58 years of poor health services, outcomes
*Tracking promises made by FG to develop sector three years after
Nigeria, on Monday October 1, 2018, marked her 58th Independence anniversary. While the country keeps increasing in population size, with an estimated growth of over 180 million people, which positions Nigeria as the most populous black country and giant of Africa, with massive foreign investments, the health sector, which should cater for the health needs of the population remains in shambles.
According to the provision of the country’s constitution, Section 17(3d), “The state shall direct its policy towards ensuring that; there are adequate medical and health facilities of all persons.” Unfortunately, this is not the case in Nigeria as she has faced several shortcomings in the management of its health system over decades resulting in repeated reforms of the sector. Also, the reforms in the sector have not significantly impacted the health status of the over 180 million residents, with the life expectancy at birth still low.
Nigeria is a political federation with 36 states and multi-ethnic groups. Its health system has been evolving in the last 58 years but remains weak, inequitable and dysfunctional. The problems of its poor health care delivery are often associated with poor policy formulation and implementation, which are attributed to factors like mismanagement of human and material resources, indiscipline, lack of the political will by the government of the country beginning from the regime that took over from the British at independence (1960) up to the present-day Nigeria.
Experts state that rather than tackle health problems in the society headlong, the country’s policy makers or the political class has appeared to sacrifice good health care at the altar of self-acquisition of personal wealth.Other challenges include, poor infrastructure, inadequate medical facilities, equipment, corruption, high mortality rate, inadequate welfare packages for health workers, and inhumane attitude towards patients, brain drain, and lack of funding among others.
The Guardian chronicles the issues that have bedeviled Nigeria’s healthcare system, despite several and continuous promises by the federal government towards improving healthcare delivery in the country.
Poor budgetary allocation for health
The present administration had promised to increase budgetary allocation to the health sector from about three per cent to 15 per cent. But three and half years after, the budgetary allocation to health has been between 3.7 per cent and five per cent.The Programme Officer at Centre for Social Justice, Abuja, Martins Eke, said health financing in Nigeria has been a major challenge in the sector.He explained that the allocation to the Federal Ministry of Health in the 2018 appropriation bill is N340.456 billion, out of the total budget of N8.612 trillion.
This, he said, represents 3.95 per cent of the total budget, which 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.He stressed that even if all the health-related expenses in the 2018 appropriation bill across all the federal Ministries, Departments and Agencies (MDAs) are added, they come up to 4.92 per cent of the total budget. He added that majority of the expenditure on health by the Federal Government goes to teaching hospitals, specialised hospitals, and federal medical centres, noting that more worrisome is the refusal of the government to provide the one per cent Consolidated Revenue Fund for the Basic Health Care Provision Fund, despite the signing of the National Health Act into Law since 2014.
President of Pharmaceutical Society of Nigeria (PSN), Ahmed Yakasai, decried the state of the health sector, saying the “situation is still terrible”.Speaking on his assessment of the sector as Nigeria marks Independence in an interview with journalists in Lagos, Yakasai said the health sector is in dire need of funding. Yakasai said the government still foot-drags on the one per cent health allocation from the consolidated revenue fund even as the National Health Act is yet to be implemented.
The pharmacist said: “The health sector is in dire need of funding. The budget of 3.9 per cent cannot take us to anywhere. We used to have five per cent, which was still not adequate.“We are asking for 15 per cent. If we cannot get 15 per cent, it should go up. Again, we don’t know where the Federal Government is as at now as far as the one per cent consolidated revenue allocation that is supposed to be accrued to the health care sector and then the implementation of the National Health Act.“If they can implement, it would help somehow midway to be able to run the health care sector appropriately. But as it is now the sector is in a very bad shape.”
Also the President, Nigeria Medical Association (NMA) Dr. Francis Fajuyile lamented that government is giving less attention to healthcare. “We have a myriad of problems affecting us as medical practitioners, the first one is about funding. We need the government to fund health more appropriately and the funding has a lot to do with the equipment that we need to have in the hospitals,” he said.
Fajuyile also decried the poor state of most hospitals in the country and urged the governments at all levels to see to its improvement.“We need to have a good working environment for the doctors and the patients to be seen and be treated properly.“It is in this funding that you can employ the adequate number of personnel. Migration of doctors has been fingered that funding of health is one of the major reason why many of our people are leaving the shores of this country.”
Mr. President also promised to boost the local manufacturing of pharmaceuticals and make non-adulterated drugs readily available.Quackery, bad economy and high cost of production are major problems Nigeria’s pharmaceuticals are still facing today. Inability of the government to effectively checkmate and prosecute quacks in the pharmaceuticals has led to the proliferation of adulterated and illicit drugs.Nigeria’s porous borders and the underhand activities of some customs and immigration officers have led to the importation of harmful drugs that have wrecked the health of Nigerians.
The bodies of pharmacy in the country had applauded the government’s stance on the closure of the open drug market and the implementation of the National Drug Distribution guideline, on December 31, but the Yakasai, said there are indications that the government will fail to fulfill its promises.Also, plans to start local production of vaccines by establishing a company, Biovaccines, is yet to materialize. The company is yet to begin production.
Promise to provide drugs for 50,000 additional people living with HIV each year
The Buhari-led Federal Government had September 2017 at the sidelines of the United Nations General Assembly (UNGA) in New York, United States (U.S.), promised to provide antiretrovials for 50,000 additional people living with HIV each year. But one year after, about one million Persons Living With HIV/AIDS in Nigeria (PLWHAN) on the not so free national treatment programme are still struggling to get their drugs. They told The Guardian that they are still paying for some tests and the drugs are not always readily available.
The Guardian investigation revealed that over 90 per cent of monies for HIV/AIDS treatment in Nigeria are from donors especially the US and that the FG’s contribution is less than 10 per cent.
Growing inter-professional disharmony
Available evidence suggests that unlike in the developed world, healthcare professionals do not collaborate well in Nigeria because of the claim of superiority of a particular health professional over others. This has often resulted in inter-professional conflict, which is threatening to tear the health sector apart at the detriment of the patients.A vivid example is the lingering conflict between physicians (medical doctors) and other health workers under the aegis of the Joint Sector Health Unions (JOHESU).
To address this issue the Federal Government had set up a Presidential Committee on Industrial Harmony in the Health Sector; and the Ministerial Committee on the Review of the Residency Programme in Nigeria.Despite efforts of successive governments to address the menace of inter-professional disharmony in the country, the situation is not getting any better.
In fact, health workers under the aegis of the Health Sector Union (JOHESU) and Assembly of Healthcare Professional Association (AHPA) have described the Presidential Committee of Experts on Professional Relationships in the Public Health Sector (YAPCEPRPH) report as “biased, one-sided and out of line.Also, doctors under the umbrella of the Nigerian Medical Association (NMA) have rejected some recommendations of the Yayale Ahmed Committee.
Doctors kick against FG’s policies
Doctors under the aegis of NMA have blamed the President Muhammadu Buhari led Federal Government for the poor performance of the sector.President of NMA, Dr. Francis Adedayo Faduyile, in a message to mark the country’s Independence Day celebration, called for paradigm shift on the health of all Nigerians as the nation marks her 58th independence anniversary. Faduyile said: “It is worth noting that 58 years after we became independent, Nigeria has not made an impressive mark, which accounts for its low ranking in the global human development and health indices…”
The doctors particularly blamed the FG for the failure to fully implement the National Health Act 2014, which they believe will guarantee Nigerians Universal Health Coverage (UHC). “It is important to reiterate that Universal Health Coverage shall not only increase access to health care delivery but also make it affordable through the National Health Insurance Scheme (NHIS) with the Community Based Health Insurance Scheme (CBSHIP) as an integral component and will be complemented by the Basic Healthcare Provision fund and other sources of fund from luxury items and ‘sin’ taxes,” Faduyile said.
He said the Association in her recent visit to President Muhammadu Buhari restated the urgent need for the Government to release the white paper of the Alhaji Mahmud Yayale Ahmed-led Committee on Inter-Professional Relationships in the Public Health Sector and to speedily commence the implementation of its recommendations as a way to arrest the tide of disharmony in the health sector. “We are confident of the pedigree and track records of the Committee members, and the thoroughness of their activities strongly suggest that they would not have misdirected the nation,” he said.
The doctors regretted that despite the expiration of NMA’s ultimatum to the FG to reconstitute the Council of the Medical and Dental Council of Nigeria (MDCN), which elapsed on the 30th September 2018, the Association has extended it by two weeks, in good faith. This, he said, “is to allow government to complete the process of its reconstitution, which we believe has reached an advanced stage. However, we will not accept any further delay beyond 14th October 2018.”
Faduyile said the dissolution of the MDCN has caused a lot of damages to medical practice in the country. He said the colossal damage brought about by the absence of the regulatory body is almost irreversible. “Nigeria perhaps could be the only country that allows the practice of medicine to go on without regulation, even for one day,” he said. The NMA further called on Mr. President to direct that henceforth, the MDCN should never be dissolved, to safeguard the health of all Nigerians.
Maternal and infant mortality
Buhari had pledged to prioritise the reduction of infant mortality rate substantially to the levels acceptable by the WHO. Though, pregnant women and children under five years are seen as the only beneficiaries of free health policy in states like Niger, Kano and Kaduna, among other northern states, the mortality rate continues to increase with Nigeria being the second country with the highest maternal mortality rate globally, according to WHO.This can be seen as compares with the data of the 2013 report, which ranged between 100-150 per 1000 live births, states in the northern region of Nigeria experience a much higher rate of under five mortality, which was 100-250 per 1000 live births, compared with those in the southern region, which was 50-100 per 1000 live births. While the maternal mortality ratio for Nigeria remains quite high at 814 per 100, 000 live births according to 2016 World Health Statistics.
Although, the Minister of Health, Prof. Isaac Adewole in 2016 announced the Federal Government’s plan to provide free health services to 100 million Nigerians in the next two years. Under this new health agenda, pregnant women across Nigeria are expected to enjoy free maternal and delivery services at the primary health care (PHC) level.Is the provision of antenatal care for pregnant women, healthcare for babies and children up to school going age and for the aged in government hospitals really free? The least that could be done is to reduce medical fees for pregnant women, children and the elderly. In fact, there had been cases where some pregnant women, after delivery, were not discharged because they could not afford the bills.
Thousands still die on the daily basis in government hospitals, including children and the elderly, because they could not afford medical bills.According to Nigeria Demographic Health Survey (NDHS) in 2013, over 60 per cent of pregnant women aged 15-49 delivered their babies at home without any antenatal care visits. The President, Society of Gynaecology and Obstetrics of Nigeria (SOGON), Prof. Oluwarotimi Akinola, said these increase in maternal and infant mortality is due to lack of facilities and low human capital
“We know that in Nigeria, only about 38 per cent of people who deliver get skilled birth attendant, which means that the rest of the women either deliver at home or in areas where there is nobody who can take care of them when complications arise and so they die,” he stressed.Giving further statistics, Akinola who is also a Medical Consultant and Lecturer at the Lagos State University Teaching Hospital, (LASUTH), as well as the led team of the Federal Government initiative on Stop Maternal Mortality nationwide said: “Nigeria right now has the worst maternal mortality in the whole world, in 2008 the ratio was 545:100, 000, in 2013 it was 576:100, 000 maternal mortality and now we are talking about 576 per 100, 000.”Several initiatives had been put in place by the federal government to reduce the death burden in the country, such as the Save One Million Lives (SOML) and the Accelerated Maternal Mortality Reduction, yet the number of deaths recorded keeps increasing.
Poor health facilities and equipment
Mr. President had also pledged to increase the quality of all federal owned hospitals to world class standard and refurbish 10,000 Primary Health Care (PHC) centres by 2019. Visiting the federal-owned hospitals and witnessing the state of services rendered there is nothing to write home about. The hospitals lack equipment, some available is obsolete and no longer in use. This puts the lives of Nigerians in jeopardy.The President’s wife, Aisha Buhari had shocked Nigerians when she said the X-ray machine in the State House Clinic that caters for the health needs of the presidency was not functioning. Furthermore, the President promised to invest in cutting edge technology such as Tele-medicine in all major health centres in the country through partnership programmes with communities and privates sector.Whereas, cutting-edge and telemedicine in Nigeria’s government hospitals are nothing but a mirage.
Meanwhile, the current structures where local governments are responsible for primary health facilities, state governments responsible for secondary health facilities, and the federal government responsible for tertiary health facilities is not achieving its desired goals.Also, the FG is yet to refurbish 10,000 PHCs nationwide as promised. Latest figures from the Minister of Health, Prof. Isaac Adewole, and Executive Director, National Primary Health Care Development Agency (NPHCDA), Dr. Faisal Shuaib, indicate that only about half of the centres have been refurbished.
Increased brain drain
Buhari also promised to increase the number of physicians from 19 per 1000 population to 50 per 1000 through deliberate medication education as epitomised in nations such as Ghana.Practically nothing has improved in this regard. In fact, due to the ailing economy and hardship in the country and the dilapidated healthcare infrastructure, a lot of medical personnel are leaving the country in their numbers to other countries where better pay and job security are guaranteed.Also, the proposed increment of the national health expenditure per person per annum from N10,000 as it was before May 28 2015, to N50,000, as the President promised, is a far cry from today’s reality.
Unending medial tourism
Mr. President had also promised to ban medical tourism by politicians. It was estimated that Nigerians spent $1bn (£690m) on foreign medical trips in 2013, which is still probably the case today and it is disheartening that the president and his household are encouraging this act with their frequently medical trips abroad.
Corruption in NHIS.When the Obasanjo administration introduced the National Health Insurance Scheme (NHIS) in 2005, many appraised it as the solution to failing health care system in Nigeria. However, 14 years down the line, it had only covered four per cent of the entire population.
Poor people constitutes about 70 per cent of the Nigerian population and lack access to basic health services, which social and financial risk protection should provide, because they cannot afford it, but Minister of Health, Prof. Isaac Adewole said the N351 billion spent on health management organisations (HMOs) did not yield any great result. With a daily mortality rate of 814 deaths, Nigeria still records over 292,000 annual deaths.
Meanwhile, the United Nation have 17 Sustainable Development Goals of which number three is to “ensure healthy lives and promote well being for all at all ages and the Nigerian constitution Section 14(b) states that “The security and welfare of the people shall be the primary purpose of government’.However, experts have proposed that political actors, policy makers and all stakeholders in the health sector should establish a government funded social and financial risk protection scheme through a general tax financing system for the poor and vulnerable, and invest in basic infrastructure for health care in rural areas for quality health care service delivery.
They noted that the Universal Health Coverage (UHC) schemes are important in addressing the problem of poor coverage, limited access to health care, and poor quality of health care services.They further noted that although the National Health Act (NHA) that was signed into law in 2014 stated that all Nigerians are entitled to basic minimum package of health care services, it is not clear if the provisions made in the NHA are capable of achieving UHC in Nigeria, adding that the NHA is yet to be implemented over three years after its signage into law.