…achieving a fairer and healthier Nigeria has more to do with the overall quality of leadership and governance than what happens in the hospitals, despite the huge importance of the latter. Nigeria has some of the best health policies and technical briefs but their implementation have been largely profligate and disheartening.

Today, April 7, is World Health Day. The global theme announced by the World Health Organisation (WHO) is “Building a Fairer and Healthier World”, which is very apt at this time given the huge negative impact of the COVID-19 pandemic on the health of the people and the global health system. The pandemic has widened the inequality and inequity in accessing health care and medical commodities in different parts of the world. The push for equitable access to COVID-19 vaccines has become intense in recent times, given that over 70 per cent of persons who have been vaccinated are residents in 10 countries.

It is imperative for me to explain the key words in this article. “Fair” simply means treating people equally and without favouritism or discrimination. Its synonyms include words like ‘just’, ‘reasonable’, ‘equitable’, ‘objective’, ‘dispassionate’, ‘impartial’, ‘rational’ and ‘unbiased’. In my (Igbo) language, it is simply explained by the concept of “egbe bere, ugo bere” (let the hawk perch, and let the eagle perch too). The English man would say that what is good for the goose is also good for the gander.

According to the WHO, health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity. Some fundamental principles which form the preamble to the WHO constitution are very critical. Let me highlight five of them: One – the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without regards to race, religion, political belief, economic or social condition; two – the health of all peoples is fundamental to the attainment of peace and security, and it is dependent on the fullest co-operation of individuals and States; three – the achievement of any State in the promotion and protection of health is of value to all; four – unequal development in different countries in the promotion of health and control of diseases, especially communicable diseases, is a common danger; five – the healthy development of the child is of basic importance; six – governments have a responsibility for the health of their peoples, which can be fulfilled only by the provision of adequate health and social measures. We should note that the fourth principle emphasises the importance of fairness, equity and non-discrimination in the promotion of the health of a people.

What is the situation of health in Nigeria? Today is the seventh day that the resident doctors in Nigeria embarked on a total and indefinite nationwide strike action. This is about the third time within the past one year, and the reasons for the strike are essentially similar. In this situation, the only people who can afford quality health care are the rich or insured people, who can afford the cost of care in private health facilities. The majority of Nigerians are living in extreme poverty, 33 per cent are unemployed, and as such quality health care has become a luxury for them. They have been left behind, and this is not fairness.

More so, the United Nations Children’s Fund (UNICEF)’s recent data shows that an estimated two million Nigerian children suffer from severe acute malnutrition, the highest in any country of the world, while six million (37 per cent) are stunted (too short for age) – a sign of chronic malnutrition. According to the National Demographic and Health Survey (NDHS 2018), 132 children per 1000 live births die before they reach the age of five years from highly preventable and treatable health conditions like malaria, malnutrition, diarrhea, and measles. With 512 out of 100,000 women dying from child birth or pregnancy-related events (NDHS 2018), Nigeria is in the list of five countries with the highest maternal deaths in the world. The other four are India, Democratic Republic of Congo, Ethiopia, and Pakistan.

Specifically, let the government of Nigeria at every level ensure that 15 per cent or more of their annual budget is dedicated to programmes and research aimed at making preventive, curative and palliative health care available and accessible to all. Health budget funds should be released and cash-backed in a timely manner, and utilised efficiently.

As a matter of fact, Nigeria is about 2 per cent of the global population but has a disproportionate share of the global burden of disease. Nigeria accounts for 25 per cent of the malaria burden worldwide, and among the 30 high TB burden countries and high multidrug-resistant TB (MDR-TB) burden countries, Nigeria is ranked sixth (World Health Organisation, Global Tuberculosis Report, 2020). Despite the progress made in the past two decades in HIV control, the national HIV prevalence is 1.4 per cent, twice the global average of 0.7 per cent. The birth rate remains high, while only 17 out of every 100 women of child bearing age use any form of modern contraceptive. Nigeria’s health budget is about 5 per cent of the total national budget, and this is far below the 15 per cent minimum agreed by the African heads of government in 2001, known as the Abuja Declaration. To make matters worse, there is a mass emigration of skilled health care workers out of Nigeria due to poor working conditions. The country continues ailing, even as over 70 per cent of drugs consumed are imported, thereby putting the country at a high risk of medical insecurity. I can go on and on.

These data reminds of my experience in Denmark in 2017, where I was one of the 1,000 young people from 129 countries of the world, who met to develop innovative solutions towards the achievement of the Sustainable Development Goals. It was the maiden UNLEASH SDG Innovation Lab. Among the solutions developed by the groups in the health sector, more than a half focused on Nigeria’s health problems. I didn’t know whether to be happy or sad about this. It looked like Nigeria was responsible for the unhealthy world we live in. Among the top three winning solutions, two were also focused on Nigeria. This explains the relevance of Nigeria in the global health space. It will not be inappropriate to describe Nigeria as a severely and chronically unhealthy country.

How then can we build a fairer and healthier Nigeria? Most of the solutions are actually outside the health sector. This leads me to what we call the Social Determinants of Health (SDH) in public health. WHO describes these as the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These social forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems. Some examples, as listed by WHO, are income and social protection, education, unemployment and job insecurity, food security, working life conditions, early childhood development, access to affordable health services of decent quality, social inclusion and non-discrimination, as well as housing, basic amenities and the environment. This list is not exhaustive. Numerous studies suggest that SDH accounts for between 30-55 per cent of health outcomes.

My prescriptions for a fairer and healthier Nigeria are simple but can only be implemented by a government with a strong political will for leaving a lasting legacy. The governments at the federal, state and local levels must be deliberate and sincere in their approaches. I will recommend the ‘One Health Approach’ to designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes. Man and animals interact closely in the same environment and this interaction is responsible for the aetiology of many ill-health conditions. Environmental health and animal health must be guaranteed, even as the social determinants of human health are optimised in a fair and just manner.

I look forward to a time when public health issues would be on the front burner during political campaigns and have a significant influence on the choices of the electorates. To achieve a fair and healthy nation, Nigeria must fix its politics and governance system and ensure that no one is left behind. Every effort counts. All hands must be on deck!

Specifically, let the government of Nigeria at every level ensure that 15 per cent or more of their annual budget is dedicated to programmes and research aimed at making preventive, curative and palliative health care available and accessible to all. Health budget funds should be released and cash-backed in a timely manner, and utilised efficiently. Leveraging on the Basic Health Care Provision Funds, governors should ensure that one or more primary health care facilities in every ward across Nigeria are made fully functional in accordance with the requirements of the National Primary Health Care Development Agency (NPHCDA)’s Ward Health Systems (2018 Review). The president should give assent to the National Health Insurance Commission Bill when it is finally passed by the National Assembly as it provides for a mandatory health insurance coverage for every resident of Nigeria. The National Health Insurance Scheme (NHIS) and the State Health Insurance Agencies should work towards achieving health insurance cover for every Nigerian by 2025.

In continuation of my health-sector specific prescriptions, I want to recommend the strengthening of the six building blocks of the health system. The ongoing response to the COVID-19 pandemic can be leveraged upon for the strengthening of health systems. The health workforce should be adequate in number, well trained and well-motivated to work in a conducive environment. The local production of vaccines, drugs and health commodities should be increased to meet at least 80 per cent of the national needs by 2030. The health management information system should be strengthened, using technology to improve the quality of health data. The leadership and governance structures should be strengthened, especially at the community level; and policy decisions should be evidence-based. An enabling environment should be provided to encourage more private sector participation in health care delivery at all levels, while relevant government agencies should monitor health service providers effectively to ensure the delivery of the highest possible quality of care.

In the other sectors, the security of lives and property is the primary essence of government and must be guaranteed for all citizens. Basic education should be of the 21st century standard and accessible to all children, especially the girl child. The government should invest in the youths to harness the demographic dividends. The unemployment rate should be reduced to less than 10 per cent by 2023, while information and communications technology is a low hanging fruit that government needs to make widely accessible. Safe drinking water should be made available to all and an end to open defecation should be achieved. Waste must be properly managed and the environment protected sustainably. The government should continue to support subsistence and commercial farmers to enable the country achieve food security. Very importantly, stability in political governance should be ensured through good governance and participatory democracy.

In conclusion, achieving a fairer and healthier Nigeria has more to do with the overall quality of leadership and governance than what happens in the hospitals, despite the huge importance of the latter. Nigeria has some of the best health policies and technical briefs but their implementation have been largely profligate and disheartening. The poor outcomes were caused majorly by poor political decisions, corruption and incompetence, especially at the sub-national levels. I look forward to a time when public health issues would be on the front burner during political campaigns and have a significant influence on the choices of the electorates. To achieve a fair and healthy nation, Nigeria must fix its politics and governance system and ensure that no one is left behind. Every effort counts. All hands must be on deck!

Laz Eze, a public health physician and sustainable development consultant, is the Founder of TalkHealth9ja and Convener of the Make Our Hospital Work Campaign. He tweets @donlaz4u. E-mail via drlaz@talkhealth9ja.com

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