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No Health, No Wealth (2)

Nasir Ahmad El-Rufai

Last week, this column promised to explore a few ideas that Nigerian public leaders need to consider in order to mitigate the debilitating challenges confronting our health sector and examine what all relevant stakeholders can do to develop and grow it. Before then however, some issues and data are worth examining. Let me also record two corrections relating to pieces of information in the first part of this article.

Nigeria is expected to be the fifth most populous nation in the world by 2050, moving up from its current eighth position. My friend Abdulhalim Ladan wrote in from Kaduna that the Kaduna State 2009 budget for "overseas medical treatment" was much less than the N900 million I quoted in the article. I have cross-checked my sources who admitted that what was budgeted was indeed less than N50 million, but a lot more "off-budget" spending from security and similar votes outside accounting oversight was incurred to take care of the well-connected and privileged. At the end, whether it is appropriate to have such a budget head at all is what we should reflect about, not the amount - but the principle of it.

Nigerians should recall that life expectancy in our country is still 48 years, one of the lowest in Africa. In Ghana, it is 57, about 52 in Cameroon, 62 in Benin Republic, 54 in Uganda and 71 in Mubarak's Egypt. Britain, Sweden and Japan have 78.5, 80.5 and 81.3 years respectively. Given the huge revenue Nigeria has earned from oil in the past five decades, this is unacceptable. We can do, and must do better.

The key factors in measuring health status are: access to clean water, safe air, adequate food and the society’s willingness to practice healthy lifestyles. There are issues to be worried about: from the report of UNDP Mid-Point Assessment of the Millennium Development Goals in Nigeria 2008, only 42.9% of Nigerians have access to basic sanitation in 2000; 33% in years 2005 and 2006; it reverted to 42.9% in 2007 but currently at 30% as against MDGs target of 100% by 2015. At the same time, 70 million of our population has no access to safe drinking water. This represents 6% of the world’s 1.1 billion persons who do not have access to potable water!

The WHO estimates that every dollar invested in improved water and sanitation produces economic benefit that ranges from $3 to $34, depending on the country and technologies applied. Unfortunately we are not in any way near the attainment of such beneficial status. In year 2010, only N49bn was allocated to the Ministry of Water resources despite the dire need of about N120bn, though in 2011 it has gone up to N70bn. The prolonged neglect of water, sanitation and health education in our schools and societies is also impacting negatively on our health system.

One factor responsible for the worsening state of health care in Nigeria is the shortage of skilled medical personnel. According to the Nigeria Medical Association (NMA), we currently have about 35,000 registered physicians (with some in Diaspora) for our population of 162 million. Our situation is further compounded by the lopsided doctor-to-population distribution. This is a ratio of only 21.6 physicians per 100,000. Within the countries, huge inequalities exist between regions, with the Northern states lagging behind Disparities also exist between urban and rural areas; 70% of doctors work in the urban areas where only about 40% of the population resides.

In comparison, South Africa has 393 nurses and 74 doctors per 100,000 people - about twice better off than we are, while the United States has 901 nurses and 247 doctors per 100,000. Cuba a developing country with a better healthcare system than the USA, has a ratio of 1 doctor to 125 people!

Many of our qualified doctors and nurses have migrated abroad to avoid poor pay, non-existent or archaic diagnostic tools and deplorable working conditions. Nigerian doctors have migrated to North America, Europe, the Middle East and even other African countries. In 1999, the Association of Nigerian Physicians in America (ANPA) informed President Obasanjo that there were over 29,000 Nigerian doctors in North America. By 2010, it is confirmed that more than 5,000 Nigerian trained consultants were practising in the United States while about 2,500 others were in the United Kingdom and Europe.

We must ask: why do our young and talented medical professionals leave Nigeria after we have invested vast resources in their training?

Regrettably, many that have stayed back in the country remain here only because they are unable to secure other opportunities elsewhere. We have come to expect a health sector perennially dogged by labour crises due to the inability of governments at all levels and the various labour unions to agree on a single remuneration structure. The doctors in Nigeria have in violation of the Hippocratic oath engaged in what is shocking doctors worldwide, and unprecedentedly unethical - refusal to treat a person in need of care, by with-holding services!

The activities of quacks in healthcare sector and counterfeit drugs cannot be discounted. Findings indicate that about 20% of all drugs circulating in the Nigerian markets are adulterated. While the war on fake drugs continues to attract our attention, not once have we seen the prosecution of the major importers of these drugs for quite a while. Arresting and shutting down pharmacies and patent medicine stores will not eliminate the root of the problem. The drug barons must be wiped out! In addition, many health technologists, radiographers, nurses, laboratory scientists and doctors operate in hospitals and clinics where unwholesome healthcare is dispensed to hapless patients.

Chronic but treatable diseases are also major threats to our country. According to the World Health Organization (WHO), of the 2.014 million deaths in Nigeria in 2005, it was estimated that 478,000 i.e. 25% of it were caused by chronic diseases. Further projection by WHO is that by 2015 over 5 million people would have died of chronic diseases. Deaths from infectious diseases, maternal, prenatal conditions and nutritional deficiencies will also increase by 6% in 2015 too. Alarmingly, the WHO statistics show that death by diabetes is projected to increase by 52% in 2015. If not checked, all these have adverse effects - economic and social impact on our families, communities and entire country. And the country stands to lose over $8 million dollars by 2015 as a result of premature deaths that may result from these chronic but treatable diseases. If the campaign to restrict tobacco consumption in Abuja had been sustained and extended to other parts of Nigeria, and healthy diet and regular physical activity are encouraged, WHO estimates that this could lead to a 2% drop in annual deaths caused by chronic diseases and a gain of $500 million in productivity in 10 years for the country.

The health industry is very dynamic: patients' needs, innovative processes, regulated environment and demographic factors constantly changing. A responsible government must therefore be proactive in figuring out how to address expanding population and outbreak of new diseases by developing and sustaining a healthcare service mechanism that is both effective and efficient. According to the US Bureau for Statistics, the population of Nigeria nearly tripled in 40 years (55m in 1966 to over 140m in 2006). If this growth rate continues, our population would hit nearly 400 million in 2050. The message is clear: if we cannot adequately care for our population now, and plan for the future today, what becomes of our health care system when our population reaches nearly 200 million in 2020; in just a few years time?

Medical research and collaboration in Nigeria is limited principally due to inadequate funding level (in the national expenditure) for both research and collaboration. Nigeria must fund its universities, medical research and other health institutions to enable them exchange information on research about tracking, treating, preventing, and curing diseases and enhance domestic manufacturing of medicines. We lag behind the global trend of intensive investments in all facets of medical sciences, life sciences and biotechnology and must redress this urgently.

What do we do in light of all these issues and challenges identified?

First thing to do is to recognize that preventive healthcare rests on improvement in enlightenment as well as provision of water supply and sanitation facilities. For too long, water, sanitation and hygiene education in our communities and schools have been given less priority. Well-structured water, sanitation and hygiene education would make a huge difference to our health system. Improvements to sanitation and hygiene behaviors combined with safe water supply could significantly prevent diarrhea, cholera, dysentery and other contagious infections. And this are services best delivered locally - so the responsibility of local governments, mostly fairly and squarely! The Federal Government has no business drilling boreholes in villages and thereby encouraging diversion of earmarked funds by local councilors and chairmen!

Second is to ensure the existence of basic laboratories and diagnostic tools in each facility. And then rapidly employ and train otherwise unemployed graduates of biochemical sciences to be physician's assistants after 12 months of education and internship, and deploying them to PHCs and SHCs to handle patient with some of the commonest ailments like malaria, typhoid, and the diarrhea which take up to 60% of doctor's time in PHCs and SHCs. Doctors will then properly spend their time on more serious ailments.

Thirdly, to rescue the Nigerian health sector, our Primary Healthcare System has to be made not only a local government matter, but functional, properly managed and funded. The National Health Insurance Scheme should be strengthened and universalized along the model of UK's National Health Service (NHS) and its activities expanded to cover every Nigerian. Given that good governance and health are intertwined, facilities should be provided to keep our environments healthy. Our political leaders should lead by example and exhibit confidence in our health system by patronizing the health facilities available in Nigeria instead of travelling abroad for even basic check-ups. It will be nice if the President, Governors, Ministers and members of the National Assembly (and their families) openly declare that they will never go abroad for medical check-ups, treatment and the like, and will go to government-owned facilities only! Then the rapid improvements will begin.

Finally, more effective spending for preventive, primary and secondary care. Can more funding lead to better health? Not necessarily. We would need more healthcare workers regardless of any level of spending to get better outcomes. However, spending generates some impacts. According to WHO, every $100 per capita spent on health creates a 1.1-year increase in Health-Adjusted Life Expectancy (HALE).

The Nigerian health industry is potentially big, possibly bigger than the successful telecoms sector. True, telecom services are necessities, but everybody needs healthcare to survive and grow, and even make phone calls! Ultimately, we must accept the maxim that ‘health is wealth’ and take appropriate steps to improve the sector. At the moment, it is creating a huge hole in our political and economic development aspirations. If Nigerians are not healthy, we cannot build a wealthy country. And the examples of healthy living and confidence in our sector must begin from the political leadership. The ball is firmly in their courts.