Medical Doctors and Public Service in Nigeria – Issues and Challenges
By: Nasir Ahmad El-Rufai
Speech at NMA Kano, September 15, 2012
Medical Doctors and Public Service in Nigeria – Issues and Challenges
By: Nasir Ahmad El-Rufai
It is not an exaggeration to say that our nation is now in crisis – from the high levels of insecurity to daily tales of fraud and corruption in governance to doctors in Lagos going on strike earlier in the year. All these are symptoms of the fundamental affliction facing our society – poor governance and culture of impunity. It is therefore commendable that the Kano branch of the NMA decided to spend some time discussing the role of medical doctors in public service. I do not know what qualifies me to speak to you about this topic today other than this – as a human being, healthcare ought to be my number one priority, and medical doctors are at the forefront of delivering this service. Though not yet a senior citizen, I am on a daily dose of ‘over-50’ vitamins, low-dose Aspirin and Garlic tablets, while thanking Allah always for a blood pressure level that has remained constant over a thirty-five year period!
There may be other reasons for inviting me: for two years between 2005 and 2007, I was chairman of the Public Service Reform Team of the federal government; as minister of Abuja, I had a confrontation with FCT healthcare professionals culminating in the firing of over 4,000 of them for going on an unlawful strike; and the ultimate retirement of many matrons for unethical conduct. I am therefore going to speak to you frankly as a consumer of medical services, a one-time public servant and more recently, a policy analyst and commentator.
I intend to begin with an overview of the public service in Nigeria and attempt to situate the healthcare sector within it. This is important for all of us to recognize the interdependencies that exist between us all. No matter how good a doctor is these days, a bad janitor, nurse or technologist can put the best treatment plan at risk. Without security, healthcare delivery is impossible to achieve. I will then review the role of medical doctors in the society followed by the issues and challenges that they face in providing healthcare services globally and in Nigeria. I hope to conclude with some suggestions to elicit debate and reflection.
Public Service in Context
It is both a truism that firstly, no nation develops beyond the capacity of its public service, and secondly, there is broad consensus amongst Nigerians that our public service is broken and dysfunctional. The quality of public servants and the services they provide to our nation are both below expectations. From the glorious days at independence when the best and brightest graduates competed to join the administrative service up until 1970s, our public service is now seen as employer of the dull, the lazy and the venal. The challenge we face as a nation is how to retrieve our old public service – by making it effective, well paid and largely meritocratic, attracting bright people imbibed with a spirit of promoting public good.
The Nigerian civil service evolved from the colonial service with its historical British roots of an independent, non-political and meritocratic administrative machinery for governing the country. Each region then had its civil service in addition to the federal service.
What is the public service? How did our public evolve from inception to excellence and now its current abysmal state of ineffectiveness? How can the public service be reformed, re-skilled and right-sized to provide the basic social services that will earn the trust of Nigerians and foreigners alike?
The Public Service – An Overview
The public service consists of the civil service – career staff whose appointment, promotion and discipline are under the exclusive control of the Federal Civil Service Commission (FCSC), national assembly service, the Judiciary, public officers in the military, police and paramilitary services, employees of parastatals, educational and health institutions. By September 2005, when the Public Service Reform Team (PSRT) was constituted, the number of federal public servants was slightly above one million. The estimated number working for the 36 states and the FCT was another 2 million, broken down as follows:
Federal Core Civil Servants, including some 2,000 directors 180,000
Uniformed Services – Military, Police and Paramilitary Services 457,000
Parastatals, Agencies, Educational and Health Institutions 470,000
Total Federal Public Service 1,107,000
Public Officers at the State Level – 36 States (Estimate) 856,000
Public Officers in the Federal Capital Territory Administration 19,000
Public Officers at the 774 Local Governments and 6 FCT Area Councils 620,000
Total Sub-National Public Service 1,495,000
TOTAL: Public Sector Employees in Nigeria 2,602,000
Adjusting for the increasing numbers of aides of the president, ministers, governors and legislators, it is not unreasonable to put the total number of those working directly for all tiers and branches of government at about three million. So while our national population has increased by about 175% between 1960 and 2005, the size of our public service increased more than twice as much – by about 350% in the same period. Our public service is clearly over-bloated as four regional services and a federal service became 36 state services, the FCT and a larger increasingly intrusive, federal public service.
Other initial diagnostics and findings of 2005 were sobering to say the least. The civil service was rapidly ageing, mostly untrained and largely under-educated. Their average age then was 42 years, and over 60% were over 40 years. Less than 12% of the public servants held university degrees or equivalent. Over 70% of the service consisted of the junior grades 01-06, of sub-clerical and equivalent skills. About 20% of the public service employees were ‘ghost workers’ – non-existent people on the payroll which goes to staff of personnel and accounts departments. In the FCT, out of an initial headcount of 26,000, we found 3,000 ghosts in the first round of audit. By the time we introduced biometric ID and centralized, computerized payroll, we found nearly 2,500 more who failed to show up for documentation! By the time I left the FCT in 2007, the headcount, even with new hiring had dropped to about 18,000 employees, out of which over 4,000 were doctors, nurses, paramedical and support staff working in our 14 hospitals and scores of primary healthcare centres.
While the public service pay is low relative to the cost of living, the overall burden of payroll as a percentage of the budget is huge. In most states other than Lagos, Kano, Kaduna and Rivers States, an average of 50% of the budget goes towards the payment of salaries – to about 1% of their population – an unfair and unsustainable state of affairs! Out of the N2,425 billion included in the 2011 Budget for recurrent expenditure, between 73% and 84% for each MDA constitutes personnel cost. We found in 2005 that the breakdown of federal public service emoluments by class of service as follows:
Core Civil Service - 18%
Military, Police and Paramilitary - 35%
Parastatals, Education and Health - 47%
The PSRT inherited a federal public service whose central management organs – the Federal Civil Service Commission and the office of the Head of Civil Service of the Federation had become inept and ineffective, and morally flexible at best. We learnt that appointments, promotion examinations, promotions, postings and discipline were bought and sold by civil servants the same way shares are traded on the stock market. Surprisingly and with some relief, we did not see these malfunctions in the armed services. The human resource management systems of the Army, Navy and the Air Force were intact, and to some extent even the Police and other paramilitary services had better personnel management systems. You may well find however, that the state public services are as bad, if not worse than the federal public service that we tried to reform.
In a State of Denial
The bulk of public servants continue to be in denial and refusing to take responsibility for the sorry state of affairs, blaming instead, their political masters for the dysfunction in the public service. They blame the collapse of merit and excellence in the public service on the Murtala-Obasanjo retirements “with immediate effect” that occurred in the mid-1970s. Others attribute the current situation to the Civil Service Reform Decree No. 43 of 1988 of the Babangida administration. The deterioration of pay and fringe benefits relative to the cost of living as a result of introducing the Structural Adjustment Programme in the late 1980s has also been identified as contributory to the de-motivation, deskilling and dispiriting of the public service.
The truth may be a combination of all three and more, compounded by the inability of the public service to renew attitudes, update its working methods, skills and technology. The public service has been short-term in its vision, self-centered in policy formulation and corrupt in programme implementation. Instead, its successive leadership has focused on taking care of itself and narrow interests to the detriment of the nation and system which would sustain it. The public service failed to reform itself between 2001 and 2005 when two successive Heads of Civil Service were given the responsibility to do so. It was therefore inevitable that driving the public service reforms of 2005-2007 had to be transferred to the economic team, with President Obasanjo leading the charge himself. An outsider was needed to administer the required medicine, but this still needed the cooperation of the patient, which was not forthcoming. The malady within the service is still with us today, and this affects all sub-sectors of the service including the healthcare area.
Health Sector Overview
For many of us, what is symptomatic of our failure to build on the foundations laid by our founding fathers to grow our human capital through creative planning, sensible spending prioritization and focused implementation is the state of affairs in our healthcare sector. I am not merely referring here to the dismal maternal mortality, infant mortality and other statistics that make the Northern part of Nigeria one of the deadliest places to live on the planet, but how hundreds of thousands of our citizens, particularly the political and economic elite, seek medical attention abroad. In contrast, I just learnt from a programme on CNN that just about 2,000 UAE residents went abroad for medical reasons in 2011! Yet as we speak, our first lady has been in Germany first to ‘rest’, then to be treated for food poisoning, followed by a raptured appendix, then fibroids surgery, and now it is sounding like another cosmetic surgery gone awry. Our prayers are with her!
Nigerians should recall that life expectancy in our country is still 48 years, one of the lowest in Africa. In Ghana, it is 57, about 52 in Cameroon, 62 in Benin Republic, 54 in Uganda and 71 in Mubarak’s Egypt. Britain, Sweden and Japan have 78.5, 80.5 and 81.3 years respectively. Given the huge revenue Nigeria has earned from oil in the past five decades, this is unacceptable. We can do, and must do better.
Nigeria’s population is projected to more than double, and move from the eighth to fifth largest in the world by 2050, after India, China, the USA and Pakistan. Less than half of the population now lives in urban areas, but more than 60% will be urbanized then. It has a very young age profile with about 45% being under 15, and this will stabilize somewhat by 2050. According to the World Health Organization (WHO), in 2006, Nigeria’s expenditure on health was US$50 per capita, representing about 4% of GDP. Also, records from UNICEF show that only 1% national budget between 1998 and 2008 went to health (compared with 3% for Defence). The projected national health budget envisages about US$26.6 billion to be spent between 2010 and 2015, of which 42% is set aside for human resources development for health, and 49% for health services delivery.
The clear import is the need to evaluate the trends in our health facilities and our rapid population growth. In 1979, Nigeria had 562 general hospitals, supplemented by 16 maternity and/or pediatric hospitals, 11 Armed Forces hospitals, 6 teaching hospitals, and 3 prison hospitals. Altogether, they accounted for about 44,600 hospital beds. In addition, general health centers were estimated to total slightly less than 600; general clinics 2,740; maternity homes 930; and maternal health centers 1,240. The establishments were distributed among federal, state, and local governments, while some are privately owned.
In 1985 there were 84 federal health establishments (accounting for 13 percent of hospital beds); 3,023 owned by state governments (47 percent of hospital beds); 6,331 owned by local governments (11 percent of hospital beds); and 1,436 privately owned medical establishments (providing 14 percent of hospital beds). Nigeria’s healthcare delivery system consists of a network of primary, secondary and tertiary facilities. By 1992, primary care was largely provided through approximately 4,000 health clinics and dispensaries scattered throughout the country. As for secondary care, there were about 700 health care centers and 1,670 maternity centers; tertiary care was handled through 12 university teaching hospitals with about 6,500 beds.
A research by McKinsey has shown that from 1900 to 1973, less than 4 percent of the decline in mortality in developed countries resulted from medical care, with over 90 percent being due to public health measures like improved sanitation and provision of clean water! This strongly suggests that focus on public health measures and primary health care should be the priority of governments that wish to improve the health of their populations. And this is not difficult for State Governors and Local Government chairmen to do. For instance, in Abuja between 2004 and 2006, on the advice of the FCT Agriculture Secretary, Waziri Haruna Ahmadu, we spent an average of N4 million monthly to fumigate the city and the satellite towns. Statistics from the FCT public hospitals showed that reported cases of malaria went down by more than 60% compared to previous years! Availability of clean water via boreholes each costing about N1 million in 77 locations nearly eliminated many water-borne diseases like cholera and typhoid in Abuja. And as indicated above, it is not very expensive to provide these basic, preventive healthcare facilities and services.
It is when preventive healthcare fails that a visit to a medical professional becomes necessary. At the moment, our healthcare facilities are grossly inadequate and can only serve 5–10 percent of their potential patient load. Huge sums of money in foreign exchange are spent by our people that seek medical services abroad. Spending by private citizens, the Federal Government, FCT and the 36 states of the federation on foreign medical services is estimated at about N30 billion annually.
While spending so much to keep foreign medical professionals employed, are we healthier? Our healthcare indicators are going from bad to worse. Life Expectancy for males stands at 46.76, while for women, its 48.41 as of 2011. And we rank 220 in terms of life expectancy in the world. According to the United Nations Population Fund, in 2010 the maternal mortality rate per 100,000 births for Nigeria is 840 compared with 608 and 473 in 2008 and 1990 respectively. So more and more of our pregnant mothers are dying during labour. The under-5 mortality rate, per 1,000 births is 143. These are mostly caused by inadequate access to quality care in rural and remote areas and shortage of midwives. In fact the workforce requirement to attain 95% skilled birth attendance by 2015 is estimated to be 6,790 according to the World Midwifery’s Report for 2011 compared to South Africa’s requirement of just 710.
A 2008 Demographic and Health Survey (DHS) found that for 25% live births, only 5% were attended by nurses or midwife, and 9% by a doctor. Correspondingly, 35% of live births took place at a health facility. Women living in urban areas were much more likely to be attended to by health care specialists than those living in rural areas (65% and 28% respectively in 2008). This imbalance in access to specialist care between urban and rural areas has been evident in all DHS surveys in Nigeria since 1990, but the gap has not narrowed over time. And as usual, the disparities between the North and South are wide, indicating that State Governors and Local Government chairmen in the North have a lot more to do, and must wake up and invest more to prevent the avoidable deaths of mothers, infants and many children under the age 5.
The challenges of the Nigerian health sector bring to bear the popular philosophical postulation: “a person that fails to plan plans to fail”. The first casualty of non-planning was the relegation of preventive, mostly primary healthcare, abolition of sanitary inspection and increasing focus on procurement-driven curative, secondary and tertiary healthcare. Olikoye Ransome-Kuti’s tenure as health minister brought back some needed focus on primary healthcare, with the publication of a National Health Policy in 1988. But the centralized regulation by the military regime of primary healthcare created its own problems which we live with. As we shall see, it appears that like with everything else in Nigeria, decentralization, true federalism and inter-state competition works better for the citizens.
The 1988 health policy was refined, revised and updated under the tenure of Minister Eyitayo Lambo in 2004 and was globally acclaimed as a near-perfect blueprint for provision of standard health care in a growing nation. The policy had all that was needed to make our health sector functional and world class. It had a three-tier health structure, with primary health care, PHC, including refined traditional medicine as the foundation, secondary health care, SHC, with general hospitals as the supporting pillars, and tertiary health care, THC, consisting of university teaching hospitals, federal medical centres and specialty hospitals at the apex.
The policy gave the responsibility of implementing PHC to local governments, SHC to state governments, and THC to the federal government. Unfortunately, it has been characterized by weak implementation and diversion of funds to recurrent spending. Also, inconsistent implementation of the structuring led to the situation where people went to SHC hospitals for their PHC needs, causing doctors trained for SHC to devote 80 percent of their time conducting PHC in the outpatients’ departments of hospitals. The condition is further worsened by inadequate facilities and low remuneration of public sector healthcare workers. These resulted in the mushrooming of private hospitals and clinics with only a fraction well-equipped, but could only be afforded by an opulent and sometimes foolish few. So in spite of all these efforts, the sector challenges remain and the stories of our medical tourists to Egypt, Dubai, India, Germany, UK and the USA remain the best metaphors for the dysfunctional state of our healthcare delivery system.
Although “health” as a sector does not feature prominently in the measurement of GDP of a country, health expenditures account for between 4% (Turkey, Nigeria), 8% (UK) and 15% (USA) of the GDP of most countries, and the sector is a major employer of labour – from doctors to pharmacists to laboratory technologists to nurses and midwives, and now includes HMOs and insurance companies!
Quality and affordable healthcare is critical to sustainable development and progress because it is human capital that drives the other factors of production. Health infrastructure (hospitals, laboratories, pharmaceuticals, health insurance organizations and other ancillaries) are essential for the efficient functioning of a healthcare system and consequently, a productive and prosperous nation.
Medical Doctors and the Society
Medical Doctors (hereinafter referred to simply as ‘doctors’) constitute an important part of the healthcare sector and constitute a major component of its workforce. In fact, they are the leaders in the composition of any healthcare team. In general, even though most of them have no administrative or management training, they head medical services departments in the public service. Doctors in public service therefore provide leadership in health care delivery in government-owned hospitals. They provide training on the job to other health personnel like physicians’ assistants, nurses, technologists, paramedics and auxiliaries.
In general, the staffing of education and health ministries, departments and agencies constitutes the bulk of the nominal roll of federal and state governments; and doctors and other health care workers are without any doubt the most active persons and busiest in public service. They put in longer work-hours per capita than any other public servant, perhaps at par or slightly below security personnel like the Police and the Armed Forces in times of crisis. Doctors are products of rigorous training from medical schools, training in preclinical (classroom-based) and clinical (hospital based) programmes that last between five and seven years. Pharmacists are similarly trained albeit for a slightly shorter period and similar but shorter routes taken by others aspiring to be healthcare professionals.
It is clear from the foregoing that the healthcare professions attract certain kinds of people that possess the intellect, patience and sense of sacrifice to undergo the long periods of education, internship and on-the-job training to be doctors, pharmacists, nurses, paramedics and the like. Doctors are also unique in another respect – theirs is the only profession that one gets admitted to after appropriate education and training – only after taking an oath – the Hippocratic Oath!
Society recognizes that doctors face the continuous risks of infection by their patients and lawsuits for negligent conduct. In many countries like the US, professional liability insurance is one of the biggest costs of maintaining a physician’s licence to practice! Doctors are also required to be permanent scholars – reading journals, attending continuing professional development programmes, and in some instances refresher courses and examinations to retain their practicing permits. As if this is not onerous enough, doctors face prosecution and imprisonment in some jurisdictions arising from the discharge of their duties to their patients. All these are perhaps heavy, even if bearable burdens.
In return for these, society places premium in the way and manner it adores, respects and compensates doctors. Indeed, they enjoy the highest salaries and allowances in the Nigerian public service. Doctors are also the only professionals given the freedom to combine public service with unregulated private practice (locum), enabling them to augment their relatively higher income. This has more or less been the case since1991 when the Babangida administration approved a special salary scale for doctors as a knee-jerk reaction to stopping the ‘brain drain’ affecting the profession at the time.
Citizens therefore expect a lot from doctors. They expect humility and kindness, not an attitude of superiority over other lesser mortals or allied professions. Society expects doctors to respect their oath, self-regulate their conduct and deal decisively with their sometimes negligent and exploitative colleagues. Society does not expect doctors to abandon patients – the violation of the fundamental tenet that differentiates the doctor from every other professional, and go on strike. In 2005 when I had to face down FCT doctors that went on strike claiming HATISS allowances while under HAPSS, there was no record of doctors going on strike anywhere in the world in the previous 30 years! We took the view that doctors that abandoned patients did not deserve a job, until Adams Oshimhole as president of NLC persuaded us to re-employ them, reluctantly. We had received applications from many doctors then working with non-government hospitals willing to take their jobs that had pay levels higher than in the private sector!
The recent altercation between Lagos State and its doctors would have been better addressed and avoided by the two parties submitting their dispute (if any) to the National Industrial Court (NIC). Instead, the doctors did the abominable – abandoning patients for weeks – and only remembering the NIC when Governor Fashola began ejecting them from their subsidized residential facilities. The lesson here – selfishness as national professional ethos will take us nowhere. The incessant strikes that were triggered in many sectors since the introduction of the Medical Salary Scale in 1991 should make all doctors pause and reflect, and ask where it will take us as a nation.
Issues and Challenges
I will now briefly look at the sector issues and challenges, and end with specific challenges that doctors in the public service face on a regular basis. Our health sector is bedeviled by a myriad of challenges that resulted from lack of planning – policy disconnections, inadequate capital spending, poor pay, outdated technologies, poor infrastructure, sharp disparities in the availability of medical facilities across the country, coupled with the severe political and economic stresses of the past years. The net effect is inadequate medical supplies, drugs, equipment, and personnel. Similarly, poor sanitation and water supply in our rapidly growing cities have increased the threat of curable, avoidable and other infectious diseases, while health care facilities are generally unable to keep pace with urban population growth.
One needs not visit hospitals without doctors or drugs, or evaluate the poor quality of health personnel, nor undertake a computation of the lost production to poor health to underscore the fact that our national development aspirations will remain just that – aspirations – if we do not embark on a concerted improvement of our human capital, especially revamped education and improved healthcare.
The key factors in measuring health status are: access to clean water, safe air, adequate food and the society’s willingness to practice healthy lifestyles. There are issues to be worried about: from the report of UNDP Mid-Point Assessment of the Millennium Development Goals in Nigeria 2008, only 42.9% of Nigerians have access to basic sanitation in 2000; 33% in years 2005 and 2006; it reverted to 42.9% in 2007 but currently at 30% as against MDGs target of 100% by 2015. At the same time, 70 million of our population has no access to safe drinking water. This represents 6% of the world’s 1.1 billion persons who do not have access to potable water!
The WHO estimates that every dollar invested in improved water and sanitation produces economic benefit that ranges from $3 to $34, depending on the country and technologies applied. Unfortunately we are not in any way near the attainment of such beneficial status. In year 2010, only N49bn was allocated to the Ministry of Water resources despite the dire need of about N120bn, though in 2011 it has gone up to N70bn. The prolonged neglect of water, sanitation and health education in our schools and societies is also impacting negatively on our health system.
One factor responsible for the worsening state of health care in Nigeria is the shortage of skilled medical personnel. According to the Nigeria Medical Association (NMA), we currently have about 35,000 registered physicians (with some 7,000 in the Diaspora) for our population of 167 million. Our situation is further compounded by the lopsided doctor-to-population distribution. This is a ratio of only 21.6 physicians per 100,000. Within the country, huge inequalities exist between regions, with the Northern states lagging behind. Disparities also exist between urban and rural areas; 70% of doctors work in the urban areas where only about 40% of the population resides. In comparison, South Africa has 393 nurses and 74 doctors per 100,000 people – about twice better off than we are, while the United States has 901 nurses and 247 doctors per 100,000. Cuba a developing country with a better healthcare system than the USA, has a ratio of 1 doctor to 125 people!
Many of our qualified doctors and nurses have migrated abroad to avoid poor pay, non-existent or archaic diagnostic tools and deplorable working conditions. Nigerian doctors have migrated to North America, Europe, the Middle East and even other African countries. In 1999, the Association of Nigerian Physicians in America (ANPA) informed President Obasanjo that there were over thousands of Nigerian doctors in North America. By 2011, it was confirmed that more than 4,000 Nigerian consultants were practising in North America while about 2,500 others were in the United Kingdom and Europe. The situation with our pharmacist and nurses is as bad or worse. Out of about 13,000 registered pharmacists, only about 5,000 are actively practicing in Nigeria – 3,000 are earning a living in non-pharmaceutical roles (Sam Nda Isaiah of Leadership studied pharmacy!), while another 5,000 are abroad.
You must ask: why do our young and talented medical professionals leave Nigeria after we have invested vast resources in their training? Regrettably, many that have stayed back in the country remain here only because they are unable to secure other opportunities elsewhere. We have come to expect a health sector perennially dogged by labour crises due to the inability of governments at all levels and the various unions to agree on a single and fair remuneration structure.
The activities of quacks in healthcare sector and counterfeit drugs cannot be discounted. Findings indicate that about 20% of all drugs circulating in the Nigerian markets are adulterated. While the war on fake drugs continues to attract our attention, not once have we seen the prosecution of the major importers of these drugs for quite a while. Arresting and shutting down pharmacies and patent medicine stores will not eliminate the root of the problem. The drug barons must be wiped out! In addition, many health technologists, radiographers, nurses, laboratory scientists and doctors operate in hospitals and clinics where unwholesome healthcare is dispensed to hapless patients.
Chronic but treatable diseases are also major threats to our country. According to the World Health Organization (WHO), of the 2.014 million deaths in Nigeria in 2005, it was estimated that 478,000 i.e. 25% of it were caused by chronic diseases. Further projection by WHO is that by 2015 over 5 million people would have died of chronic diseases. Deaths from infectious diseases, maternal, prenatal conditions and nutritional deficiencies will also increase by 6% in 2015 too. Alarmingly, the WHO statistics show that death by diabetes is projected to increase by 52% in 2015. If not checked, all these have adverse effects – economic and social impact on our families, communities and entire country.
The health industry is very dynamic: patients’ needs, innovative processes, regulated environment and demographic factors constantly changing. A responsible government must therefore be proactive in figuring out how to address expanding population and outbreak of new diseases by developing and sustaining a healthcare service mechanism that is both effective and efficient. According to the US Bureau for Statistics, the population of Nigeria nearly tripled in 40 years (55m in 1966 to over 140m in 2006). If this growth rate continues, our population would hit nearly 400 million in 2050. The message is clear: if we cannot adequately care for our population now, and plan for the future today, what becomes of our health care system when our population reaches nearly 200 million in 2020; in just a few years time?
Medical research and collaboration in Nigeria is limited principally due to inadequate funding level (in the national expenditure) for both research and collaboration. Nigeria must fund its universities, medical research and other health institutions to enable them exchange information on research about tracking, treating, preventing, and curing diseases and enhance domestic manufacturing of medicines. We lag behind the global trend of intensive investments in all facets of medical sciences, life sciences and biotechnology and must redress this urgently.
In specific terms, medical doctors like all other professionals in the public service face many challenges. I made this point quite advisedly because there is nothing doctors face – whether it is poor pay, absence of needed equipment and the like that other public servants do not face. What is unique about healthcare is that lives are lost when these issues are not given priority. I will list some of these below, certain that the audience will expand and enrich the list:
Non conducive working environment due to lack of maintenance of public property.
Inadequacy of basic working materials (medical equipment, drugs, tools, etc.)
Lack of modern diagnostic equipment and technologists trained to use them
Constant feeling of being under-paid and over-worked, while being denied opportunities to study further and get exposed to modern technologies.
Politicization of jobs and positions instead of giving priority to professional achievement.
Pressure to covet administrative and non-clinical positions for pecuniary gain, rather focus on professional career. Doctors find themselves increasingly having to juggle administrative roles with professional duties. Administration is better left with trained Hospital Administrators or doctors with MBAs and MPAs. Doctors are not trained to manage organizations!
Inadequate learning tools, equipment and tutoring for highly specialized areas of medicine e.g. Neurology, trauma care, cardio-vascular diseases, nephrology, microsurgery and the like.
Recommendations and Roadmap for Action
So based on the foregoing and the facts on ground, what steps are needed to restructure and improve Nigeria’s health sector? What do we do in light of all the issues and challenges identified? I will outline what I think need to be done at sectoral level. The medical profession itself needs to be introspective and decide what doctors can contribute to make things work better. At the end of the day, the change begins at the individual level – so at the end of it all, you must ask – “what can I do to make my nation, the healthcare sector and the citizens of Nigeria better?”
First thing to do is to recognize that preventive healthcare rests on improvement in enlightenment as well as provision of water supply and sanitation facilities. For too long, water, sanitation and hygiene education in our communities and schools have been given less priority. Well-structured water, sanitation and hygiene education would make a huge difference to our health system. Improvements to sanitation and hygiene behaviors combined with safe water supply could significantly prevent diarrhea, cholera, dysentery and other contagious infections. These are services best delivered locally – so they are the responsibility of local governments, mostly fairly and squarely! The Federal Government has no business drilling boreholes in villages and thereby encouraging diversion of earmarked funds by local councilors and chairmen!
Second issue is to revamp our vaccine research, testing and production capabilities. This means better linkages between our medical research institutions, universities, teaching hospitals and field practitioners. Related to this and connected to preventive medicine is the need to design a programme to wipe out insect vectors like mosquitoes through nationwide fumigation on a continuous basis similar to what we were doing in Abuja, and modeled on how DDT was deployed to wipe out mosquitoes and kick out malaria from southern US in the last century.
Third is to ensure the existence of basic laboratories and diagnostic tools in each healthcare facility. We can then rapidly employ and train otherwise unemployed graduates of biochemical sciences to be physician’s assistants after 12 months of education and internship, and deploying them to PHCs and SHCs to handle patients with some of the commonest ailments like malaria, typhoid, and the diarrhea which take up to 60% of doctor’s time in PHCs and SHCs. Doctors will then properly spend their time on more serious ailments.
Fourthly, to rescue the Nigerian health sector, our Primary Healthcare System has to be made not only a local government matter, but functional, properly managed and funded. The National Health Insurance Scheme should be strengthened and universalized along the model of UK’s National Health Service (NHS) and its activities expanded to cover every Nigerian. Given that good governance and health are intertwined, facilities should be provided to keep our environments healthy.
Fifthly, our political leaders should lead by example and exhibit confidence in our health system by patronizing the health facilities available in Nigeria instead of travelling abroad for even basic check-ups. It will be nice if all public servants, but particularly the President, Governors, Ministers, Presidential Aides, members of the National and State Assemblies (and their families), commissioners and Permanent Secretaries, Judges and Special Advisers/Assistants openly declare that they will never go abroad for medical check-ups, treatment and the like, and will patronize ONLY government-owned facilities in Nigeria with effect from 1st October 2012! – Then the rapid improvements in our healthcare delivery system will begin to manifest.
Finally, we need to ensure more effective spending for preventive, primary and secondary care. Can more funding lead to better health? Not necessarily. We would need more healthcare workers regardless of any level of spending to get better outcomes. However, spending generates some impacts. According to WHO, every $100 per capita spent on health creates a 1.1-year increase in Health-Adjusted Life Expectancy (HALE).
The Nigerian health industry is potentially big, possibly bigger than the successful telecoms sector. True, telecom services are necessities, but everybody needs healthcare to survive and grow, and even make phone calls! Ultimately, we must accept the maxim that ‘health is wealth’ and take appropriate steps to improve the sector. At the moment, it is creating a huge hole in our political and economic development aspirations. If Nigerians are not healthy, we cannot build a wealthy country. And the examples of healthy living and confidence in the health sector must begin from the political leadership. The ball is firmly in their courts.
I wish you happy deliberation, and regret my inability to be with you this morning. Thank you for inviting me and God Bless.
Nasir Ahmad El-Rufai
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