Can We Rouse Healthcare In Nigeria from Its State of Coma?, By Simbo Olorunfemi
There is no future to a healthcare system where uncertainty governs access and the system is largely powered by out-of-pocket payments in the private sector and an over-burdened public sector. The answer does not even lie in government simply putting more money in the health sector.
“No nation can succeed or become strong without a strong health care system” – Dr. Ama Adadevoh
Reports of yet another meningitis outbreak in Nigeria is unfortunately a reflection of the state of healthcare in the country. Daunting as the task of providing adequate healthcare might be, our still grappling with basic primary healthcare in the manner we have seen is simply not good enough. As at April 5, 2017, 3,959 suspected cases have been reported as part of the current outbreak, of which 181 cases have been laboratory confirmed. A total of 438 deaths (11 percent of all the cases) have been reported from 106 local government areas in 19 states in the country.
It is well-known that Nigeria is within the meningitis belt and even though outbreaks over the years were caused mostly by Neisseria meningitidis serogroup A (NmA), the claims out there is not wholly true that the outbreak of the C strain was only a recent development as “two sequential, localised outbreaks of meningitis …caused by a new strain of Neisseria meningitidis Serogroup C (NmC)” were reported in 2013 and 2014 in some states in Northern Nigeria. It is a surprise that given that experience and a suggestion in a scientific report that “a vaccination campaign against NmC with a long-lasting conjugate vaccine should be considered in the region,” we’ve had to wait, since 2014, till now for another massive outbreak and deaths of 438 people before, first, responding with reactive vaccination and hopefully then the conjugate vaccination to prevent outbreaks of this nature, in the future.
That we had to wait for a disaster that we could have prevented before taking action, is sadly a true reflection of who we are as a people, our attitude to life and virtually everything else and an advertisement for the state of healthcare in the country. We will rather leave things to chance, fate or God, even when we have what it will take to address the problems.
The evidence out there establishing a clear correlation between the state of health of the people and the state of health of the nation is clear. “Better health improves economic outcomes. Health correlates positively with happiness, productivity, and an improved sense of personal well-being,” we are told. According to a report quoted by the World Health Organisation, “better health enables more people to participate in the economy … [such that] reducing the costs of lost productivity by only 10–20% could add billions of dollars to the economy.” It also finds that “improved health conditions are also beneficial for social cohesion, especially in terms of equity. As societies with better and more equitable health systems are more stable, and function more effectively. Conversely, poor health imposes large economic costs on the affected society. Diseases such as tuberculosis, malaria, HIV/AIDS, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Zika, and Ebola can afflict large numbers of people in a short period of time. Large-scale outbreaks can lead to losses in economic activity as great as $60 billion, according the Coalition for Epidemic Preparedness Innovations.”
So is it that we are yet to connect the dots that apart from the human costs, the economic costs of diseases also matter? Several studies attest to the positive correlation between improved health and economic well-being. Even if it is only about saving lives, is it not worth it? That vaccines have saved millions of lives has been long established. A study by the World Health Organisation Global Vaccine Action Plan found that “a measles vaccine would save 10.6 million lives over the next 10 years, a Hepatitis B vaccine would save up to 6 million people, a Haemophilus influenza type B vaccine would save up to 1.7 million lives, a Pneumococcus vaccine would save up to 1.8 million lives, a Rotavirus vaccine would save 900,000 lives, and a Human Papillomavirus vaccine would save 500,000 lives if there were widespread coverage.” Yet Rotavirus and Pneumococcal vaccination are not on the National Programme on Immunisation menu for administration to all Nigerian children.
… we have these daunting challenges facing us in the health sector and the government obviously has limited resources. Obvious also is the fact that governments, over the years, have been rather restrained in terms of what they are willing or able to invest in healthcare…
A 2016 study, published as part of the Brookings Private Sector Global Health R&D Project, assesses the overall health governance capacity of 18 nations in sub-Saharan Africa and Asia by examining 25 indicators related to the five dimensions of management capacity, regulatory processes, health infrastructure and financing, health systems, and policy conditions in those countries. Needless to say that Nigeria sits at the bottom of the Health Governance Capacity Index (HGCI) rankings among the 25 countries assessed, which include countries such as Liberia, Mozambique, Ethiopia, Congo (DR) and Sierra Leone.
Indeed, the statistics available out there don’t look good. 37 percent of Nigerian children, under five years, have stunted growth; 23 percent of children between 6 to 23 months are underweight; over 90 percent of Nigerians are at the mercy of malaria attack, with over 100 million cases reported every year, and 300,000 deaths annually; 36,000 Nigerian women die in the process of childbirth, with 69 children out of 100,000 dying in the process of birth. UNICEF tells us that every single day Nigeria loses about 2,300 under-five year olds and 145 women of childbearing age, which make the country the second largest contributor to the under–five and maternal mortality rate in the world. We are told that malnutrition is the underlying cause of morbidity and mortality of a large proportion of children under five in Nigeria, as it accounts for more than 50 percent of deaths within this age bracket. It also says that the death of new-born babies in Nigeria represents a quarter of the total number of deaths of children under-five. The majority of these occur within the first week of life, mainly due to complications during pregnancy and delivery, reflecting the intimate link between newborn survival and the quality of maternal care. Yet to cater for the health needs of Nigerians, only four percent of the federal budget is devoted to health, coming to N257.3 billion in the 2016 Budget.
So, we have these daunting challenges facing us in the health sector and the government obviously has limited resources. Obvious also is the fact that governments, over the years, have been rather restrained in terms of what they are willing or able to invest in healthcare, but the question still arises – Are the resources available being applied judiciously and in the most cost-beneficial manner? Can we not be more creative in addressing these challenges, which I see as a sea of opportunities?
I have made different arguments in previous interventions (see: Faffing Around Healthcare: Whose Job Is It To Keep Nigerians Healthy?; Diarrhoea, Rotavirus Vaccine and Nigerian Lawmakers; and Are we doing enough to manage this Annual Outbreak of Meningitis?) pointing to the level of attention at the primary level, especially calling for an expansion of the range of vaccines covered under the national immunisation scheme not only as a means of saving more lives of our children but to ensure that the cost of secondary healthcare goes down. I have argued for a community-based, all-inclusive healthcare system founded on health insurance, that will not only phenomenally grow that sector through a public-private partnership, but would offer a major investment opportunity if the right framework can be put in place.
I am not convinced the policy drivers of the nation’s health sector have the same understanding as I have or are headed in the direction I think they should. It does appear that the Federal Ministry of Health under its National Primary Healthcare Revitalisation initiative, through the National Primary Health Care Development Agency is still held captive by the brick and mortar mentality, with the same emphasis on putting up structures, throwing good money at the problems without paying enough attention to the sustainability of the project.
You cannot build the future around a system where government has to build everything from primary health care centres to tertiary hospitals and pay competitive salaries to healthcare workers at all levels. The resources are not there and even if they were, it is not the smart way to go.
The Ministry had initially (January, 2016) announced plans to build 10,000 functional primary healthcare centres across the country. Apparently, there was a redesign of plans which translated into a ‘revitalisation’ rather than a construction, as initially laid out. By the time President Buhari was commissioning the Model Primary Health Care Centre, Kuchigoro, Abuja, in January this year, the project seemed to have been further reviewed as one to be executed in phases. According to Emmanuel Odu, acting Executive Director of NPHCDA, “We are targeting 109 but we have completed the work in two healthcare facilities – Voka in Niger State and Kunchigoro in the FCT.”
On the Primary Health Care Centres, the questions arise – How sustainable is it to fund the operational expenses of Primary Healthcare Centres (PHCs) across Nigeria from the Basic Healthcare Provision Fund (BHCPF) which itself depends on contributions majorly from an annual grant from the Federal Government of Nigeria amounting to not less than one percent (1%) of its Consolidated Revenue Fund, of which there is no guarantee of payment by governments which struggle to pay pensions and statutory remittances? Can we rely, long term, on the sustainability of this template solely on the strength of additional contributions from donors and international partners which seem to be the leg upon which it presently stands?
It does appear that the 500 million dollar World Bank International Development Association (IDA) loan advanced in 2015 as a new development financing help for Nigeria to achieve its “Saving One Million Lives (SOML) Initiative” might be coming handy now. It would also appear that it is from this 500 million dollar facility that the 1.5 million dollar grant to each state is being financed. But how sustainable is such a plan, going forward? What measurable key performance indicators are in place to track the use and benefits of the grant to the states, given our recent history and the weakness in governance structure at different levels of government, which the Health Governance Capacity Index (HGCI) quoted above has noted? What really is the role of the other two tiers of government? It is good to be ambitious and dream big, but what can be possibly wrong with starting small and at the bottom? Can we address the problem bottom-up, rather than top-bottom? Can we spare a thought for a different approach to private sector-involved, community-based health insurance scheme, with some of these funds, rather than sinking it all into brick and mortar and equipment, with our poor maintenance culture? Can we design a community-led management team in this revitalisation initiative?
Recent advances have led medicine more in the direction of technology-led precision in diagnosis and treatment. Expensive as the new tools and gadgets are, but with every technological disruption, it does offer the smart ones at the bottom of the ladder the opportunity to leapfrog and take advantage of innovation. This cannot be wholly different in Healthcare. But it is the tendency on our part to go hardware rather than think software in fashioning solutions that is worrisome. The same tendency is evident in the healthcare sector. The capitalists have identified the gap and diagnostic centres are springing up all over the place, taking advantage of Nigerians, as expected. Even the Air Force Chief caught with his hand in the jar was kind enough to see the opportunity in investing in a top-range diagnostic centre. He probably didn’t think it was a good idea for the Air Force to set up one but by his own ingenious round-about approach, the one he set up as a private enterprise has now been handed over to the same Air Force.
There is no future to a healthcare system where uncertainty governs access and the system is largely powered by out-of-pocket payments in the private sector and an over-burdened public sector. The answer does not even lie in government simply putting more money in the health sector. You cannot build the future around a system where government has to build everything from primary health care centres to tertiary hospitals and pay competitive salaries to healthcare workers at all levels. The resources are not there and even if they were, it is not the smart way to go. It is the quality of our thought that is holding us back, not necessarily the lack of resources. That, to me, is the greatest impediment in many sectors in Nigeria, healthcare inclusive.