USE THE NHIS TO DEVELOP ACCESS OF THE PEOPLE TO ORGANISED HEALTH CARE SERVICE

By Dr Abayomi Ferreira

 In the past few days, we have witnessed a flurry of lamentations in the press and on the Internet on the sordid and killing state of the Nigerian healthcare delivery situation. The Sunday Punch of 8 March 2009 devoted four full pages of woes and disappointments and hopelessness to its readers. The Internet in the past one week is awashed with wailings particularly from the Nigerians in the Diaspora with regard to relations at home wasting away in hospitals. Indeed, WHO rating of the Nigerian healthcare services is ranked 197th out of 201 countries. Obviously, there are answers to the numerous questions in search of a functional healthcare delivery system. 

 The purpose of this short paper is to point to some little efforts that should be made to establish a service that will deliver care to Nigerians, starting with some of the facilities that are already available.

Obasanjo, as President launched the NHIS in 2005 and declared it as a part of the poverty alleviation programme of the PDP government. Before then, Abacha under the forward looking posture of his Minister of Health, Madubuike had utilised the Action Plan Committee of the National Health Conference of 1985 to repackage the healthcare delivery concept that had been incubating on the .shelves of the Nigerian government for some 23 years into a workable programme. At the time of Obasanjo’s inheritance of the Scheme, it was already backed by an Act and provided with operational directives in form of various guidelines and regulations that were carefully put together for use by all segments of operators that would be involved whether as regulators, funders, operators or beneficiaries in the event of the Scheme coming into being. It is very sad to observe that so soon after the post mature delivery of such a much needed programme and 45 years after Moses Majekodunmi as Minister of Health brought the concept into government thinking, we are yet unable to get the programme to work right. The programme today fails to thrive in that its features as reported in some details by Ben Ukwuoma on page 19 of The Guardian of Tuesday March 4, 2008 include 

• Truncated access to organised and limited healthcare services by only 1.8 million Nigerians
• Governments are still setting up committees to define standards, qualities and roles of professionals in running the scheme
• Key professional groups, in particular the doctors, pharmacists and laboratory technologists are still quarrelling over roles in the scheme and payments for services
• The Nigerian populace in the main still do not have access to organised healthcare delivery
• The scheme is merely being grafted onto the anarchy that is healthcare delivery in 2008 in Nigeria, and is still so in 2009
• The deadly Nigerian cankerworm of corruption has invaded the project so early in its life as shown by the behaviour of two out of how many Executive Secretaries of the Scheme.

In a country, where the quality of life is getting worse in the midst of rising national wealth, the national health statistics remain quite abysmal with life expectancy at birth at an all time low of 43 years. An examination of the three mortality rates shows the continuing worsening of the situation following 1985, the year of Babangida’s unsolicited adoption of the Structural Adjustment Programme: maternal mortality, infant mortality and under-five mortality rates have worsened; life expectancy at birth fell from 56 in 1980 to 46.5 in 2008. The Human Development Index rating is falling. The latest Human Development Report in 2008 placed Nigeria 158^th among 177 nations. In 2000, Nigeria was 151^st from 136^th in 1993. It is informative to digress very briefly to state that in 2003, when Nigeria rated at 158^th position, the occupied territory of Palestine, not Israel but the occupied Palestine rated at 102^nd position. Further, 33% of Nigerians, that is 46 million Nigerians have no access at all to any form of organised modern healthcare service. Of the remaining 94 million, access to healthcare services are as follows, 

• 1.8million can readily access some limited care through the NHIS
• 16,560 political office holders can access healthcare services readily in Europe, India, Dubai, Israel and North America for which the taxpayer bears the heavy estacode, professional, travel, hotel costs as well as travel, hotel and estacode costs for family members accompanying the sick
• 18 million can access some form of care such as traditional, herbal, alternative or modern care service
• The remaining 76 million are at the mercy of relations and friends who are able to pool resources when the need arise.

It is a dismal fact that the entire health care delivery system, if we are true to lexicography to call it a system is anarchical and disorganised in that the doctor, pharmacist, paraprofessional practitioners, public healthcare delivery institutions, private hospitals and clinics, pharmacies, laboratories and other paraprofessional institutions are operating with practically no peer assessment of the services being given to the sick. There are some regulatory institutions, but their effectiveness hardly goes beyond registration of professional personnel and institutions. Everyone in practice is on his own and every institution is on its own. The level of public confidence in the Nigerian healthcare delivery system ( that desired term again!) is rather harshly but truly and aptly described in The Guardian editorial of Friday March 7 2008 as, The medical issues thrown up in this saga are all too common. There have been cases of patients who were given wrong drugs or treatment. Hospitals often fail to carry out correct diagnosis of ailments, and therefore end up treating symptoms rather than causes. That quotation is an apt summary of the lamentations that we have been inundated with in the last few days in the press and on the Internet. 

Using the NHIS to develop a system of healthcare delivery

Having  described the chaotic states of access and availability of respectable health care delivery in our country in 2009, we will state very clearly that the NHIS can be a veritable field to address the issues that pervade the healthcare sector in Nigeria. I must state at this stage that there are many documents and reports on the shelves of the Ministries of Health across the country that have proposed clear approaches and solutions to addressing these issues. Several Committees either of government origin or on the initiatives of professional organisations across the entire health sector have studied and made recommendations on many aspects of health care delivery in the country. A good number of these reports were supported by foreign donors. One readily recalls the public statement of the WHO representative in Nigeria in 1987 or thereabout to the effect that all that the government of Nigeria needed to do to turn the healthcare delivery system for the better was to implement the three reports and recommendations that were the outcome of the 1985 National Health Conference. We know that there are many more reports and recommendations than those three.

The National Health Insurance Scheme has the capacity and inherent virility and vitality to address the following basic issues in the Nigerian healthcare delivery situation 

• Access by all Nigerians to modern healthcare delivery service is imperative and urgent. We are aware of the problems this policy might pose to a government that is implementing a structural reform programme at the behest of the World Bank and International Monetary Fund. It is our belief however that the government can overcome the dilemma by insisting that the NHIS is a part of the poverty alleviation programme it is pursuing. The point really is that it is unacceptable to have in these years of the 21^st century even one person who cannot access healthcare services not to mention the 122 million Nigerians that are in that deprived category

• Provision of an organised and integrated flow track from primary care level through secondary to tertiary facilities. Care delivery institutions must be appropriately designated for a level of care delivery on the bases of facilities, personnel and relevant functions. The regulators of the Scheme and the various governments will have to dismantle mixed services that are lumped in the various institutions as of now. Each institution, either publicly or privately operated will provide service and care either at primary or secondary or tertiary level. Aside from easier overall monitoring and administration of the system (yes, we do need a system), practising professionals and the institutions will focus their skills and facilities on a definable spectrum of service provision and care delivery. Peer and regulatory monitoring of service delivery whether at institutional level or at individual or group professional level will be clearer and easier thus enhancing the quality of service delivery throughout the country.

• The very unfortunate and anti-professional behaviour of practitioners in the health sector that has been upgraded to corporate levels in forms of quarrels among the professional associations of medicine, pharmacy, laboratory technology and other paraprofessional groups should not have arisen at all. There are laws in the books that very clearly define the different roles of the various professionals in the wide field of health care delivery. The relevant law that regulates each of the professions defines the roles of each profession in the wide terrain of giving care for the sick. The NHIS should be used to regularise professional service delivery in consonance with global tradition and practice through the ages and with the laws in Nigeria. That straight and simple solution to the unwarranted quarrels will willy-nilly lead to a resolution of the associated quarrels over fees.

• Certainly, we can and should utilise the NHIS to integrate service delivery to patients and training of healthcare professionals at all levels To some degree, there will be a coordinated and better integration of training facilities across the country.

• The NHIS can be oriented to serve as a spark for the development of local capabilities for healthcare technology take off, local production of equipment and instruments, local capability for the maintenance of materials. This can be done within a programme of intersectoral coordination of efforts involving the health sector, manufacturing and industries, public and private investment.

• Over time, funding of healthcare delivery services in the country will generate considerable excess pool of funds that can be utilised through well organised system of disbursements both as loans or grants to refurbish, maintain, and expand facilities at institutional levels in addition to sectoral development of facilities in the country.

Conclusion

Other countries in the developed and not so developed world have successfully utilised concepts that are similar to the NHIS to solve the individual and national burdens of health care delivery in their societies. Having gone this far in a period of 46 years of imbibing the concept by starting the scheme, we should put available intellectual, managerial and operational efforts to create a credible system of access to good healthcare services by the underprivileged millions that are victims of the present anarchy in the sector. Indeed, the 16,560 political office holders and few civil servants who access taxpayers funds that should be applied to better use for the good of all will no longer need to travel abroad to sort out their minor and other ailments. To achieve these good objectives, it is wise that for a period of some ten years at the least, membership of the Governing Board of the NHIS should be restricted to serious intentioned professional experts drawn from the health sector and other areas in management, finance, and development economics. Politicians and their cronies should for now stay off to allow a proper building of the operational infrastructures that are badly desired to lift the Nigerian healthcare delivery services to a modern age. 

Dr. Abayomi Ferreira,

Chief Consultant in Surgery,

Head, Clinical Services

Med-In Specialist Hospital, Ogudu, Lagos

abayomiferreira@yahoo.co.uk 

Robot  # 1 | 13.03.2009 07:24

...Read the full article.

Ph3y  # 2 | 11.09.2009 07:55

yep