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Why President Tinubu, political office holders may still travel abroad for medical treatment

• After spending N3.66tr in six years on budget for sector, country loses more than N900b yearly to medical tourism
• Over 6,000 doctors, 400 medical consultants, 57,000 nurses left country for greener pastures in last eight years
• Only 20% of PHC centres has capacity to provide basic emergency obstetrics services after over N1.95tr investment
• Experts insist on increased funding for health to at least 15% of yearly national budget in line with Abuja Declaration 2001
• Adequate attention to financing pivotal to improved healthcare in Nigeria, says Idoko
• Strengthen PHC, ensure effective utilisation of lean resources, adopt sustainable health care financing, Adeyanju advises
• Regenerative medicine has potential to revolutionise healthcare in Nigeria, says Ikudayisi
• Six regional teaching hospitals should be supported for cutting-edge medical services to reduce medical tourism, says Salako
• Govt should set up national action committee to implement research findings, says Adegboro

More reasons have emerged showing President Bola Ahmed Tinubu and other political office holders may continue to travel abroad for medical treatment, following the footsteps of former President Muhammadu Buhari.

Analysis showed that after spending N3.66 trillion in six years on budget for the health sector, the country lost more than N900 billion yearly to medical tourism, while over 6,000 doctors, 400 medical consultants and 57,000 nurses left the country for greener pastures in last eight years.

Further breakdown showed only 20 per cent of the 10,000 Primary Health Care centres (PHCs) the Federal Government, under Buhari, promised to refurbish in 2015 has the capacity to provide basic emergency obstetrics services, after over N1.95 trillion investment.

According to the National Association of Resident Doctors (NARD), about N900 billion ($1.2 billion) is lost to medical tourism yearly in Nigeria, an amount that could have been invested in development of the country’s health care system and the country . This is about N117 billion less than the estimated N1.17 trillion allocated to the health sector in the 2023 budget.

Also, a Price Waterhouse Coopers report states that Nigerians spend $1 billion yearly on medical tourism, with 60 per cent of that on four key specialties: oncology, orthopedics, nephrology and cardiology. This is nearly 20 per cent of the total government spending on the public health sector for the year, including salaries of all public sector doctors, nurses and other healthcare workers, as well as other health programmes like malaria, tuberculosis, polio and Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) prevention.

President, Nigerian Medical Association (NMA), Dr. Uche Ojinmah, earlier in the year, said 5,600 medical doctors left Nigeria for greener pastures abroad in the last eight years. Coupled with deplorable health infrastructure, this has put the country’s health sector in the red.

The President of the National Association of Nigeria Nurses and Midwives (NANNM), Michael Nnachi, said over 57,000 nurses, out of Nigeria’s less than 150,000, have migrated from the country for greener pastures abroad within a period of five years, spanning 2017 to 2022.

The NANNM official said with a population of between 160 million and 200 million, Nigeria now has a ratio of one nurse to about 1,160 patients, instead of an average of one nurse to five patients. The Medical and Dental Consultants Association of Nigeria (MDCAN) has said more than 100 of its members left the country in the past 24 months.

Also, nearly five years after the Federal Government promised to refurbish 10,000 Primary Healthcare Centres (PHCs) across the 774 councils, a new study has indicated that about 80 per cent of the facilities are still non-functional.

The work, commissioned by Embassy of Kingdom of The Netherlands in Nigeria and put together by PharmAccess Foundation’s Nigeria Office (PAF), is titled ‘Nigeria Health Sector: Market Study Report’.

According to the study, “there are 34,076 PHCs in Nigeria, accounting for 85.3 per cent of total hospitals and clinics in the country. Of this number, it is estimated that only 20 per cent are functional. Most of them lack the capacity to provide essential healthcare services, in addition to challenges of poor staffing, inadequate equipment, poor condition of infrastructure and lack of essential drug supply.

“The World Health Organisation (WHO) reported that only a quarter of PHCs have more than 25 per cent of the minimum required equipment package. The capacity to provide basic emergency obstetrics services is limited to about 20 per cent of the facilities. Due to the foregoing, N1.95 trillion ($5.4 billion), representing 84 per cent of primary health care expenditure, was spent in non-PHC facilities (that is, secondary and tertiary care in 2017).”

It concluded: “As part of its goal to ensure access to healthcare for 100 million Nigerians, the FMoH (Federal Ministry of Health) plans to build 10,000 PHCs throughout the country, with, at least, one PHC per ward (that is, an administrative unit with 10,000 people) to facilitate healthcare access across a wide geographic area. It is understood, however, that 4,500 PHCs have been covered, so far, with support from donor partners.”

ALSO, cumulative health budget in the last five years- 2023 (N1.17trillion), 2022 (N826.9 billion), 2021 (N547 billion), 2020 (N414.46 billion, 2019 (N423.92), including 2015 (N278.31) showed Nigeria spent N3.66 trillion. For the first time in the history of health funding in Nigeria, over N1 trillion was allocated to the sector in the proposed 2023 budget.

An analysis of the 2023 budget shows that N1.17 trillion was allocated to the health sector out of a total of N20.5 trillion for the 2023 fiscal year.

The health budget significantly increased from N278.31 billion in 2015 to N1.17 trillion in the 2023 proposed budget. However, despite the increase, only 5.75 per cent of the 2023 total budget is allocated to health, sustaining the country’s refusal to meet the commitment made by African leaders under the Abuja Declaration to allocate, at least, 15 per cent of their yearly spending to the sector.

It was the reality of the deficiencies in their health systems that made African heads of states and governments under the African Union (AU) commit in April 2001 to dedicate, at least, 15 per cent of their yearly budgets to the health sector in what is now known as the ‘Abuja Declaration.’

While countries like Rwanda and South Africa have met the commitment by allocating, at least, 15 per cent of their total budgets to health, Nigeria has not found a way or the will to do so.

A review of the budgetary allocation to the health sector in the last 21 years revealed that Nigeria has never met the 15 per cent target agreed upon in the Abuja Declaration.

Little wonder, healthcare indices in Nigeria are some of the worst globally, especially in maternal and child deaths. Indeed, Nigeria is one of the countries that may not be able to achieve Universal Health Coverage (UHC) by 2030 as stipulated by the United Nations (UN) Sustainable Development Goals (SDGs), with more than 90 per cent of the population (180 million) still paying out-of-pocket for health services and without any form of health insurance.

The country also has one of the worst doctor to patient and health worker to patient ratio in the world, with more Nigerian-trained medical professionals, including doctors, nurses, pharmacists, physiotherapists migrating abroad for better remuneration and condition of service.

The World Health Organisation (WHO) recommends a doctor to not more than 600 patients, while in Nigeria, the figure, according to the Nigerian Medical Association (NMA) is a doctor to more than 6,000 patients.

Also, several reports by WHO and United Nations Children Fund (UNICEF) have shown that Nigeria is home to the least vaccinated people and non functional primary health care centres in the world.

However, to reverse the trend and set the country on the right path to better healthcare delivery, medical experts have set agenda for the incoming President, National Assembly, governors, state Houses of Assembly and other people in leadership positions.
A public health physician and former Commissioner for Health in Ondo State, Dr. Dayo Adeyanju, told The Guardian that to be able to appropriately advise the incoming government, one must look at the current situation of the health sector in Nigeria.

Adeyanju said the government must know they are inheriting a health sector with poor indices. According to Nigeria Demographic and Health Survey (NDHS) from 2008 to 2022, the country’s health indicators show alarmingly high number of women dying during or soon after giving birth. The maternal mortality (MMR) was 545/100,000 live births in 2008 rose to 576 deaths per 100,000 live births in the 2013, with slight drop in 2018 to 512/100,000 live birth. There is also slight improvement in under-five mortality and infant mortality, although 240,000 infants still die within 28 days of birth from preventable causes.

Adeyanju said while the number of deliveries by skilled attendants is increasing, there is a high percentage of delivery at home and traditional birth attendants. He said these are places where the skill of who takes the delivery cannot be ascertained. They also don’t have emergency plans in case of any eventualities and thus, make complication a death sentence.

Moving forward, Adeyanju said the incoming government needs to strengthen primary health care, which is close to the grassroots and can ensure access to health care within the shortest distance. “We can take a clue from my Ondo State experience while in the saddle as commissioner for health. We strengthened the primary health care, leading to a drastic drop in maternal mortality,” he said.

Adeyanju also recommended sustainable health care financing. He said in terms of funding for health a closer examination of Nigeria’s health budget reveals that vast proportion of the funding—86 per cent—is taken by recurrent expenditure, mostly paying the salaries of health workers. Adeyanju said the low level of capital expenditure raises questions about the feasibility of fixing Primary Health Care (PHC) and thus, there will be need to have a Public Private Partnership (PPP), where there will be adoption of some of the PHCs by corporate organisations as Corporate Social Responsibility (CSR). He said the incoming government can consider this, and health insurance also needs to be strengthened towards achieving UHC.

The former health commissioner also called for effective utilisation of lean resources. He explained: “It is obvious there is no adequate budgetary provision for Nigeria’s health system. The country’s health budget out of the total yearly budget is still less than 10 per cent. How much of what is budgeted translates to releases? Between 2013 and 2015, an average of only 41 per cent of the capital budget allocation for health was utilised. This leaves most of the spending on health to be out of pocket by individuals. Increasing funding does not always translate to improving health outcome. If the fund is not efficiently utilised, it will not give desired result. The fund must be channeled towards strengthening our primary health care, which is closer to the people and has a greater impact. Lagos State invested more fund between 2011 and 2016 than Ondo. However, in terms of health indices, Ondo performed better with reduction in infant mortality. The Ondo performance was as a result of strengthening the primary health care, with more deliveries taking place in PHCs. This resulted in a drastic reduction in maternal mortality. This has further buttressed the need to prioritise PHC by the incoming government.”

On the area of focus or priority, Adeyanju said maternal and child health need attention. “We must however not lose focus on emergency medical services for management of road traffic accident, which is also a leading cause of death. It has cut vibrant productive and promising able-bodied youth down in their prime. We have also had series of medical emergencies like Ebola, Lassa and coronavirus. We are yet to learn lessons from all these outbreaks. The country should be well prepared to save the citizens when these occur,” he said.

The public health physician said there is need to track performance and excellence. He said the major reason Nigeria’s health indices have not improved is poor performance management, adding that data from the Nigeria Bureau of Statistics should be well disseminated, and improvement on it should be celebrated and rewarded. Adeyanju said there should be a quarterly, biannual, and yearly performance review, and the best performing state should be rewarded.

Adeyanju said brain drain could be reversed to brain gain. He said human resources have constituted great challenges in view of the alarming rate at which health professionals are seeking greener pasture. “You cannot really blame these people, in view of too numerous challenges they have had to contend with: irregular salaries, insecurity, and inflation, to mention a few. To reverse these, remuneration must be attractive and regular. There is a need to improve the working environment and reward excellence,” he said.

“To reposition our health system, all the above need to be considered. The country loses a lot of funds to medical tourism and needs reversal for lives of the people to be saved,” Adeyanju added.
A United States (US) Board Certified Internist, a consultant in Geriatric Medicine, Regenerative Medicine, Cosmetic & Aesthetic Medicine and Medical Director of Glory Wellness & Regenerative Centre, Lekki Phase 1, Lagos, Dr. David Ikudayisi, told The Guardian that regenerative medicine has the potential to revolutionise healthcare in Nigeria by promoting repair, replacement, rejuvenation and regeneration of damaged or diseased tissues and organs.

Ikudayisi said to fully integrate regenerative medicine into healthcare protocols, there is a need for concerted efforts to encourage research and collaboration between practitioners and medical academy. He said encouraging conversations on achieving universal access to regenerative medicine, in addition to general medical practice, is also crucial. He said regenerative medicine procedures are offering hope to patients with Alzheimer’s and Parkinson’s disease, to mention a few of the medical conditions currently considered incurable.

Ikudayisi said one way to support the advancement of regenerative medicine in Nigeria is to set guidelines for best practices, integrate them into medical education and encourage international collaboration between local and international practitioners. He said investment in technology to make local production and processing of cell-based therapeutic agents possible, such as cell and tissue banks, is also necessary. Additionally, the physician said establishing a publicly searchable database of local regenerative medicine practitioners will improve access to the services they offer.

The medical consultant said there is a need for a meaningful referral system between practitioners of general medical practice and regenerative medical practitioners, especially where there are limitations to the benefit of traditional medical or clinical protocols. Ikudayisi said this would ensure patients receive appropriate and comprehensive medical care. Also, policies to control quackery and promote ethical practice must also be put in place to protect patients.

He said the benefits of a well-developed regenerative medicine subsector in Nigeria are enormous and savings for patients who can access regenerative medical therapy locally without the need for international migration or medical tourism is a significant advantage. Furthermore, Ikudayisi said Nigeria could become a regional hub, serving the Sub-Saharan region and potentially the entire African region, by becoming a global powerhouse in regenerative medical practice. “This will also create job opportunities and contribute to the economic development of the country,” he said.

Ikudayisi added: “The integration of regenerative medicine into healthcare protocols is crucial for improving healthcare in Nigeria. Encouraging research, collaboration, and international partnerships are necessary steps to achieve this goal. The establishment of guidelines, investment in technology, and the promotion of ethical practice will help strengthen the regenerative medicine subsector in Nigeria. The benefits to the nation are immense, including savings for patients, job creation, and contribution to economic development.”

Executive Secretary/ Chief Executive Officer (CEO) of Enugu State Agency for the Control of AIDS (ENSACA) and former Chairman, Enugu State Hospital Management Board, Dr. Chinedu Idoko, told The Guardian that adequate attention to healthcare financing is pivotal to much needed improved healthcare in Nigeria.

Idoko said it is interesting, and a welcome development that many states in Nigeria have embraced UHC; setting up agencies backed by law for health insurance. According to Idoko, it is worthy of note that most of healthcare financing in Nigeria have been out of pocket financing, and this has made healthcare access out of reach of most Nigerians as one needs to pay at point of receiving health services.

He said the incoming government needs to pay a great deal of attention to improving health care access of Nigerians. Idoko said principal focus has to be on improving healthcare financing, strengthening and collaborating with various established State Health Insurance Agencies, while exploring and expanding other options of Health financing, like Community Based Social Insurance Scheme (CBSIS). “Here, little contributions from members of a community could serve a pool for provision of health services to those that become vulnerable. This way those that ordinarily would have been denied access are able to afford care when they have need. It is really a way the incoming government should look regarding healthcare,” he said.

The public health physician said, on the other hand, there are a lot of healthcare facilities built and scattered all over the country but literally unequipped with materials and manpower. “The irony is that new governments that come in keep building new ones, most, of course, left in the same aforementioned state. It is imperative that the incoming government deviates from this trend by making available necessary human and material resources to the structures and appropriately linking them with existing strata of care,” Idoko said.
NATIONAL President, Nigerian Association of Resident Doctors (NARD), Dr. Emeka Innocent Orji, told The Guardian that as healthcare professionals, they expect better from this administration. Orji said for too long, the health sector in Nigeria, doctors particularly, have received far less than adequate attention from the government, which is mainly responsible for widespread disenchantment among healthcare professionals.

The NARD President said: “We expect increased funding to health, at least, 15 per cent, in line with the Abuja Declaration of 2001, and to be honest, that will be the first yardstick that will indicate to us whether this administration is serious with tackling the myriad of problems bedevilling the health sector. Second, we expect improved infrastructural development from all aspects, wether architectural, technological or human.

“We expect improved remuneration for health care professionals, to tackle increasing economic hardship and dwindling naira value. It is unimaginable that there are doctors being owed several months of salaries and allowances, especially In the State Tertiary Health Institutions (STHIs).”

Orji said this ugly trend must stop, and how government performs in these basic areas will show Nigerians how serious they are and the kind of health care to expect in the next four years, adding, that is when any serious discussion can start.

Orji said priority areas include: training both within and outside the country, especially areas of deficiencies; increased funding for the health sector; improved remuneration and condition of service; infrastructural development; and primary health care.

On the incoming administration solving the issue of brain drain, the NARD President said: “Well, it’s not a question of what we think but a question of whether the incoming administration is ready to be different and serious in tackling the problems of the health sector.

“We believe they are capable; we will not impugn their capacity, rather we will wait and see. But we all know that brain drain is one of the biggest challenges facing the health sector now and if nothing is done urgently, we might see a total collapse of the sector, which will take very long to revive.

“So, we want the incoming government to identify and solve the root cause of the syndrome and take deliberate measures towards reversing it for the sake of the ailing nation.”

To tackle brain drain, Orji said the following areas need urgent attention: health infrastructure due to poor funding; inadequate training especially in highly specialised areas; dwindling economy and quality of life; poor remuneration; lack of incentives and welfare packages; and unsafe work environment/insecurity.

“As an association, and the largest medical workforce in Nigeria, we are always open and ready to partner with government in resolving these challenges,” the NARD President said.

DIRECTOR General of the Nigerian Institute of Medical Research (NIMR) Yaba, Lagos, Prof. Babatunde Lawal Salako, told The Guardian: “I advise on primary care focus and adequate funding and support. Ensure effective staffing at this level using task shifting and task sharing where necessary. Six teaching hospitals, one from each zones should be supported financially and technically to deliver in specific areas of expertise to provide access to cutting-edge medical services that will reduce medical tourism.”

Salako said training of Health Care Workers (HCW) should be prioritised to ensure necessary skills at all levels, and state governments should be encouraged and supported to develop secondary level care, which has currently collapsed in many states. He said indigenous pharmaceutical companies should be supported and encouraged to manufacture drugs and vaccines locally, even if they need technology transfers that can be guaranteed by government. The NIMR DG said medical councils, should be supervised to maintain standards in all areas of medical, nursing, laboratory, physiotherapy, and pharmaceutical disciplines.

Salako added: “Of course, remuneration of HCWs should be improved and loans made available to all workers. We must attend to general indiscipline in the country, coming from incessant industrial actions in the health and education sectors. Government needs to be bold and firm to protect laid down rules for government-workers relationship. It is necessary for stability in the system.”

He said alternative medicine should be developed and brought on board at the primary care level. Majority of our people often access them first before coming to hospitals. This has been done by many countries and Nigeria should not be an exception. Salako said doing this would provide opportunities for orthodox practitioners to help them refine their processes and practice.

The NIMR DG said health research should be given priority funding like it is done in many advanced countries of the world this will generate new knowledge, treatment, drugs, vaccines, policy briefs and preventive strategies that respond to the country’s peculiar health challenges.

A consultant pharmacist and National Secretary, Pharmaceutical Society of Nigeria (PSN), Gbenga Falade, told The Guardian that the PSN, at its yearly conference, Tin City 2023 in Jos, Plateau State, endorsed a nine-point charter of demands from presidential candidates of all political parties and will present same to the President.

Some of the salient and core areas of intervention expected include: headship of the Federal Ministry of Health (FMoH) and Ministries Departments and Agencies (MDAs) in the health sector; welfare of public sector pharmacists; establishment of Bank of Health; attainment of UHC and implementation of National Health Insurance (NHIA) Act 2022; local manufacturing of drugs, excipients, packaging materials, and related matters; funding of healthcare; proper implementation of the National Health Act 2014; need for gradual importation substitution; and consideration of issues constraining natural development of pharmacy.

Falade added: “Also, I will add that it is time to repeal the Residency Programme Act, which provided for a government sponsored residency programme for medical doctors. The money should be used to provide infrastructures for the hospitals, and money realised from the residency fee to be introduced should be added to funds the operational expenses. This will help to bring our health institutions closer to the ideal that resident doctors under the aegis of National Association Resident Doctors (NARD) have quest for over the years and forever stamp out industrial actions from the tertiary health institutions.”

Professor of microbiology and immunology at the Department of Medical Microbiology and Immunology, Nile University of Nigeria, Abuja, Boaz Adegboro, told The Guardian: “We already have enough primary health centres in all local government areas of the country. Therefore emphasis should be shifted in the next five years from constructing new health centres to provision of running water; provision of toilet facilities; improving office, clinic and laboratory furniture; insuring adequate supply of clinic consumable such as gloves, aprons, needles and syringes, antiseptics, disposal bins, incinerators; ensuring adequate supply of dispensary drugs and efficient management through provision of initial seed money for drug revolving funds; regular payment of staff salaries and wages. This can only be possible if Federal Government allocates money directly to the LGAs, and puts in place a good audit system at LGA level.

“There should be improvement of training schools for community health workers (CHEWS) and midwives; adequate maintenance of facilities and the environment to provide a good working environment; operating an efficient National Immunisation Programme; continuing education programme, including training CHEWS and midwives to know when to refer patient to the next level of care; and good record keeping, with submission of monthly morbidity and mortality reports.”

Adegboro said as in the case of PHC, there is a need to shift from constructing new General Hospitals to modernising and kitting the hospitals. He said these facilities are under the State Governments and Federal Government; and they should be advised to maintain the facilities.

The immunologist said emphasis should additionally be focused on the following: operation of a good referral system fem PHC to this level of care; running a good ambulance system that could be called upon from the PHC and other areas in need of the facility; kitting the operating theatres with adequate equipment, consumables, gowns, gloves, and other materials; maintaining an immaculate environment to provide a good working environment; adequate remuneration and regular payment of salaries and wages; continuing education programme; organisation of ward rounds, seminars and workshops as part of routine procedures in the hospitals; enabling at least two hospitals in each State to be upgraded to the level of meeting the requirements for accreditation by he National Postgraduate Medical College of Nigeria to train specialists in both Clinical and laboratory medicine; encouraging the consultants at this level to apply as Visiting Lecturers to neighbouring Medical Schools, to deliver lectures one day in a week (or four consecutive days in a month if the medical school is far away).

Adegboro said this would sharpen the professionalism of the consultant, and help to keep them up to date, because as they teach students they are reminding themselves of the best professional practice.

Also, he said good National Blood Banking Policy to be well implemented; laboratories should be able to perform all that the clinicians need to make correct diagnosis and monitor the progress of their patients; good record keeping, with submission of monthly morbidity and mortality reports, with reports sent to the Federal Epidemiological Unit; and operation of hospital essential drugs to be recommended by the various departments.

For tertiary health care facilities, Adegboro said there might be a need to establish more hospitals at this level. In addition, he said, emphasis must be placed on: state-of-the art equipment for the clinical and laboratory departments to be recommended by the heads of the various department; modern operation suites; over ready consumables, reagents and drugs; all clinical and laboratory departments to be accredit-able for training by the National Postgraduate Medical College of Nigeria; weekly interdepartmental seminars; monthly morbidity and mortality rounds, with reports sent to the Federal Epidemiological Unit; research grants for Senior Registrars to conduct their Part II FMCPath and FWACP dissertations; continuous education programmes for doctors, radiologists, technologists and nurses; engagement of institutions with the National Health Research Priorities; excellent interdisciplinary referral system; involvement of experts at this level in National Research efforts, like, vaccine production for malaria, COVID-19, meningitis, measles and yellow fever. He said this should be in collaboration with other medical, pharmaceutical and Technological Research Centres.

Adegboro said government should set up an action committee comprising the Presidents of the Academies of Science, Medicine, Medicine Specialties, Director General (DG) Nigerian Institute of Medical Research (NIMR), DG, Veterinary Research Institute, DG National Agency for Food and Drug Administration and Control (NAFDAC), Nigerian Institute for Pharmaceutical Research (NIPR), and a number of other eminent health care researchers to study the research activities of resident doctors, PhD students with the aim of implementing their research findings.

The immunologist said there should be a Special Adviser to Government on Science in every State and at the Presidency. He said this office should follow up the research activities of Masters, PhD and Fellowship Students and ensure that their discoveries are pursued to production and escalation level for manufacturing and technological development. Adegboro said this office should link up (like exchange programmes) with special or gifted students with overseas Universities, Space and other technology or state-of-the art health research centres to help Nigeria’s speedy development.

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