‘COVID-19: Our challenges treating patients’ was the headline of a news report of the Vanguard newspaper of Friday, April 10, 2020 in which health professionals across the country bemoaned their plight over shortages of personal protective equipment and supplies in hospitals. Specifically, staff of the Federal Medical Centre, Owerri, complained that ‘gloves, sanitizers, are luxuries here’.
Health workers revealed the dilemma in which they find themselves namely having to watch out for their safety while treating patients – a situation they find strenuous. This reported reality raises the issue of the poor state of our health infrastructure and the weak health system generally, which recently shocked Mr. Boss Mustapha, the Secretary to the Government of the Federation (SGF) and Chairman of the Presidential Task Force on COVID-19.
In one of its remarkable publications in 2007 titled: Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes (WHO’s Framework for Action), the World Health Organisation (WHO) aptly says that ‘a health system consists of all organisations, people and actions whose primary intent is to promote, restore or maintain health’. According to it, a health system goes beyond ‘the pyramid of publicly owned health facilities that deliver personal health services’ to include a wide range of other complementary things as ‘private providers, behaviour change programmes, vector-control campaigns, health insurance organisations, occupational health and safety regulation’, among others (Accessible via: https://www.who.int/alliance-hpsr/resources/Strengthening_complet.pdf).
Going further to operationalise this definition, WHO in this publication, presented what it calls ‘a single framework with six building blocks’ comprising (a) service delivery, (b) health workforce, (c) information, (d) medical products, vaccines and technologies, (e) financing and (f) leadership/governance.
For us in this article, this single framework is key to rebuilding or strengthening Nigeria’s weak health system. One can only talk of rebuilding or strengthening of a weak health system of a country when there is a clear understanding among all stakeholders of the various components of the health system that require remedial attention. A tripod comprising policy makers, practitioners and health system policy researchers, have to be on the same page on this common understanding. But what do we find in Nigeria?
It was actually more shocking hearing Mr. Boss Mustapha on national television (April 9, 2020) make an open confession that he never knew our healthcare infrastructure was in such bad condition until he was appointed Chairman PTF on COVID-19. According to him, ‘I can tell you for sure, I never knew that our entire healthcare infrastructure was in the state in which it is’ (see https://www.premiumtimesng.com/health/health-news/387036-i-never-knew-nigerias-healthcare-infrastructure-was-in-such-bad-state-sgf.html. Although the SGF reacted later on April 10 that he was quoted out of context, many Nigerians would not believe this revision of his earlier honest admission of inadequate knowledge of our poor health infrastructure. This attempt to revise his earlier statement was not surprising, as it is in the nature of politicians to do so.
By wearing their political garbs, politicians (even the most sincere ones) hardly see issues beyond their narrow and partisan lens. Their overriding political interest hardly allows them to see and comprehend issues and occurrences objectively. For example, the manner in which the leadership crisis in the National Health Insurance Scheme (NIHS) (which lingered on in 2018 and 2019), was eventually ‘resolved’, is a demonstrative evidence of how top policy makers mostly see things from their narrow and partisan lens. How else can one explain a situation where an executive secretary of the agency had (a) running battle with his minister (who suspended him), (b) had fierce and long running battles with labour union under his agency, (c) had problems with the Health Maintenance Organisations (HMOs), and above (d) had serious problem with his Governing Council, and yet when he was sacked, he had to go along with others (members of Governing Council and some others). This is indeed not how to enthrone a good governance culture in a public health agency thereby negating one of WHO’s six building blocks identified above. The Nigerian health system has been weaker for this type of federal government handling of certain issues in the health sector.
Only recently (in March 2020), 25 elders drawn from various tribes in Taraba State (highly multi-ethnic with about 50 tribes) sent a petition to President Muhammadu Buhari over what they observed to be a ‘consistent lopsidedness in federal appointments in the state’. This followed the appointment of a Chief Medical Director of the Federal Medical Centre, Jalingo. They complained that the leadership of that Medical Centre had come from senatorial zone and from one particular ethnic group for a long time now (see http://www.news-af.feednews.com). The point here again is about the issue of leadership, which when poorly handled impacts negatively on the other five building blocks (of a health system) with the health system generally weaker for it. The lesson here is that for the PTF on COVID-19 to achieve its strategic goal of strengthening our weak health system, it has to be holistic by adopting WHO’s single framework of six building blocks, as they are all complementary in building a strong health system.
With respect to the state of our health infrastructure, Nigerians (including the so-called illiterates) already knew long ago that their leaders are far removed from those they govern and the reality surrounding their lives. Many Nigerians knew long ago that a good number of their leaders do not go to hospitals in Nigeria when they are sick, and that many of them do not have their children in secondary and tertiary institutions in Nigeria. This is why budgetary allocations to the social sector have remained abysmally low ranging between 5% -10 leaving the country with poor human capital development. This is in spite of the fact that health professionals and professors have been at the head of the ministries of health and education. They, as individuals, could not influence in any significant manner budgetary allocation to either health or education despite their knowledge of the poor state of the sectors. This was because of the reactionary character of the ruling class that have dominated the Nigerian public governance system.
It is now very clear based on our COVID-19 experience that research is not feeding into policy and practice in Nigeria. ‘Getting research into policy and practice’ (GRIPP) was a point well made in a publication titled: Strengthening Health Systems: The Role and Promise of Policy and Systems Research under the auspices of the Alliance for Health Policy and Systems Research in collaboration with WHO in 2004. Indeed, the importance of getting the findings of health systems research into policy and practice in Nigeria is urgent now than ever before. Rebuilding our weak health system requires that the earlier identified tripod need to work more collaboratively now and in the post-COVID-19 pandemic era (God permitting our lives).
It is heart-warming to hear that the PTF on COVID–19 is adopting a strategic approach in utilising available funds towards strengthening the health infrastructure across the country. To start with, there is need for massive expansion of our health infrastructure at the tertiary level for specialist training. Presently for example, our new medical graduates find it extremely difficult to secure places to do their compulsory housemanship. This is a national embarrassment to say the least. The expansion of number of Federal Medical Centres to 22 (if I am current) across the country, is commendable but we still need to establish more in other states. There might also be need to explore partnering with tested private sector health institutions towards achieving this goal. Finally, WHO’s six building blocks should serve as strategic reference point for rebuilding our weak health system. Capacity building of the entire health workforce (in all occupational groups) should be aggressively pursued, as they perform complementary functions in strengthening the weak health system.
•Prof. Obasi, a public policy expert teaches Public Administration at the University of Abuja. Email: nnamdizik@gmail.com