{ANALYSIS} How Coronavirus exposed the failings of Nigeria’s healthcare system

April 13, 2020
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Sedans moved in slowly with their hazard lights on. Cries of his name rang out from high-rise apartments and the nation mourned in regret. Dr Li Wenliang, the ophthalmologist who warned his colleagues, China and, indeed, the world of the Coronavirus pandemic from his base in Wuhan in December 2019 was dead and 11 million residents of Wuhan could not grief enough.

Fast forward to about four months after his warning which was neglected, the world is grappling with a pandemic which has crippled global economy, infected more than 1.8 million and killed about 114,000 people, according to Johns Hopkins University Coronavirus Resource Centre and left healthcare systems gasping for breath.

Nigeria, Africa’s largest economy, has had its share of confirmed cases, deaths and recoveries. The novel virus has given the country a false respite by taking eyes away from other diseases prevalent in the country but has drawn more attention to the frailties of the country’s healthcare system exacerbated by years of neglect, infrastructural decay, the dearth of manpower, inadequate funding and medical tourism by the political class.

Inadequate funding

When the Coronavirus broke out and hit western countries hard, civil society organisations and experts, including the World Health Organisation (WHO), called on the Nigerian government to prepare for the pandemic’s arrival in the country. In response, the government announced it was ready to combat it, latching on the euphoria of its strides in managing the Ebola outbreak of 2014. Some experts reminded the government of the country’s weak healthcare system and the disappointment that awaited.

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A few weeks after the virus arrived and the surge in confirmed cases continued, the Secretary to the Government of the Federation and chairman, Presidential Taskforce on COVID-19, Boss Mustapha, said during a meeting with the leadership of the National Assembly that he never knew the healthcare system was in such a bad shape, although he retracted the following day and explained that he was quoted out of context.

But some experts would argue that he meant what he said as it explains the neglect the sector has suffered. For example, in 2001, the heads of state of 52 African countries met in Abuja and committed to spending 15 per cent of their yearly domestic budget on health.

This Nigeria has not shown any commitment to since it was signed. It has struggled to allocate less than six per cent of its annual budget to health, and a chunk of it is spent on salaries, BudgIt says.

A 2015 report by researchers at the Brookings Institute found that Africa bore 23 per cent of the world’s disease burden, but sadly, it accounted for only one per cent of the global health spending.

“In per capita terms, the rest of the world spends 10 times more on health care than Africa,” it said. It went ahead to warn that at this level, a country like Nigeria will find it difficult to achieve the Sustainable Development Goals (SDGs) with a 2030 deadline.

Comparatively, South Africa’s 2017 national expenditure dedicated 13.5 per cent to health, while as of 2011, Mauritius, Seychelles and Eritrea had met the target of allocating 15 per cent of its national budget to health.

The call for more budgetary allocation to the sector is what Nigeria Medical Association (NMA) has championed of late.

Chairman, Oyo State chapter of the association, Dr Akin Sodipo, told the Nigerian Tribune that the decision of the government at both the federal and state levels not to make adequate funds available for the sector has cost the nation a lot.

“NMA has been shouting, but everybody seems to be having a field day at the expense of the health system. We spoke, but nobody listened to us. I think this (Coronavirus pandemic) is an eyeopener for us that we have a system which we have neglected for so long.

“The threshold is 15 per cent and they are giving us three or four and everybody is shouting ‘we are better than last year’ because we got 4.3 per cent. We are just nowhere about it. So, it is for the government to wake up to its responsibility, allot what is supposed to be allotted to health, so that the health system will wake up.”

The neglect, Mr Mustapha agreed, has made the primary healthcare system with over 10,000 clinics unworkable, as many lack basic drugs and equipment. The result of this is dire with grim stats.

Every day, approximately 2,300 under-five-year-olds and 145 women of child-bearing age die in Nigeria. These deaths are mostly preventable. About 50 per cent of maternal deaths in Nigeria is said to result from preeclampsia and eclampsia, obstetric haemorrhage, an analysis of Nigeria’s health sector budget in 2018 by BudgIt revealed.

It also revealed that the country has one of the highest numbers of new-born deaths in Africa and at least 124 children die per 1000 before their fifth birthday, making the under-five mortality rate in Nigeria one of the world’s highest.

State governments have been at the heart of criticisms as they control the primary and secondary healthcare systems which take care of a larger chunk of the population.

Experts agree that, for the system to live up to expectations, the states must do more. For example, only Bauchi State in 2018 allocated up to 15 per cent of its annual budget to health while states like Anambra and Oyo allocated 1.21 per cent and 1.22 per cent, respectively, to the sector, the BudgIt report said.

‘Pre COVID-19 hazard allowance N5000 per month’

Thursday last week, the Minister of Health, Osagie Ehanire, shocked Nigerians when he said he did not know if medical workers at the frontline of the fight against Coronavirus receive any hazard allowance. The statement irked many, especially the National Association of Nigeria Nurses and Midwives (NANNM) who immediately called for his resignation for displaying gross insensitivity to the plight of healthcare workers at the frontline.

Even though the Lagos State government and the Minister of the Federal Capital Territory (FCT), Mallam Muhammad Musa Bello, reacted, assuring that caregivers in the state and FCT are adequately taken care of, the minister’s statement brought to the fore the poor welfare system for medical workers in the country. Mallam Bello said each doctor is being paid N50,000 daily; nurses, pharmacists and laboratory assistants receive N30,000 each, while cleaners and drivers get N20,000 on a daily basis. This claim has not been confirmed.

However, Dr Sodipo revealed that before the Coronavirus pandemic, medical workers were receiving a hazard allowance of N5000 ($13) per month, an amount he said was not just insignificant, but not in any way commensurate with what is obtainable in other parts of the word.

Poor remuneration is one, but delayed payment is another big factor that has seen to the decline of the sector’s fortunes. Some states are unable to pay the salaries of workers. This is true for healthcare workers too.

This gap has been identified as the major cause of ‘brain drain’ in the medical profession. It is estimated that well over 2000 healthcare professionals have left Nigeria in the past few years, choice destinations being mostly the United States, the United Kingdom (UK), Saudi Arabia, United Arab Emirates and South Africa. According to the UK General Medical Council register, about 6,289 doctors who qualified in Nigeria are practising in the country.

The Organisation for Economic Co-operation and Development says Nigeria is one of the three leading African sources of foreign-born physicians, an assertion Dr Sodipo echoed when he told Nigerian Tribune that Nigeria subsidises medical workers for the developed world.

As far back as 2004, the country was the only African country listed among the 20 top exporters of physicians. This has expanded the skill gap in the sector.

Welfare system also trickles down to the value placed on the lives of caregivers, especially in the light of the Coronavirus pandemic. Sadly, inadequacy in this regard has been exposed too.

All over the world, caregivers do not battle the pandemic without Personal Protective Equipment (PPE).

Meanwhile, in Kwara State, health workers at the General Hospital, Ilorin, protested what they described as risky working conditions and lack of PPE. Under the aegis of NANM, they demanded that the provision of PPE has become necessary in the light of risks of attending to COVID-19 patients.

One doctor per 5,000 people

Nigeria has a fast-growing population estimated to be around 200 million, but projected to explode to about 400 million in 2050, the United Nations says. The country is ranked seventh globally and has an equivalent of 2.64 per cent of the total world population. This is, indeed, massive strength and also a time bomb. With a lack of funding and the continuous exodus of Nigerian doctors to other countries, the current situation may worsen.

In mid the 2019, Nigeria’s Minister of Labour and Employment, Chris Ngige, told the world that the country had a surplus of medical doctors and was glad to export to other countries. Meanwhile, the country’s former Minister of Health, Professor Isaac Adewole, had said at a conference of the National Association of Resident Doctors of Nigeria (NARD) in 2018 that Nigeria had only one doctor per 5,000 people against the current global recommendation of one doctor to 600 population.

The Medical and Dental Council of Nigeria (MDCN) says there are about 72,000 nationally-registered Nigerian doctors, with only 35,000 practising in the country as of 2018. Juxtaposing this figure with national population estimates, there is a deficit of over 260,000 doctors in Nigeria and a minimum of 10,605 new doctors need to be recruited annually to meet global targets.

The gap may be closed substantially if the 3000 medical doctors trained annually in the country, of which about 2000 leave, stay back and practise. But Dr Sodipo says this may not be possible as “you cannot force a doctor” to stay back in the country and practise amidst poor infrastructure and other debilitating challenges.

Decayed infrastructure

The infrastructure gap in Nigeria’s health system has been exposed by the pandemic. There are hardly tertiary health institutions in the country that have received adequate funding to keep them properly equipped and staffed. With the paltry allocation to health which almost goes entirely into payment of salaries, little or nothing is actually left for capital projects at the hospitals. And where there exist good structures, lack of manpower lets them down.

Most of the healthcare facilities in the country lack basic equipment, electricity and the capacity to serve people in the rural areas. Non-maintenance of existing infrastructure has also decimated the sector’s capacity.

In the face of the pandemic, the private sector has stepped up to salvage the situation with provision of ambulances, beds and intensive care units.

For Kwara State, lack of proper maintenance of health facilities in the state has cost it some fortune. For example, the oxygen plant which was refurbished and unveiled on Friday had been built and put into use in 2004, but was later abandoned when it developed faults.

Capital flight

Medical tourism has not helped the sector. It is estimated that Nigerians spend over $1 billion annually to seek medical treatment ranging from oncology orthopaedics to nephrology and cardiology, outside the shores of Nigeria, the Nigerian Sovereign Investment Authority (NSIA) says.

To put this in perspective, the published Federal Ministry of Health budget proposal for 2016 was just $1.3 billion, while in the same year, about $1 billion left the country in medical tourism. This figure does not include the undisclosed amount spent by Nigeria’s president, Muhammadu Buhari, on medical trips abroad.

Beyond the loss of foreign exchange, the PWC researchers on ‘Restoring Trust to Nigeria’s Healthcare System’ think it has more debilitating effects not just on the healthcare system, but on the economy.

“The patients who travel abroad for treatments are the ones who can pay for services at market prices in Nigeria. Their healthcare spending can deliver the margins that can enable Nigerian providers to cross-subsidise patients who are unable to pay for their costs.

“If we assume gross margins of 45 per cent, and an average healthcare spend per capita of $120 per patient for the Nigerian population, then the $1 billion spent on medical tourism translates into a loss of a potential 3.7 million patient treatments per year in Nigeria,” the study found.

“Investment in our healthcare infrastructure must be looked at seriously. No one can travel out for medical attention now. So, we need to sit down and address the issue,” Boss Mustapha, Secretary to the Government of the Federation, said.

Bunmi Oyebanji, Programmes Manager, Nigeria Health Watch, on the other, hand thinks the healthcare system has to be fixed and agencies like Nigeria Centre for Disease Control (NCDC) given more funds to enhance its capacity.

“We need to find ways to fund health. We were campaigning for increased funding for NCDC last year not knowing the challenge at hand would come,” Oyebanji said.

NIGERIAN TRIBUNE

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