Omoniyi Salaudeen, Olakunle Olafioye and James Ojo Adakole
The hopes of Nigerians that the 2020 budget proposal would mark the commencement of delivery of the promises made by the All Progressives Congress-led (APC) Federal Government became shaky following the presentation of the Appropriation Bill by President Muhammadu Buhari to a joint session of the National Assembly penultimate Tuesday.
In the run up to the 2015 general elections, the party anchored its campaign message on ‘Change,’ which resonated with the generality of the people. Indeed, that message contributed immensely to the party’s victory at the centre, but today the government appears to have failed to a large extent in delivering on its promises.
Again, as the country prepared for the 2019 general elections, the party vowed to take Nigerians to the ‘Next Level’ in deliverance of good governance. But, as has been the case of the first four years of APC piloting the affairs of the country, the budgetary allocations in the Health and Education sectors of the economy again got the short end of the stick, signifying that nothing had changed in the perennial marginalization of the two sectors, which are critical to the wellbeing of the majority of the populace, particularly the poor and the not-so-poor, who depend largely on the two sectors for their health and educational needs because of cost factors.
Going back in history, it would be noted that in 1983, when the military overthrew the Shehu Shagari administration, one of the reasons given by the junta then was that the country’s hospitals had become mere consulting clinics, where medications (even as basic as Paracetamol), medicaments, vital surgical supplies had become out-of-stock, creating the OS Syndrome common at the time, which prompted the irrepressible Chief Zebrudaya, Alias 4.30 (Chief Chika Okpala) of NTA’s popular Masquerade drama programme to even present a scintillating characterization of the national embarrassment which the OS Syndrome had become. That drama skit was broadcast long before the military struck.
Again, recall that the Petroleum Trust Fund (Special), PTF, was set up by the defunct General Sani Abacha regime. President Buhari headed the special agency as chairman, and it is on record that he approved funds for Nigerian pharmaceutical companies to produce drugs for public hospitals. It was during this time that Emzor Pharmaceuticals Limited introduced “Paracetamol by Emzor” which competed favourably with the popular foreign brand. When Nigerians adopted and renamed it as “Emzor Paracetamol” the foreign brand fought back with a hostile advertising campaign.
While the PTF strove to cope with the multifarious infrastructural deficiencies bedeviling the country, the problem of brain drain, which began after the then Olusegun Obasanjo military regime sacked doctors in government hospitals, increased as more Nigerian healthcare professionals relocated overseas to practice in better equipped and funded health facilities. In this special report, Sunday Sun looks at the present state of the health sector in the face of the present budgetary allocations to it in the 2020 proposal.
No respite in sight as brain drain worsens
As noted earlier, there was real hope that the coming of the APC Federal Government would usher in a better dispensation for the nation’s ailing health sector, but this appears to be difficult after the end of President Buhari’s budget speech. This is because of the N10.33 trillion proposal, N46 billion was allocated to the sector, a development experts described as a confirmation of the government’s insincerity to the touted commitment of providing adequate and quality health care services to the citizenry.
For experts, government’s failure to demonstrate its seriousness to multifaceted problems plaguing the nation’s healthcare sector has largely been identified as the major factor fueling the exodus of medical practitioners from the country.
A recent study revealed that no fewer than 5,250 Nigerian trained doctors are working in the United Kingdom, which translates that an average of 12 medical doctors may be fleeing the country on a weekly basis. Perhaps more disturbing is the claim that no fewer than 88 per cent of doctors in Nigeria are considering working abroad.
This trend, as noted by Dr Tonde Elijah Gargah, chairman, Nigerian Medical Association, Adamawa State chapter, would continue until the government is ready to show more seriousness to rescue the situation.
Speaking in an interview with Sunday Sun, Dr Gargah identified lack of employment opportunity for medical graduates and poor remuneration for those employed as some of the reasons for brain drain in the nation’s medical sector.
“The issue of brain drain is a major problem. On a daily basis a good number of doctors leave the shores of Nigeria in search of greener pastures. Quite a number of them have left the country because even after graduation it is difficult for them to get employment while the few of them who are employed are poorly remunerated. So, all these put together and the poor working conditions are pushing our young and talented doctors in search of greener pastures elsewhere,” he posited.
The exodus is believed to have further widened the doctor-patient ratio in Nigeria. Nigeria has always fallen short of the World Health Organization’s standard of one doctor to 600 patients by a wide margin. A former Health Minister, Prof Isaac Adewole had sometime last year boasted that Nigeria had a better doctor-patient ratio compared to some other African countries at 1:4,088, but medical experts are quick to point out that the deficit is much higher and could be as worse as 1:1,000.
The position of these experts is predicated on the argument that the frequent industrial actions, which healthcare practitioners embark upon to push home their demands often compound the healthcare needs of Nigerians. For instance, health workers in Abia State are currently on strike following the failure of the state government to pay their salaries in the last one year. Secretary of the state chapter of the Nigeria Medical Association, Dr Umenwa Joachim, said in a telephone interview with Sunday Sun that such disincentive was responsible for brain drain in the health sector.
“Just as we have in Abia State now, the Hospital Management Board is on strike. As I talk to you, all the general hospitals in Abia State have been closed down. The workers are being owed between 11 and 13 months. How do you expect practitioners to remain in such system and practice medicine? It is not possible; if one has any means of leaving the country, one will definitely leave,” he said.
Besides incessant strikes, skewed distribution of doctors is also identified as another reason for the wrong assumptions on doctor-patient ratio in Nigeria. While states like Lagos and Rivers could boast of having a few thousands of doctors, some states, especially in the North are said to have less than 500 medical practitioners. Adamawa State, for instance, with the total population of over three million people, Sunday Sun gathered, has less than 300 medical doctors. This makes doctor-patient ratio in Adamawa State 1:10,000.
Added to this are other myriad challenges confronting the nation. The NMA had last week raised the alarm over the incessant kidnap of its members across the country. The President of the association, Dr Adedayo Faduyile, who made this disclosure in Ondo State, said that 48 members of the body were kidnapped between 2018 and 2019. Apart from being kidnapped, he also revealed that doctors in Nigeria are also confronted with other challenges such as robbery and assault and called on the government to find lasting solutions to the problems confronting Nigerians as a whole and the medical practitioners in particular.
As a way of forestalling further drain on the deeply depleted population of the nation’s medical practitioners, Tonde called on the government to lift the embargo placed on employment in the health sector in the country.
“To reverse this ugly trend, the government, first and foremost, must lift the embargo on employment. Hospitals in the country must be allowed to employ more doctors. Secondly, doctors’ welfare must be properly taken care of: there must be proper remuneration for doctors. This is very important if you are to discourage them from seeking better pay elsewhere. Also, the government must be prepared to revamp medical facilities in the country. Once the government is able to do these, we will be able to discourage exodus of doctors from this country,” he stated.
But while Nigerians look up to the government to address the crisis in the health sector, the government declared that it lacked the resources to solely fix the problems in the sector. The Vice President, Professor Yemi Osinbajo, last week, called on Nigerians to seek alternative sources to complement government’s efforts in healthcare service delivery in the country.
Speaking through his personal physician, Dr Audiferren Nicholas, at National Health Dialogue, organised by Premium Times, an online news platform, with focus on the role of state and non-state actor in healthcare funding and support, the vice president conceded that Nigeria had poor healthcare indices, “but that could be corrected if state and non-state actors recommit to the cause of quality and affordable health care services to Nigerians, perhaps, using a changed approach.
“But there is one simple truth that we must tell ourselves. Federal and state governments cannot provide adequate and quality health care services to 200 million Nigerians. That may not be possible soon. However, we would continue to do our best to encourage private sector participation in health care delivery services to Nigerians. One per cent of consolidated revenue was allocated to funding of basic healthcare services in the 2019 budget. The effects are there, but there is more that could be done and we hope to improve on what we have,” he said.
Rising prices of drugs
Apart from the dearth of medical personnel, one other major issue of concern is the prohibitive cost of essential drugs, which now compels the less privileged in the society to seek solution in alternative herbal medicine. Those with critical conditions have to spend their fortune to access prescribed medication.
It was, indeed, lamentation galore at the Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State capital, when Sunday Sun visited on Monday to assess the situation. The Pharmacy department of the hospital was a ghost of itself, as only a few patients were seen seated in the expansive lobby trying to purchase their prescribed drugs. One of them, who wore a forlorn look in apparent disillusionment as he walked out of the pharmacy, while speaking with Sunday Sun could not hide his frustration, saying the price for anti-convulsant drugs prescribed for his son was beyond reach and even unavailable.
He lamented: “I am here for son’s routine checkup. For sometimes now, he has been on anti-convulsant drugs, and to the glory of God he has been seizure-free. But since late last year, the price has gone astronomically high that we have to pay through the nose to access the drugs. For instance, a pack of Lamotrigine (100 mg), which we used to buy for between N2.500 to N3,000 now goes for N18,000. So also Levetiracetam which used to be about N1,500 per pack now goes for N6,000. So, in a month, I spend an average of N25,000 on complete medication. Today, to my greatest shock, the hospital pharmacists told me that they had ran out of stock. My dilemma now is where to get the drugs and at what cost. Big pharmacy stores who manage to keep stock sell at prohibitive price. We had hoped that the price would come down, according to what the dealers told us, but it appears it has come to say. It’s quite saddening that an administration that promised so much could not even guarantee people’s access to basic healthcare needs.”
The situation was not different at the Lagos State University Teaching Hospital (LASUTH), where patients complained bitterly about high cost of drugs. A middle-aged woman, who identified herself as Mrs Folashade Adigun, told Sunday Sun that access to her diabetes medication had been a major challenge she has had to grapple with since the Buhari government came into power.
She said: “There is no gainsaying that this government does not have any policy direction as far as healthcare delivery is concerned. Since Muhammadu Buhari-led administration assumed office, health sector has been tottering from one crisis to another. You and I know how many times doctors have gone on strike in this country with attendant casualties at every round of strike. Even though I have had to spend a good chunk of my monthly earning to take care of my diabetic condition, I have every reason to thank God for keeping me alive till today. The sad irony is that Buhari, who spent taxpayers’ money to seek medical treatment abroad, when he had health challenge, doesn’t consider it necessary to invest in the health sector. Either by design or otherwise, all his policies are geared towards making healthcare inaccessible to the people. We can only hope that the new Minister of Health will realise that the wealth of a nation is directly related to the health of its citizens. For now, the story is not cheery at all.”
Sunday Sun went round the town to do a survey of retail prices of essential drugs. At Agege, the proprietress of a popular pharmacy around Pen Cinema blamed the high cost of drugs on the exchange rate vis-a-vis the dwindling value of the naira. “We are not the ones determining the price of these drugs. Most of these drugs are not produced here in Nigeria. And it costs several millions of naira to import them from either the UK or US. Sometimes, you even have to be very careful before you place an order, because if there is a sudden crash in price, your loss would be unimaginable. I am just being frank with you by telling you this. We are in business to make profit and nobody wants to do a business and lose money. If the naira appreciates, the price will automatically come down,” she explained.
The President, Pharmaceutical Society of Nigeria, Mazi Sam Ohuabunwa, in an interview with Sunday Sun, gave a long list of government policies that made the cost of essential drugs highly prohibitive. These included, among others, multiple taxations, inflation, unstable exchange value of the naira, NAFDAC charges, and the general hostile business environment.
His words: “The Pharmaceutical Society of Nigeria is doing its best to mull local production so that more of these drugs are produced locally. That way, it will help to reduce the price. But again, that depends on the overall cost of production in Nigeria. Nigeria is a high cost environment. You have to source for your own power, provide your water, provide your security and provide everything. There is also incidence of multiple taxations. All these put pressure on local production of medicines. Inflation is more than double digits. These are the factors that affect prices of essential drugs. And we are desirous to make sure that prices come down by promoting competition, by ensuring that many more are manufacturing. We are asking government to provide a more enabling environment by improving the ease of doing business so that cost and prices could come down. Pharmaceutical products are essential medicines. And it doesn’t make sense after spending so much money to produce them and people cannot afford them. People who made them want patients to use them.
“Pharmacists don’t on their own raise the price of drugs; it is usually based on what they buy. Every pharmacist will like to buy drugs and sell at a profit at least to recover his cost. So, they cannot deliberately increase their price except there is pressure due to other factors. It is not done arbitrarily; it is a reaction to the inflation in the economy and policies of government, which have increased the cost of doing business in the country. There is little we can do except we ask government to take away things that are leading to high cost of drugs. The moment they take away those things, then prices will come down. Secondly, they need to encourage local production. By simple law of demand, the more the products are available, the lower the price will be by the pressure of the market.
“Prices are high because tariff has been introduced; there have been custom duties and other taxes that are being put in, left, right and centre. There are taxes everywhere. NAFDAC itself has increased its cost. In fact, there is no pharmaceutical product that is priced according to its real value. If you price them according to their real value, nobody will pay. The Pharmaceutical Society of Nigeria is not happy that drugs cannot be accessed.
“But investment cost on research products is very high. It costs so much money to do research and proof that it is effective. It takes a minimum of $5 million to discover a drug from research before you then take it to a point where it can be seen to be useful. In some cases, it goes beyond one $1 billion. You must recover that money before the patent for that brand expires. For that much, you have intellectual protection for years, after which the protection of patent on it will expire and then everybody else can copy and sell it the way they sell paracetamol and multivitamins. And for every one product you bring to the market, 10 or 15 others have failed. If at the first stage, they find out that the product has a serious side effect, then all your investment is gone.
“That is why all over the world, essential drugs that come out of research development cost a lot of money. So, what governments do is to introduce what they call health insurance and other forms of aids. In America, you have all kinds of aids to bring down the cost for the patients. But in Nigeria, health insurance is not working because it is still at its infancy. So, patients have to pay from their pockets. And that is why drugs are expensive here.”
In order to ameliorate the situation, Ohuabunwa advised the Federal Government to reactive the National Health Insurance policy to enhance people’s access to costly drugs.
“We are begging government to try and put pressure on the National Health Insurance so that people can pay for drug they cannot buy from their pocket through insurance,” he said.
He further suggested giving incentive to local manufacturers to enhance local production so that drugs could be readily available for the end users.
“For those products that are not in that category (imported), one way to reduce the price is to produce them locally. In the next one week, we will have an opportunity to interface with the government in the area of accessibility to essential drugs,” he assured.
Frustration, long queues at hospitals: A reporter’s diary
A visit to public hospitals tells the story of the decay in the health system which fuel patient frustrations with the system and create long queues.
At exactly 12:45p.m, Sunday Sun correspondent walked through the main gate of the Federal Medical Centre, situated at Ebute-Metta, Lagos Mainland Local Government Area of Lagos State to ascertain the accessibility of the facility to Nigerians. The hospital premises maintained relative tranquility with people trudging along different sections. Shortly after entering the premises, the reporter feigned illness, and sought direction to the X-ray section of the hospital from one of the security officials on duty.
At the X-ray unit, he spoke briefly with a staffer, explaining the reason for his visit. He was then referred to the GOPD (general out-patient department), to see a doctor for proper consultation, and the reporter swiftly followed.
On getting to the section, the reporter met one of the officials and inquired to know how he could see a doctor. In response, the official, an average-sized, dark complexioned lady, handed over a copy of the hospital’s Patient Data Form, which the reporter filled as a first time patient and paid the N1,000 registration fee. The lady said that the information provided on the form was sensitive and would be processed on a computer.
While waiting, the reporter visited the rest room, to ascertain the state of the facility. On getting there, the reporter was asked to use the female toilet with the explanation that the male toilet was not in good shape.
“This is Nigeria my brother, enter the female toilet and use it like that,” a woman told this reporter, flashing a smile.
As you walk around, you find a crowd of people at various sections of the hospital, and this can leave one easily frustrated. Scores of patients sit around waiting to be called to see the doctors. While some were seen struggling, ostensibly due to fatigue, many others kept themselves busy with either phones or just discussed with other patients.
At the Medical Records Department of the hospital, a man looking frustrated, told Sunday Sun how long it takes for a patient to see a doctor, saying that it is determined by the number of people on the queue. “The situation today is pretty good, but it is not always like that. Sometimes, you come here and sit for hours just to see a doctor because of the crowd,” he explained.
Also speaking, Mrs Hannah (not real name) decried the low response rate of health officials to patients at the hospital. She said: “The first ugly experience I had at FMC was with a young male doctor. He had left his office and went out, probably to chat with his fellow doctors. Patients waited and waited and when he eventually came back, he showed no remorse at all for making the patients wait for so long.
“Secondly, I went to the clinic and the doctor was busy with phone calls when I got to her office. She didn’t bother to open my case file to know what was my problem. She just asked me why I came to the hospital, but I did not bother showing her the result of the tests I had been sent to do by the previous doctor who I was used to seeing. I was just pissed with her attitude. I did not have confidence in her.”
For the poor, getting access to quality healthcare has become a herculean task as it has become expensive. Some patients who spoke with Sunday Sun at FMC lamented over the costly nature of health services in public hospitals.
“We pay too much money in Nigerian hospitals to access health. Here, for instance, (referring to FMC), you need to have money before anyone attends to you. If you can’t foot the bills given to you, then you are at your own risk. It’s like that in every hospital.”
Corroborating him, Hannah also recounted her experience at a Lagos hospital. She told Sunday Sun: “At the General Hospital, Marina, Lagos, a guy who had been injured by a stray bullet was rushed to the hospital by two police officers.
“The doctor and nurses on duty insisted he should make some deposit before they could commence treatment. The guy was bleeding profusely and pleaded that they treat him, but they still refused because of the money. The policemen pleaded too. At a point they left and made calls to his relatives. The guy’s parents got to the hospital around 3:00a.m with cash, but he had already died before his family got to the hospital.”
Mrs Abigail, a mother of two, while decrying the parlous state of the Nigerian health system, told Sunday Sun: “These days, hospitals are scary because of the trauma people go through just to access health. It’s possible some who arrive at hospital by 6:00a.m could leave by 4:00p.m or 5:00p.m due to crowd of people with no sufficient doctors to attend to them. Sometimes when you enter into a doctor’s office, he or she would be so tired.”
Clearly, the country’s healthcare system is riddled with inadequacies that prevent it from meeting the health needs of Nigerians.