First, there should be increased funding for universal health coverage, by expanding the federal budget for healthcare to meet the Abuja Declaration of a minimum of 15 per cent of the total budget, by tapping into the private sector to support healthcare delivery. Funding universal health coverage to address the catastrophic out-of-pocket healthcare expenditure of Nigerians would require adequately financing the newly minted National Health Insurance Authority, working in partnership with state health insurance schemes.
In the past month, presidential candidates from Nigeria’s three major political parties have emerged. Asiwaju Bola Ahmed Tinubu for the All Progressives Congress (APC), Alhaji Atiku Abubakar for the Peoples Democratic Party (PDP), and Mr Peter Obi for the Labour Party. Over the past couple of years, the most populous black nation in the world, and Africa’s largest economy, has seen an incessant spread of unbridled insecurity, breakdown of law and order, a crippled economy, and worsened health indices. The choice of whoever emerges as the country’s next president and commander-in-chief of the armed forces is therefore critical.
Nigeria currently has the highest number of cases of malaria in the world, the highest rate of deaths in children below five years in Africa, and the fourth highest maternal death rate in Africa. In addition, the country is steadily experiencing a torrential exit of qualified medical doctors, nurses, and other healthcare workers to other countries. According to the Nigerian Medical Association (NMA), between 2016 and 2018, over 9,000 medical doctors have left the country to work in the United Kingdom, Canada, and the United States of America. The Association has also reported that out of 75,000 doctors officially registered in Nigeria, more than 33,000 have left the country due to unfavourable government policies, low wages, poor economic conditions, frequent labour strikes, poor work conditions and widespread insecurity. So, where the World Health Organisation recommends a ratio of one doctor to every 1,000 patients, Nigeria is currently operating at one doctor to more than 5,000 patients.
The healthcare system operates across three-tiers, where up to 90 per cent of the population’s health issues can be addressed at the local community level in primary care centres, and more complicated health issues at the state district hospitals, followed by federal tertiary hospitals. The higher the level of healthcare, the more complex the health conditions expected to be managed there. In Nigeria, this is far from the case. For a start, less than a third of the country’s 30,000 primary healthcare centres are functional. This means that for most of Nigeria’s population, they cannot easily access health education, prevention, or care for ailments such as malaria, respiratory infections, diarrhoea, hypertension, diabetes, and malnutrition. The higher-level teaching hospitals are constantly besieged with patients seeking medical treatment for conditions that could have been easily managed in their community clinics – if only they were working. Therefore, advanced levels of technological innovation and development expected from Nigeria’s teaching hospitals can therefore not emerge due to these system inefficiencies.
This failure of the health system has fuelled medical tourism, which is estimated by the Federal Government to cost the country between $1.2 billion and $1.6 billion each year –  close to Nigeria’s 2022 budget for healthcare. Global reports of medical tourism approximate that about nine thousand medical tourists every month are Nigerian, half of whom seek medical treatment in India. It is also reported that 75 per cent of these patients pay out-of-pocket, 15 per cent of the medical fees are government-paid, 6 per cent covered by health insurance companies, and 4 per cent employer-paid. The payment for medical care in-country is no different, with barely 5 per cent of the population having access to health insurance through the country’s National Health Insurance Authority (NHIA). In fact, more than 70 per cent of Nigeria’s patients must pay out-of-pocket for their healthcare, putting them at risk of worsening poverty from health care expenditure. For many families, it is usually a choice between food and medical care, with often tragic outcomes.
…emphasis must be laid on the allocative efficiency of the budget. The primary health sector that is responsible for up to 90 per cent of health conditions and should be easily accessible to Nigerians, has been neglected. The majority of current health spending is tilted towards secondary and tertiary care, with enormous amounts spent on expensive equipment that, according to the World Health Organisation (WHO), “often deliver modest health gains”.
In a country emerging from the devastation of COVID-19 to the health and economic sectors, there is an urgent need to prioritise the health and wellbeing of Nigerians as drivers of economic advancement. The fact is that in the recently released five-point and seven-point agendas of Alhaji Atiku and Asiwaju Tinubu, Nigeria’s health sector was not highlighted. The Labour Party’s front-runner Mr Obi is yet to reveal his own agenda for health. This omission across board illustrates the neglect that the health sector has historically faced in successive lists of government economic priorities.
First, there should be increased funding for universal health coverage, by expanding the federal budget for healthcare to meet the Abuja Declaration of a minimum of 15 per cent of the total budget, by tapping into the private sector to support healthcare delivery. Funding universal health coverage to address the catastrophic out-of-pocket healthcare expenditure of Nigerians would require adequately financing the newly minted National Health Insurance Authority, working in partnership with state health insurance schemes. Additionally, there is need to muster the political will to stop fuel subsidy and channel those funds towards health insurance cover for the poorest and most vulnerable Nigerians. The presidential candidate of the APC recently promised in a presentation of his proposed roadmap, that if elected he would increase the country’s annual healthcare budget to 10 per cent. Over the past decade, Nigeria’s health sector allocation from the annual budget has fallen from ‘a high of 5.97 per cent in 2012’ to an average of 4 per cent year-on-year. However, increased budgetary provision must be tied to improved governance, with facilities and leaders being held accountable, and leakages and corruption plugged by working closely with communities and civil society organisations.
Secondly, emphasis must be laid on the allocative efficiency of the budget. The primary health sector that is responsible for up to 90 per cent of health conditions and should be easily accessible to Nigerians, has been neglected. The majority of current health spending is tilted towards secondary and tertiary care, with enormous amounts spent on expensive equipment that, according to the World Health Organisation (WHO), “often deliver modest health gains”. For example, in Nigeria’s 2022 budget of N724 billion, N24 billion is allocated to the National Primary Health Care Development Agency, which is in charge of the country’s primary healthcare centres (PHCs). Considering that there are approximately 30,000 PHCs in the country, this amounts to about N800,000 ($1,925 at a Central Bank exchange rate of $1/N415.63) per PHC as operating budget each year. If efficiency and effectiveness of health investments are anticipated, there must be a reliance on valid data for evidence-based planning and decision making.
Third, there needs to be a focus on social determinants of health. Healthcare delivery is a continuum of care and does not end in health facilities. Several factors impact on access and quality of healthcare, such as good nutrition (including school feeding), sanitation, clean water, improved security, and regular power supply. These social determinants of health have enormous impact on the quality of healthcare delivered and the population’s health.
Improving the conditions of service for health workers must address not only staff motivation and incentives, but also uphold accountability by imposing sanctions on erring workers. Technology, regular training, and retraining can be leveraged to enhance their work, with task-shifting to enable certain key health services to be provided, especially in remote communities.
Fourth, improved conditions of service of health workers are crucial. A 2017 survey on emigration of Nigerian medical doctors by Nigeria Health Watch and NOI Polls revealed the reasons why doctors and other health workers emigrate. Most of these border on poor working conditions. Improving the conditions of service for health workers must address not only staff motivation and incentives, but also uphold accountability by imposing sanctions on erring workers. Technology, regular training, and retraining can be leveraged to enhance their work, with task-shifting to enable certain key health services to be provided, especially in remote communities.
Lastly, there has to be increased funding for epidemic preparedness by adequately funding the Nigeria Centre for Disease Control. Indeed, it is cheaper to prevent than respond to infectious diseases. The threat of infectious disease outbreaks is a constant one. COVID-19 will not be the last pandemic. There are still various components of the prevention, detection, and response to infectious disease to address. Of note is the implementation of the National Action Plan on Health Security (NAPHS). This requires ensuring that federal agencies that have responsibilities for the implementation of NAPHS are encouraged to budget accordingly. Furthermore, infectious disease outbreaks are local. Consequently, the Federal Government must continue to work with states and local councils in the prevention, detection, and response to infectious disease outbreaks.
To quote the great American philosopher, Ralph Waldo Emerson, “The first wealth is health”. This quote has often been cited by leading economists and health experts to highlight that the only foundation on which to build an economy is health. Therefore, for both political candidates and the voting public, health should never be left out of the political dialogue. Demands for optimal attention and investment in our health must be made, and our leaders held accountable for these at all levels of governance. After all, “without health we have nothing”.
Adaeze Oreh is a consultant family physician, and a Senior New Voices Fellow for Global Health with the Aspen Institute in Washington D.C. She is also a Doctoral Researcher in Global Health with University of Groningen, Netherlands. Ifeanyi M. Nsofor is a Senior New Voices Fellow at the Aspen Institute and Senior Atlantic Fellow for Health Equity at George Washington University.
 
 
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