During a recent ranking of
Global Health Systems of the United Nations member states by the World Health Organization (WHO), the Nigerian Health System was ranked 187th out of 191 member states ranked. This ranking looked at the impact of the health system on the member states population health using well accepted health indicators.
In developed countries, healthcare, education, and welfare of the population are accepted responsibilities of the government. This principle and concept has recently been consolidated by the United Nations (UN), declaring the provision of basic healthcare to the population of every country one of the Fundamental Human Rights. And Nigeria is signatory to this Declaration.
This article draws our collective attention to an expensive and wasteful national crisis with many silent victims. Let’s begin the review.
An America adage says, “you have to know where you come from in order to know where you are going”
The Nigerian two-tier Health System has its genesis from the colonial era when Nigeria was under the British Empire. During the Colonial days all British nationals and Nigerian politicians with any serious health condition in the country were transported to Britain for treatment. Meanwhile, functional General Hospitals were built and operated in the cities and some midsize towns, and British Missionaries also operated excellent Missionary Hospitals for the rest of the population in the remaining midsize towns.
Since independence in 1960 and for over 53 years, this relics of colonialism has remained in the Nigerian Health System. Today, the Nigerian politicians, top civil servants, military officers, current and retired, and heir families that constitute the “neocolonial masters” are routinely air-evacuated to Canada, Britain, France, Germany, South Africa, Middle-Eastern countries, Australia, and other European countries for all their medical care including, medical check up in the form of medical vacation at public expense while the rest of the Nigerian population makes do with ill-equipped, poorly maintained, inadequately staffed, and dysfunctional public health facilities, most of which are in very deplorable State.
Lest we forget, our national health infrastructure was neglected for many years under the series of military dictatorships some of who just allowed poorly trained staff to run these institutions due to severe brain drain and intellectual flight from the country for various reasons. The patients at these hospitals usually get a list of medical supplies including drugs, intravenous fluids and tubings, syringes, needles sheets, and disinfectants to come with at admission or family members must rush to get the items on the list while the patient is processed.
This “two-tier health system” as it operates in Nigeria is medically unethical, morally indefensible, and discriminatory by class. The Nigerian political elites invariably commit “moral hazard” overseas as they consume more medical services than if they had to pay the entire bill out of their pockets.
From Health Policy and Management perspective, this “two-tier health system” in Nigeria creates severe health disparities, and makes the totality of the Nigerian Health System appear disorganised, dysfunctional, uncoordinated, fragmented, duplicative in services, expensive, wasteful, and economically unsustainable, thus, the very poor ranking by the WHO (187th out of 191).
A quote from a recent policy paper from the Federal Ministry of Health, Abuja is both instructive and substantiates most of the above mentioned health policy concerns, I quote, “the health status of Nigerians are in deplorable state with numerous problems including low motivation for health professional workers, a culture of corruption and little consultation between the Federal and the State authorities and between Federal Ministry of Health and other Federal Ministries” unquote. Given such self-assessment, do you wonder why Nigeria has the second highest maternal mortality in the world?”
It is imperative to state that there are enough accumulated blames in the 53 years of our independence to go around. We need to recognize that we can not waste any more time or resources. Everyone must sacrifice, specially our elected officials who remain the most beneficiaries of “the two-tier health system”.
Health care reform takes time to mature and for a reform to endure, it has to be a comprehensive overhaul and not patchwork of incremental healthcare improvements on the status quo. We know that our current health system is broken and needs fixing immediately. We ought to develop a comprehensive National Health Plan and stick to it, but right now, we do not have one. If we do, it should not be put close to the vest of the Minister of Health and his Federal Ministry of Health officials. Unfortunately, this Minister’s actions appears to favour “For-Profit” Health System solutions for Nigeria to a Universal Health System where healthcare is a right of all Nigerians and not to a privileged few. Data from WHO shows globally that, the nations with the best health Systems (France, Japan, Sweden, and Britain) also have the most cost-effective healthcare, and they are insuring the health of all their citizenry.
What every Nigerian must realize is that as a nation, we have wasted billions of US dollars (or Trillions of Naira) in Overseas Health Care the last 53 years on our “neocolonialists” (our political elites). These are resources we could have used to improve our national health infrastructure, purchased modern equipments for our health facilities, build adequate capacity, recruit, train, and retain the health professionals needed to operate the system. Hopefully, the next 53 years will be innovative and more visionary for the Nigerian Health System than the last 53 years.
Consequently, I make the following few of many recommendations:
*Regionalisation of the National Health System following the Six Geo-Political Zones/Regions and formation of Regional Health Systems and Regional Health Management Teams. For example, North Central Health System and the Niger Delta Regional Health System.
*Any reform agenda must comprehensively review all four-components of any health system namely: finance, insurance, delivery system, and payment. Imperative questions on these components are: 1) How will the reform be sustainably financed nationally, regionally, at the State, LGA, and community levels? 2) Can the National Health Insurance Scheme be rolled out immediately for all Nigerians as a National Universal Health Insurance Plan as in Britain? If not, why? There has been enough pilot studies of the scheme and it is time to get serious and stop wasting resources. The new health delivery system should have universal access to healthcare for all Nigerians and should be located close to where the people live. Finally, what type of payment system do we need for all the providers? Single-payer system as in Britain and Canada or multiple-payer system as they are trying to work out in the United States?
*Some form of health workforce brain drain Reversal Program must be developed and instituted to bring home Nigerian Health Professionals Overseas and stem the exodus of our “best and brightest health professional” graduates to foreign countries.
*Health Information Technology and Electronic Health Records (HIT-EHR) diffusion must be an integral part of any 21st Century Health Care Reform. Computers will help the reform go faster, smoother, reduce cost, provide accountability, transparency, improve patient safety, improve quality of care, with no more lost patient paper charts and records.
*Primary care and evidence based preventive care must be central to the basic health care for all with medical homes for chronic disease care. Primary and preventive care must be key to this reform agenda because data shows that 75-85% of any population only need primary care service in a given year and only 5-10% need tertiary (University Teaching Hospital) type care. Further, high ratio of Primary Care Providers in any population is associated with lower hospitalisation rate, and adults who have primary care physician as their regular doctors experience lower mortality and lower health care costs.
*Our federal proxy Health Agencies and Commissions must be streamlined and merged to work co-operatively with the regional, states, and local governments. The University Teaching Hospitals and Federal Medical Centers will co-ordinate the healthcare in each state, down to the local government, and community levels through the Clinical Service Line (CSL)-Model chaired by their more skilled, competent, and highly trained chairmen and Chiefs of Service. The CSL will be Co-Chaired by a management expert for efficiency and effective management of the program and resources allocated to each Clinical Service Line.
*Every community in Nigeria needs either Community Health Centre (CHC) or Mobile Clinics for our Very Rural Areas coordinated from their LGA-District Hospitals. Each CHC must have Teams of Medical Home Primary Care Physicians with Health information -Systems-Electronic Health Records, Out-Patient Pharmacy, Medical Labs, x-Ray, Urgent Care, and a Birthing Center run by midwives supervised by doctors at their LGA District Hospitals. Each Clinical Service Line will have directors at the LGA-Hospitals and CHC coordinated from the University Teaching Hospital or Federal Medical Center at the State capital.
*Patient Safety initiatives and Patience Compensation for medical errors, accidents, injury, and death as a consequent of health care through no fault of theirs should be considered in the new health delivery system to be formulated.
*A National Healthcare Consensus Conference should be convened consisting of: 1) national, regional, state, and local legislative and executive branches of government: 2) representatives of the health professions, health industry, and labor: 3) experts in health economics, health policy and Management, budgetary processes, and health services administration. This should be a retreat of workshops, small group sections, and presentations for 3-4 weeks at the end of which a truly National Health Plan will emerge that will provide universal access to healthcare for all Nigerians executed (95-99.9%) in Nigeria by Nigerians to be implemented over 3-4 years that will eliminate the “two-tier health system”.
*While the foregoing reforms are taking shape, the Federal Ministry of Health should immediately buy health insurance in every country Nigerian governments transport Nigerians for cost-effective healthcare. It is well known that health services overseas is more expensive without health insurance than with one.
This comprehensive overhaul of the National Health System as proposed above will enormously expand the health sector of the Nigerian economy, creating thousands if not, millions of jobs nationwide, and thus, contribute to our economic growth and Gross Domestic Product (GDP) in the next rebasing of the Nigerian economy.
The National Conference and the National Assembly should carefully review our health system on national security grounds, the dysfunction of the current Nigerian Health System, and the waste of our scarce national health resources. They must not accept any patchwork of incremental healthcare improvement on the status quo if, there is no comprehensive reform agenda to eliminate “the two-tier health system” as discussed above. It will do nothing for the greater good of Nigerian healthcare, knowing what they do now, about the national need for universal health insurance and universal access to healthcare. .
As an expert in Population Health Policy and Management, I can say, it is not that Private (For-Profit) Health System has not been tried, it has failed woefully everywhere. This is why all European countries, Japan, Norway, Denmark, Australia, and South Korea have abandoned it since after the Second World War and embraced Universal Healthcare for its cost-effectiveness and provision of universal access to healthcare for all their citizenry. United States was the last industrialized country to change their health system and they too are in the process of making the switch right now. There are multiple countries with best practice of Universal healthcare Nigeria can emulate like Britain, Canada, Sweden, and other players that will help us get it done like WHO and the World Bank. Nigeria will not be reinventing the wheels here.
Consequently, the National Conference must forge a new direction and leave a legacy of transformative recommendations in healthcare for all Nigerians to experience for a lifetime that will bring Nigeria squarely into WHO standards that Ghana and South Africa have already achieved for all their citizenry. Why must our political officials have better healthcare than those who elected them?
Finally, the Conference should propose and the National Assembly should immediately merge “the two-tier health system” in Nigeria into a single Universal National Health Plan for all Nigerians executed in Nigeria by Nigerians most of who had their specialisation training overseas.
Prof. Amaye-Obu is United States-based Population Health Policy and Management expert.
Prof. Fons A. Amaye-Obu