Little To Cheer In Health Sector, One Year After Buhari’s Second Term
• COVID- 19 Exposes How Unprepared Nigeria Is In Emerging World Diseases
• Healthcare Personnel, Medical Equipment, Especially In Rural Areas Have Remained Major Challenges.
• Health Has Never Really Been On The Priority List Of Governments At All Tiers
• Out- of- pocket Payments By Patients, Rundown Primary Health Centres Burden Health Sector
SINCE 2015 when he was inaugurated for his first term, President Muhammadu Buhari has continued to visit the United Kingdom ( UK) for medical checks contrary to the promise he made to Nigerians to end the practice. Shortly after he was inaugurated for a second term on May 29, 2019, he repeated the ritual.
Apart from Buhari, most members of his cabinet dash abroad to treat varying ailments, including non- life- threatening ones. In a good number of instances, they are treated by Nigerian doctors in these British hospitals.
Consequently, medical tourism and brain drain have continued to thrive as most Nigerian doctors and nurses are ever- willing to migrate abroad for further training and work as a result of better pay, improved facilities and exceptional conditions of service.
Under the present government, in late 2018, Nigeria was ranked as the country with the fourth worst maternal mortality rate in the world, only ahead of Sierra Leone, Central African Republic, and Chad.
According to the World Health Organisation ( WHO), Nigeria is rated 187th out of 191 countries in terms of healthcare delivery, and the third- highest in infant mortality in the world.
Last year and this year have witnessed heightened disease outbreaks, ranging from different strains of meningitis in the North, Lassa fever, monkeypox, and the rampaging Coronavirus Disease ( COVID- 19).
Before COVID- 19, the healthcare sector had its fair share of challenges, chief of which is inadequate funding. The budget for the health sector in 2019 was N340.45b, which represented 3.9 percent of the total budget – a+ far cry from the recommendation of the Abuja Declaration.
Capital expenditure for the sector in 2019 was about N50.15b, while the estimate for the 2020 Fiscal year was N46b.
In one of his addresses to lawmakers, President Buhari said his administration was interested in improving the lot of the health sector and this was the major reason for the increase in Value Added Tax ( VAT) rate draft, as communicated through the Finance Bill from five percent to 7.5 percent. There were promises to provide standard, quality, affordable, and accessible healthcare to all to achieve Universal Health Coverage as stipulated by the World Health Organisation ( WHO).
Available information on the planned health expenditure for 2020, before the outbreak of the pandemic, showed that the government was committing more of its resources to vaccines and immunisation efforts.
Also, the government has shown commitment in confronting high infant mortality as reflected in the setting aside of some funds in the 2020 health budget for the expanded midwives service scheme. The WHO proclaimed 2020 as the Year of the Nurse and Midwife in honour of the 200th birth anniversary of Florence Nightingale, with emphasis on strengthening Universal Health Coverage.
Another component of the 2020 health budget is the provision earmarked for the Basic Health Care Provision Fund ( BHCPF), which has the goal of substantially increasing revenue and improving Primary Health Care ( PHC) as contained in the country’s National Health Act.
In the work environment, there was relative peace and harmony among the various professional groups that make up the sector within the last year.
The three leading professional groups in the sector - the Pharmaceutical Society of Nigeria ( PSN), Nigerian Medical Association ( NMA) and the National Association of Nigerian Nurses and Midwives ( NANNM) recently signed a Memorandum of Understanding ( MOU) to work together for the ultimate good of patients.
That MOU was similar to that signed between the three groups and the Federal Government ( represented by the Federal Ministry of Health) that culminated in the increase in hazard allowance for all healthcare workers.
In the last one year, however, the country recorded some breakthroughs in polio eradication and is on the verge of eliminating polio despite the activities of Boko Haram insurgents and the significant increase in Wild Polio Virus type one ( WPV1) cases globally in 2019.
The progress is significant in the face of many challenges, including poor access to children in some parts of the country due to insecurity; poor health- seeking behaviour of Nigerians; vaccine hesitancy; malnutrition; poor sanitation, and inadequate funding for PHCS, especially at state and local council levels.
The country made history on August 21, 2019, when she went three years without a case of Wild Polio Virus ( WPV), as the last WPV case was isolated in a child in Borno State on August 21, 2016. With this record of three years without the virus, the country is supposed to be certified WPV free by the WHO, this month.
The certification, according to the WHO would happen after a careful assessment of the risk of missed transmission in inaccessible areas of Borno State, and in other countries in the region, where there is a lack of confidence in surveillance.
The global organisation, for the first time on September 25, 2015, delisted Nigeria from the polio- endemic list after interrupting transmission for 12 months beginning from July 24, 2014. Unfortunately, 25 months later, on August 21, 2016, another case of WPV was discovered.
If the WHO goes ahead to certify the country free of WPV this month, it would be one of the pleasant news in the sector in the last one year. Another positive step recorded in the sector of late is strengthening of the Nigeria Centre for Disease Control ( NCDC) ever before the COVID- 19 pandemic. The NCDC was getting ready for a possible Ebola virus or the WHO predicted Disease X before COVID- 19 emerged.
Conversely, the National Health Insurance Scheme ( NHIS), which was established to promote affordable healthcare to Nigerians has remained one of the major drawbacks in the sector over the years. After 20 years of its existence, about 75 percent of payments for health services in the country have remained out- of- pocket payments by patients. This development has constituted a major financial burden for many.
For consultant haematologist and Deputy Chairman, Medical Advisory Committee, University of Nigeria Teaching Hospital ( UNTH), Ituku Ozalla, Enugu State, Dr. Theresa Nwagha, the performance of the sector in the last one year leaves a lot to be desired.
According to her, one key contributor to the poor performance recorded in the health sector is the struggling nature of the structure, as well as the implementation of social and financial risk protection programmes for the poor, and the vulnerable group.
She noted that this risk protection should normally be provided through legislationbacked programmes geared towards poverty eradication, and addressing vulnerability and inequality in healthcare delivery.
The haematologist said one of such programmes is the NHIS. “Since its establishment, Nigeria is yet to cover the majority of its citizenry as up to 90 percent are still without health insurance coverage. Out of pocket payments remain the major source of healthcare financing thus limiting the poor and vulnerable from accessing quality and standard basic healthcare.”
She added that corruption, insecurity, lim
ited institutional capacity, and an unstable economy remain some of the major factors that are responsible for the poor development, deployment, and performance of health services in the country.
Nwagha, who blamed the dwindling population of experienced healthcare workers on the brain drain, which has ravaged the sector, noted that in addition to this, the ratio of the distribution of health workers within healthcare facilities, intra and inter- professional rivalry, poor remuneration and welfare packages have in the past led to numerous strike actions, strife, and disruption of healthcare delivery in the country.
The Founder/ Chief Executive Officer ( CEO) of Innovative Biotech Limited, Keffi, Dr. Simon Agwale, shares Nwagha’s views that without a functional primary healthcare subsector, nothing much can be achieved in the sector since most Nigerians reside at the grassroots level.
The virologist/ vaccinologist said: “Any nation that has not got a solid primary healthcare base is still far from reality. Our primary healthcare sector is yet to have the basics, and most primary healthcare centres do not function optimally. They lack facilities and personnel. I will also emphasise vaccines because they are the foundation of a solid health base. These primary health centres are the custodians of vaccine administration. So unless they are made to function properly, we shall continue to record occurrences of preventable diseases in the country. The non- functioning of primary health centres shifts the pressure to tertiary health institutions, which now treat ailments, which should be handled at the primary level. The implication of this is that the cost becomes out of hand, thus making some people who are mainly low- income earners to be unable to access such services.”
So, for Agwale: “I rate the health sector performance in the first year of Buhari’s second term very low. It is a pity that some ailments that are preventable through vaccination are still prevalent in Nigeria. Some of them are yellow fever, typhoid, diarrhoea, Human Papilloma Virus ( HPV), diphtheria, meningitis, etc. We do not have vaccine capacity in the country and so we rely on the outside world for this, and it is unfortunate. What our health authorities have failed to realise is the injury caused to the economy by not building the nation’s vaccine capacity. What is spent on purchasing vaccines in a decade can build our vaccine capacity and create many job opportunities for our teeming youths.
“Only recently, the United States government threatened to permanently stop funding the WHO. If this happens, the impact will be very serious for Nigeria because the WHO supports most of our programmes, and our vaccination programme is already complicated by COVID- 19 and disease surveillance systems. This again calls for Nigeria to localise the production of vaccines and other medical supplies, as well as drive the distribution and market share growth across SubSahara Africa. This strategy will provide local, reliable, and sustainable supply. This strategy will also enable us to be strategically positioned to respond to epidemics within the sub- region.”
But as far as the Chairman, Expert Committee on COVID- 19, Prof. Oyewale Tomori is concerned, the country’s greatest public health risks and threats are our political leaders who, over the years, have subjected our healthcare services to unparalleled neglect and leaving us vulnerable and defenseless against all imaginable diseases, ranging from Lassa fever to yellow fever, to monkeypox and now COVID- 19…”
Tomori, a virologist said COVID- 19 has succeeded in exposing the underbelly of the country’s health sector, stressed that the time has come for the country to do a serious selfassessment if it is serious about preserving the health of Nigerians.
Tomori said: “COVID- 19, whenever it is over, may yet be another lesson forgotten, or it may be an opportunity for us to do some deep thinking regarding where we are; where we come from; why we are where we are; what we have done wrong; what was and is still responsible for our wrongdoing, as well as who was and is still responsible. Let us move away from self- pity and blame and identify the strengths; the talents; the attitude and the decent morality that made us a once proud and confident nation, and a nation that against all odds and expectations overcame Ebola…”
Equally assessing the performance of the country’s health sector in the last one year, the President, Pharmaceutical Society of Nigeria ( PSN), Sam Ohuabunwa said: “The performance of the healthcare sector in the last one year cannot be objectively assessed due to lack of current data. However, from anecdotal reports, I do not know, which health statistics have shown any significant improvement in the last year. When I checked the infant mortality rate ( 76 per 1, 000 life births), the under- five mortality rate ( 120 per 1, 000 lifebirths), maternal mortality ( 576 per 1, 000 live births, and life expectancy ( 52/ 53 years) reported in 2018 have remained largely flat or worsened in some cases.
“Death due to malaria has not shown improvement in the last two years. Seasonal epidemics of Meningitis and Lassa fever are still ravaging parts of Nigeria. Our tertiary hospitals are still managing primary healthcare issues as many of the primary and secondary healthcare centers are poorly resourced and managed.”
Ohuabunwa added: “Then the arrival of COVID- 19 caught us largely unprepared and further exposed the frailty of the health systems in many states. Were it not for the commendable philanthropic intervention of the private sector, things would have been worse.”
As a stakeholder in the value chain of healthcare contributing to access to medicine, the Chairman, Pharmaceutical Manufacturers Group of the Manufacturers Association of Nigeria ( PMG- MAN) and the CEO/ MD Fidson Healthcare Plc, Dr. Fidelis Ayebae says access to medicine is a huge component of healthcare delivery that guarantees medicine security.
While deploring a situation where a patient in the creeks, or in that remotest village still dies due to preventable diseases, or not being able to have guaranteed, timely access to safe, quality and affordable medicine or care, Ayebae said a lot is still needed to change the narrative, which is dependent on strong political will to drive radical policies that offer homegrown solutions to the myriad of problems facing the sector. This, he said, includes, creating an enabling environment for the private sector to complement the role that government plays in the healthcare sector; putting in place policies to retain our health professionals that are leaving the country; taking away mediocrity on issues of leadership- by always engaging those that are fit for purpose to lead in the sector, and strengthening the capacity of our institutions from infrastructural to skillset and knowledge.
“Our research institutes should be well funded, the same with our health institutions and regulatory agencies. There must be the sincerity of purpose at all levels of healthcare policy engagement,” Ayebae stated, adding that for local pharmaceutical manufacturers to complement the healthcare sector and keep closing the gap in access to medicine, some policy measures must be followed through by the government.
And for consultant pharmacist and former President of the PSN, Mr. Olumide Akintayo, the sector has not witnessed any substantial change because its drivers are essentially the same, and if the mentality does not change, the output will, of course, be static.
He noted that apart from leadership challenges, the country has continued with the culture of poor health plans and management, which allows inadequate competencies and capacities to fester in the health system rated in the recent past as 187th out of 191 health systems around the world. Akintayo said politics in the health sector, which encourages the trampling of other professions apart from doctors, remains a destructive factor, which constantly militates against its proper functioning, and which must be ameliorated before the country can re- strategise and raise the bar. Interestingly, the Executive Director, National Primary Healthcare Development Agency ( NPHCDA), Dr. Faisal Shuaib, is of the view that the country has made significant progress in the primary healthcare landscape in the course of this administration, and within the last one year. According to him, to objectively assess the performance of the sector, it is important to look at the indices and the plans that are already being implemented, stressing that it is noteworthy that Nigeria is on the verge of being declared polio- free in the next few weeks, and over the last one year, the team has worked assiduously to ensure that the transmission of polio is halted and the gains achieved translate to the overall goal of polio eradication in the country.
While pointing out that the North East has been most impacted by insurgency and its attendant effects, including the lowest maternal and child health indices in the country; population displacements, insecurity and general distortion in the healthcare architecture, he said in many communities in the North where health facilities were no longer in existence, “under the leadership of President Buhari, there has been a strong commitment to restoring the required primary health infrastructure in the region.”
The National Chairman, Association of Hospital and Administrative Pharmacists of Nigeria ( AHAPN), Dr. Kingsley Chiedu Amibor, who believes the government may be rated high by some because of the way it responded and handled the Coronavirus pandemic, however, regretted that the major challenge that the sector has encountered is its inability to meet the health needs of the people due to poor budgetary provision.
“The provision was significantly below the 15 percent benchmark set by the African Union in 2001 to promote healthcare delivery across the continent.”
Glaring Public Health Challenges
ACCORDING to Amibor, some of the major public health challenges that the country has continued to grapple with include infectious diseases, maternal mortality, infant mortality, poor sanitation and hygiene, disease surveillance, non- communicable diseases, and road traffic injuries, while top causes of deaths include, malaria fever, lower respiratory infections, Human Immuno- deficiency Virus
( HIV)/ Acquired Immune Deficiency Syndrome ( AIDS), diarrheal diseases, malnutrition, cancer, meningitis, stroke, and tuberculosis.
The President, Nigerian Association of Resident Doctors ( NARD), Dr. Aliyu Sokomba, who maintains that the sector in the last one year leaves a lot to be desired, explained that factors that have impacted negatively on its performance include poor government commitment; corruption; absence of legislation to sanction medical tourism; inadequate resources/ budgets, and lack of a coordinated response by the Federal Ministry of Health ( FMOH) and all partners including state governments.
But the Director- General of the Nigerian Institute for Medical Research ( NIMR) Yaba, Lagos State, Prof. Babatunde Salako, begs to differ from Sokomba.
In assessing the sector’s performance, he submitted: “I will say it is stable. Although there were some threats of indus
trial actions, we did not see any serious one, so hospital users enjoyed whatever standard of healthcare that we were able to provide. Oftentimes, strikes have prevented us from maximal use of the healthcare services available. I believe we have the right calibre of healthcare workers, but our infrastructure needs a serious facelift.” Even though he admitted that access to high- quality health is still a challenge and needs to be improved,” he added that “disharmony in the health sector is a big deal and needs to be tackled headon,” he said.
For Professor of Pharmacology and pioneer Director- General for the National Institute of Pharmaceutical Research and Development ( NIPRD) Charles Obadiah Wambebe, the inadequacy of health centres, healthcare personnel, and medical equipment, especially in rural areas have remained major challenges.
He regretted that despite the Federal Government propagating various healthcare reforms, not much has come to fruition at the state and local government levels. Wambebe, who currently serves as Professor Extraordinaire at the Tshwane University of Technology, Honorary Professor of Pharmacology, School of Medicine, College of Health Sciences, Makerere University, Uganda, as well as a consultant for the WHO, said the country’s healthcare system has been weakened by lack of proper coordination; inadequate resources ( including drugs, consumables); inadequate and deteriorating infrastructure; unequal resource distribution and access to care, and even deplorable quality of care.
Wambebe stressed that access to healthcare is less than half of the country’s population, which may be due to demographics, as about 55 percent of the population reside in rural areas.
He pointed out that about 70 percent of healthcare is provided by private health practitioners and 30 percent by the government, noting that this results in significant outof- pocket expenditure in a country where over half of the population live below the poverty line, on less than $ 1 a day.
He recalled that due to little impact made on the country’s health sector with the introduction of the Federal Government’s primary healthcare plan in 1987, the NHIS, which was established to reduce the financial burden of medical bills on the citizens, among others has been ineffective in catering for Nigerians since the scheme represents only 40 percent of the entire population that work in the formal sector.
The high cost of accessing government tertiary hospitals and the bureaucratic bottlenecks involved, the pharmacologist said, has led to an increase in the demand for private healthcare, which caters mostly for the middle- class, and not generally available to the masses due to the high cost of their services.
Also analysing challenges in the sector, Shuaib, the NPHCDA boss said it is evident that the country has not attained the desired outcome, hence the need to redouble efforts in addressing some niggling issues, including inadequate human resources ( especially skilled staff); haphazard distribution of the available health workers; inadequate funding, poor infrastructure, and poor service delivery.
Achievements Hard To Find
DIFFICULT as landmark achievements are hard to find in the sector in the last one year, several experts agree that eradicating WPV, which the country is on the cusp of is worth celebrating.
According to Ohuabunwa: “One major success I think Nigeria has scored in recent times is the eradication of wild poliovirus ( WPV). I think we have seen some states building new hospitals and the Federal Government has been rehabilitating some primary health centres. This is the much of achievements that I can point to.”
But for Tomori: “If you are talking about achievements in healthcare, please help me name one. Oh yes! At least we have finally eradicated polio as the last nation in Africa to do so. Hopefully, we will be certified soon. However, this COVID- 19 matter, which has taken all our attention and made us neglect every other aspect of our lives, maybe the undoing of our hard- earned polio achievement. If we are not careful, this COVID- 19 may be the beginning of the health calamity that is looming, as we relegate other healthcare interventions to the background…”
The NARD President Sokomba equally agrees that there is very little to cheer in the first year of Buhari’s second term. His words: “There are quite a few achievements in the sector in the first year of Buhari’s second term I must say. But the eradication of polio is commendable, just as the improvement of the NCDC’S capacity is.”
While Salako said that making the Basic Healthcare Provision Fund functional has the potential to make funds available to the Nigerian health system, leading to effective healthcare services, Shuaib maintains that currently, more than 2,
200 primary healthcare facilities have been established in the six North East states and other states, including Ondo and Nasarawa states, with improved functionality, through performance- based financing ( PBF) model.
He said that in the last two years, the number of beneficiaries accessing care through this PBF initiative doubled from an initial 16 million to 33 million.
In explaining Buhari’s strides in ensuring that children are protected against vaccine- preventable diseases, NPHCDA’S executive director, Shuaib drew attention to the 2016/ 2017 National Immunisation Coverage Survey ( NICS)/ Multiple Indicator Cluster Survey ( MICS), which showed a national immunisation coverage of 33 percent, with more than two- third of children, who are under the age of one year unprotected against vaccine- preventable diseases.
He said: “Under the leadership of
Mr. President, a state of emergency of public health concern was declared on routine immunisation and this culminated in the establishment of the National Emergency Routine Immunisation Coordination
Centre ( NERICC) to lead efforts towards revamping routine immunisation.”
Shuaib, who explained that NERICC has implemented key strategies to set the country back on the upward trajectory of improvement for routine immunisation, added that the most recent National Demographic Health Survey ( NDHS) of 2018 showed evidence of improvement with a leap from 38 percent to 50 percent in the national immunisation coverage. Other recent surveys such as the National Nutrition Health Survey ( NNHS) show similar improvements from 49 percent in 2015 to 57 percent in 2018.
He said to strengthen community participation and ownership of primary healthcare, Buhari also launched the Community Health Influencers, Promoters and Services ( CHIPS) initiative as part of the revamped Village Health Worker Model. Through CHIPS, he said community- based resource persons have been trained to facilitate improvements in access to healthcare by linking communities with health facilities.
While admitting that the country has a high maternal mortality rate of 512 maternal deaths to 100, 000 live births, and in response to this, this administration established the National Emergency Maternal and Child Health Intervention Centre ( NEMCHIC), following the state of emergency declared on maternal and child health.
Additionally, Shuaib said to strengthen the human resource gap on maternal health, 2, 500 midwives were recruited under the Midwives Services Scheme ( MSS), which was also launched by President Buhari. The focus of this is to ensure that there is a skilled birth attendant in every primary healthcare centre, and the MSS programme has also been successfully incorporated into the in- service training programme of nursing schools by the Nursing and Midwifery Council.
Shuaib said in a bid to further improve access and delivery of PHC services, the Integrated Medical Outreach Programme ( I– MOP) was also launched on March 16, 2020, and the programme, which was put on hold due to the current COVID- 19 outbreak, is aimed at improving health services provided to targeted low performing communities in 53 percent of LGAS ( 409) in all 36 states and the FCT.
Like Tomori and Sokomba, the former PSN President, Akintayo said there have been marginal gains in the sector and points at the increase of hazard allowances for health workers as one of them.
He, however, criticised the dichotomy in the payment of hazard allowances to reflect senior and junior players insisting that the “virus or infecting pathogen does not discriminate on this basis before it strikes. We do hope this will be redressed in the post- COVID19 dispensation.”
For Agwale, Innovative Biotech Limited’s founder/ CEO: “One of the achievements of the sector in the last year is that we now know how unprepared we are on health matters. We have also realised that we did not build on the lessons from Ebola. No thanks to the fact that again, the Lagos State government, and the late Ebola Heroine, Stella Ameyo Adadevoh were proactive enough to stem the spread.
“The COVID- 19 lessons are many, and if we learn better and faster, we can achieve a lot from it. One, molecular testing centres are springing up across the states.
I have also read that a privately owned testing centre has been launched in Anambra State and another in Abuja. I commend the private sector initiative on this. In developed societies, these things are almost in the hands of the private sector while the government regulates and provides incentives for research.”
Consultant haematologist, Nwagha believes that it would be unfair to say that there has not been any achievements in the last one year even though she admits that there is room for a lot to be done. According to her, “there has been a marginal increase in budgetary allocation to the health sector, but it is still a far cry from the advocated 15 percent, and the government has also signed into law, the NCDC Bill; these are great milestones.”
She regretted that Nigeria is a country with good ideas and policies, but still struggles in the implementation of such policies, adding that social and financial risk protection strategies to ensure basic healthcare through UHC like NHIS, PHC among others should be further encouraged and supported. “Even the government realisation of the needs and gaps in the health care sector, especially during the COVID- 19 pandemic gives a lot hope to the Nigeria health sector,” she said.
Surmounting The Hurdles
THE NARD President, Sokomba is of the view that one of the best ways to make a head way is to have a “robust stakeholders summit on revamping the health sector, and it should involve governments at all levels, the Central Bank of Nigeria ( CBN), and the organised private sector. The government may wish to take a queue from the Nigerian Medical Association ( NMA) health summits of the past.
“We need to strengthen the FMOH to play the coordinated role of the health sector, and perhaps consider the need for appointing a Chief Medical Officer/ Surgeon General for the country to help direct a coordinated response.”
For Salako, “improving infrastructure at the primary healthcare level would increase access to robust primary care services. Encourage states to bring back secondary care levels as tertiary care are currently overwhelmed; increase internship spaces for HCWS in that category, and monitor and evaluate the system closely to ensure judicious use of the available resources,” he submitted.
Nwagha agrees that the government needs to do more by putting the healthcare sector at the priority level that it deserves. This it could start with proper budgetary allocation to health, proper funding and governmental support to NCDC, NHIS, PHC and other healthcare programmes.”