Nigeria’s health sector performance trailed behind other countries in 2019
When Nigerians welcomed the year 2019, they had high hopes and expectations of a better healthcare system, despite failures of the past years.Nigerians were optimistic of the fulfillment of the presidency’s promises to provide standard, quality, affordable and accessible healthcare to all, in order to achieve universal health coverage, as stipulated by the World Health Organisation (WHO).
There were projections by experts and stakeholders in the healthcare industry on how the Federal and State Governments could achieve universal health coverage by putting the right strategies in place.But with the look of things, Nigeria is still far from achieving better and standard healthcare system for her citizens, compared to her African counterparts and other developed climes.
Meanwhile, all the United Nations’ member States had earlier agreed to try achieving universal health coverage (UHC) by 2030, as part of the Sustainable Development Goals, which requires that all individuals and communities receive the health services they need without suffering financial hardship. This includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.
The UHC also provides everyone access to services that addresses the most significant causes of diseases and deaths, and ensures that the quality of those services is good enough to improve the health of the people who receive them, thereby protecting people from the financial consequences of paying out of their own pockets to reduce the risk of being pushed into poverty.
Whereas, African Union leaders, as measures to achieve the UHC, on April 2001, converged in Nigeria, which resulted to the Abuja Declaration of committing at least 15 percent of their yearly national budget to healthcare, following the widespread shortfall in their budget for health.
While seven countries – Rwanda, Zambia, Malawi, Burkina Faso, Botswana, Niger and Togo have met the Abuja target, Nigeria has failed to meet up, as it has continue to allocate less than six percent of its annual budget to the health sector, with that of 2019 standing at 4.1 per cent, that is N365.77 billion, out of the country’s total budget of N8.83 trillion.The highest percentage allocated to health since the declaration was in 2012 when Nigeria earmarked about 5.95 percent of the budget to healthcare.
Though, the 2019 budget on health is lower than the previous year, some positive projects were included, which are the inclusion of the one percent Consolidated Revenue Fund (CRF) earmarked for the Basic Health Care Provision Fund (BHCPF), which amounts to N51.22 billion. Meanwhile, Nigeria still awaits the release of the BHCPF funds in the 2019 budget till today, as only 25 percent of the 2018 BHCPF has been released amounting to 13.77billion.
Others, which have also not been implemented include, the 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; N7.63 billion for procurement of Routine Immunisation (RI) vaccines and devices; N3.5 billion for counterpart funding including global fund/health.
It also includes the 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.
While various statistics puts Nigeria as one of the worst in healthcare delivery records in the world, the World Health Organisation has rated it 187th out of 191 countries in terms of health care delivery.
The health body also placed Nigeria as the third highest in maternal and infant mortality rate globally, with about 70 percent of the country’s population still spending out-of-pocket for health services till today, according to Budgit, a platform analysing Nigerian budgets and public data.
Stakeholders in the health sector have, however, repeatedly decried the poor performance of the country’s health system in all aspects, which has affected the indices.Rating the country’s health sector 2019 performance on a scale of preference, they said, though, there were some improvements, Nigeria has performed below par in all aspect when compared to other climes, especially going by the world health organisation’s standard.They however highlighted the major areas in the health sector with very weak performance, which they said the government must address immediately. They include:
Poor budgetary allocation
Professor of Virology, Oyewale Tomori in his rating for the health sector’s performance for 2019 said: “In the face of huge infrastructural gaps in, and inadequate budgetary allocation to the health sector (range between 3.90 percent and 4.75 percent of national budget from 2017 to 2020), it is difficult to rate Nigeria health sector performance any highly.
“I will avoid numerical scoring, but with below, you can decide where we stand. Yes, we took some positive steps in the right direction, but these steps were insufficient, as the progress we made was too little, too late and too lopsided.”
Former President, Association of Resident Doctors, Lagos University Teaching Hospital (ARD- LUTH), Dr. Kayode Makinde, said: “The health sector performed below par in 2019, especially when compared with other countries. There were small wins here and there. For example, the allocation of one percent from the consolidated revenue funds to service the provision of basic healthcare to Nigerians, which the government has not implemented.”
Senior Registrar, Department of Preventive Dentistry, Lagos University Teaching Hospital (LUTH), Dr. Ekowmenhenhen Uyi Idah, who rated the performance of the health sector as “fair”, said there are lots of things to be done starting from funding, which is crucial.He said the budget for health was definitely below par – way below the World Health Organisation and Inter-country agreement/commitment to healthcare funding.
“It is still below the two digits score, which is very poor. Countries cannot develop under such low budgetary allocations. That is the starting point, we have to take health more seriously,” he said.Head of Legal Department, Lagos University Teaching Hospital, Sesan Olajide, said funding is an area the government has continued to fail to improve on, noting that the country must understand that it is grappling with limited competing resources, as funding is needed to maintain personnel, equipment, trainings and infrastructure.
President, Association of Psychiatrists in Nigeria (APN), Taiwo Lateef Sheikh, lamented that there is inadequate funding of mental health services and provision of psychosocial support services to persons living with mental and psychosocial disabilities, which fails to guarantee mental wellbeing of the people, protect their fundamental human rights and does not ensure social inclusion.Registrar, Department of Anaesthesia, Federal Medical Centre, Ebute Metta, Dr. Olaoye Oludare, lamented that the yearly budget on healthcare is far below optimum standard as set by the World Health Organisations
Brain drain, human resource crisis, insecurity and poor reward system
According to the World Health Organisation, to meet the health workforce requirements of the Sustainable Development Goals and the universal health coverage targets, over 18 million additional health workers are needed by 2030.
Also, the growing demand for health workers is projected to add an estimated 40 million health sector jobs to the global economy by 2030, with investments needed from both public and private sectors in health worker education, as well as in the creation and filling of funded positions in the health sector and the health economy.
This is not the case with Nigeria as the President, Pharmaceutical Society of Nigeria, (PSN), Mazi Sam Ohuabunwa lamented that many of the Primary Health Centres and State General Hospitals remain without appropriate manpower and adequate equipment.“Many hospitals have no pharmacists and virtually all the primary health centres are running without pharmacists,” he added.
Senior Resident, Department of Restorative Dentistry, Lagos University Teaching Hospital, (LUTH), Dr. Judith Jolayemi, said: “The major challenge we have in the healthcare system is manpower, we are so short of manpower, especially doctors. Some departments in LUTH do not have one registrar, not even house officers. A whole lot of issues would not have occurred if we have enough hands to take care of the health of the citizens.
“Every year we have thousands of medical students graduating but they are not been employed. A lot of them, when they graduate, they leave the shores of the country. But if avenues are provided to make medical profession more interesting and comfortable for the doctors, I think the doctors would want to stay and practice in Nigeria.”
Idah said there is increasing brain drain, which is causing lack of manpower in the health facilities, as the environment is not conducive for healthcare workers, in terms of remuneration, working environment, and attractions.He also identified the disparity in human resource allocation between the rural and urban settings, adding, “We have lots of medical practitioners in the urban setting. We have a lot of rural areas that are depleted of doctors and one of the reasons is because there are no attractions there. Young doctors graduate and they do not want to go to the rural areas because there are no social hubs there, no added incentives and we all know that all the attractions are in the urban setting.
Oludare lamented that the state of healthcare in Nigeria has been worsened by shortage of physicians, adding that the emigration of healthcare workers is now a recurring trend, as retaining them in the country is an important objective, noting that the current ratio of doctor to patient is 1:2,500. “Migration of healthcare personnel to other countries is a tasking and relevant issue in the healthcare system of the country. From a supply push factor, a resulting rise in exodus of doctors and nurses may be due to dramatic factors that make the work unbearable – knowing and presenting changes to arrest the factors may stem a tide.
“Because a large number of nurses and doctors migrating abroad benefit from government funds for education, it poses a challenge to the patriotic identity of citizens and also the rate of return of federal funding of health care education.“Many Nigerian doctors have emigrated to North America and Europe. Retaining these expensively trained professionals has been identified as an urgent goal. The brain drain cuts across all healthcare Professionals; thousands of Nigerian Pharmacists and Nurses are practising in the United Kingdom and United States of America. From the above premise, it is obvious that the rate of healthcare performance is not yet to full capacity,” he maintained.Olajide said the machines in the hospitals cannot operate itself, hence, the need for adequate personnel who would operate the equipment
“The thing is that, the workforce generally need to be motivated, they also need exposure. Science and knowledge is dynamic, we need to let our practitioners to be abreast of the development in the medical worldwide, so that we can have the best here,” he said.Makinde said there is need to speedily put constructive measures in place to address the issue of brain drain, adding that as a nation, the government needs to improve domestic security, as it is central to the success of any establishment.
Failure to refurbish 10, 000 Primary Health Centres
According to the World Health Organisation, Primary healthcare is the most efficient and cost effective way to achieve universal health coverage around the world, but Nigeria is yet to achieve full primary healthcare package, as experts posit.
Meanwhile, the former Minister of Health, Prof. Isaac Adewole, had in 2017 said the Federal Government had concluded plans to rehabilitate 10,000 primary healthcare facilities spread across the six geopolitical zones of the country beginning from 2019.
He said the 2018 and 2019 appropriation bill would provide funds for the exercise. Also the N50.15 billion allocated for capital projects in the 2019 budget, which is a short fall from the previous year technically knocked out the refurbishment of 10,000 primary healthcare centres (PHCs) and execution of other projects in the sector.
From then till today, the federal government has only refurbished 4,000 PHC’s on the grounds that it should be a public private partnership effort, which has resulted into the failure to meet the federal government’s mandate of 10, 000 PHCs.
This is contrary to the promise of the President, Muhammadu Buhari’s administration to give a better, qualitative and accessible healthcare to all citizens, regardless of their location.In his reaction, Tomori said the establishment of the Basic Health Care Provision Fund (BHCPF), to extend Primary Health Care (PHC) to all Nigerians in 2018 was regarded as a major achievement in addressing the huge health problems of Nigeria.He said the federal government began the National Primary Healthcare Revitalisation Initiative with the aim of resuscitating over 10,000 health centres across the country and bring healthcare delivery to a large percent of Nigeria’s population.He noted that two years after, the scorecard shows a dismal performance or achievement, which all points to a failure of “our health sector to deliver the much-anticipated universal health care to Nigerians.”
Jolayemi stressed that the country does not have enough equipment, materials and infrastructure that is needed, which should be at the disposal of health workers, noting that in some units at LUTH, “Resident doctors use their money to buy materials to treat their patients, as these patients pay to the hospital and it is really unfair.“These materials should be made available by the hospital management. We have enough hands on deck, it would be more better for us as healthcare practitioners.”
Ohuabunwa said Nigeria’s President, Buhari spent many days in the United Kingdom and is still traveling, seeking medicare because no healthcare centre in the country is up to global standards. Oludare added that even where comprehensive health services are provided, lack of bed spaces in general hospitals and tertiary health centers have now become the order of the day, leaving many critically ill patients to their fate, as they are being referred with little or no resuscitative measures.He added that geographic inequality is also a major constraint, as healthcare in Nigeria is influenced by different local and regional factors that impact the quality and quantity present in one location. He said the healthcare system in Nigeria has shown spatial variation in terms of availability and quality of facilities in relation to need, as this is largely as a result of the level of state and local governments’ involvement and investment in health care programs and education.He added that the ministry of health usually spends about 70 percent of its budget in urban areas where around 50 percent of the population resides.
Disease outbreak and management
Tomori said while the signing of the Nigeria Centre for Disease Control (NCDC) bill into law is another achievement; the escalating outbreaks of diseases continue to hamper health care delivery in the country. The Professor of Virology cited the NCDC report in 2018, which stated that there were 3498 suspected Lassa fever cases, (633 confirmed and 171 deaths) and as of week 49 of 2019, it already reported 4820 suspected Lassa fever cases, with 806 confirmed and 166 deaths.
Tomori continued: “The yellow fever outbreak which began in 2017, is yet to subside. While the increasing reports of outbreaks may point to increase awareness and some improvement in our ability to detect and confirm potential outbreaks, we have shown our national inability to mount timely and appropriate response needed to bring these and other diseases, such as Cerebrospinal Meningitis (CSM), measles, cholera among others, under control In 2017.”While Ohuabunwa said Nigeria experienced outbreaks of vaccine preventable diseases during the year, as many hospitals owned by governments faced out of stock syndrome – lack of essential medicines.Jolayemi said: “To the best of our ability, we do what we can to control diseases, but then we work with what we have on ground. Even if we do not have the facilities, there is a limit to how much we can do.”
Oludare said about 80, 000 Nigerians die of cancer yearly, with over 100,000 diagnosed with the disease.
He said more people are dying of cancer in Nigeria, as Non-Communicable Diseases (NCDs) are not given priority in the country’s health budget, noting that there are only seven cancer radiotherapy centres in Nigeria.
“Many of the cancer-related deaths in Nigeria can be attributed to lack of knowledge regarding this family of diseases. This is most notable from the fact that there is no word for cancer in any of the many Nigerian languages and dialect. “Furthermore, lack of education on both prevention and early detection and a culture which endorses silence and places a negative social stigma on such illnesses has led to more than one-third of preventable cancer death,” he added.
Ohuabunwa said the health sector’s performance in 2019 is generally below expectations, “at best around 50 percent average performance rating.”
He said the average rating arises from the fact that there is no significant increase in the national health insurance coverage, as most Nigerians still have to purchase medicare out-of-pocket, which will have caused more morbidities and mortalities.
Oludare said one major way of solving the health sector’s problem is with a very effective and transparent health insurance scheme.He said while health insurance in Nigeria can be applied to free healthcare provided and financed for all citizens, provided by government through a special health insurance scheme for government employees and private firms entering contracts with private health care providers, less than five percent of Nigerians is covered by health insurance.
He added that the number of Nigerians covered by the National Health Insurance Scheme (NHIS) since its establishment is 1.5 percent of the population, noting that in 2017, the House of Representatives Committee on Health Care Services in Abuja, organised a two-day investigative hearing; where the then Minister of Health, Prof. Isaac Folorunsho Adewole said that the sum of N351 billion had been expended on health management organisations (HMOs) so far without commensurate result.
Drugs insecurity, abuse, misuse, fake and substandard medicine
Ohuabunwa said though, the incidence of substandard and falsified products have reduced, it is still at an unacceptable rate as the whole nation continues to allow drugs to be sold in open markets and by unqualified personnel.Sheikh stressed that the scourge of substance abuse is threatening the collective survival of Nigeria, as the most vulnerable remain the youths, who are the future of the country.
Mental health and suicide rate
Sheikh who gave his qualitative assessment of the Nigerian healthcare, described the system is “very weak” in all aspects, as it has not been able to effectively bring to the fore the health needs of Nigerians based on categorical needs, noting that the 2019 performance of the sector is “very poor”.He added that it has also not been able to develop effective coordination strategies for the implementation of universal access to comprehensive healthcare for Nigerians, specifically, in the area of mental health care service provision and mental wellbeing of Nigerians.
Sheikh said the performance of the health sector in the area of mental health is very poor, as the Association of Psychiatrists in Nigeria (APN) has been advocating the need to address youth mental health challenges in this country, as the government has not been able to respond effectively.
He said these challenges have been depicted by the continuous rise in the trends of suicide rates among Nigerians, especially amongst the youths.
Inability to implement policies and pass health bills
Oludare said health policies in Nigeria have undergone tremendous evolution since the country got its independence, but without the desirable quality of healthcare delivery system in place to advance the health status of Nigerians. He said while successive governments have made frantic efforts to promote health equity and ensure unrestrained access to health services, majority of the citizens are still grappling with various health challenges.
“Although some federal health institutions are taking responsibilities to improve the image of healthcare system by formulating policies provision of structural facilities, which are comparable to what is obtained in developed world. There are still the challenge of limited sophisticated resources to serve teaming population,” he said.
Sheikh lamented: “We lack a National suicide response strategy for our citizens, not only that we are unable to provide humane and compassionate approach to care for suicidal persons; suicide remains criminalised in the country. “APN collaborated with other stakeholders and participated in the first National Suicide Prevention Conference in Nigeria, it was followed by communiqué and recommendations but nothing has happened terms of National response.“Despite the setting up of Presidential Advisory Committee on Drug Abuse, the trend of mental health and related disorders emanating from use of psychoactive substances is still on the increase.
“We have not been able to develop programs that will address maternal and child mental health promotion, illness prevention and treatment for the country; neither do we have well articulated school mental health programs.“We have not been able to effectively implement integration of mental health care into all levels of health care delivery system, especially primary health care service. This integration is expected to enhance access to humane and compassionate mental health care service to Nigerians, address stigma, promote strategies for mental well being promotion and mental illness prevention.“Finally, the National Assembly is processing the mental health and substance abuse bill; the lack of passage of the bill in 2019 also represents low scoring for mental health performance in 2019.
Makinde lamented that there was relative stability across board pertaining to industrial disharmony. Olajide on his part, said consequently, industrial disharmony among health workers is causing huge socio-economic loss to Nigeria.He said: “ Strike is one of the banes of our healthcare system. It is one of the issues that discourage investors. For example, if you are a private sector investor and you invest millions of naira in an hospital, which has been on strike for eight months in a year, how would you be expecting return on your investment?
“But fortunately the thing is not that prominent now and I think people are now realising that this is our system and we need to be careful of the way we down tool. It is not everything you just down tool. See how it is done elsewhere. Before they go on strike they must have been pushed to the wall, they must have made agitations to the authority, interventions here and there; strike will not be the last resort.
“That is what the World Health Organisation expects, it is not every little thing, and you just down tool. This is our health system and if we destroy it, we are the ones that will suffer from it. We need to show some empathy, we need to change our attitude and government need to support the health force in terms of financing infrastructure and training of personnel among others.”
Slow achievement of Universal Health Coverage
Makinde said Nigeria is slow in its effort to achieving universal health coverage, adding: “We can do better with regards to universal health coverage. This will impact not just Nigerian patients, but also the health care providers positively.”Poor utilisation of Public Private Partnership Idah said there is actually need for the government to involve more private participation, adding that a survey round Nigeria, shows that lots of hospitals are still lacking in equipment, and basic things such as consumables that are far-fetched.
Olajide said government cannot fund the health sector alone, but requires the private sector injection of funds into the system, which has not been implemented in all the healthcare facilities, adding that if the country embrace public private partnership, and is well managed, definitely it is going to have improved infrastructures.“We have ultramodern cancer centre here in LUTH that is public private partnership, the radiology centre is an aspect of PPP. These are facilities that government and hospital management cannot afford to provide, but when you pool in the resources of the private sector, with the expertise of the public sector, definitely you will be able to manage pooling resources to get all these equipment that we need and if properly managed, will definitely give us all the modern equipment that we need to work with. So our patients will not need to travel abroad for medical treatment or any other thing, because the expertise are here,” he said
Ohuabunwa said to improve the situation of health in the Nigeria, the Federal and State Governments must enforce Health insurance at all levels, noting that those who are poor, should receive support inform of subsidy.He said the Health Development Fund should be spent on equipping existing health facilities, “so we can focus on Primary and preventive healthcare nationally.”
The PSN president also stressed on massive employment and competitive compensation of health personnel to ensure that no health institution operates without adequate professional manpower . He urged the federal government to reintroduce the drug revolving fund schemes in all tertiary health institutions to assure continuous access of essential medicines, as well as pass all outstanding legislations, especially the Pharmacy Bill to help improve regulation and sanitise our drug distribution system.
Ohuabunwa further called on government to progress the plan to establish at least four centres of medical excellence in Nigeria to stem medical tourism and restore National prestige.Tomori said to improve the situation of healthcare in Nigeria; there is an urgent need to increase budgetary allocation to the health sector to deal effectively with filling the infrastructural gaps in our health institutions.He said the government must ensure that routine immunisation is accelerated and scaled up to protect the millions of new born and other Nigerian children from vaccine preventable diseases, as well as improve disease surveillance and laboratory diagnosis for rapid detection and confirmation of potential disease outbreaks.
The Professor of Virology further added that Nigeria must not continue to depend on foreign donors to provide basic healthcare for her citizens.“In particular, we must take the health of our children more seriously than hitherto. After all, when we are making the babies, we do not call on donors for assistance,” he stated.Idah on his part charged the government to improve on the budget, which will have a ripple effect on the quality of administration, service delivery in the hospitals, investigations and modalities for investigations. He said there is also need for the federal and state governments to initiate policies and walk the talk when it comes to balancing the rural-urban disparity.
“The way to go is for the National Primary Development Agency to ensure that in all the 774 local governments in Nigeria, there is at least a primary health centre that has a full complement of all primary healthcare components. That is the way to go and to ensure that there is adequate funding.“We must find a way of keeping the personnel we train with so much of our resources within the country so that they can contribute to the development of the health sector. Instead of training them at such exorbitant cost and then losing them to other climes/countries because of the better attractions there and as a result of the frustration they face back home in Nigeria,” he added.
Sheikh said: “There is an urgent need for the recruitment of mental health professionals into the healthcare structure at all levels of healthcare delivery service, as mental health is inseparable from physical health. “Adequate provision should be made for the training of all healthcare personnel on basic mental health and psychosocial skills for effective task sharing and task shifting generally and specifically.
“Mental health professionals should be routinely trained and retrained on strategies for effective mental health promotion, mental illness prevention activities and early recognition of mental health and psychosocial problems for comprehensive care and mitigation of disabilities.”Oludare said good health provision is one of the basic needs of individuals irrespective of their status in the society, while he charged the government to consider the issue of health as critical and fundamental.