Minister of Health, Prof. Isaac Folorunso Adewole, at a recent interactive session with editors in Abuja, speaks on Nigeria’s efforts towards achieving universal health coverage amidst challenges as well as the ministry’s programmes in the year ended and plans for the 2017. CHIZOBA OGBCEHE was there.
Overview of the sector
When you look at the health sector, it’s very challenging. The Health sector is like the economy and you cannot separate the health sector from the economy. In fact, many countries have recorded improvement in their economy when they experienced improvement in the health sector. Malaysia, Thailand recorded improvement in their health sector before the recorded improvement on the socio-economic platform.
National health policy
So, health is important to us. Well, the first thing we did was to do diagnostics of what is the situation. The first thing we noticed was that there was no policy. The country has had three policies, one in 1988, another in 2004 so we decided to fast track and make sure that we have a policy, the third national health policy in the history of the country.
So, we tagged it: Promoting the health of Nigerians to accelerate socio-economic development. It was approved at the National Council of Health meeting in September and the edited copy is available.
The committee that worked on it is chaired by a former Minister of Health, Prof Eyitayo Lambo. We will send it to Federal Executive Council (FEC) and once it is approved by FEC, we will have a national health policy. So, it is one of our deliverables for the year.
Universal health coverage
The policy looked at key essentials, how do we make things better? When you look at the health indicators, number of women who die, number of children who, malaria, HIV, what will baffle you is that the health care indicator of you and I is the same with that of Europe. 91 per cent of educated Nigerian women receive anti-natal care, quite close to what obtains in Europe. However, when you look at the un-educated its 20 per cent. So, the real problem in Nigeria is that of the poor, the un-educated and the rural people. And anything we must target them.
One of the things we did was to look at the manifesto of the party, when the president appointed me minster, I’m sure he would have said go and implement the health agenda. The party made promises, they said, we will offer health care within 5km radius, it will be affordable, it will be accessible and of good quality.
And to me as a technocrat, what those who wrote the manifesto wanted is universal coverage and we decided that we’ll attend universal coverage. How can we achieved universal coverage? We said, only way is by implementing a policy of revitalising Primary Health Care (PHC) because that is the base.
70 per cent of Nigerians can receive care at the PHC level, 20 per cent can go to secondary and 10 to tertiary, National Hospital, UCH, LUTH and UNTH but what we’ve been having is a situation where everybody will rush to the teaching hospitals because they have lost confidence in the PHC. This is because PHCs are no longer working.
We looked at the data, there are 30,000 PHCs in the country but only 20 per cent are working. And we said if we can make 10,000 of them work, we’re for it and that’s how we came about this concept of revitalising 10,000 of the 30,000.
We didn’t say we will build 10,000 PHCs because there after some media reported that we said that we will build 10,000 PHCs and by the third day I started receiving quotations. One even sent a bill that will cost N320m to build each PHC.
That’s not what we want for a PHC. A PHC is a small building where you can receive care, get advice, deliver, receive immunization with a small lab to treat malaria and you go home. That’s what 70 per cent of Nigerians need.
We said this is what we will do and so we developed this ambitious project of revitalising 10,000 PHCs and we know we cannot do it alone, we will work with partners, and other agencies. And the DFID which is a UK government funded agency promised to gives us 950 of the 10,000. The world Bank is working on about 1,000. In 2017 the EU will do 774 and when you add that together its almost 3,000.
Some state government have started work, I flagged off the project in Borno state three months ago, and Niger state is doing 66. And we said in spite of what happened to our budget, we’ll find money to 109, one per senatorial district. You see our budget was reduced by about 33 per cent, that is history because we don’t really want to go into it.
The executive proposed N35billion for capital but NASS in the end reduced it to N28billion for some curious reasons. Strange but it happened. We allocated money for the 109, each one will need about N5million, so we’ve earmarked N55million to renovate that and we’re doing it as pilot because we want to learn by doing so.
We’re also not keen on just renovating it so that nothing will happen there after, we want something that is sustainable. We tried to improve on the model in Ibadan, funded by a private person, a business man, Chief Kolwole Daisi. It’s in Ward 3 of Ibadan-north LGA. He donated the building as well as gave N200,000 every quarter, in five years the PHC has N21million in their account and they have registered 18,000 people.
We said, for urban centres we can replicate this and it means the facility can stand on its own. Of the 109, we chose the one in Abuja, it’s in Kichingoro, President Buhari has agreed to flag it off early next year, symbolically to encourage many states to do something different. So, the Kichingoro PHC we’ve revitalised and put it right spending about N7million, though many of the things we did there we won’t do in other places like tiles and other things.
The partnership is between General Electric GEC, that will do equipment, and many others. Sterling Bank has agreed to give N5million as seed grant, FCDA will put some shops so they can collect some rent, so that PHC will stand on its own.
Lassa fever
In addition to this, we worked on policies and while we were doing this we had Lassa Fever. Unfortunately, we were almost saying Lassa Fever was gone till we recorded one or two cases which turned out sour.
The one in Abeokuta was particularly worrisome. A nurse who spent almost two weeks in the hospital and they did not even think of it and that created a big problem because we had to monitor about 350 people who came in contact with that nurse.
They thought it was malaria and when she did not respond, they started giving her anti-biotics and IV fluid and so on then they moved to ICU. And because she was a nurse they never thought of Lassa Fever which is unfortunate.
So, we continued the sensitisation, we said even if the person is a bishop, a general, a professor it could be Lassa Fever. We said it when we launched the malaria programme, nobody should treat malaria without diagnosis. Many people once you have fever they say you have malaria. And simply you can use micro scope to diagnose malaria, there is rapid diagnosis text for malaria.
Polio
We also succeeded with polio. I said that polio did not reoccur in Nigeria, there is no resurgence of polio. What happened was that an area of Nigeria where we had no access to, thanks to the insurgents, we now discovered polio there.
The areas that had accesses to peace and good health care have not really demonstrated polio. So, it’s not that polio occurred, if polio occurred in Sokoto, Ibadan, you will say that there is resurgence. Because we have good surveillance method we picked polio there.
Rapid Result Initiative (RRI)
Much more importantly in the year, we did what we called: Save One Million Lives. We were looking at an innovative programme where we can partner with states and we gave each state $1.5million so they can do something good with their PHC look at maternal health, immunisation, family planning and so. And that if they do well we will give them more money next year.
And part of it we are using to fund the Rapid Result Initiative (RRI) which is like doing something impossible within a short time. We said within 100 days let’s do the impossible and make waves and create noise. It does not mean we will achieve it but it will set us running.
We said, in three months we will do 10,000 surgeries, free for poor Nigerians. In three months, we will revitalise 110 PHCs. In three months, we will screen 200,000 people for nutrition, 500,000 for diabetes. We will set up seven labs, all in three months. Impossible tasks but we started running. We said that we will partner with the media to promote trust in the Nigeria health system.
Medical tourism
Many people go out of the country for treatment because they don’t have trust in the health system, not because the health system is bad.
We’re noted more for strike than for good service. People will immediately move to India.
Someone tweeted last week that a child was not well treated at the National Hospital and I called the MD and he came to my office.
He said as we are talking now they are operating on the child. He said they did cystic hygroma surgery on the child and it recurred and they took the child to India, it recurred because cystic hygroma can recur.
Last week Friday, they spent eight hours operating on the child and went to see them the next day, a team of about six surgeons spent eight hours and the surgery was successful. We need to build trust.
Somebody wanted to go to India and I said no, go to UCH and it will be done and it was successful.
There are many surgeries that can be done here but we need you to help us build trust. We are not saying you should cover us when we are not doing well but please there are skills in the country and many things can be done.
We are even saying that no junior doctor should write referral out of Nigeria. It should be written by a consultant and counter signed by the head of the hospital that it cannot be done in Nigeria so that we can save money.
We know here are gains for going abroad. When a public servant goes to India, that public servant will collect surgical fee, admission fee and estacode. So, there are incentives to go out and we’ve been trying to say no.
People now realised that we are saying no, so they now go and come back and say give us reimbursement. And usually the cost is between N10 to N11million and when you put N10million in a hospital like National Hospital it will handle many cases. So, this RRI is to build trust and engender the trust in the system and let people know what can be done.
North-east medical emergency
One of the things that we are doing in January is to dispatch a team to the North-east to handle their emergencies. We’ve declared nutritional emergency there. We’re working with UNICEF, we’ve had a team there for over one month trying to manage the emergency pan for the North-east.
The money has been released to us and so we are sending the team there and we hope that first week of January we’ll be in the North-east to handle the situation in Borno and take control of the lives of our people.
Much more importantly for next year, we’ll continue with the free surgeries, revitalisation of the PHCs, we’ll then partner with the private sector. We want to upgrade many of our teaching hospitals in 2017.
Tertiary hospital upgrade
In our budget proposal, we have N11.7billion for the upgrade of the teaching hospitals. It is not enough but we will partner Nigeria Sovereign Wealth Authority to grow the money so we can do more for the teaching hospitals and there will be no excuses to go abroad.
We’ll also continue with immunisation, making sure that we eradicate polio completely, make sure that there is regular vaccination for our children, we’ll continue revitalisation of PHCs and upgrade tertiary hospitals so that Nigerians can smile, health wise.
Emergency response
The issue of trauma centre is not complicated but it is not also simple. Each of our hospital should have a trauma centre, no matter how small. As part of the evolution or what we can call an upgrade in the system, we’re now creating specialised trauma centres. It’s not peculiar to Nigeria, there one at National Hospital and Specialists Hospital Gwagwalada.
The last time I visited Maiduguri I actually invited seven Chief Medical Directors (CMDs) to my ministry and I said am looking for money to upgrade these seven, one in each goe-political zone. I picked Maiduguri in North-east, ABU in North-west, National Hospital in North-central, I picked UNTH, UBTH, Ibadan and Ilorin. I said in 2017 I will start with you and each one of you should identify two major priorities. We can’t do all.
Maiduguri said they wanted a trauma centre and I think the next one will be cancer or something. The trauma centre in Maiduguri will cause us about N2.5billion. When you add that to what we need for the cancer centre then each teaching hospital might need up to N5billion. So, if we want to do seven that’s roughly about N35billion. We have N12billion so we said let us start. Sovereign World Investment Authority will bring in private sector.
We will continue the upgrade of the trauma centre. We are working on a trauma policy. The ministry on an emergency policy, what do we do for emergencies? That will soon become a public matter but in between what have we been doing.
We had a problem in Uyo recently and what I did was to ask four teaching hospitals to set up a rapid response team, Lagos, Ibadan UNTH, Port Harcourt and Enugu. The first one that was ready was Lagos, a team of 10 flew from Lagos to Uyo and they operated for seven days, day and night. Two plastic surgeons, two neuro-surgeons, two trauma surgeon and nurses.
And I said even after this we would keep these standing teams all over to address emergency situations. This is part of what we are working on and because of the success of the team, we had to demobilise the others.
So, across the country we should have these teams, get materials ready so that when can move them quickly. We are also partnering with Federal Road Safety Corps. They have given us an inventory of all their facilities for us to adopt for emergencies and we’ll pre-position ambulances all over including trainings.
So, once we are done with this Nigerians will begin to see changes in the way we respond to emergencies. One, how do we call them? Two what do we do on the spot? And when we pick them where do we take them to?
One of the things we are telling the emergency response is don’t ask for money. None of us will travel with large sums of money, except you are a trader I can’t see you travelling with N100,000 cash. So many people will travel without money and the Health Act says you can’t as for money. When the person is stable then they can ask for money. And if they don’t have, the law doesn’t allow you to stop treatment. And all these we are educating our people.
Cancer menace
On the issue of cancer, yes there are no functional cancer machines in the country. I worked for international atomic energy so years back and concluded that for I million people we need at least one cancer machine, radio-therapy machine. There are three main ways of treating cancer, surgery, drugs or radio-therapy.
The radio-therapy is useful because a lot of our cancers are advanced. Nigerians don’t report early, 80 per cent of our cancers are advanced. You can’t treat them outside this country, they won’t touch them.
We did some work in Nigeria, Ghana and South Africa on the cancer of the cervix, the neck of the womb. We discovered that each woman would have seen three or four doctors before getting to the end point. The diagnosis is not made on time and sometimes when you tell them this is the problem they ruin away.
What is worrisome about cancer of the neck of the womb is that at the early stage, the woman bleeds after intercourse and the first they do is to say is their husband or partner has infected them and they won’t meet with him again. And when they stop meeting the bleeding will stop but the cancer will continue to grow.
Radio-therapy machine
So, for the machine we estimated that we would need 140 machines, as of today, we need close to 200 machines to treat out population but as at today we have only seven. I think five or so of the seven were installed through the virement.
We signed the virement but did not sign the maintenance agreement that would last for long. Some of them had maintenance agreement of five years and after the five years lapsed it became a major problem.
Secondly, we had a situation where our doctors treated patients free of charged. I am sorry to say that many of the leaders cannot manage the institution, we doctor are poor managers, if you come to my office and say you have headache the first thing I’ll do is to check you and write prescription. Go to a lawyer and he’ll say see me in my office.
The doctors were treating people free of charge, they said they cannot pay. When the heads of the radio-therapy machines expired, they had no money to replace them and that was part of the problem.
So, what we are doing now is that we are approaching the major manufacturers of the machines, there are two of them. One Varian medical system, an American company and the other one Elekta, which is Sweden. We are talking to them directly, we want to upgrade at least seven of the centres. If the agreement goes right, we will increase to 10. Each of the 10 will have two machines, one as a back -up.
The seven we had because they over use them they break down regularly, as of last week, only two were working. Our ambition is to have 14 machines minimum working across the country and then we will be increasing.
The sad part is that National Hospital, they had machine in the crate for three year un-installed and when I got to know I gave them a matching order that the machine must work by December 31, 2016.
They said the building to house the machine was not completed, unfortunately if we don’t get it right gain the maintenance agreement may be five years, equipment has been in crate for three so you are left with two years.
We are looking at a situation where we can ask the two companies to compete. Half to Varian, Elekta and then none of them will have less than 10-year service agreement.
Also, we’ll have stores for spare parts and train people, Elekta has South Africa as the lead agent so if the machine breaks down today they will invite somebody from South Africa who will look at the machine and then travels back to look for the spare parts. So, I said no they must train Nigerians on ground and must have a stock of spare parts. We don’t have to go anywhere to repair the machines.
These are all going to be funded as part of the upgrade though we are also talking to the private sector to help us, government can’t do it alone.
Cancer treatment
In addition to this, I’m talking to my colleagues. I had a meeting with them in Paris. I am raising a team of people who have worked with me over the years to come to Nigeria and train people to do surgery. So, that we can improve the surgical skills and the use of drugs, so that we can build a robust portfolio to manage cancers. So, by the end of 2017, I think we’ll be on ground to manage cancers. Cancer can be cured, 40 per cent of cancers can be prevented, 40 per cent can be cured of treated early, so we can handle about 80 per cent of cancers.
NHIS
The unfortunate thing about NHIS is that we have not gone far in terms of coverage and the new chief executive says we may not be covering up to the six per cent which we claim. So, we are retrieving the bill at the National Assembly, we are looking forward to a situation where it will be compulsory. For now, it is more like it is for public servants and few private sector organisations. We want it to cover the entire country and increase the scope of the coverage.
The thing is that for every insurance you limit the scope of what covers. You may say it’s just for normal delivery, it for blood pressure. Many of them don’t cover HIV, they don’t cover cancer but if it is compulsory then they’ll be more resources and we can spread it and say there is no limits. We working with respect to the coverage.
