Nigerian Health “Reforms”: Rhetoric Or Real?

We live in times of sweeping change. An estimated 10 million Nigerians now own and use mobile phones. The recent recapitalisation exercise in the banking sector has led to the emergence of 25 strong banks with at least N25 billion in reserves. Recently, the Ministry of Finance successfully negotiated a debt relief of US$18 billion out of our debt stock of US$32 billion. When any Nigerian talks about reform in the telecommunications, banking and financial sectors, the outcome of these reforms are obvious to all.

The same cannot be said of the health sector in Nigeria. Since the inception of the present administration, we have heard the words “Health Sector Reforms” bandied about in every speech, yet hardly any Nigerian can point to a single aspect of these reforms that has affected his or her life. Pundits will quickly remind us that NAFDAC is a parastatal of the Ministry of Health and that their achievements in bringing some order into the licensure and sale of food and medicines are well known. While this is true, we must also look to parastatals like the National Programme for Immunisation (NPI) and the National Primary Health Care Development Agency (NPHCDA) from whom we have heard so little and whose core functions have important implications for public health. On occasion we read in the newspapers about refurbishments going on in various teaching hospitals, and indeed one of the core messages in 1999 at the inception of the present government was that at least one teaching hospital in each geopolitical zone would be refurbished to world class standards. However evidence that this has failed to happen is abundant; from the failure of referral services in Port Harcourt, one of the biggest cities in Nigeria to care for the critically injured and provide adequate mortuary facilities to keep the dead after the Sosoliso crash, to the continued need for high profile individuals to be flown abroad on a regular basis for medical treatment.

We inherited a health care system from the British after our independence and have adapted this piece-meal over the years. The British National Health Service (NHS), on which ours was modelled, has undergone great change over the years. Profound thinking and strategising by policy makers precede each change to the system. Elections are won and lost on health issues and Margaret Thatcher’s failed market reforms in the NHS were one of the most significant factors that brought down her Government. Even now, the battle over NHS reforms is predicted to have a large impact on the forthcoming local government elections in the UK. While we are not attempting to compare these two countries, which are at two extreme ends of any development index, it is important to point out that reforms in health care at the national level should not be a vague theoretical concept which no one can understand or interpret. This government owes it to the people to have clear-cut health related goals on where it wants to take us to in terms of health care.

The present government seems to have prioritised certain sectors of the economy, and this is reflected in every discussion on its performance. Any averagely literate Nigerian will mention Ngozi Okonjo-Iweala, Nasir El Rufai, Oby Ezekwesili, Charles Soludo and Nuhu Ribadu as the most progressive personalities in this regime and from where most of its credibility is drawn. The reasons for this are not far-fetched; they have all produced tangible results in their sectors. Ask the same group of people who the Minister of Health is, and you will see blank faces. One could come to the conclusion that certain aspects of governance have been given priority over others and that health does not seem to have fallen into the chosen few. We could argue that this is because initial efforts have been focused on the economy, but the question remains- is this decision wise, and more importantly, is it sustainable?

Jeffrey Sachs, world renowned economist and Special Adviser to the General Secretary of the United Nations in his report commissioned by the World Health Organization a few years ago made the landmark link between macroeconomics and health, when he and his colleagues showed that paying attention to population health was not merely of altruistic value but also in the interest of national and global economic development. The bottom line of the Commission’s report is that it pays to invest in health.

The medical profession has historically been conservative and hierarchical, and one in which radical change is always viewed with suspicion and scepticism. This perhaps may have accounted for some of the difficulty in producing tangible health reforms, but still leaves worrying questions unanswered.Globally, treatment for diseases such as HIV/AIDS have become cheap and affordable; yet over the past 5 years we have struggled in Nigeria, to raise the number of people living with HIV/AIDS accessing treatment from 15,000 to 30,000, despite our being the first country in Africa to take on the responsibility of making life-saving anti-retroviral drugs available for her HIV infected population. While we applaud the vision behind the commitment, we must acknowledge that against a backdrop of millions of infected individuals, a more radical response is required.

Turning to another public health intervention- immunisation, the story is no better. Childhood immunisation is widely recognized as one of the most effective public health interventions in modern history. It requires relatively straightforward systems of delivery and the cost of the measles vaccine, for instance is less than 100 naira. These vaccines have been available for the past 40 years, and yet more children die from measles in Nigeria than in any other country in the world. That northern Nigeria is the epicentre of the last vestiges of polio in the world is no news.

The systems delivering health to the Nigerian people need radical reform, with clear explicit goals against which progress can be measured not just by bureaucrats but also by the common people. Examples of such targets could be a 20% reduction in maternal mortality over the next 5 years or putting 100,000 people living with HIV/AIDS on treatment in the next 3 years. The health of the Nigerian people should no longer be measured in terms of how many health centres are built or how many teaching hospitals are re-furbished or indeed how many tons of fake drugs are burnt, but in terms of real quantifiable change in disease burdens and mortality. Can we reduce the number of children who die from vaccine preventable diseases such as measles and polio? Can we eradicate guinea worm? Reform in the health sector, should not be a vague rhetorical term that means nothing to the average Nigerian but a collection of measurable policies and strategies with well-defined, measurable outcomes.

It is nothing short of a scandal that even with regard to programmes such as immunization and HIV/AIDS, which receive strong multilateral support, much less has been achieved than could be feasible within the resources available. Is it because that we are pursuing these schemes using old paradigms and methods, which are not capable of achieving the targets set? Perhaps it is time to re-examine the methods and systems currently in use and begin to implement radical change and reform that yields real benefits to the average Nigerian. Radical reform is often painful, and is likely to be met with stiff resistance by the medical establishment, as we experienced in the banking sector. Yet in the long run, the benefits of well thought through changes in how we deliver health to the population is an essential part of any developmental ambitions we might have as a country.

At a time when much is being made of the foreign reserves that a

re being built up and the general improvement in Nigerian economic indices, it is perhaps time to re-examine the systems that will be needed to deliver results to the Nigerian people from the funds that have been stockpiled through prudent economic management. We owe a duty to the people of Nigeria to utilize the windfalls from the increases in oil prices to effect changes in their lives. One way we can do this is through ensuring that these funds are used to eradicate preventable disease and despair.

To achieve this, the Federal Ministry of Health will need to provide strategic, progressive leadership. A leadership that is willing to discard failed and tired structures, systems and indeed individuals. A leadership that is willing and able to maximize and harness all the resources that come the country’s way through this ministry; one that can manage and direct these in a planned and structured way with the best interest of all Nigerians as its ultimate goal. A leadership that is willing to set targets for itself, is ready to communicate these targets to the general public and willing to be held to account in the way that, for instance, the Ministry of Finance has taken the lead in publishing its accounts and disbursements.The Nigerian public and the media will then be in a better position to judge when real progress is being made in improving the health of the nation.

Reform in itself is not an event, but a description of a process that should lead to an improvement in the way a service is delivered. True reform takes time, but even in the realm of public health, where indices take time to change, seven years is long enough time for measurable change to have occurred. If over a period of seven years, these improvements are still difficult to quantify, or cannot be described, then there is no justification for the use of the term “reform”.

Dr Ihekweazu and Dr Anya are public health physicians and founding members of the Nigerian Public Health Network, a global network of Nigerian public health professionals.