After 61 years, where the health sector stands: Experts speak on way forward

•Nigeria’s health sector among worst in the world, says Dr. Madu
•Community healthcare financing is the way to go- Prof. Okoye

As Nigeria celebrates its existence as an independent nation today, experts are worried that after 61 years, so many things are wrong.

President Muhammadu Buhari still travels abroad for medical checkups, the doctors and other health workers are still going on strike frequently, people still pay out of pocket for health care, the Federal Government still allocates no more than six per cent of the annual national budget to the sector, over 70 per cent of primary health care centres nationwide are non-functional, less than four per cent of the population have received COVID-19 vaccination compared to 75 per cent in most developed nations among other anomalies.

The Guardian investigation revealed among other things that the health care system remains weak as evidenced by lack of coordination, fragmentation of services, dearth of resources, including drug and supplies, inadequate and decaying infrastructure, inequity in resource distribution, and access to care and very deplorable quality of care.

Meanwhile, at independence, Nigeria built a health system structured basically along with the model of the colonialists. From the ’60s through the mid-eighties, the health system was anchored and led by seasoned health administrators who coordinated the health manpower comprising pharmacists, doctors, nurses, laboratory scientists, physiotherapists, radiographers and other cadres of health workers. Infrastructure from the 60s to about the late 80s was modest but adequate to keep services well above average and a benchmark within the rank of African nations.

One of the most noteworthy developments in the health sector remains that the University College Hospital (UCH), Ibadan, was actually rated one of the top five facilities in the Commonwealth.

UCH since the 1960s through the mid-1970s was the ‘Mecca’ of medicine in Africa and indeed medical tourism. It ranked the fourth best university teaching hospital in the Commonwealth were, in fact, Saudi kings came for treatment, queens delivered princes and princesses. Consultants and professors were like deities and appeared infallible. By 1975, it was designated Centre of Excellence in Medicine. A big legacy!

Lagos University Teaching Hospital (LUTH), Idi-Araba made big strides nationally also while the University of Nigeria Teaching Hospital (UNTH), Nsukka was renowned for open-heart surgeries.

By the mid-1980s, the finest medical teachers were departing to the Middle East and the West and the young physicians they trained were mostly leaving for the West for postgraduate training. Human capital suffered and consequently the quality of research, medical education and patient care outcomes. Infrastructure was decaying from poor funding and management. The few decades that followed witnessed a continued downturn in both human capital and infrastructure as well as the resultant spike in human capital flight, brain drain and medical tourism.

As part of efforts to improve healthcare performance in the country and reverse the negative indices, The Guardian spoke to several experts on why the sector is performing badly despite efforts of government and what could be done to better the situation.

A public health physician and Executive Secretary, Enugu State Agency for the Control of AIDS (ENSACA), Dr. Chinedu Arthur Idoko, said Nigeria is indeed facing a myriad of health problems.

Idoko, however, said the country has to move away from the phase of constantly talking about these problems to taking focused and impactful actions to tackle them.

He said strikes and lockdowns have lingered as a result of insincerity to decisively dealing once and for all with the issues that throw it up. “My opinion is that government should (with the certainty of capability/ capacity of meeting up with its promise) say and stay on what it could afford/ implement while the striking professionals on the other hand objectively consider the offer and if it suits them to accept or pursue a realistic renegotiation. A situation where a party accepts terms with a mindset not to eventually adhere to it does the system no good. It only leads to rebound and incessant strike actions,” Idoko said.

On out-of-pocket payments for services, Idoko said: “Considering the situation of out-of-pocket payments for health services by Nigerians; the issue of healthcare financing is one that we as a country need to take the bull by the horn. The options of Community Based Social Insurance for people not in formal employment should be widely pursued. The Universal Health Insurance Schemes should continually be institutionalised and strengthened.”

On COVID-19, Idoko, who was the Chairman of, Enugu State Hospital Management Board, said the awareness and sensitisation on the need for immunisation as well as safety of the vaccines should be scaled up to increase/ improve vaccine uptake (this is even as other COVID-19 safety protocols continue). “Four per cent vaccine uptake is actually a poor index for us as a nation when compared to developed nations with as high as 75 per cent COVID-19 vaccine uptake. This is especially as a set target is in view to achieving a possible herd immunity,” he said.

Consultant clinical pharmacist and National Chairman, Clinical Pharmacists Association of Nigeria (CPAN), Dr. Joseph Madu, said the fact that President Muhammad Buhari still goes abroad for medical treatment after about 61 years of the country’s independence is expected. He said the major reason is that Nigeria’s healthcare system is among the worst in the world.

Madu explained: “For instance, in the World Health Organisation (WHO) rating of countries, Nigeria is on position 189 out of 191 countries. How do you expect the President not to go abroad for medical treatment?

“Again looking at the life expectancy, that of Nigeria is about 54 compared to countries such as the United Kingdom (U.K.) and the United States (U.S.) with about 97 and 98 respectively. No doubt the state of healthcare of a country will affect the life expectancy of the citizenry.”

The clinical pharmacist said the major reason for all these including the low COVID-19 vaccine coverage is due to poor leadership at all levels in the country.

Madu said the Nigerian healthcare system handlers and the government have refused to learn from countries that have the best healthcare indices.

He further explained: “You cannot be doing something the same way over and over again but expecting different results. Is that not madness? For instance, community pharmacies are used as vaccination centres for COVID-19 in many countries such as the UK and US, but the Nigeria Federal Ministry of Health and other COVID-19 handlers have failed to borrow a leaf from such countries.

“The community pharmacists are globally recognised as the most accessible trained healthcare providers and that over 80 percent of the citizenry trust them and use them as the first port of call on health matters. If I may ask, what is difficult in using them to increase wider access and coverage of COVID-19 vaccination by the populace?”

Madu said the poor remuneration of healthcare workers has led to recurrent strikes, which have further deteriorated the output of the country’s healthcare system.

He said the solution is for the government to pay healthcare workers very well.

“That is not to say that people should threaten the government over every little thing with a call for strike action. I think the government should have options. For instance, in developed countries, the laws were reviewed to grant nurses, pharmacists and optometrists, independent prescribing powers. In that case, when one group such as physicians are on strike it will not tell too much on the health of our people because pharmacists or nurses will prescribe drugs for patients,” Madu said.

Madu faulted the constitution of the health reform committee recently inaugurated. He said many healthcare professionals are not well represented. “Just one pharmacist and one nurse with so many physicians. I heard there is even no optometrist. Does it mean Nigerian leaders are not aware that the Health Ministry is a multicomponent one where different health professionals should be adequately captured? I think those advising the government on health matters are not doing well at all and this is negatively affecting the health of Nigerians,” he said.

Madu said the government should use healthcare administrators to manage health institutions rather than saying one group of healthcare professionals should head health institutions whether the person is knowledgeable in administration or not.

A professor of radiology, College of Medicine, University of Nigeria, Nsukka/University of Nigeria Teaching Hospital Enugu (UNTH), Enugu State, Ifeoma Okoye, said Nigeria is greatly underserved in healthcare. Health facilities (health centres, personnel, and medical equipment) are inadequate, especially in rural areas.

Okoye, who is also the Director, the University of Nigeria Centre for Clinical Trials (UNNCECT), and Founder /Co-Chair African Clinical Trial Consortium and Breast Without Spot (BWS), a non-governmental organisation (NGO), said while various reforms have been put forward by the Nigerian government to address the wide-ranging issues in the healthcare system, they are yet to be implemented at the state and local government area levels.

Okoye said the objectives and functions of the 2005 Nigerian Healthcare Insurance Scheme (NHIS), to ensure that every Nigerian has access to good healthcare services and protect Nigerians from the financial burden of medical bills, has been an abject failure as healthcare delivery continues to be limited; not equitable and does not meet the needs of the majority of the people.

The radiologist said this is indicative of the current high infant mortality rate/poor maternal care, very low life expectancy, and periodical outbreak and recrudescence of the same disease, as well as the long period of time spent for control of the various outbreaks.

The oncologist said, while not fit for its purpose, the National Health Insurance Scheme (NHIS), if managed well, could be a useful ground for good healthcare delivery.

According to Okoye, allied to the absence of collective and centralised health insurance, to defray the healthcare costs of a country with the largest population living under the global poverty line is the spectre of inadequate government funding

She said the current government expenditure on health as a percentage of her Gross Domestic Product (GDP) hovers slightly above four per cent, according to some reports. This spending, Okoye said, is forecasted to reach N1,478 billion by 2021 and in 2019, this figure amounted to N1,191 billion. On the other hand, she said private spending on health is projected to add up to N4,284 billion by 2021, representing the main source of expenditure on health in Nigeria.

The cancer expert said this public-private spending disparity compounds the funding issue and this is because private healthcare spending, while evidently welcoming, carries prohibitive costs for average Nigerians, further limiting access to healthcare for the most vulnerable.

Additionally, she said, financial managerial competency remains a major problem and statistics show that health institutions rendering health care in Nigeria are 33,303 general hospitals, 20,278 primary health centres and posts, and 59 teaching hospitals and federal medical centers. Okoye said while this represents a huge improvement compared to previous decades, healthcare institutions continue to suffer shortages.

She said the situation is stark. According to reports “Health access is only 43.3 per cent. The inadequacy of the healthcare delivery system in Nigeria could be attributed to the peculiar demographics of the Nigerian populace. About 55 per cent of the population lives in rural areas and only 45 per cent live in urban areas. About 70 per cent of healthcare is provided by private vendors and only 30 per cent by the government. Over 70 per cent of drugs dispensed are substandard. Hence, the ineffectiveness of the NHIS had recently been attributed to the fact that the scheme represents only 40 per cent of the entire population, and 52-60 per cent are employed in the informal sector.”

On how to improve healthcare delivery in the country, Okoye recommended: “At the primary healthcare level, we need to encourage and mobilise support for community health financing schemes [Community Based Health Insurance (CBHI)] from individuals’ (taxi drivers, market women, etc.), which provide the health needs for their communities and have extended their reach to urban areas. CBHI is critical to augmenting healthcare access as it targets areas that are largely overlooked by current insurance schemes.

“In addition to providing financial support to these schemes, such as special credit facilities, grants etc. from financial institutions, we must rework our regulatory system to ensure that CBHIs are able to easily register as Health Maintenance Organisations (HMOs) to turbocharge their operations.”

Okoye said further funding support can be mobilised via innovative channels such as issuing tax-free healthcare bonds and providing tax credits to incentivise increased private sector investor investment in health care

She said as the first line of defence, the country needs to develop the preventative component of her healthcare system by investing in Medical Intelligence and Surveillance systems (MIS). “A modern MIS is critical to elevating our healthcare delivery capacity to international standards. Such a system must be tailored to Nigeria’s need and will perform text mining from a variety of sources and track diseases (contagious, sexually transmitted diseases. etc.), and other events implicating health issues,” Okoye said.

The radiologist said the central system would then analyse, process results of reports and send information, where appropriate to local points, government organisations, towns, villages, health agencies, etc. She said the system would also be able to issue health-related threats, track ongoing medical interventions, and have a database repository of indispensable information to enable a proactive approach to healthcare delivery.

Okoye said: “In short, we need to leverage our robust tech ecosystem to catalyse our moribund healthcare system.”

The cancer expert said Nigeria requires urgent intervention to address the issue of brain drain in the medical sector and inadequate remuneration for medical professionals. She said this requires several remedial steps, including mass funding to medical schools, teaching hospitals, research labs etc.; robust legislation to protect the role of medical professionals as essential and thus eligible for preferential funding; and the government will, from the Federal to local levels, to enforce legislative provisions.

On how to address vaccination rate gaps in Nigeria, Okoye said the long-term solution must revolve around the classic carrot and stick approach. “That is, governments must provide incentives to the populace, especially essential workers, given the limited supply of vaccines in Nigeria, to take the vaccine. This will require some creativity, but it can be done,” she said.

Okoye added: “Incentives must be part and parcel of a wider public information campaign about the necessity and relative safety of vaccines. Strategic discourse is the key, highlighting the advantages of being vaccinated while combatting misinformation about the risks and dangers. Public messaging will require collaboration with the private sector, such as telecoms, to leverage their robust network infrastructure to reach the hearts and minds of the populace.”

Okoye said the Federal Government must continue to exert influence on the international stage via multilateral organisations such as the African Union (AU) to ensure that all efforts are made to secure a steady supply of vaccines in the country. “Vaccine availability, indeed, even the impression of its unavailability or limited availability, has an impact on vaccine adoption,” she said.

A public health physician and former Commissioner for Health in Ondo State, Dr. Dayo Adeyanju, said: “Each time the nation celebrates Independence Day, the reflection of the song the legend musician Sony Okosun ‘which way Nigeria’ comes to once mind. He sang that many years after independence we still find it hard to start. How long shall be patient before we reach the promised land. Let save Nigeria so that Nigeria will not die.’”

Adeyanju said Nigerians are already dying from the current health indices. He said it is unfortunate medical tourism is still the order of the day 61 years after independence and the irony is that Nigerians go to meet Nigerians that have left the country to seek green pasture. “They pay exorbitantly to see same people that left the country. Over 1.2 billon dollars is to be lost yearly to medical tourism. Currently, several thousand doctors practice abroad. These are people if well-taken care will make Nigeria health system great,” Adeyanju said.

The question of ‘how long shall Nigerians be patient before they reach the promised land is begging for an answer. “With abundant resources, we are suffering in the midst of plenty. I believe and strongly do that our leaders have not prioritise the health sector. The political will is lacking. This is because some of the leaders didn’t get to power with the mandate of the electorate; our votes never count. It becomes difficult for the electorate to demand good governance. Knowing the critical significance of health to national development health should be accorded the right priority. If there is political will there will be a clear agenda for health and key deliverables for the minister leading the sector to achieve. Failure to deliver will have severe consequences. However, the political leader also will provide the enabling environment for success,” he said.

Adeyanju said President Muhammadu Buhari, recently, demonstrated political will by setting up of health reform committee. “Yes, it is coming six years later but better than never. The committee headed by the Vice President also demonstrates further commitment. This committee’s task should be how to strengthen our primary healthcare towards achieving universal health coverage. Settle the incessant health workers strike by providing enabling environment for them to perform. Also, improve their welfare and reward excellent performance. Efficiently and effectively fund the sector with accountability. These will ensure the quick reversal of the unacceptable health indices and medical tourism. It requires all our collective effort. This way we can save Nigeria so that Nigerians will not die,” he said.