Ben Atonko
21 September 2008
interview
Dr Sunday Omale Onuh is Consultant Gynaecologist and Medical Director of Nisa Premier Hospital, Abuja. He told Sunday Trust that corruption has delt primary health scheme a deadly blow. According to him, even the National Health Insurance Scheme (NHIS) has failed to get to the grassroots. Excerpts
What really was the purpose of the Primary Health Scheme?
The primary healthcare initiative was a wonderful and laudable initiative. It was pioneered by Prof Olukoya Ransom Kuti of the blessed memory. Indeed, he put a lot of force to see that the scheme achieved its goals. The essential goal of the primary healthcare was Health for All. Then it was targeted at the year 2000. Now we're in 2008, yet far from achieving the goals.
The essential ingredient of the primary healthcare falls on preventive medicine-prevention of diseases and even if diseases occur, complications are prevented. It was discovered that there was scarcity of health facilities in the country particularly in the rural areas. It was also discovered that highly skilled personnel were not really going to work in the rural areas. But primary healthcare was conceived to take health to the grassroots because most of the health problems of our people come from the grassroots.
So what is the situation today?
Now the facilities and manpower matching the population is a far cry in terms of ratio by the WHO standards. We don't have manpower and where this manpower exists, it's unevenly distributed between urban and rural centres. Qualified personnel prefer to stay and work in urban centres but we know that the majority of the population is in the rural areas.
The primary healthcare was supposed to have healthcare posts where simple ailments could be treated and health talks given and deliveries taken in a clean environment devoid of infections and complications that might arise. The health status of a nation is measured in terms of maternal mortality and infant mortality-how many women die in the course of child birth; how many children under five die because of one thing or the other. We're really not doing well in this area at all.
Several years after the coming of primary healthcare, what do we see? It's appalling. It's very unfortunate that the whole system is almost non-existent. We went down gradually! We talk of the political will, government's participation, and continuity-when a policy is formulated, people would believe it's personal so when the person that initiated the policy goes, the programme dies with the person.
The primary health posts are just like monuments-there are no personnel inside. And where they exist, there're no facilities at all. There's no replacement for what was initially put there.
Well, today, we have what is called the National Health Insurance Scheme (NHIS). I would like to believe that NHIS has come to bridge the gap that has been created by the collapse of the primary healthcare system. But this is largely in the urban centres. The rural areas are still suffering from this collapse of the primary healthcare centres. The rural areas don't even know what we're talking about. But the good thing is the incorporation of the private sector into the NHIS, the private sector has been forced to offer primary healthcare to the populace. As such, people who ordinarily can't afford to go to private hospitals now come to private hospitals. But there're limitations in the sense that-we're good at policy-making, but implementation is always the problem.
The NHIS idea had been cultivated over decades but it came to actualisation in early 2007. We hope and pray it won't die because it holds good for the future of the healthcare of Nigeria.
Is this collaboration really successful?
I see a big communication gap-a big communication collapse between the healthcare provider and the patients who're the beneficiaries; on the other hand, between the healthcare provider and the HMOs i.e. the Health Maintenance Organisations who are supposed to be anchor people of the NHIS; on another hand, between the patients themselves and the HMOs. The national healthcare is supposed to operate in a system that people who're beneficiaries would contribute to this thing. If I'm contributing to something, I should have the free will of choosing where I should go! But you'll see a situation whereby people are contributing they're given hospitals that they don't know where they are located. It means that that healthcare provider will be collecting what we call Capitation on behalf of these people and the people would never utilise the privilege. But that is just a fraction of what we're talking about. The maintenance organisations don't have much information about the operations of the NHIS so they don't get to educate the healthcare providers adequately. And sometimes they misinform the beneficiaries. With that misinformation, they think it's the healthcare provider that isn't doing them good. Rather, it's the system as it were.
I'll give you an instance: the tariff for NHIS was actually made long ago-up to 10 years ago. And when the implementation came only last year, the same tariff was applied without a review. The capitation is N550 per head per month. It means that with this N550, even if the person comes to the hospital 20 times, they're covered. How can the healthcare providers cope with this, knowing fully well that most hospitals now especially private hospitals here in Abuja, will charge less than N500 to open a card?
Isn't the NHIS limited to the primary healthcare?
No, it transcends primary healthcare-there's the primary, secondary and tertiary levels of care. But the primary level is the one that most people belong to. It involves clinic attendance only; no admission, no specialised treatment. But when a case requires a specialised treatment, you'll have to write to the maintenance organisation-i.e. the health provider has to write formally to maintenance organisation seeking approval for the patient to be given secondary care. It's a process! When we started, it used to take two weeks, one month to get a reply because most of these HMOs don't have offices everywhere. So where there's no office, you'll have to relate to the headquarters office, maybe in Lagos-you email them or you sent a letter before you get reply. But now, some of them honour phone conversation especially in emergency situations. In some emergency situations, you go ahead and give treatment and approval comes later. But it can be disadvantageous to the provider because in a situation where you seek approval and the maintenance organisation tries to prove to you that after all it wasn't an emergency situation because the case has been treated, you lose.
NHIS receives only patients whose organisations have registered them. What happens to the chunk of the unemployed there?
That's where we still talk about primary healthcare. The primary healthcare structure isn't formal. But NHIS is an insurance scheme, of its working everywhere in the world-most of the civilised countries. But we know that in those civilised countries, they have social fund that takes care of the unemployed which is not well developed here now. NHIS doesn't take cognisance of the unemployed. It doesn't take cognisance of those in the rural areas. Why? Because they don't know what's happening. They don't even know that they have to contribute to something-and even if they contribute, which health facility will they use?
In my own local government as a whole, it's only the local government headquarters that has a hospital. It's funny. If you take this thing to them and they have to register and contribute from their farm work, how can they access care? We must tackle this because if we want to attain health for all, then we must not segregate between the employed and the unemployed.
If you go to the Scandinavians-Sweden, Denmark for instance, if you're unemployed, everything is free for you. Because people are paying tax-they utilise their tax. But we haven't got to that level yet. But for us to move ahead, we should start thinking in that direction.
The private sector is coming up strong in the health sector just like it did in education, leaving government structures crippled.
It is agreed that the private health sector is gradually taking over management in this country. The reasons are obvious. There's general apathy when we come to health. Government isn't giving health the attention it deserves. For instance, for the past eight months, we don't have a minister of Health. We have an acting minister that's doubling. It shouldn't be!
Generally, private hospitals are doing better than the government hospitals. Bureaucracy and corruption are the big problems. We keep on saying government! Government! The people that are working in these institutions are running them down. Bureaucracy is killing them while the private sector is moving fast. If I want anything done now, it's for me to give orders. But in the public sector, no! It has to pass through this office, that office and what is to be done in one hour, takes one week! Because everybody want to be recognised.
But education is different from health. NHIS will not allow health go the way education has gone. Private sector-driven society actually gives room for more development. However, in the civilised society, there's provision for the underprivileged.
I was in Denmark and I observed that their health insurance system is limited to public hospitals. The private hospitals are there for the bourgeoisies who want to go there. See their government hospitals-they're better than any private hospital you can think of in this country. The people working these public hospitals even work harder than those in the private hospitals because they have the interest of the nation at heart. They know that they're being paid from the tax-payers' money. So they take their jobs seriously.
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