Health reforms: Knocks, Kudos trail Osinbajo committee

• Committee Came At Right Time, Should Work Fast, Say Ihekweazu, NARD President
• Nigeria Has Good Health Laws, Policies, Problem Is Poor Implementation, Says Idris
• ‘Govt Sincerity In Doubt’ • Osibogun, Adeyanju, Ojo, Others Chart Way Forward

Although stakeholders see the current move by the Federal Government to reform the country’s health sector towards optimal delivery as a step in the right direction, they fear that the outcome of the exercise might be left to gather dusts in the archives.

According to many health professionals who spoke with The Guardian, the nation’s health sector ought to be better placed if the various Acts of parliament governing the sector, especially the National Health Act 2014 and the Yayale Ahmed Inter-professional Health Committee Report were being properly implemented.

President Muhammadu Buhari had, last Monday, set up a Health Sector Reform Committee charged with the development and implementation of a Health Sector Reform programme for Nigeria.

The committee, to be chaired by Vice-President Yemi Osinbajo, would also work in collaboration with state governments and the FCT administration.

Senior Special Assistant to the President on Media and Publicity, Malam Garba Shehu, who confirmed the development in a statement, had added that the committee, set up for a period of six months, had members drawn from the private and public sector, health care management professionals, development partners, representatives from the National Assembly, as well as the Nigeria Governors Forum, among others, adding that it would undertake a review of all healthcare reforms adopted in the past two decades and lessons learnt, and factor them into the development of the new health sector reform programme.

Speaking with The Guardian on the development, a former President of the Nigerian Medical Association (NMA), Dr. Omede Idris, said he received the news of the setting up of the committee with mixed feelings.

“Mixed feelings on the basis that in most instances in this country, committees are tactical and diplomatic ways of delaying a process or killing an idea. The idea in this instance is a better health care delivery in terms of training, research and service delivery to the people at an assessable and affordable manner. Most often, the outcome of the committee are not heard, or if heard are swept under the carpet, except for a few.

“Notably, the telecommunication and banking sector reforms stand out as fairly successful, which notably and originally were more private sector based. We are still battling with electricity sector reform that had more public orientation,” he said.

Idris argued that if the Federal Ministry of Health and its Department and Agencies had demonstrated practical and keen interest in leadership, governance, implementation, accountability, monitoring and evaluation of the National Health Act 2014 (NHAct2014), the Yayale Ahmed inter-professional Health Committee Report and many other similar reports, the nation’s health sector wouldn’t be in its current abysmal state.

“It is in the wake of such that there has been repeated calls for the full implementation and strict observance of the content of NHAct 2014, and many existing Acts of parliament and reports in the health sector as well as the avarice of some conflicting Acts of parliament on regulation of the health sector.

“If these were done, the nation wouldn’t need such committee at this moment in the name of reform. Until the system and institutions really and justifiably apply carrot and stick approach to leadership and governance, irrespective of who is involved or whose ox is gored, the sector wouldn’t be better placed. In which case, reform committee like this, would just be mere formalities.

“With the above background, it must be observed and unambiguously stated that in health, with the various Acts of parliament in place and operational, ranging from National Health, NPHCDA, Health Insurance, Medical and Dental regulatory and other health regulatory Acts, the nation ought to be better placed in health either in public or private sector. We are equally aware that some of these Acts and laws are undergoing amendment and or repeal in the National Assembly in line with changing times, dynamism of professionalism, governance, administration and politics, focusing on best approach to health issues. Obviously and frankly, the committee does not have right of enforcement over Acts of parliament or constitutional provisions.

“Nonetheless, we look forward to the inauguration of the Health Sector Reform Committee and its detailed and clear Terms of Reference (TOR). The inclusion of Bureau of Public Enterprise gives an insight into the possible direction of the committee, that is privatisation. We need to tread carefully on this path, but rather government looks to enacting a law for Health infrastructure bank whose application will further enhance the efficiency, effectiveness, productivity and job satisfaction in the health sector.” 

However, to the outgoing Director General of the Nigeria Centre for Disease Control (NCDC), Dr. Chikwe Ihekweazu, the setting up of the committee was an indication of political commitment to ensure a stronger health sector and improved health indices for Nigerians.

He said: “The establishment of the committee comes at an important time in our history, as we respond to a pandemic globally, and other disease outbreaks in Nigeria. This has presented us with important lessons and moments for reflection.

“While we have recorded gains in our health security capabilities in the last five years, there is no doubt that the country will benefit from a stronger and better united public health system. The work of this committee will be very important in shaping this. Based on our experience at NCDC, we continue to advocate for improved investment, coordination and collaboration as well as strong leadership for health security at federal, state and local government levels.

“We are grateful that NCDC is part of this Committee, and remain committed to sharing our insights, expertise and experience for a stronger health sector.”

Also, a former Commissioner for Health in Ondo State, Dr. Dayo Adeyanju, welcomed the coming of the committee, saying Nigeria’s abysmal health indices was no longer news.

“The Maternal Mortality Ratio (MMR) of 576 deaths per 100,000 live births, recorded in the 2013 Nigeria Demographic and Health Survey, was even worse than the MMR of 545 in the 2008 survey although was a slight drop in 2018, which is 10 years after. The defective health system is further exposed by the COVID-19 pandemic, which underscores the need to strengthen the health system or deliberate reform.

“In finding reason for this unacceptable health indices, looking at the funding for health and efficient utilisation of the lean resources can provide answer. In terms of funding for health, a closer examination of Nigeria’s health budget reveals that the vast proportion of the funding, 86 per cent is taken by recurrent expenditure. There is a big disparity between the amount approved in the health budget and what is released. What is more is the efficient utilisation of the lean resources.

“In other to address the insufficient funding, PHC was made priority and the National Health Act, passed in 2014, contains legislative efforts to channel more funding to this most neglected part of the health system. Under the act, not less than one per cent of government revenue must be set-aside for a Basic Health Care Provision Fund (BHCPF). The act defines exactly how the fund is to be apportioned: half must be used to provide a basic minimum package of health services to citizens through the National Health Insurance Scheme (NHIS); 45 per cent must go toward PHC, equipment, facilities, and human resources, managed by the National Primary Health Care Development Agency (NPHCDA); and the remaining five per cent must be spent on emergency medical treatment. The first tranche of the fund was released by Federal Government to demonstrate its commitment about a year ago.

“However, beyond the funding challenge there were more challenges still bedeviling our health system. This includes human resources, infrastructural deficit and many more,” he said.

Adeyanju advised the committee to look at committing more resources to health, adding: “This will address not only the recurrent but also a capital expenditure of one functional PHC per ward; but more importantly a functional ward with portable water, sanitation and hygiene.

“They must look at how to promote accountability, probity, and transparency in the sector. This is critical to ensuring the efficient utilisation of the limited resources particularly with the economic meltdown. It will also be good to see the committee address the incessant health workers crisis that will ensure uninterrupted quality health care services to the good people of Nigeria. The committee should submit a report that will lead the country out of the deplorable health system and ensure the achievement of Universal Health Coverage.”

To the President of the National Association of Resident Doctors (NARD), Dr. Uyilawa Okhaeyesi, the task ahead for the committee was to end the decay in the health system, which hampers positive growth of the health of the citizens, curb emigration of health care workers and reduce brain drain while at it and reduce industrial disharmony.

He added: “There is a foundation already to look into the issues bedeviling the health system. In 2014, a similar committee headed by a former Head of Service, Ahmed Yayale, CFR, has laid a foundation, which should be used as a springboard.

“The committee should work fast using that as a framework and clearly define every health worker’s job description as it’s found in every clime.”

On his part, a former Director General of the Nigerian Institute for Pharmaceutical Research and Development, Abuja, Prof. Charles Wambebe, said the key to improving health services was in making primary health care available. “If we can invest in PHC, the benefits will be enormous,” he said.

For the DG/CEO, Delta State Contributory Health Commission, Ben Nkechika, the Nigeria Healthcare system does not just require reforms, it also requires a redesign and a reconfiguration that is innovative.

His words: “Health and its definition expectation has evolved and become more than walking into a healthcare facility to receive healthcare service. With the changing demographic structure, illness patterns and technology advancements in healthcare delivery, the countries healthcare system needs to be upgraded to current realities.

“An actual current status Situation Analysis of the entire spectrum of the Nigeria Healthcare system is an important start off point. It should not take a long time to accomplish. It will provide the foundation for the expected scale up reform through a purpose driven redesign and reconfiguration of the current healthcare service systems.

“The Health Reform through system redesign and reconfiguration should be domesticated to the counties peculiarities and should be fully dependent on the countries in-house capacity which is abundantly available.

“The Health Reform should be strategically innovative leveraging on prevailing challenges and past positive outcomes that have prevailed in the country. Most important will be how to achieve a “Reverse Healthcare Personnel Brain Drain” in which a Nigeria-trained healthcare personnel will look forward to graduating and staying back to work in a comfortable and rewarding healthcare service work space.

“The Heath Reform should give good focus to Primary Healthcare Service rejuvenation and revitalisation ensuring a basic infrastructure status, adequate human resource and direct financing as a baseline for the Primary Healthcare level of care. Gigantic healthcare service infrastructure should not be part of the current focus.”

A Consultant pharmacist and Medical Director of MeritHealthcare, Dr. Lolu Ojo, also said the setting up of the committee showed that the government was responsive and alive to its responsibilities.

“Our healthcare system is not working and nothing confirms this status more than the penchant of our leaders at different levels to rush abroad any time they need personal medical attention. We have one of the worst health indices in the world and certainly, our health sector is in need of urgent reform.

“Having the Vice President Yemi Osinbajo to head the committee is a pointer to the seriousness attached to the reform project and we need to thank the President and the government for this.

“The reform will involve a fundamental change of processes in policies and institutional arrangements of the health sector, which is usually guided by the government. It is important to note that the success of reforms will depend on how the process is applied, and by whom, rather than how the contents are formulated. This is where I am worried about the constituent of the committee with about 50 per cent of its population being Medical Doctors.

“Leadership is key to whatever success we desire for the health sector. Over the years, we have not been blessed with the right calibre of leadership that could propel the sector forward. Sadly, virtually all institutions are headed by physicians who lack a worldview in the management of human and materials resources. The reform should look critically at the leadership setting in the sector and institutionalise competence and skills, rather than sentiments, as the appropriate qualifications for appointing leaders.

“The reform should focus on the pharmaceutical sector for growth and development emphasis. Nigeria has a huge potential demand base, which makes our market attractive to the world. However, lack of focus and appropriate action has denied us the benefit of this potential. The reform should include having a Special Adviser (of cabinet rank) on Pharmaceutical Affairs to take charge of training, capacity development, regulation, research, manufacturing, procurement and distribution of pharmaceuticals in the country. We need to move away from the current state of development on foreign products and inputs.”

A public health consultant and former Chief Medical Director of Lagos University Teaching Hospital (LUTH), Prof. Akin Osibogun, said the critical issues to be resolved by the committee include defining an equitable and sustainable financing mechanism that leaves no citizen out; training and retaining quality health workforce; supporting a conducive work climate including health infrastructure, equipment and rational processes; prioritising health promotion and disease prevention strategies and promoting good governance including community co-management of health institutions, accountability and adherence to agreed rules and laws.