Last year, I paid close attention to the way the four leading presidential candidates addressed issues affecting health. It was quite clear that no one had a reasonable understanding of the problems in the health sector. We are ranked 203rd of 204 for life expectancy, 198th of 200 for maternal mortality, and 192nd of 193 for under-5 mortality, yet they all echoed the recurring theme that people think pouring more money into a poorly structured system will solve the problem.
My hope was that even though our candidates did not know what to do with health, they would at least be able to appoint someone with a good understanding of the sector. Thus, it was pleasant to see Dr. Muhammad Ali Pate appointed as the Coordinating Minister of Health and Social Welfare.
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In November, he unrolled his health sector renewal plan, termed “business unusual.” It is on account of this document, alongside other public interactions, that I decided to write this article.
Overall, I would say the renewal plan did not meet my expectations. I believe he has the intention to work and drive change based on his experience and his understanding of the situation. The problem a lot of people who want to change these systems have is thinking that they can improve efficiency by merely being there.
The renewal plan was mostly a disease-oriented approach. It looked very nice with ambitious targets, but the strategies to achieve those targets did not pass the scrutiny test. The approach targeting disease is one that assesses specific concerns and then designs a system aimed at eradicating that problem. The paradoxical effect of such disease-oriented approaches is that they tend to weaken the health systems as the resources are pumped into that targeted disease, with human and physical resources focused on only a few things.
Health financing
The renewal plan spoke about universal primary healthcare coverage through equity-driven decentralised facility financing. The aim of this is to reduce administrative costs by directly funding the facility and allowing them to utilise the funds under supervision. I do not see sustainability in this approach, as there is no specific programme to be implemented; rather, we should be looking at how to ensure the sustainability of PHC.
Past ministers have spoken about and allocated resources for building PHCs or buying more equipment to enhance service readiness. This has repeatedly failed because no one thinks about the sustainability of the projects. In some states, there are PHCs in close proximity to each other: the older one is dilapidated and dysfunctional, and the newer one is semi-functional. This is because primary health care is not about buildings or equipment. It is about the availability of essential drugs and skilled personnel as well.
The focus, therefore, should be on understanding why the previously functional PHCs failed and finding ways to fix those problems. If I aim to eradicate polio, I can do a short-term programme, but if I want to improve health care in a community, it needs to be a ng-term, sustainable plan.
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Health insurance coverage
The renewal plan mentioned briefly about improving health insurance coverage but did not highlight the way this insurance coverage will be expanded. This, I believe should have been on the front-burner as it is key to improving health coverage. If health financing is to be decentralised, health insurance is the only way for it to be sustainable.
Currently health insurance covers mostly the formal sector and leaves out the informal sector which has the most vulnerable groups.
There are two key aspects here: how to get people into an insurance scheme and how to ensure accountability at the PHC level. For the first time, there have been numerous ideas on community health insurance systems, but the most beautiful I have heard was about harnessing technology. A proposed system looked at signing up voluntarily to a health insurance scheme using mobile phones or airtime. Discussions are being had on leveraging existing telecommunication and finance sector partnerships to improve health insurance coverage. With this same technology, harnessing cashless transactions with little to no access to cash can improve accountability. Thus, more people can get enrolled, and less money can be misappropriated.
Health workforce/human resource for health
The reasons behind brain drain and ways to reverse it weren’t emphasised. Rather, there was a lot of emphasis on training and retraining community health extension workers (CHEWS) and CHIPs. This, I believe, is due to the disease-oriented approach to the entire plan. If I want to reduce the burden of TB, I can train community members on how to fill out a checklist to identify at-risk people and how to treat them. However, this does not solve the problem of community members having a urinary tract infection.
Medical training is long, tedious and expensive and task shifting can only go so far.
A close look at the reasons behind this exodus and efforts to mitigate it should be an important aspect of salvaging this sector. I have written previously about public-private partnerships, which can create more opportunities with competitive wages. This can also lead to significant revenue generation for the country.
Another thing I found surprising was conditional cash transfers, which have in the past simply been ways and means by which people looted resources. Accountability tends to be poor, and the N5000 stated hardly seemed impactful.
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A final note
I believe the current minister of health has good intentions, but it is impossible to keep doing the same thing and expecting different results. The health sector in the country is evidently one of the worst in the world. This is despite a large, trained workforce, a good knowledge base, and significant resource allocation. All stakeholders need to come together and brainstorm on ways for a radical shift and possibly a complete reorientation of our health sector.
The aim is not to merely criticise but to spur more conversation and inspire people to pay more attention to this key sector.
Obikili Chinedu George; Consultant Obstetrician and Gynaecologist, Abuja, FCT.
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