Akinbolagbe: Nigeria Needs Enormous Private Sector Investment to Deliver Quality Healthcare

Akinbolagbe: Nigeria Needs Enormous Private Sector Investment to Deliver Quality Healthcare

With Nigeria’s elite often going overseas for medical attention, Nigeria’s healthcare system has always grabbed the front burner as the nation debates how to establish an efficient system in the country. A major facet of the debate revolves around the role of the private sector, an issue that brings to mind the Private Sector Health Alliance of Nigeria (PSHAN), a platform founded by Alhaji Aliko Dangote, Mr. Jim Ovia, Mr. Aigboje Aig-Imoukhuede, and other business leaders, to mobilize private sector resources and capabilities to support improvement of Nigeria’s healthcare system. It was thus that THISDAY’s Eromosele Abiodun and Ugo Aliogo sat down with the Chief Executive Officer of PSHAN, Dr Tinuola Akinbolagbe to discuss Nigeria’s healthcare challenges and PSHAN’s flagship project, the Adopt-A-Health Facility Program. Excerpts!

Can you tell us about the Private Health Sector Alliance of Nigeria and why this coalition is so important in healthcare development and delivery in Nigeria?

PHSAN is the Private Health Sector Alliance of Nigeria. The coalition is formed because we found out that the private sector needed to actively get involved in healthcare and improving outcomes in Nigeria. We have come to the realisation that the federal and state governments cannot do it alone. Therefore, we have a lot of international bodies that are involved in one way or the other. So, the private sector decided to step up, take responsibility, and take a lead on that. The ultimate objective is to have improved healthcare outcomes in Nigeria.

What are the major challenges that pose a threat to quality healthcare delivery in Nigeria?

PSHAN has done a scan of the healthcare space and discovered the common problems that are obvious to everybody. Nigeria has some of the worst health indices in the world, both in maternal and infant mortality. We have infectious diseases and non-communicable diseases, even the COVID-19 pandemic. So the myriads of problems are there. We have a population that is exploding and growing rapidly. We have a lot of people that are concentrated on the lower ends of the demographics, which are the young people in Nigeria who constitute more than 50 percent of the population. Therefore, when you look at the health indices and the facilities you will see that there is need for interventions. What the government is trying to do is obvious to anybody.
So, the problems we have noted are both on the demand and supply side. On the demand side, there is virtually no access to healthcare in a lot of sectors; the rural sector in particular.

Even in the urban areas, you find people that live in Lagos but they do not have access to standard healthcare services. So, the access problem is there in the rural and urban sectors. Also, you have a problem of ability to pay, which is critical. We have said as a nation we are committed to universal health coverage and you have more than 70-80 percent of Nigeria paying out of their pockets for healthcare. If someone has to pay for healthcare, they are focused on making the choice between eating, transporting themselves, feeding their children, and going to the hospital. So, going to the hospital becomes a low priority-access to payment and quality health and services that are not available. Most facilities available are not up to par or even in line with baseline standards, talk more of being in best healthcare practices. On the supply side, there is not a lot of funding in healthcare. You have not gotten a lot of banks involved in financing. If I approach a bank that I want to open a music studio, the chances of me getting funding is high. But, if I go to a bank and say I want to open a hospital, they will laugh me out of the place because it is not seen as viable, and the model is not making sense.

There is poor funding.

We have the brain drain problem, but their skills are not being reinforced or improved upon. You have a lot of skilled medical personnel leaving. I will like to cite an example with myself. When I graduated from the University of Lagos we were a group of 130 students in medicine and dentistry. In less than five years, we were less than 10 left in Nigeria. The others have all gone overseas to practice medicine. I am counted as a medical doctor, but I cannot remember the last time I picked up a stereoscope. And when they are counting medical doctors in Nigeria, they count me. But really I’m not a practicing doctor.

Honestly, we need to improve the conditions and make healthcare delivery in Nigeria attractive. We need to focus on things such as task shifting. In most countries, it is not the medical doctor that does everything; nurses, healthcare practitioners, physiotherapists, and others do a lot of tasks. There are so many people on the value chain. But in Nigeria, we load everything on the medical doctors, and we don’t go out of our way to reward or encourage the doctor. So, we have the problem of manpower and infrastructure. The average clinic you visit is not up to standard, the healthcare workers may be paid or not be paid, and they may be cutting corners, which is not ideal. The government is trying, but it is not something that they can do alone.

With healthcare poorly and badly maintained in Nigeria, how does PSHAN intend to revitalize that sector with keen concentration in primary healthcare delivery?

We did an assessment and realised that during the days of former Minister of Health, Dr Olukoye Ransome-Kuti, there was a lot of attention on the primary healthcare sector. It was not that the health sector was so much better then, but efforts were put in place and you could see the difference in the health indices. So, if you can find a solution that affects 70-80 percent of the population, then your chances of getting improved health outcomes are better. So, why don’t we address the health problem at the grassroots, which is the primary healthcare level where most people can go and get their problems sorted before it is escalated? Some of the health problems we have in Nigeria are malaria, pneumonia, tuberculosis, HIV/AIDS and others that can be handled at the Primary Healthcare Centers. You don’t have to wait until the thing gets out of control before going to the tertiary care level, which is more expensive to build, operate and maintain and keep up to standards. So, PSHAN came up with the initiative, which was an idea from one of our directors, Mr. Aigboje Aig-Imoukhuede. He is the chairman of Coronation Group and Co-Chair, Global Business Coalition on Health, (GBC Health) based in New York. He said why don’t we come up with a concept where Nigeria can be divided into regions? Nigeria have 774 local government areas, they are not that many. If we have one global standard Primary Healthcare Center in each of these LGAs, it may not solve the problem in its entirety, but will go a long way in improving the situation. So, that was the initial vision.

We have done a lot of work in developing this and we have also engaged with a lot of people. We have had a high-level engagement and we have a full plan in place that is divided over four phases, and it is expected to run over six years, where we would fund these centers and put them in place, then get the organised private sector fully committed to delivering on these projects for all Nigerians.

Given what you have said, funding will be an issue and you are not a government agency. So how do you hope to fund your initiatives?

PSHAN has in the past six years managed to raise over N6 billion to intervene directly. We have realised that the organised private sector is powerful. In fact, look at how much they were able to raise for CACOVID. We must applaud the Nigeria private sector organisations. We had over a 100 private sector organisations and some government organisations take the lead and managed to raise over N30 billion at a relatively short notice. They intervened at the height of the pandemic, and that is what helped Nigeria. As a result, the federal government was able to set up screening and testing centers, wards and provide relief materials. So, it means if the private sector is organized, they will and can make a difference. We are calling on like-minded private sector organisations that are carrying out activities in the form of Corporate Social Responsibility (CSR) to see how we can pull resources together because in that, we are better and big, we use the economies of scale to make very definite strides in the healthcare sector. I don’t think there is anybody in the organised private sector that has not been affected by the pandemic. This is something that if you don’t intervene, it affects where you make money. Your staff cannot go to work and business cannot resume. You can see that the rest of the world is moving on and picking up, and Nigerians are still waiting to be vaccinated. The point I am making is that the private sector cannot afford to stand aloof. They must throw what they have into the ring and actively take the lead.

PSHAN offers a credible and neutral platform. We are not affiliated with any political party, tribe, or region. We are simply saying that we are the organised private sector and we have on our board industry leaders who have made the impossible happen. They are lending credence to the credibility, integrity, and full transparency of the platform. So, we just need to pull our resources together to make a difference for the betterment of all of us, so that you can give back to your staff, their families, and the community where you make your living and do good. Some organisations have proven that it is profitable to do good, you can still do good and make profit, they are not mutually exclusive.

Speaking specifically about outcomes, what can you say PSHAN has delivered in the healthcare sector in Nigeria?

As I said, PSHAN was formed in 2010 as a private sector roundtable aligned with the government initiative. We are not here to compete. Instead, we are here to align with the government and support some of the programmes and initiatives that they have and we have had a lot of success stories such as the Malaria-to-Zero programme, Nigeria Health Quality initiative (NHQI), which was involved in improving the quality of services in Nigeria. We have had the Nigeria Health Innovation Marketplace (NHIM) and the focus of this was to bring to scale innovations in the healthcare space that could better the health of Nigerians. We also had the ARC project, which is the Africa Resources Centre for Supply Chain management, and it was done with GAVI and Bill and Melinda Gates Foundation. The project was very instrumental in the eradication of polio in Nigeria. We got that certificate finally late last year, but because of the pandemic, it didn’t get as much fanfare as it should have. Our founding Director, Alhaji Aliko Dangote, and also our Chairman, Jim Ovia, were very much involved in that effort.

What policies should the government put in place to drive interventions in the healthcare sector?

Government is trying and you can see a lot of successful public-private partnerships. You can see what the Lagos State government did through partnerships to get the testing of the diagnostic center of the COVID-19 virus. You have also had Public Private Partnership (PPP) at the National Hospital. The truth is that governments don’t have the capital to dedicate to certain fields, but if they partner with the private sector, and the governance framework is in place, then the private sector provides the resources and equipment, and they work together, it will be good. For me, a very easy thing will be to mandate health insurance in some form. You find out that a lot of states have domesticated the laws for health insurance. We have some micro-health insurance schemes, but so long as it remains an option, and not mandatory, then you will not have increased uptake. For healthcare in any sector to make sense, you must have a pool of funds. We don’t have that pool of funds and capacity, which if it was available, it will be a value chain enhancer. Just by saying that health insurance should become mandatory, those who cannot afford it will not be left behind.

If you recall, the government passed a law saying that one percent of the consolidated revenue should go to providing for the vulnerable, and half of that was supposed to go to Nigeria Primary Healthcare Development Agency (NPHDA). We came up with a beautiful prototype of minimum standards and things that should be done. The other half was to be expended through the Nigeria Health Insurance Scheme to provide insurance for the vulnerable (below age 5, pregnant women, prison population, and the elderly). So, there are beautiful frameworks that are in place. But for them to become effective, health insurance should be made mandatory and PPP should be encouraged.

Regarding the ongoing disagreement between the striking doctors and the federal government over unpaid hazard allowances, and other benefits, what is your advice to the government on how to resolve the crisis so that it doesn’t become a recurring issue?

The health sector should be treated the same way the banking sector and other sectors are treated. There should be minimum regulations, you cannot just wake up and open a quack center. There should be standards and adequate monitoring. There should be funding. Let me say that the federal government has positioned the Bank of Industry (BOI) and the Central Bank of Nigeria (CBN) to make some efforts to provide funding for pharmaceuticals. But you must make the sector attractive such that private sector funds also flow there. You cannot have the entire health sector fund based on the public sector funds. Private sector funds must be encouraged to go there. Before private sector players must put their funds there, they must see some stability and indication of direction from the government. So if you come and say health insurance should be mandatory, then you will have people in digital health space, health software space, pharmaceuticals, equipment manufacturers and so many other people that will drift in that direction and the funds will follow them.

Let’s be fair to Nigerians; the reason why people seek alternatives that don’t seem to make sense is because the cost of accessing things that make sense is out of their reach. I am a believer in God and I do know that God works through people. I also feel that God works through medical doctors to provide care. But if my salary is such that I can barely feed by the 20th of the month, there is an issue there. For some people, the month ends on the 20th, while for others it ends on the 30th. So, for those that their salary ends on the 20th, it means that during that time of the month, the salary is finished and if someone falls sick on 22nd there is no income to treat such a person. Then at this point, people allude to the fact that health-seeking behaviour is poor. It is not a matter of health-seeking behavior; rather it is about available resources. If the health insurance is in place, and I know that I can get to the hospital and be attended to because my premium is already paid and it is well underrated, why will I not visit the hospital?

HMOs are major players in the industry. Do you intend to work with them or is there an existing collaboration with them?

It is a multi-sectoral approach that we have. HMOs and micro health insurance schemes must function to be able to pull the resources. And so when that happens, people are able to access healthcare without having to consider what is in their pocket. For healthcare to work in Nigeria, each of those sectors – health insurance, healthcare financing, healthcare provision, standards, monitoring and evaluation, must all work together.

One of the major challenges concerning healthcare in Nigeria is financial barrier to accessing health services. What do you think is the way out?

For me, it is about treating healthcare delivery like every other sector and taking it seriously, and ensure that the sector grows actively. For the bankers, they put some regulations in place, though it is not as simple as it sounds. But if we have regulations that are properly adhered to, there is transparency, if you meet the standards, you will be granted a license, and then you will have more credible people coming into the sector. A lot of healthcare investments are small Small and Medium Scale Enterprises (SMEs), almost micro. You have a medical doctor graduating from medical school and he/she sets a private clinic. It is fine; he is qualified to do that. Imagine if you have a group of doctors come together and say they are forming a group practice. They have pulled all their funds together; there is no need to replicate the head of pharmacy or procurement. So, the economics of scale comes into play. But the government has to put in place an enabling environment for that to happen. Like I said before, it cannot be government-funded, you must direct private players and encourage them by having a level playing field.

So going forward what do we expect from PSHAN?

For PSHAN, a lot of what we have done in the past was done by my predecessors and kudos to them for the work they did. We also have a very strong board that despite their busy schedules, still have the time for PSHAN, and they are very much involved. We have restructured over the past 18 months, and we are focused on addressing the needs of the entire Nigerian population. We are engaging actively with a lot of private sector players. We are doing a lot of engagements with government and international agencies to identify gaps.

Our frontline project is the Adopt a Primary Healthcare Facility Programme (ADPHF) and we do have other programmes, which we will roll out soon. So, I do expect that you will see a lot more visibility and impact from PSHAN.

What is the expected timeframe for the ADHFP creation/implementation, and, more significantly, what will the impact be in Nigeria?

The Adopt a Primary Healthcare Facility Programme (ADPHF) is expected to run over a six-year period. It is divided into four phases and we intend to start the pilot phase later this year with the launch programme and the pilot phase. The learnings from that will be used to ramp up and scale to stage two, three, and four. The impact will be immediate. We are targeting about six or seven Sustainable Development Goals (SDGs) because we are not just providing medical care, but we are looking at the entire value chain. We are providing security, potable water, power, building, staff, staff remuneration, medication, equipment, medical furniture and furnishing, training for the staff, monitoring and evaluation, quality control and an end-to-end value chain. So, with that in place, we are addressing about seven or eight SDGs, which is in line with what the government is doing. We are looking at poverty, health, and water; those are some of the major SDGs, cooperation, partnerships, sustainable communities, and infrastructure. It is a huge task, but we are confident that we will deliver.

Why is ADHFP being implemented now?

I think the pandemic has exposed the underbelly of our healthcare system and how fragile it is. You have seen some kind of efforts from certain states in Nigeria and the federal government. We managed to get through Ebola, Lasser Fever, and now we are currently in a Cholera issue and we are trying to solve that. We must applaud the government because they are trying, but they cannot do it alone. We need the diaspora to get involved because as I mentioned earlier, a lot of people in my set practicing overseas are looking to give back. So, these persons in Diaspora can come and organise these programmes, then return to their base, which is good but the programmes are fragmented. We like all these efforts to be aligned together, so we can see credible movement in the right direction.

What role will PSHAN play in the post-COVID era in Nigeria?

PSHAN is going to act as an aggregator and provide a neutral platform. We are looking at a situation where people contribute financially no matter how small or big, so far it is able to make a difference. So we will pool the resources together and advise you on the options that are available and we will also advise on best practices for HSC and handling health for your staff as showed by this pandemic. People are trying to solve this problem on their own individually. Each organisation is making up the rules as they go along, while for some even though they have right intentions, they don’t have the right resources and information to make the right decisions.

How will COVID-19 influence the organization’s operations?

COVID-19 pandemic has shown us that a lot of things can be done remotely, partnerships can move quickly in the right direction. It has also shown us that we need to make decisions quickly because things change and they evolve. Look what we have in two, three months, things have changed and they are changing again with the Delta variant. Decisions in healthcare must be taken quickly, databased, and scientifically. I must commend the Nigeria Center for Disease Control (NCDC) and a lot of the states, they are working the way it should. At the center of all of these is the Federal Ministry of Health, who are guiding things and making evidence-based decisions. A lot of the decisions of the Presidential TaskForce are made based on scientific data. They are very transparent and carry people along. They also have a lot of stakeholders. So, stakeholders must be called to the table; it should not be a top-down approach, instead, it should be a collaborative effort.

As a healthcare professional, what in your opinion should come first between profitability and humanity?

It has to be a mix of the two because if you say, ‘it should be humanity,’ it is a good idea but is it sustainable? If I say I am going to pay for healthcare for everybody in this facility, that assumes that my business continues to improve and other competing needs don’t come to take that. So, it must be set in such a way that there must be a viable model such that it is self-sustaining and it continues in perpetuity rather than just addressing the immediate needs, then petering out when there is no fund or structure in place. There must be funds coming back in to sustain the business. I think it has to be a healthy mix of the two.

Related Articles