Healthcare performance after 59 years is at its lowest ebb
A critical review of the healthcare performance in Nigeria 59 years after Independence concluded that although the country has made some progress especially in infrastructure in tertiary hospitals, but delivery and outcomes are at their lowest ebb.
According to the review, fewer Nigerians can access quality healthcare today than they did years back and it blamed the situation on corruption, bad leadership, worsening level of poverty and low level of health insurance and financing.
The review showed that poor funding of the Pharmacists Council of Nigeria (PCN), National Agency for Food, Drug Administration and Control (NAFDAC) and the National Drug Law Enforcement Agency (NDLEA) continue to impugn the regulatory activities and fuel rise in fake drugs, medicines abuse and misuse in the country.
The review, however, recommended among other things that increasing budgetary allocation to health would revamp ailing sector.The critical review was done by a group of health experts including: President, Nigerian Medical Association (NMA), Dr. Francis Faduyile; President Pharmaceutical Society of Nigeria (PSN), Sam Ohuabunwa; a consultant obstetrician and gynaecologist and Medical director of Optimal Specialist Hospital, Surulere, Lagos, Dr. Celestine Ugochukwu Chukwuneye; and former President, PSN, Olumide Akintayo.
How will you rate healthcare performance in the country today especially after 59 years?
Ohuabunwa said the performance of healthcare in Nigeria in the last 59 years has been mixed. He explained: “From an infrastructural perspective, one can say that we have done fairly well. We have more health centers than we had years ago; every state has at least a tertiary health institution (Federal and/or State). We have many more private hospitals, clinics and community pharmacies.
“In terms of Human Resources, there can not be gainsaying the fact that we have more Pharmacists, more nurses, more medical doctors and more medical lab scientists today than we had many years past with several schools of medicine and pharmacy scattered all over the country.”
The pharmacist, however, said the country has not done well enough in health outcomes. Ohuabunwa said malaria is still ravaging Nigerian children to no end, Nigerian children still die from vaccine preventable diseases and maternal mortality and under-five mortality rates are among the highest in the world although some improvement has been recorded recently.
The pharmacist said fake drugs in circulation in Nigeria remains significant and many Nigerians obtain their drugs from unauthorized sources leading to high levels of drug misuse and abuse. He said life expectancy at about 54, though improved is still below many countries in Nigeria’s category and what is worse is that fewer Nigerians can access quality healthcare than they did years back. Ohuabunwa said given the worsening level of poverty and the low level of health insurance, many Nigerians are turning to unorthodox sources to seek healthcare and the damning consequences are reflected in our miserable health statistics.
Chukwunenye said healthcare performance in Nigeria today, especially after 59 years of independence, could be said to be at its lowest ebb. He said most healthcare institutions are just basking in their old glory, with most of their staff completely disenchanted, and looking for the slightest opportunity to travel overseas for supposedly, greener pastures. The truth however, according to Chukwunenye, is that there are daunting challenges overseas, and many that have taken a one-way ticket overseas are living in regrets.
Akintayo said: “It is truism when we posit that healthcare is almost non-existent in this clime. A health system that is rated 187th out of 191 systems cannot be reckoned with especially when war ravaged countries have better rated health systems.
“Evidence based realities confirm that we still live with very statistically significant negative health indices. We remain a major exporter of the wild polio virus and you cannot help marveling at the type of contributions we add to human history.”The pharmacist said research institutes in the country are in obvious coma and it will take resurrection power to bring them back to life in a country where there is little or no premium on Research and Development (R & D).
He said regulatory agencies in health can best be captured as being in a state of somnambulism and they are not just sleepwalking but they are sleepwalking backwards. Akintayo said the totality of these drawbacks weighs down health practitioners which contribute to the exit for greener pastures and those left behind are certainly not fulfilled which is a major reason we continue to contend with a harvest of strike actions in the health sector.
He said About 14 years ago when the Obasanjo Government introduced its version of Social Health Insurance dubbed the National Health Insurance Scheme (NHIS), we thought we could attain Universal Health Coverage (UHC), particularly because the National Health Act (NHA) was structured to enhance Social Health Insurance through a one per cent consolidated funding (first line deductions from Federation Account), but poor management and inexperienced drivers have ensured that the NHIS is another project that is dead-on-arrival because coverage after almost 15 years is less than two per cent (1.72 per cent).
Akintayo said whatever remains of the health services is about to be sent a death knell because contemporary reports confirm the Federal Government (FG) through its rampaging the Infrastructure Concession Regulatory Commission (ICRC) has now approved concessioning of 22 Federal Health Institutions (FHIs) in Nigeria.
The pharmacist said healthcare in a country like Nigeria where poverty is endemic should ordinarily be a social welfare inclined agenda, but this last bastion and window for healthcare through public facilities for the downtrodden will be handed over to private profiteers if President Muhammadu Buhari does not stop the thieves in high places whose are bent on handing over guaranteed markets in the public sector to private profiteers and doomsday merchants who paint rosy pictures of what the involvement of entrepreneurs in healthcare will bring to bear on health services in the public sector.
Akintayo said President Buhari needed to order a critical evaluation and investigation into the fortunes of Garki Hospital, Abuja, which was handed over to a concessionaire some years ago. He said it is the shame of a nation that a country that nurtured a facility like University College Hospital (UCH), Ibadan which was rated one of the top five facilities in the commonwealth at a point in the 60s and 70s now contends with 55 mediocre teaching and specialist hospitals as well as Federal Medical Centres (FMCs) in 2019.
He warned that the pharmaceutical sector which is rewarding in other climes, are now put on notice that pharmaceutical manufacturing may be completely eclipsed in another five years because of poor capacity utilisation and wretched patronage by government at all levels. Akintayo said at some point, the pharmaceutical sector was worth about $2 billion and contributed a poor less than two per cent to National Gross Domestic Product (GDP). The pharmacist said, today, fortunes have nosedived to less than $1,5 billion and a contribution to GDP is tending towards less than 1.3 per cent.
Akintayo said every observant Nigerian is familiar with episodes of fake drugs and new dimensions of drug misuse and abuse, which continue to weigh the pharmaceutical sector down with dire consequences to consumers of health. He said poor funding of the PCN, NAFDAC and NDLEA continue to impugn regulatory activities such that all the goals and objectives of the National Drug Policy (NDP) 2005, the new National Drug Distribution Guidelines (NDDG) of 2015 have failed or are on the path of being rested in peace.
Akintayo said the amplitude of the contraption in the pharmaceutical sector informed a call for the setting up of a Presidential Committee on Drug distribution to resuscitate ailing fortune in the pharmaceutical sector of the economy some weeks ago. “I like to align with this viewpoint as it might prove to be the ameliorating balm the strategic pharmaceutical sector needs at a time like this,” he said.
Have we made progress? If “Yes” or “No”, explain with instances?
Chukwunenye said Nigeria has made some significant progress over the last 59 years, but these pale in significance in the presence of colossal mismanagement of the healthcare sector. The consultant O&G said the number of institutions at the various levels of care have tremendously increased, so also the number of registered practitioners in the various fields have grown significantly, but they are still far from the ideal as recommended by the World Health Organisation. He said this is the best one can say of Nigeria’s healthcare system but in terms of standards of care of patients in the various institutions, and the quality of training their graduands receive, much is to be desired.
Chukwunenye said a few institutions however, can be said to be trying their best. “I know of a hospital that has marked 22 years of zero maternal mortality in Lagos, Nigeria. Nigeria is said to be the country with the worst maternal mortality rate in the world,” he said.
Akintayo said: “It is obvious from the various scenarios that I projected that we moved from the heights of glory like the UCH, Ibadan phenomenon of yesteryears to the depths of declivity. That is the story that cuts across in the sector. A Research Institute like Nigerian Institute for Pharmaceutical Research and Development (NIPRD) does not enjoy any substantial subvention despite the array of pharmaceutical scientists and pharmacists in the system.
“I also explained the decay in the value chain of drug distribution despite the antiquity of pharmacy and drug laws some of which are over 130 years old.”Akintayo said, today, the country contends with almost three million unregistered pharmaceutical premises kept alive by huge drug market structures, which have not been registered in many years.
The pharmacist said the NDDG he referred to proposes to replace the Open Drug Markets (ODM) with Coordinated Wholesale Centres (CWCs) in at least seven States of the Federation. He said avarice and greed have become militating bane because some state government officials and chieftains in affected states have used bureaucracy to frustrate advancements in the concepts by willing investors.
Akintayo said the FHIs epitomises the extremely bizarre as the Chief Executive Officers (CEOs) often times have become tyrants and emperors. “If that was all, we would not be lamenting but it is now commonplace to observe CEOs of FHIs misappropriating billions of naira even when we mouth poor funding,” he said.
Akintayo further explained: “A very palpable one remains the FMC, Owerri where a particular CEO excelled so much in thievery to the chagrin of even hitherto complacent staff. When the place erupted, prominent personality cults at the Federal Ministry of Health (FMoH) and the Imo State Government (IMSG) deplored machinery of the state to protect the favoured CEO. He said even those who raise alarm in consonance with the whistle blowing policy of the FG were suppressed and denied routine promotion instead of being honoured. Akintayo said at the Federal Staff Clinic, Abuja, yet another CEO terrorises the system in that facility by making use of only locum staff contrary to Labour Laws to pave way for massive looting of resources in that facility.
Akintayo said in one of the teaching hospitals in the North Central geo-political zone, the CEO is on record to have unilaterally squandered some young billions of naira daring the anti-graft agencies with his many acts of impunity. “I can go on and on with the whirlwind of recklessness, incompetence and massive brigandage that goes on in the health sector,” he said.
What have been the challenges?
Chukwunenye said the greatest challenge remains poor management of the available resources, from the highest to the lowest levels of care. In this regard, he said, concessioning some aspects of public health institutions, or the entire institution, as is being proposed by the Federal Government, is a welcome development. The medical practitioner said one only hopes that the concessioning exercise would be transparent, and well organised to achieve the desired results, unlike what was witnessed in the power sector recently.
The second challenge, according to Chukwunenye, said is poor healthcare financing and the NHIS as an instrument of government to address some aspects of healthcare funding has continued to flounder. He said the incessant board and management crises have not helped matters as well as the frequent interference by the FMoH and the Presidency has only made matters worse.
Chukwuneye said there is a need for enabling laws that would shield the NHIS from political interference and manipulation, while ensuring better finance for it. “The health of the people deserved to be shielded from the vagaries of partisan politics,” he said.
Chukwuneye said the issue of each state trying to establish its own Health Insurance Scheme should be discouraged. Instead, he said, they can invest in Health Maintenance Organisations (HMOs) as a way of helping their workforce and dependants under the present NHIS. This, Chukwuneye said, would help strengthen the HMOs, and give them a better voice in how NHIS is managed, while improving funding to the healthcare institutions.
The third challenge, the medical director said is the dearth of needed manpower, occasioned by the mindless brain drain. “It is ironical, and a shame, that we expend our meagre resources to train out highly needed manpower, only to allow most of them exit to other countries to work. It becomes really sad, when one realises that these needed manpower exited from our country because of poor conditions of service in the country, while their host countries give them better conditions of service from monies realised from medical tourism of fellow Nigerians. When will this our stupidity end?” he said.
Chukwunenye said the same patients who refuse to pay reasonable fees in this country to help develop and sustain the local healthcare institutions, are eager to pay the much higher fees overseas, to consult the same Nigerian healthcare practitioners overseas and the profit then goes to the healthcare institutions of the host countries. “When shall we stop these self-inflicted injuries on our economy?” he asked. Chukwunenye said any government that truly loves Nigeria, and her peoples, must as a matter of urgency; reduce both brain drain and medical tourism to the barest minimum.
He said other challenges in the healthcare sector, including poor training facilities, dearth of needed equipment, quackery, undue rivalry among healthcare workers, to mention a few, can be better solved if the main headaches above are resolved decisively.
Akintayo said the challenges are multifaceted. He decried poor ministerial and related appointment. He said one of the misnomers in the Buhari’s administration with particular emphasis on the health sector is the configuration in structuring of the FMoH, FHIs, and agencies in health. Akintayo said like it was in his first tenure, President Buhari has again placed two medical doctors in charge of the FMoH and arithmetically, doctors account for less than five per cent of the membership of this multidisciplinary sector. He said for those who understand the governance architecture of the health sector which is grounded on a unique power equation, this will continue to be unholy ground for harmony in the health sector. Akintayo said President Buhari makes it worse for the health sector with the appointment of another doctor, Chris Ngige, who is saddled with the running of a critical Ministry like Labour and Productivity.
Akintayo said: “Ngige and his former colleague in the FMoH who have identical physiognomies waged a war of bitter attrition against health workers apart from doctors in their stewardship from 2015 to 2019. After a 2018 strike, members of Joint Health Sector Union (JOHESU) who participated had their six weeks salaries withheld. In the same sector, doctors have gone on strike in Jos University Teaching Hospital (JUTH) and Lagos University Teaching Hospital (LUTH) without suffering same fate. He said, presently, Resident Doctors at the Psychiatric Hospital, Yaba are on strike because they know the big brothers at FMoH and the Labour Ministry will protect them. Akintayo said it is also on record that salaries of Academic Staff Union of Universities (ASUU) members who were on over two months strike recently was never withheld by Government.
Akintayo said government failed woefully with the NHIS through the insistence on having its pool of incompetent doctors run the scheme. He said in other serious climes professional insurers or actuaries run this scheme with a lot of success and impactful growth rate and that government must also imbibe a culture of balancing appointments in its FHIs. Akintayo said in the 22 teaching hospitals, the reality on ground is that eight out of 13 slots are the exclusive preserve of doctors on the Board of Managements. He said this is why those Boards fail and will continue to fail if the FG does not change the conqueror mentality/disposition of sacred cows in healthcare.
The pharmacist said government can and must change the narrative in healthcare by implementing the entire spirit of the NHA. He said the one per cent Consolidated Fund must be appropriated to drive procurement of essential drugs from local manufacturers, training of health workers and facilitate lawful implementation of NHIS protocols, standards and procedures for effect.
Another challenge of the health sector, according to Akintayo is the Privatisation, commercialsation and concessioning of health facilities. He said the government has allowed itself to be hoodwinked into buying into privatisation, commercialsation and concessioning of some public health facilities at varying times in different locations. He said all of these experiments ultimately fail because at their heart is the motivation to steal if we were to rely on an apocalyptic declaration.
Akintayo said those who aspire to take-over the country’s collective national heritage should be encouraged to build their world-class health facilities where they can treat the highly placed people rather than impose death sentences on the masses that can only afford to patronise the public sector health facilities.He said at a global level and these reports should interest the Presidency and top echelon of government, International Labour Organisation reports indicate albeit unambiguously that all Private Public Partnership (PPP) models in health facilities worldwide have failed.
Akintayo said government must evaluate why they failed rather than allow the pseudo-technocrats and greedy bureaucrats at ICRC, Bureau of Public Enterprise (BPE) who in alliance with entrepreneurs in health and some dubious International Finance Institutions (IFIs) to sentence more of our compatriots to early graves because of ill-conceived reports which can only misguide the FG. “Let us learn from the deadly errors in the unbundling of Power Holding Company of Nigeria (PHCN), which still remains a mass of putrefying sores,” he said.
What are your recommendations on how to improve healthcare delivery in the country after 59 years?
Faduyile said: “We need to take care of corruption in the system, corruption is killing the healthcare system in this country.“We need our people to be accountable, we need a way in which the populace should be able to demand from their leadership, especially at the local level, for daring to be more responsive to the health… it is not going to be possible for us to think that you can control health from the central government, that is from the Federal Capital Territory, it cannot be possible for someone to sit at Abuja and be controlling what is happening in the different local government areas in the country.
“So we must be able to get local leaders in our different local government and communities to be more responsible and responsive to the healthcare of our people. It is until that awareness is taken to the people and the people demand for it that we can now say yes we are going in that right direction.”
The NMA President said the country must be able to have the government to put in place a mandatory health insurance scheme, which is the minimum requirement for us to revamp the health.The consultant surgeon said the government needed to put machinery in motion, so that all the nationwide programmes are enforced. For example, he said, the country is supposed to have a national programme for the prevention of cancer of the breast, cervix that is either using test. “We should have a national policy on all these cancers,” Faduyile said.
The medical practitioner said the country does not have a national policy on cancer of prostrate and the federal government needs to ensure that there is immunisation policy to get people to be immunised at a particular period or years of their life because it is very difficult at those lower level.
Faduyile said the government needs to show more commitment and control and the people need to be able to have their state government or governors to showcase what they have done at the secondary healthcare system. “It is at this place we have many of the government general hospitals that are in shambles, totally kempt, in fact in some places you just think that it is rat holes and it is really unfortunate. We don’t have staff, we may have general hospitals that just have one doctor, some may not have doctors and what are we doing?” he said.
The NMA President said Nigerians should be able to demand from their state governors on their policies on health. “Gone are the days when you go to the general hospitals and you get what you needed in place, today you have almost a dead general hospitals nationwide,” he said.
Faduyile said President Muhammadu Buhari and the Federal Executive Council to showcase that they are interested in health by increasing the budgetary allocation to health.He said, in 2001, African Heads of State had a meeting in Abuja, which is, the Abuja 2001 declaration where they agreed that a minimum of 15 percent should be budgeted for health and Nigeria who hosted that meeting and was an active participant had never gone beyond five percent. “That is really unfortunate,” he said. Faduyile said a country like Rwanda that have gone as high as 15-25 percent at a time have had a dramatic jump – a change in the health system. He said there has been a dramatic revamping of the health system even in Ghana once they have increased budgetary allocation to health.
The NMA President said the country should be able to make legislation and put every health worker in his or her different positions so that Nigeria can now end this political rivalry that exists in this health institutions nationwide. Faduyile said there are people who are largely not being utilised appropriately within the health system, causing disruption in the system. “Let us be able to have good evaluation for every member of the team, so that we can ensure that we can do the proper management that we have been trained to do,” he said.
The medical practitioner said some people have gone about privatisation, which looks good on the face value, but if the country still continue to have corruption still deeply entrenched in the health system, privatisation may not yield much. “We will soon see that a lot of health system, management or institution may likely privatise by people who have corruptly enrich themselves and does not have the interest of the people,” he said.
Faduyile said, so, a lot needs to be done with clearing the health sector of corrupt practices and Nigeria needs to have opportunity of sending people and staff outside for them to obtain better on more specialised skill so that it can be of benefit to this country.
“These are my immediate recommendations and we are hoping that President Muhammadu Buhari can make the major statement in terms of health, as Nigeria is going into the national celebration very soon,” he said. Ohuabunwa’s want President Buhari to make primary healthcare functional by empowering the local governments or it should be taken over by the Federal Government. He said a truly functional primary healthcare system would improve the country’s health statistics significantly.
The PSN President want the Federal Government to make health insurance compulsory with government at all levels subsidising those who are too poor to buy insurance. He said if Rwanda can achieve 95 per cent health insurance, somebody needed to convince him why this is not possible in Nigeria.
Ohuabunwa called for support local pharmaceutical industry to improve availability of affordable and quality medicines through patronage and fiscal incentives.He recommended restoration of harmony in the health team by treating all fairly and equitably and encouraging professional practice.
The pharmacist want empowerment the regulatory agencies with adequate legislation for example the new Pharmacy law awaiting Presidential assent and resources to ring fence drugs, allowing access only to those qualified to handle or use them through prescription or recommendation. That way, he said, Nigeria can phase out fake drugs and medicine peddlers while reducing misuse and abuse.
Ohuabunwa called for the integration of traditional healthcare into the country’s conventional system in a manner that will offer choice, guarantee affordability and save Nigerians from exploitation by the current way traditional/ herbal medicine is practiced in Nigeria.
The pharmacist recommended elevation of at least four teaching hospitals in Nigeria into world class and save foreign exchange drain in medical tourism and the accompanying embarrassment of treating the country’s leaders in foreign hospitals.
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