‘Health Sector Needs Total Reforms, Not Half Measures’

The former Chief Medical Director (CMD) of Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, Prof. Akin Osibogun, a Consultant Public Health Physician and Professor of Community Health at the College of Medicine, University of Lagos (CMUL), in this interview, avers that Nigeria’s healthcare system requires urgent reforms by the government.

If we must continue with the model we are using (government providing funds and health services), then we must take additional steps to ensure that there are no frequent strikes, and ensure that productivity level improves, ensure that there is efficient use of resources and ensure that Nigerians get utmost benefits from publicly invested resources. We have to put that mechanism in place. That itself is a challenge, because it will then means that we have to totally overhaul the system. How do you recruit people? You must have transparent and above-board mechanism for choosing round pegs for round holes so that people do not get in when they are not qualified and to cover up for their deficiencies, they use unionisation and politicalisation to cover up.

Second, we must set performance indices for all the institutions – for the departments in the institutions and for units in the institutions – so that everybody must have minimum level of productivity against which their performance level must be measured. And if there is any unit that is measuring below 10 and 20 per cent of the performance level, something drastic has to be done about that unit. It means that they are not performing. We need to set performance standards for all the institutions; people must have target so that when they are sufficiently busy, there will be less time for inter-professional rivalry .

We need to spell out what is expected of each employee. What I am advocating is not half measures; you cannot reform this system by taking half measures. We have to do a whole sectorial reform; look at every aspect of the sector, and tackle it.

When you define for each employee the job expectations (what they are expected to do each morning when they come to work, and what they are expected to deliver at the end of one week and at the end of one month), progress becomes easier to measure. That means that out of the 100,000 cases of swelling that comes, certain number has to be performed per month. Setting performance standard is very critical in reforming the system.

The terms of engagement have to be very clear so that where the service of somebody is not required, if the performance level is below certain point, it will not require any union intervention, if the person has not performed. Setting those standards will require you looking into the environment as well. For instance, I will not be expecting a surgeon in Nigeria to perform the same number of surgeries as a surgeon in the Unite Kingdom for the simple reason that electricity is taken for granted in the United Kingdom.

But electricity is not taken for granted here. Even then, we can give allowance for electricity and allowance for all the insufficiencies of the environment, and tell the employee that ‘you are expected to do this number of surgeries, you are still expected to nurse certain number of patients and dispense drugs to certain number of patients.’

So, we can still set standards relating to the environment we operate in. If we rethink the model, we can transform the model into a viable model.

But how can we overcome the challenge of poor referral system and dying primary healthcare centres?
As I hinted, the funding has been inadequate and the efficiency of uses of resources has not been optimal. So, what we therefore need to look at is: are there better ways to fund the health services and use available resources to achieve better results? There are other ways. If you keep on doing the same thing the same way, you cannot get a different result . So, if we have been doing things this way for so long, it means we need to rethink and think outside the box, and start doing things in a different way.

Remember that $61 per capital is the total expenditure on health. But of that total health expenditure, only about 30 to 35 per cent comes from public sector. So, 65 to 70 per cent of the total health expenditure comes from the private sector. That itself is not a problem. It would not have been a problem in an environment where the consumers are knowledgeable. So, the money they are spending will be to buy remedy of good value. But if people are not knowledgeable, they may be spending a lot of that money on motor pack remedies, remedies of doubtful value. I do not want to mention herbs and concoctions. Some herbs are useful. But we need to quantify them; we need to determine their good and extract the active ingredients.

But of the 65 per cent that is coming from the private sector, almost 60 to 70 per cent of that is coming from out of pocket. You can then see that there is a challenge, because there is no direction to the expenditure. Because most of the expenditure is coming out of pocket, people just buy Panadol when they have headache. But what is the cause of the headache? It is not quite defined.

If you go to the motor parks, there are some concoctions they take four times a day. If you buy opa-eyin for N50 in the morning, afternoon and evening, because it has a lot of alcohol, it makes you feel fine and forget your pains, mind you, that alcohol dulls senses. So, you will not feel pain. But it has not removed the cause of the pain.

If we can then design a mechanism to bring sanity to the expenditure, in other words, if you can encourage people to bring private expenditure to the purchase of remedies of proven value, we will achieve greater value.

Is it a must that we harmonise the spending through health insurance?
That is one possibility. But it is not the only option. What we need to do is to let people regain confidence in the health system, and then organise people to participate in the delivery of health services to them.

Health insurance is one good model. And I have advocated for community health insurance for the past years. Through community health insurance, you involve the people in the organisation of their health insurance programmes so that there will be confidence.

If you take a country like Sweden, 80 per cent of the health expenditure comes from the public sector. But in Britain and Sweden, that public fund comes from taxation. If you are able to establish a robust tax base, then you can say that a certain percentage of the collected pooled tax will then be deployed into the provision of health services so that we will guarantee for all some minimum standard of healthcare.