Why I didn’t re­sign when Pres­i­dent re­in­stated NHIS boss –Ade­wole

Min­is­ter of Health, Prof. Isaac Ade­wole, tells GBENRO ADEOYE and TUNDE AJAJA about the chal­lenges in the health sec­tor, what the gov­ern­ment is do­ing about them and why he did not re­sign his po­si­tion fol­low­ing the po­si­tion of Pres­i­dent Muham­madu Buhari on

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The health sec­tor is a very im­por­tant as­pect of the econ­omy as it has to do with the well­be­ing of the peo­ple. How dif­fi­cult has it been manag­ing this crit­i­cal sec­tor? It has been very in­ter­est­ing and tax­ing. The sec­tor spans research de­vel­op­ment, pol­icy-mak­ing and ser­vice de­liv­ery, with dif­fer­ent agen­cies, paras­tatals and depart­ments un­der the sec­tor fo­cus­ing on dif­fer­ent el­e­ments. As a min­is­ter, I pro­vide the sec­tor with strate­gic lead­er­ship and stew­ard­ship. From a ser­vice de­liv­ery point of view, I en­gage reg­u­larly with the depart­ments to en­sure pro­grammes are be­ing im­ple­mented ac­cord­ing to plan. I re­ceive up­dates from the Nige­ria Cen­tre for Dis­ease Con­trol on emer­gency re­spon­sive­ness to dis­ease out­breaks and work with other sec­tors to col­lab­o­ra­tively ad­dress the so­cial deter­mi­nants of health. I also in­ter­act with heads of ter­tiary health in­sti­tu­tions to en­sure that we ful­fil our man­dates. I also in­ter­act with Nige­ri­ans who nurse griev­ances and seek as­sis­tance. Since you as­sumed of­fice as the min­is­ter, what would you de­scribe as the most dif­fi­cult de­ci­sion you have made or the tough­est part of your job?

The tough­est part is manag­ing peo­ple and the most dif­fi­cult de­ci­sion was ex­plain­ing to Mr Pres­i­dent why a po­lio-virus case was de­tected in Borno State. Luck­ily, he demon­strated to­tal un­der­stand­ing and pro­vided un­par­al­leled sup­port. He di­rected full re­lease of N9.7bn bud­geted for po­lio erad­i­ca­tion. This was the first time Nige­ria would re­lease the to­tal amount of money ap­pro­pri­ated for any health chal­lenge. Be­ing a for­mer mil­i­tary man, he un­der­stood the chal­lenges of de­liv­er­ing ser­vices in a con­flict zone. Peo­ple have al­ways de­scribed the health sec­tor as a trou­bled one and that no sub­stan­tial progress has been made over the years, in terms of in­fras­truc­tural de­vel­op­ment? Why has it been dif­fi­cult to sur­mount the in­fras­truc­tural deficit in the sec­tor? The cur­rency for mea­sur­ing the health sec­tor should be the cov­er­age of health in­di­ca­tors and not in­fra­struc­ture.

In this re­gard, we have done a lot but can do more. Our rou­tine im­mu­ni­sa­tion cov­er­age (Penta 3) for in­stance, has gone up to 57.2 per cent from 48 per cent in 2015. We are dis­tribut­ing more lon­glast­ing in­sec­ti­cide-treated nets to re­duce the bur­den of malaria. We recorded a drop in the preva­lence of malaria from 42 per cent to 27 per cent.we are com­plet­ing the aban­doned Can­cer Cen­tre at Na­tional Hos­pi­tal, Abuja and have in­stalled the High En­ergy Lin­ear Ac­cel­er­a­tor (Can­cer Ra­dio­ther­apy Ma­chine) that was in the crate for three years. Since in­stal­la­tion, we have been treat­ing 80 to 100 pa­tients daily at the can­cer cen­tre. We also ac­quired a sec­ond ma­chine through the gen­er­ous sup­port of SNEPCO. This should be­come op­er­a­tional soon. Work is go­ing on at the Univer­sity Col­lege Hos­pi­tal, Ibadan and Ah­madu Bello Univer­sity Teach­ing Hos­pi­tal, Zaria, where we are build­ing bunkers to house high en­ergy lin­ear ac­cel­er­a­tors to of­fer can­cer care to Nige­ri­ans. I have vis­ited Univer­sity of Benin Teach­ing Hos­pi­tal, Benin; ABUTH, Zaria; Fed­eral Teach­ing Hos­pi­tal, Ido-ek­iti, among oth­ers to in­au­gu­rate up­grades and newly com­pleted pro­jects. We have com­pleted the Cen­tral Lab­o­ra­tory at Gadua (Bauchi State) and in­au­gu­rated two ul­tra-mod­ern to our sig­na­ture ware­houses pro­jects of in mak­ing Abuja and 10,000 La­gos. pri­mary These health are ad­di­tional care pro­jects Nige­ria func­tional and two across war-torn the coun­try. coun­tries (Pak­istan and Afghanistan) the scourge of are po­lio. the Do only you ones not that some­times have failed find to things tackle like this em­bar­rass­ing?

No one is happy about the cur­rent sit­u­a­tion. It how­ever must be said that the de­lay in declar­ing Nige­ria po­lio-free, arose from the de­tec­tion of a po­lio case in the con­flict zone in Borno. Since then, we have re­dou­bled our ef­forts and no case of wild po­liovirus has been de­tected in Nige­ria in the last 30 months. We are cau­tiously op­ti­mistic that this will re­main so. mor­tal­ity Nige­ria is rate also in said the world, to have and the peo­ple high­est have ma­ter­nal said with Nige­ria the has level no of busi­ness its skilled be­ing man­power on that and level, re­sources. es­pe­cially Is this A bit not of dis­com­fort­ing? cor­rec­tion, Nige­ria does not have the high­est ma­ter­nal mor­tal­ity rate in the world. We ac­knowl­edge that our in­dices have not been great, but we have in­sti­tuted sev­eral in­ter­ven­tions to ad­dress this. For in­stance, the Ac­cel­er­ated Ma­ter­nal Mor­tal­ity Re­duc­tion pro­gramme is aimed at rapidly re­duc­ing the MMR in states with the worst mor­tal­ity rates. Also, the Ba­sic Health­care Pro­vi­sion Fund and the Saving One Mil­lion Lives ini­tia­tive would help bridge the gap in ac­cess to high im­pact ma­ter­nal in­ter­ven­tions aimed About at re­duc­ing three years mor­tal­ity. ago, you in­au­gu­rated the one pri­mary how long health will the care pub­lic cen­tre wait per for ward the gov­ern­ment pro­gramme. to For cover the re­main­ing 10,000 wards af­ter its in­au­gu­ra­tion at Kuchin­goro Ward of the Fed­eral Cap­i­tal Ter­ri­tory by Pres­i­dent Muham­madu Buhari? The pro­gramme is on­go­ing and we are happy with the progress. Al­most all the states have now iden­ti­fied their one pri­mary health care cen­tre per ward and are at dif­fer­ent stages of re­vi­tal­i­sa­tion. We have, through the sup­port of part­ners and other op­tions, re­vi­talised over 4,000 PHCS mostly in ru­ral ar­eas and we are still count­ing. Many states such as Kaduna, Kano, Niger, Borno, Edo and Osun are tak­ing on the ini­tia­tives

It has been ob­served that a large num­ber of pa­tients in the ter­tiary hos­pi­tals should have vis­ited pri­mary and se­condary health fa­cil­i­ties in­stead, but the re­verse of that has put enor­mous pres­sure on the teach­ing hos­pi­tals. What is the way out? We are aware of this and we are putting in mea­sures to re­verse this. One of the mea­sures is the Ba­sic Health­care Pro­vi­sion Fund, which guar­an­tees that ser­vices de­liv­ered at se­condary care fa­cil­i­ties must be based on ap­pro­pri­ate re­fer­rals. Also, the PHCS re­vi­tal­i­sa­tion pro­gramme is specif­i­cally tar­geted to­wards this. On the NHIS cov­er­age, what per­cent­age of cov­er­age did you meet on the ground and how much have you added? We are con­cerned about the low cov­er­age. With the BHCPF, we hope to rapidly ex­pand ac­cess to mil­lions of Nige­ri­ans. Look­ing at the amount of money Nige­ri­ans spend on med­i­cal tourism yearly, why is it dif­fi­cult for the Fed­eral Gov­ern­ment to set up a mul­ti­pur­pose med­i­cal fa­cil­ity that can take care of the med­i­cal needs of Nige­ri­ans, es­pe­cially on is­sues of can­cer and heart-re­lated prob­lems?

This is of ut­most con­cern to the Pres­i­dent Muham­madu Buhari ad­min­is­tra­tion. We have worked hard on this and have started see­ing the re­sults. re­quired Why is ma­chines it that Nige­ria to save could the not lives buy of cit­i­zens, many of be­cause the there of the are seven times in the that coun­try? only one or two will be work­ing out

The Na­tional Hos­pi­tal now has all it takes to treat can­cer cases. We have two high en­ergy LINAC ma­chines that have ca­pa­bil­ity to treat 200 pa­tients per day. Many Nige­ri­ans who went to Ghana and In­dia for treat­ment are coming back as it costs about 20 per cent of the cost of treat­ment over­seas to get treated in Nige­ria. The Pres­i­dent once frowned upon med­i­cal tourism but he has con­tin­ued to do that him­self, es­pe­cially when the State House clinic is not in proper shape af­ter al­legedly gulp­ing bil­lions of naira. Shouldn’t there be a law that would bar pub­lic of­fi­cers from trav­el­ling abroad for treat­ment?

Pub­lic ser­vants, like ev­ery other

Nige­rian, should be able to seek care any­where they are com­fort­able with.

Don’t for­get also that in­di­vid­ual pref­er­ences mean peo­ple may have per­sonal doc­tors they are used to. In ad­di­tion, some were treated in the past and may re­quire fol­low-up. We are also very se­cre­tive about our health and med­i­cal his­tory. Most Nige­ri­ans die af­ter a brief ill­ness.

I hon­estly be­lieve it is part of their rights in as much as pub­lic funds are not used. In in­stances where the ca­pac­ity to treat lo­cally is lack­ing, then pub­lic ser­vants may get sup­port from gov­ern­ment for fund­ing. The health sec­tor has suf­fered low bud­getary ap­pro­pri­a­tion over the years, de­spite the glar­ing needs in the sec­tor. Are there no other ways the min­istry could gen­er­ate funds or other ways it could meet its obli­ga­tions to the Nige­rian peo­ple?

There are, and we are work­ing on it. To­gether with the Min­istry of Fi­nance, we are ex­plor­ing some in­no­va­tive ways to ex­pand the fis­cal space. For in­stance, we are con­sid­er­ing the sin taxes and tele­coms levy. There are plans to en­cour­age pri­vate sec­tor par­tic­i­pa­tion in health­care fi­nanc­ing by de­vel­op­ing in­vest­ment case for health. The ini­ti­a­tion of Ba­sic Health­care Pro­vi­sion Fund and the op­er­a­tional­i­sa­tion of Saving One Mil­lion Lives ini­tia­tive are de­signed to ex­pand the fis­cal space. In the past, it was gath­ered that peo­ple came from out­side the coun­try for surgery, but now it’s Nige­ri­ans that run to other coun­tries for treat­ment. How did Nige­ria’s health sec­tor de­gen­er­ate to the level it is?

Poor fund­ing in the past con­trib­uted to this, but that is grad­u­ally chang­ing now. The gov­ern­ment has ear­marked the sum of N55.1bn for the Ba­sic Health­care Pro­vi­sion Fund. Also, the teach­ing hos­pi­tals are now be­ing sup­ported to im­prove their per­for­mance man­age­ment in a man­ner that en­sures con­tin­u­ous qual­ity im­prove­ment of ser­vices and skills train­ing. How­ever, I must point out that not all Nige­ri­ans go on med­i­cal tourism. A lot of our peo­ple seek care at home and they have good tes­ti­monies about our health­care sys­tem. Af­ter the Na­tional Health In­surance Scheme boss, Prof. Us­man Yusuf, was re­in­stated by the Pres­i­dent, fol­low­ing his sus­pen­sion amid cor­rup­tion al­le­ga­tions and ob­vi­ous in­sub­or­di­na­tion to your of­fice, many Nige­ri­ans who know you and what you stand for thought you would re­sign. Why did you not re­sign?

Peo­ple who un­der­stand what lead­er­ship is all about can­not but un­der­stand why cer­tain de­ci­sions taken by a su­pe­rior au­thor­ity should be re­spected. I saw it in that con­text. My ap­point­ment is a call to ser­vice and not an op­por­tu­nity to com­pete with my boss. Af­ter his re­in­state­ment, the Pres­i­dent only said he should learn to work with his boss. Peo­ple feel the Pres­i­dent took sides with Us­man. Did you feel bad about

it dur­ing that pe­riod? As an in­sider, I did not (feel bad). And how was your work­ing re­la­tion­ship with him be­fore he was even­tu­ally sus­pended?

We worked to­gether and am­i­ca­bly to im­prove the cov­er­age of health­care ser­vices. Re­cently, the Pres­i­dency said the board lacked the power to sus­pend the chief ex­ec­u­tive of an agency. In your view, would you say the min­is­ter should be armed with such power since you head the su­per­vis­ing min­istry?

Once boards are con­sti­tuted, a min­is­ter’s role in su­per­vi­sion be­comes min­i­mal. The is­sue of the pow­ers of the min­is­ter is se­condary. Broadly speak­ing, the NHIS Act would need to be re­viewed to en­able the or­gan­i­sa­tion to carry out its func­tions op­ti­mally. Re­cently when you were asked about the stress doc­tors go through for their house­man­ship, you said not all of them would be spe­cial­ists and that some of them could go into farm­ing. Peo­ple feel that com­ment was not good enough as it seemed to un­der­mine the as­pi­ra­tions of those doc­tors. Do you stand by that state­ment?

The point I was try­ing to make was lost in the con­text. Firstly, there are dif­fer­ences be­tween med­i­cal schools and res­i­dency pro­grammes. As at to­day, we pro­duce more med­i­cal grad­u­ates than the avail­able res­i­dency slots. This sim­ply means the de­mand is greater than the sup­ply. Re­cently, a teach­ing hos­pi­tal in­ter­viewed 850 po­ten­tial ap­pli­cants for 120 slots. It is also im­por­tant to note that as at to­day, the Fed­eral Gov­ern­ment’s spend­ing on health is dis­pro­por­tion­ately tilted to ter­tiary care, which makes ad­di­tional in­vest­ment in ter­tiary care and by ex­ten­sion res­i­dency dif­fi­cult.

I would also like you to note that the ex­pan­sion of slots for res­i­dency has im­pli­ca­tions on civil ser­vice wage and va­can­cies de­clared in au­tho­rised es­tab­lish­ments have to be ap­proved by the civil ser­vice com­mis­sion. Sim­i­larly, the Fed­eral Gov­ern­ment is the sin­gle largest em­ployer of res­i­dent doc­tors as there are lim­ited pri­vate ter­tiary fa­cil­i­ties.

My point about doc­tors max­imis­ing their vo­ca­tional skills and po­ten­tial was based on these re­al­i­ties above and cer­tainly not meant to slight my hard-work­ing col­leagues or Nige­ri­ans at large.

Some of the doc­tors are ask­ing why you would say that es­pe­cially when you didn’t go through all that as a bud­ding doc­tor as some peo­ple be­fore you had made things easy for you. Do you have a feel of their plight?

I was mak­ing a case for the de­vel­op­ment of en­tre­pre­neur­ial ca­pa­bil­i­ties to re­po­si­tion doc­tors for the 21st cen­tury labour mar­ket.

That said, I com­pletely un­der­stand the con­straints, frus­tra­tions faced by med­i­cal doc­tors seek­ing res­i­dency slots and we are work­ing hard to in­crease the slots. For in­stance, we are ac­tively en­cour­ag­ing pri­vate sec­tor in­vest­ments in ter­tiary care that pro­vide more op­por­tu­ni­ties for spe­cial­ist train­ing. We are also work­ing on re­duc­ing the ex­tended stay of those who have fin­ished the res­i­dency pro­gramme but still hang on.

Some peo­ple see it as an ad­mit­tance of fail­ure on the part of the Fed­eral Gov­ern­ment be­cause they feel gov­ern­ment should be work­ing on ways to bridge that gap. What is the so­lu­tion you are prof­fer­ing to the

short­age of place­ment for house­man­ship and res­i­dency train­ing?

There is no short­age of place­ment for house­man­ship. What is cre­at­ing the bot­tle­neck is the in­abil­ity of states to pay the right wages to doc­tors. We are com­menc­ing cen­tral place­ment of house­man­ship with ef­fect from 2019. The cen­tral post­ing of other health pro­fes­sion­als will fol­low there­after. When you came in, you promised to do some­thing about the plight of can­cer pa­tients, many of who put their hopes in one or two ma­chines in the whole coun­try when small Morocco has many of them. Why is it that gov­ern­ment presents it­self as in­ca­pac­i­tated as Nige­ri­ans suf­fer from can­cer and are still dy­ing need­less deaths?

Like I men­tioned ear­lier, we now have two fully func­tional ma­chines at the Na­tional Hos­pi­tal, Abuja ca­pa­ble of treat­ing 200 pa­tients per day. We have or­dered for more ma­chines and we are up­grad­ing the teach­ing hos­pi­tals across the coun­try to be able to pro­vide ad­e­quate care. We will con­tinue to do ev­ery­thing to al­le­vi­ate the chal­lenges as­so­ci­ated with ac­cess­ing qual­ity care. There seems to be a surge in the in­ci­dences of can­cer and heart-re­lated ail­ments. Some peo­ple have tied it to life­style and some other rea­sons. As a doc­tor of many years, what is re­spon­si­ble for this rise?

A num­ber of rea­sons are re­spon­si­ble for these. Like you have rightly said, life­style is a fac­tor. One other thing to note is that we are hear­ing about it more now be­cause there’s more data out there and also be­cause of the in­ter­con­nec­tion aris­ing from the use of mul­ti­ple so­cial me­dia plat­forms. We have also im­proved our di­ag­nos­tic ca­pa­bil­i­ties. Can­cer is also es­sen­tially re­lated to age­ing. We ex­pect the bur­den to in­crease as our life ex­pectancy in­creases. We have been talk­ing about Lassa fever for many years and noth­ing has changed in the year 2018. Why is it so dif­fi­cult for Nige­ria to deal with this and many other vac­cine-re­lated dis­eases af­ter so many years?

Lassa fever is a dis­ease deeply rooted in the en­vi­ron­ment. We have im­proved our un­der­stand­ing of the dis­ease and ca­pa­bil­ity to di­ag­nose and treat it. We are send­ing out alerts and warn­ing mes­sages to Nige­ri­ans about the threat and I can as­sure you that research for can­di­date vac­cines is in top gear. Global warm­ing could be con­trib­u­tory to low level trans­mis­sion dur­ing wet sea­sons.

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