Public analysts consistently criticised the President's medical trips abroad, blaming him for "championing the distrust in Nigeria's health sector," especially by the members of the elite class.
No Nigerian leader spent more time in hospital abroad than President Muhammadu Buhari's approximately 232 days. It took him only two years in office to beat the record set by one of his predecessors and Katsina kinsman, the late Umar Yar'Adua, who spent 109 days on medical trips abroad in his 32-month stay in office.
Public analysts have criticised the outgoing president's medical tourism, blaming him for "championing the distrust in Nigeria's health sector", especially by the elite class.
"The president as the symbol of the nation has consistently breached the oath of allegiance and the people's trust in him by his distrust in the health facilities at home. And that is very unfair for a leader who was elected by the people to provide the very best care in health and other sectors of national development," said Lekan Oladapo, Project Director for Lygel Youth and Leadership Initiative, a non-governmental organisation.
He said the president's conduct encouraged medical tourism abroad, which according to an earlier report by PREMIUM TIMES, costs Nigeria an estimated N576 billion ($1.2 billion) yearly.
But this was not what Mr Buhari and his political party promised Nigerians.
Campaign manifesto
Ahead of the 2015 general election, Mr Buhari, candidate of the then opposition All Progressives Congress (APC), presented his party's manifesto themed: "Building a New Nigeria."
A major promise in the manifesto - described at the time as one of the most ambitious and elaborate in the nation's political history - was the provision of robust healthcare services by an APC administration.
The specifics of the promise for the health sector include nationwide domestication of Child Rights Act, free ante-natal and maternal care for pregnant women; free healthcare for babies and children up to 12 years old and the aged, and free treatment of persons with infectious diseases; raising the gross national health expenditure per person per annum from less than N10,000 to about N50,000, and raising federal government-owned hospitals to world class standard within five years through investments in infrastructure, diagnostic equipment and continuous professional development.
Mr Buhari also promised to improve healthcare in the country by prioritising Primary Health Care, ensuring increased budgetary allocation, and improving welfare for health workers, among others.
Speaking specifically on the challenge posed by medical tourism, the president, in April 2016, months after his first medical trip to London, said the government's hard-earned cash would not be spent on treating officials overseas, especially when Nigeria has the expertise.
"While this administration will not deny anyone of his or her fundamental human rights, we will certainly not encourage expending Nigerian hard-earned resources on any government official seeking medical care abroad, when such can be handled in Nigeria," former Health Minister, Isaac Adewole, said at an event where he represented the president.
However, President Buhari is leaving behind a legacy contrary to those promises. Beyond medical tourism, he will be remembered for poor performance in industrial relations in the sector and primary healthcare development, and scary maternal and infant mortality statistics.
On health infrastructure
Despite promises by Mr Buhari's administration to revitalise PHCs and improve the quality of government-owned hospitals, many health facilities across the country still lack basic equipment and infrastructure required to provide quality health care.
Various reports have revealed the dilapidated state of PHCs across the country, especially in rural communities.
Going by the blueprint of the National Primary Health Care Development Agency (NPHCDA), a PHC should have one or more doctors, a pharmacist, a staff nurse and other paramedical support staff to provide outreach services.
It should also have a well-equipped open ward, labour room, children and female wards, doctor's office and staff quarters, an ambulance for referrals and drugs and equipment for immunisation, preventive and basic curative care. The centre is also to provide monitoring and evaluation, as well as maternal and child health services.
Meanwhile, this is not the situation in PHCs across the country. The majority of these PHCs are short-staffed, poorly equipped, lack electricity and water, and cannot effectively cater for the people.
Many pregnant women still seek the services of traditional birth attendants for delivery. Many children in the rural areas also miss out on routine immunisation which is meant to be one of the responsibilities of a functional PHC.
In January 2017, President Buhari flagged off a scheme to revitalise 10,000 PHCs across the country to enhance the access of Nigerians to qualitative and affordable health services. However, six years after the flag-off many PHCs are still not functional and those that are functional are offering health services below standard.
Various investigations carried out by PREMIUM TIMES between 2018 and 2022 reveal that the majority of these PHCs are still in a poor state.
The director, PHC system development, NPHCDA, Ngozi Nwosu, also confirmed this during a health dialogue organised by this newspaper in November, 2022. Ms Nwosu said some PHCs facilities across the country are poorly equipped, with only a quarter of about 30,000 facilities having more than 25 per cent of the minimum equipment package.
Ms Nwosu said the limited coverage of important PHC interventions is further aggravated by poor quality care, with poor performance of health workers also contributing to this.
The Executive Director of the agency, Faisal Shuaib, at a recent event also reiterated the poor state of PHCs especially in rural areas.
Mr Shuaib said there is an unequal distribution of available Skilled Birth Attendants (SBAs) among the PHC facilities, noting that only 463 (1.8 per cent) out of 25,380 PHCs in the country possess the required number of SBAs.
The story is not different at federal government-owned secondary and tertiary hospitals in the country. These health facilities lack basic medical equipment, such as diagnostic equipment, patient monitors, and surgical instruments, making it difficult for health workers to provide quality health care to patients.
For instance, over 300 radiotherapy machines are needed to cater for cancer patients in Nigeria but the country has only 13 according to the Nigerian Cancer Society (NCS).
Cancer patients travel across states and also join a waiting list to access radiotherapy machines.
Industrial crises
While health workers' strikes are not a new phenomenon in Nigeria, the Buhari administration witnessed more of these than the previous administration. Within the last eight years, these providers of essential services downtooled for 163 days, and still counting, especially as the Joint Health Sector Unions (JOHESU) on Thursday directed its members to begin another round of indefinite strike.
Other unions mostly affected by the industrial crises are the National Association of Resident Doctors (NARD) and the Nigerian Medical Association (NMA).The health workers, at different times, went on strike to demand improved welfare, increased hazard allowance, payment of salaries arrears, among others.
For instance, in June 2016, members of NARD embarked on a nationwide strike to protest unpaid salaries, poor working conditions, and inadequate funding of the health sector. The strike which lasted for seven days was eventually called off following negotiations between the government and the association.
In September 2017, NARD and NMA jointly declared a nationwide strike which lasted for 10 days.
The longest of all the strikes was by NARD which was declared on 2 August 2021. It lasted for 63 days. The association declared the strike over government's failure to pay house officers' salaries and the non-recruitment of house officers. The union again just returned from a five-day warning strike due to the government's failure to meet their demands over the years.
During an interview with PREMIUM TIMES, the President of NARD, Emeka Innocent, said from 2015 till date, the health workers have embarked on multiple industrial actions. "I will let the public do the maths on the number of times health workers have embarked on strikes during President Buhari's administration."
Brain Drain
The exodus of healthcare professionals, especially doctors, pharmacists, and nurses to developed countries has been a burning issue under Mr Buhari's administration.
Although the president promised to improve the welfare of health workers while campaigning ahead of the 2015 election, the health sector is said to have experienced the worst brain drain under his administration.
With a doctor-patient ratio over five times worse than the WHO recommendation, Nigeria has continued to lose hundreds of doctors annually to brain drain, a large number of them to the UK.
Various statistics shows that over 5,000 Nigerian medical doctors have migrated to the UK in the last eight years.
Data documented by the development Research and Project Centre (dRPC), shows that in 2015, 233 Nigerian doctors moved to the UK; in 2016 the number increased to 279; in 2017 the figure was 475, in 2018, the figure rose to 852, in 2019 it jumped to 1,347; in 2020, the figure was 833 and in 2021, it was put at 932.
The continued emigration of health practitioners has led to a shortage of skilled health workers in the country, which has negatively affected the quality of healthcare services provided to the citizens.
Mr Innocent, the NARD President, said although the government may have done its best, it failed in addressing numerous challenges facing the health sector.
"We still have inadequate infrastructure, inadequate manpower," he said, adding that "Poor remuneration for health workers, among other issues, have been identified as causes of the brain drain which is a reflection of failure of the government."
He said as long as this is not addressed, the brain drain will continue and it will get to a time where the health system will collapse.
Health financing
Although the health sector got its highest budget ever under the Buhari administration, it still failed to meet the 15 per cent commitment made by heads of African countries in 2001.
African Heads of States and Governments under the African Union (AU) in April 2001 made the commitment to dedicate at least 15 per cent of their annual budgets to the health sector in what is now known as the 'Abuja Declaration.'
While countries like Rwanda and South Africa have met the commitment, Nigeria has not found a way to do so. A review of the budgetary allocation to the health sector in the last 21 years revealed that Nigeria has never met the 15 per cent target.
However, for the first time in the history of health funding in Nigeria, over a trillion naira was allocated to the sector in the 2023 budget.
An analysis of the budget shows that N1.17 trillion (5.75 per cent) was allocated to the health sector out of the total N20.5 trillion budget for the 2023 fiscal year.
Speaking with PREMIUM TIMES, the director of programmes at the PACFaH@scale, Stanley Ukpai, said the Buhari administration improved on health financing but still failed to meet the 15 per cent commitment agreed upon by African leaders.
Mr Ukpai said although there is an increase in the percentage allocated yearly, especially in the 2023 budget, the amount is still too low to finance the health sector. He said without adequate financing, the healthcare needs of the nation cannot be addressed.
Scary statistics
For several years, Nigeria's health system has been rated as one of the worst globally. In 2017, the World Health Organisation's analysis of health systems ranked Nigeria 187 out of 191, better only than the Democratic Republic of the Congo, the Central African Republic, and Myanmar.
The same survey carried out in 2021 ranked Nigeria's healthcare system as the fourth worst in the world.
The 2013 National Demographic and Health Survey (NDHS) shows that infant and under-five mortality rates were 69 and 128 deaths per 1,000 live births, respectively. But, in 2018, the infant mortality rate reduced to 67 deaths per 1,000 live births, while under-five mortality rose to 132 deaths per 1,000 live births.
The maternal mortality ratio was 576 maternal deaths per 100,000 live births in 2013. In the NDHS 2018 report, it was estimated at 512 maternal deaths per 100,000 live births.
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A WHO report put the maternal mortality rate in Nigeria as 814, per 100,000 live births only outperforming Chad with 856, Central African Republic; 882, and Sierra Leone; 1,360.
Statistics also shows that for every 1,000 births in Nigeria, 108 infants and children die before the age of five.
Also, the 2021 World Malaria Report indicates that Nigeria had the highest number of global malaria cases (27 per cent of global malaria cases) and the highest number of deaths (32 per cent of global malaria deaths) in 2020. The country also accounted for an estimated 55.2 per cent of malaria cases in West Africa in 2020.
The case numbers increased by 5.3 per cent between 2017 and 2020, from 298 to 314 per 1,000 of the population at risk. Deaths increased by 4.7 per cent, from 0.92 to 0.97 per 1,000 of the population at risk during that same period.
The 2022 World Malaria Report also shows that Nigeria recorded 31 per cent of the 619,000 deaths recorded globally in 2021.
Other communicable and non-communicable diseases in which Nigeria takes the lead globally includes cancer, HIV/AIDS, tuberculosis, cholera, typhoid, Lassa Fever, hypertension diabetes.
Not all gloomy
As poor as Mr Buhari's performance in the sector may be, key positive developments were also recorded. Some of these include the fight against the global coronavirus pandemic, eradication of wild polio virus, the signing into law of some very significant bills such as the mental health bill, and the National Health Insurance Authority Bill. The latter had repealed the law establishing the National Health Insurance Scheme (NHIS).
On polio eradication
Nigeria and the rest of Africa were formally certified free of the WPV on 25 August, 2020, by the World Health Organisation (WHO) after no case of the virus was detected on the continent for three years.
Nigeria became the last African country to eliminate the virus which could be prevented with adequate vaccination. About 11 years ago, Nigeria accounted for half of the world's polio cases.
The poliovirus, which causes paralysis by attacking the nervous system, is spread from person to person mostly through contaminated water.
Mr Buhari had said Nigeria used data systems, community engagement and innovative technology to monitor and predict the occurrence of polio outbreaks as part of the country's efforts to eliminate the disease.
NHIS to NHIA
Towards achieving Universal Health Coverage (UHC) for all, Mr Buhari signed into law the National Health Insurance Authority (NHIA) Bill 2022. The NHIA, which repeals the National Health Insurance Scheme (NHIS) Act that has been in existence since 2004, makes health insurance mandatory for all Nigerians. Mr Buhari promised that the authority would collaborate with the various state governments' health insurance schemes to accredit primary and secondary healthcare facilities and ensure the enrollment of Nigerians.
The law also included the Vulnerable Group Fund (VGF), to ensure coverage for 83 million Nigerians who are believed to be incapable of paying premiums as recommended by the Lancet Nigeria Commission.
