How to revive ailing health sector in 2019

Dr. Francis Adedayo Faduyile is the President, Nigerian Medical Association (NMA) and Associate Professor/Consultant Pathologist, Department of Pathology and Forensic Medicine, Lagos State University College of Medicine (LASCOM)/ Teaching Hospital (LASUTH), Ikeja, Lagos. Faduyile in this interview with The Guardian made recommendations to President Muhammadu Buhari on how best to revive the ailing health sector in the New Year. CHUKWUMA MUANYA writes. Excerpts.

Non Functional Cancer Treatment Equipment In most teaching hospitals
Cancer treatment is one of the most expensive treatment/management in the world. This starts from the diagnosis, the relevant investigations and treatment (surgery, chemotherapy, radiotherapy and supporting treatment). Cancer patients need long term treatment to be able to effectively manage the ailment. In Nigeria, there is dearth of cancer diagnosis equipment and this made most cases to present at late and advanced stages.

The non-availability of functional cancer treatment equipment or inadequate numbers of such equipment in our tertiary hospitals has compounded the already poor care for this set of consumers of health care. The standard recommendation in line with international best practice is 250,000 people to one machine. In a country of over 180million people and currently with eight cancer treatment centers and only two centers- National Hospital, Abuja and University College Hospital (UCH), Ibadan- with functional radiotherapy machines as at the end of December 2018, and with over 50 per cent of all cancer patients requiring radiotherapy in the course of their treatment and issue of affordability considering the fact that over 80 per cent spending for health is out-of-pocket, we have to act decisively and fast.

As a matter of fact, few months ago, we had a terrible situation in Nigeria where there was no single functional radiotherapy machine in Nigeria. Many of our patients had to travel to Ghana and join the long queue of patients. This has both economic and moral implications. I must commend the Honourable Minister of Health for addressing this issue head-long. Recently, some centres in Nigeria like Lagos University Teaching Hospital (LUTH) were selected and currently being equipped to serve as centre of excellence in cancer management. The Federal Government recently bought another radiotherapy machine for National Hospital, Abuja. All these interventions will go a long way to alleviate cancer treatment and care in our hospitals.

The target in 2019 should include but not limited to; urgent replacement or repair of existing equipment in the eight centers, capacity building on the use and maintenance of the equipment, timely replacement of parts in accordance with manufacturer’s instructions, expediting action on the planned establishment of t least two cancer treatment centers in each geopolitical zone for comprehensive cancer care, and incorporation of cancer care and management in the National Health Insurance Scheme. The latter is particularly important as most cancer cases are seen in the 60 years and above where many of them are either retired if in public service or are not actively productive and hence may not be able to surmount enough funds for proper care. .

Failure of the National Health Insurance Scheme (NHIS)
The NHIS established in 1999 with the commencement of operation in 2005, is yet to deliver on its mandate and appears to be far from affecting a paradigm shift soonest. It is no news to state that the performance of the scheme is largely abysmal with less than five per cent of the population covered. The poor performance has been attributed to many factors ranging from poor funding to lack of transparency in its administration. Recently, the Governing Council of NHIS noted the following as key to the failure experienced so far: decline in remittances, persistent budget deficit, management fiscal indiscipline, conflict and corruption.

With the provision of the one per cent Consolidated Revenue Fund (CRF), a significant source of the Basic Health Care Provision Fund (BHCPF) for which 50 per cent is supposed to be disbursed through the NHIS, in the 2018 budget, it has become a must to nip the challenges encountered so far in the bud for Nigerians to benefit reasonably from Basic Health Care that the fund is meant for. The Federal Government/Federal Ministry of Health (FMoH), NHIS, Health Maintenance Organisations (HMOs), Health Service Providers (HSP), enrollees, civil society organizations, professional bodies in the health sector including the NMA, must rise to the occasion and synergize appropriately.

Few States are now starting their own version of the scheme without involving critical stakeholders like NMA. The states governments have largely politicized the State Health Insurance Scheme in their respective state. Although, we want all States to come on board but the proper process should be followed, otherwise it will not be sustainable. The Federal and State Governments should also bring a template for the inclusion of the non- formal sector-the farmers in the village, pretty traders among others in the scheme. There is also need to review the current operational strategies of the scheme and ensure that all the relevant stakeholders are on the same page.

Non-Implementation of the National Health Act (NHA) and the BHCPF
It is laudable that the Federal Government finally showed some level of commitment to the implementation of NHA with budgetary provision of N55 billion for the Basic Health Care Provision Fund (BHCPF) in 2018 after its passage into law in October 30, 2014.Though the disbursement and administration of the fund did not meet the expectations of Nigerians as the Federal Government through the Ministry of Health could not commence its implementation across the 36 states and FCT, even none of the two states selected for the commencement of the implementation among the six states planned for the first roll out could be said to have possibly felt the impact, the most important thing is that the ball has been set rolling. A key factor that have been identified as responsible mainly for the delay is the administrative/bureaucratic tussle between the FMoH,
National Primary Health Care Development Agency (NPHCDA) and the NHIS.With the design and production of the strategic 123 pages manual for the implementation of BHCPF by the FMoH, it is hoped that the lessons learnt from the delay in the implementation in 2018, will be put to good use in 2019.

We note the Commitment of the federal government to earmark N51.22 billion from the Consolidated Revenue Fund (CRF) in 2019 for the Basic Health Care Provision Fund and other related commitments in the recently presented 2019 budget proposal to the National Assembly. I want to encourage the federal government to ensure timely release of this fund after the 2019 budget is signed into law.

Poor funding and budgetary allocation to health
To stop the discourse on issue surrounding the funding of the health sector vis-à-vis poor budgetary allocation to the sector with the attendant conspicuous implications on health care delivery, is tantamount to saying Nigerians should accept the low level of prosperity that we are facing because a Nation can only be wealthy if the people are healthy.

In 2001, the African Heads of State met and came up with the Abuja Declaration, which prescribed that a minimum of 15 per cent of the total budget of each country should be allocated to health. Unfortunately, the best we have got since then was 5.95 per cent in 2012. It is pertinent to note that it was less than four per cent in 2018. Worst still, the over 60 per cent said to be dedicated to Primary Health Care is yet to be fully disbursed for that purpose as at December 2018, due to unhealthy bureaucratic issues within the sector.

President Muhammadu Buhari has recently proposed a recurrent expenditure of N315.65 billion for the ministry of health in its 2019 appropriation bill submitted to the National Assembly on Wednesday, December 19, 2018. Although this is about 46.3 billion increase from the 2018 budget when N269.3 billion was allocated as recurrent expenditure for the ministry of health, it must still be noted that the budgetary allocation to health in the 2019 is less than 4%.

Brain drain and poor reward system
Brain drain occurs when significant numbers of highly skilled professionals leave their countries of origin to seek employment or establish businesses abroad. This has a negative effect on the economics of developing countries, because the skills of remaining professions may not be adequate to grow the economy. This is apart from the fact that the health needs of the population cannot be met due to reduced number of health personnel. One of the greatest threats to the renowned efforts in re-positioning our healthcare system for a better and responsive system is the on-going mass exodus of health workers especially medical doctors and nurses. Virtually, on a weekly basis in the last four years, we have been experiencing mass resignation of all cadres of medical doctors including consultants for greener pastures. There are many reasons attributable to this mass exodus, the major factors are poor, obsolete and dilapidated infrastructures in our hospitals across in the country, lack of job satisfaction, lack of job security, poor working conditions and poor reward system including poor remuneration. The remuneration of health workers are very poor in this country and health workers take home in Nigeria is about 30% of what their colleagues are being paid abroad. The reward system is so bland that most health workers see nothing that is keeping them happy. There are no opportunities for car loan, housing loan and special allowances as applicable to their colleagues working abroad. All these contributed significantly to the on-going mass exodus of health workers.

Inter-professional rivalry
For the health sector to meet up with the demands and needs of over 180millions Nigerians in 2019, the rivalry within the sector must be curbed or reduced to the minimum. This requires sincere commitment by stakeholders including group of workers/associations and government at all levels.The current leadership of the NMA, which came on board in May 2018, has been having fruitful engagements with other professional groups especially the Pharmaceutical Society of Nigerian with laudable understanding reached, as well as the National Association of Nigeria Nurses and Midwives, aimed at ensuring inter-professional harmony in the sector. We have discovered that most of the disagreements are based on misinformation, with the “divide and rule tactics” of government playing a huge role in this regards.

According to the WHO and international best practices, doctors are the leaders of the health team. This fact must be acceptable to all health care providers and should be respected. I want say that this does not mean that other health workers are inferior, they are all very important in the health care delivery system. For example, the cleaner can disrupt the job of the surgeon in the theatre if the environment is not clean and fit for surgeries. The patients have been at the receiving end of the consequences of this unholy and unhealthy professional rivalry in the health sectors.

The solution to professional rivalry in the health sector is for all health workers to understand that there are many professionals involved in contributing to healthcare delivery of the patient and everyone of us is important. We must also to stop emphasizing our differences but promote team spirit among the health professionals. Effective team work among health professionals has been recognised as an essential tool for patient- centred health service delivery, and the process of providing health care is interdisciplinary requiring all members of the health team to work together.

The NMA is committed to the understanding reached with the Pharmaceutical Society of Nigeria, and the National Association of Nigeria Nurses and Midwives. We have also set mechanisms in motion to get more bodies of health workers on board, in the interest of Nigerians for a hitch free health care delivery.

Frequent strike actions
There is no doubt that incessant strike actions in the health sector is one of the factors that have brought a lot of hardship to Nigerians that seek health care at the public health institutions. It has also contributed to the loss of confidence in the sector by many Nigerians.

While we cannot entirely blame the workforce for the numerous factors that led to previous strike actions as it is the right of every group of workers to agitate and press home their demands through legitimate means, all stakeholders including the professional bodies/unions and government, must come together to chart for workable alternatives in resolving disputes. The workforce/bodies of workers must realize the need to exhaust alternatives in dispute resolution, with strike as the last option in dispute situation. Government must live up to expectation with emphasis on sincerity of purpose and openness. We must discard mutual distrust!

On a general note, in 2019, we expect a reduction in the frequency of strike in the health sector especially those that may arise from inter-professional rivalry/disharmony, if we can build on the foundation already laid by the NMA, the Pharmaceutical Society of Nigeria, and the National Association of Nigeria Nurses and Midwives. The consciousness of the ‘divide and rule tactic’ of government, will be of immense value for all of us on the need to talk more with ourselves.

Drug insecurity, abuse and misuse
The consequences of drug insecurity occasioned by drug abuse and misuse witnessed unprecedented rise in 2018 with codeine based medications and Tramadol at the top of the drugs. You will recall the ban on the importation and production of codeine-based cough syrups in 2018 following the reported cases of illicit marketing and mental illness resulting from its addiction. While that action may seem to be appropriate as at the time by many Nigerians, it is important to state that winning the war against issues surrounding drug insecurity will not be only by such action but requires the deployment of strategies centered on Prescription Rights. The enforcement of Prescription Rights will ensure that only with prescription from a doctor would a pharmacist dispense such drug(s).

The government should ensure more security measures are put in our borders to guide against the importation of these drugs, work more on how to halt the distribution lines as well as educating the youth on the evil of drug abuse.Another dimension to drug insecurity is the unnecessary and wasteful spending on drugs like antibiotics in a society with poor per capital income. Apart from its capability to worsen poverty, it also leads to the development of drug resistance especially in the case of antibiotics and antimalarial.In 2019, government and its agencies must ensure the enforcement of prescription rights and the monitoring of the distribution and dispensary of drugs especially at dispensary outlets.

Quackery in all the professions
The proliferation of quacks and its practitioners in the health sector has brought about devastation to the unsuspected public. These quacks have infiltrated all sections of the health care delivery including our public health institutions.The NMA in realisation of the danger of the continued rise in this deleterious act instituted a potent anti-quackery measure, the doctors’ stamp. The onus is on public and private institutions, corporate organizations and the judiciary establishments to insist on this stamp on all medico-legal documents and reports.

In this same vein, the NMA pursued the reconstitution of the Council of the regulatory body for medical practice in the country, the MDCN. Before its reconstitution and subsequent inauguration in November 2018, medical practice has remained largely unregulated for the upward of three years. With this development, we expect that in 2019 the Council will activate and deploy relevant strategies that will help in stemming the tide of quackery and related practices in the medical profession. This is also expected of the sister’s regulatory bodies in the health sector with the observance of boundaries.

Setting agenda for health in 2019
The following will constitute our agenda for 2019; increase budgetary allocation release to meet 15 per cent of the total budget, universal health coverage for all Nigerians, improve work environment in our hospitals and upgrade of the infrastructure to meet international standards in order to reverse medical tourism, immunization particularly, strengthening polio virus immunization, surveillance and monitoring before the anticipated declaration of Nigeria free of Polio virus in August this year, strengthening of National Health Insurance Scheme (NHIS), State owed health insurance Scheme and Community Insurance Scheme to ensure qualitative services delivery, promoting industrial harmony in the health sector , improve welfare conditions of all health workers in Nigeria , ensuring that the one per cent of the Consolidated Revenue Fund of the federation in the 2018 budget already released for properly utilized for improved funding of primary healthcare in Nigeria as mandated by the National Health Act 2014, to capture more Nigerian and putting strategies in place to curtail the emergence and re-emergence of viral haemorrhagic diseases and epidemic diseases in Nigeria.

Falsified and substandard medicines
The rise in falsified and substandard medicines is one of the issues confronting health care delivery the world over. However, the havoc from these is alarming in the developing countries including Nigeria due to lack of effective regulation and monitoring, poor access to quality-assured drugs, poverty and corruption.According to the World Health Organisation (WHO), one in 10 (10 per cent) medical products sold in developing countries is either fake or substandard. Recent report in JAMA Network Open journal suggested that this figure might be as high as 19 per cent.

In Nigeria, both urban and rural settings, the hawking of drugs/pharmaceutical products even in commercial vehicles in some cities, have become a routine. Recently in Lagos, the Lagos State Police Command uncovered an illegal outlet where fake/falsified and substandard medicines were produced in large scale. This is another form of quackery!Many Nigerians, families and the general public have suffered huge health challenges including deaths from this criminal act.

As all stakeholders commits to a robust health care delivery in 2019, the challenges faced as a result of these practices must be tackled with the National Agency for Food and Drug Administration and Control (NAFDAC) taking the lead in area of regulation and monitoring of the importation, production and distribution of drugs and pharmaceutical/medical products, in collaboration with other agencies of government including security agents. The diligent implementation of the NHA and other strategies tailored towards ensuring Universal Health Coverage (UHC) should also be pursued. Nigerians are advised to embrace healthy health seeking attitude.