OUTSIDE THE BOX
By Alex Otti; firstname.lastname@example.org
“I would like to be realistic to say a few words concerning health delivery system in Nigeria. It is very poor, sorry to say that. I am happy that the MD of Aso Clinic (Dr. Manir) is here. There are lots of constructions going on in that hospital, but there is no single syringe there, what does that mean? Who will use the buildings?”
The above statement made by the President’s wife, was as honest as it was reassuring. Honest, because it was rendered in the no-holds-barred style, typical of Mrs Buhari, and exemplified in her berating of a few people she claimed had hijacked her husband’s presidency and her “Animal Farm” analogy. Though we are still awaiting the eviction of the Hyenas and the Jackals from the kingdom, four months after. She, indeed, hit the bull’s eye with that comment. Reassuring, because it provided some succor to the rest of us that the decay in the healthcare delivery system is not limited to lesser mortals like us. Similar to the soap opera of the yesteryears, it shows that “the rich also cry”. It is helpful because one can also understand why our healthcare delivery system has continued to fail. The First Lady squarely put the blame where it belonged: leadership.
Perhaps, the most important point the First Lady made which may not have been intentional was to provide answers to those of us who had been wondering why her husband had spent a lot of time in the UK on medical vacation. We are not oblivious of Buhari’s campaign promise of ending medical tourism in Nigeria if he became President. Over 2 years after, he has not only failed to end it, he has joined the train. Therefore, Mrs. Buhari’s outburst was very useful in helping us understand why the President preferred London hospitals to the one in Aso Rock. You can say what you want, but the point remains that if Aso Clinic does not have a syringe, it would be an act of suicide for the President to submit himself to that hospital for the treatment of an ostensibly very serious ailment.
It is sad that in most of our discourse, little or no attention is paid to healthcare delivery. Most people focus on the economy, the polity, ethnicity and religion. These may be important but we tend to ignore the more important issue of health. As a result, we keep dealing with avoidable deaths of our people. Life expectancy in Nigeria remains abysmally low at around 54.5years placing us as number 177 out of the 183 nations ranked by the World Health Organization (WHO) as at 2016. Meanwhile, average life expectancy in the world, according to the United Nations is 71.5 years as at the end of 2015. However, beyond the damage that poor healthcare delivery has done directly on the populace, is the vexed issue of capital flight that has been engendered by the rich seeking help elsewhere. Medical tourism has been estimated to cost the country over $1billion annually. This figure was provided by the Honourable Minister of State for Health, Dr. Osagie Ehanire at an event in Lagos recently. An investment of $1billion annually would eradicate the need to go elsewhere for medical attention. It is of concern that we spend a large chunk of our foreign exchange earnings on medical care abroad. Related to medical tourism is brain drain. Most of our best qualified healthcare professionals are found in foreign countries to where they migrate, in search of better conditions of work. It has been reported that there are over 3,000 Nigerian medical doctors in the UK and over 5,000 in the US. This is in addition to thousands of others spread elsewhere around the world. Meanwhile, according to the WHO, out of the country’s requirement of about 237,000 medical doctors, we only have about 35,000, leaving a gap of over 200,000. This is a very serious problem that should not be left to address itself as we have so far done. I shall return to this in due course.
The challenges of the healthcare sector can be discussed under four broad headings. There may be a few others that I may not be able to discuss in this column, but the idea is to bring this matter firmly into public consciousness and have many more people begin to interrogate ourselves with a view to finding solutions to the problems. I will now take the challenges in turn.
Just like other sectors like education, health care is grossly underfunded. This did not start today. However, the paucity of funds has assumed more frightening dimensions in recent times. Looking at the federal budgetary allocations to health care, it would not be difficult to understand why there is no traction in this sector and why there may not be any improvements until we change our priorities. In Naira terms, except in 2017, we have continued to allocate less funds to healthcare year after year. In 2014, the allocation to healthcare was N264.5b which represented about 5.6% of the total budget of N4.7t. By the 2015 budget of N5.1t, we allocated a reduced amount of N259.75b to the sector, which was about 5.2% of the total budget. In 2016, healthcare attracted a further reduced amount of N250.06b from a budget size of N6.06t representing 3.73% of the budget. It was only in 2017 that the sector was lucky to attract a larger allocation of N308.4b out of a budget size of 7.44t representing 4.15% of the budget. If these stories appear sad on the surface, then the application of the concept of ‘time value of money’ would make it worse. Applying an average conservative inflation rate of 15% per annum, over the period, would show that the N259.75b in 2015 represents only about N221b in 2014 prices. Similarly, the N250b of 2016 represents N175b in 2014 prices while the N308.46b of 2017 represents N185b in real 2014 prices. These don’t sound attractive, but they are not only real, they are true. If we apply the exchange rate variable into the equation, it would be very clear that what we are dealing with is a massive compression of our healthcare budgets over the years. Exchange rates hovered around N160 per dollar in 2014, N199 in 2015 and early 2016 and N305 later in 2016 until now. So, if we convert the allocations into dollars, we would see that this sector should actually have collapsed by now. So, we must salute those who have managed to keep it alive till this time.
According to the WHO, Nigeria spends only $67 per person on health care per annum. Angola, on the other hand spends over $200, while South Africa spends seven times what Nigeria spends at about $470. The WHO recommends that no less than 15% of the annual budgets of countries should be dedicated to healthcare. A lot of countries are in compliance. In spite of all the hullabaloo of Obama Care and Trump “Careless”, America dedicates over 20% of its huge budget to health care delivery. Iran’s healthcare budget is 18% while China is close to 13% and Turkey, 11% of much larger budgets.
Meanwhile, we are here, struggling with 4 to 5 % of a kindergarten budget.
It is conceded that a larger budget does not necessarily guarantee a better quality healthcare delivery system. We know that budgets do not deliver results. Conversely poor budgets cannot deliver results irrespective intentions. Norway, Switzerland and the United States are the world’s three biggest healthcare spenders –spending $9,715 per person (9.6% of GDP), $9,276 per person (11.5% of GDP), and $9,146 per person (17.1% of GDP) respectively.
But other countries’ health systems are managing to achieve similar or better results for far less. Hong Kong spends $1,716 per person (6% of GDP), Israel $2,599 per person (7.2% of GDP) and Singapore $2,507 (4.6% of GDP). These countries, like Norway and Switzerland, have life expectancy of between 82 and 83 years. By comparison, life expectancy in the US is 79.
Going by constitutional provisions, healthcare delivery is divided amongst the three tiers of government viz, local government, state and federal governments. Local governments are responsible for primary healthcare which includes the management of local dispensaries, environmental sanitation and protection and routine immunization.
The State governments look after the secondary healthcare system including the General Hospitals and Health Centres while the Federal Government is in charge of tertiary and referral institutions such as the National Hospital, the Specialist/Teaching Hospitals and the Federal Medical Centers.
We all know that the local dispensaries and community health centers have disappeared. Why won’t they disappear when they are not being funded? They are supposed to be looked after by LGAs. The LGAs themselves are non-existent in majority of the states because many state governors want to be in control of the finances of the LGAs and instead of holding elections for the LGAs, they foist their thugs and cronies as Transitional Council Chairmen, an arrangement which should not last more than 6 months. They renew their tenures after every 6 months in perpetuity. These transitional Chairmen do not have access to the LG allocation and owe their stay in office to the Governor. On receipt of the allocation, the governor gives them some stipend to help them run the LG and keep the rest. It would be a pipe dream to expect that part of the priorities of these Chairmen is healthcare. They know they cannot do it and instead of wasting their time, they face other things. Once salaries of LG staff are paid, (that is, where they are paid) every other thing becomes secondary. Any wonder why the primary healthcare system has completely collapsed.
In essence, the first level of healthcare provision and prevention of diseases cannot be implemented. So, what is the alternative? The first level, where possible, now moves to the second level, the state level for solution. Where that cannot happen, four other options are open. The options are that the people who should have been beneficiaries would resort to quacks and undocumented health workers, engage in self-medication, descend to the level of seeking alternative help from native doctors, spiritualists and herbalists or simply resign to fate and wait for death.
Statistics have it that out of the 30,000 Primary Health Centres nationwide only about 2,500 or a meagre 8.3% are functional. If this is not a bad report, I wonder what else is. The implication is that diseases that could have been arrested or prevented at lower levels are left to blossom into unimaginable national epidemic dimensions. Given this state of affairs, the Federal Government has had to intervene with the Nigerian Primary HealthCare Development Agency (NPHCDA) to take care of primary healthcare needs and immunization. I must acknowledge the positive impact this agency has made.
On the State level, we have seen that most general hospitals are ill equipped and ill funded and have dilapidated to terrible levels. The Federal government is now saddled with the responsibility of maintaining Federal Medical Centers in the States as well as the statutory responsibility of managing teaching hospitals and other tertiary centers like research institutes. But the Central government has had to intervene in both the primary and secondary levels where the owners have failed.
It is important to examine this structure to be sure it is working. My sense is that it is not.
Closely related to funding and structure is infrastructure. My personal contact with healthcare professionals both in Nigeria and abroad shows that one of the major reasons for the brain drain we mentioned earlier is the poor medical infrastructure and ineffective medical policy of the country. Some of our doctors would have stayed back if they were assured of support in terms of modern infrastructure for them to operate. In a country of over 180m people, one can count on one’s fingers, the number of sophisticated equipment like MRIs, CT scan equipment, dialysis centres, and cardiology centres we have. Even if you are the best doctor available, you will record very limited success if you rely on antiquated equipment for diagnosis and treatment. So, when our brothers and sisters look at the infrastructural support available in the country, the urge to relocate becomes more imperative. Yet this is a country that hands over a billion dollars annually to other countries (its competitors) for medical bills. We must, therefore, agree on how to put the required infrastructure in place for our hospitals to compete. You must trust me on this, the money we are talking about here is very small. We must also discuss efficiency and cost effectiveness in terms of shared services and infrastructure. Is there any use duplicating equipment in a particular location where services could be shared and its savings passed on to the consumer?
MEDICAL POLITICAL ECONOMY
This is probably the most important aspect of this subject. How is healthcare delivery organized? Who is in charge? Does he understand the issues? Is he just a quota minister representing his state or he is a professional who would resign if decisions that impinge on his performance are taken? We remember the late Prof. Olikoye Ransome Kuti, who was Minister of Health in Babangida’s government. Kuti who was also Fela’s elder brother moved the nation’s healthcare delivery system to a crescendo through his focus on primary healthcare Programme. How did he do it? He was clear about where he was headed and astute as a professional. It was easy for everyone to follow him. It happened before, during a military administration, it can happen again, but the appointment has to be devoid of sentiments.
Access is also very important as the National Healthcare Insurance Scheme was set up in 1999, to address. Several years after, just about 5% of the population has enrolled in the scheme.
The whole idea of this section is to point our attention to the fact that the success of any policy is dependent on the philosophy behind it. Sloganeering and propaganda will not cut it.
I have heard a few people raise stiff opposition to the discussion of the basis of our continued mutual existence. I think such position is misguided. I believe that the only choice we have is to sit down and talk. Some people refer to the constitution as sacrosanct. I agree with them to the extent that there is no new constitution in the horizon. Anytime a new constitution emerges, the present one becomes obsolete.
As we discuss, we should avoid the temptation to focus only on the very important subjects of the economy and politics. Any discussion that does not focus on having a heathy populace is meaningless. Like the saying goes, a healthy nation is a wealthy nation.