Abayomi Olarinmoye is the Senior Partner, Real Sector at Verraki. In this interview she called for immediate removal of financial barriers preventing access to universal healthcare. She also recommended technology innovation and training for health workers as measures to improving health outcomes in Nigeria. Emma Okonji brings excerpts:
What is your take on the state of the Nigerian health sector?
According to the World Health Organisation (WHO), Nigeria has one healthcare worker to 2,753 people, whereas the WHO recommends one to 1000 citizens. Per facilities, we have one facility (whether a basic healthcare hospital or a teaching hospital) to 4943 Nigerians. If we look at life expectancy, we see a similar trend; life expectancy in Nigeria is 55.2 years; the African average is 61 years. Access to healthcare is also limited; we have five hospital beds per 10,000 populations in Nigeria. Most hospitals are in urban areas, impacting access in rural areas. Where primary healthcare in rural areas is characterised by insufficient hospitals and health workers, this becomes a challenge.
In terms of affordability, 40 per cent of the population live below the poverty line and cannot afford healthcare. This impacts our healthcare spending per capita as one of the lowest.
How does healthcare in Nigeria compare with other sub-Saharan African nations?
Not as well as one would like. Namibia, for instance, has 27 beds per 10,000 of population, South Africa has 23, and Ghana has nine per 10,000. We have five. Based on publicly available WHO health indices for Africa, Namibia, South Africa, and even Ghana appear to be faring better than us. When you look at healthcare financing across sub-Saharan Africa, Nigeria is one of the places where people spend the most money out of their pockets for their healthcare, as high as 70 per cent; that means what you put down for your healthcare is more than what the government pays or your health insurer (if you have one), pays on your behalf. In other sub-Saharan Africa countries, the average is 34.5 per cent. This out-of-pocket cost drops down to 13.84 per cent in Organisation for Economic Co-operation and Development (OECD) countries and other advanced nations.
However, there has been progress, compared with 10 or 15 years ago; improvements are especially notable for infectious disease interventions and, to a lesser extent, for reproductive, maternal, and child health services but there is still a lot that needs to be done to move the needle.
What are the key challenges facing healthcare in Nigeria, especially those that can be tackled now?
There are several challenges; the unavailability of healthcare facilities is one. We have 33,303 general hospitals with 20 000+ primary healthcare centres but we need more primary or basic medical outposts or facilities which are the first line of contact for many patients. We have 59 teaching hospitals and federal medical centres in Nigeria averaging less than 1.5 tertiary care centres per state.
Another has to do with the inadequate number of skilled health workers. For example, the proportion of births in Nigeria that are attended to by skilled health personnel; a midwife, nurse, or doctor is just 43 per cent; implying that over half of deliveries in Nigeria do not have a skilled health personnel present.
86 per cent of the hospitals in Nigeria are focused on primary healthcare, which is good but we also need to equip our healthcare system to treat the increasingly sophisticated diseases that more Nigerians now have due to our changing lifestyles. Many private hospitals even in the urban centres, are focused on primary healthcare; but are ill-equipped to offer secondary or tertiary services. We have limited hospitals in Nigeria that have modern cancer care machines, or renal care, or critical care facilities that can provide 24/7 life support.
It has been said previously, that Nigeria is the ‘fourth-worst place’ to give birth in the world. Institutional deliveries, deliveries in a health centre are only 39 per cent, with 60 per cent out-of-hospital. Our neo-natal mortality rate, i.e the number of deaths per 1000 births is 36. If these children survive birth, 76 of every 1000 die before they are 5 years old. In advanced countries, these are single-digit numbers, maybe 9, 10, or 4. Nigeria has just overtaken India as the world capital for under-five deaths, according to the 2020 mortality estimates released by UNICEF.
The healthcare gap is huge, with so much to do; we cannot leave it to the government. Having health insurance for your family doesn’t guarantee health security in a country where over 93% of the population is outside the insurance envelope, especially during periods of viral infections like now.
Where are the opportunities?
Healthcare financing is an area of immediate opportunity. We need to remove the financial barriers that prevent access to healthcare for Nigerians especially poor/vulnerable populations. We need private sector participation in financing health insurance to complement the National Health Insurance Scheme (NHIS).
Another area of potential impact is in the provision of health facilities and making sure that we have a critical mass of health care facilities available both in the rural and in urban areas. I once mentored doctors from the South-Western part of Nigeria who were start-up finalists in the Nigerian Economic Summit Group (NESG) competition and had the innovative idea of putting diagnostic centres on wheels and providing services across rural outposts. They planned to cover all the local government areas in their state and were going to put their X-Ray machines and other equipment in a vehicle/mobile clinic because they found out that many people had to travel to the state capital just to get X-rays done. Innovative ideas like these around the provision of healthcare facilities will improve healthcare significantly.
The increasing availability of healthcare workers is another area of opportunity, where you create more training centres that enable more workers to be trained. The firm I worked with previously had a Social Development Practice (ADP) and one of the projects they worked on had to do with training health workers in Kenya remotely.
Similarly, we can set up online academies to provide basic nursing and lab diagnosis education where nurses e.g. midwives, traditional birth attendants, and other health workers are taught the basics needed to improve health care within their localities. Some NGOs are providing this service currently but we need to multiply this to achieve critical mass. Technology can also help in what I call healthcare next-sensing, to borrow a term from Prof Pistrui. This would involve deploying technology and epidemiology to pre-emptively diagnose where there would be infections/epidemics, whether on ground or remotely.
For instance, we can use technology to gather data on diseases most frequently occurring across the country and use analytics to figure out which diseases are more frequent, in which area, and among what age group. This could then influence healthcare expenditure e.g to determine what kind of resources or additional healthcare facilities to put there. If I know that there is an area of the country where they are prone to diabetes or have an unusually high prevalence of sexually communicable diseases, I know what to spend on in terms of healthcare in those areas. We can also make huge strides with telemedicine, leveraging solar power. We can ensure every village has solar-powered mobile clinics with access to a health official who can consult remotely.
Speaking of health insurance in Nigeria; do you think we have enough to ease the financial burdens of healthcare in Nigeria?
Health insurance penetration is very low in Nigeria, even in the capital cities like Lagos. A few state governments are implementing health insurance schemes at the community level. Lagos, Ogun, and I think Oyo are rolling out Public-Private Partnership (PPP) schemes where market women and other small business owners make small monthly contributions and have access to health insurance that is subsidised by the government. I think Lagos State also offers a community-based health insurance scheme for about N40,000 per family. This provides access to insurance cover for medical care in all the Lagos State primary health care, secondary health care, and teaching hospitals.
A major telco previously had a partnership with a health insurance company and sold access to health insurance off mobile phones. It had over 700,000 enrollees in the first six months but was shut down by regulators. We need more schemes like that and we need to think creatively about how we can get health insurance across to all villages in the country partnering with HMOs, insurance, and solutions companies like Verraki.
What are the critical health areas that you think Nigeria should immediately focus on?
We must start with primary healthcare. Six of the 10 most prevalent disease areas in Nigeria fall under the primary healthcare banner e.g malaria, diarrhea, pneumonia, polio, malnutrition, etc.
Nigeria has a protein deficiency problem, as we do not consume sufficient protein; meat, fish, or eggs with many children being protein-deficient with low immunity to diseases. So, let’s tackle that first. We can reduce protein deficiency, tackle malaria, and then tackle a few of what you call tertiary diseases like cancer, high blood pressure, and obesity. The government also needs to find an efficient way of training more community health workers at the grassroots and to do it at scale.
Healthcare is getting more attention from those who want to invest and give back in Africa and Nigeria but there is still a huge gap. Healthcare startups accounted for just $18m of the $1bn in venture funding that was poured into Africa in 2018. We have identified infrastructure and policies as limitations. But infrastructure is not about building additional expensive facilities. Parts of existing national facilities can be converted into basic, medical outposts that can be equipped to do basic primary health diagnosis. For instance, with 955 Post Offices and over 3,000 Postal agencies managed by NIPOST, every local government in Nigeria has a post office.
NIPOST is aiming for post offices to provide banking services to promote financial inclusion but we have a significant opportunity to also use post offices as medical outposts. PPP arrangements will also help to implement these healthcare initiatives across the nation, leveraging existing infrastructure, for instance, owned by some older generation banks with large branch networks across the country that are not being used to full capacity.
If we find a way to partner with post offices and banks to provide basic diagnostics equipment, furnish the centre with internet facilities so that anyone can have a scan done, and communicate this to a doctor via telemedicine, healthcare has been provided.
How can Verraki play a role in improving our healthcare?
We can consider partnering with other players in the financial services sector. We plan to partner in the area of providing health insurance schemes, particularly for the underprivileged, find a way of getting at least 30 per cent of citizens across the nation insured for health, using mobile phones or traditional Esusu cooperatives that they have in the village, it can be done.
We can also partner to set up automated disease registries. As part of the work we were doing for a client recently, I started checking for the prevalence of cancer across Nigeria, and I saw that we have cancer registries in about 10 locations across Nigeria. But some of those cancer registries are not updated as frequently. It is not just cancer; we can set up registries for other diseases. We can collect all of these data and using analytics, begin to draw a picture of the disease patterns in this nation, to determine what kind of equipment to put there. Automated disease registries can be used not just by hospitals but also by those who are doing research and development (R&D) into drug development.
We can also consider partnering stakeholders (medical and financial) to accelerate and commercialise drug development, especially for Africa. There are stories of people who have researched into how chewing stick can be used as a cure for sickle cell anaemia, and a host of others that have developed herbal drugs which are undergoing tests. If we have up-to-date disease registries, we can partner with pharmaceutical companies to develop African-focused treatment and Verraki can also play in the area of technology-enabled medical education. We can find doctors in the diaspora, whether the USA, Russia, or Hungary who are willing to give two to three hours of their time each week to train student nurses, student doctors, and midwives remotely.
We can also help in improving institutional capability for the public and private sectors to tackle health care problems at scale. The problem in Nigeria is not about structures. The Nigerian health system has structures for every level or cadre of healthcare; primary and tertiary health care with ministries of health at the federal, state, and local government levels, and health care vehicles funded by global foundations and donor funds. We also have the NHIS.
The issue is upgrading the capability that we have as a nation to get targeted outcomes, with specific emphasis on setting up visible, transparent performance management systems. I’m talking about recording what is being tackled, the initiatives, how, and where we are seeing improvement and putting in place a health performance management system that rewards both public and private sector health players who can move the needle.
There is a lot to do and there are many spaces where interested civic-minded and entrepreneurial driven private organisations can play from affordability, financing to access to healthcare, upgrading institutional capability, and adopting technology improvements across the value chain in diagnosis, education, treatment, or research.