Meagre budget for mega threat
Nigeria’s health sector is in dire straits. Available data show that the country has one of the worst health records in the world.
A 2014 World Health Organisation (WHO) report on healthcare delivery, which surveyed 200 countries, placed Nigeria at an abysmal 197th position, just ahead of Congo Democratic Republic, Central African Republic (CAR) and Myanmar.
Its verdict was damning: “Nigeria lacks a serious approach to health care.”
That the Nigerian government does not see health as a priority is no news as this can be clearly seen in the amount of money budgeted for the health sector over the years.
According to the WHO, for countries to effectively fund the health sector, they must allocate at least 13 percent of their annual budget to the sector. Nigeria, one of the 194 member nations of the WHO, is a signatory to this recommendation, just as it also signed the 2001 Abuja Declaration by all African Union member countries. The Abuja Declaration recommended that for the continent to be at par with other nations of the world in terms of health-care provision, African countries should allocate at least 15 percent of their annual budget to the health sector.
Available figures from BudgIT, a Lagos-based civic tech organisation, however, show that the health sector got an allocation of a total of N278,819,991,790 in the 2013 federal budget, representing 6.57 percent of the government budget for the year. In 2014, the figure dropped to N264,461,210,950 (or 4.50 percent of total budget). The sector got N259,751,742,847 (3.82 percent of total budget) in 2015, and in 2016, a total of 250,062,891,075 (4.11 percent of total budget) was allocated to health.
In the 2017 federal budget, out of a budget of N7.298 trillion, N304,109,961,401 (or 4.17 percent) was allocated to the health sector to cater for a population of over 180 million Nigerians. In other words, the country proposes to spend about N1,688 on the health of every citizen for the whole year, far below an annual minimum spend of N6,908 per Nigerian recommended by the WHO for the country to be seen to prioritise healthcare. This year, the federal and 36 state governments are spending less than 5 percent of their N13.5 trillion combined budgets on public health.
Even the little allocated to the health sector, the bulk of it goes to paying health personnel, whereas serious public health issues get just a little fraction. For instance, of the N304 billion health budget for 2017, only N51 billion is allocated to capital projects while the rest will go into salaries and overheads.
Compared to other countries of the world, including even its peers on the continent, Nigeria’s health sector budget is a far cry. For instance, reports show that while Rwanda devoted 18 percent of its total 2016 budget to healthcare, Botswana budgeted 17.8 percent to health, Malawi 17.1 percent, Zambia 16.4 percent, and Burkina Faso 15.8 percent. South Africa’s per capita spend on healthcare is about seven times more than Nigeria’s, while Angola’s is about three times more.
Similarly in 2015, the United States allocated 20.7 percent of its annual budget to health, Germany 19.4 percent, Iran 17.5 percent, China 12.6 percent, and Turkey 10.7 percent. The United States is spending at least $7,000 per citizen on healthcare alone in 2017, just as Switzerland is spending $6,000.
At a retreat on immunization, health financing and the National Health Act earlier in the year, stakeholders in the health sector urged the Federal Government to allocate 6 percent of the 2017 budget to health sector, which should be increased progressively to 7.5 percent in the 2018 budget with a view to attaining 15 percent by 2026.
A direct fallout of the grossly inadequate budgetary allocation to the health sector is the poor state of health infrastructure across the country. Whereas the 2014 National Health Act (NHAct) made a case for setting aside 1 percent of the Consolidated Revenue of Government for establishment and maintenance of basic health-care facilities and provision of basic healthcare services to all Nigerians, this recommendation is yet to be activated.
The worst hit in this regard is primary health care. Across the states of the federation, primary health care centres (PHCs), which ought to be the first port of call for every citizen seeking medical care, are either ineffective or moribund, piling pressure on the tertiary health facilities. Nigeria has a total of 21 federal teaching hospitals, 13 specialist hospitals and 22 federal medical centres (FMCs), mostly situated in the state capitals, leaving the rural dwellers to depend on quacks or retail druggists commonly called chemists.
Years of neglect, poor funding, inadequate equipment and lack of personnel combined to deal a death blow on the PHCs. With the exception of Lagos, Anambra and Rivers States, as well as Ogun and Kebbi States which are making commendable efforts, the bulk of Nigerian states lack functional PHCs.
Since his appointment in 2015, Isaac Adewole, minister of health, has at several forums said the Federal Government was making efforts to strengthen primary health care in order to cut the heavy burden on tertiary hospitals having to deal with a flood of minor ailments. Specifically, the minister promised that government would “make functional” 10,000 PHCs in two years – 5,000 in 2016 and another 5,000 in 2017 – to be delivered at the rate of one per day over 110 days starting from May 1, 2016.
“We want the Primary Health Care Centre (PHC) to be the first port of call so that it will be able to offer the basic care that ordinary Nigerians will require,” he said in an interactive meeting in Abuja.
BDSUNDAY checks, however, suggest that much of these promises are being kept in breach. An online search on the subject brought up only reports of the minister’s promises and not a single report on delivery, even as Nigeria Health Watch, an online health advocacy group, faulted the minister’s promise of creating “functional” PHCs, saying creating functionality is about creating systems that work.
Also direly affected is cancer management. The alarming death rate from cancer in Nigeria is mainly traceable to poor infrastructure to deal with the problem. Nigeria has no mobile cancer centre (MCC) – described as a clinic on wheels in which screening, follow-up and treatment (including surgeries) can take place – thereby denying most Nigerians access to basic cancer screening. Likewise, the country has no single comprehensive cancer centre (CCC), which means that most citizens lack access to optimal cancer treatment. Radiotherapy, which is one of the essential equipment needed to manage cases of cancer, is unavailable in most tertiary hospitals in Nigeria. As at 2015, only four public hospitals and one private hospital were said to have such facilities in the country, and some of these are said to be non-functional at the moment.
In the week ending September 8, 2016, Nigeria entered a critical stage as the last two functional cancer treatment machines in the country were reported to have packed up, leaving scores of cancer patients stranded at the Lagos University Teaching Hospital (LUTH).
A BDSUNDAY report of September 9 titled ‘Nigeria risks more cancer deaths as last 2 functional treatment machines crash’ projected that the country’s scary cancer death ratio might spike following the breakdown of the only two functional cancer treatment machines in the country at that time, one in Sokoto and the other at LUTH, without a possibility of immediate repair.
“We called the engineer from Sokoto. It was our own machine and Sokoto that were working before. Sokoto has broken down, LUTH too has broken down,” Remi Ajekigbe, professor of Radiotherapy & Oncology and consultant radiotherapist and oncologist at the College of Medicine, University of Lagos and LUTH, told BDSUNDAY.
“The engineer came down and checked the machine after which he said he was going to Sokoto to bring something. Actually, if he brings the something, the machine would work, but what he is going to bring is just a substitute and it’s just temporary. He’s supposed to buy it either from South Africa or The Netherlands,” Ajekigbe said.
But a staff of LUTH, who gave his name simply as Victor, said he was not surprised that the machine broke down because it was overstressed.
“We are overworking the machine. We put it on around 6am and it runs until 8pm/9pm on a daily basis. This one machine attends to 80 to 100 people every day. In South Africa, one hospital has eight machines and it’s 20 patients to one machine,” he said.
Consequently, Nigerians spend $200 million annually on cancer-related medical tourism, sometimes with poor outcomes because of late detection. Incidentally, $200 million is the approximate amount needed to establish three CCCs (at an estimated cost of $63 million per unit) or to acquire 300 MCCs (at the cost of about $600,000 per unit).
While poor maternal health indicators have been reported in Nigeria since the 1990s, records show the country is the second-largest contributor to under-five and maternal mortality rate in the world. A recent UNICEF report indicates that 145 women die daily during childbirth in the country. In the country’s worst affected areas, 1 in 13 women die during childbirth. Nigeria also loses about 2,300 under-five year olds every single day, 25 percent of whom are newborn babies. And whereas only 35 percent of deliveries are attended by skilled birth attendants, less than 20 percent of health facilities offer emergency obstetric care.
More worrisome is the fact that more than 70 percent of the estimated under-five deaths in Nigeria are caused by preventable or treatable infectious diseases such as malaria, pneumonia, diarrhoea, measles and HIV/AIDS.
According to a 2015 report from World Fact Book, Nigeria records about 72.7 deaths of infants under one year per 1,000 live births, whereas Rwanda records 58 deaths per 1,000 children under five, Malawi 42, Gabon 46, Togo 45, Kenya 39, and Libya 11.
The figures for cancer are even more mind-boggling. Nigeria has a cancer death ratio of 4 in 5, one of the worst in the world. According to the WHO, over 100,000 people are diagnosed with cancer annually in Nigeria, and about 80,000 die from the disease, amounting to 240 Nigerians every day or 10 Nigerians every hour dying from cancer as at 2015.
Furthermore, cervical cancer, which is virtually 100 percent preventable, kills one Nigerian woman every hour. Breast cancer now kills 40 Nigerians daily, up from 30 daily in 2008. Prostate cancer kills 26 Nigerian men daily, up from 14 daily in 2008. These three common cancers alone kill 90 Nigerians daily.
The average life expectancy in Nigeria is at 52.
The absence of health emergency responses means that outbreaks like Lassa hemorrhagic fever (LHF), which was first described in Nigeria dating back to the 1950s, is still killing scores of citizens in 2017. A resurgence of the fever in November 2015 killed at least 76 victims, with over 200 cases across 17 states of the federation placed under quarantine and observation. During the current outbreak which began in December 2016, 17 Nigerian states have reported at least one confirmed case. As at June 9, 2017, a total of 501 suspected cases including 104 deaths had been reported, according to WHO. Of the reported cases, 189 had been further classified, 175 laboratory-confirmed including 59 deaths and 14 probable cases (all dead).
Malnutrition, which accounts for more than 50 percent of deaths of under-five children in Nigeria, currently affects 11 million children in Northern Nigeria alone.
And despite a global multibillion dollar immunization campaign over the past few decades that has made most of the world polio-free, Nigeria is one of three countries (alongside Afghanistan and Pakistan) where poliomyelitis, a crippling disease, remains endemic. Dozens of children become paralyzed and ultimately die from the highly infectious disease every year. A report cites poor health infrastructure, government negligence, and political instability as among the reasons responsible for the continued prevalence.
More than 60 million Nigerians are said to have various degrees of mental disorder, while between 20 and 25 percent live with a full-blown mental disorder.
The WHO records that about 90 percent of the 285 million people estimated to be visually impaired worldwide live in low-income settings like Nigeria. According to the National Blindness and Visual Impairment Survey conducted in 2005-2007, 4.5 million Nigerian adults aged 40 years and above are visually impaired or blind.
Brain drain in the health sector
Meanwhile, citing poor working environment, which implies lack of adequate equipment, infrastructure, and medical supplies, among other factors, Nigerian medical doctors are moving abroad in their numbers in search of better work opportunities.
At the 5th Moses Adekoyejo Majedunmi Foundation (MAMF) ‘The August Event’ held in Lagos August 22, Clare Omatseye, president, Healthcare Federation of Nigeria (HFN), said due to lack of investment in health care in the country, Nigeria has lost a lot of its good doctors in the last couple of decades.
“There are about 37,000 Nigerian doctors in diaspora, with about 30,000 Nigerian doctors in the United States, and over 5,000 in the United Kingdom. We have almost equal number of doctors abroad that we have in country,” she said at the event themed ‘Health: A National Challenge – Restructuring and Driving Sustainable Growth’.
“Currently, we are suffering from patients’ drain, where there is a lack of confidence in the sector, and people are now leaving for medical tourism, where we lose over $1 billion,” she said.
Only recently, Ben Murray-Bruce, senator representing Bayelsa East and founder, Silverbird Group, tweeted that “700 Nigerian doctors relocate abroad annually because we prefer spending $1bn on medical tourism than spending it on our health sector”.
Some Nigerians who responded to the senator’s tweet contended that the figure was an understatement.
To buttress this point, a recent survey by NOIPolls on ‘Emigration of Nigerian Medical Doctors’ found that almost 9 in 10 doctors interviewed disclosed they were seeking work opportunities abroad.
According to the poll carried out in partnership with Nigeria Health Watch, of 88 percent doctors who said they were considering work opportunities abroad, 91 percent are at junior level, followed by 8 percent who are mid-level, and 73 percent are senior level medical practitioners. Top locations for Nigerian doctors seeking work opportunities abroad include United Kingdom 93 percent, United States 86 percent, Canada 60 percent, Saudi Arabia 59 percent, Australia 52 percent, and UAE 29 percent.
“Between now and September, 2,500 doctors will be leaving the country for better opportunities because it has been a trend. It is imperative to improve and invest in the health sector. What happens to the sector if all trained doctors emigrate?” said Bell Ihua, CEO, NOIPolls, said during a panel session with stakeholders to discuss the findings.
The poll also rated other reasons some Nigerian doctors are seeking overseas job to include low work satisfaction 92 percent, poor salaries and emoluments 91 percent, huge knowledge gap 47 percent, poor quality of practice 8 percent, and high taxes/deductions from salary 98 percent.
A bad example
But while the public health sector remains poorly funded, with its characteristic dilapidated infrastructure, obsolete equipment, incessant strikes by health workers, lack of professionalism among health personnel, among other problems, and while millions of Nigerians depend on these mostly ill-equipped public and private hospitals for their medical needs, often paying through their nose to get the required attention, Nigerian public officials and their families increasingly seek medical attention abroad even for issues as minute as regular health check.
Other Nigerians with means have joined the fray, with the country said to lose between $1 billion and $20 billion annually on medical tourism, depending on whose figures you choose to believe.
Nothing exemplifies this anomaly as much as the fact that in 2017 alone, President Muhammadu Buhari, the country’s number one citizen, has spent more than five months receiving medical attention in a foreign country. Despite promising that he would end medical tourism, Buhari spent 51 days in London earlier in the year (January 19-March 10) and another 103 days (from May 7-August 19) on medical grounds, making a total of 154 days. He had in June last year travelled to London to treat a “persistent ear infection”, despite the country having over 250 ear, nose, and throat specialists and a national ear hospital.
This is even after the State House Medical Centre in the Aso Rock Villa, built to provide health-care services to the president and vice-president, their families, civil servants working in the State House, and some notable dignitaries, had gulped a total budgetary allocation of N4.4 billion in four years (2013-2016).
The State House Medical Centre got N619.9 million in the 2013 budget, N862.9 million in 2014, N137.9 million in 2015, and a whopping N2.8 billion allocation in the 2016 budget. For the 2017 fiscal year, a total of N331.7 million has been proposed for the medical centre in the draft budget, higher than the capital allocation to any federal teaching hospital in the country.
Defending the draft 2016 budget before lawmakers, Jalal Arabi, permanent secretary, State House, said the initial N3.8 billion for the State House Clinic in the draft 2016 budget sent to the National Assembly was earmarked for the upgrade of the clinic to Centre of Excellence.
“The budget for the State House Medical Centre included N3.219 billion proposed for the completion of on-going work as well as procurement of drugs and other medical equipment. The anticipated improvement of the Medical Centre will propel it to serve as a Centre of Excellence and also reduce medical tourism,” said Arabi.
During the president’s January-March medical trip, Osadolor Ochei, a Benin-based human rights activist, had told BDSUNDAY that the Senate was reasonable to have approved N2.8 billion for the State House Medical Centre in 2016 given President Buhari’s promise on assumption of office that he would discourage overseas medical trips by government officials in order to give attention to the country’s failing health facilities. Subsequent events have, however, shown that the president’s promises were empty rhetoric.
“The N2.8 billion was expected to improve on the facility of the Aso Rock clinic. But if the president of this country cannot improve on a facility that is directly meant for him, I wonder how he will improve on the public facility that is meant for the generality of the people of Nigeria. That is why every facility in Nigeria is going comatose,” Ochei said.
Need for private sector investment
In the face of inadequate funding by government, experts in the health sector have continued to emphasise the criticality of private investment in the sector to meet the considerable shortfall in public-sector investment. Reports have it that some private sector groups have long been active in Nigeria.
Nigeria Health Watch reports that organisations such as the Wellbeing Foundation Africa, MamaYe Nigeria – E4A, Society for Family Health, and Pathfinder International have been carrying out interventions to help address maternal and child health issues in the country, while grant-makers like The Bill and Melinda Gates Foundation and the TY Danjuma Foundation have also consistently committed resources towards improving Nigeria’s maternal and child health indices.
“In September 2016, the World Bank-supported Saving One Million Lives programme gave every state in Nigeria, including the FCT, $1.5 million each to improve maternal, child and nutrition health services for women and children throughout the country. Also in 2016, the MTN Foundation carried out a Maternal Ward Support Program where it renovated 24 maternal centres in six beneficiary states to complement the national objective of reducing maternal and infant mortality in Nigeria,” said Nigeria Health Watch.
In the area of cancer awareness and treatment, non-governmental organisations, such as Mass Medical Mission, which pioneered community-based mass cervical cancer screening campaign in Nigeria, known as the National Cervical Cancer Prevention Programme (NCCPP), which was later renamed the National Cancer Prevention Programme (NCPP) following the incorporation of screening for other cancers. Since its establishment in 2007, it is said to have directly screened and treated over 100,000 Nigerians, and through its awareness campaign has helped to protect millions of Nigerians from cancer; the Committee Encouraging Corporate Philanthropy (CECP-Nigeria), a private sector-led tripartite (private, social and public sectors) collaboration aimed at mobilising Nigerians to unite in tackling major national problems. CECP has a short-term goal to acquire and deploy 37 mobile cancer centres, one for each state and FCT Abuja, which will take cancer prevention and early treatment to the grassroots, and a longer-term goal to spearhead the establishment of one comprehensive cancer centre in each of Nigeria’s geopolitical zones.
In a recent article for Africa Renewal, Pavithra Rao reported how billionaires Bill Gates and Aliko Dangote have come together to fund health-care projects in Africa ravaged by poor health-care systems, the persistence of HIV/AIDS, malaria and tuberculosis, and the growth of lifestyle diseases such as hypertension, heart disease and diabetes.
In 2014, Dangote donated $1.2 billion to Dangote Foundation, which used the money to buy equipment to donate to hospitals in Nigeria and set up mobile clinics in Côte d’Ivoire. For its part, the Bill & Melinda Gates Foundation focuses, among other projects, on strengthening Africa’s health care resources, reports Rao.
“In 2016, the Dangote Foundation and the Gates Foundation formed a philanthropic dream team when they announced a $100 million plan to fight malnutrition in Nigeria. The new scheme will fund programmes to 2020 and beyond, using local groups in the northwest and northeast Nigeria. The northeast has for the past seven years been ravaged by the Boko Haram’s Islamic militant insurgency, affecting all health care projects in the region,” Rao said.
Experts say these interventions must continue if the country’s health sector is to be salvaged.