Ever since COVID-19 pandemic began, it has been a collective battle against a common enemy.
Over 180 countries and territories have been affected, with over 4 million confirmed cases and more than 280,000 deaths. The numbers are harrowing, and even those with strong healthcare systems have been put under a significant amount of stress.
The virus has questioned the global healthcare system's ability to tackle an emergency of this magnitude. Many had warned that we weren’t ready for such a crisis.
When the pandemic is over, you can expect to hear more conversations about the importance of building a stronger healthcare system.
Hopefully, it leads to action.
The state of Nigeria’s health system
In our case, it is no secret that Nigeria’s health sector has been neglected over the years. Health consistently struggles to receive 5% of the country’s annual budget expenditure.
So in many ways, it wasn't a surprise when Boss Mustapha, the Secretary to the Government of the Federation, commented on how bad the situation is.
“I can tell you for sure; I never knew that our entire healthcare infrastructure was in the state in which it is. Until I was appointed to do this [COVID-19] work.”
Still, it was perhaps shocking to see how the government itself was unaware of its own neglect.
We know things are bad, but how do we move forward from here? Well, the conversation should start with primary healthcare.
Primary Healthcare (PHC) is the bedrock of the Nigerian health system and the first level of contact with the population - 80% of health-related visits are for primary healthcare conditions. They also make up 86% of total healthcare centres.
There are secondary and tertiary healthcare institutions as well, who provide specialised healthcare services for specific diseases based on referrals from primary centres.
But primary facilities deal with essential activities such as promotive and preventive services like pregnancy care and sex education; as well as curative (e.g. treatments of common diseases) and rehabilitative (mainly therapeutics) needs.
Their focus is mainly to provide the basic health requirements for a socially and economically productive life.
Maternal centre reception
Source: MCSP via Flickr
Primary Healthcare Centres (PHCs) are managed by local governments, with a Medical Officer for Health (MOH) who handles the revenue, staffing and general supplies of every PHC in each ward.
They adopt a hub-and-spoke model with a flagship health centre, which runs for 24 hours and offers all the health services that could be offered by a primary healthcare facility.
Then, there are supporting health stations, called community health centres, which run for 8 hours and offer minor services but refer their patients to the flagship centres for ailments they are unable to handle.
The idea for these community health facilities is to be as close to the people as possible - another benefit of primary health care.
However, the limited capacity of the supporting health facilities stops them from providing essential services.
"In a case where the Officer in Charge (OIC) of a PHC is a nurse, this means she closes work by 4, so if patients who require more than normal preventive medication come after the OIC has left, they (PHCs) refer the person to another facility because they cannot treat the patient," explains Dr Momoh, HIV/Tuberculosis Prevention Specialist.
Dr Chidinma, who shares her experience while working in a primary health centre during her NYSC posting, said - “We didn’t have an oxygen tank.” According to her, PHCs should be equipped for first aid, which sometimes requires oxygen. “We have to increase the scope of healthcare services that the PHCs can provide because some of them are small and they don't work for 24 hours” she advised.
At the root of the ‘capacity’ problem is a lack of funding.
Primary health care is mainly funded through two major channels; government allocation and private funding.
Despite the crucial role PHCs play in ensuring a healthy population, they can’t rely on the government for their operational costs. Only 8% of their current spending comes from the Nigerian government. This is in contrast with smaller countries like Ethiopia and Ghana with government contributions at 22% and 36% respectively.
With little help from the government, PHCs augment their expenses with private funding that consists of: payouts from insurers, household out-of-pocket spending and donations from developmental organisations or NGOs.
Occasionally, PHCs have development partners supporting staff capacity building, medicines, vaccines and other projects.
For instance, UNICEF spends between $200 to $400 million annually in Nigeria through programmes focused on immunisation, feeding, sanitation, prevention and treatment of malnutrition. Between 2015 and 2019, USAID also contributed over $850 million to Nigeria for family planning, malaria prevention and treatment, HIV/AIDS control and other primary healthcare projects.
Out of pocket spending - the money PHCs generate from individuals who receive health services - accounts for the highest portion of primary health care (PHC) revenue. In 2013, it was responsible for almost 70% of total expenditure, leaving the PHCs at the mercy of individuals.
However, leaving PHCs to rely on the spending power of the community is risky.
In areas where the majority of the population are poor, the health centres are at risk of not meeting their financial obligations. We recently learnt from the National Bureau of Statistics that almost 90% of the population in three northern states live on less than ₦376 a day.
Can PHCs rely on a community with that level of income?
The result of these funding challenges is that the quality of services provided is limited.
So how can we increase the ability of primary health centres to provide adequate care?
Chinny Ogunro, CEO of WellSpring Healthcare, a large scale health management company, believes it's more of a question around the practicability of solutions.
“What is our best bet? What is the best avenue for success?” Chinny asks rhetorically.
Given the government’s historical reluctance or inability to properly fund the healthcare system, a practical solution involves teaming up with the private sector.
Cold storage for vaccines
Source: MCSP via Flickr
Bring in the private sector
Public-Private Partnerships (PPP) can take different forms.
The infrastructure model is one of such arrangements. Here, the private sector designs, finances, and constructs the health facility in line with the government’s requirements. The private firm also handles renovation and maintenance, as well as operating non-clinical services like catering, cleaning and infrastructure management.
The government pays the private company for these services over time. It is also responsible for providing the main healthcare services such as the workforce.
The UK adopted this plan under its Private Finance Initiative (PFI) and was able to quickly build 34 hospitals in six years compared to seven of the same kind of hospitals in 17 years prior to the PFI.
What this model does is that it provides enough funds for the hospital to be built on time, without the government providing all the funds.
The project has, however, received criticisms for being more expensive than if the government took up the project on its own. The contracts awarded are also prone to political influence which can disrupt the completion of the facility.
A local example of this is the Calabar Specialist 105-bed Hospital, a 10-year project (built in three years and managed for eight years) initiated in 2013.
Like many capital intensive government projects, it is yet to be completed after seven years because a new government commissioned a similar project with other private organisations.
Another option for the government is a discrete services model, where the private sector offers specific clinical services under short to medium-term contracts.
Services provided by the firm include diagnostic or laboratory services to support the already existing public health facility. An example is Romania’s Dialysis Project, where private organisations operate dialysis centres in eight hospitals to increase the public’s access to dialysis centres, while the government paid a fixed cost.
So, unlike the infrastructure model, there’s less room for delay in building the structure as a result of contracts changing hands.
There are also hybrids of these proposed models where the private sector can be as involved as required. There are options, and each government would need to decide what works best for them. In cases, the right answer could be more government involvement.
In line with using these private solutions, Lagos and Delta state governments have entered into PPP with PharmaAccess- a private foundation. The partnership is to provide funding for private organisations to revitalise existing PHCs in their communities.
In Lagos, a scheme was introduced for the revamp of 43 PHCs by private organisations which would receive loans from PharmAccess’ Medical Credit Fund (MCF), the bank of Industry (BoI) and the Lagos State Government Employment Trust Fund (LSETF).
These small steps show that some state governments are aware of their limitations and bringing in the private sector to assist.
If successful, this could be the roadmap to revitalise the health sector; what better time to implement this than now, when the health sector is under the spotlight.
Follow our financial journalist on Twitter @GbemiAlonge