•Mandatory health insurance, increased funding, better remuneration of health workers, local solutions for COVID-19 top wish list for 2022

The health sector has had its up and downs in year 2021. The strike by resident doctors and other healthcare professionals due to unmet expectations on their ideal remunerations, health care delivery standards, continued battle with the COVID-19 virus and its continually changing variants, most recently the Omicron strain, brain drain issues and a host of other dynamics affected performance of the sector this year.

Medical experts have reviewed health sector performance in 2021 and made recommendations on how to improve delivery in 2022.

Public health physician and Executive Secretary, Enugu State Agency for Control of AIDS (ENSACA), Dr. Chinedu Arthur Idoko, told The Guardian: “On a real scale, I would rate the health sector performance as below par to average.”

Idoko said the peculiar challenges have been those of low COVID-19 vaccine uptake occasioned by a myriad of conspiracy theories, reduced attention and funding of other diseases of public health importance like Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) due to the COVID-19 emergence and changing dynamics. He decried the continued brain drain of health professionals on a larger scale to Saudi Arabia, United Kingdom (U.K.) and the low per capita funding of the healthcare system in Nigeria among many others.

Idoko acknowledged: “There were achievements, though it could be better.” The public health physician said the continued pursuit of attainment of health for all Nigerians through Primary Health Care (PHC), coupled with effort at increasing on many fronts the number of Nigerians accessing different forms of organised healthcare financing, is in itself an achievement.

“Furthermore, I believe that the fact the country has received and continually receives consignments of different types/ products of COVID-19 vaccines is in itself an achievement. Low uptake is a different issue entirely,” he said.

For better healthcare performance in 2022, Idoko recommended that federal and state government should increase, in a real and practical sense, their funding of health care. This, he said, would go a long way to strengthen healthcare and foster confidence of both healthcare professionals and the general populace.

Idoko said options for healthcare financing need be explored and expanded, especially different forms of Community Based Insurance Schemes (CBIS) to improve access to healthcare of increased number of Nigerians.

For Harvard-trained health economist and Executive Director, Delta State Contributory Health Scheme (DSCHS), Dr. Ben Nkechika, the country has performed relatively well in the sector considering various healthcare challenges Nigeria and the world experienced with COVID 19 topping the list. “Nigeria was able to considerably overcome the challenges,” Nkechika said.

The health economist said the significant challenges the country experienced this year include the COVID-19 pandemic, which the country has been able to effectively manage considering various predictions. He said expanding health insurance coverage through enhancing quality primary healthcare services has continued to progress despite economic challenges of the year.

Nkechika, however, said the health sector has achieved a lot. According to him, this includes: improved PHC service delivery processes that has enabled revitalisation of PHC infrastructure and availability of vital commodities; enhancement of various strategic partnerships with stakeholders for improved quality healthcare service delivery; and effective and efficient vaccine delivery across the country.

To improve Nigeria’s healthcare system, Nkechika said there is need for a healthcare service system modernisation review. “I believe the current system needs to be modernised to meet with new global standards. The focus should be redirected to measurable health outcome benefits with patient-centered care instead of just input to meet expectations that are not tied to measurable outcomes,” he said.

President, National Association of Resident Doctors (NARD), Dr. Godiya Ishaya, said: “I would rate the health sector as fair. It has been a challenging year just like the last and we still have a lot of challenges that have not been taken care of.”

Ishaya said the challenges are the usual perennial problems of an impoverished health sector with lack of adequate equipment, manpower, inadequate finding resulting in poor remuneration and in addition, challenges of the COVID-19 pandemic. All these, he said, have caused a mass exodus of doctors and other health workers to places where service conditions are better. “These are the same reasons why we, the Nigeria Association of Resident Doctors, embarked on a strike,” he said.

The resident doctor said some achievements were made, especially in the aspect of containing the COVID-19 pandemic and other outbreaks, like the recent cholera outbreak.

Ishaya said there needs to be improved funding of the healthcare sector. “In the 2022 appropriation bill, only five per cent of the budget is allocated to health and this falls short of the recommended 15 per cent. So, these are the issues that hinder progress in the health sector. The funding is inadequate because almost everything depends on funds, be it projects, programmes or health personnel,” he said.

A professor of Ophthalmology and Chairman, Lagos State Traditional Medicine Board (LSTMB), Adebukola Adefule-Ositelu, said the health sector has been faced with tremendous life-threatening health challenges that it is not equipped to cope with. She said the sector is also grossly underfunded and health workers are not well remunerated or fairly treated despite their dedication and the health risks they are exposed to. “We do not have enough of them to meet our needs, and unfortunately, they are being driven away from their homeland to serve in foreign nations. This is very unwise and sad indeed.”

Adefule-Ositelu told The Guardian: “The brain drain is ongoing. With pride and in truth, I say, see and know that Nigerian trained doctors and other paramedics are well trained. Globally, they are respected. They excel in their different disciplines of health sectors; they are outstanding in the performances of needed related cares, in standards and qualities. These poor trends of shabby treatment and impoverished status they receive nationally may discourage and reduce interest in the number of our oncoming medical undergraduates. Our resources should be properly planned for and must be channelled justifiably and equitably. We need all-round, better commitments and fairness for all arms of national workers. The country is like a diabetic, with enough resources but suffering because of lack or loss of that ‘hormone’ needed for vital and useful distributions to designated destinations (organs). The populace deserves more from our leaders, on account of our God-given endowments.”

She said researches are not well funded and the country continuously relies greatly on westernised cultures and decision. Adefule-Ositelu said this is one area where Lagos State Government (LSG) stands out. “She recognises the relevance of Traditional Medicine Practitioners (TMPs) in her health sector set up and has inaugurated a LSTM Board. Lots of works have been done and achieved in regulating this sector. Also, it is awesomely discovered that over 70 per cent of our people do consult TMPs. The TMPs are at work,” the ophthalmologist said.

The eye doctor said Nigeria, therefore, needs more enhancements quite urgently to be able to achieve international standardisation and authentic TM products to meet the needs of Nigerians and run a parallel system of practice with the orthodox system.

Adefule-Ositelu said other states should emulate LSG. “We cannot shy away from it. Our people believe in them and they consult them and use their medicinal products. The well-performing government is by the people and for the people. There is no doubt that we have lots of medicinal plants that even our tertiary institutions’ lecturers have researched into from decades back. They are abandoned at promotional levels. These discoveries need to be further developed into useful and needed health remedies for our people. Collaborative moves are needed and should be encouraged, practised and uplifted for our own good. A healthy nation is an achieving nation. We are endowed. We are able. We can do it. Some of us are awake and we are out now waking others up from degrading impoverishing slumbers,” she said.

The ophthalmologist said Nigeria has effective natural anti-COVID preparations and can manufacture her own vaccines; the country did years back. “In all aspects of life, I pray we all imbibe individual relevant responsibilities. God is helping us; let us help ourselves too. What we erase here on earth may still be relevant in heaven and what we insist on writing here on earth may be permanently deleted, that is, removed in heaven. May all we do remain relevant to our owner, creator,” she said.

A public health physician at the Department of Community Health and Primary Care College of Medicine, University of Lagos/ Lagos University Teaching Hospital, Idi-Araba, Surulere, Lagos, and Chairman, Lagos State Primary Health Care Board, Prof. Akin Osibogun, in a keynote address at the Ondo State Health Summit, Akure, on December 6, titled, “Strategic Options For Strengthening Health Systems”, said the world is indeed changing and the COVID-19 pandemic has been a very good teacher to those willing to learn and be better prepared for the future. “A strengthened health system will be one that has capacity, is effective and resilient,” he said.

The theme of the summit was “Health System Strengthening in a Changing World.”

Osibogun said there are determinants of health sector performance. He said from available evidence globally, the higher the total health expenditure per capita, the better the infant mortality rate and other health indices.

Osibogun said political declaration of free emergency health services without an appropriate budgetary allocation is a guarantee for a deteriorated health service. “Fortunately, in compliance with the National Health Act, for the first time since enactment of the law in 2014, a budget of five per cent of one per cent of the Consolidated Revenue has been set aside for Emergency Health Services in 2018. It is obvious that there remains the challenge of implementation,” he said.

Osibogun said doctors, nurses, pharmacists, laboratory scientists and other health workers are required to get health technology delivered to the population and the density of human resource for health is important in determining variation in rates of maternal mortality, infant mortality and under-five mortality across countries.

He said, unfortunately, while Africa accounts for more than 24 per cent of the global burden of disease, it has access to only three per cent of the health workers and less than one per cent of the world’s financial resources inclusive of external loans and grants. While the United States has 300 doctors for every 100,000 citizens, Nigeria has only 38.5 for every 100,000 of its citizens and that is exclusive of the number of Nigerian doctors currently leaving for other countries. He said there is the challenge of attracting and retaining quality manpower.

Osibogun said availability of common medications and consumables is a major challenge. He said there are other policy options that can not only ensure regular availability of required drugs but also at reduced prices, for example bulk purchase and guaranteed payments by the State Contributory Health Commission, incentives to manufacturers to open drug factories in the state.

He said another major challenge is service delivery.

On how to improve health sector performance in 2022, Osibogun recommended: “Government’s main responsibility is to ensure the availability of quality and relevant health services and not necessarily the direct provision of services. Through service purchase contracts on behalf of the poor, government can satisfy the equity question.

“In order to improve the efficient delivery of services purchase contracts even with both public and private health facilities may be the way to go as it will ensure pay for performance. This will eliminate or at least reduce the competition for which professional group can stay away from work for the longest time!

“At current tax levels and width of capture, Government alone cannot fund the provision of health services. Also, in the absence of guaranteed markets, it is unlikely that there will be serious private investments into quality and high technology health services. Mandatory health insurance in the State will guarantee effective demand and attract the required private investment in health. Additional policy tools to attract private investment may be through soft land allocation and tax holidays for investors.

“Some have argued that there are communities in Nigeria that are too poor to be able to pay premiums for health insurance. I have travelled all the States in Nigeria and I have not seen any single community without one asset or the other. What I have seen in some places is a failure to recognize and meaningfully use these assets. If Israel could grow food on desert land, what excuse do we have to be hungry when we have plenty of arable land? Why should there be so much unemployment when there is a lot of work to be done? Millions of Houses are yet to be built, roads to be constructed, children to be taught and yet we talk about unemployment. I think our economists and politicians have to unlearn and relearn!

“I have no doubt that if we look more closely at the financing and provisioning functions of our health system, we will find the solutions to the myriad of problems currently being faced. I am convinced that we can, if we choose to, build a resilient and sustainable health system for our country but we need to be bold to face the challenges.”

A public health physician and Executive Director, National Primary Health Care Development Agency (NPHCDA), Dr. Faisal Shuaib, said the performance of the health sector can be rated as ‘good’ in view of the successes achieved despite numerous challenges faced nationally and globally in the last two years. Shuaib said despite global economic downturns and given the available resources as well as the array of conflicting public sector priorities in the country, the Federal Government continued to demonstrate its commitment to health through increased budgetary allocation to the sector; with a 32 per cent increase in health budget from N414.5 billon in 2020 to N547 billion in 2021 excluding COVID related emergency expenditure.

Shuaib said the singular outstanding challenge has been the COVID-19 pandemic. He said the pandemic not only ignited a national and global economic downturn but also specifically targeted the health sector, which stressed under the burden of expanding access to laboratory services and provision of emergency and intensive care. Coupled to this, he said, was the sudden peak in demand for health workers globally, which is likely to have led to a ‘silent’ emigration of significant portions of Nigeria’s health work force.

The public health physician said there are traces of challenges across all the six building blocks of health. “In the area of governance and coordination, there are still some fragmentations in the implementation of the Primary Health Care Under One Roof (PHCUOR) especially around transitioning of all Primary Health Care (PHC) personnel to the management of the states Primary Health care Boards (SPHCBs),” he said.

Shuaib said inadequate human resource for health challenge in terms of number and capacity is still a major challenge at all the three levels of health care. He said the area of infrastructure and supply of commodities require significant amount of investment for improvement. Shuaib said there are still some of elements of verticalisation of programmes and services in the health sector, which pose a barrier to a more productive service integration and better coordination.

Additionally, he said, poor data quality and data falsification are barriers to a more informed evidence-based decision-making, resource mobilisation and allocation including better accountability of all inputs into the health system. Shuaib said community participation and ownership are also threatened by inadequate community engagement and demand for health services. All these, he said, culminate into suboptimal availability and quality of health service with resultant high Out of Pocket Expenses (OPE) with high financial hardship on the poor and medical tourism by the well-off segment of the society.

On whether there were any achievements, Shuaib said: “Yes, despite all the challenges, the health sector in Nigeria has yielded significant socio-economic gains in lives saved and enhanced economic productivity. Remember, Nigeria has successfully eradicated poliomyelitis and certified polio free in August 2020 through unrelenting vaccination of children across the country. As a result, the entire African continent is now free of wild poliovirus. There is reliable evidence indicating that up to 69,164 maternal deaths were averted and another 16,933 maternal deaths were averted through contraceptive use. The country also averted 255,792 neonatal deaths and saved over 1.6 million children under the age of five years.”

On recommendations on how to improve the situation, Shuaib said: “We need to prioritize health sector through deliberate capital investment into the system especially the primary health care space which forms the bed rock of our health system and provide the health care needs of approximately 70 per cent of our population. This is critical in addressing the human resource gaps, infrastructural decay, and supply shortfalls. Full implementation of PHCUOR will go a long way addressing governance and coordination shortcomings, which inhibit service integration and accountability.

“This is why as part of efforts for long term and sustained improvements in the health systems and by extension health of Nigerians, the Executive Director NPHCDA under the leadership of the Honorable Minister of Health has embarked on the implementation of a holistic primary health care re-imagining strategy. Working with the private sector, partners, donors and government institutions, PHC re-imagining involving the implementation four-point agenda focused on guaranteeing the right number and skill mix of health workers, particularly skilled birth attendants (midwives), with the right equipment’s and seamless access to medicines in a conducive revitalized PHC facility available 24 hours daily to provide care to Nigerian.

“The strategy deploys lessons learnt from polio eradication and is utilizing emergency operation center style to address maternal and child morbidity and mortality in at the primary care level. It further emphasizes community mobilization and demand creation through the CHIPS Agents and use of technology for improving health data, decision making and access to care in the most remote parts.”

Shuaib said this holistic approach to PHC revitalisation is the sure response to sustained improvements in Nigeria’s health system. He said a PHC summit is equality being planned to mobilise the additional resources required to ensure the successful implementation of the agenda.

A professor of Veterinary Medicine and Clinical Virology at the Michael Okpara University of Agriculture Umudike, Abia State, Maduike Ezeibe, told The Guardian: “That Nigeria has not fully vaccinated (two doses) up to four million people of our 200 million people (two per cent) against COVID-19 means our health sector has not done well. Even though some of us believe vaccination would not solve the problem the failure shows weakness of our system.

“Government is threatening to force workers to vaccinate but how many doses do we have in the country? Should all workers turn up for vaccination tomorrow do we have enough? What is happening in the world is warning us to stop this idea of waiting for donations and work towards producing what we need.”

Ezeibe said he is not sure anybody in Nigeria can produce (not package) human vaccines but Nigerians can mass-produce the broad-spectrum antiviral medicine they have invented which government has patented.

He further explained: “All we need is to invite World Health Organisation (WHO) to confirm our claim. It is duty of government to invite them, not that of the researcher. Government should also insist that the assessment is transparently and honestly done because if it gets the approval the country takes the economic and diplomatic benefits. People ask inventors have you got this approval or the other. Supposing somebody invents something so wonderful but doesn’t want or cannot apply for the approvals should we allow it waste or be stolen?

“People claim that those in authority do not want local inventions to fly because they are benefiting from donations received from other countries. If we prove we have a medicine that can achieve quick cure of COVID-19 shall we not be in position to be donor nation? Who is superior (or richer) the donor or the receiver? Apart from COVID-19 now ravaging the world what of HIV/AIDS, Lassa fever and other diseases killing our people, which are not being vaccinated against? Why is government not showing interest when scientists who are paid with tax papers money come up with scientific argument that even detractors cannot challenge? Is there a better way to make Nigerian economy research based than proving to the world that we have what other countries need but do not have?

“So, the biggest challenge health sector has is that government doesn’t not encourage development of local drugs and vaccines. If a scientist discovers something and government helps him/her get certifications and the product is commercialized. He/she gets his/her reward, other scientists will then work hard to come up with their own inventions (whether in medicine or other areas) but presently it appears that it is a sin to achieve what other countries have not achieved. This should change. There should also be organized collaboration between veterinary medicine and that human medicine in research to follow the spirit of one world one health. Most diseases affect both human beings and animals. More so, if the country decides to go into serious medical research to discover new drugs and vaccines or new medical techniques that would require researching with animals and any drug, vaccine or technique to be used on human beings must undergo thorough clinical trials.

“So, as we have National Veterinary Research Institute for veterinarians and Nigerian Institute of Medical Research (NIMR) Yaba, Lagos, for physicians, there should also be National Zoonotic Research Institute where both veterinarians, physicians and other professionals in the health sector would be collaborating to find solutions to the nation’s health challenges and also to develop vaccines and drugs for export. Development of antimicrobial resistance (AMR) by disease-agents is fast becoming a bigger challenge in the world than COVID-19. Nigeria has solid minerals that can be converted to adjuvants to prevent and cure AMR. If that institute comes up and we develop such adjuvant, pharmaceutical industries all over the world would be patronising us.