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No health, no wealth (1)
By Nasir El-rufai
Thisday
Email:
nasir.elrufai@thisdaylive.com
This week, Nigeria lost Chief Edwin Ume-Ezeoke, the former
Speaker of the House of Representatives in the Second Republic.
He died in India. May his soul find peace. Chief Ezeoke joins a
long list of Nigerian political and economic elite that now live
mostly in Nigeria and die in foreign countries in search of
better healthcare.
And it is symptomatic of our failure to build on the foundations
laid by our founding fathers to grow our human capital through
creative planning, sensible spending prioritisation and focused
implementation.
Our nation has conceived several five-year development plans
from Independence until the mid-1980s. The overthrow of the
Buhari-Idiagbon administration marked the death of multi-year
development planning. Since then, we had toyed with perspective
plans and rolling plans under Ibrahim Babangida, Vision 2010
under Sani Abacha, then the NEEDS programme in Olusegun
Obasanjo's second term, leading to what is now Vision 20:2020.
No sectors have suffered more than education and healthcare from
our abandonment of development planning in our governance
strategies.
The challenges of the Nigerian health sector bring to bear the
popular philosophical postulation: “a person that fails to
plan plans to fail”. The first casualty of non-planning was
the relegation of preventive, mostly primary healthcare,
abolition of sanitary inspection and increasing focus on
procurement-driven curative, secondary and tertiary healthcare.
Olikoye Ransome-Kuti's tenure as health minister brought back
some needed focus on primary healthcare, with the publication of
a National Health Policy in 1988. But the centralised
regulation of the military regime of primary healthcare created
its own problems which we live with. As we shall see, it appears
that like with everything else in Nigeria, decentralisation,
true federalism and inter-state competition works better for the
citizens.
The 1988 health policy was refined, revised and updated under
the tenure of Health Minister Eyitayo Lambo in 2004 and was
globally acclaimed as a near-perfect blueprint for provision of
standard healthcare in a growing nation. The policy had
all that was needed to make our health sector functional and
world class.
It had a three-tier health structure, with primary healthcare,
PHC, including refined traditional medicine as the foundation,
secondary health care, SHC, with general hospitals as the
supporting pillars, and tertiary healthcare, THC, consisting of
university teaching hospitals, federal medical centres and
specialty hospitals at the apex.
The policy gave the responsibility of implementing PHC to local
governments, SHC to state governments, and THC to the Federal
Government. Unfortunately, it has been characterised by weak
implementation and diversion of funds to recurrent spending.
Also, inconsistent implementation of the structuring led to the
situation where people went to SHC hospitals for their PHC
needs, causing doctors trained for SHC to devote 80 per cent of
their time conducting PHC in the outpatients’ departments of
hospitals.
The condition is further worsened by inadequate facilities and
low remuneration of public sector healthcare workers. These
resulted in the mushrooming of private hospitals and clinics
with only a fraction well-equipped, but could only be afforded
by an opulent and sometimes foolish few. So in spite of all
these efforts, the sector challenges remain and the story of
Ume-Ezeoke above remains the best metaphor for the dysfunctional
state of our healthcare delivery system.
Although "health” as a sector does not feature prominently in
the measurement of GDP of a country, health expenditures account
for between 4 per cent (Turkey, Nigeria), 8 per cent (UK) and 15
per cent (USA) of the GDP of most countries, and the sector is a
major employer of labour - from doctors to pharmacists to
laboratory technologists to nurses and midwives, and now
includes HMOs and insurance companies! Quality and affordable
healthcare is critical to sustainable development and progress
because it is human capital that drives the other factors of
production.
Health infrastructure (hospitals, laboratories, pharmaceuticals,
health insurance organisations and other ancillaries) are
essential for the efficient functioning of a healthcare system
and consequently, a productive and prosperous nation.
Our health sector is bedevilled by a myriad of challenges that
resulted from lack of planning - policy disconnections,
inadequate capital spending, poor pay, out-dated technologies,
poor infrastructure, sharp disparities in the availability of
medical facilities across the country, coupled with the severe
political and economic stresses of the past years.
The net effect is inadequate medical supplies, drugs, equipment,
and personnel. Similarly, poor sanitation and water supply in
our rapidly growing cities have increased the threat of curable,
avoidable and other infectious diseases, while health care
facilities are generally unable to keep pace with urban
population growth.
One needs not visit hospitals without doctors or drugs, or
evaluate the poor quality of health personnel, nor undertake a
computation of the lost production to poor health to underscore
the fact that our national development aspirations will remain
just that – aspirations - if we do not embark on a concerted
improvement of our human capital, especially revamped education
and improved healthcare.
So what are the facts on ground, and what steps are needed to
restructure and improve Nigeria’s health sector?
Nigeria’s population is projected to more than double, and move
from the fifth to the eighth largest in the world by 2050, after
India, China, the USA and Pakistan. Less than half of the
population now lives in urban areas, but more than 60 per cent
will be urbanised then.
It has a very young age profile with about 45 per cent being
under 15, and this will stabilise somewhat by 2050. According to
the World Health Organisation (WHO), in 2006, Nigeria’s
expenditure on health was $50 per capita, representing about 4
per cent of GDP. Also, records from UNICEF show that only 1per
cent national budget between 1998 and 2008 went to health
(compared with 3 per cent for Defence).
The projected national health budget envisages about $26.6
billion to be spent between 2010 and 2015, of which 42 per cent
is set aside for human resources development for health, and 49
per cent for health services delivery.
The clear import is the need to evaluate the trends in our
health facilities and our rapid population growth. In 1979,
Nigeria had 562 general hospitals, supplemented by 16 maternity
and/or paediatric hospitals, 11 Armed Forces hospitals, six
teaching hospitals, and three prison hospitals. Altogether, they
accounted for about 44,600 hospital beds.
In addition, general health centres were estimated to total
slightly less than 600; general clinics 2,740; maternity homes
930; and maternal health centres 1,240. The establishments were
distributed among federal, state, and local governments, while
some are privately owned.
In 1985, there were 84 federal health establishments (accounting
for 13 per cent of hospital beds); 3,023 owned by state
governments (47 per cent of hospital beds); 6,331 owned by local
governments (11 per cent of hospital beds); and 1,436 privately
owned medical establishments (providing 14 per cent of hospital
beds).
Nigeria's healthcare delivery system consists of a network of
primary, secondary and tertiary facilities. By 1992, primary
care was largely provided through approximately 4,000 health
clinics and dispensaries scattered throughout the country. As
for secondary care, there were about 700 health care centres and
1,670 maternity centres; tertiary care was handled through 12
university teaching hospitals with about 6,500 beds.
A research by McKinsey has shown that from 1900 to 1973, less
than 4 per cent of the decline in mortality in developed
countries resulted from medical care, with over 90 per cent
being due to public health measures like improved sanitation and
provision of clean water! This strongly suggests that focus on
public health measures and primary health care should be the
priority of governments that wish to improve the health of their
populations.
And this is not difficult for state governors and local
government chairmen to do. For instance, in Abuja between 2004
and 2006, on the advice of the FCT Agriculture Secretary, Waziri
Haruna Ahmadu, we spent an average of N4 million monthly to
fumigate the city and the satellite towns.
Statistics from the FCT public hospitals showed that reported
cases of malaria went down by more than 60 per cent compared to
previous years! Availability of clean water via boreholes each
costing about N1 million in 77 locations nearly eliminated many
water-borne diseases like cholera and typhoid. And as indicated
above, it is not very expensive to provide these basic
amenities.
It is when preventive healthcare fails that a visit to a medical
professional becomes necessary. At the moment, our healthcare
facilities are grossly inadequate and can only serve 5–10 per
cent of their potential patient load. Huge sums of money in
foreign exchange are spent by our people that seek medical
services abroad in places like India, Dubai, Egypt and Europe,
etc.
Spending by private citizens, the Federal Government and the 36
states of the federation on foreign medical services is
estimated at about N30 billion annually. For example in 2009,
the Kaduna State government spent about N900 million for
overseas medical treatment for the well-connected and much less
on primary healthcare!
While spending so much to keep foreign medical professionals
employed, are we healthier? Our healthcare indicators are going
from bad to worse. Life expectancy for males stands at 46.76,
while for women, its 48.41 as of 2011. And we rank 220 in terms
of life expectancy in the world.
According to the United Nations Population Fund (UNPF), in 2010,
the maternal mortality rate per 100,000 births for Nigeria is
840 compared with 608 and 473 in 2008 and 1990 respectively. So
more and more of our pregnant mothers are dying during labour.
The under-5 mortality rate, per 1,000 births is 143.
These are mostly caused by inadequate access to quality care in
rural and remote areas and shortage of midwives. In fact, the
workforce requirement to attain 95 per cent skilled birth
attendance by 2015 is estimated to be 6,790 according to the
World Midwifery’s Report for 2011 compared to South Africa’s
requirement of just 710.
A 2008 Demographic and Health Survey (DHS) found that for 25 per
cent live births, only 5 per cent were attended by nurses or
midwife, and 9 per cent by a doctor. Correspondingly, 35 per
cent of live births took place at a health facility.
Women living in urban areas were much more likely to be
attended to by health care specialists than those living in
rural areas (65 per cent and 28 per cent respectively in 2008).
This imbalance in access to specialist care between urban and
rural areas has been evident in all DHS surveys in Nigeria since
1990, but the gap has not narrowed over time.
And as usual, the disparities between the North and South are
wide, indicating that state governors and local government
chairmen in the North have a lot more to do, and must wake up
and invest more to prevent the avoidable deaths of mothers,
infants and many children under the age five.
The problems of the Nigerian health sector are numerous and
require collective effort from every one of us, and creative
planning, focused management and sensible application of
resources on the part of the Federal, states, and local
governments as well as the private sector.
Next week, we shall, by God's Grace conclude our discussion on
the health sector with further analysis of the challenges and
exploration of options for the way forward.
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