Setting Healthcare Agenda for Nigeria (1)

HEALTH CARE AGENDA 2019 – 2023

As Nigerians go to polls on Saturday, February 23 and Wednesday, March 6 for the presidential and governorship elections respectively, to usher in successive governments that would steer the nation and various states until 2023, experts have shared templates they believe would change Nigeria’s healthcare narrative and put the sector on the global map. Martins Ifijeh reports

Ever wondered a scenario where Nigeria’s healthcare system is adjudged one of the best in the world, and the previous poor indices the country is known for now becomes a thing of the past? Wonder no further. Some players in the healthcare industry believe this is possible with conscious decisions, political will and deliberate actions.

According to them, with implementation of working models in various areas of healthcare, the country’s maternal and child health will improve, disease burdens will reduce, doctors and patients will no longer need to travel abroad for work or treatment respectively, expectancy rate will increase, among other benefits.

But they are also quick to warn that these templates can only be feasible in the face of an enabling policy environment driven by committed leadership and a government that is sincere about its human capital agenda. They are also of the opinion that Nigerians, armed with their PVCs should vote in leaders who will be interested in their health and human capital development.

National Mental Health Agenda
A recent study by the World Health Organisation (WHO) has shown that one in four people globally will be affected by mental or neurological disorders at some point in their lives; that is at least 1.7 billion persons worldwide.
Across the world, not fewer than 450 million people are currently suffering from such condition; making mental disorder one of the leading causes of ill-health and disability globally.

Mental health has been ranked the fourth leading cause of global disease burden, while it is estimated that it will rank second by 2020, lagging behind only ischemic heart diseases.
Despite being an alarming public health issue due to the large population affected, studies have shown that mental disorder is not taken as a priority, especially in low and middle-income countries like Nigeria, where it is highly misunderstood.

Statistics on Mental Disorders in Nigeria
Several indications show that over 60 million Nigerians have one form of mental disorder or the other with only about 20 per cent of persons in such category seen to have the obvious forms of it, which includes what the ordinary Nigerian refers to as madness, schizophrenia, and perhaps extreme case of drug or alcohol addiction; a reason that has largely made mental disorder in the remaining 80 per cent or 48 million Nigerians ignored or poorly understood.
To be exact, the WHO in 2017 said 7,079,815 Nigerians suffer from one of the most ignored and misunderstood form of mental disorder in the country – depression.

This, according to the world health body, represents 3.9 per cent of the entire population of the country, thereby making Nigeria the most depressed country in Africa. Globally, Seychelles has the lowest number of depressed persons with just 3,722, according to WHO.
It also said 4,894,557 Nigerians, that is 2.7 per cent of the population, suffer anxiety disorders. The country is closely followed by Ethiopia with 4,480,113 sufferers, Democratic Republic of Congo with 2,871,309, South Africa with 2,402,230, and Tanzania with 2,138,939 sufferers
WHO data has shown that although treatments are available, nearly two-thirds of people with a known mental disorder never get help from a health professional as stigma, ignorance, discrimination and neglect continues to prevent care and treatment from reaching majority of people with mental disorders.

Tackling stigma and ignorance thus remain one of the greatest challenges to accessing mental health care Nigeria, and other low and middle income countries.
Despite the apathy in accessing mental care in Nigeria, government records show that the branch of science is underfunded in the country, leading to poor awareness and inadequate service provision.
This, in no small measure has aided the increased prevalence of drug abuse, use of prescription drugs, and recent increases in suicide reports in the media.

Oluwatayo, UK based mental health expert

In tackling this, as the country moves into another political dispensation come May this year, a UK trained Consultant Psychiatrist and Medical Director, Lakeside Hospital, Wyboston, Bedfordshire, Dr. Olufemi Oluwatayo believes going forward, deliberate efforts should be made to tackle the growing public health concern in Nigeria.
He said the incoming federal government should appoint a National Mental Health Czar with a sole purpose of pushing a National mental health agenda for the country, especially with the spate of mental health issues in the country, adding that states should appoint same.
He called for review of the present National Mental Health Policy to reflect current needs, noting that the mental health desk of the Federal Ministry of Health should be revived and revitalized.

Oluwatayo, who is also the Chief Executive Officer, The Retreat – a mental healthcare facility in Lagos, said: “We should urgently pursue and push through the Mental Health Bill at the National Assembly and other relevant legislation, such as decriminalising suicide or attempted suicide. We should push for relevant legislation that will commit the federal and state governments to provide specific amount of their annual budget to mental health and ensure that the money should be ring fenced for use of mental health services only.

“Because governments alone are unable to meet the need of the teeming Nigerian population, there is massive scope for private, International organisations and charity sector participation in mental health services provisions. There should be an active programme to involve, encourage and give incentives to involve these providers.

“There should be collaboration with the National Health Insurance Scheme such that a modality is provided that will include treatment of common mental disorders under the current health insurance payment systems. Government should explore the option of collaborating with the pharmaceutical industry for affordable psychotropic medications purchased nationally and disbursed nationwide,” the psychiatrist said.
Establish Institute of Mental Health

While also stating that government should establish the Federal Institute of Mental Health, he said the role of the institute will include conducting mental health related researches.

“This will help to plan services adequately, establish a national database of the prevalence of various mental disorders in Nigeria by collating existing researches and commissioning new ones as appropriate. Government should also complete a national mental workforce planning audit to determine how many psychiatrists, mental health nurses, psychologists, occupational therapists, social workers and speech and language therapist that the country needs.

“Based on the outcome of this, government should liaise with Nigerian universities and institutions to offer courses that will address the deficits. There should also be a national standard and regulatory body that can produce national standards for provisions, treatments, monitor and enforce compliance to the standard. Government should also set up National Audit standards and systems,” he added.

Prevention of Mental Disorders in Nigeria

He said while these models can be adopted going forward, preventive care should be given utmost priority, adding that with general improvement in quality of life of Nigerians mental disorder will be reduced.

He suggested that there should be a suitable work-life balance, appropriate lifestyle choices (no smoking, drinking alcohol in moderation and avoiding obesity). “We should endeavor to educate the public through various educative programmes and media. There should be suicide prevention activities such as education and managing suicide hotspots that are beginning to emerge in Nigeria,” he added.

Treatment of Mental Disorders

On treatment at primary, secondary and tertiary levels, he said “There should be full integration of mental care into primary healthcare with front line staff being able to identify and treat common mental disorders such as anxiety, stress, depression and sleep problems using resources such as the mental health Gap Action Programme (mhGAP) tool.

“There should be the establishment of fully functioning psychiatric departments that can treat most mental disorders such as schizophrenia and bipolar affective disorder in all general hospitals in the country. Also, there should be a referral centre for treatment of the most severe mental disorders that require long stay in hospital and specialist interventions in psychiatric departments of all Teaching hospitals and Federal Medical Centres and national Neuropsychiatric hospitals,” he added.

Healthcare Financing Template
Nigeria currently has one of the poorest healthcare financing models in the world; a scenario that has played a major role in the abysmally poor healthcare indices the country is presently known for. The Nigerian government on its part has not helped in addressing the financial gap.
With the country presently spending less on healthcare than nearly every country in the world – a reflection of its under-prioritisation of the sector, health spending has become dominated by out-of-pocket expenditures with its well-known impoverishing effects, especially since majority of those who purchase healthcare in the country are poor Nigerians.

In 2016, total government health expenditure was 0.6 per cent of Gross Domestic Product (GDP). And as a share of total government expenditure, government health spending was also low at 6.1 per cent, amounting to just $11 per capita.
This level of spending is grossly below regional and lower middle income averages and the recommended US$86 per capita for low and middle income country benchmark needed to deliver a limited set of key health services.

Olumide; Health finance expert with World Bank/IFC

But Senior Health Specialist, International Finance Corporation and World Bank, Olumide Okunola believes moving into another political dispensation, Nigeria can get it right if the present reforms instituted by the federal government were built upon.
Among such reforms presently instituted are the implementation of the transformative National Health Act, of which the Basic Healthcare Provision Fund (BHCPF) is a major financing vehicle.

This BHCPF, according to the federal government will mobilize close to N60 billion (approximately US$150million) in new money per year for Primary Healthcare Centre strengthening and service delivery.
The reform also include institutional reforms, and among those that stand out are the development of state social health insurance schemes by state governments which mobilises additional financial resources from states, pools resources and is a veritable strategic purchasing mechanism; and then the Primary Healthcare Under One Roof (PHCUOR) which emphasises the integration of primary care services and promotes governance and accountability for delivery of primary care.

The present government also ensured reforms recognising private participation in health delivery through expanded service delivery by private providers and provision of financing by financial institutions.
However, Olumide believes for Nigeria to meet its expected outcome in healthcare in the next political years ahead, series of approaches should be considered.

Emphasis on Basic Minimum Package of Health Service
He said the new government must give emphasis to Basic Minimum Package of Health Services, noting that the significant resources from the recently launched Basic Healthcare Provisions Fund (BHCPF) means that there will be a significant reallocation of resources towards the defined package of services as stipulated in the National Health Act.

Scale Up Strategic Purchasing Approaches
“I am of the opinion that if we scale up strategic purchasing approaches, there will be a healthy competition in the healthcare market. The increased use of strategic purchasing means that public providers will now compete with private providers for the delivery of the package of services financed through the BHCPF.”
He believes empaneling private providers will expand the capacity to deliver services while also incentivizing more private participation in underserved areas, adding that such approach will force providers both public and private to focus on quality and efficiency in the delivery.

Innovative Contracts for Underserved Services
Okunola, who is a healthcare and finance expert noted that the concept of strategic purchasing will expand the use of innovative approaches to expand coverage in underserved services like Oncology.
He said: “For instance, the creation of a special fund for oncology will incentivise private providers to develop greenfield projects or partner with public facilities to develop Public Private Partnership projects which will serve as off takers to bid for the delivery of services.”

Leveraging Financing from Outside Public Sector
He said one of the key ways of addressing healthcare financing issues in Nigeria is to leverage financing from outside the public health sector.
According to him, the next five years will see a wave of new investments from non-traditional sources of financing from the health, adding that as a necessity, the public sector will need to redesign current modes of service delivery to keep pace with reforms.
“With this, public sector managers will realise that they need to earn their payments; existing public PHCs will be outsourced to the private sector to form networks of high performing facilities, and financial institutions like banks will begin to see opportunities in the sector and develop financial instruments to support private operators who are mostly micro, small and medium enterprises.”

He believes the future of health financing in Nigeria is dependent on the continued commitment to the implementation of the BHCPF. “It cannot be a one off implementation. Also, it is important to note that the BHCPF is currently implemented as a “service wide vote” and not as a “statutory transfer” like the Universal Basic Education Commission (UBEC) as such monies are not rolled over at the end of the financial year. This brings with it a level of uncertainty that needs to be addressed.

Okunola also warned that financing itself was not on its own a sufficient condition for improved health outcomes, emphasising that there is a need for the establishment of both public and social accountability mechanisms that will help in the improvement of service delivery.
He said: “In this regard, financial reports showing the source and use of funds as well as improvements in monitoring and quality assurance criteria are a necessity while on social accountability; a focus on participatory approaches will renew and reinvigorate the current lack of a consequential and voter-sensitive compact between the government and the population.

“This will impact the future of health financing in two distinct but interrelated ways – politicians will take seriously the prioritisation of health financing when making budgets, and secondly it could mobilise additional resources from development partners who are waiting with resources to catalyse a much needed change in the sector.”

Universal Health Coverage
While Universal Health Coverage (UHC) is currently the single most discussed healthcare agenda globally, many countries, including Nigeria are still far from achieving it; making access to quality healthcare a herculean task for millions of Nigerians, especially the poor ones who still pay out of pocket to get treatments.
On specifics, about 73 per cent of Nigerians are presently paying for their healthcare, with a major chunk of them not able to access quality care due to lack of funds. This therefore has in no small measure increased the country’s mortality rate, reduce life expectancy, and the myriads of poor healthcare statistics which the country is known for.

No wonder when health indices are discussed on global stages on a country-by-country basis, Nigeria often emerges one of the countries with the worst indices among key global health issues. The country sits comfortably among the 10 worst countries in the world with disease burdens.
On specifics, Nigeria has the highest burden of malaria globally, with about 40 per cent of global malaria deaths occurring in the country and Democratic Republic of Congo alone. Not only that 90 per cent of Nigerians are at risk of it, it kills over 300,000 of them yearly, with 11 per cent of maternal deaths linked to it.

Also, Nigeria is rated as the second worst country with maternal and child deaths globally, just second to India. About 15 per cent of global maternal deaths occur in Nigeria alone, and the deaths of newborn babies in the country represent a quarter of the total number of deaths of children under five worldwide. In fact, a woman’s chance of dying from pregnancy or childbirth in Nigeria stands at one ratio 13, if indices from the World Health Organisation (WHO) are referenced.

Nkechika: Heads Nigeria’s biggest mandatory health insurance scheme

Among other areas, Nigeria is the second worst recipient of malnutrition burden globally, just second to India.
Several countries with similar poor health indices decades ago have prioritised universal health coverage. For instance, countries like Turkey, Mexico, Thailand, Kenya, Ghana, among others are currently doing well in healthcare coverage for their citizens; an approach that has reduced their disease burden.

While UHC has helped in shaping healthcare globally, Nigeria just recently woke up to the reality that that is the way to go. Thankfully, the Minister of Health, Prof. Isaac Adewole and his ministry are championing the cause.
First, it was through a pledge to implement the once abandoned National Health Act, and then the launch of the Basic Healthcare Provisions Fund (BHCPF), Saving One Million Lives Reward for Performance, and a host of other initiatives.

These initiatives have recently started paying off with the earmarking of N57.15 billion for BHCPF, and the seed fund from International Global Partners (World Bank Group, Bill and Melinda Gates Foundation and Dangote Foundation).
But the Director General and Chief Executive Officer, Delta State Health Contributory Scheme (DSHCS), Dr. Ben Nkechika believes going into the next political dispensation, the country must do if it truly wants to achieve UHC, adding that when all Nigerians are covered, many of the health issues affecting the country will reduce or in many cases tilt towards being eradicated.

Improve Healthcare Access in Rural Communities
Nkechika said: “To consolidate on the above achievements in 2019 and beyond, the country should put in a greater effort that is focused on improving healthcare service access in rural communities spread across the country through innovative partnerships, implementation of quality of care, improvement of programs that encourage performance based incentives, better resource management that ensures accountability through strategic purchasing mechanisms and a pragmatic monitoring and evaluation program to track performance for reviews and adjustment that improve outcomes.”

He said the plan by the federal government to implement the BHCPF across the country in 2019 was a great step in the right direction, but however stated that the requisite processes and infrastructure that will drive the implementation especially in the rural communities that mostly need these interventions should be aggressively considered to ensure that the rural populace are not disenfranchised from getting the program benefits.

States Should Have Health Insurance Schemes
Of what value would the BHCPF be if only few states key into the drive for universal health coverage, or if in the end, only few states benefit from federal government support in the disbursement of basic healthcare fund?
Nkechika, who has grown the Delta State health insurance scheme to the tune of 500,000 enrollees – the biggest so far in the country, apart from the National Health Insurance Scheme – believes if all states of the federation are given the support they need from the federal government to ensure that no state or rural community is denied the benefits in one way or another of the Basic healthcare Provision Fund, this would push the nation an inch further towards achieving UHC.

He said: “The resources are there to be harnessed. A focused strategic planning and implementation with proper resource mobilisation and utilisation that granulates care at the basic level will help achieve better health outcomes in 2019 and beyond.”
Believing that if all states adopt the Delta State model, there would be a significant improvement in achieving UHC, he said in the next political dispensation, no state should be left out of establishing health insurance scheme, as that is the way to go in the 21st century.
Nkechika said: “Delta State in the forefront of the implementation of the state health insurance scheme currently has over 500,000 registered enrollees with over 300 government primary healthcare facilities, 65 government secondary healthcare facilities and 50 private healthcare facilities accredited to provide healthcare services under the DSCHS.
“Several States that include Kano, Lagos, Oyo, Bayelsa amongst others, have also commenced the state health insurance scheme and are making significant progress in its implementation.”

The DG, who says he was sharing the Delta model because he believes if between 2019 and 2023 all states adopt same, Nigeria would be able to meet the 2030 target on UHC set by global health bodies, emphasised that the state has commenced the implementation of its “Access to Finance” program to rehabilitate and revitalise 25 previously defunct healthcare facilities spread across the state, especially in rural riverine communities.

“We have also achieved the ‘One PHC per Ward initiative’ with a Ward Development Committee (WDC) to support PHC services in each federal ward, using monitoring and evaluation program tools that ensure accountability and performance based incentives.

“Each accredited primary healthcare facility and secondary healthcare facility will have an ICT Platform program that covers e-medical records, e-treatment support, e-pharmacy and e-billing protocols, as well as provide analytics and reporting with follow-up management and reminders of post care requirements. The software for the above programmes will be embedded in a solar powered ICT Infrastructure to ensure 24 hours service in rural communities that have power challenges,” he said.

Primary Healthcare Agenda
It is no longer news that for a country to have a better healthcare system, its primary healthcare must be accessible, affordable and qualitative to its people. But same cannot be said of Nigeria’s primary healthcare facilities, where many Nigerians still lack access to basic healthcare, especially in rural and hard to reach areas.

Kana is a primary healthcare expert

As the engine room of healthcare all over the world, there is no gainsaying that if governments at all levels, moving forward, fix primary healthcare, it would have solved more than half of the problems in the sector.
A public health expert, Dr. Richard Salu said the country presently has about the worst maternal, newborn and child mortality rate in the world, with children and mothers dying from what ordinarily can be prevented. He believes if this is the only thing in the health sector the government will focus on from now till 2023; they would end up making a difference in the health sector.
“When basic health facilities are put on ground, pregnant women will no longer give birth at home or with traditional birth attendants. With functional PHCs, children will be immunised, they will not die from malaria, cholera, pneumonia or diarrhea. This is how other countries run their system,” he said.

Sharing his template for a functional PHC in Nigeria, National Programme Manager, Saving One Million Lives Results for Performance, Dr. Ibrahim Kana said the country can achieve universal health coverage through an effective primary healthcare system.
He noted that as the country moves towards another political dispensation, priority should be given to strengthening compulsory state social health insurance schemes while also revatilising primary health facilities across the country.

“Moving forward, we should have a massive recruitment of human resource and deploy the personnel appropriately. We should also establish efficient primary healthcare development agencies. The country should invest in infrastructure, equipment, strengthen cold/supply chain system, and all PHCs should have water supply, power, among others.”
He called for boosting of a comprehensive outreach programme and engage in maternal, newborn and child health weeks to sustain Penta3/ Insecticide Treated Nets (ITN) coverage.
“Going forward, there should be a comprehensive mass media campaigns with community-health-worker-led family planning programmes which are sure to boost modern contraceptive prevalence rate.”

Launch of BHCPF in All States
Kana said to holistically address lack of health coverage, especially in primary healthcare level, state governments should be supported and encouraged to launch the Basic Health Care Provisions Fund.
“For effectiveness, we should strengthen supervision, pay for outputs, not in puts. We must also decentralise funds, as well as pay laser focus on data analysis and utilisation.”
On training, Kana said there should be review of training methodology of primary healthcare workers, adding that trainings on biostatistics and other focus areas should be given priority, just as he stressed that each state should achieve universal health coverage at their pace.