Experts score health sector low at 56
After 56 years of nationhood, healthcare delivery in Nigeria has failed in meeting the needs of its citizens. Why? What is the solution?
President of Nigerian Medical Association (NMA) and consultant orthopaedic and trauma surgeon at Ahmadu Bello Teaching Hospital (ABU) Shika-Zaria, Kaduna State, Prof. Michael Ogirima Ozovehe; Immediate Past President, Pharmaceutical Society of Nigeria (PSN) and Chief Executive Officer of Togomed Ventures Limited, Olumide Akintayo; and Specialist Obstetrician and Gynaecologist at Christus Specialist Hospital Ibadan, Chief Executive Officer of Premier Medicaid, and Immediate Past President of NMA, Dr. Kayode Obembe, examine the situation and proffer solutions.
What Went Wrong With The Health System
The NMA President Ozovehe, said by World Health Organisation (WHO) standard, a well-functioning health system is built on trained and motivated workforce, well-maintained infrastructure, reliable supply of medicines and technologies, strong health plans/policies backed by adequate funding.
He said while the Nigerian health system can still be described as evolving, there are serious challenges in all the components that make up the health system currently. The surgeon said there is scarcity of human resources in health, even the available human resources are poorly distributed and skewed towards the urban centres.
He said the Primary Health Centres (PHCs) may be worse hit, but none of the three strata of healthcare service structure in Nigeria is spared. Ogirima said Nigeria is far from achieving a reasonable ratio of healthcare provider per 1000 population and that the ratio is rather worsening by migration of healthcare workers abroad for better working environment in terms of infrastructure and welfare.
The surgeon said the level of infrastructural development is slow and of course, given the systemic nature of corruption in Nigeria, this has its own negative bearing in the health system with funds misapplication, misappropriation and diversion.
The NMA President said there is also a high level of intra-professional rivalry and incessant industrial action, oftentimes leaving the patients stranded and there are issues of quackery, as well as, counterfeiting of drugs that are putting the lives of unsuspecting populace in great danger. “Worse still is the issue of poor funding, budgetary allocation is usually low,” he said.
According to Akintayo, perhaps, Nigeria needs to start from basics.
The pharmacist explained: “At the level of a geographical expression called Nigeria, we have never built institutions in any endeavour. The health sector therefore, cannot be an exemption. Recall, that it was not until 2014 when the poorly implemented National Health Act was enacted that we first had national health legislation. The National Health Act in the ideal; should have been a supreme health legislation from which other sub-sectorial laws should flow. When you compare this to pharmacy practice, which had regulatory laws laced in substantial antiquity because the pharmacy ordinance was enacted as far back as 1887, with some amendments in 1902, then you begin to appreciate some of the foundational defects rocking healthcare plans and policies in Nigeria. In 1979 Health matters was on the concurrent list and strangely today it is not listed under the Exclusive, Concurrent or Residual list, which means it is just floating. That shows you the importance people attach to health in our country.
“The last straw appears to be deficiencies and lacuna embellished in most health statutes and laws, which oftentimes super-impose one profession over others in a multi-disciplinary sector. If you reckon with the input of one interest to the detriment of a multitude of others, then you will institutionalize a consuming evil of voracious appetite on the operating template.”
The former PSN President said healthcare was reduced to medical practice and all the requisite paraphernalia/structures in the care process were inclined on this unfortunate agenda.
This, he said, encouraged devilish diabolism as one group was empowered to trample on others without looking back and created a fundamental distortion of a familiar grab-grab syndrome of all privileges and resources appropriated to the Health Sector by privileged persons.
Akintayo further explained: “How do you explain a situation whereby bastions of excellence like the University College Hospital (UCH), Ibadan, which was rated as part of the best five health facilities in the commonwealth when health administrators managed our health facilities (House Governors), pales into infamy or is it sinks into oblivion when late Olikoye Kuti came up with the obnoxious decree 10 of 1985, which vests leadership in health facilities on doctors who are not routinely trained for this responsibilities). The rest like they say is history, because the legacies of the involvement of these guys in health management are our legendary negative health indices that every stakeholder is familiar with.”
To Obembe, Nigeria has always had very detailed plans, but at implementation the plans crumble because of poor funding, inadequate man-power, and defective monitoring and evaluation of health systems. “Instead of building up on existing systems, we always condemn previous ones and start another afresh,” the specialist obstetrician and gynaecologist said.
The Way Out
OZOVEHE said the solution remains in the fact that government will have to prioritise healthcare in Nigeria. According to the NMA President, by that it implies that due attention will have to be given to all the various components of the healthcare system and the health system will have to be adequately funded by which the government will be able to provide the infrastructure and technologies required, continuous training and retraining of human resource and of course, a well-motivated human resource.
The orthopaedic and trauma surgeon said appropriate health policies that are cross cutting and likely to improve the people’s access to qualitative and affordable healthcare services should be given priority.
To Akintayo, the solution is to begin to open the restricted boundaries in healthcare to all concerned by reckoning with their areas of competence. He explained: “We fought the battle of our lives as representatives of Health workers on the Allied Health Professionals Association (AHPA) and Joint Health Sector Union (JOHESU) platform to ensure the National Assembly enacted a justiciable Health Act. It is the first time we have a law acceptable to the majority in our sector.
“The major legislative tool I kept emphasising at the turbulent public hearing on the erstwhile National Health bill was the need to factor the proviso in section 42 a(1) and (2) of the 1999 constitution, which forbids discrimination to a citizen of Nigeria on the basis of his social, cultural, religious, sex and professional affiliations.
“As former PSN President, I took this matter to both former Senate President David Mark and Rt. Hon. Tambuwal, who was the Speaker of the House of Representatives on the same day at different scheduled appointments. The National Assembly subsequently amended all clauses that conferred exclusive privileges to any profession.
“Some of the erstwhile Senators, who are now governors and ministers resisted, but our unity of purpose propelled us to sustain the inertia to change the unfavorable status quo. We got a good National Health Act. Whether the implementation is right is a matter for another day.”
Akintayo said some of the benefits inherent in pharmacists’ struggle against discrimination is that a few bills, which the National Assembly had worked on subsequently, took cognisance of section 42. This, he said, includes the National Health Insurance Scheme (NHIS) amendment bill in the 7th National Assembly and the Cancer Institute bill of the current National Assembly. “Today, the emerging principle is that any competent care-provider can lead healthcare endeavours. I insist this is the road to travel,” the former PSN President said.
The solution now, according to Obembe, is that Nigeria should be focused, consistent and articulate in the pursuit of Universal Health Coverage (UHC), which can be achieved on the template of Community Based Health Insurance Programme (CB-SHIP) and Public Private Partnership (PPP) that is CB-SHIP + PPP = UHC.
Progress Made So Far
OZOVEHE said: “Certainly Yes! In as much as Nigeria health system is not where it ought to be, it is certainly not stagnated. Slow but progressive developments abound in the healthcare system in Nigeria. Successive government has as a matter of necessity tried to improve on healthcare worker welfare via improved and designated salary structure that is Consolidated Medical Salary Scale (CONMESS) and Consolidated Health Salary Scale (CONHESS). There are infrastructural development leading to designation of some hospital as centre of excellence for specialised care with supplies of technologies in line with global standards in some hospitals.
“Open heart surgeries are now being done in Nigeria, kidney and stem cell transplant now possible in Nigeria and tremendous results are available in the treatment of infertility and In Vitro Fertilisation (IVFs). Endoscopic and laparoscopic surgeries (Pin Hole Surgeries) are becoming commonplace. There is the Health Insurance Scheme that is getting robust, the National Health Act now exist for the regulation of practice in Nigeria.”
According to the NMA President, the country has done well in the area of public health practice, in the control of Ebola, with international accolade; the gains in polio eradication efforts will have to be mentioned.
He said the private practitioners are contributing a great deal to the healthcare needs of the population and some of them are competing with some world-class health facilities and are being quoted in the stock market.
But Akintayo disagrees. The pharmacist said the obvious answer is that Nigeria has not made significant progress. He explained: “It is always difficult to move ideas and concepts forward once they are grounded in contraptions. It will be too painstaking to begin to delve into the amplitudes of the contraptions in the health sector. In most climes, healthcare delivery is sustained through Social Health Insurance, a viable form of healthcare funding. You need to appraise the charade called NHIS in Nigeria.
“The NHIS has become one of the biggest avenues for thievery in our sector because what I see is sharing of resources. Little wonder the NHIS is stalled in growth and stature. It has covered less than 3.5 per cent of the citizenry since 2006 when it was inaugurated. If separation of professional roles and responsibilities, payment mechanisms, segregation of capitation for different facilities pose a challenge, it will be naturally difficult to expand the frontiers to Community Based Social Health Insurance, which serves the dominant informal sector.
“The new NHIS boss observed some of the recklessness I just highlighted because I read his comments on the contributions of Health Maintenance Organisations (HMOs) to the NHIS.”
Akintayo added: “I just took a position that the growth rate is extremely wretched for our imagined strength and potentials. If you really probe why it is this way, I will summarise in this short phraseology –poor attitude.”
To Obembe, Nigeria has made some progress. “I give kudos to doctors in this country, that despite all the challenges we are facing, we have had some improvement in Maternal Mortality Ratio (MMR) and other related indices. In the year 2000, the MMR was 1,500, but in the year 2015 it has reduce to 454. In developed countries their figures are approaching single digits that is less than 10. MMR is the number of women dying as a result of pregnancy or child birth out of 100,000 deliveries,” he said.
Obembe further explained: “It is as a result of the resourcefulness of doctors in Nigeria. For example, a doctor working in United Kingdom (U.K.) or United States (U.S.) may never know how to start an electricity generator but in Nigeria, because of the epileptic nature of our electricity supply, one may have to switch off the main supply and put on generator so that power failure does not lead to patient’s death on operation table.
“Unfortunately, our authorities are not aware of these hardships and these usually result in industrial impasse. The other programmes that have improved the MMR include the National Health Insurance Scheme, Millennium Development Goals, Midwives Service Scheme and Community Based Social Health Insurance Programme. There has also been some increase in immunization coverage.
“Unfortunately, recently, there has been a recrudescence of polio and Ebola. So there is need for synergy between the Ministry of Health, NMA and other health professionals to nip the diseases in the bud. However, with the technology and manpower available at the global arena, Nigeria should have done better.”
Spending On Healthcare
The NMA President said de does not think Nigeria is spending enough on anything; healthcare funding is really not in any good standing. He said Nigeria has consistently fallen short of the Abuja declaration of 15 per cent allocation of national budget on health. Ozovehe said donors’ fund in the health sector is huge and often time outweighs the national spending. “This is not good enough,” he said.
Akintayo said Nigeria, especially in recent years does not have enough money to spend on any sector. He explained: “We must manage the little we have for the benefit of our people. Even when we take a position that there is a dearth of resources, what did the managers of our sector do with what was made available to them in the past?
“Let me say the National Health Act gives a window for improved healthcare funding through first line deductions from the Federation Account. Today, section 10 provides that 50 per cent of this accrual must be channeled towards health insurance, 10 per cent will be for procurement of medicines and equipment at primary care level and five per cent for the training of personnel.
“On paper this is beautiful and laudable, but will government actualise this to become deliverables. I can only say we are watching.”
Obembe said Nigeria is not spending enough for healthcare delivery. He said, according to International Labour Organisation, every employee should be insured with 22 per cent of his income. He said Nigeria scaled it down to 15 per cent, government was paying 10 per cent and employees were to pay five per cent. According to the former NMA President, up till date the only fund available to NHIS is 10 per cent from the government.
The doctor further explained: “In order to augment this, the National Health Act prescribed one per cent of Consolidated Revenue Fund for basic healthcare. This did not appear in 2016 budget. Nigeria is a signatory to the agreement in 2001 where all African Heads of State recommended that 15 per cent of the National Budget should be for health. Nigeria has never gone above seven per cent. Therefore, the health sector is financially decapitated and incapacitated at all fronts.”
Availability Of Manpower
Ozovehe said there is no sufficient manpower, or better-put, human resource in health in Nigeria. However, he said, there are very well trained healthcare workers in the various specialties of medicine available in Nigeria. The NMA President said as at today, Nigeria maintains a very poor doctor to patient ratio of one doctor to more than 4,000 patients and the ratio is worse in nurse to patient population. He said this is a far cry from the WHO recommendation of at least, 1:600 doctors to patient ratio.
Akintayo said Nigeria may not have sufficient manpower, but she definitely has well trained personnel who can match their counterparts globally.
He explained: “Today we have about 20,000 pharmacists, over 50,000 doctors, 250,000 nurses and about 25,000 laboratory scientists. The figures do not meet WHO projections certainly.
“How do we incentivise and motivate the care-workers who have decided to work here? Not anything too palatable.”