Nigeria budgeted over N100b in 2018 for the health sector. In 2017, the budget for the health sector was about that cost too; The USA on the other hand, spent about $1 million per prisoner in Guantanamo Prison within the same period. Do you think the major problem with healthcare in Nigeria is inadequate funding?
Funding is certainly important and the fraction of the budget does reflect a government’s level commitment as a corollary. However I do not believe that inadequate funding is necessarily the limiting factor in Nigeria’s case or in the case of many developing countries for that matter. Having worked professionally in Nigeria I can address this with some familiarity. My sense is that the limiting factor is a lack of resource optimization. Funding may be a major problem but the resource underutilization problem is a more insidious and overwhelming problem in my opinion.
Many people die yearly of basic/common diseases in Nigeria. Do you think early diagnosis is a problem and how do you think that challenge can be addressed?
Early diagnosis is certainly a problem. I would clarify that early correct diagnosis may be the issue. There is a tendency to adopt empiric therapies with little diagnostic effort or pursuing biased diagnosis – what I call diagnostics with prejudice,
Proliferation of low quality hospitals in Nigeria remain a big problem. Is that a challenge affecting healthcare in Nigeria and how do you think that challenge can be solved?
This is a tremendous challenge and one that I think has far region implications for the next 3 generations of Nigeria’s because I think it will take that long to remedy some of the damage that has been done. The damage, if you will permit, is a cultural 1 and the lack of quality is not necessarily once again structural or the absence of resources says but more functional and related to how the culture of medicine is practiced and executed. It relates to how resources are managed and this would include human or labor resources, financial resources and intellectual resources. It has significance and poignancy for how trainee medical students are groomed through the process of becoming independent providers and stewards of Nigeria’s health system themselves.
What do you think we need to do to get health system right and working in Nigeria and Africa?
This is a very open-ended question. I believe that he will necessarily call for a multipronged approach. There is no simple answer. However I do not believe that listing of platitudes brought from development technocrats is an appropriate way to address this question. I believe that the way to begin approaching some of the problems a country like Nigeria faces in the healthcare sector is again emphasis on optimizing resources that are already present I believe this requires building scaffolds where they do not exist and strengthening existing scaffolds if they are appropriate. One can then layer the resources on a system that is optimized. This approach requires root cause and systems analysis of processes, or what I like to call process relays, in the healthcare delivery machinery.
For decades, Nigeria has not been able to get its health insurance system right, despite several attempts. How can that challenge be addressed?
I usually try to refrain from talking about Nigeria’s healthcare leadership. However, what I understand is that the current minister is getting it right even though many in the system are opposed to it.
One of the most promising accomplishments of the first 4th republic administration was the NHIS. For the first time Nigerians’ had a promise of health insurance and this attracted me to study how this could yield dividends. A shortcoming however was that many of the programs targeted the middle class by structure. One can argue that you needn’t “let best be the enemy of good” but it has been acknowledged that a great deal of individuals were left out. Instead the mandate instructed informal sector workers to form community health insurance programs. In fact my first adventure into Nigeria’s health system as a professional was to study the feasibility of this and work towards a proof or disproof of concept.
Accountability is also an issue: many of the health insurance companies became hugely profitable without delivering any care. For several reasons: at least for the first 3-4 years after it had been in force, many civil servants did not realize they had insurance. Moreover many conditions listed were not covered for care and patients were still saddled with paying cash upfront before receiving care. One can debate the reasons for this (including insufficient “marketing” or advertising of the program by the government, but the net effect and hence report card if that it did not deliver as promised – a failure perhaps attributable to omission. I am aware though there are those who believe there are failures due to commission as well. It may seem cynical but I believe that any honest analysis of outcomes now some 10 years after the program must consider, explore and address this as well.
What do you think can be done to encourage experts like yourself to come back home and help fix our health systems? What needs to be in place to bring people like you back home?
There are many facets to this. I know many like me who were genuinely committed to go into the battle of fighting or future of Nigeria’s health care…and under huge personal sacrifice with costs to their family lives. I know many for whom it became too frustrating or unsafe even. The best minds I know who made this journey were not in it for money or personal gain. And unfortunately it appears we do not appreciate people like that. What would it take? Nigeria needs to court these brains. They populate the halls of the most prestigious institutions the world over. The nation can stew in its pride and decide it does not need the absconded diaspora. But it is to our detriment. What recruitment programs are there for these individuals?
Where do you see the future of healthcare in Nigeria in particular and Africa in general?
It’s a dismal future from my current vantage point if the cultural issues (I mean professional culture) are not addressed. There are some countries that seem to have gotten it right somehow. Rwanda, Botswana are two examples. But one can argue, correctly or incorrectly, that their small sizes make change and progress more manageable. But it also reduces your human and intellectual resource capital doesn’t it? So I am not sure if that argument can withstand a deeper dive critique.
What do you think should be done by stakeholders that will attract serious investments in the healthcare development in Nigeria and Africa?
Accountability. Would be stakeholders would be more engaged if there were disincentives for not engaging. We conducted an extensive feasibility project on establishing a 911 system in Nigeria in 2008. One of the first things I did after charging my mobile card was to call the emergency access number listed in the instruction booklet/page of the card. It never worked. It does not exist. This was a slap in the face. A fallacy. Where is the accountability in that? We reached out to the FRSC an offered free help in designing a nascent EMS but were rebuffed by its leadership then. We met with reps of a major mobile corporation but did not get past the first meeting because we could not tell them “what was in it for us”. Despite these experiences, which were no doubt demoralizing, we continued our study and completed it with devastating conclusions.
If you are to advise the president of Nigeria or the Minister of Health on healthcare delivery system, what would that counsel be?
Accountability. Resource optimization. More Accountability.