Why government should restructure healthcare in Nigeria

Prof. Philip Chidi Njemanze MD (Hons.) is a medical doctor, clinical researcher in neuro-cardiology and neuroscience. He is the chairman of the International Institutes of Advanced Research and Training, Chidicon Medical and Diagnostic Center, Owerri, Imo State. He is an academician of the International Academy of Astronautics (IAA), the UNESCO body for space research. A former principal investigator of the National Aeronautic and Space Administration (NASA) and National Institutes of Health (NIH) of the United States in the project ‘the study of the brain in Space’ mandated by an Act of the United States Congress in the ‘Decade of the Brain’1990-2000. He spoke to IGHO AKEREGHA, Abuja Bureau Chief on the problems in the health sector and what needs to be done.

I would like to start by congratulating you on the recent publication where you led Nigerian medical researchers on malaria that reported a breakthrough and another international study you led that unveiled new secrets of brain function. These new milestones underscore the growing influence of Nigerian medical research. Can you comment on these breakthroughs before we proceed?
I thank you for this opportunity to speak to The Guardian on the healthcare system. Nigeria is the most innovative country in the World but we either don’t write about it and when we write, we do not announce it to the World. This must now change. Our finding on malaria published in Journal of Environmental Neuroscience and Biomedicine (JENB) was as a result of a multi-center study over a decade to use satellite remote-sensing and geographic information system technologies on a risk analysis plate form to identify mosquito breeding sites and perform the risk analysis associated with the disease prevalence. Also we were able to find measures to mitigate against these risks. It showed that rain water harvesting in land streams was contributing immensely to malaria disease prevalence and elimination of such land streams with availability of potable water could greatly reduce malaria disease prevalence rates. We studied the pattern of the malaria prevalence peaks and concluded that provision of free anti-malarial drugs to be taken four times a year by everybody in Nigeria at the same time (four national malaria days) could eradicate malaria within two years. As a result of taking the drug at the same time, no one has the malaria parasite in blood and biting of mosquito would not result to any disease. At 120-days (3 months) intervals the red blood cells are naturally exchanged and would be treated. This we hope could be a Presidential Initiative for expanded Roll-Back Malaria to achieve a simultaneous synchronous eradication of the malaria parasite from human hosts. This could save Nigeria $1 billion USD per year and reduce infant mortality by at least 30%, and maternal mortality by 11%.

The work we did with our German counterparts published in the United States in the journal PLOS One in July edition 2017, used positron emission tomography (PET) and magnetic resonance imaging (MRI) combined (PET/MRI) scan to study the brain of mice, we showed that colour was visualized with the left brain in male and right brain in female mice, which was the opposite of what we found a decade earlier in humans. This new work and our previous findings were major breakthroughs that revealed how the brain processes colours, faces and general intelligence, established here in Nigeria for the first time in literature.

Despite these successes in individual institutions, would it be fair to say that we face a real systemic crisis in the health sector in Nigeria?
You are correct to say that, the problem in the Nigerian Health Sector is that of a systemic failure, maybe because there is no real system at the present time. All healthcare systems are designed to stand on a Tripod that is: the Preventive arm, the Research arm and the Curative arm. The Preventive arm serves to prevent diseases. A Surgeon-General heads it.  The idea of a Surgeon-General was first conceived by the United States in 1798 as an advisory office for public health. The Surgeon-General acts as the Chief Spokesperson on health related issues nationwide. The office assists in various fronts in disease prevention and outbreak of epidemics. In Nigeria, in the first republic, Sir Samuel Layinka Ayodeji Manuwa, CMG, OBE (1903–1976) was a pioneering Nigerian Surgeon, Inspector General of Medical Services and former Chief Medical Adviser to the Federal Government of Nigeria. The Surgeon-General tells us simple common sense things that prevents deadly diseases such as ‘Smoking Kills’, or “Eating too much of crayfish can clot your blood and cause deep vein thrombosis orstrokes; “Eating Kanda could clog your arteries and cause heart attacks and strokes”; “Hand washing prevents infections”. These common sense things if pronounced by the Surgeon-General resonate across the country to prevent diseases in millions of people.

But we do not have a Surgeon-General now, however I am aware that there was some understanding that the Federal Government is considering the establishment of such an office.

The issue does not really end with appointing and announcing someone as the Surgeon-General of Nigeria. It is a whole structure at the Federal, State and Local Government levels. We need to equip and upgrade the research at the Nigerian Centers for Disease Control (NCDC) and set up similar disease surveillance and control at State and Local Government levels. Our work here in Nigeria, has introduced a new tool for disease prevention for the first time in literature, a new possibility to use Satellite Remote Sensing and Geographic Information System Technologies for Vector Borne Disease Surveillance and Control. The Office of the Surgeon-General is important and needs to be one of the issues of Constitutional Amendment since health is on the concurrent list at Federal and State levels and more importantly because the pronouncements of the office are legally binding. It must be free of political interference and protected by enabling laws.

What is your understanding of the Research arm of the Health Sector?
The Research arm would provide research into health problems faced by the citizens of Nigeria. It should have at least five institutes in its network that research into the five body systems namely: Mental Diseases, Cardiovascular Diseases, Musculo-skeletal diseases, digestive diseases, and diseases of the urogenital system. The other broad categories are communicable and non-communicable diseases for each system in childhood, adults and old-age. There are a host of other more focused institutes within the network. Hence the institutes perform intra-mural research within their own institutes and coordinate review of extramural research done through contracts with public and private universities and research institutes outside. We cannot as a nation rely on research done in other countries for our own data because the population and environmental conditions differ greatly. For example, the commonly used Human Papilloma Virus (HPV) vaccines which work for prevention of cancer in White women does not work in Black womenbecause we have different types of the virus.  The research institutes would use a network of peer-reviewers in Nigeria and outside Nigeria to examine objectively the validity of the scientific postulations to be tested in a proposal for research. The problems studied must be relevant to national interests or problems that we may face in the future. The National Science Foundation (NSF) would be a counterpart funding agency for research in biological and physical sciences that also greatly helps development. We can start this research endeavors with a budget of about a hundred billion naira (N100 billion). The leadership must be guided by the quest for evidence-based medical research and would be made free of political interferences.

Nigeria has a curative arm but it is not functioning as it is now. Many fault the doctors, as not having group practices, how true is this?
I don’t agree, rather I would say that the doctors do have group practices. When you go to your doctor and he says you need an X-ray and writes you a referral letter to another doctor a radiologist, this means that the two doctors are seeing you and making a diagnosis on your illness. Group practice does not need to be in the same building or even the same place. It saves costs and spreads outreach if medical practices are disseminated. The experience in Western countries has shown that centralization of care in large hospitals may not also work in the interest to the patient. We say in Igbo that a goat owned by many dies of lack of food. Care can be very impersonal in large hospitals. Moreover, a patient goes to a doctor not to the hospital! The problem in the Curative arm is beyond what the doctors can control. For example, the problem of fake and adulterated drugs being sold in the market. This you could be solved with the proposed Prescription Rights Act which we have long advocated as private doctors. What this means is that, only the doctor can issue a prescription in Nigeria as in other countries of the World, and that prescription can be filled by a trained pharmacist or dispense rout side or in the hospital setting.  This would allow us to track fake drugs from the prescription through the dispensing of the drug to its place of manufacture. The work by NAFDAC has been very helpful but it is at the tail-end of the process in most cases the harm is already done. What NAFDAC needs is that doctors effectively prevent the patient from getting the ‘fake drug’ in the first place. If it happens that they missed, it could still be traced to the source through the pharmacovigilance network. Doctors and pharmacists could work very closely to achieve this system of Prescription Rights.

Many patients complain that the aesthetics of the hospital environment in Nigeria is nothing to write home about?
I don’t quite agree, many of our hospitals are looking much better today than they did 10 years ago. Remember where we are coming from. Our people received healthcare from village native doctors in bushes and they still do patronize them to this day. I think the issue is effectiveness of personalized care. More importantly, modern Western healthcare service is very detached from the human sympathy that is most needed by the person who is sick. This scares people and makes it seem as if the care in impersonal. We really do have a problem there but it is not peculiar to Nigeria. Even when we build 5-star hotels as hospitals, it would do little to change the poor health indices.

What then accounts for the high infant/child mortality rate and maternal mortality rate (MMR)?
Both indices are complex but provide a reflection of the general state of the health care system and the level of socio-economic development. For example, in our study, we noted that in 2005 when the power problem developed there was significant reduction in power output to supply electric motorized water pumps at city surface water sources that provide potable water. The infant and child mortality rose significantly nationwide. This was due to increase in rain water harvesting that increased the mosquito breeding sites that caused higher incidence of malaria and diarrheal diseases in infants and children. The high mortality rate could have been prevented by have solar-powered pumps with ultrafiltration to provide potable water. No amount of medication could have prevented the surge in infant mortality aside from potable water. The maternal mortality rate is even more complex. It was have been shown for example in Chile, where maternal mortality is much better than in the United States, that education of women was the most important factor in reducing maternal mortality. Women need more information about pregnancy and the necessary precautions they need to take during pregnancy. Here in Nigeria, in a study I led that surveyed over three decades the institutional impact factor of published research works in Nigeria, it demonstrated that the institutional impact factor was inversely proportional to the maternal mortality rate. In other words, the better the level of research in an institution as an index of better preparedness of the medical personnel the lower the maternal mortality in that institution. This goes to reinforce the need for a Research arm of the health sector in Nigeria that would encourage research in both government and private health institutions. Unfortunately, maternal mortality is much higher in public institutions than in the private sector as we found out in our survey.  The issues of access to healthcare both transportation and financial costs play a major role in MMR.

What in your view are the problems of the National Health Insurance Scheme (NHIS), and why is this scheme grossly underperforming, how do we improve on it?
The problem with the NHIS is improper conceptualization. What social system engineers in Nigeria must understand is that the most effective system is hierarchical with total subsidiarity. This is what is called for in restructuring that maintains unity of purpose and autonomy. What this means is that, you have a central chain of command to establish the main rules by law working for a common purpose but total autonomy of the various components for practical execution. The NHIS should be a regulating body to accredit and adjudicate between the major players that would include the healthcare providers, health management organizations (HMOs), insurance companies and private associations. There should not have been a monopoly of only registered HMOs. Any group of people could provide health insurance for its members to the measure they all deem fit without going through the HMOs. All they need to do is to register with NHIS at minimal cost to function all over the federation or register with the State Health Insurance Scheme (SHIS).  Breaking the monopoly of the ‘cabal’ that formed would not only reduce costs caused by ‘middleman syndrome’ it would also make for greater competitiveness. For example, churches may decide to establish their own health fund and run it by themselves without an HMO. The NHIS registration makes them credible to tender their identification cards that must be honoured by healthcare providers anywhere in Nigeria and obligates them to pay for health services rendered. This would spread the use of health insurance to every citizen in Nigeria within a short time. To legislate by law that health insurance must be compulsory though possible but may do little to change the present attitude towards it. There is need for a rethinking of the overall structure.

I would not end this interview without asking you about President Buhari’s health and why is there so much conversation about medical tourism?
I join other Nigerians to give thanks to God for the safe return of President Buhari in good health. It was a moment of joy and reflection of the great gift of good health given to us by God and what that means for us as a nation to have our President back in good health. However, even though it may not apply in the case of the President because of his ailment, the cases of illness by leaders could be used in a very effective way to stop the tide of medical tourism. Could you imagine if you see regularly the President and governors walk into Nigerian government or private hospitals to receive medical attention that is televised across the nation? The message to the people is that, it is okay to go to Nigerian hospitals. I would challenge anybody anywhere in the world that Nigerian doctors, nurses and pharmacists are the best in the World, even in London, most Nigerians who travel on medical tourism go to see Nigerian doctors abroad. Many talk about diagnostic possibilities; today Nigeria has a full range of diagnostic modalitiesthat cover at least 80%-90% of the usually required medical indications. There are lapses as they are elsewhere in the world. When I was in the United States you could only learn of medical mistakes from reading court proceedings. In Nigeria, you will see medical errors as headline news. Remember, that most prominent Nigerians that died had their diagnosis correctly established in Nigerian hospitals before they travelled overseas but were callously disregarded by their foreign doctors. It is unfortunate to have these medical errors occur, but it is not in the national interest to publicize them. This is because it scares people away from obtaining needed care in Nigeria, and does nothing to correct the errors in the first place. It does not make sense for a Nigerian who lives in Nigeria to have his doctor in the United States, England or India. If he should suffer a heart attack the best hospital for him is the one five minutes away where he can get prompt emergency attention. The hospitals abroad are practically useless for him at the time he needs medical care the most. There must be a concerted effort to develop homegrown facilities here in Nigeria.