The quagmire of Medicare in Nigeria
By Andrew Obinna Onyearu
One of the most disturbing features of life in Nigeria is the abject state of the medical facilities and dispensation of medicare in the country. This situation, sad as it is, is undeniably recognised at all levels of the society. Worse still, the notoriety of the poor medical condition in Nigeria is known all over the world. It features quite prominently in the negative indices that are so readily bandied around the world. Instances abound so let’s look at some excruciatingly painful illustrations.
One of the most disturbing features of life in Nigeria is the abject state of the medical facilities and dispensation of medicare in the country. This situation, sad as it is, is undeniably recognised at all levels of the society. Worse still, the notoriety of the poor medical condition in Nigeria is known all over the world. It features quite prominently in the negative indices that are so readily bandied around the world. Instances abound so let’s look at some excruciatingly painful illustrations.
The US State Department Consular information Sheet on Nigeria and our medical facility explains to all who seek information from it that medical facilities in Nigeria are poor. It asserts that diagnostic and treatment equipment is most often poorly maintained and that many prescriptive medicines are unavailable. It asserts that counterfeit pharmaceuticals are a common problem and may be difficult to distinguish from genuine medication. It also adds that whilst Nigeria has many well trained doctors, hospital facilities are generally of poor quality with inadequately trained nursing staff. Providing further information to its readers, it asserts that the quality of government’s medical facilities is unacceptable by US standards and that the quality of health care providers ranges from poor to fair. If further affirms commonly known facts that infrastructural maintenance was mostly ignored for about 10 years prior to 1998 and that although government has been upgrading some of the facilities, the quality of physicians and nurses is poor considering that recent graduates lack experience with modern equipment and sophisticated procedure. It is further asserted that 80% of our pharmaceutical and medical supply needs are imported. The tirade continues on other quite harrowing revelations, enough to warn off only the most ardent visitors whose sustaining motivation to continue their journeys can only be the obvious commercial potential that Nigeria retains.
Nigeria’s health indices make extremely poor reading. Some of the most disturbing indices include those asserted by the World Bank, in 2005 that 1 in 5 children (approximately 20%) die before the age of 5 as opposed to say the United Kingdom where the proportion is 0.6%. Average life expectancy in Nigeria is 44 years, as compared to, say, the United Kingdom where this is 79 years. Approximately 800 women in 100,000 die in child birth and 4.4% of the population of Nigeria between 15 and 49 years (in the region of 2.6 million) are living with HIV.
The provision of comprehensive and adequate health care services to its citizens should be one of the central objectives of any responsible government. This is the approach adopted by developed countries and this much is acknowledged by this and previous governments. In a public petition campaign initiated by the Social-Economic Rights and Accountability Projects (SERAP), it very aptly observes that
“every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity …. Nigeria illustrates the paradox of poverty amidst plenty. Despite Nigeria’s oil wealth and resources, full enjoyment of the right to health still remains a distant goal for millions of Nigerian women and children and for those of them living in poverty. This growth is becoming increasingly remote … Gross under-funding and inadequate management of health services have led to rapid deterioration of health infrastructures in hospitals. Hospital patients including poor women and children are frequently asked to buy drugs and supply needles, syringes and Suture threads, in addition to paying for bed space, even in the so-called big teaching hospitals”.
This assertion applies, with equal measure, to the vast majority of Nigerians in all areas of medicare.
Amidst these disturbing statistics and beneath the unanswered queries lie critical questions aimed at examining what the current health policy is and the reasons for its continued failure. The truth is that successive governments have articulated National Health policies in numerous forms, all anchored on an operational system that has failed and continues to fail the nation. Presently, there is a 3-tier system of health care neatly but cumbersomely divided into primary, secondary and tertiary. There, the efficacy of the system ends.
Primary, as its definition connotes, relates to the provision of health care at local government level with the support of state ministries within a National Health policy. Private medical care provided by the private sector is subsumed within this tier. Secondary health care relates to those specialised services for patients referred from primary health care through an out and in – patient service of hospitals. These are supposed to cover general medical, surgical, paediatric and community health services to patients. This is supposed to be available at district, divisional and zonal levels of the state and is supposed to encompass support services such as laboratory, diagnostic, blood banking, rehabilitation and physiotherapy services. Tertiary health care, supposedly sitting at the apex of this system, comprises those specialised services provided by teaching hospitals which are targeted at dealing with specific ailments. These also are expected to incorporate support services and ought to be administered from Teaching Hospitals who were, directly, encouraged to develop expertise in reliance upon modern technology.
Encouragingly, this government recognises and has asserted that this National Health policy is innately flawed. This much is acknowledged by President Umaru Musa Yar’Adua because, as recently as 18 September 2007, he urged the Federal Ministry of Health to undertake a re-examination of the national health policy to correct a number of inherent defects. One of those that he pointed out was the assignment of responsibility for primary health care to the local government. In the President’s eminently right view, he explained that it was clearly a mistake to have assigned responsibility for primary health care services – on which about 80% of the national population was dependent – to local government, a tier of the government that had the least capacity to providing these services. This, in many senses, is only one of several defects and flaws in the delivery of health care services to Nigeria as a whole. The Health Minister, Professor Adenike Grange has also recently accepted that there was a need to embark on a comprehensive health care reform programme with a view to restructuring the sector by integrating and improving the availability and health management of resources as well as increasing consumer awareness of their obligations.
That the government is undeniably mindful of the unpleasant health indices can now be taken as accepted. This signifies, in many senses, the engendering of political will that is required to redress this disturbing and undesirable position brought about by amongst many innumerable factors, sustained infrastructural decay occurring over the last 30 years; chronic underfunding; the irksome effect of the “brain drain” of medical personnel from Nigeria abroad; institutional reluctance to formulate and implement reform initiatives; all aggravated by in-grained corruption, to name but a few.
Where do we go from here? First, it is critical that the Presidency review the exclusion of health from the President’s seven point agenda. On inception of office, President Yar’Adua identified energy, power, security, the Niger Delta, poverty and education, rule of law and land reforms as the centre points of his Government’s governance of the country for the tenure of his presidency. Revisiting the appalling medical indices that the country has will be the rehearsing of the obvious. Central to human existence is life expectancy. This is a recurring decimal in every Nigerian’s outlook to life. DFID, one of the world’s leading international bodies with a long involvement with the health sector in Nigeria says that two of the leading causes of child mortality in Nigeria are malaria (30%) and diarrhoea (20%). It also states that malnutrition causes 52% of deaths in children under 5, with a mortality rate of 1 in 5 children dying before the age of 5. In 1999, life expectancy amongst men, according to a World Bank Development report was 52 for the Nigerian male and 55 for the Nigerian woman. In 2007, these have dropped to 44 and 47 for men and women respectively, a deterioration of 14.55%. Whilst, as presently constituted, the significant responsibility for redressing these indices lies with local and state governments, it is the Federal Government that is responsible for setting overall policy goals as well as coordinating activities to ensure that these goals are met. It is critical to the sector’s revampment that health re-emerges from its current relative obscurity to assume the position of priority that it so desperately deserves. Adding health to the 7 Point Agenda; raising the profile of the health sector and paying serious attention to its fortunes will initiate the process of review necessary to begin to address this dire problem.
Second, in enhancing the crucial importance that health bears for the average Nigerian, a proactive disposition must be assumed in the reformed process. Practical, viable initiatives must be conceived and implemented without delay. The bridge between discourse and implementation must be narrowed because, with the passage of time, Nigerians continue to be exposed to significant risks entailing inevitable ill health and avoidable fatality. One of the ideal models to observe if not copy would be the United Kingdom’s National Health Service, this being, by a distant margin, the most far reaching such system in existence in the world. Created after the 2nd World War, this initiative came as part of the Government’s “cradle to grave” welfare-state reforms. Whilst at the beginning it had experienced teething problems, this programme has now evolved into the world’s leader in the welfare- based health services, across the world. The current United Kingdom National Health Scheme is divided into trusts, comprising Primary Care Trust which administers Primary and Public health. These trusts oversee over 29,000 General Practitioners and 18,000 dentists. Hospital trusts are responsible for 290 organisations that administer hospitals, treatment centres and specialist care in over 1,600 hospitals across the country. The scheme comprises also Ambulance Care Services and Care Trusts. In addition, there are several special health authorities who provide dedicated services including the NHS Blood and Transplant, NHS Direct; NHS Professionals; NHS Business Services Authority; National Patients Safety Agency; and the National Institute for Health and Critical Excellence (NICE).
It is also common knowledge that Nigeria’s Health sector is abominably underfunded. In 2001, African Union members, meeting in Abuja – of all places – promised to set aside 15% of the respective budgets to meet compelling health care demands. This commitment was renewed in May 2006 at a special summit. Nigeria has not met this commitment. Despite its resources, World Health Organisation figures suggest that in 2004, health was responsible for only 3.5% of the budget. It is impossible to achieve this target – which will have a significant effect on the delivery of health services in Nigeria – without a proactive attempt being made to make the resources available. Compare this, for instance, with the United Kingdom, a country that we have, historically, sought to imitate. The total NHS budget for the United Kingdom in the 2007/2008 year is approximately £105 billion. This reflected an average increase per annum of 7.4% for the 5 years prior to that and at an increase of approximately 43% in real terms from 1997, when the Labour Government came to power. Health is at the top of the political agenda in the United Kingdom. Quite simply, a government that fails in maintaining and improving the sector is effectively guaranteed electoral failure. Nigeria is, by posture and action, a long way from this position. This picture is even bleaker when the circumstances are considered in the light of the suspension of the construction of the primary health care centres in 774 local governments in the country. There are two features of this particular project that must convey serious disappointment and embarrassment to those who were directly involved in its failure. The first is that it is suggested of the N18.5 billion ostensibly deducted over N5.8 billion had been paid out, some in circumstances that were clearly not envisaged by the scheme. Simply, suggestions are rife that a large proportion of those funds were diverted. The second is that, without prejudice to the legality of the deductions, the basis of objection appears not to be founded on the recondite application of the deducted funds, namely the erection of health care centres that will provide ultimate benefit to its citizens – but upon legal and political premises. There is little doubt that the idea behind the scheme itself was a genuine one. Government is encouraged, in its reform directives, to consider an apposite replacement because it serves, in the short term, the critical function of ensuring that a few more fatalities are avoided.
The unavailability of committed and trained medical personnel is a significant factor at the core of the deterioration of Medicare in Nigeria. It has been suggested that as at 2003, there were approximately 35,000 doctors involved in the practice of medicine in Nigeria. In 2005, there were approximately 25,000 doctors of Nigerian origin in various forms of employment in the United States. There is an even higher number in the United Kingdom and certainly in other parts of the world, particularly in the Middle East. With the nurses, the statistics are even more disturbing. The reform initiatives necessary to bring about amelioration and change must be designed at improving first, teaching hospitals, training standards and universities which are all central to supporting a training environment in Nigeria. This, combined with improved service conditions for employees in the medical profession, will enable the sector somewhat more adequately to deal with some of the key issues surrounding the enforced emigration of trained personnel out of Nigeria. Whilst emigration generally is dictated by, amongst other features, prevailing economic circumstances in the country, an improvement in these circumstances will at least operate, to a large extent, to maintain a higher proportion of locally trained medical personnel in the country than is clearly, presently the case. Additionally, incentivised investment in the medical sector should be encouraged so that, like other areas of commercial endeavour, foreign countries and their nationals will be attracted to investing in medical structures in Nigeria. After all, the depressing medical indices clearly mean that until this is redressed, there will be no shortage of potential customers in various areas. In similar vein, incentivised importation of medical technology must be encouraged. It is embarrassing that diagnostic medicine in Nigeria – itself dependent upon the availability of modern and sophisticated technology, – is in a depressingly repressed state. It is commonly known that , for instance, there are no facilities in Nigeria for MRI scanning, this being at the peak of diagnostic analysis of some of the most serious medical conditions. Serious consideration needs to be given to private sector participation with Government in mega-sized hospital projects, especially those that may be targeted at servicing a growing traffic of those seeking medical attention and treatment abroad.
Institutional corruption has not spared the medical industry. This sector is not immune from the kind of scrutiny that currently exists in other sectors. The consequences of corruption are even more dire because, as must be manifestly evident, the consequences continue to ensure a degree of fatality amongst Nigerians that is and will remain unacceptable. Project implementation must be monitored with a high degree of watchfulness. It is suggested that an anti-corruption unit is set up in the Federal Ministry of Health and that this measure is encouraged at state and local government levels. This, combined with an enhanced due process mechanism, will inevitably provide a value for money service even if a complete solution to corruption does not so emerge.
For the sake of its citizenry, as well as prevailing emergencies, it behoves those charged with the responsibility of the administration of the health sector at local, state and federal levels to ensure that significant improvements are brought about by the language of change. The sour state of affairs is affecting people across all strata of the society. People – including high profile Nigerians previously “immune” from the effects of this decay – are now experiencing the pervading unpleasantness that exists with poor medical facilities. By the day, lives continue to be needlessly lost in circumstances where better diagnoses and treatment would have ensured different results. As a nation, it is time for us to ask our leaders to take our lives more seriously because without life, the populace cannot enjoy or have access to “…energy, power, (adequate)security, the( solution to the) Niger Delta problem, poverty and education, rule of law and land reforms…” Governments in the country are requested to begin processes to ensure that this appallingly depressive state of affairs does not subsist before it is too late.
Andrew Obinna Onyearu is a Solicitor who practices in Nigeria and the United Kingdom
