How lack of political will by successive governments undermines health sector

Dr Henry Olusegun Gbelee, a consultant Pediatric Nephrologist, is also Chairman and CEO of St Mary’s Specialist Hospital, Omole Phase 1, Ikeja. The certified general practitioner, National Health Services, UK, in this interview with KEHINDE OLATUNJI, spoke on Nigeria’s health sector and how to address prevailing challenges

What are the core challenges in Nigeria’s health sector?
Healthcare indicators in Nigeria are some of the worst in Africa. The country has one of the fastest growing populations globally with population growth rates of 3.2 per cent and a 54.07 life expectancy per annum. It is estimated that Nigeria’s population would rise to 440 million by 2050. The quality of healthcare services in Nigeria at present disregards the poor and remains a huge source of concern. Most of the Primary Health Care facilities are signatory to the poor health services provided in the rural areas, because it is poorly funded.

Primary healthcare, which is the most important level of care, is in the hands of the weakest level of government. This has resulted in a weak and disjointed health care system with an overall poor inadequate population health.
 
According to the South East Asian Journal Of Public Health (2017), the programmes designed to address the numerous health problems in Nigeria have led to little improvement in our health status. Besides, the continuous neglect of the importance of addressing public health issues would make matters worse for poor Nigerians, most of whom are at the receiving end. The major public health challenges Nigeria faces are infectious diseases, maternal mortality, infant mortality, poor sanitation and hygiene, disease surveillance, Non-Communicable Diseases (NCDs) and road traffic injuries etc.

Nigeria has the highest burden of sickle cell disease among the black skin population. About 150,000 children die from it every year. There are about 3.4 million HIV infected people currently living in Nigeria. 150,000 people died from AIDS in Nigeria annually and only about 33 per cent of the infected people received treatment annually. The depleting status of healthcare services in Nigeria is mainly due to political instability, corruption, limited institutional capacity and unstable economy.
 
In 1970, the average life expectancy for men was 37.2 years and for women 36.7. By 2011, these figures increased for women to 55.3 and for men 48.9. This indicated an improvement in the quality of life and medical care. The current life expectancy is 54.07 years. The country’s life expectancy is ranked 216 in the world and 16th in Africa.
In China and Japan, average life expectancy is 83-84 years, while in some European countries the life expectancy is 82 years.

Because of expensive healthcare, 72 per cent of health expenditure in Nigeria are out-of-pockets payments, this expenditure accounts for a significant percentage of household expenses in Nigeria. The Nigeria National Insurance Scheme (NNIS) only covers employees working for the Federal Government and some private sector, covering only three per cent of the population. Only about five per cent of the population has access to healthcare through government provided health insurance or voluntary private insurance plan.

Another challenge in the system is the issue of poorly trained and poorly compensated staff. Inadequate trained staff in the sector is a major factor as well as over burdening of most medical staff, who are poorly compensated.
 
Healthcare in Nigeria should be a major national priority. Out of 191 countries, the World Health Organisation (WHO) health system performance ranked Nigeria at 187th. For Nigeria to improve and maximise its population health, the major challenges such as health national budget allocation should be increased to match the global standard that is the per cent per Gross Domestic Product (GDP). Expanding the National Health Insurance Scheme (NHIS) will drastically reduce out-of-pocket spending for families.

Training more medical staff, improving current facilities, awareness camps, engaging the populations will help to improve the general healthcare of the population. The Nigeria health system has performed woefully against vital health indices, trailing behind many African countries despite our enormous potential.

How will you rate Universal Health Coverage in Nigeria?
The United Nations Sustainable Development Goal (UNSDG) in 2005 included a resolution on Universal Health Coverage. This coverage has two essential foundations: equitable access to quality healthcare and protection from financial risk.

The universal health coverage targets eight of the UN’s Sustainable Development Goals 3 (SDG3). Other important SDGs include poverty reduction (SDG1) gender equality (SDG5), inclusive economic growth (SDG8) and reduced general inequality (SDG10). After two decades, Nigeria still has one of the worst health indices in Africa despite being Africa’s largest economy.

The primary reason for a large number of medical doctors emigrating each year is the lack of adequate funding in the sector. The 2021 health expenditure accounted for only seven per cent of the total national budget. It is less than the 15 per cent agreed by the Nigerian leaders.

There is a mass movement of highly skilled professionals to advanced countries like the USA, Germany, Saudi Arabia, Australia and UAE, what danger does it portend?
Over the decades, doctors leaving to other countries have increased. In 2018, a survey revealed that 80 per cent of Nigerian doctors were seeking employment abroad. Furthermore, between 2015 and 2021 about 4,528 Nigerian trained doctors have migrated to the United Kingdom (UK). The migrating trend exacerbates a deteriorated healthcare system and it is unlikely to stop. This could potentially be the death knell on the country’s health sector. Currently, there are 80,000 doctors registered by the medical and dental council of Nigeria as at June 2021 out of which only 35,000 are practicing in the country.

Reasons behind such massive exodus include: poor working conditions, poor remuneration, lack of improvement in research and advancement of professional proficiency and the contemporary treatment from the arm of government.
  
Other reasons are unemployment and low paying jobs, lack of financial security, poor health care facilities, bad leadership, corruption, high rate of poverty, kidnapping, Boko-haram bombings and killings by Fulani herdsmen. According to the National Health Mission (NMH), approximately 2000 doctors left the country each year. Social health services schemes have been introduced to expand coverage of political engagements of the people at all levels to gain awareness of the needs of universal healthcare and sharing substitute funding. There is a need to strengthen the health system as a basis for universal healthcare and address hunger and poverty at the same time. Universal healthcare is not a stand-alone issue and an integrated approach to other services is very crucial. Also, there is a need to make the NHIS more accessible or affordable to the poor.

What are your thoughts on the amendment of the medical and dental practitioners act?
The amendment of the Medical and Dental Practitioners Act, aimed at stopping the migration of Nigerian-trained medical professionals by the House of Representatives is very unfortunate and retrogressive. It restricts doctors and infringes on their fundamental human rights. It is against international labour laws and since everybody that passed through the university in Nigeria were subsidised, so why is the focus only on Nigerian medical personnel? Why is the House of Representatives not interested in laws that prevent elite Nigerians from travelling abroad in droves wasting billions of taxpayer’s money on such travels to treat any minor medical problem. The solution is not the bill but to find out what is causing the brain drain and take care of it. The bill is insinuating that they are going to look for greener pastures, why not increase and improve the health budget to create greener pastures in Nigeria. It is the constitutional right of every Nigerian to work freely anywhere in the world and this is a right nobody can impede on.

How can Nigeria put an end to brain drain?
Brain drain is a very big disadvantage to Nigerians as a people. It is a waste of human capital resources and intellectual properties. Putting an end to Nigeria’s brain drain requires the collective approach of all and sundry towards ensuring that the juicy remunerations, which make many Nigerians to go abroad, are also made available in Nigeria.

Brain drain could prove detrimental and poses a significant constraint in achieving SDG3 (Good Health and well-being) in Nigeria. The government should prioritise the health sector, given its link on the better life quality and economic development; workers remuneration should be made competitive with international standards.
   
To address the challenges of brain drain, more job opportunities with adequate remunerations must be encouraged, quality educational opportunities at both undergraduate and postgraduate levels, provision of local incentives, provision for conducive environment for workers, funding of tertiary institutions and accountability in governance, these are the things to look out for.

Out-of-pocket payment for healthcare services is a major challenge, how can it be addressed?
Most private health care facilities demand a deposit before treatment. There is an over reliance on out-of-pocket payments in Nigeria. Since 70 per cent of Nigerians are living in poverty, such out of pocket demanded deposits can make individuals and households incur large health expenditure that can exacerbate their level of poverty. Such a source of healthcare financing negatively affects people’s living standard and welfare.

More than 90 per cent of Nigeria’s population is uninsured despite the establishment of NHIS. Out-of-pocket payment for healthcare services is a very big challenge. Government and decision makers need to address this problem. The NHIS needs to be expanded to lower people in both the formal and informal sectors. Private health insurance has to be made mandatory. The community based health insurance scheme needs to be scaled up across the country.

The persistent low quality and inadequacy of health services provided in public facilities has made the private sector an unavoidable choice for most patients seeking good health care in Nigeria. Ineffective state regulations of private healthcare have led to little control over the clinical activities of the private sector providers.  
 
The cost of private medical services has grown faster in recent years than the average rate of inflation. The government at local, state and federal levels needs to put in reforms that are targeted at reorganising the private sector with a view of enhancing efficiency in the supply of services. This intervention is needed urgently. If costs are to be contained or reduced, consumers can then be assured of good value for their money.

Do you believe the sector could have been better if the federal government injected more funds into it?
Policies on budgeting and persistent inadequacy of health services provided in public facilities have made the private sector an unavoidable choice. The ineffective state regulation, however, has little control over the clinical activities of the private sector.

The government at local, state and federal levels need to put in reforms that are targeted at organising the private sector with efficacy and efficiency in the supply of services. This intervention is needed and expected, if the costs in the private sector are to be contained or reduced so that consumers can be as sure of good value for their money.
  
Many Nigerians do not seek medical expertise from doctors until their condition significantly worsens. One of the major challenges is inadequate allocation and poor financial resources to maintain an informed general public health. To keep up with the standard within the global health arena, a projected nine per cent of GDP should be allocated to healthcare spending.

What is the way out?
The healthcare system in Nigeria is mainly driven by the public sector; currently the three tiers of government- federal, state and the local councils own 66 per cent of the country’s 34,000 health facilities, even though the private sector still contributes substantially to the provision of health services. It is important to note that secondary and tertiary healthcare facilities are mainly located in urban areas, while primary healthcare facilities are prevalent in Nigeria’s rural areas.
    
Without proper financing in the development of the health sector, it will continue to be stifled. The sector needs proper assessment as well as proper investment, if not, the sector will continue to suffer. The sector’s challenges led to the unfortunate practice of medical tourism, where the more privileged elites spend over one billion naira annually seeking better medical care outside the country.

How do you think hospitals should handle situations where patients are unable to pay their bills?
Patients attending most private healthcare facilities are asked to pay a deposit before treatment and overreliance on out-of-pocket payments in Nigeria is not very good.
Since 70 per cent of Nigerians are living in poverty such out of pockets demanded deposits can make individuals and households incur high health expenditures that can exacerbate their level of poverty.

More than 90 per cent of the country’s population is uninsured despite the establishment of NHIS. Out-of-pocket payments for healthcare services are a very big challenge for the patients. The Nigerian government and decision makers need to come up with more policies to address this problem. The NHIS needs to be expanded to other people. Private health insurance must be made mandatory. The family based health insurance scheme needs to be the gold standard across the country.

How would you rate the performance of the present administration in the sector? 
The quality of healthcare services delivered remains a huge source of concern, most of the Primary Health Care (PHC) facilities that are signatory to treat the health needs of the people are virtually in coma due to poor budgeting allocation. Out of 191 countries the WHO health system performance ranked Nigeria 187th. For Nigeria to improve and maximise its population health the major challenges such as Health National Budget Allocation should be increased to match the global Standard per GDP. Expanding the NHIS will drastically reduce out-of-pocket spending for families.
 
The Minister of Health, Dr Osaghae Ehanire said there are enough medical doctors in the country, do you agree with this?
 
WHO reports reveal that Nigeria’s doctors/patient ratio is 4 doctors per 10,000 patients, under five hospitals bed per 10,000 patients, with over 200 million Nigerians. It would take about 25 years to provide enough doctors to keep up with the population, this dire situation can only lead to poor help outcomes and high child and maternal mortality rates.
  
The minister’s assertion that the number of doctors leading Nigeria every year is less than 1000 is also false; it is estimated that no fewer than 2000 doctors are leaving Nigeria yearly.
 
Data from the Medical and Dental Consultants’ Association of Nigeria (MDCAN) has revealed that the total numbers of doctors that have migrated to the UK in the last two years were nearly 9000, and the total in the USA was 3895.

In each of those years, yes the minister was right; Nigeria produced about 3000 doctors each year.
Another summary contradicted by the Nigerian health minister is that Nigeria has a deficit of qualified doctors and needs at least 237,000 doctors to ensure the population’s health needs are adequately catered for.
 
 Do you think the government has been doing enough for private hospitals in terms of policies and budgeting?
 Policies on budgeting have persistently invoked the quality and inadequacy of health services provided in public facilities and has made the private sector a viable choice.