Need to Restructure, Transform the Nigerian Health System

Ifeanyi Nsofor

Recently, Vice President Professor Yemi Osinbajo underwent a surgical procedure for recurrent leg pain at Duchess International Hospital, Lagos. This use of a Nigerian hospital by one of Nigeria’s political elites is rare. President Muhammadu Buhari himself is notorious for frequent travels to the United Kingdom for medical treatment. In 2017, Buhari spent 104 days in one visit receiving medical care in the UK.

Expectedly, Nigerians showed their support and wished Osinbajo well. Duchess International Hospital tweeted: “honoured to have been chosen to provide His Excellency’s surgical treatment” and issued a press release. The CEO and Medical Director of Duchess International Hospital went on media rounds.

One can imagine that the hospital pulled all the stops to provide quality healthcare to Osinbajo. In all the accolades surrounding Osinbajo’s surgery, we must remember that the quality of care the hospital provides, which gave Osinbajo the confidence to go there for care, should be the norm and not the exception. All Nigerians irrespective of social class deserve such care, but too often they do not. We must restructure and transform the Nigerian health system to achieve this equity.

These are five ways to restructure Nigeria’s health system.

First, restructuring the health system must begin with informed active citizens. Nigerians must be educated on how the constitution describes responsibilities for health. That is when we can begin to rightly hold politicians accountable for upholding these promises. According to Nigeria’s constitution, health is on the concurrent list. This means that federal, states and local government areas have core responsibilities for healthcare. The federal government is responsible for setting policies through the federal ministry of health and its health agencies. It provides tertiary healthcare through teaching hospitals and federal medical centers. State governments are in-charge of secondary hospital care and supporting primary healthcare implementation in local councils. Primary health care, the bedrock of healthcare, is within the purview of local government areas.

Nigerians should know that when the primary health center in a village lacks vaccines for immunizing our children, it is a failure of leadership at local government areas and the state. We must hold those two levels of governments responsible. At a recent Nigeria Health Watch Health Security Policy Dialogue, Peter Hawkins, UNICEF Representative in Nigeria said, “States should be accountable for integrated services for immunisation, ensuring that funds allocated to immunisation and other services are used appropriately”.

The election season is heating up and it is an opportunity to ask candidates the right questions. Afterwards, we must hold them accountable for healthcare under their purviews.

Second, healthcare is incomplete without providing social determinants of health. The World Health Organization defines social determinants of health as the non-medical factors that influence health outcomes. These factors and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Therefore, restructuring Nigeria’s healthcare system must consider these factors. For instance, it is impossible to provide quality healthcare without constant electricity. Sadly, Nigeria’s national grid, which provides less than 4,000 megawatts of electricity to 200 million people, has collapsed six times already this year. Imagine, managing a premature baby at a well-equipped and adequately staffed Newborn Intensive Care Unit. The baby is doing well despite being born at 32 weeks old. Days later, the electricity was cut – as we say in Nigeria, “there was no light”. All monitors that depend on electricity stop working and the baby dies. This loss happened due to the factor of poor electricity supply which is usually not considered during health planning. Therefore, restructuring the Nigerian health system should include provision of regular uninterrupted electricity in all health facilities, by investing in renewable clean energy such as solar power.

Third, we must restructure health financing in Nigeria. The current situation with high out-of-pocket expenditure is unsustainable, inequitable and pushes Nigerians into poverty. Indeed, healthcare budgets by federal, state and local councils in Nigeria cannot provide the healthcare that a nation of more than 200 million need. About $7.7 billion (77%) of Nigeria’s estimated $10 billion annual total health expenditure is out-of-pocket. Nigerians pay for healthcare at the point of need. To achieve universal health coverage, health insurance must be widespread. Federal, state and local authorities must increase advocacy to encourage Nigerians to channel the high out-of-pocket expenditure for health insurance. There are enabling legal frameworks for this through mandatory health insurance at the federal level as well as across more than 31 states of the federation. More Nigerians having health insurance moves the country gradually towards universal health coverage and ensures pandemic preparedness.

Fourth, the government alone cannot provide the healthcare Nigerians require. The private sector is an important but often overlooked stakeholder in healthcare delivery in Nigeria. Duchess International Hospital which treated Osinbajo, is a private hospital. Governments in Nigeria can learn or even partner with such hospitals to restructure healthcare delivery. This is why public-private partnerships for healthcare are imperative. There are examples where this has worked. PharmAccess Foundation Access to Finance Framework led to revitalization of non-functional primary health centers in Lagos and Delta States. It was achieved through a unique partnership between PharmAccess’ Medical Credit Fund, Bank of Industry and the State Governments. At the Nigeria Health Watch Health Policy Dialogue, Njide Ndili – country director of Pharmaccess Foundation stated that the private sector needs better coordination to partner with the government. We are hoping that there will be a coordinated policy document or instrument or some kind of mechanism where the private sector can plug into supporting health security, she said. Furthermore, through the private sector coalition against COVID-19 (CACOVID), the private sector showed its willingness to support Nigeria’s pandemic preparedness.

Lastly, restructuring Nigeria’s health system should leverage the power of digital health technology. It holds so much promise to make healthcare equitable. From electronic medical records for better coordination of care to health insurance enrollment and platforms for remote consultations. They are also useful for health education to change behaviors. For instance, the Nigeria Center for Disease Control’s #TakeResponsibility campaign delivered via social media platforms, radio and TV encouraged Nigerians to take individual and collective responsibilities to limit the spread of COVID-19. Such social media campaigns would help galvanize youths to participate in Nigeria’s pandemic preparedness efforts. There are more than 204 million active mobile GSM lines in Nigeria, according to the National Communications Commission. This opportunity for deploying technology to reach millions of Nigerians should not be allowed to go to waste.

A restructured health system means that just like most Nigerians, Osinbajo should make use of a public hospital next time he needs medical care. This would build trust in the health system, save lives, ensure pandemic preparedness and make healthcare equitable in Nigeria.

Ifeanyi Nsofor Senior New Voices Fellow at the Aspen Institute, Washington DC.