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 countriesto 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.
MEDICAL FUNDING
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 ratevariable 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
incompliance. 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.
MEDICAL STRUCTURE
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.
MEDICAL
INFRASTRUCTURE
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.
Source: reubenabati.com
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