State of health in Nigeria
Background:
Nigeria is a nation on the west coast of Africa. It is made up of a large number of ethnic nationalities and diverse landscapes.
The population has increased massively since Independence in 1960, when it was estimated at 45.2 million people. Currently the best estimation stands at 185 million.
There are over five hundred languages spoken locally.
Nigeria is an oil-producing nation and a prominent member of the Organization of Petroleum Exporting Countries (OPEC). Oil still constitutes the mainstay of Nigeria’s economy, despite the efforts by succeeding governments of an intention to diversify the economy.
Nigeria, despite its oil wealth, is not a rich nation. The indices concerning its citizens – their quality of life and standards of education and health, are abysmal. More than half of the population live on less than $1.25 a day (‘Poverty Head-count’) making them one of the poorest populations in the world. In the 2018 ranking of the Human Development Index (UNDP), a measure of general quality of life for the citizenry, Nigeria is ranked 157 out of 189 countries ranked in the world.
Human Development Index (2018). Nigeria 157
The total government expenditure on Health as a percentage of Gross Domestic product (2014) was 3.67 and has not changed much in the years since. (GHO;Key Country Indicators;Nigeria key indicators – WHO), and as a percentage on all government expenditure it is 8.7.
Private expenditure on health as a percentage of total health expenditure is 74.85%. The implication of this is that government expenditure for Health is only 25.15% of all the money spent on health all across the nation. Of the percentage spent on health by the citizens (74.85%), about seventy percent is spent as out of pocket expenditure to pay for access to health services in government and private facilities. Most of the remaining money spent by citizens on their health is spent in procuring ‘alternative’ remedies of dubious value.
In absolute numbers, Nigeria is better provisioned with health personnel than most other African countries. However, given its size and population, there are fewer health workersper unit population than are required to provide effective health services to the nation. The density of physicians for every 1000 of the population is 0.376.
For nurses and midwives, the comparative figure is 1.489. These figures – ten years old, do not appear to have improved significantly since. Despite the presence of at least25 accredited Colleges of Medicine and several Schools of Nursing in the country, the numbers have not increased over the years for a number of reasons. The most commonly advertised reason is the ‘Brain Drain’ of health professionals to other countries, especially in Europe and America. The less well known, but equally important fact in any analysis, is that many of the doctors, nurses, pharmacists, laboratory scientists, physiotherapists and other cadres have difficulty getting into paid employment. The unmet need in society does not always translate to employment positions for eligible candidates. As example, many doctors, fresh out of Medical School, find it difficult to get Housemanship positions. Some of them have to take unpaid ‘Supernumerary’ appointments in order to get the experience without losing time vis a vis their peers. A similar situation occurs every year in finding placement for Pharmacy interns, Physiotherapists and laboratory scientists. The problem persists beyond the period of internship, when it comes to finding jobs. There are generally not enough job positions to go around.
Life expectancy average is 55.2, with 54.7 for men, and 55.7 years for females.
The population of Nigeria may be described as young but getting increasingly old. 44% of the population are aged under 15 years, while 24.0% are aged 60 years and above.
Literacy: 61% of adults in the country cannot read or write, though the pattern varies from area to area, being worst in some parts of the North of the country.
Child Mortality: 100.2 out of every 1000 children die before they are five years old. Out of these, 32.9 die in their very first few weeks of life, all due to largely preventable causes.
Maternal Mortality: Though there has been some improvement in the recent past, the evidence is still that there are 814 maternal deaths per 100,000 live births.
Deliveries by Skilled Birth Attendants: One of the best guarantors of survival for mother and child in childbirth is to have a properly trained ‘skilled birth attendant’ taking the deliveries of all the babies being born in the country. 57% of babies are still delivered by persons without formal training, usually ‘traditional birth attendants’, with consequences as detailed in the indices.
The evolution of policies in Nigerian health, and the challenges of implementatio
It is appropriate that such a complex and diverse assignment as ensuring that every citizen of a country lives a reasonably healthy life and has access to good health care, both preventive and curative, be guided by clearly defined policies that set out goals to be achieved and pathways towards the attainment of those goals. Nigeria has had a succession of well-articulated policies both in the broad area of health and in specific areas such as mental health, HIV/AIDS, and Integrated Disease and Surveillance and Response.
A National Health Policy was formulated in 1988. It was subsequently reviewed in 1996, 2004 and as recently as 2016. Though the terminology employed in the different documents has evolved, the central objective remains the same – that Nigerian citizens should enjoy a level of health that would enable them to lead fully productive lives, attaining their own personal development goals and contributing meaningfully to national development. In order to attain this, there would have to be at least one health facility within reasonable distance of every Nigerian, in whatever part of the country he is located.The citizen should be able to secure access to the service without suffering undue economic hardship. The concept of Universal Health Care encompasses these ambitions and is a regular feature of latter-day discussions on the subject.
In moving towards unhindered access to healthcare for all citizens, an effort has been made to define the inputs of the three tiers of government in the country. Primary Health Care includes the provision of facilities and personnel to carry out ‘public health’ functions such as immunization, but also such ‘private health’ interventions such as the treatment of common health problems such as malaria and diarrhoeal diseases. It is meant to be essentially the duty of the Local Governments, of which there are a total of 774 in the nation. State governments were to provide support for the local governments – financially and organizationally, as well as being responsible for a second tier of health facilities in the form of General Hospitals. Responsibility for a third tier of care – tertiary healthcare – Teaching Hospitals, Specialist Hospitals and ‘Federal Medical Centres’ belongs in the province of the Federal Government.
A number of assumptions embedded in this division of power and responsibility have proved faulty in reality and may have contributed, along with poor finance and a lack of political will on the part of succeeding governments, to the failure to achieve the desired impact on the health of the citizenry so far. One of these is that there is no formal recognition of a role for the local community in the design and implementation of what goes on at the Primary Care level. Another is that the neat parceling out of authority and responsibility has not worked well on the ground. Some local governments for political reasons have in the past expended scarce resources on building expensive showpiece health structures which they are unable to operate – such as diagnostic centres and even General Hospitals. Sometimes the politicians at that level are not interested in committing resources to ‘invisible’ public health activities such as maintaining a cold chain for immunization. Another problem is that there is no mention of private resources – personnel, facilities and finance,as potential or actual stakeholders at the three tiers. And, finally, it isnot correct to say that TertiaryHealthcare, including the ownership of Teaching Hospitals and the offering of tertiary health services to the citizenrycan only be done by the federal government, an assumption that is repeated even in the National Health Act of 2014. Some states run their own Teaching Hospitals, and quite well too. The Lagos State University Teaching Hospital has achieved a certain amount of prominence in the nation for some cutting-edge interventions, despite its relatively young age.
Still further, state governments have been encouraged to set up Primary Healthcare Boards to supervise and coordinate the activities at that level.Many have discovered that in order to be able to implement policy or put out uniform, standardized services at the community level, they need to be substantially involved financially and operationally. Some employ and pay the salaries of the doctors nurses and other staff working in the Primary Care system. The national coordinating body – the National Primary Healthcare Development Agency, centrally coordinates local and donor-sourced resources for development and operation of Primary Healthcare across the nation. It disburses them according to its own rules, which have a significant amount of latitude. The states complain they are not always carried along. Even the wording of the terms for disbursing the provision of the Basic Healthcare Provision Fund in the Health Act (45% of the 1% of the total budget is reserved for training, drug supplies and other improvements in Primary Care system) reflect some of this subjective latitude that may result in unequitable distribution of resources.
Human resources for health
It is a given that Nigeria has fewer health workers than it needs. There is also the problem of skewed distribution, with the few available personnel being mostly concentrated in the cities, where most of the large facilities such as General Hospitals and Teaching Hospitals tend to be located. Beyond this, there is a geographical skewing, with some states being extremely lacking in health personnel resources while some other states appear to be relatively well provisioned. The underpinning issues for this may include the political dimension, with some states unwilling to recruit large numbers of workers from other parts of the country as an act of deliberate policy, preferring to employ their own indigenes, or, where there is a short-fall, preferring to employ foreigners mostly from North Africa on short-term contracts.
A National Human Resources for Health Policy was formulated by the Federal Ministry of Health and approved by the National Council on Health in 2007.
Subsequently a Human Resource for Health Strategic Plan 2008-2012 was drawn up to guide implementation of the policy at all levels. It was to provide a framework for resource mobilization along priority lines, especially as they concern planning, management and development of the health workforce. The ultimate aim was to ensure adequate numbers of skilled and well-motivated health workers were available and equitably distributed through the nation in order to ensure provision of quality health services.
The situation appears set to get worse. As the era of Sustainable Development Goals is commenced and the target of 2030 begins to come into focus, the statistics are far from providing reassurance. An ever-widening ‘supply gap’ for Doctors, Nurses/Midwives and other categories of health workers makes it necessary that close attention be paid to the problem of personnel, and some innovative solutions procured in short order.
A medical researcher from the University of Ibadan, Dr Oladimeji Adebayo and his collaborators, used the following tables to depict the Estimated Supply Gap of some key health personnel:
Supply gap for doctors
| Year | Population Estimate | Doctors Required | Doctors Available | Estimated gap/deficit | Percentage Deficit |
| 2016 | 185,093,806 | 101,803 | 70,390 | 31,413 | 30.86 |
| 2017 | 190,278,488 | 104,653 | 72,164 | 32,489 | 31.04 |
| 2018 | 195,606,286 | 107,583 | 73,983 | 33,600 | 31.23 |
| 2019 | 201,083,262 | 110,596 | 75,847 | 34,749 | 31.42 |
| 2020 | 206,713,594 | 113,692 | 77,758 | 35,934 | 31.61 |
| 2021 | 212,501,574 | 116,876 | 79,718 | 37.158 | 31.79 |
| 2022 | 218,451,618 | 120,148 | 81,727 | 38,421 | 31.98 |
| 2023 | 224,568,264 | 123,513 | 83,786 | 39,727 | 32.16 |
| 2024 | 230,856,175 | 126,971 | 85,898 | 41,073 | 32.35 |
| 2025 | 237,320,148 | 130,526 | 88,062 | 42,464 | 32.53 |
| 2026 | 243,965,112 | 134,181 | 90,281 | 43,900 | 32.72 |
| 2027 | 250,796,135 | 137,938 | 92,556 | 45,382 | 32.90 |
| 2028 | 257,818,427 | 141,800 | 94,889 | 46,911 | 33.08 |
| 2029 | 265,037,343 | 145,771 | 97,280 | 48,491 | 33.27 |
| 2030 | 272,458,388 | 149,852 | 99,732 | 50,120 | 33.45 |
Supply gap for Nurses and Midwives
| Year | Population Estimate | Nurses &Midwives Required | Nurses & Midwives available | Availability gap | Percentage deficit |
| 2016 | 185,095,806 | 320,216 | 236,668 | 83,548 | 26.09 |
| 2017 | 190,278,488 | 329,182 | 242,538 | 86,644 | 26.32 |
| 2018 | 195,606,286 | 338,399 | 248,553 | 89,846 | 26.55 |
| 2019 | 201,083,262 | 347,874 | 254,717 | 93,157 | 26.78 |
| 2020 | 206,713,594 | 357,615 | 261,034 | 96,581 | 27.01 |
| 2021 | 212,501,574 | 367,628 | 267,507 | 100,121 | 27.23 |
| 2022 | 218,451,618 | 377,921 | 274,142 | 103,779 | 27.46 |
| 2023 | 224,568,264 | 388,503 | 280,940 | 107,563 | 27.69 |
| 2024 | 230,856,175 | 399,381 | 287,908 | 111,473 | 27.91 |
| 2025 | 237,320,148 | 410,564 | 295,048 | 115,516 | 28.14 |
| 2026 | 243,965,112 | 422,060 | 302,365 | 119,695 | 28.36 |
| 2027 | 250,796,135 | 433,877 | 309,864 | 124,013 | 28.58 |
| 2028 | 257,818,427 | 446,026 | 317,548 | 128,474 | 28.81 |
| 2029 | 265,037,343 | 458,515 | 325,423 | 133,092 | 29.03 |
| 2030 | 272,458,388 | 471,353 | 333,494 | 137,859 | 29.25 |
One of the facts that will have to be accepted in the Nigerian situation is that what is required to get round the problem of inadequate numbers of health workers of all categories, which itself is due to inadequate training capacity, brain drain, inadequate numbers of employment positions, the uneven spread of workers not only between urban and rural areas, but also between southern and northern states,may not just be to throw numbers at the problem, but to think creatively and out of the box in order to come up with a bouquet of implementable remedies. Some of the issues are political, reflecting the distortions that are still living realities in the Nigerian federation. The reluctance to offer full-time employment to Nigerians just because they are not from a particular state or region while a yawning gap is still left in the employment situation and the people are underserved is the proverbial case of cutting one’s nose to spite one’s nose.
Employment positions and dispensations for employment in public facilities are technically limited by the ability of the various governments – federal, state, and local government, to pay salaries. However, where a whole state has such a paucity of health staff that it has fewer health workers all told than a decent General Hospital elsewhere, something is clearly wrong. It is not just a problem of finance but also of prioritization. This is borne home when such states expend huge resources on sending people on religious pilgrimage or building ‘International Conference centres’.
The ultimate weapon in the hand of the Health Manager for bringing a defined bouquet of services to everybody at the grassroots all over the nation is a readiness to practice a meticulously detailed and carefully monitored system of Task Shifting and Task Sharing. This involves training people who are not ‘specialists’, some of whom may not even be doctors and nurses, to carry out certain clearly circumscribed medical interventions using protocols and guidelines that ensure they do not go beyond what they are trained for, and with the services arranged in such a way that they are directly or remotely supervised by people who have the requisite formal training and skills. The reality is that there will not in the foreseeable future be a time when it will be possible for a full complement of ‘proper’ medical staff to be deployed in all the Primary Care facilities in all the 774 local government areas of Nigeria. On the other hand, there are probably already available in virtually all of those areas enough people who can be trained and supervised to carry out a defined set of services in a uniform way.
The private medical sector is not often mentioned in discussions of the human resource for health limitations in Nigeria. The sector is affected by a similar situation of chronic shortage. A closer examination of the shortage situation in the private sector, though, would reveal that the limiting factor is invariably finance rather than availability, except in some areas where rare skills are required and are not available, such as Intensivists for Critical Care, and Perfusionists for Heart Surgery.
The economics of private medical practice in Nigeria are such that specialist services are under-utilized due to low numbers, not because there are too few patients needing the services but because there are few who have the ability to pay.
Health finance
In April 2001, members of the African Union, at a meeting in Abuja, decided to make a radical departure from the past and begin a movement to devote adequate resources to the peoples’ health. They resolved to devote a minimum of 15% of their annual budget to Health in what would become known as the ‘Abuja Declaration’. Seventeen years later, while a few countries have taken steps towards that goal, most of the countries have failed to show seriousness on the issue. The health budget of Nigeria has tended to hover around somewhere under the 5% mark, although some states such as Lagos regularly devote a higher percentage, although still short of the prescription. Such funds as there are are mostly spent mostly on Overhead and Recurrent costs – mostly the payment of emoluments of personnel, with very little being left for Capital Development, Programs and Research.
The commencement in the 2018 budget of funding for the implementation of the Basic Healthcare Provision Fund – with the allocation of 1% of total government spending towards funding emergency care, primary care and basic health insurance for the citizenry as provided for in the Nigeria Health Act – all measures crucial to the attainment of the long-held dream of Universal Health Care, was regarded as a salutary development by all srtakeholders. Unfortunately, the actual implementation of BHCPF is yet to commence.
The reality on the ground remains that a spluttering National Health Insurance system covers only a small minority of the population. There are individual and corporate social health insurance arrangements covering perhaps 1-2% of the population. Beyond these, for the most part, access to healthcare is through out of pocket payment on the part of the citizens. The implications of these are manifold – both for the citizenry and the healthcare industry. Access to care, especially expensive cutting-edge treatments for conditions such as Cancer and Cardiac problems, is currently not based on need but on the ability to pay. Capacity utilization in good advanced care hospitals is low, again due to an inability on the part of most citizens to pay realistic costs, making such hospitals less economically sustainable and bankable, despite the great need for their services. In the end, everybody suffers.
The National Health Insurance scheme was established under the National Health Insurance Scheme Act Cap N42 of 2004. Despite the high hopes vested in it at the beginning, it has barely been able to offer cover to 5% of the population – mostly federal civil servants. It has been bedeviled by frequent crises whose issues often reflect personal difficulties of chief executives of dubious provenance, but also fundamental flaws in the structure of the organization itself. Money is often at issue, and it is clear that a separate legal framework needs to be created for handling the huge amounts of money going into what was meant to be a health fund, but which has become a treasure trove to struggle over.
Some states, such as Lagos and Delta have inaugurated their own Basic Health Insurance Schemes.
There is, a requirement to decentralize the Health insurance project and coordinate the work of stakeholders in the three tiers of government, just as there is a need for legislation to make insurance compulsory for citizenry, as a way of showing seriousness in the drive to Universal Health Care.
Legislation, standardisation and regulation
A National Health Act was signed into law in 2014 as an umbrella law for healthcare in Nigeria. There are several laws guiding various aspects of health as well as regulating professional practice. Some of the laws, such as the Lunacy Act of 1958 are embarrassingly anachronistic. For several years there has been a move at the National Assembly to pass a new Mental Health Act. Efforts to achieve a similar purpose in Lagos State have met with somewhat greater success, with a new Mental Health Law having passed through the House of Assembly and currently awaiting the signature of the State Governor.
The Health Facilities Accreditation and Monitoring And Accreditation Agency (HEFAAMA) represents a model for the nation as a body charged with registering health facilities and ensuring that they meet minimum standards for registration and renewal.
The need to create a regulatory framework for advanced research and medical interventions such as transplants and IVF, including the creation of special registers for eligible practitioners, is yet to be properly addressed, though Lagos State has commenced some effort in this direction.
The health team and its discontents
Operations of the health system, especially within public health facilities, have been marred by labour disputes, with different categories of health staff in the employ of federal or state governments embarking on strike actions.
An even more fundamental area of discontent is the inter-professional rivalry and disharmony that afflicts the space and inhibits efficient function of what is supposed to be a medical team, with doctors, pharmacists, laboratory scientists and other categories of workers perpetually at loggerheads. The battle for power has been carried even to the corridors of the country’s legislature, with different professional groups pushing through the enactment of professional practice laws, some of which are mutually contradictory and impossible to implement in the same space. At the heart of the ‘battle’ is a shortage of goodwill. The practice of Medical Healthcare, afterall, is an international science, and it is hardly worthwhile re-inventing the wheel. Another point worthy of note is that the much-advertised ‘war’ between the medical professionals is limited to the civil service and does not take place in private health establishments. The health team in government-service will have to find a way back to the path of communication, coordination, and mutual respect, borrowing a leaf from how healthcare is practiced in countries with successful health systems.
The challenge of quality
A recognition of the need for continuous Quality Improvement has become one of the defining features of modern Healthcare. The hallmarks of Quality are Measurement and the standardization of all practices and procedures through the use of protocols. There are other elements that ensure a continuous adherence to best practice, leading to the best possible outcomes in both clinical and non-clinical functions. The ultimate evidence of Quality is the achievement of International Accreditation. Only a few Nigerian hospitals have passed formal Quality evaluation. None of them is a government hospital. Lagoon Hospitals leads the way with accreditation from Joint Commission International (JCI) – the gold standard. Reddington Hospital and one or two others hold accreditation from COSASA – the South African equivalent.
It is always interesting in a bizarre way to hear succeeding heads of government talking about creating ‘Centres of Excellence’ in different parts of the country. Such statements usually arise when they are commissioning some new fancy equipment they have just purchased at great cost to the public purse – a linear accelerator, and MRI machine – for the National Hospital or one of the Teaching Hospitals. The truth is that ‘Excellence’ is a quality measure and is not about linear accelerators but about practices, procedure, measurement. On those scores none of the public facilities – state or federal measure up at present, or are likely to be accreditable in the near future. ‘Excellence’ is not a chieftaincy title.
Quality Improvement is an expensive rigorous journey for health facilities. The payback is being able to achieve outcomes comparable with the best centres in the world, whether it is for open heart surgery or knee replacement. People would, and should, pay good money to be treated in a facility with Accreditation, in preference with a cheaper so-so facility, even if they have exactly the same equipment and number of specialists. That is why the emotional argument about stopping Nigerian citizens from going abroad to shop for good quality is never going to achieve anything but pander to the base sentiment of the public. People may be stopped from using government money for such purposes. But if they have their own money, the right to seek best quality care even for their non-life-threatening conditions is a fundamental human right. The true way to fight back is for the country to encourage its own health facilities to seriously embark on the journey of quality improvement and accreditation.
A past Minister of State for Health – Dr Ali Pate, indeed made some effort to start a quality drive in the federal tertiary facilities. He achieved only a faint beginning that needs to be aggressively given life. PharmAccess and some private individuals are also working in the field to help health practitioners and willing state governments achieve the first tentativesteps of quality improvement in their facilities. Some private facilities, such as Paelon Hospital in Lagos and Lily Hospitals Warri are taking significant steps in that direction.
Given Nigeria’s standing in Africa, it is also necessary to facilitate the setting up of a local body that is able to do Accreditation of facilities to international standards. It would build up indigenous expertise in that crucial area, and also save the foreign exchange that is being expended on Accreditation by foreign bodies. The Society for Quality Health in Nigeria (SQHN) has set up such a body from scratch, trained assessors, and secured its bona fides with the international accrediting authority ISQUA. It would be to the advantage of the Nigeria and its healthcare industry if the government deliberately took steps to recognize and encourage SQHN in this project, although it would need to remain privately held to retain its credibility.
Disrupting health – the place of appropriate technology
There has been a rush, mostly by young Nigerian entrepreneurs, to introduce ground-breaking technology and new ideas into the healthcare space in the past few years. Innovations such as iDokita and various smartphone apps and software have been created to bridge information and service gaps or create new opportunities. Nowhere in Nigeria is there a greater need for innovative, technology-based thinking than the healthcare space. Take, for example, the three ‘delays’ that need to be overcome in order to reduce the maternal and child mortality rates in the country. Delay 1 is the awareness of the woman in the rural area about the availability of the service she needs in the PHC nearby, and her readiness to use it. This is Information and Advocacy. Can the message be repackaged and resold more effectively? The woman in the rural area does not have television, does not read newspapers, and is not sure to listen to the radio. But she has a phone, or her neighbour has one.
Delay 2 – She has been convinced to seek help in the PHC. But the PHC is quite a way away. How does she get there, especially when she is in distress, or in labour? Can on-demand functional logistics that doesn’t cost a fortune and actually works be packaged and deployed?
Delay 3 has to do with the facility itself – can it be guaranteed to meet the woman’s needs and keep her trust?
There are still other levels. She may need to be transferred to the General Hospital far away. Who owns the problem? How can it be seamlessly, sustainably executed?
Healthcare in 2018 is not about doctors and nurses and pharmacists alone, but young nerds who code and create apps, and mechanical engineers, and marketing communications experts. Everybody has a role to play.
Advanced healthcare: The problem of health tourism
Mega-hospitals to the rescue?
In the latter days of the last administration, there was some talk of a government initiative to get the private sector to build six ‘mega-hospitals’ in the six geo-political areas of the country. There was, of course, something anomalous about the government taking the lead in something that was supposed to be a private sector initiative.
The need to substantially shore up private sector participation in the business of Healthcare has been evident over the years. In a cosmopolitan environment such as Lagos, more than 60% of daily health encountersare carried out in private facilities, as distinct from government-owned facilities. In terms of gross numbers, the government has somewhat under 300 health facilities in Lagos State. The private sector has about three thousand.
The private sector is already participating in government health facilities – state and federal, through the agency of Public Private Partnership in some important areas of operation, such as the Mortuary service of the Lagos State University Teaching Hospital and the operation of the Pathcare Laboratory at LUTH. There has also been an effort to get the business side of Healthcare operations more actively focused upon, especially in the tertiary hospitals.
Borrowing from the example of India, there is a realization that part of the solution to the egress of large numbers of Nigerians abroad in search of specialist treatment must be a greater participation of the private sector in creating and operating facilities for specialist care. Capital – both local and foreign, would need to be sought for such projects, and somehow, they would need to be made viable and sustainable. The best specialists, including those in the diaspora, would be able to function in such entities, because there would be personalized, performance-based remuneration. They would not be encumbered by strikes and inter-professional wrangling.
The challenge is – how would the hospitals make their money back? They cannot be sustained on the basis of a patchy NHIS and out of pocket payment. There would have to be return on investment for the investors. Obviously, a good business case could onlyand adequate numbers of patients guaranteed if there is compulsory health insurance in the country. A few such hospitals are already beginning to emerge on the landscape.
The future for Nigeria’s health
That there are a lot of problems afflicting Nigerian health is quite obvious.
Embedded within the problem situation are opportunities for new thinking, radical change and dramatic progress.Possibilities include the following:
- Direct Commissioning – bulk purchase of specialist procedures. The government could commit every year to buying a defined number of interventions for needy Nigerians at market cost. The interventions should be those ones that normally cause Nigerians to go seek care in India. Perhaps 1000 Open Heart surgeries, 500 kidney transplants,500 knee or hip replacements, 500 advanced Cancer treatments. They should look for the facilities with the best track records in these interventions, or investors who are ready to build the facility and provide the service at the highest level, possibly using skilled Nigerians from the diaspora. Without spending one naira on brick and mortar, the nation would be buying service for Nigerians selected purely on clinical need, and facilitating the operation of advanced medical care, and making a dent on medical tourism.
- Removing the Public-Private dichotomy: dotted all over the Nigerian rural landscape are health facilities, many in disrepair, and many offering poor quality services, admittedly. Those facilities are a mixture of private clinics and primary health centres. All the centres are running what is essentially primary care. But in any audit, it is only the ‘government’ facilities that are counted, giving a distorted impression of shortage. With the advent of Basic Healthcare Provision fund, the government does not need to ‘own’ a facility to deliver primary care from it, especially if it is the only one in the area. What is required is to define the package of services to be offered, and set the minimum standards to be attained. Government could then pay for access for every citizen that attends. The citizen is served, with minimal building or maintenance commitment on the part of government. The ramshackle ‘private’ practice is boosted. A win-win is achieved.
- Task Shifting: The need to deliver a defined package of services at Primary Care level requires that a deliberate and carefully executed system of task shifting and task sharing be executed, across the nation, so that optimal use is made of locally available resources, and the services are affordable and sustainable.
- Identification of gaps and problem areas for deliberate input of technology solutions, including the commissioning of ‘translational’ research and development (eg a battery-operated desktop lab equipment that can be used by the doctor or nurse to do basic hematology and chemistry tests, and get an instant report.
- Government to facilitate and encourage investment in healthcare industry by tax incentives, customs waivers for equipment and other measures.
- Pharmaceutical industry to be encouraged to increase local production of drugs in the nation’s formulary.
- Local manufacture of medical equipment to be encouraged, possibly through subsidized partnership with designated manufacturers.
- Immediate implementation of compulsory health insurance requirement across the nation.
- Revamp of the NHIS with creating of separate structure for administration of health fund.
- Handshake between State and ‘Federal’: Better interface between NHIS and state health insurance structures, as well as between NPHCDA and State Primary Healthcare Boards.
Femi Olugbile
Dr Femi Olugbile is an acclaimed physician, health administrator and writer. An astute psycho-profiler, he was for nine years chief medical director of Lagos State University Teaching Hospital, which he built into a first-class health facility. He has also served as permanent secretary of the ministry of health.