In this concluding part of his series on the state of tertiary health facilities in the country, Assistant Editor ADEKUNLE YUSUF reports that the regular harvests of woes in the public hospitals will continue unless the right structures are put in place
The trouble with Nigeria’s hospitals
A glorified general hospital! That is exactly how a resident doctor described the University of Ilorin Teaching Hospital (UITH), Kwara State, where he works and undergoes obligatory residency training to boot. He begged to be anonymous to avoid the wrath of the management. But by the time The Nation spent some days observing activities in the ailing hospital last month, it was apparent that the disillusioned resident doctor was not being uncharitable at all, for it is an open secret within the state that the apex hospital does not have what it takes to be so called. Like the stream of patients thronging the health facility daily in search of succor, UITH, as it is currently, is too terminally ill to live up to its billings.
Even from its entrance, the necessary usual hospital ambience that usually provides a helpful psychological bulwark or reassurance for the sick is evidently lacking. First, the road network within the hospital is also in an appalling condition, with broken down drainages and mostly dirt roads that are decked with potholes. Perhaps with no conscious attempt at landscaping or beautifying the environment, the complex, which is primed to be a five-star hospital for about 5 million people in Kwara State and its environs, is enveloped in dust last month.
As for the buildings housing the various critical sections in the hospital, they are evidently substandard and poorly designed, to say the least, as cracks everywhere on the walls that are begging for repainting easily advertise the teaching hospital, which began operations in a temporary location in 1992 and moved to its permanent site in 2010, as an antiquated facility. From one section to another in the hospital, it is not unusual for the eyes of patients and their family members to be assailed with dilapidated ceilings, while entrance doors and other building accoutrements have mostly decayed or worn out. And without any space or facilities for patients’ family members, it is a daily affair at almost every turn seeing crowds sleeping or sitting on the bare floor or mats at every time of the day.
But the problems of the apex hospital are not limited to physical issues, for the institution is indeed being seriously held back by the “curse of sub-optimal equipment,” as another resident doctor described it. In separate interviews, doctors disclosed that medical facilities in the wards do not only always break down at UITH; they do so regularly that it often casts a pall of frustration on the morale of enthusiastic workers. And going by the murmurs of medical workers, each time any major equipment packs up, it often takes minimum of six months before it is fixed. For instance in the radiology department, tools such as magnetic resonance imaging (MRI) and computerized tomography scan (CT scan), which are taken as a given in any teaching hospital that is worth the name, hardly function at UITH. Last month, workers in radiology department said the hospital’s only MRI usually works for only one week before it breaks down, adding that it has now become a recurrent migraine that is militating against efficiency and optimum service delivery. “The MRI here is substandard. I can’t remember when it works for more than a week because it always breaks. Unfortunately, it always takes a couple of months before management repairs it.”
In the course of investigations, it was further discovered that UITH did not enjoy the luxury of having a functional x-ray machine for the greater part of both last year and this year. Why? The ones in the hospital broke down and repairing them became a luxury. Also this year, medical hands who are fed up with inefficiency told The Nation that the teaching hospital did not have one single functioning x-ray machine for an upward of six months, forcing a teaching hospital owned by the federal government to resort to referring patients to private facilities and laboratories, which are also not easily accessible due to long distance away from an institution tucked in the outskirts of Ilorin, capital of Kwara State. Designed as a 500-bed health facility, UITH is still surprisingly lagging behind in many subspecialties of medicine, unlike most of its counterparts in the country.
Being an apex hospital, it will be expected to see specialists in virtually all areas of medicine plying their trade in the institution, but the opposite is the case. For example, one resident doctor lamented that “it is sad that we don’t have specialists in some subspecialties of surgery and in internal medicine as a whole, leaving the ones available overworked.” Some four years ago, when UITH started nephrology and successfully carried a renal transplant, it was said to be the much-needed elixir that would herald the beginning of great things for the hospital. However, that was the end of the good news because a coterie of distractions seemed to have clogged the hospital’s march towards progress, for no other transplant sessions, which would have helped the system grow and carve a niche for itself among its peers in the subspecialty, had been done since then.
Another migraine is electricity conundrum in a federal facility that does not enjoy a dedicated power line like most of its peers in the country. The result is that power outages have crippled clinic sessions, sometimes lasting for hours, condemning doctors and nurses to resorting to torchlight or phone light during surgical operations in a federal facility whose management claimed it uses a whopping N16million to settle diesel bill every month. “It is distressing because I want to be proud that I am working here. But at the moment, I cannot bring anyone I love or recommend anyone to come here for treatment. There is no water sometimes. I have to be sincere because most of us working here are just doing because of our salaries. The system here is not helping us at all,” one doctor lamented.
Unfortunately, as bad as things are, treatment costs do not reflect the state of affairs. According to Khadijat (surname withheld on request), a teacher who recently delivered a baby at the VIP section of UITH, the services and facilities are too poor compared to the prohibitive charges. Before using the facility, she paid N60,000 deposit first, apart from N10,000 being charged daily for the bed space. “It is only VIP in name; there is nothing to suggest that it is VIP except in the payment. No electricity. Mosquitoes traumatize patients. Nothing works there,” she complained bitterly. Like Khadijat, a well-to-do patient who sustained multiple injuries of bones was recently managed by top echelon of medical workers in the hospital, mostly consultants and professors, for over a year without any meaningful recovery. Surprisingly, after deferring to advice from more discerning friends, the woman received succor and was able to walk again in less than three months after she quit the services of UITH for a private orthopedic hospital in Abuja.
Like its counterpart in Ilorin, the Ahmadu Bello University Teaching Hospital (ABUTH) in Zaria, Kaduna State, is the shame of a nation. Although its vision says it wants to be a healthcare facility that is “second to none in Nigeria and comparable to any center in the world,” the current state of the hospital shows that it is achieving the exact opposite. To say the least, ABUTH scores poorly on aspects of what make a tertiary hospital tick, at least judging from the state and condition of the buildings housing the various wards and offices to the general environmental sanitation in the facility. For upward of a week in August, when The Nation was monitoring activities in the apex hospital, leaking sewages dotted several sections of the complex, leaving users wondering what is wrong with the hospital. Of particular places that are eyesores as a result of leaking sewages are the labour ward, hematology and medical laboratory.
Although Professor Lawal Khalid, CMD, painted a picture of Eldorado regarding activities in the hospital, it is glaring even to the blind that all is not well with ABUTH. Among other things, the CMD boasted that all the state-of-the-art medical facilities, including the ones procured through the Vamed initiative during the administration of former President Olusegun Obasanjo, are in good shape because of good maintenance culture in the hospital. He also added that he always leaves no stone unturned in ensuring ABUTH enjoys electricity supply twenty-four hours a day, which he says costs the sprawling complex a fortune in terms of diesel and other consumables for power generating sets.
However, three days after, a protest by the resident doctors erupted in the hospital, with placards bearing messages that thoroughly indict and condemn the failure of management in the hospital. The protesting doctors were irked that environmental sanitation in the hospital is so poor that one of their members was bitten by a poisonous snake at the staircase of the surgical wards. As if that is not enough, the unlucky doctor “almost lost his life as he suffered envenomination as the hospital cannot provide anti-snake venom for its doctor on duty for over 36 hours after the snake bite.” During the protest, the resident doctors’ union condemned the “deplorable state of health facilities” in ABUTH, which it also described as astonishing. They went further to lament that there is a chronic shortage of resident doctors in the hospital, adding that the last time ABUTH recruited its last batch of doctors was in 2012, which has created a big vacuum in both service delivery and learning. “Investigations such as x-ray, ultrasound and MRI have to be postponed due to faulty machines. A hospital that has a transfusion unit but which cannot produce blood components due to lack of cold centrifuge cannot be differentiated from a general hospital. Residency training, which is the bedrock of specialization, is at its lowest as currently it is less than 8 departments that residents can comfortably complete their rotations without going for outside postings due to lack of or partial accreditation of the various units,” the resident doctors said.
As unpalatable as the ABUTH story seems to be, the situation report is not anything different at the teaching hospital arm of the Kaduna State University, also in Kaduna State. The hospital, which started off as a general hospital and later renamed Barau Dikko Specialist Hospital, became a teaching hospital in 2012 when the need arose for the state university to have a medical school. However, since it was accredited by the Medical and Dental Council of Nigeria (MDCN), nothing significant seems to have been done so far to make Barau Dikko Teaching Hospital ready and competent to provide clinical education and training as expected of a five-star hospital. Besides the constraint of being crammed in a small space, there is little opportunity for expansion. Although the state government is currently upgrading the facilities with two buildings, as it is sandwiched that
But if you conclude that the teaching hospitals above are the only ones that are distressed in the country, you will be in for a rude shock by the time you reach Ibadan, capital of Oyo State, where the University College Hospital (UCH), Nigeria’s first and most ambitious teaching hospital that provides clinical education and training to various categories of health professionals, is sited. Built during colonial rule, the medical facility that was officially opened to the public for the first time on November 20, 1957, cost the then British colony a whopping sum of 4.5 million pounds. No doubt, UCH still parades arguably some of the finest architectural masterpieces in the country, being the most well-designed apex hospital. Right from its magnificent doorway, a well-manicured patch of lawn that generously beds it with breathtaking scenery adorns the environment, bestowing it with the right ambience befitting a preeminent medical center of its status and stature.
However, as you escape from the peripheral aesthetics and descend deep into the dusty bowels of the wards and clinics in a hospital once rated as fourth best in the entire 52-member Commonwealth, you are most likely to have a slight mood swing, if you are not instantly filled with a gushing sense of foreboding about a paradise lost. Last month, when The Nation was in the hospital, Luqman Ogunjimi, outgoing president of the UCH chapter of Association of Resident Doctors, but he declined to grant an interview. “We are not happy,” he repeatedly said without elaborating. Pensive, saying At UCH, it is highly possible for patients to contact diseases before leaving the gigantic facility, no thanks to the current sorry state of affairs in the hospital. , there is a high likelihood for patients to contact diseases
But this does not suggest, in any way, that doctors in the hospitals have not been crying for help in the face of crippling challenges. After calling off a four-month strike in August last year, the resident doctors were bitter that clinical service delivery was being hampered by infrastructural collapse in the hospital, such as non-working elevators (with attending health implications for members of staff), lack of reagent and laboratory materials, disposables like gloves and so on. Also, in a communiqué they issued after calling off one of their strike actions last year, resident doctors, who form the bulk of medical hands that manage patients, vented their spleen over the deplorable condition under which they are made to work. They are particularly unhappy that they “have been reduced to sleeping in cars when on call-duty.” This, they complained, is understandably so because “UCH call-rooms are extremely indecent and deplorable or totally unavailable.”
Besides the fact that the available call-rooms are in bad shape, it is learnt that ad-hoc call rooms, most of which are attached to patients’ side-room toilets, are also grossly insufficient. Over the years, to make the call-rooms usable after repeated appeals to the management to renovate them have reportedly fallen on deaf ears, many doctors have resorted to making efforts to fix some of the dilapidated call-rooms, on a surface level though. Apart from dilapidated call rooms, doctors complained of delay and non-promotion of members, even after meeting all requisite conditions, unremitted pension fund deductions/refusal of enrolment of members on the Contributory Pension Scheme and non-implementation of the Federal Government’s directive of 2013 and conditions of service.
Although it also has its own challenges, Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto State, is like a giant among dwarfs, when compared with its counterparts around the country. Established in 1985 and relocated to its present location in 1989, UDUTH has grown to over 800 beds, including having two health centres in some parts of Sokoto state, which it manages under one budget. In 2008 when our number of staff was about 1500, we were getting N48 million as monthly subvention to run the hospital. At the time, its number of consultants was just 28. Even then, it was not enough to manage the hospital. Now that it has grown and expanded in number of beds, equipment, personnel and varieties of services; currently has over 2,066 workers, with over 90 consultants. Sadly, instead of the overhead to rise along with the expansion, it is the opposite.
Now UDUTH enjoys a paltry N7 million as monthly subvention, having been experiencing a gradual reduction over the years until it reached its current level. Yet the hospital pays between N15 to N16 million every month as electricity bill for power supply that is anything but stable. And for the hospital to enjoy electricity twenty-four hours per day, it coughs out additional N6 to N8 million every month for procuring diesel and other items to fuel the power generator sets. This means the overhead from government cannot even pay for electricity supply and diesel needs, let alone take care of obligations requiring gargantuan financial expenses for the teaching hospital to meet public expectations.
By the time The Nation was in Sokoto last August, medical engineers in UDUTH were busy installing new facilities in upcoming sections such as its new open heart surgery, kidney transplant, cancer section and other special health services that the rich often jet abroad to have. To the credit of the current leadership of the hospital, an ultra-modern Aliyu Magatarkarda Wamakko Medical Library, fully built and equipped by the immediate past governor of Sokoto State, makes it stand out from its peers. Unlike some other teaching hospitals battling with recurrent breakdown of facilities, UDUTH is surprising adding to its stock of modern equipment. Asked the secret behind this, Dr Yakubu Ahmed, the CMD, said he achieved the feat through public-private partnership to help in stemming the tide of the much-talked about medical tourism. Preparatory to the arrival of the set of facilities, Dr Ahmed said his hospital has trained medical engineers to maintain the equipment.
A similar achievement in Aminu Kano Teaching Hospital (AKTH), Kano State, is being hampered by bureaucratic bottlenecks. In the hospital, private-public partnership is equally working to the benefit of users, as philanthropists keep assisting AKTH with building and equipment of centers for treatment of drugs, cancer and other ailments. However, instead of enjoying the full benefits of the investments, government has often delayed in approving employment for medical officers that will man the units. According to Professor Aminu Zakari, the CMD, some people have been interviewed and found worthy but getting the supervising authority to approve their employment is dragging the system back.
As poor health funding
imperils Nigerians
Despite Nigeria‘s regular pledge to improve healthcare spending to scale up service delivery in the sector, successive governments have not matched words with actions, even as the country’s indexes on healthcare service delivery continue to plummet. With abysmal record of universal health insurance coverage and the deteriorating out-of-pocket spending, annual budgetary allocations to the moribund sector have not only been paltry, they have also failed to attain the minimum standard recommended by the World Health Organization (WHO).
Perhaps that was why stakeholders in the health sector were disappointed last year when President Muhammadu Buhari, who was voted into office on the mantra of change, presented his first budget. In the budget, which drew unnecessary controversies and sparked unprecedented delays in passage, a paltry sum of N221.7 billion was appropriated to the health sector, far below public expectations. Many experts had expected a health budget higher than previous years, considering the numerous challenges facing the sector. Although the 2016 budget of N6.08 trillion was lauded for being big on capital spending (N1.8 trillion compared with N557 billion appropriated for capital expenditure by last administration in 2015), capital spending on health did not enjoy a better lease of life.
But paucity of fund has always been a common feature of the country’s health budget. It would be recalled that N262 billion (1.7Billion USD) was allocated to health 2014 of which 82 per cent went to recurrent expenditure. The N262 billion allocated to health was about six per cent of the total budget and second only to defense, education and finance (finance includes debt servicing). It was slightly less than the N279 allocated to health in 2013. The 2013 budget allocation to the healthcare sector, on a per capita basis, was N1, 680 as against WHO recommendation that governments spend a minimum of N6, 908 per head, on providing healthcare services to their citizens. The gap of N5, 224 per head at the Federation level was too wide to be filled by autonomous spending from state governments.
Although WHO recommends that all developing economies should earmark 11 per cent of their annual expenditure for the health sector, this has consistently been observed in the breach by successive administrations. In 2001, a paltry N14 billion was allocated to health sector. It grew to N19.5 billion in 2003, amounting to only 2.5 per cent of the 765 total budget. In 2005, the sector’s fortune improved to 5.5 per cent of, only for it to nose-dive to an abysmal 1.8 per cent out of N2.1 trillion in 2006. In 2007, N52.5 billion went to the sector out of N2.31 trillion total expenditure, which is just 2.28 per cent. Even with N89.45 billion out of N3 trillion budget in 2008, Nigeria occupied a space in the WHO book of defaulters.
That is not the only anomaly. Annually, budgetary allocation to healthcare delivery is being made worse because about 80 percent or about N80 of every N100 allocated to the ministry is expended on paying personnel in the sector, leaving just N20 of every N100 for capital expenditure. Experts insist that all the 20 federal teaching hospitals and 22 federal medical centers have been left in the lurch over the years as a result of this unthinking budgetary/spending pattern. With almost nothing as subventions, it is practically difficult if not impossible for the top medical facilities to maintain existing facilities or acquire modern medical equipment, engendering a playing-the-ostrich tendency among political office holders and affluent Nigerians who travel abroad to take care of their healthcare needs, while the teeming masses who cannot afford to travel abroad make do with the poorly-equipped and under-resourced local hospitals.
Unknown to many, Nigeria also has one of the lowest healthcare spends per head, even when compared with country peers in Africa. South Africa spends about seven times more per head on healthcare than Nigeria does, while Angola spends about three times more per head than Nigeria. Medical professionals maintain that Nigeria’s healthcare spend per head, which the 2012 World Health Statistics report put at US$67, was paltry in comparison with more developed countries. For example, a report had it that the United States healthcare spend per head stands at $7000, that of Switzerland is US$6000, while the average healthcare spend per head among countries of the Organisation for Co-Operation and Development (OECD) is put at US$3,600. The true import of low government spend on healthcare is that Nigerians, irrespective of their economic status, are forced to pay for healthcare delivery directly from their incomes or out of pocket expenses, as WHO prefers to call it.
According to WHO, the level of out-of-pocket payment is a major indicator of the state or quality of healthcare delivery available in a country. Another report showed that out-of-pocket expenses in Nigeria, which accounts for over 70 per cent of the total healthcare expenses in the country, is one of the highest in Africa. For example, out-of-pocket expense in Ghana is about 29 per cent, in South Africa it is just 17 per cent, while it is just 10 percent in Angola. Health sector professionals explain the danger of high out-of-pocket payment, saying it could lead to tragic deaths, especially if increasing number of patients is unable to afford the cost of healthcare, thereby denying people access to healthcare.
Unfortunately, this is telling off on Nigeria’s records, deemed one of the worst healthcare statistics in Africa. For example, about 143 children die out 1,000 births before their fifth birthday in Nigeria, a terrible record surpassed only by Angola in Africa. The African average is 119 for children dying before their fifth birthday. In Kenya, the average is 85, in Senegal 75, in Ghana 74 and in South Africa 57. As for life, the average Nigerian had a life expectancy of just 54 years in 2009, just about the average in Africa, but well below 62 years for Senegal and 60 years for Ghana. For Nigeria, the situation has hardly improved over the years. Yet Nigeria was ranked 152nd in the 2016 report of the African Human Development Index, released by the United Nations Development Programme, UNDP, in Nairobi, Kenya, last August. Consequently, the country retained its 2014 status as there was no forward or backward shift from the computation. Nigeria’s HDI value for 2014, according to UNDP’s 2015 report, was in the low human development category, positioning it at 152 of 188 countries.
Brain drain, dearth
of professionals
By the WHO standard, Nigeria, with an estimated population of 180 million, requires at least 300,000 medical doctors to be categorized as a medically safe country. It recommends 1 doctor to 600 patients (1:6). But achieving this standard has remained an elusive dream in a country plagued with acute shortage of medical practitioners. According to Professor Mike Ogirima, President of the Nigerian Medical Association (NMA), the membership database of the professional body has 87,000 doctors on its list. However, out of this figure, only about 45,000 are currently plying their trade in Nigeria. The rest, he added, are either outside of the country or dead. Sadly again, majority of the doctors working in the country concentrate in the big cities and towns, while many hospitals in the rural areas, where the teeming majority of Nigerians reside and eke out a living, are crying for medical hands.
Situating the figures within local realities, what this means is that a doctor in Nigeria has nothing less than 4,000 patients to manage – almost seven times more than 600 patients suggested by the global health body. This implies that the nation currently has a deficit of about 250,000 doctors. In 2015, Professor Folashade Ogunsola, Chairman of Association of Colleges of Medicine of Nigeria, was quoted as saying Nigeria had a deficit of 237,000 doctors to meet the WHO standard. Given the increase in population without a corresponding increase in the number of doctors, the deficit keeps rising in an alarming rate. It means Nigeria requires close 100 years to meet the recommendation doctor-patient ratio, since it currently produces less than 5,000 doctors yearly.
As Nigeria groans under the pangs of inadequate medical professionals, doctors and nurses trained with Nigerian taxpayers’ fund swell the ranks of medical system in more developed countries. Professor Ogirima said “nothing less than 20,000 Nigeria-trained doctors are working in America, and maybe another 15,000 in the European countries.” It is a fate that befalls almost every African country, as more prosperous countries that have resources to train medical workers now resort to poaching from Africa, leaving the continent where the heaviest global burden of diseases resides more vulnerable. In a recent report, brain drain of doctors costs Africa over $2 billion annually, as African clinicians seek work in more prosperous nations. Medical experts are emigrating to the West due to poor pay and low level of scientific research, listing Nigeria, Ethiopia, Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia and Zimbabwe as countries that have suffered the worst economic losses due to the clinical brain drain. The recent Ebola crisis, which caught some countries unawares, highlighted the continent’s doctor shortages.
While Nigeria, Ethiopia, Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia and Zimbabwe have emerged as biggest losers, Australia, Canada, Britain and the United States have benefited the most from recruiting doctors trained in Africa. Kenya’s Education Secretary Dr. Fred Matiangi, who urged African governments to stem the dangerous tide, said doctors moving to work abroad cost sub-Saharan Africa up to $2 billion invested in training the clinicians. “The migration of trained health workers from poorer countries to richer ones exacerbates the problem of already weak health systems in low-income countries battling epidemics of infectious diseases like HIV/AIDS and tuberculosis (TB) and malaria and lately, Ebola. The number of qualified doctors moving abroad to work in the West has been high over the years, where nine sub-Saharan African countries have ended up losing $2 billion as the clinicians seek work in more prosperous nations,” he said during the 6th Annual Medical Education Partnership (MEPI) symposium in Nairobi, Kenya.
This was also the subject of a study by Canadian scientists, published in the British Medical Journal. Led Edward Mills, chair of global health at the University of Ottawa, the study called on destination countries to recognize this imbalance and invest more in training and developing health systems in the countries that lose out. “Many wealthy destination countries, which also train fewer doctors than are required, depend on immigrant doctors to make up the shortfall. Developing countries are effectively paying to train staff who then support the health services of developed countries,” the report concluded.
As one of the country bleeding Africa dry of medical professionals, British health service system benefited from an influx of foreign doctors and nurses up to 190,000 doctors and nurses from outside the EU in just eight years. According to a figure in the British Home Office, work permits were issued to 22,090 doctors and 165,780 nurses from non-EU countries between 1999 and 2006 alone. The British Department of Health confirmed that 101,329 extra doctors and nurses joined the NHS over the same period. Of the non-EU figure, at least 64,000 doctors and nurses came from African countries, increasing from 2,600 in 1999 to 17,620 by 2010. In 2006, the British Home Office gave work permits to 4,615 nurses and 650 doctors from African countries. It also issued 15,705 work permits to Zimbabwean nurses and 8,505 to Nigerian nurses in 1999 alone, including 1,610 and 600 respectively, in 2010. In 2003, a staggering 1,510 work permits were also approved in UK for medical personnel from Nigeria, 5,880 from South Africa, 2,825 from Zimbabwe and 850 from Ghana, forcing Who to organize a world brain drain summit in Uganda.
Although the estimates for Nigeria were not known, governments in Uganda and South Africa spend $21,000 and $59,000, respectively, to train a doctor – only to see many of them migrate to richer countries. “Among the nine sub-Saharan African countries most affected by HIV/AIDS, more than $2 billion of investment was lost through the emigration of trained doctors. Our results indicate that South Africa incurs the highest costs for medical education and the greatest lost returns on investment.” The findings suggested the benefit to Britain was around $2.7 billion, and to the United States was around $846 million. Australia was estimated to have benefited to the tune of $621 million and Canada was $384 million better off.
To arrest the drift, WHO adopted a code of practice in 2010 on international recruitment of health personnel, which highlighted the problem of doctor brain drains and called on wealthy countries to offer financial help to poorer ones affected. Among other things, the code was hailed particularly for its significance and possibility to help sub-Saharan Africa, which suffers from a critical shortage of doctors despite having a high prevalence of diseases such as HIV, TB and malaria. But whether this is achieving any positive result or not is anybody’s guess. In 2007, appalled by the global offensive of medical poaching, South Africa signed an agreement with Canada to put a stop recruiting South African health personnel through the back door. Whereas, Nigeria, one of the poor countries infamously tagged doctor-producer nations, does not have a seamless arrangement on how to immerse an average of 4,000 doctors it trains annually into internship institutions.
Explaining the
NHIS conundrum
Since former President Olusegun Obasanjo made history as the first Nigerian to register with the National Health Insurance Scheme (NHIS), when he formally launched the scheme in 2006, nothing much has been achieved beyond the fanfare. Fifty-six years after gaining independence from colonial rulers and more than ten years after NHIS came on stream, the scheme, which was designed to achieve universal healthcare access by eradicating the regressive out-of-pocket payment system, is still beset with numerous challenges, though some of the teething resistance and speculations about the novel system have largely been overcome.
Although the drafters of NHIS law crafted it with the lofty goal to provide universal healthcare access in a country of about 180 million people, experts say the scheme has only captured about three per cent of the population, rendering it almost useless and ineffective in the face of mounting national health maladies. Chief in the scheme’s bag of woes is the law setting up the NHIS itself. In the wording of the Act setting up NHIS, which was signed into law by General Abdulsalam Abubakar (now retired) on 10th of May, 1999, it is only mandatory for only federal government employees and private sector businesses with 10 or more employees to register with NHIS. Unfortunately, the majority of public sector workers work for Nigeria’s 36 state governments and 774 local government areas, not federal government. And since the law does not make it mandatory for them, most state government employees have elected not to join the NHIS, robbing the scheme of the bulk of revenue to shore up its finances.
As for the private sector where the lion’s share of Nigerian workers ply their trades, most companies don’t register their employees with the government, perhaps to also avoid paying the right taxes and other obligations. According to experts, because of the loose monitoring cum enforcement system as well as loopholes in the law, many companies in the private sector have also devised other ways of sidestepping the scheme, leaving far less than 2 per cent of Nigeria’s GDP re-invested into healthcare sector. The import of all this is that the vast majority of employees in the country find themselves working without joining the NHIS – to the detriment of the citizenry and the sector itself.
But critics lament that the labour unions, which should have insisted on having all workers join the universal healthcare net, have also not helped either, for efforts to enact legislations that would force employees to contribute to their own healthcare plan with salary deductions have continually met brick walls erected by the unions. According to the President of Nigeria Medical Association (NMA), Professor Mike Ogirima, before Nigeria’s moribund health sector can enjoy any significant improvements, the law setting up the NHIS needs to change, including making enrolment mandatory for all public and private sector workers. This, he added, will force more people to join the NHIS, especially from the 36 states. The more people enroll in health insurance, the consultant orthopedic and trauma surgeon believes the cheaper it will be for every Nigerian to reap the humongous benefits inherent in universal healthcare which the NHIS seeks to deliver, but which it is currently ill-equipped to provide.
Going by the views of healthcare professionals, the public also needs more enlightenment regarding what health insurance truly entails, especially the benefits therein, so as to engender a better public perception and support. Currently, according to them, many people have next to nothing knowledge or information about NHIS and what it does, which makes the scheme still largely unpopular in a country where the health sector is in a shambles. And for many Nigerians not to continue to view health insurance as just another monthly expense that is not worth adding to their already bloated bills, industry players call for public advocacy and education so that the citizenry can start seeing health insurance as an investment that can save them lots of money and agony in the event that a health problem suddenly develops. But achieving this also demands an expansion to the scope of NHIS. As it currently works, health insurance does not cover treatment for patients needing renal dialysis, organ transplants, heart surgery and other ailments on its exclusion list because they are deemed to be very expensive to manage. Analysts insist that a situation where subscribers to NHIS still have to be burdened with out-of-pocket payment whenever they have unforeseen cases will certainly not make the scheme a popular idea in the country.
Experts chart the way forward
From UDUTH to ABUTH and other teaching hospitals, the consensus of CMDs is that any hospital that runs on generators can hardly lay claim to best medical services, because all attempt to excel will be hampered by erratic power supply, among other things. The NMA boss, Professor Ogirima, also advocated an improvement in the funding to the sector, insisting that universal healthcare coverage that can be achieved through making everybody to subscribe to the NHIS. But all this is not happening, at least for now. What this means is that the thick pall of frustration and depression hanging over Nigeria’s health sector will continue to thicken.