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Experts x-ray challenges in Nigeria’s healthcare system, set agenda for 2019

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After over 58 years of Nigeria’s political independence from her colonial overlords, the performance of her healthcare delivery system remains unpleasant due to several conspiring factors and challenges. However, with the successful berthing of the National Health Act (NHA), Nigeria now has a historic significant opportunity to improve her healthcare delivery system and attain Universal Health Coverage (UHC) predicated on the constitutional imperatives of social justice, equity and egalitarianism.

Against this background, medical experts hope that the President Muhammadu Buhari-led Federal Government, as well as the various elected state and local governments, will abandon the era of paying lip service to the health sector, and translate their widely circulated promises (including the promise to allocate 15 per cent of the National budget to the health sector within the first year of President Muhammadu Buhari’s tenure) on health into practical reality.

Undoubtedly, there have been some significant developments in Nigeria’s health sector. These gains and progressive developments, notwithstanding, the reality and hard fact is that when placed on the balance, the story of Nigeria’s healthcare delivery system is still pre-eminently an unpleasant one laced with unattractive health status indicators that fly in the face of local, national and global expectations.

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Are there truly challenges that need to be urgently identified and addressed?Undoubtedly, there are challenges that have significantly conspired against Nigeria’s healthcare delivery system and health sector.But what are these challenges?

Poor budgetary allocation
The Federal Government has again failed to meet the aspiration of stakeholders in the sector and the recommendation by African Heads of State in 2001, the Abuja Declaration, to set aside at least 15 per cent of yearly national budget for health.A breakdown of 2019 Federal Government of Nigeria (FGN) budget proposal presented to the National Assembly by President Muhammadu Buhari indicates that although there is a marginal increase from 3.95 per cent in 2018 (that is N340.456 billion, out of the total budget of N8.612 trillion) to 4.1 per cent in 2019 (that is N365.77 billion, out of total budget of N8.83 trillion), the monies fall short of what is needed to meet the needs of the sector.

The appropriation is however close to 4.15 per cent appropriated in 2017.A further breakdown showed that President has proposed a recurrent expenditure of N315.62 billion and N50.15 billion for capital projects for the ministry of health in its 2019 appropriation bill. This is about 46.274 billion increase from last year’s recurrent expenditure, which was N269.346 billion.

However, there was a short fall in capital expenditure from N71.11 billion in 2018 to 50.15 billion in 2019.Another positive to the proposed budget is the inclusion of the one per cent Consolidated Revenue Fund (CRF) earmarked for the Basic Health Care Provision Fund (BHCPF).This amounts to N51.22 billion from the nation’s CRF. This is; however, lower than what was obtainable in 2018. The BHCPF in the 2018 appropriate bill was N55 billion.But the N55 billion in the 2018 budget has not been released. Till date, the BHCPF for the ongoing year is yet to be released, though framework and mechanisms for the disbursement and implementation of the funds are already in place.

However, there are some laudable projects included in the 2019 proposed budget for health. They include:
•N51.22 billion provisioned for the implementation of the National Health Act
•N21.25 billion provided for GAVI (vaccine alliance)/Immunization
•N1.26 billion for the procurement of non-polio Supplementary Immunization Activity (SIA) vaccine
•N1.12 billion for the procurement of kits and commodities for community health influencers
•N780 million for the establishment of chemotherapy centres in University of Benin Teaching Hospital (UBTH), University of Ilorin Teaching Hospital (UITH), Ahmadu Bello University Teaching Hospital (ABUTH), University of Maiduguri Teaching Hospital (UMTH), Obafemi Awolowo University Teaching Hospital (OAUTH), University of Nigeria Teaching Hospital (UNTH), University of Port Harcourt Teaching Hospital (UPTH), Federal Medical Centre (FMC) Owerri, and FMC Abeokuta
•N7.63 billion for procurement of Routine Immunisation (RI) vaccines and devices
•N3.5 billion for counterpart funding including global fund/health

Further analysis showed that the N50.15 billion allocated for capital projects in the 2019 budget may have technically knocked out the refurbishment of 10,000 primary healthcare centres (PHCs) and execution of other projects in the sector.The entire vote if spent only on rehabilitation of the facilities, it will only translate to N5 million per centre, which is still grossly insufficient to meet the earlier promise of the President Muhammadu Buhari administration to give a better deal to the sector.

The Minister of Health, Prof. Isaac Adewole, had in 2017 told journalists in Lagos that the Federal Government had concluded plans to rehabilitate the 10,000 facilities spread across the six geopolitical zones of the country beginning from next year. He had spoken with infectious optimism that the 2018 and 2019 appropriation bill would provide funds for the exercise.

There is also no provision for the refurbishing of ailing and dilapidated teaching hospitals spread across the country.Also, it is hard to see whether there is a provision in the budget for the takeoff of Biovaccines, set up under the joint venture, between the Federal Government and May and Baker Pharmaceuticals for local production of vaccines. The company promised to deliver its first set of yellow fever vaccines next April.There is also no mention of emergency preparedness fund in the health sector that would help in procurement of vaccines and other relief materials in the event of deadly epidemics like the recent Cerebro Spinal Meningitis (CSM) and Lassa fever.

Although the N8.6 trillion estimates presented on Tuesday is 16 per cent higher than that of 2017, the allocation to health sector however fell from 4.15 per cent in 2017 to 3.95 percent in 2018.Indeed 4.1 per cent of the total 2019 budget for health is a far cry from the April 2001 Abuja Declaration on health which mandates African Union Countries to commit at least 15 per cent of their national budget to healthcare.Chief Consultant Family Physician and Head of Department of Family Medicine at University of Benin Teaching Hospital (UBTH), Dr. Osahon Enabulele, has identified the challenges in Nigeria’s healthcare delivery system.

Enabulele who is also a past President of the Nigerian Medical Association (NMA), Vice President, Commonwealth Medical Association (CWMA), Adviser to World Medical Association (WMA) and member WMA review committee has also provided solutions to the challenges of Nigeria’s healthcare delivery system.Enabulele who is also the coordinator, Coalition of African National Medical Associations (CANMA) told journalists that poor governance and political commitment to the health of citizens remains one fundamental undermining factor that has led to the sorry state of Nigeria’s healthcare delivery system.

Enabulele said this poor governance and political commitment which largely results from a poor understanding of the economic importance of health and health care, by most political and public officers at all levels of government.On poor budgeting for health, the former NMA President said the poor understanding of the nexus between health and the economic prosperity and productivity of nation states partly explains why 17 years after Nigeria hosted the Abuja 2001 summit of African Heads of Government which declared that African Governments should allocate a minimum of 15 per cent of their budgets (at local, state and national levels) to the health sector, the Nigerian Government (aside from a few State Governments) has never attained even half of the African benchmark on budgeting for health.

He said a look at the sectorial allocation to health at the federal level from 2009 to date shows an average allocation to the health sector of less than six per cent. “The situation is even worse now in the current dispensation, and much more worse at the state and local government levels where the aggregate sectorial allocation to the health sector ranges from one to three per cent,” Enabulele said. President Pharmaceutical Society of Nigeria (PSN), Mazi Sam Ohuabunwa, told The Guardian: “Poor budgetary allocation has been a major factor that has made Health care provisioning chronically poor. Nigeria has remained embarrassingly at the bottom of Human development index (HDI). We are doing below what the WHO and the Abuja Africa Health summit recommended. It is true that even the little that is budgeted is frittered away by corruption, nevertheless we must raise budgetary provision to minimum of I5 per cent of National budget. The best we have achieved in the past is only five per cent.”

Enabulele said poor utilization of Nigeria’s health facilities and outward medical tourism is another evidence of poor political commitment to Nigeria’s healthcare delivery system by the nation’s political leaders and public office holders. “Rather than utilize health facilities they claim to have constructed in their communities, and therefore inspire citizens within their jurisdiction to do same, most of Nigeria’s political and public office holders (including Mr. President) take delight in frequently travelling abroad for medical care under government sponsorship and at the expense of tax payers,” he said.

The consultant physician said this bugbear of outward medical tourism characterized by frequent medical travels which are sometimes for very basic medical conditions and procedures has done incalculable harm to Nigeria’s healthcare delivery system, with a humongous capital flight out of Nigeria, to the tune of well over $1 billion dollars (as at 2013), with the Indian economy and hospitals securing over 50 per cent of this capital outflow.He said it is always shameful to see some of our elected political leaders and public officers stay on queues in foreign hospitals for basic medical consultation and health checkup, instead of adequately investing in quality health infrastructure and services within their jurisdictions.

“In the course of my duties as Vice President of the Commonwealth Medical Association, I once met a prominent Nigerian political leader in a foreign hospital in one of the commonwealth countries. When I engaged him to find out why he was yet to be seen on that day by the doctors, I found out that all he simply came for was a basic medical check-up, which he gleefully stated was a regular routine for him. That, to me, was a huge shame and blackmail of our Nigerian state,” Enabulele said.

Minister of Health said: “The word poor is rather inappropriate. I will rather say it is not sufficient. But then we have gone through a lot as a nation. We went into recession in 2016. We are just coming out of recession. Even in spite of that, if you look at the quantum of money given to money from 2015 has increased. What has happened is that government borrowed to fund infrastructure because those infrastructure will benefit health. Government is funding water, funding agriculture, and funding power things that will benefit us. Our hospitals cannot function without power. So these are things that we need to factor in whatever we do.

“I would like to see more money coming to health but I have to be realistic that some money should go into education because when people are enlightened it helps me. I want to see more money in agriculture because when people are well fed it helps me, when there is clean water it helps me. These are things that influence health. I wan to see more money in the environment so that some of those diseases like cholera will become the thing of the past.“Mr. President actually said so that gradually we will focus on education and health- human capital- and you will begin to see changes.”

Brain drain, human resource crisis and poor reward system
The President of the Association of Resident Doctors, Lagos University Teaching Hospital (LUTH) chapter, Dr. Olawale Oba, said the government’s performance on the health sector has been poor, which is why the country’s health sector would continue to decline globally.He said the brain drain would continue to increase if nothing is done to salvage the situation.

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“Certainly, there is serious brain drain because the condition of services are poor, there is poor remuneration, poor development, things are just degenerating and even paying salaries alone won’t stop the brain drain. There must be something critical that must be done for the government to save the country from experiencing massive brain drain.

The condition of service must be improved, doctors must have confidence within the system and it is in the system that they are cared for. “It is just unfortunate that many people don’t have such opportunities otherwise we would have massive brain drain all over the places, it is not related to medicine or doctors alone, it is also witnessed in other fields of practice in Nigeria. There are lots of brain drain going on because people are not satisfied with what they are getting, politicians are there carting away billions of naira and the Nigerian masses are suffering and if care is not taken things will get worse,” he lamented.

The PSN President said the truth is that traditionally the most brilliant in a class are the ones who go to the healthcare professions especially Medicine and Pharmacy. But today in Nigeria, Ohuabunwa said, after many long years of arduous work, they are very poorly rewarded. “In addition the operating environment remains demotivating, therefore, there is a natural migration to jurisdictions where their professional services are better recognized and better rewarded,” he said.

The pharmacist said Nigeria must vastly improve compensation and working environment to arrest the growing emigration of healthcare professionals to greener pastures.To Enabulele, the challenge of brain drain and mal-distribution of human resource for health in Nigeria should be holistically addressed. He said there is need for government to urgently and patriotically address the worsening medical manpower and health human resource crisis in Nigeria, largely traceable to the daily exodus of Nigerian-trained medical doctors and health professionals.

So, rather than present them with a pathway to tailoring and farming, the consultant physician said government must make concerted efforts to imaginatively create attractive recruitment, retention and professional development schemes for medical doctors and other health professionals practicing in Nigeria.

Drug insecurity, abuse, misuse and fake and substandard medicines
Ohuabunwa said the reason there is drug insecurity, abuse and misuse is the inability or refusal of the State to empower the pharmacists to exercise full responsibility as custodians of drugs. He said the government has allowed the profession to be invaded by all kinds of pretenders and merchants of death who see medicines as essentially item of commerce or trade, thus allowing access to all and sundry.The PSN President said the sure way out is to strengthen the pharmacy laws and give power to PSN and the National Agency for Food and Drug Administration and Control (NAFDAC) to protect the pharmaceutical space.Ohuabunwa said falsified and substandard medicines come mostly from outside our shores and the sure way is to ring fence drug importation and ensure no medicine gets into the nation-without NAFDAC approval.

He said the customs and immigration departments must support NAFDAC and that open markets and itinerant drug peddling must be stopped as they represent entry points for counterfeit drugs. Ohuabunwa also said the approved National Drug Distribution Guidelines must be fully implemented. Ohuabunwa said quackery in all the health professions could easily be routed out by empowering the regulatory agencies such as the Pharmacists Council of Nigeria (PCN), Medical and Dental Council of Nigeria (MDCN), Nurses and Midwifery Council of Nigeria (NMCN), among others to enforce regulatory standards.

The pharmacist further stated: “First, the boards or councils must not be dissolved at will. They are no political boards and so must serve their terms and are replaced seamlessly with the approval of the Federal Ministry of Health (FMoH). Secondly, they must be properly funded to employ enough educators and inspectors to help sustain standard and route out quacks. Nigeria is a large country and sufficient manpower is required to police the land space.”

Slow progress in sector and science
Oba stressed that, though few steps have been taken to amend some loopholes in the health sector and science in general, there is still more to be done if progress must be achievedHe said that the country must first address the national budget allocated to the health sector, stressing that the old practice of the less than five per cent allocation must be stopped.

“If we want progress, the way to look at it is to first start from budgeting. As a nation what did we budget on Nigeria’s health? If it is still the old practice of less than five per cent of the total national budget on the health of the people, then no progress is achieved; we will just continue the way we are.

Poor research development
The ARD President said research in Nigeria has received minimal attention as the country only depends on foreign researches rather than develop its local research institutions.“For instance, LUTH is meant for research, teaching and rendering service and if you look around, the research that will make meaningful impact in our lives as Nigerians – because many of the research that we depend on are coming from Americans, even the meaningful researches that would make impact in our lives, that would be locally made with great impact, they are no where, no grants for the researchers, where are the funds?“Things don’t just happen, things happen because people make them happen. Nigerian government really need to do more to make things happen in this country not lying to Nigerians, it is the action and sincerity being put into developing the nation that will change our country.

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Projections for 2019
Although, President Muhammed Buahri presented N8.83 trillion budget estimates to the National Assembly for their consideration, the 2019 national budget proposal is N300bn lesser than the N9.12tn, which was the size of the 2018 budget.This, Oba said would leave a heavy blow on the health sector.He stressed that the government should improve on budget allocation to health, which he noted is very critical.

He said funds appropriated for a particular issue should not be diverted for another due to personal interest, adding that it is the only way the nation can make progress in its health sector and the health of its citizens.“Globally, what is the major problem that may drive us out of our current position now, so that is the primary problem to tackle,” he said.

The physician argued that as the elections draws nearer, most politicians don’t give health a priority in their manifestos. He said rather they tell lies and deceits just to get votes. “It is all deceit, they only say what people what to hear and do the little vote buying and whatever guise. We Nigerians are not naive and power will certainly come to us one day and people will ask questions on how you have administered their resources. So until we get to that point, I will advise Nigerians to vote wisely and not listen to what they say. We have to look at their track record and then vote wisely,” he advised Nigerians.


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