No Health, No Wealth (1)



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 prioritization 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 Babangida, Vision 2010 under Abacha, then the NEEDS programme in 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 centralized 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, decentralization, true federalism and inter-state competition works better for the citizens.

The 1988 health policy was refined, revised and updated under the tenure of Minister Eyitayo Lambo in 2004 and was globally acclaimed as a near-perfect blueprint for provision of standard health care 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 health care, PHC, including refined traditional medicine as the foundation, secondary health care, SHC, with general hospitals as the supporting pillars, and tertiary health care, 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 characterized 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 percent 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% (Turkey, Nigeria), 8% (UK) and 15% (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 organizations and other ancillaries) are essential for the efficient functioning of a healthcare system and consequently, a productive and prosperous nation.

Our health sector is bedeviled by a myriad of challenges that resulted from lack of planning - policy disconnections, inadequate capital spending, poor pay, outdated 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% will be urbanized then. It has a very young age profile with about 45% being under 15, and this will stabilize somewhat by 2050. According to the World Health Organization (WHO), in 2006, Nigeria’s expenditure on health was US$50 per capita, representing about 4% of GDP. Also, records from UNICEF show that only 1% national budget between 1998 and 2008 went to health (compared with 3% for Defence). The projected national health budget envisages about US$26.6 billion to be spent between 2010 and 2015, of which 42% is set aside for human resources development for health, and 49% 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 pediatric hospitals, 11 Armed Forces hospitals, 6 teaching hospitals, and 3 prison hospitals. Altogether, they accounted for about 44,600 hospital beds. In addition, general health centers were estimated to total slightly less than 600; general clinics 2,740; maternity homes 930; and maternal health centers 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 percent of hospital beds); 3,023 owned by state governments (47 percent of hospital beds); 6,331 owned by local governments (11 percent of hospital beds); and 1,436 privately owned medical establishments (providing 14 percent 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 centers and 1,670 maternity centers; 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 percent of the decline in mortality in developed countries resulted from medical care, with over 90 percent 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% 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 percent 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, 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% 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% live births, only 5% were attended by nurses or midwife, and 9% by a doctor. Correspondingly, 35% 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% and 28% 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 5.

The problems of the Nigerian health sector are numerous and requires 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.