By Felix Abrahams Obi
Nigeria has in the last couple of years attracted considerable attention within the global health community for the wrong reasons. We have one of the worst health indices in Africa despite our leadership position in the continent and clearly will not meet the health-related MDGs targets especially for Maternal, New-born and Child Health (MNCH) by the end of 2015. Nigeria’s 2015 target for MDG4 (Under-5 mortality) is 70 deaths per 1,000 live-births and 250 deaths per 100,000 live-births for Maternal Mortality Ratio (MMR). However, the findings of the current National Demographic and Health Survey (NDHS) show that under-5 mortality is 128 per 1,000 live births, while the MMR stands at 576 deaths per 100,000 live births.
Nigeria is recording approximately 800,000 under-5 deaths every year, accounting for about 11% of total global under-five deaths. As much as 40% of these deaths result from diseases that are vaccine preventable and can be averted through routine immunization for children and infants. The same goes for the unacceptably high number of mothers that die during child birth due to preventable causes. The average Nigerian if given an option will likely not visit our public hospitals and this lack of trust has deepened over the years due mainly to the poor performance of our health system despite efforts at implementing reforms in the last decade.
The health system that President Buhari has inherited is not performing at an optimal level and he had alluded to this during his campaigns. Upon winning the presidential elections he released a statement of commitment to Nigerians, promising to revamp the health sector which he re-emphasized during his inaugural speech at Eagle’s Square Abuja before Nigerians and world leaders. Expectations are high indeed and hope is rising that things will change for good. However if after 4years, little change is seen in the quality of health services delivered in Nigeria or no appreciable progress made in improving the health status of Nigerians, President Buhari would go down as a leader who made promises that were not delivered.
The consensus among healthcare management experts and key stakeholders within the health sector is that underlying the poor performance of the Nigerian health sector is overarching poor governance and stewardship for health by successive governments especially at the PHC level. The problems are compounded by the fragmentation and multiple management structures, unclear roles and responsibilities, inadequate funding, weak referral system and accountability mechanisms and weak collaboration and coordination among the different players in the sector among others.
While setting up efficient and functional performance management and clinical governance systems will go a long in improving the quality of services delivered by workers at the health ministries and our hospitals, one major challenge the Buhari administration will grapple with is the funding of the health sector. Although Nigeria is not a donor-dependent country, however most critical public health interventions in the country are largely funded and implemented by donors. With the huge debt burden and depleted foreign reserves, the APC government in Nigeria will need to think deeply on how to creatively source funds to provide critical public health services and sustain ongoing programmes to save the lives of women and children.
For instance, the Nigerian government in 2010 made commitments to release US$3 million annually (to be matched by contributions from donors) for the procurement of family planning commodities, and later at the London Family Planning Summit in 2012 made an additional commitment of US $ 8.35 million annually over the next four years for reproductive health commodities including contraceptives. However, these commitments have not been met considerably by the Government, and poor funding of key public health programmes has remained a concern to health advocates. Like Ghana which graduated to medium-income country a few years ago, we have to now look for alternative sources of funding other than official development assistance and grant aid.
In the spirit of transferring responsibilities to the home government, some bilateral donors such as USAID have gradually been withdrawing part of their financial support for HIV/AIDS programmes to allow federal and state governments to take up more responsibility in funding public programmes, which is part of their current engagement plan with Nigeria. For sure Nigeria is not a poor country that needs donors to stand on her feet, despite the pervasive poverty in the land. While donor agencies have no immediate plans to withdraw support from Nigeria completely, their focus now is to support the government in building and strengthening institutions and structures that will help deliver good governance.
And following the rebasing of the Nigerian economy and the resultant upgrade from a low-income country to a low-medium income, most donor countries no longer see Nigeria as a country that needs grant aid for financing critical public health interventions. With this upgrade Nigeria is no longer qualified to receive grants for purchasing vaccines and supporting routine immunization services from the GAVI Alliance. The reality hit home few months ago when it became obvious that Nigeria could not set aside budget for the purchase of vaccines for children in 2015. It took the intervention of Bill Gates who is committed to the eradication of polio virus in Nigeria to strike a deal through which the soft loan provided by the Japanese Government and World Bank could be converted to grant aid if some key deliverables are achieved by the federal and state governments.
The task of fixing the myriad problems and challenges in the health sector is enormous but the high expectations of Nigerians are not misplaced. It behooves our President to appoint a courageous and inspiring Minister of Health who will take the bull by the horns and lead the efforts to transform the health sector. Our President should look beyond party lines, tribe and religion in selecting the next Minister of Health. While Nigeria is not bereft of experts with knowledge and experience in the health sector, ministerial appointments are often influenced by political considerations and done without recourse to merit. Thankfully, Buhari has promised to dump this practice by ensuring that competent and experienced technocrats and professionals form the core team that will conceptualize and implement his reform agenda and policies.
With an enviable track record of performance, one potential candidate that readily comes to mind is Dr. Muhammad Ali Pate who left his position at the World Bank to heed the call by the late President Umaru Yardua in 2008 to lead the fight against polio. Nigeria had then been experiencing shame globally as the only country in Africa that was exporting the wild polio virus and re-infecting countries where the disease has been eliminated. Even Saudi Arabia had allegedly forced adult Nigerian pilgrims to be immunized at the point of entry before they could perform their pilgrimage. It was against this backdrop that Dr. Pate was brought in to serve our country in October, 2008.
As the head of the Presidential Task Force on Polio Eradication cum Executive Director/CEO of the National Primary Health Care Development Agency (NPHCDA), Dr. Pate brought renewed vigor into the fight and inspired confidence among his staff and within the public health community that the elusive fight against polio will be won in good time. In the fight against polio, he rallied the support of traditional and religious leaders, as well as the State Governors. Within two years of his tenure, Nigeria experienced a remarkable drop in polio cases of about 95% from 861 cases in 2008 to 48 cases by the end of 2010. We however experienced some setbacks in the polio fight after his exit in 2011 as the Executive Director/CEO with the cases rising to 98 in 2011 to 130 in 2012 to the shock of the global community.
During his tenure he significantly transformed the agency by instituting system-wide reforms that helped change the organizational culture, rebranded the agency and improved the work ethics among staff of the agency through the help of a reputable management consulting firm. Realizing that the weakest link in the PHC system lies at the state and LGA levels, he partnered with Duke University’s Global Health Institute to initiate a Mid- level Management and Training for doctors, community health officers, midwives, nurses and health administrators from all the states in Nigeria who all serve as links between the PHC centres and top-level administrators and policy makers. The practice-based training program focused on core areas of management, including leadership, financial management, economics, communications, strategic planning, and epidemiology, as well as key aspects of health policy. The findings an independent study conducted to evaluate the impact of the programme showed that the training had helped to improve the management and analytical skills of the trainees
With Nigeria’s unusually high mortality in the North due largely to lack of skilled manpower to deliver needed services at the PHC level, Dr. Pate in 2009 initiated the award-winning Midwives Service Scheme (MSS) through which about 4000 newly graduated, unemployed, and retired midwives mostly from the South were recruited and posted to provide 24-hours comprehensive emergency obstetric care in some PHCs in the rural areas of the North where maternal deaths were high. Some remote hard-to-reach areas in the northern zones (NC, NE, and NW) were further provided with an additional 1,000 Community Health Workers (CHWs), with two CHWs posted to each PHC to provide support and complement the work of the midwives. The idea of streamlining and reducing the fragmentation of PHC services at the state and LGA levels led to the development and implementation of the Primary Health Care Under-One-Roof Policy.
In 2011 Pate was appointed Minister of State for Health, upon moving over to the Ministry of Health, Pate established himself as a focused leader and public health professional and set out clear goals and milestones he planned to achieve by 2015. Pate’s vision of transforming the health sector was anchored on four strategic pillars. He sought to expand access to primary care services, especially in rural areas by expanding the MSS programme he’d pioneered at NPHCDA. The plan was to recruit more health workers especially midwives, start outreach services through CHWs and village health workers, refurbish PHC centres, and provide incentives to pregnant mothers to attend ANC clinics, deliver at health facilities and complete the immunization of their babies.
Pate’s second target was to strengthen disease prevention. He sought to check the increasing prevalence of non-communicable diseases (NCDs) through early detection and diagnosis, as well as health education and awareness campaigns for lifestyle modification, smoking cessation, and tobacco control, in addition to screening for risk factors and for NCDs such as diabetes, heart disease, and cancers. The Prevention of mother-to-child transmission of HIV and introduction of new vaccines such as Pneumoccocal Conjugate Vaccine (PCV) to tackle deaths of children caused by pneumonia were additional elements of the prevention strategies he had envisioned.
Tackling the poor quality of services delivered at both public and private health facilities was his third focus, and he planned to achieve this through institutionalizing better clinical governance and accountability mechanisms; all aimed at improving quality of healthcare in the country. His fourth goal was the vision of ‘unlocking the market potential of the private sector for health’ in Nigeria so as to harness the vast human and financial resources which can be leveraged on to implement population-wide health interventions all aimed at saving the lives of women and children in the country.
As a reflection of his broad-mindedness and detribalized nature, Pate convinced Dr. Kelechi Ohiri (an experienced public health expert with McKinsey in London) to come and serve the country as his Senior Adviser and head of his Technical Team. Kelechi and the crack team of Nigerian professionals he had assembled together worked assiduously to realize the visions Dr. Pate had set out. This team designed the SURE-P Maternal and Child Health programme which eventually was run by Dr. Ugo Okoli with support from Dr Tokunbo Oshin- both were members of his core team. One of his technical advisers, Dr. Saddiq Muntaqa led the private sector work stream which culminated in the establishment of the Private Sector Health Alliance of Nigeria, through which enormous resources have been mobilized in the last 3 years by big players in the private sector such as Aliko Dangote, Jim Ovia among others. Kelechi Ohiri eventually became the technical lead for the implementation of the Saving One Million Lives (SOML) initiative which was launched by President Goodluck at the State House in 2012. These programmes have become institutionalized as PPP initiatives while maintaining links to the government.
With Kano as the epicenter of polio virus in Nigeria, Pate in 2012 brokered a tripartite partnership between Kano State Government, Bill Gates and Aliko Dangote through which both billionaires jointly pooled funds to fight polio and build and refurbish PHC centres in Kano. Thankfully the worrisome trend had been reversed in the last 2 years such that currently Nigeria has not recorded any new case of polio this year. And all this happened courtesy of a visionary and inspiring leader in Dr. Pate who conceptualized and led the implementation of these laudable initiatives which no previous Minister of Health had possibly thought of in the past.
With the ovation growing louder and Pate’s profile on the ascendancy, the whole global public health community received the shocking news of his impromptu resignation ostensibly to accept the position of a visiting professor at Duke University’s Global Health Institute, U.S.A. as well as senior adviser on African initiatives to the Bill and Melinda Gates Foundation based in Washington, DC. Although President Goodluck accepted his offer to continue his technical support of Nigeria’s polio eradication and the Saving One Million Lives Initiative on part time basis, many analysts sensed his resignation was not unconnected to the attendant frustrations and politically-nuanced challenges that followed his rising profile as a junior Minister.
Pate true to his words continued to provide technical support to Nigeria’s polio eradication efforts and the SOML initiative among others. He reportedly played a key role in ensuring the recent approval of a low interest $500million credit by the World Bank to support the SOML initiative. The performance-based funding will be disbursed to the Federal and State governments to aid the provision of much needed services such as routine vaccination of young children, family planning services, Vitamin A supplementation, ANC services and skilled birth attendance, as well as HIV counselling and testing among women attending antenatal care, and preventing new malaria infections among children by using insecticide-treated bed nets.
Nigeria needs a savvy Minister of Health who will inspire confidence within the sector and equipped with the requisite knowledge and skills set to lead the implementation of the key provisions of the newly-signed health focused laws such as the 2014 National Health Act, the 2015 Tobacco Control Act, and the 2015 Violence against Persons (Provision) Act. For someone who has the passion and understands what needs to be done to fix the health system, there is a limit to what he can do remotely from his base in USA. The new government need not look too far when the likes of Dr. Ali Pate is still willing to serve his fatherland.
A few weeks back, Dr Muhammad Ali Pate reportedly made a presentation to President Buhari’s Transition Committee in Abuja titled “Creating a More Responsive Health System to deliver a Better Health Care to Nigerians” during which he clearly articulated the causes of the problems in the health sector, and proffered practical solutions to address them. As we await with an anticipation for the announcement of President Buhari’s cabinet, many within the global public health community are hopeful that President Buhari will consider such seasoned health professional like Dr. Ali Pate as the substantive Minister of Health.
Felix Abrahams Obi is a Physiotherapist and Health Systems & Policy expert who lives and works in Abuja. He can be reached via firstname.lastname@example.org