Act further stipulates that 50 per cent of this must be dedicated to National Health Insurance Scheme (NHIS), which normally should advance the philosophy of Universal Health Coverage (UHC). In a country where the ambits for normative civility remains in short supply, the Nigerian version of health insurance is a colossal failure because of factors like indiscriminate capitation of facilities by NHIS, unlawful payment mechanisms through global capitation and a public sector driven project, rather than private sector agenda.

“The same Section 10 makes a provision of 10 per cent for essential medicines and vaccines, while another five per cent is for capacity building of relevant personnel. The intendments are noble, but nobility is not a common Nigerian virtue, so all the symphonies of progress and benefit package intended for consumers of health have been unduly compromised through deft machinations.”

Meanwhile, President Buhari’s medical trip to the UK has reignited calls for a quaternary hospital to be located at the Federal Capital Territory (FCT) Abuja.

Stakeholders in the health sector, including the NMA and the PSN have called for the refurbishing of the existing twenty teaching hospitals spread across the six geo-political zones of the country and increasing the budgetary allocation for health from paltry 3.75 per cent in 2016 budget to at least 15 per cent henchforth.

Tertiary and Quaternary Healthcare refer to specialised care available in referral centers and very rarely accessible to the general public. The term quaternary care is sometimes used as an extension of tertiary care in reference to advanced levels of medicine, which are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. These services are usually only offered in a limited number of regional or national health care centres. A quaternary care hospital may have virtually any procedure available, whereas a tertiary care facility may not offer a sub-specialist with that training.

The past administration of President Goodluck Jonathan had concluded plans for the establishment of a quaternary hospital but could not execute it because of paucity of funds and low budgetary allocation to the health sector.

The administration, however, transmitted the plans to President Buhari’s government.

Based on Jonathan’s approval of the third phase, the then Minister of Health, Prof. Onyebuchi Chukwu, inaugurated a Technical Working Group (TWG) under the chairmanship of the then Permanent Secretary Federal Ministry of Health (FMoH), Mr. Linus Awute.

The TWG considered and agreed on a PPP model for the construction of a new 500-bed world class quaternary Hospital, rehabilitation of the remaining teaching hospitals, including the National Hospital Abuja and revamping of the 14 already rehabilitated through the Federal Government of Nigeria (FGN)/VAMED Engineering Project.

According to the document sent to President Buhari by the FMoH, to fund the PPP project, VAMED Engineering, Austria/CPL Medical Group Nigeria has offered about 400 million Euros; and the Federal Government is expected to make budgetary provision in 2017 for the plan. As part of the PPP, the Federal Government is to make provision of 15 per cent of the 400 million Euros, which is further broken down to three per cent annually over a five-year period.

Following recent events in the country where top political office holders including Mr. President have frequently been going abroad for medical treatment, stakeholders believe that the Federal Government should pursue the third phase of the teaching hospital rehabilitation project, by including it in the subsequent budget proposal and beyond to take care of its share contribution to the PPP arrangement.

They said when completed, it will save the country the billions of dollars it loses in foreign exchange due to frequent overseas medical treatment by citizens and retain thousands of home-trained medical personnel that migrate abroad yearly for greener pastures.

The TWG said the state-of-the-art medical facilities that will be available in the 20 teaching hospitals and the Quaternary Hospital in Abuja include, among others, Linear Accelerator, Magnetic Resonance Imaging (MRI), mammogram, and surgical and diagnostic suites.

How does the country raise its counterpart funding for the third phase of the teaching hospitals project when only 4.15 per cent (N303 billion) is proposed for health in the 2017 national budget of N7.29 trillion?

It is believed that the National Assembly must do an upward review of the budgetary allocation for health to meet the minimum 15 per cent recommended by African heads of state in Abuja in 2001, popularly known as The Abuja Declaration; so that the country can urgently begin refurbishing of 20 teaching hospitals and establishing of a quaternary hospital in Abuja.