Ike Anya wrote this piece on behalf of the Nigerian Public Health Network; a network of over 100 Nigerian Public health professionals around the world.
Nigeria has had an elected civilian government since May 1999. Over the next few weeks, elections will be held to identify successors to the Obasanjo regime. Many candidates are putting themselves forward for the various positions in government. In this piece as a network of Nigerian public health professionals we put forward our analyses of some of the issues that should be paramount in the health agenda for the next 4 years. We hope that this analysis will provide some fairly basic frameworks to help politicians focus on health issues and assist Nigerians in demanding these from their politicians. Beyond that, it could act as a template in the future for reviewing the performance of whoever is elected to lead government at different levels on issues relating to our health.
We explore several themes and proffer not just problems but solutions. Generally we feel saddened that the health sector does not seem to have benefited to the same extent from the innovative strategic thinking and planning that other sectors have benefited from. We have seen obvious and significant developments in the banking, telecommunications, insurance and lately also in the education sectors. While the term "reform" has been extensively used with regards to health, very few Nigerians can identify significant changes to their daily lives in terms of their health outcomes, and access to health care. While the population has become ever more suave in demanding and getting improvement in banking, telecommunications and other sectors, we all seem to have resigned our health to fate. Why is this the case?
A simple analysis of the health sector in Nigeria and its challenges can take two perspectives - the population's health perspective and the perspective of healthcare services.
Firstly, when we speak about a population health perspective we are talking in terms of broader health outcomes- what is the maternal mortality rate? What is the infant mortality rate? What is the prevalence of HIV? What is the prevalence of malaria, and how have all these changed over time? These are broad indices that are indicative of the state of health of the population of Nigeria as a whole. These may not be immediately obvious to the man or woman on the street but are indicative of the health of the general population and also serve as an index of development. Also relevant from a population perspective are the population's knowledge, attitudes, and behaviours towards factors that influence their health outcomes. How much are preventive measures promoted and how much are these adopted by our growing population? The influences of these factors are of course largely subject to the socio-cultural diversity of Nigeria, but are most significantly underlined by the economic situations of the people.
Secondly, in terms of healthcare services, we refer to those services with which every one is immediately familiar and associates with health. If I fall ill today, where can I go for treatment? Can I afford the treatment? Are health care facilities adequately equipped and staffed to make the appropriate diagnosis? Will the treatment I receive be of good quality? What is a minimum standard of treatment and care that I can expect and can demand? How long will I have to wait for it? Although some improvements have been made, notably in the refurbishment of some teaching hospitals, a lot more work is required in Nigeria on both levels and in this piece we highlight some of the outstanding issues. It is important to stress that health cannot be divorced from socioeconomic factors and therefore efforts at improving the socioeconomic status of the Nigerian people are key to improving health in Nigeria. Having acknowledged this broad perspective, there are however issues that can be addressed from a more specific health perspective.
Population health in Nigeria suffers on various levels. The most pressing perhaps is the lack of data. This might appear unrelated to health to the casual reader, but fundamentally, one cannot manage what you cannot measure. A priority for an incoming President and his minister of health must be a careful review of what data is currently available and what further data is needed in the health sector and how best to collect this. This does not necessarily require sophisticated mechanisms- examples exist in other developing countries and we can harness these examples. The data we need to collect relate to both population health and also health care indices.
Firstly, in the sphere of population health, systems already exist for the collection of sentinel surveillance data for HIV and for the childhood vaccine-preventable diseases. Lessons can be learnt from these programmes and expanded. The information collected can then be used to set health related targets. I.e. rather than promise the building of x number of primary care facilities, a health goal would be to reduce the prevalence of HIV from 5% to 3% in the next 5 years, or to increase the uptake of measles vaccination from 60% to 80% in the next 10 years. The performance of government can then be related to how they achieve these goals.
Secondly data on the availability, and spread of health care infrastructure, finances and resources. How many hospitals exist in Nigeria, at national, state and local government levels? How many are privately owned, how many government owned?What services do they provide? Where are they located? What are their staff strengths? What are referral systems upwards and downwards? Is there a registration and accreditation system for private providers? Is this data managed and accessible?Just like the performance of the telecommunications sector is not measured on the number of telephone companies, but on the teledensity (proportion of the population with an active telephone line), the health care sector should not be measured by the presence of hospitals, but on the access of people to a functioning health care provider. The National Health Insurance Scheme is a potential source of useful health information as well as the recent contentious census, which included questions on health and social services. Over the past 8 years we have often heard from the National Primary Health Care Development Agency on the number of Primary Health Care Centres that have been or are being built. We have heard nothing on how many of these centres are providing adequate health care to people. Indeed the building of health care centres should be the responsibility of a ministry of works, not a parastatal under the ministry of health!
Another priority should be access to potable water and sanitation. Nothing surprises first-time visitors to Nigeria more than the refuse on our roadsides. The ubiquitous pure water sachet, while solving thirst problems for people, has led to a big refuse disposal dilemma. There is no reason why Nigeria should not be able to provide its citizens with clean water and sanitary disposal of wastes. Tackling these issues will boost population health. Similarly, providing a minimum compulsory education of high quality to junior secondary school level is a key part of boosting population health. Education, especially the education of girls is critical in ensuring improved health for the people of Nigeria and must be made a priority. Without investing in education any improvements in other sectors will be transient and unsustainable.
We have one of the highest road traffic accident rates in the world. Literally, our roads are killing us. This affects the rich just as much as the poor. Reducing this will require firm and decisive action- in improving road safety, the introduction of compulsory helmet use by motorcyclists, sustaining the use of seat belts, imposing and insisting on speed limits and other safety measures. These need to be accompanied with through driver education and public enlightenment. The difficulty in some of these measures e.g. helmets in the Nigerian heat is understandable. But contrast this inconvenience to a broken femur, skull or a wasted life! The enforcement of these laws is of paramount importance and the need for an enlightened and disciplined police force is obvious. This example highlights the complexity of improving health, as most of the necessary actions actually lie outside the realm of the health sector.
When accidents do happen, as they always will, at the very least the provision of at least one adequately staffed and resourced Accident and Emergency unit in every state capital will literally save thousands of lives. In Nigeria, children are perplexed when they grow up to realise that most ambulances they see on the road are not carrying emergency services as they are taught in school, but only appear on Fridays, carrying corpses to funerals This needs to be readdressed urgently. A good starting point would be to build up a pool of 2 – 5 ambulances absolutely dedicated to accidents and emergencies to each of the afore mentioned centres described. These as well as other practical solutions should be encompassed in a comprehensive emergency medical system for response, transport, evacuation and treatment of acute medical conditions and injuries at the state levels with a national emergency referral plan.
Emergency services and emergency planning are key areas – many of the recent disasters have led to unnecessary loss of life because the emergency services required were not in place. What does it take to ensure that every fire service has functional equipment and running water? This may have saved lives in the plane crash in Port Harcourt and more recently the petrol explosion in Lagos. One shudders as the economic costs of maintaining a Fire service, which at the best of times, fires being rare occurrences, are idle, and yet on the odd but urgent occasion when these do occur, those paid to respond cannot do so due to lack of water?
This leads to the question of health care services- where the question may be approached from two angles. In the first place, why is there no single world-class tertiary hospital in the entire country to negate the continued need to fly patients to South Africa, India or the United Kingdom? What exactly is the role the National Hospital in Abuja? Why is it necessary for a sitting vice president and the supposed front-runner in the presidential elections to be flown abroad for a knee strain and to treat "catarrh"? What needs to be done with the National Hospital in Abuja to make it meet these challenges? Anyone that has visited the centre knows it does not lack facilities yet, beyond the well-manicured lawns, why do we feel the same lackadaisical attitude so prevalent in our hospitals? Is it the absence of learning incentives through the lack of a comprehensive postgraduate training scheme for doctors in training? Is it the absence of a financial incentive due to the lack of specific health outcome targets tied to the huge financial resources being invested? If our most pre-eminent have no confidence in our premier health care facility, what can the ordinary Nigerian expect? The next president must create a genuine centre of excellence- if not for the sake of the ordinary man but also out of self-interest – it could save his life. Many will argue that this is not a priority but the creation of such a centre will raise standards in the provision of health services and therefore boost the general quality of services. In addition it can act as a magnet to draw highly qualified Nigerians from all over the globe as well as provide education and training to healthcare professionals within the country.
Looking more broadly at health services, it is immediately obvious that the majority of Nigerians obtain healthcare from the private sector-be it the roadside chemist or the fancy ten storey private hospital. Improving health services therefore must include restructuring the regulatory framework within which private providers of health provide care. There should be minimum standards for the opening of a health facility and these standards must be clearly communicated to the public so that they can make their own judgements. If members of the public know which banks to put their money in and which bus companies or airlines to use, they also have a right to know what standards they can demand from their healthcare providers. Chemists should be given minimal basic health training to recognize symptoms that they can manage and those beyond their capacity, which they need to refer. They can be issued licences which are regularly reviewed and which must be displayed in their shops. Public awareness campaigns should be carried out enjoining members of the public to demand evidence that their chemist has undergone the training.
care to where it is most needed. We acknowledge that there are complex challenges in getting more doctors to practice in the rural areas. There are however several options in providing the incentives to do this, as is being done in South Africa at the moment. However, none of these can be tried if we have no information on what the distribution of health care personnel is at present, stressing again the need for data.
Looking at the public sector, a lot of focus has been on increasing or improving buildings and facilities in government clinics and hospitals. Emphasis needs to shift from the numbers of buildings required to the quality of care delivered within the buildings. We suggest that most Nigerians will prefer going to a public sector hospital if they will not have to spend the whole day waiting to get a card, waiting to be seen by a doctor who might or might not turn up, waiting for tests, waiting at the pharmacy only for the customary ticks with a red pen on the items that are available, while the rest have to be purchased outside. Why is it no longer okay to take a sleeping mat to the bank, but still okay to take a mattress to the hospital? One possible solution would be for public hospitals to provide a high standard private wing services to draw in patients who would otherwise have gone to the private sector. The income from these patients can help subsidize care for others. Introducing minimum service standards should also be considered- for instance a target that all patients are seen within two hours could be introduced and communicated to the public. The media and the public can then monitor which institutions are meeting these targets, and hold the politicians accountable. These politicians will then put pressure on the hospitals, which would then lead to more efficient services for patients.
Another important area for consideration should be the question of medical education and specialist training. Is the current curriculum fit for purpose? Should it be reviewed to make sure that the doctors we produce are the doctors we really need? Have changes in the prevalence of diseases and the roles of doctors been reflected in their training? How much managerial training are provided for medical doctors who suddenly find themselves appointed as Chief Medical Officers (effectively CEOs) of large teaching hospitals with budgets running into billions of naira and staff strengths of close to a thousand in some instances. How have the Medical and Dental Council of Nigeria, the Nigerian Medical Association, and the Nigerian Universities Commission worked together in preserving the quality of medical training in the ever-increasing Nigerian universities?
A more aggressive approach towards cases of clinical negligence should be combined with provision of opportunities for continuing professional development. The legal profession, the courts and the media also have a role to play in ensuring that patients are not short-changed. Doctors and other healthcare workers need to be held accountable and these institutions must do this. This can only be realistically achieved if the role of the Medical and Dental Council of Nigeria is strengthened. Self-regulation should be preserved as the first line of enquiry. The Medical and Dental Council of Nigeria has a major role to play in ensuring that standards are maintained in the private and public sector.
To achieve all this, 3 issues are key:
1. Leadership. To implement the issues raised requires a visionary committed team that understands the issues and is passionately committed to change. That this has happened in other sectors of the economy is not in doubt. It is time that this approach was brought to the Nigerian health system. Sometimes it does take a single, motivated and skilled individual at the steering wheel.
2. Money. It will require money, lots of it! In many parts of the country, there has been an absolute collapse of the health care infrastructure and anything other than an emergency injection of funds immediately will not be helpful. While there is a need for an absolute increase, innovative funding mechanisms (such as the NHIS) need to be further explored and nurtured to maturity. With political stability, we believe that the investments will keep flowing into profit-oriented sectors of the economy. This is not necessarily the case for sectors such as health and education where financial returns cannot be the primary motive, yet these areas are imperative for national development.
3. You. When next your neighbour dies from measles, during child birth or even in a car accident, rather than conclude it is all as "God wanted it", we should spare a few minutes to think and maybe act on the failings in the system, the missed chance at vaccination, the inadequate antenatal care or the non-existent emergency services that might have prevented these deaths. The only alternative would be to conclude that God really has a problem with us Nigerians; why else would he let so many of us die from causes no one else is dying from?
The way forward:
-The new government should urgently put a process together to identify 10 health priorities: (e.g. Childhood immunisation, Maternal care, Access to emergency services, Prevention and care of HIV&AIDS, Environmental sanitation, etc)
-These priorities should be in the public domain. It is the people who elect (or for that matter, don't bother to elect or indeed challenge) people in office. In many countries, elections are won and lost on health issues. Just as we demand for electricity, good roads etc, we have a right to basic minimum level of health and health care and must learn to ask for this.
-These priorities should all be data driven. No matter how rudimentary, we need to set up, resource and sustain an information management system for health and healthcare management data. This is the only way of measuring progress.
-As a matter of urgency, we need to assess, map and categorise existing health infrastructure and personnel and set up a mechanism to track and manage these over time.
-The entire health system is in dire need of bold, innovative strategic management.
These are ambitious pointers. We do not expect immediate success. Positive change is often painful and will face resistance and often resentment. There might be strikes, and people might die. But it cannot be business as usual. Our health is our greatest asset. Without good health, little else is possible. With a clear agenda, good leadership, a good implementation plan, and a good team with the requisite health and managerial skills these can be achieved.They start might be slow, some will stumble, then over a year or two, there will hopefully be significant improvement.
Ike Anya wrote this piece on behalf of the Nigerian Public Health Network; a network of over 100 Nigerian Public health professionals around the world. (www.nphnet.org)