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Fixing

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

Dr. Ola Brown

Copyright © 2018 by Dr. Ola Brown. All rights reserved.

No part of this publication or the information in it may be quoted from or


reproduced in any form by means such as printing, scanning, photocopying or
otherwise without prior written permission of the copyright holder.
CONTENTS

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

Chapter 4 Chapter 1 Chapter 5 Chapter 3 Chapter 2

PRIMARY TERTIARY FOCUS ON TASK SUSTAINABLE

HAELTHCARE HEALTHCARE MATERNAL SHIFTING HEALTHCARE

EXPANSION CENTRALISATION AND CHILD FINANCING

HEALTH

IMPROVE REDUCE
QUALITY COST

EXPAND
ACCESS

According to the Journal of the American Medical Association,


any healthcare policy should focus on these three goals. 4
Dr Ola Brown (Orekunrin)
Dr Ola Brown is a medical doctor, a trainee
helicopter pilot and an entrepreneur who
founded West Africa’s first indigenous air
ambulance service, the Flying Doctors
Nigeria which saves hundreds of lives
across the region every year especially in
the oil and gas industry, rendering medical
evacuation services.

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.

She has published two medical textbooks ‘EMQ’s in Paediatrics’ and


‘Pre-Hospital Care for Africa as well as articles in the British Medical Journal, New
York Times and the Huffington Post.

She is an international speaker who has received multiple awards and


nominations. These include the Mouldbreaker’s Award, the THIS Day Award, The
Future Award as entrepreneur of the year, New Generation Leader for Africa,
Ladybrille Personality of the month, Silverbird entrepreneurship award, Nigerian
Aviation personality of the year award and Vanguard WOW Awards. She is also a
TED fellow, an Aspen Fellow and has been honoured by the world economic
forum as a Young Global Leader.

She is a member of the American College of Emergency Physicians, international


editor of the Journal of Emergency Services and a LinkedIn top ten global
Healthcare Writer.

management@flyingdoctorsnigeria.com @naijaflyingdr Dr Ola Brown #fixnigerianhealthcare


5
INTRODUCTION

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.

Yet, with a subject as complicated and technically sophisticated as a healthcare system,


sometimes the most difficult steps are the first few. That is why I have gathered my ideas and
set them down in this book.

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

What Aliko Dangote can teach us about healthcare

Back in University, my youth pastor discovered I had a picture of Aliko Dangote


on my bedroom wall. It caused quite a bit of discomfort as the house
fellowship was held in my room. My youth pastor accused me of idolatry and
demanded to know why it wasn’t a picture of Jesus on my wall. The reality was,
I grew up in a mostly white town and discovering a black, impactful business
mogul like Dangote was a tremendous inspiration. I refused to take the picture
down, because even though I was secretly in love with my youth pastor, I was
more in love with my dream of perhaps making that kind of impact one day.

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

CAPE VERDE BURKINA FASO

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

Chinese Cement Industry Dangote Cement

The Chinese Cement Industry compared to the success of Dangote Cement.

9
The Chinese Cement Industry can be summed up as follows:

Chinese Cement Industry

$
Produces a lot Some factories Tiny to
Fragmented of poor located far from non-existent
quality cement the source of profit margins
raw material

The estimated number of Chinese cement


plants ranges from 8,000 to 9,300. About
50% of these factories are rural township
enterprises with an average annual output of
fewer than 30,000 tons. This makes produc-
tion very fragmented. In 2000, #325 and low-
er-grade cements accounted for about 30%
of Chinese production; #425 cements made
up a little over 60%; and about 10% represent-
30% ed high-grade #525 cement. This highlights
issues with quality also. On the other hand, in
#325
10% Nigeria we have mega-factories like Dan-
gote’s Obajana factory. This factory is one of
#525
the most advanced and largest cement facto-
ries in Africa and benefits from enormous
economies of scale. According to The Econo-
#425
mist (2008), economies of scale are factors
60% that cause the average cost of producing
something to fall as the volume of its output
Chinese Cement increase.
10
production in 2000
However, the most important part of
the Dangote model, is his massive
network of small distributors in the
various communities. One of such
distributors is Mrs. Ganiyat. Distribu-
tors like Mrs. Ganiyat sell small
amounts of cement to their communi-
ty. These small distributors are the
lifeblood of Dangote’s business. Due
to these small sellers being available
in the community, not every customer
has to go to Obajana to buy cement.
Only large orders from corporates go
directly to the mega-factories. Imag-
ine how congested and inefficient it
Dangote Cement
would be if everyone had to go to Oba-
jana.

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

Three lessons that the healthcare industry in Nigeria


can learn from Dangote

In many ways, we can see how the Chinese Cement Industry


represents how Nigerian healthcare is structured. It is frag-
mented, has quality challenges with hospitals frequently situ-
ated far away from the urban centres where the ‘raw materi-
als’ for acute care such as doctors, constant electricity, good
internet and advanced equipment can be situated. It is also
focused on hospitals as opposed to primary care. The World
Health Report (2008) is not wrong for its revelation that, “the
experience of industrialized countries has shown that a
disproportionate focus on specialist, tertiary care provides
poor value for money”.
12
LESSON 1: Focus on the Mrs. Ganiyats’

Dangote has built his business model primarily


around smaller retailers that can sell cement in
small quantities in their communities. The
majority of the cement that they sell is used to
build small bungalows and community projects
which occur commonly. In the same vein, primary
care is provided in the community and is suitable
for managing the ailments that occur commonly
such as throat infections, uncomplicated malaria
and constipation.
Primary care is the initial point of contact
between a patient and the healthcare system
that provides individuals with access to the
information and resources they need for opti-
mal health outcomes. It is the provision of inte-
grated, accessible healthcare services by clini-
cians who are accountable for addressing a
large majority of personal healthcare needs,
practicing in the context of family and communi-
ty. The current healthcare system is hospi-
tal-centric with an overemphasis on expensive
hospital-based medical interventions that
improve life for a very small number of people,
at the expense of public health and primary

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.

MEDICAL DOCTORS PER 1000 PEOPLE

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

South Africa 0.81

India 0.75

Nigeria 0.37

An innovative approach to healthcare in Nigeria, using telemedicine, remote support


for paraclinical healthcare staff and institution of robust systems to manage patient
journeys is also what we need. In addition to this, embarking on protocolization of
common and easily preventable disease management guidelines, task shifting and
efficient referral systems will transform healthcare in Nigeria by improving accessi-
bility and reducing cost.

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

SOURCE DESCRIPTION FINDINGS

‘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%)

Modelled the theoretical


proportion of patients with
intracranial haematoma who
Modelling development
Coats et al (2000) would have reached specialist
of trauma system in
-UK trauma surgeon within 4 hours=
London
20% if taken to local hospital, vs
90% if taken direct to specialist
centre.

Preventable deaths less

Comparison of frequent in trauma centre

management of road (20%) vs other hospital groups


Cooper et al (1998) traffic fatalities at trauma (40%-62%); similar trends for
-Australia centres vs non-trauma high severity injuries.

hospital in Victoria Recommends trauma system


with bypassing arrangements.

16
Nigeria currently has some of the highest rates of death from road traffic accidents
in the world.

30

25

20

15

10

NIGERIA UK TURKEY MEXICO PAKISTAN EGYPT


Mortality caused by road traffic injury (per 100,000 people)

b) Premature infants are up to 50% more likely to survive in high volume,


centralized hospitals.

PREMATURE NEWBORN SURVIVAL 50%


HIGHER IN HIGH VOLUME NEONATAL CENTRES

And 50% higher for very The survival of premature newborns in


premature babies born England is 30% higher in
after less than 27 weeks specialist units treating large numbers
of pregnancy of neonates, reveals an analysis of
national data published in the online
journal BMJ Open
17
2009-2011

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.

A landmark inquiry into the Bristol babies’ scandal ruled that it


would be in the best interests of patients to concentrate
services in far fewer hospitals.

It means babies born with serious heart defects in some parts


of England and Wales will have to travel further for surgery than
they do currently.

“They will be treated in bigger, 24/7 centres, with specialist surgeons


performing more complex operations every year”
-The Bristol Inquiry Review

By using high volumes or by increasing volumes, we can significantly lower


healthcare costs.
18
CENTRAL, LEARN FROM
HIGH VOLUME, INDIA’S LEADING
SPECIALIST WHAT
CENTRES HOSPITALS
NIGERIA
CAN
MNCP?RGML ASR AMQRQ
India’s Narayana Hrudayalaya Hospital uses
IN BANGALORE, INDIA,
heart surgeons perform high volume to lower health-care costs.
daily state-of-the--art
heart surgery on adults
and children at an Average price changed for coronary
AVERAGE COST OF $1,800.
artery bypass graft surgery*

FOR THE RECORD, Narayana Hrudayalaya


2% OF that’s about $ 2,000
Average heart Indian private hospitals
surgery costs in
THE UNITED STATES. $ 5,000
U.S. Medicare
the $90,000 that the $ 20,000 to 42,000
And when it comes to the quality of
the heart surgery, the patient Coronary artery bypass graft
outcomes are among the best in the surgeries performed in 2008
world
Narayana Hrudayalaya
3174
SURGEONS IN THIS
Cleveland Clinic
INDIAN HOSPITAL
1367
Massachusetts General Hospital
Performed 37 Heart
Surgeries on 536
ADULTS AND CHILDREN
Pediatric cardiac surgeries
performed in 2008
Including one
HEART TRANSPLANT
in a single day. Narayana Hrudayalaya
24h
2,777
Cleveland Clinic
That translates into
about 900 procedures 1,026
a month, or about what
most U.S. university * Price for overall packages including
19
hospitals do a year. hospital stay and surgery
In order to provide complex health-
care safely, professional teams need
to see sufficient volumes of patients
with a particular condition. More lives
can be saved if advanced services
are centralized in more specialist hos-
pital.
It is high time health systems in Nige-
ria optimized resource allocation to
focus on reducing the disparity in
health-access and quality of health
within the majority, rather than extend-
ing life for the minority. When individu-
als do not have the usual source of
primary care because of geographic,
financial, or other barriers, the care
they receive through emergency
departments may be both costly and
inefficient, Shea et al, (1992) reveals.

Primary care does this, by providing


solutions to the vast majority of health-
care needs for people in their commu-
nities just the same way Dangote
empowers his network of small distrib-
utors like Mrs. Ganiyat. Dangote has
invested heavily in logistics to ensure
that the right amounts of cement get
to the right distributors in the right
timeframe. This is what the Nigerian
healthcare system should be doing. It
needs to ensure that when the few
people who need specialized, tertiary
level care have emergencies, they can
access a hospital within the neces-
sary timeframe.

20
CHAPTER 2
How to finance healthcare in Nigeria

No country has made significant progress towards universal health


coverage (UHC) without increasing the extent to which its health system
relies on public revenue sources.
-WHO

Poverty magnifies the need for healthcare whilst simultaneously decreasing


the capacity to finance it. Africa’s healthcare problems are mainly economic.
With low per capita income, limited growth prospects, poor domestic revenue
mobilization potential, shortages of health manpower/brain drain and the high-
est disease burden in the world, Africa faces extremely complex health financ-
ing decisions. The table below compares the cost of healthcare in the UK to
Nigeria’s entire GDP.

The Healthcare (NHS) budget in the UK is almost $200bn yearly

In Nigeria, $200bn is roughly equivalent to:

Nigeria’s federal health Nigeria’s entire budget for


budget for 200 years! almost 10 years

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.

Solutions: How to finance healthcare in Africa

Let us consider how to go about settling


HEALTHCARE SPENDING the case of finance. Earlier on, I said that
PER CITIZEN the major problems in healthcare are eco-
nomic, not clinical. Similarly, the solu-
tions are not economic. The World Bank
paper titled, Health Financing Revisited
suggests:
Additional revenues can be raised by
$6,177 Norway collecting new taxes or by strengthening
tax administration. Lower-priority expen-
ditures can be cut to make room for
more desirable ones. Resources can be
borrowed, from either domestic or exter-
$3,235 UK nal sources, or released through debt
relief. Governments may benefit from
the fiscal space arising from the receipt
of grants from outside sources. Finally,
governments can use their power of

$6 Nigeria seigniorage (having the central bank


print money to lend to the government).
22
This is good but I don’t agree with all of the methods suggested, especially the sug-
gestion of seigniorage; that would worsen our already damaging levels of inflation.
Also, more borrowing would not be ideal as even at current levels, our debt to reve-
nue ratio is among the highest in the world. The debt to revenue ratio describes the
percentage of a country’s income that goes toward paying debts.

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.

INTEREST PAYMENTS (% OF REVENUE)

25

20

15

10

0
1990 2007 2009 2011 2013 2015

Nigeria World Japan North America

Also, the issue of taxation is interesting. Especially in a country like


Nigeria, which remains Africa’s largest mobile market, with about
162 million subscribers. If each subscriber was subjected to a yearly 162
levy of N1000-N2000, deducted directly as they buy airtime on their million
mobile phones, we could raise an additional $1bn to fund healthcare. subscribers
There are also various other levy-driven schemes that could be imple-
mented to raise additional funds.
23
Micro-insurance companies offer community-based arrangements offering low-cost
health insurance can provide financial protection for poor households. Currently,
more Nigerian’s pay for healthcare out of pocket than many other countries.

OUT-OF-POCKET HEALTH EXPENDITURE


(% OF TOTAL EXPENDITURE ON HEALTH)

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?

According to Lancet Journal, Surgical specialists


per 100,000 people.
116 Greece

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

As defined by the WHO, task shifting is the process of


delegation whereby tasks are moved, where appropri-
ate, to less specialized health workers. By reorganizing
the workforce in this way, task shifting can make more 300
efficient use of the human resources currently available. years
Advantages of task-shifting as codified in the Alma Ata Declaration on primary
healthcare include it’s potential to address health worker shortages, reduce
costs for training and remuneration, and shift care to cadres that are more
easily retained in rural areas.

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.

Similarly, a systematic review of almost 3000 research papers, published in


the Human Resources for Health Journal, concluded that non-physician health-
care workers are able, with careful training and supervision, to deliver equal
and sometimes better results than doctors. Similarly, there is now considerable
evidence regarding the possibility of shifting tasks from professionals or
mid-level workers to lay or community health workers.

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.

However, the Task-shifting Literature suggests that delegation of tasks from


one part of a weak health system to another is no more likely to be successful
than the status quo unless more fundamental structural changes to strengthen
the health system are brought about. Therefore, in addition to task shifting
policy, fundamental changes to strengthen weak healthcare systems must be
undertaken simultaneously to increase the chances of a successful outcome.

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

With a total population of approxi-


mately 182,200,000, Nigeria has
Shared Principles some of the poorest healthcare
of Primary Care outcomes in the world. For example,
the under-five mortality rate has
been reported by the World Health
Organization at 117 per 1000 live
Person & Family births. In other words, 1 in 10 Nigeri-
Centered
an children under the age of 5 die
annually. A stratification of the
Continuous
causes of mortality amongst them
reveals some of the chief causes
which are as follows—malaria,
Comprehensive acute respiratory infections and
& Equitable
diarrhoea. These causes of mortali-
ty are worth deliberating, as they are
Team Based & preventable.
Collaborative
Child mortality is not our only prob-
Coordinated lem. From the number of people
& Integrated
who die from road traffic accidents,
to the number of mothers who die
during childbirth to malaria deaths
to malnutrition; the statistics paint
Accessible
an abysmal picture of Nigeria’s
healthcare system. As our popula-
High Value
tion continues to grow at a rate as
high as 4%, the need for healthcare
reform has never been more urgent.

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.

The ‘McKeown thesis’, was an original and inventive First Delay:


idea proposed by the eminent physician-historian
Thomas McKeown between 1950 and 1980. He pos- DELAYED DECISION
tulated that the population growth in the post-indus- TO SEEK CARE
trialization era was primarily attributable to improve-
ments in overall standards of living such as diet and
nutrition, sanitation and vaccinations rather than
life-saving advancements in medicine. McKeown’s
postulation resonates strongly with Nigeria. Only 24h
3.7% of her GDP is utilized on health expenditure. In
stark contrast, developed countries such as the USA Second Delay:
and the UK utilize 17.1% and 9.1% of their GDP on INADEQUATE
health expenditure respectively. This cost con-
TRANSPORTATION
straint imposed on the treatment of preventable
diseases can be alleviated by long-term social
improvements that focus on prevention rather than
treatment. This will not only translate to reduced
morbidity and mortality rates, but also relieve the
burden of patient load in Nigerian hospitals.

Hospitals are a big part of Nigeria’s problem. Our


politicians love to launch them, celebrate them, we Third Delay:
are sentimental about them, we constantly order SPECIALIST/
expensive equipment for them, but in the grand EMERGENCY CARE
scheme of things; they don’t really matter. Nigeria’s
hospital-dominated health system overemphasizes
medical interventions at the expense of public
health and primary care. Our Hospitals tend to
focus on the very sick, sometimes using very expen-
sive interventions to extend or improve life for a
small number of individuals. This means that their
potential to actively promote health is limited.

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.

STEP As healthcare advances, more can be

01 done to treat patients who have what


were previously disabling or life-threaten-
Healthcare ing conditions like burns, severe injuries
agencies merged
or strokes. But, in order to provide com-
under one roof
plex healthcare safely, professional
STEP teams need to see sufficient volumes of

02 patients with a particular condition. The


potential benefits from specialization
Entire are greater for some life-threatening con-
counrty 104 ditions like heart attacks and major inju-
was divided in
104 primary ries, but the safest treatments cannot be
health zones provided at small general hospitals
because there are not enough patients
STEP for teams to maintain their skills. More

03 lives can be saved if advanced services


are centralized in more specialist hospi-
Multi-
disciplinary tals.
teams assigned We can find encouraging examples
to each
community from London where stroke services
were centralized as well as the central-
STEP ization of the treatment of premature

04 babies. Premature babies are up to


50% less likely to die in high volume
Use of neonatal centres. Also, there is further
big data for
monitoring evidence that bypassing smaller hospi-
tals for more central, high volume hospi-
tals produces better outcomes for
trauma patients also.

32
CHAPTER 5

The child death epidemic in Nigeria


Earlier this year, a woman known as Kawaii Child posted
pictures of herself and her dead baby on Instagram. She
received intense online backlash; some people were
disgusted, some were outraged, and many voiced their Nigeria
displeasure on Instagram and via other platforms. What I
realized is that as a society, we are yet to reach a
consensus on the best way to confront the death of a
child. I have my own story.

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.

It has been over a decade since her death, and I want to


tell you about the person who brought so much joy into
my life. I want to tell you about the sweet little girl who so
deeply loved her family. And I want to tell you about the
way she died—and how we could have saved her.

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.

Children die every day in Nigeria. In fact,


nearly one million Nigerian children die
each year before their fifth birthday,
according to the UN. To put this into
proper perspective, imagine a Boeing
777: one plane carries approximately
350 passengers. Now, imagine a single
Boeing 777, filled with 350 children,
crashing. There would be an internation-
al outcry, a full investigation, and a vow
to make safety a national priority. To
equal our national health crisis, you
would need 3000 Boeing 777 plane
crashes—every year. 10 crashes per day.

Every year, children like my sister


continue to die—yet there is no press
coverage, no national attention, all
while our sisters, our daughters, our
brothers and sons continue to die in
record numbers.

34
Why do so many children die in Nigeria?

STATE Under Five Mortality Rate


203

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:

1. Lack of community-based 2. Lack of specialist care expertise.


primary care services.

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.

However, currently, only 20% of Nigeria’s primary health-


care facilities are functional. This means that children with
highly preventable or easily treatable illnesses lack access
to the healthcare services that they most critically need. A ONLY
common illness becomes a medical emergency because
our primary healthcare facilities are not equipped to meet
20%
their needs.

Mortality rate, neonatal (per 1,000 live births)

30

25

20

15

10

South Africa Nigeria China UK Brazil Sweden 36


When children become critically unwell, referral to specialist care is imperative.
The Dutch Pediatric Journal argues that centralization is essential in these
moments:

“Substantial evidence indicates that outcome of critically ill children,


treated in tertiary pediatric intensive care units (PICUs) is superior to
that of those treated in other settings.”
-Ned Tijdschr Geneeskd

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.

Also, Tilford and his team from


Arkansas Children’s Hospital discov-
ered that the higher the volume of
sick children a hospital sees, the
less likely the children were to die.
The French Health ministry went as
far as making sure that each tertiary
hospital performing certain types of
specialist surgery on children had to
perform a minimum number of
surgeries per year or the hospital
would not be allowed to perform
them at all.

As a result, intensive care services


for children have undergone substan-
tial centralization in the UK, as docu-
mented by the Lancet.

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.

The truth about Busola is


that she could have lived.
Had she had access to quali-
ty healthcare, had she been
taken in quickly to the right
facility, she would be with us
today. She is the reason that
I started our air ambulance
company almost a decade
ago. Her story is not unique.
One million children die
each year in Nigeria—and it
doesn’t have to be that way.
We have the ability to
dramatically and permanent-
ly improve the quality of
healthcare in Nigeria.

It is not every day that we


have the chance to save a
million children. This is the
opportunity facing us now. I
will work tirelessly to bring
about this positive change,
so that stories like my
sister’s become the excep-
tion, not the rule. Mind you,
all efforts must be from all
so that families will no
longer have to bury their chil-
dren; we need a healthcare
system that saves our chil-
dren.
38
Conclusion
Now that you have experienced my perspectives on the problems and challeng-
es in our healthcare system, do you agree with my suggestions? Disagree?

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

What Aliko Dangote can teach us about healthcare


https://medium.com/@drola/what-aliko-dangote-can-teach-us-about-healthcare-
400d2c4e37d6

How to finance healthcare in Nigeria

https://medium.com/@drola/how-to-finance-healthcare-in-nigeria-58c2dacd754d

Task shifting 101


https://medium.com/@drola/task-shifting-101-1027f79a09e

Reinventing primary care in Nigeria


https://medium.com/@drola/reinventing-primary-care-in-nigeria-be4a7d1f76c2

The child death epidemic in Nigeria


https://medium.com/@drola/my-sister-died-at-12-years-old-she-was-one-in-a-
million-aed37840a843

40