Medical tourism has become as much drain on the economy in the health sector. Fintan Ekochin, Commissioner of Health, Enugu State told Ahamefula Ogbu that a universal health coverage system coming on stream in the second quarter of 2019 would set the state apart as running a globally approved and people-friendly healthcare system. Excerpts:
Can we know what your primary healthcare delivery system and approach is like in Enugu State?
The primary healthcare service in Enugu State is quite robust. When I say robust, I stand on the strength of the structures we have. In the 17 local governments of the state, we have 420 primary healthcare centers, rural outposts, health posts and the likes. This large number is a very big base to the pyramid of the primary healthcare. These facilities exist across the three senatorial zones and form the primary level of healthcare in the state. Hitherto, they had been managed by the local government health authorities whereby each local government is headed by a HOD Health in charge of the primary health centers in his or her domain. That is how we met it until when a big change is set to come on board. The local government has run the primary health centers; however things are going to change very soon.
Is the health insurance scheme working in your state?
Enugu State is yet to bring on board its own state-supported health insurance scheme. The prerequisite however is done and we are very proud of it. Rt. Hon Ifeanyi Ugwuanyi has assented to that bill so we now have a health sector reform law. This law is the most important thing in bringing our own self-support health insurance bill on board. In the last quarter of 2018 we were able to renovate a temporary office for the universal health coverage agency which is of course the body that will house the SSHIS. We have seconded staff from the state ministry of health. Currently the NHIS, the national body is doing training of these staff even today; the training has been going on alongside other NGOs who also do training for other staff who we posted there; so with all these on ground we are confident that we will soon roll out our own state- supported scheme.
Can you tell us how soon that would be?
In the first quarter of 2019 we are optimistic that the last and very important staff of our agency will be appointed which is the executive secretary. Right now we are running with an acting executive secretary but in this quarter we expect that to happen. In this quarter we expect the training to be advanced; we expect the basic healthcare fund provision roll out at the national level to also give us experiences based on the pilot states. The only pilot state in the South-east now is Abia State, so we are looking at Abia State to see how they fared with basic healthcare provision. So in the second quarter of 2019, I believe everything would be ready for us to take off in earnest.
Before this rollout, what have you on ground to ensure people access healthcare?
Like I said, we have a flagship programme, Free Maternal and Child health which is over 10 years. Infact in 2018 we successfully repositioned it by integrating and expanding the scheme to now include faith-based organisations. These Faith-based Organisations signed MOUs with the ministry of health to render services to pregnant women and children under five years and present their bills as claims for us to approve and reimburse them. It has started in Enugu State but with the expanded reach of this programme, the ground is set for us to transition from free maternal and child health which is nothing but a model of state health insurance whereby government is taking the bill completely to a state whereby formal and informal sector beneficiaries will make a monthly contribution which is the next step, so we are not starting from zero in Enugu State, we already have a successful platform we are building on to deliver that improved service. We are hoping the media will continue to enlighten people about all these things so that let them ask for it, let them clamour for it, let them be happy when His Excellency says this is going to come their way because people don’t really understand what the health insurance scheme is all about, so when they understand it, ask for it and are happy to hear it as part of campaign and part of what the ministry is offering, it will equally go a long way.
What plans have you to ensure that doctors stay and give services in rural areas?
We have 54 secondary health facilities in Enugu State, we call them general hospitals and cottage hospitals; before now this government met what they call the District Health system, it has been repealed by the Health Sector Reform law, we are now going to run a hospital management board to oversee these secondary facilities and also a Ward Health system so this is the way forward and we will take it to the next level in the second tenure. This brings specialist care to the people. Cottage hospitals are the first point of specialist contact but in order to accelerate the availability of specialist doctors, this government has done a great and giant stride in that area by quickly bringing specialists on a PPP platform so the ministry of Health got executive council approval to go into this process, advertising, getting expression of interest from specialists from areas of internal medicine, surgery, obstetrics and gynecology and pediatrics for now.
These four areas are the places we got expression of interest from. The specialist doctors we did not care whether they were indigenes or not, we did not care if they were working with the federal establishments or even in states or the private, the important thing is that they were specialist doctors and we are willing and able to key in to the PPP health programme in the state. Now they have keyed into this programme, we have an MOU that is guiding us in our working together, so we have a list of specialist doctors giving services at very modest amount which must for now be paid for by the patient, however they make out time per week to visit general hospitals, see patients there, do surgery as necessary and get paid at the end of the month. It is a successful PPP model and we are proud of it.
Is the government subsidising healthcare delivery apart from the free maternal and child health delivery system?
Sure, it is subsidising it by the fact that we have a drug revolving fund in Enugu State. We are one of the few states in Nigeria that have a very well organised and functioning drug revolving fund by the fact that government runs a central medical store under the ministry of health and has a laboratory that tests drugs and acquires them in bulk from producers. We are able to make these drugs available and affordable price, so that is already a form of subsidy, so whoever visits any of our hospitals and has a prescription is sure to pay much less for drugs than when you visit a private hospital or are sourcing drugs from the open market. Furthermore, take example of these PPP programme; these specialist doctors offer their services in the rural settings in our general hospitals in the rural settings at a subsidised cost so you pay much less to see a specialist doctor, so that is another form of subsidy that is coming up on board. The teaching hospitals is the tertiary level, a whole number of patients there get services at a very much reduced cost. If you check the prices paid for services given at the teaching hospitals, compare them to the private sector, compare them to other states and even the federal establishments and hospitals and you see how we are subsiding services. Yesterday the Governor visited a teaching hospital again and in his usual way, offset the bills of every patient at the emergency room. On the 1st of January the governor’s wife also visited the hospital and offset the bills of every baby that was born in the new year; likewise other stakeholders from the state House of Assembly and other representatives of the constituencies at the green and red chambers have also continued to do so; all these constitute how we subsidise healthcare in Enugu State.
What is the doctor to patient ratio in the state?
I don’t have exact figure for now. Infact it is very difficult to keep that figure because Enugu State among every other state in Nigeria is challenged by brain drain. We have a continued attrition not just by retirement but by brain drain specifically, so it is what the state government along with other states have to come up with a solution. The solution is quite challenging but the first thing to do is to address what is attracting our doctors and nurses; these are the two most challenging areas. They look over the fence and see a greener pasture out there so we are challenged to pay better like every state but in 2016 because of this ongoing challenge, there was a very large recruitment of medical staff of all cadres at the state teaching hospital. Right now in first quarter of 2019, we have drawn up a list of staff to be employed again into the state hospital management board, likewise in the schools of health technology at Nsukka, Oji River and school of basic midwifery at Awgwu, so we are looking forward now for executive council approval which we hope to get in this first quarter of 2019 and have another mass recruitment, so that will beef up again the staff we have lost to brain drain.
Where did you meet the health ministry, where is it now and where are you taking it to?
I speak for this government, Ifeanyi Ugwuanyi’s tenure and I already mentioned some of the things, this government met a district health system and in the first tenure has dropped it and picked up a hospital management system and a ward healthcare system. This government met the primary health system being run by local governments but has keyed in to the under one roof model as suggested by the Nigerian Governors forum and the national primary healthcare development agency and has made an enabling law and is already setting up the stage for Enugu State Healthcare Development Agency to run primary healthcare and take it to the next level, so the second tenure is where it is going to start, where the foundation that has been laid would be built upon. This government met the visions and dreams of past governments about state health insurance and has already gotten this law for the universal health coverage. Note that Enugu State is the only state in Nigeria that has taken that bold step of going into universal healthcare coverage and use it as a baptismal name for its own state health insurance .
Universal health insurance is larger than health insurance because you are bringing in funding agencies, charities to all participate. State health insurance is simply you contribute monthly and you get a benefit, if you can’t contribute you are out. Universal health coverage says if you can contribute, do so, if you can’t, the system will still take care of you because other stakeholders will still key in, so Enugu State and this government has made that success and we know that the only way forward in the health sector in Nigeria and Enugu State is bringing universal health coverage on board and that is the model the whole world is running. Out of pocket expenses cannot work. Government driving free health care like the mother and child health has a limit, those are the things.
At the point of rounding off your call of duty in the ministry of health, what would you want to be remembered for?
We all will be in the month of May exiting and I am very satisfied about what we have been able to do. Perfection is a destination that is unattainable perhaps only by the divine so what we do and what we have done we are proud of so far is that we have taken several miles on the journey towards the vision of perfection in the health sector so we are very happy that we have seen to the signing of the state health reform law which is a big achievement.
Even before the law was signed, we did all that we could to see to the development of the primary healthcare development agencies structurally, staff-wise, training-wise, we are also very happy that in our time we were able to see to the development of the universal healthcare coverage temporary office setup, secondment of staff and commencement of training. We are very happy that we were able to see to the accreditation of all the schools in the state. This government met a lot of schools lacking accreditation, top on the list was the basic school of midwifery Awgwu that was shut down for lack of accreditation for 12 years. We are proud it is back online and as we speak, 70 students have been admitted back into that school and training is ongoing right now. Hopefully before we hand over in May, the last and only school which is the school of Nursing, ESUTH Teaching Hospital, Park lane which has not been accredited will been accredited and with that we will have a full package of accreditation successes in the ministry of health. Furthermore we have effectively rebranded the ministry of health, we have a website, signage, new stationery and we have asphalted the premises, repainted everywhere and we have public healthcare operation center also at the ministry headquarters in collaboration with the NCDC, so if you come to the ministry of health we are proud of the rebranding we have done within the short period.
Since you are exiting by May and the universal healthcare coverage is starting by second quarter it means it will be operationalise before the end of this tenure?
Yes it will. The second quarter starts April so we will take a shot at getting achievements in that area but remember government is a continuum, whatever achievement or strides we achieve, we hope government will continue to build on that.
What are the challenges your ministry has faced?
One of the biggest challenges we have faced is the brain drain, it has affected our strength of doctors, nurses and to a lesser extent some other health workers. It has caused us to lose well trained hands; in the past years Enugu State has benefitted from HSDP1 and 2 and a host of other development partners programmes and all these programmes brought about training of many of these highly skilled workers so it is sad when we lose them. Another will be the fact that people in Enugu don’t really understand what health insurance is talk more of universal healthcare. When you are pushing an agenda the people are not requesting for, like they are asking for roads, water, electricity but not universal health coverage, in fact that may be the biggest challenge because when they request for it, every person will go for it, it is asking for something the general public don’t know is needed meanwhile it is the basic one they need.
Is funding also not a problem in the sector?
Funding is a challenge. If you go to the table on revenue allocation, Enugu is number four from down, not from the top so most of the things we have achieved is by virtue of prudence and continued improvement in IGR, funding is a problem but we live up to it. There are so many loop holes in the sector that we are yet to address so we call for what we call Joint inspectorate. When Joint Inspectorate go out into the field they will be able to ensure that every hospital is dully registered and operating with an annual registration, likewise pharmacists, laboratories and other key players in the sector. We have that funding problem but I believe government should run the sector as a business because that is what leads to efficiency. We will do our own which is the monitoring and evaluation and inspection. By the time the ministry of health does all these things and deliver on an improved IGR package, we stand a better chance of better allocation.