Professional Documents
Culture Documents
Healthcare
in NIGERIA
FIXING HEALTHCARE IN NIGERIA
A guide to some of the key policy decisions that will provide better
healthcare to all Nigerians
By
INTRODUCTION 6
CHAPTER 1
What Aliko Dangote can
teach us about healthcare 7
CHAPTER 2
How to finance healthcare
in Nigeria 21
CHAPTER 3
Task Shifting 101 25
CHAPTER 4
Reinventing Primary
Care in Nigeria 28
CHAPTER 5
The child death epidemic
in Nigeria 33
CONCLUSION 39
REFERENCES 40
3
5 PILLARS OF HEALTHCARE REFORM
HEALTH
IMPROVE REDUCE
QUALITY COST
EXPAND
ACCESS
She is extremely passionate about healthcare in Africa and works with various
foundations, charities and governments to improve standards of healthcare.
Dr Ola studied medicine and surgery at the Hull York Medical School after which
she worked in Acute Medicine in the UK. She then went on to be awarded the
Japanese MEXT scholarship which allowed her to further her studies in Tokyo,
Japan. She also has a certificate in Economic policy making from IE business
school, Spain and a certificate in Accounting for decision making from the
University of Michigan in the United States.
The World Health Organization ranks Nigeria’s health system 187th out of 190 countries.
This makes the Nigerian healthcare system one of the 5 worst healthcare systems in the
entire world.
Virtually everyone I know – my family, my friends, my coworkers – have been touched by one
or more shortcomings in the Nigerian healthcare system. And I suspect the same is true for
you.
As a physician actively involved in providing critical care to those who desperately need it, I
may see the situation more closely and from a different perspective than many. However, I
think anyone – rich or poor – can relate to and understand what I have observed and the ideas
I have gathered from my years of experience and professional work.
If you look at the statistics translated into charts and graphs – and I have presented many
here – the picture they paint can be gloomy. But the positive side of that is that whenever
reform is started from a low point of development, it is easy to make the initial progress quick-
ly, and that success can serve to fuel even more improvements; success builds on success.
These are solid starting points, explained in straightforward terms and supported by data as
well as both my professional and personal knowledge and experience. I look at the challeng-
es facing the Nigerian healthcare system and the nation’s citizens from various angles:
• An organizational perspective,
• The financial challenge,
• The benefits of task shifting, and
• The re-prioritization of primary care and public health.
It’s my sincere wish that you consider the modest proposals I forward in these chapters. Per-
haps they will spur you to take a fresh look at how we manage healthcare in Nigeria and you
might refine them even more or see other steps that we should consider.
One final thought: We need to always keep in mind that although we’re often talking about
large healthcare systems and institutions, in the final analysis we are making decisions about
the wellbeing of our families and neighbors and their ability to live happy, healthy lives, contrib-
uting to the future of our country.
6
CHAPTER 1
A few years later I started my air ambulance service that transports critically
unwell patients all over the world.
7
SOME OF THE GLOBAL AND REGIONAL EVACUATION REQUEST
RECEIVED BY FLYING DOCTORS AIR AMBULANCE
GLOBAL
LONDON GERMANY
SWITZERLAND
WASHINGTON
NEW YORK
SPAIN LEBANON BEJING
ATLANTA DUBAI
EYGPT
ABU DHABI
SAUDI ARABIA
EQUATORIA GUNEA INDIA
ETHOPIA
GABON KENYA
CONGO
RIO DE JANERO
SOUTH AFRICA
REGIONAL
ALGERIA
SENEGAL MALI
SIERRIA LEONE
BENIN
LIBERIA
GHANA CAMEROON
TOGO
8
I believe we all should have big dreams we are in love with. So, over a decade
later, I still have a picture of Dangote on my bedroom wall, and I think there are
a few major lessons Dangote can teach us about healthcare in Nigeria.
To do this, we are going to take a quick look at the success of Dangote Cement
Company compared to the Chinese Cement Industry. We will look at the
changes that need to happen for Nigeria’s healthcare to move forward and
bring in examples from Costa Rica and India.
vs
9
The Chinese Cement Industry can be summed up as follows:
$
Produces a lot Some factories Tiny to
Fragmented of poor located far from non-existent
quality cement the source of profit margins
raw material
11
If you compare the Nigerian cement industry, led by Dangote Cement to the
Chinese Cement Industry, you see the success of it in the following:
Factories
Centralized Healthy
located close to
production margins
raw materials
Benefits from
Mega-factories internal & external
economies of High quality
scale
Primary care can take care of the majority of medical consultations in Nigeria.
Developing countries that have drastically improved their healthcare outcomes like
Costa Rica, have done so by focusing on primary care; the Mrs. Ganiyats on any
healthcare system. Primary care is the central nervous system of any healthcare
system. As stressed by Gonnella et al, (1977), a primary care orientation has been an
important variable in improving health status. It enables individuals to obtain
services for illnesses before they become severe.
13
LESSON 2: Innovation
Whilst building his company which controls majority of Nigeria’s cement industry
Dangote established innovation around cement quality/strength and logistics.
Germany 4.2
Argentina 3.9
China 3.6
France 3.2
UK 2.8
US 2.5
Saudi 2.5
Canada 2.5
Japan 2.3
Poland 2.2
Mexico 2.2
Brazil 1.8
India 0.75
Nigeria 0.37
14
LESSON 3:
Centralize healthcare
for serious problems
around “Obajana’s”
Obajana is like a mega-hospital and the
small distributors like Mrs. Ganiyat repre-
sent primary healthcare centres in the
different communities. The primary
healthcare centres solve the basic prob-
lems on a smaller scale while the big hos-
pitals cater to those who are really sick
and need serious intervention. Just like
only large, serious construction compa-
nies will purchase cement projects direct-
ly from Obajana and the smaller purchas-
es purchase from the smaller sellers, so
will primary healthcare centres reduce the
congestion to the big hospitals and cater
for the needs of the smaller communities.
However, this is not a call to ignore cen-
tralized hospitals. There is good evidence
that patients do better at “Obajana’s”.
a) Trauma Patients
Trauma patients are far more likely to
survive if treated at central, high volume
trauma centres, bypassing local, smaller
hospitals to the “Obajana’s” with the
correct levels of expertise.
15
EVIDENCE THAT SPECIALIST
CENTRAL TRAUMA CENTRES SAVE LIVES
‘Aggressive’ management of
Severe head injury care
Bulget et al (2002) head injury associated with
- ’aggressive’ vs
-USA decreased risk of mortality
‘nonaggressive’ centres
(hazard ratio 43%)
16
Nigeria currently has some of the highest rates of death from road traffic accidents
in the world.
30
25
20
15
10
The advantage is particu- But after a review in 2003, To gauge the impact of
larly evident for very the government in treatment volume within
premature babies born England decided to an MCN, the researchers
after less than 27 weeks reconfigure services into looked at the survival
of pregnancy, where the managed clinical and health of 20,554
figure rises to 50% networks (MCNs). premature babies admit-
ted to 165 NHS hospital
neonatal units in England
between 2009 and 2011.
For example, after hundreds of babies died in the 1980’s in the UK in Bristol
Scandal. A decision was taken to reduce the number of hospitals performing
pediatric surgeries in the UK.
20
CHAPTER 2
How to finance healthcare in Nigeria
GDP
%
An amount that could Half of Nigeria,s
pay back all of Nigeria’s GDP
external debt
There is less money available to build and run specialist hospitals in Nigeria compared
to the UK. Air ambulances allow us to do more with less budget by transporting
patients to specialist facilities which are often too far to get to by road. 18
21
By re-organizing our healthcare system, we can definitely improve healthcare, but the
issue of financing still remains. To deliver healthcare that approaches the standard
available in the developed world, African governments will not only have to find more
source of finance but also tackle the following challenges:
$ $ $ ?
Low tax Limited High levels of debt- large Tiny to
revenue base accountability proportions of the budget non-existent
and allocated to debt financing; profit margins
transparency in Nigeria nearly 70% of our
entire budget is used to
service debt.
It is like saying that Dangote owes more money than me and you. Say you owe your
best friend the sum of five hundred thousand while Dangote owes billions of dollars.
You could argue that you are better off than Dangote, as he owes billions of dollars.
Sure he does. But if you are unemployed and living with your mum with no source of
revenue; his ability to pay back is probably higher as he generates more money.
The chart below compares Nigeria to the world average as well as countries like
Japan and North America. Even though those countries have A LOT more debt than
us, they demonstrate a much higher ability to pay back that debt as they also have
higher revenues.
25
20
15
10
0
1990 2007 2009 2011 2013 2015
South Africa
UK
US
Norway
Brazil
China
Nigeria
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
However, the low level of benefit and a low share of premiums limit these schemes’
ability to extend coverage, offer financial protection, and retain members. A study by
Marketwatch in India, shows that even though hospital utilization was increased,
retaining clients on these schemes is difficult. A similar study published by the Jour-
nal of Health, Population and Nutrition shows that micro-insurance for health as
currently offered in Bangladesh, increased access to, and use of, basic health
services among excluded populations but did not reduce the likelihood that essen-
tial health-related costs would be a catastrophic expense for a marginalized house-
hold.
Donor funding can also help. But to effectively increase recurrent health expendi-
tures, donor funding must be predictable, not erratic. It must also be offered over
extended periods; like for 20–30 years in some countries. Without long-term com-
mitments from donors, many African countries will not be able to handle the recur-
rent fiscal contingencies generated by this type of funding.
We must accept that funding healthcare initiatives will always be difficult in Africa,
due to the various challenges discussed in this article. We have looked at different
potential approaches in this article, from micro-insurance to taxation to donor fund-
ing and even printing money directly from the central bank. While there is no
approach that will please everyone, what is clear is that to achieve universal health-
care for all in Africa; we will have to do more with less. This requires a unique
approach to healthcare financing combined with frugal innovation. 24
CHAPTER 3
Task Shifting 101
What is task-shifting? How does it work and why is it an essential part of
building a functional healthcare system in Nigeria?
114 Italy
113 Sweden
112 Germany
109 Spain
90 UK
88 Russia
72 Australia
65 Belgium
58 France
54 US
50 Egypt
50 Turkey
40 China
37 Japan
35 Canada
34 Brazil
10 Argentina
6 India
5 Iran
1 Nigeria
25
“Given Nigeria’s current training models and health delivery practices, it
would take that country 300 years to train the same number of doctors
per capita as it currently exists in developed countries”
-WEF
Many fear that task-shifting will reduce quality but the evidence often states
the opposite. A 2008 comprehensive study by Luis Huicho and colleagues pub-
lished in the Lancet, compared results across four countries. They found out
that health workers with a shorter duration of training performed at least as
well and sometimes substantially better than those with a longer duration of
training in assessing, classifying, and managing episodes of routine childhood
illness, and in counselling the children’s carers.
26
A new report from the U.K. think tank Reform claims that
only one of three people who visit a GP surgery are ill enough to need to
see a doctor and that the remainder could talk with a practice nurse
instead.
I must emphasize, whether or not we like it, that task shifting is going to
become an increasingly important competent of healthcare delivery in Nigeria.
We currently do not produce anywhere near the number of doctors we need to
provide adequate healthcare; particularly in primary healthcare centres and
rural areas. It is therefore imperative that we begin to think about how to
implement an effective task-shifting policy to improve the quality and
efficiency of the Nigerian healthcare system.
27
CHAPTER 4
Reinventing Primary Care in Nigeria
28
In this chapter, we will be reviewing the current
primary healthcare model in Nigeria, as well as the Why
impetus to change to address these unsettling
Mother Die
indices.
29
As a developing country, Nigeria has much untapped potential with regard to social
reforms. Comprehensive vaccination programmes, health education, institution of
basic sanitation and water-provision infrastructure are not novel ideas and have been
employed with great success in other developing countries. Our focus should be on
emerging technologies and social reforms which Nigeria can tap from even at this
stage to achieve modest morbidity and mortality rates. These include telemedicine,
remote support for paraclinical healthcare staff, institution of robust systems to
manage patient journeys, protocolization of common and easily preventable disease
management guidelines and efficient referral systems.
A preventative health system would be primary and community-care led, and hinge
on the shift in resource allocation from tertiary institutions (hospitals) to community
and primary care facilities. This philosophy has recently been re-endorsed by the
World Health Organization in 2003 by means of the Declaration of Alma-Ata, which
states categorically that all governments should formulate national policies,
strategies and plans of action to launch and sustain primary healthcare as part of a
comprehensive national health system and in coordination with other sectors. To this
end, it will be necessary to exercise political will to mobilize the country’s resources
and to use available external resources rationally.
IF EVERYONE SAW A
PRIMARY CARE PROVIDER,
THE U.S. WOULD SAVE AN
$67B
ESTIMATED EVERY
YEAR
Refocusing and developing primary care will save billions of dollars and millions of
lives.
30
A case study of Costa Rica
Costa Rica is a developing country in South America. Its citizens have access to one
of the most effective primary healthcare systems in the world. The country’s unique,
team-based model of primary care service delivery successfully combines preventive
and curative care to provide comprehensive primary healthcare to nearly all Costa
Ricans. The system produces better health outcomes while spending less than most
other countries in the world. In fact, Costa Rica has achieved the third highest life
expectancy in the Americas—behind only Canada and Bermuda, and well ahead of the
United States. Its infant mortality rate is half the average of the Latin America and the
Caribbean region.
Costa Rica has been listed by Bloomberg in its 2018 ranking, as one of
the top 25 economies with the most efficient healthcare in the world.
Health reform in Costa Rica was conducted in deliberate and targeted pursuit of the
country’s vision of achieving equal healthcare for all. Reforms were implemented in
an iterative fashion—supported by strong measurement and monitoring—which
allowed for ongoing adaptation and continuous improvement and refinement. The
result of the reforms is a robust primary healthcare system, rooted in public provision
of care, that supports comprehensive, continuous, coordinated, and equitable care for
the entire population. 31
What about hospitals? The number of
How Costa Rica hospitals in Nigeria need to reduce, not
Developed one of increase. The main expansion should be
the best primary care in primary care centers. This may seem
system in the world counter-intuitive, but allow me to explain
why.
32
CHAPTER 5
One-in-a-million sister
My younger sister died when she was 12 years old. Her
death was so shocking, so earth-shattering, that we did
not hold a burial or a memorial service. We did not speak
of it at all.
She was born in 1992. When I first laid eyes on her, I fell in
love. One of the most striking things about Busola was
her kindness. Even at a young age, she tried to make
breakfast for the entire family—an act that was both
entertaining and incredibly touching. She was always
trying to help, always serving, always thinking of others.
Even as she lay dying in the hospital bed—alone in Nigeria,
without any family around her—she made a simple
request: “Pray for the other sick children around the world.”
33
= 1000 Kindness. Empathy. Self-sacrifice.
one million Nigerian These were what the world lost when
children die each year she died. I lost my angelic baby sister.
And even though her death continues to
influence me, I know that her story is
not unique. She is, quite literally, one in
a million.
34
Why do so many children die in Nigeria?
192
161 162
95 86 96
83 84 82 82 82
73 63 62
53 52
Abia Adamawa Akwa Anambra Bauchi Bayelsa Benue Borno Cross Delta Ebonyi Ekiti Gombe Imo Jigawa Kaduna Kano
lbam River
210
149
174
135 121 119
101 105 102
75 73 80 71
66 67
50 58
45
Katsina Kebbi Kogi Kwara Lagos Nasarawa Niger Ogun Ondo Osun Oyo Plateau Rivers Sokoto Taraba Yobe Zamfara FCT-
Abuja
There are two main reasons that so many children die in Nigeria:
35
Primary care is the day-to-day healthcare given by a healthcare provider. Typical-
ly, this provider acts as the first contact and principal point of continuing care for
patients within a healthcare system. According to the American Academy of
Pediatrics, pediatric primary healthcare encompasses health supervision and
anticipatory guidance; monitoring physical and psychosocial growth and devel-
opment; age-appropriate screening; diagnosis and treatment of acute and chron-
ic disorders; management of serious and life-threatening illness and, when
appropriate, referral of more complex conditions; and provision of first contact
care as well as coordinated management of health problems requiring multiple
professional services.
The primary care doctor is the person your child should see for a routine check-
up or non-emergency medical care. If your child has a mild fever, cough, or rash,
or is short of breath or nauseated, a primary care doctor/general practitioner usu-
ally can find the cause and decide what to do about it. As generalists, they are
trained to recognize and provide initial health management. One of their most
important jobs is to help keep children from getting sick in the first place. This is
called preventive care.
30
25
20
15
10
In his paper, “Location, Location, Location,” Dr. Watson argues that centralized
pediatric services are essential for delivering the highest standards of care to
children. He found out that many hospitalized and critically ill children with
fatal outcomes in the United States were not treated in the correct, type of high
volume, central specialist hospitals.
What have these doctors, researchers, and nations discovered? One of the
single most effective steps in improving national healthcare is to provide cen-
tralized care services. Rather than relying on 50–60 poorly-funded, non-func-
tional facilities, we must dedicate our efforts to creating far fewer centralized
centres with the best, most highly-skilled physicians and specialists 37
Saving Our Children:
A priority.
I hope we can agree on some fundamentals that guide my ideas and sugges-
tions. First, we need to allocate our resources wisely. And, by that I mean they
should be invested to deliver the highest healthcare to the greatest number of
As you can see from my comments throughout this book, this dictates a reorga-
nization that emphasizes a more decentralized – but funded and supported –
primary healthcare system along with an improved public health infrastructure.
Funding is, of course, always a challenge, but what is more important than the
health of our citizens? Good health is required for success in all levels of life, and
a successful citizenry is required to move our nation forward, grow our economy,
and improve opportunities for all. These, I might add, will dramatically increase
revenues available to invest in the public good.
Further, we need to think a little “outside the box.” Hospitals, specialists, and gen-
eral practitioners are certainly integral to our healthcare system, but much of the
routine care can be done by less specialized (and less expensive) workers. In the
same way, we need to get the proper balance between primary health facilities
and large hospitals. When funds are limited, they must be strategically invested
so they do the most good for the greatest number of Nigerians.
Finally, along with innovative approaches, we need to “go back to the basics.”
Easy improvements to our public health systems – education, sanitation, water
– will pay huge dividends for our population. There is nothing new or complicated
about these improvements; we have the knowledge and workers who can imple-
ment them now.
39
References
https://medium.com/@drola/how-to-finance-healthcare-in-nigeria-58c2dacd754d
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