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‘With BHPF people do not have to pay for healthcare when they are in need’

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Minister of Health, Prof Isaac Adewole


*Nigeria has procured vaccines, deployed experts to contain another meningitis epidemic
*Country has reduced malaria burden from 42 to 27%, improved immunisation coverage by 12%
Prof. Isaac Adewole is the Minister of Health. Adewole in this exclusive interview with The Guardian unveils the Federal Government’s health plan for 2019 and what the ministry is doing to address major challenges faced by the sector especially poor access to affordable and quality care. CHUKWUMA MUANYA writes. Excerpts:

What is the health plan for 2019? What does President Muhammadu Buhari plan to do for health if re-elected?
Some things have dramatically changed. We are going to see new innovations. We are going to see Mr. President flagging off the Basic Healthcare Provision Fund (BHPF), which is unique. The BHPF is in the National Health Act (NHC) but the implementation is unique. The President actually signed the 2018 appropriation N55.1 billion for the BHPF. Minister of Finance has graciously approved 25 per cent of the money to kick-start the process.

But it has not been released?
No. It has been released to us. We have transferred it to the Central Bank account.

When? Yesterday?
No. Not yesterday. It was released about a week ago.

But I didn’t know?
How would you know? You wont know?

But the latest information about 48 hours ago is that it has not been released?
It has been released, 25 per cent of the money.

But there is a differential. In this new 2019 appropriation I heard it is about N50.1 billion less than that of 2018?
No. It is still N55.1 billion. And what is also different in 2019 is that government has also approved N22.8 billion for vaccine production because we signed a commitment to GAVI (global vaccine alliance) that over the next ten years Nigeria will gradually increase the funding allocation to vaccine administration by 10 per cent every year so that in 2028 Nigeria will take full responsibility for immunization of our children. So GAVI extended the transition period, which is normally five years. But for the first time taking into consideration of Mr. President, and the strong performance of the Federal Ministry of Health (FMoH) and our agencies, the National Primary Health Care Development Agency (NPHCDA), GAVI has graciously approved the extension that transition over a ten-year period. So we have N22.8 billion in 2019 for vaccine and N55.1 billion for BHPF.

Is it for just procurement of vaccines or for the local manufacture that the country is planning?
No the local manufacture is a Public Private Initiative (PPI). They have not started so we cannot put money in 2019 budget for them.

What are we going to see in 2019 in terms of reviving the health sector?
What you are going to see in 2019 is that we will now move money directly from central bank to primary health care (PHC) facility. Each PHC will get money for commodity, maintenance and for human resources. This is the first time it has ever happened in this country.

How was it funded before?
Nothing. They were left alone. They were orphans. That was why they collapsed. What we have done is to say we knew what happened in the past. In the past under Ibrahim Badamosi Babangida (IBB) and when Olikoye Ransome Kuti was the Minister of Health, PHC was revitalized across the country but there was no mechanism for keeping them alive. It was like you delivered a baby and you gave them the first food and there was nothing else to keep the baby going, and they collapsed. So two years ago we started with the concept of revitalizing the PHC. Although it is not our responsibility as the Federal Government (FG), it is the responsibility of the Local Government Area (LGA), but if don’t do it the health system will not take shape, people will rush to the teaching hospitals and everybody will complain, “We waited there for hours.” That is not where they were ought to go. So we are working in partnership with our partners, the state governments, to make sure that the PHC will be okay and that money will go to the PHCs. That will also be the incentive of getting the Governors to make sure that their PHCs are in order. In fact what we are saying if you look at the guideline, the states are supposed to contribute 25 per cent of the money but that money should be used to put their PHCs in good shape. Osun has started, they said they are going to do 332 PHCs in Osun and the Governor is personally taking charge. Kaduna has done 225 and the Governor is in-charge. So things are moving. Working with our partners we have done over 4,000. Many of the state governments are writing to us now that they are ready.

So that means you could not meet the target of 10,000 PHCs?
No. There was not such. The target of refurbishing 10,000 had no deadline. It was a vision. It was even at minimum. Osun has over 900 PHCs. We said no don’t go for 900 just make sure your 332 are working because it was a vision of one per political zone. It was a vision that if we can get 10,000 PHCs working, we can deliver basic health care to about 100 million Nigerians. What do we mean by basic care? When they are pregnant they can deliver and then we can also take care of their delivery even if it by operation it will be free. So delivery will become free for Nigerians. We treat them for malaria free. We give them malaria nets especially pregnant women and children. We will give vaccine free. We will give family planning free.

How can that be sustainable?
That is why the BHPF is there. We will also use that to build up the insurance scheme. We are going to say anybody that comes in they will be registered and we are saying the states should also start the state health insurance scheme. So we are going to use that opportunity the BHPF to ram up the provision of basic care to our people, we will use it to revitalize the National Health Insurance Scheme (NHIS) so that across the country people do not have to pay for health care when they are in need.

That brings us to the question of the NHIS. Since 2005 when President Olusegun Obasanjo launched it till now we don’t have more that four percent of Nigerians on the scheme. Also the scheme has been shrouded in a lot of controversies in recent times. What is the situation now? It is like we are going backwards?
No. I don’t think so. I just told you as at the last count, I think about 16 of the states have health insurance scheme. So we are working in partnership with the states and we are also working with the National Assembly particularly the Senate Committee on health. They are working on a bill that will make health insurance compulsory and universal.

But the National Assembly has been on that Bill for almost 10 years?
Well I am not aware of that. This administration has only been there for less than four years. What we have done in four years is remarkable.

May we know what you have done?
We started with the National Health Policy (NHP), the third in this country. We moved on to the National Health Strategic Plan (NHSP) where we calculated what it takes to move the NHP forward. We got the law on Nigeria Centre for Disease Control (NCDC) passed. We completed the laboratory in Gadua, Abuja so that we will not have problem with health emergencies. There is a functioning lab there and even the monkey pox we had we diagnosed it at the NCDC lab in Gadua, Abuja. We passed the law on the BPP, which was there for 16 years and nobody passed it. We secured extension on GAVI. We paid money passed to Global Fund for AIDS, TB and Malaria for the first time in several years. Nigeria made pledges but it was never paid. It is in our appropriation and it has been released that is $10 million.

My concern is that we are not where we should be on the issue of health insurance?
We recognize our limitations. But when it is compulsory and approved by the National Assembly then companies will have no option but to buy into the scheme.

How about the issue of leadership tussle at the NHIS? The main issue is that it is alleged that the Health Maintenance Organisations (HMOs) are corrupt and are not performing their duties. Also, the former Executive Secretary was accused of corrupt practices. What has gone in to sanitise the system?
I am sure that you are aware that Mr. President actually commissioned a fact-finding panel and that panel submitted its report on Monday. I gave the commitment that government will fully implement the recommendations of the fact-finding panel. As soon as it is studied and sorted out, things will happen.

Consistently, this government has not budgeted more than 4.15 per cent to health despite the Abuja Declaration in 2001 for 15 per cent of yearly national budget should be for health. Why? Generally the funding for health is very poor?
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, funding power and things that will benefit us. Our hospitals cannot function without power. So these are things that we need to factor in whatever we do. In addition, the BHPF has come in, extra money to health sector. The capital allocation to health has increased; initially from N32 billion we have got to N80 billion and N135 billion. When you add all these together you will see.

But the capital budget for health has gone down for 2019?
No. You need to add the BHPF of N55 billion. You need to add the N22.8 billion for immunization to the health budget. 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.

But are there plans to increase the budgetary allocation for health?
Yes! Mr. President actually said so that gradually we will focus on education and health- human capital- and you will begin to see changes.

So you are saying that by 2020 budget, if the administration remains in power, we will be talking about 7 per cent for health?
For 2019, what we have done is to put more money into vaccine and into BHPF. We are still working, disbursing $500 million for Save One Million Lives initiative. There is another $225 million for nutrition that was approved to us at the last National Executive Council meeting that is coming to health. People look only on budgetary allocation; they do not look at other money coming in. We are working on another $350 million for malaria, it is all coming to malaria, and it is all coming to health.

But another major issue is that of release of the funds for the programmes. Are there assurances?
Those monies are even with us; there is no issue of release. We have 100 per cent of the monies. The $225 million when it comes is with us fully. The $500 million is with us fully. When you even look at budgetary released for health, it is about 80 per cent. They have done better than many other sectors.

That brings us to the issue of the teaching hospitals. Most of them are ageing, dilapidated and most of the equipment is not working?
I am not aware of that. To be honest with you, I have visited quite a number of them. They are ageing, yes! Some like University Hospital Ibadan (UCH) where constructed about 60 years ago so that is ageing. But the fact you are ageing does not mean non functional. I was in India two weeks ago a hospital established in 1928 is still one of its best, the all Indian Institute of Medical Sciences about the same time as UCH. I think it is like wine, the older it is the better.

I am talking about the infrastructure?
Can you mention one or two that is ageing that you are worried about?

The Lagos University Teaching Hospital (LUTH), Idi-Araba is a typical example?
Oh! They are doing a remarkable job in LUTH. It now has a 24-hour plant; they are refurbishing structures in LUTH. Even the cancer centre is being refurbished.

That means they cannot offer those services now for months?
They decommissioned it to make it better. They are getting two high-energy machines- higher energy and low energy, which by January should be functioning.

But that is not captured in the 2019 budget?
The Sovereign Wealth Investment Fund (SWIF) is handling it. That is the thing. When you talk about money to health you are not capturing that. You should to health because Sovereign Wealth Investment Authority (SWIA) is investing in LUTH, Federal Medical Centre (FMC) Umuahia and Aminu Kano University Teaching Hospital (AKUTH) Kano. And by the time they finish in LUTH you will be shocked by the first class treatment centre that will be in LUTH in a couple of months. We need to commend this administration. Have you been to the National Hospital Abuja? Go and see the cancer centre there. Now that cancer centre can treat up to a 100 people a day. A second machine donated by Shell Nigeria Exploration and Production Company (SNEPCo) is there. Ultra modern and that will be the only centre may be in Africa that has two high-energy linear machine working. Visit LUTH, visit UCH, visit AKUTH where two bunkers are under construction in each and almost ready to also accommodate high-energy linear accelerators.

Almost every year Nigeria has crisis with Cerebro spinal meningitis (CSM). What is being done to contain the imminent outbreak?
We have mounted campaigns there have been campaigns not just with meningitis but Lassa fever. We are telling people that the season is coming. Certain things are seasonal. When the rains come there will be cholera. We are advising people to be careful. The NCDC is one agency that now well positioned. We have repositioned vaccines. We have repositioned drugs. We have trained people. We are deploying surveillance officers across the country.

Let me interrupt you Sir! The main issue the country had last year was lack of vaccine for the new subtype C that caused the epidemic. Do we have the vaccines now?
You see certain vaccines are not routinely available because you do not stockpile them. If you stockpile them and you do not use them it is a waste. So it is like the vaccine for Yellow fever, it is not freely available. It when you have an outbreak you then apply to WHO that there is an outbreak then they will verify and then give you the vaccine. The same thing for meningitis C, it is not freely available, limited quantity but we have procured some from some sources. But when you have an outbreak that far exceeds the vaccines you stocked then you have to shout for WHO to give you more and that was what happened. If you have too much of it, it will waste.

Another major issue is that of inter-professional disharmony. The doctors are being seen by the other professionals in the health sector as playing God. What are you doing to address this?
Let me say first that I am an apostle for inter and intra professional harmony. The health sector is actually meant and can only function when there is teamwork. Nobody can do it alone and that is what we are promoting. But occasionally we are about to have frictions even when you have identical twins they do fight. So we could have discord, we could have disharmony, we could have occasional fight but what we are saying is that this can be handled and I am happy that the Nigerian Medical Association (NMA) has taken some strong positions. They are meeting with other unions and we have recommended to the NMA that we are revising remuneration please carry everybody along so that we do it for everybody. We do not have to negotiate with doctors today, nurses tomorrow and technologists thereafter. We should just look at it holistically. Government has come out with some regulations to maintain professional harmony and industrial peace in the health sector and many other sectors and I believe that the implementation of the recommendations will go a long way to make sure that things remain peaceful in the health sector.

Nigeria is consistently being rated as having one of the worst health care indices especially on maternal and child mortality. Has anything changed?
The last time any health system was assessed was 2001 and so it worries me when even knowledgeable people cite the 2001 ranking of health system by WHO and since then WHO has never done any because many countries challenged that ranking. So they have never ranked any system since 2001 and number two the health indicators you are citing was done in 2013. We are currently doing one in 2018 and it is this one that we tell us exactly where we are. But I can tell you that we are improving in terms of maternal mortality. We are also being proactive in reducing maternal mortality. We are working actively in six of our worst states and we have developed a road map for reducing maternal mortality. We are also working to reduce under-five mortality. So things will change because you need to get things done properly. I can assure you that by the time we are revising our statistics you will notice a change. We have reduced malaria from 42 to 27 per cent. We have improved immunization coverage with about 12 per cent. So things are improving in spite of the constraints, in spite of the reduction in the fiscal space- fall in oil prices. We have shown commitment to health and we will begin to get results.


In this article:
BHPFIsaac Adewole
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