THE CHALLENGES OF HEALTH CARE DELIVERY—PUBLIC PRIVATE PARTNERSHIP AS A SOLUTION
A speech presented to the Association of Resident Doctors at Delta State University Teaching Hospital, Oghara.
That the health-care delivery in Nigeria is in dire straits is no longer news. It is exemplified by the fact that our president had to be held up in the United Kingdom for weeks for an undisclosed illness. Our former Vice President, Dr. Alex Ekwueme, just died overseas late this year.
It is very pathetic because in the early 1970s, the King of Saudi Arabia used to send his family members to the University College Hospital, Ibadan, for medical checkups. The resultant effect was that a lot of our Professors and Consultants emigrated to Saudi Arabia to work in their hospitals.
One of our late presidents was also held up in a Saudi hospital for months before he was eventually brought back to Nigeria where, sadly, he later died.
The challenges of health-care delivery are not insulated from the fact that Nigeria is fast degenerating to a dysfunctional society on all fronts.
PUBLIC PRIVATE PARTNERSHIP IN THE HEALTH SECTOR
This is any collaboration between public bodies—central and sub-national governments—and the private sector—private companies or institutions, religious or faith-based organizations, non-governmental organizations—in the development and funding of health-care facilities and institutions. (M. Asogwa, PhD and S. Odoziobdo, PhD, 2016) It will include private finance initiatives, provision of technical services like collaboration with mobile telecommunication companies in the management of HIV and tuberculosis patients as in Kenya, etc.
Recently, in East Africa, drones were being used to deliver blood supplies to rural and remote hospitals in a collaborative effort between a private concern and the government.
It also involves technical support and transfer of skills like the Orbis Foundation, which has a Flying Eye hospital. The DC-10 plane was donated by Fedex, a courier company. They fly to countries where they do eye operations and train local ophthalmologists on modern surgical skills, etc.
The increase in Public Private Partnership, PPP, as it is called, in Africa, is as a result of the Bretton Woods Institutions’—that is, the World Bank and IMF—insistence on the deregulation and privatization of the economies of underdeveloped nations. It is a result of the shift from government-controlled economies to more liberalized- and market-oriented economies.
In this situation, government plays a regulatory role, and also provides enabling environments and the necessary legal frameworks.
The questions that arise, therefore, are as follows:
- Will PPP solve the challenges of heath-care delivery in Nigeria on its own?
- What are the results of PPP in other nations like India, South Africa, Germany, and other European nations?
- What are the results of PPP in Nigeria and the challenges that emerged?
Effective health care delivery must have services that are:
- adequate, and
One of the major challenges of public health-care delivery in Nigeria is funding; another is lack of government commitment to the welfare of her citizenry.
Dutta et. al, (2009), stated that up to 50% of health care services in Nigeria come from the private sector. Other reports indicates that a great percentage of the poor who live on less than USD2.5 a day, hardly patronize private health facilities routinely. They only do so in emergencies. So, if the cost of health care, as a result of PPP, increases, the issue of affordability comes in.
According to a UNDP (2005) report, 1.3% of the national GDP was spent on health in 2003 and 2.2% in 2006 (WHO, 2007). Government expenditure as a percentage of expenditure on health was 29.6% in 1999. This declined to 25.5% in 2003 (WHO, 2006), while that of Germany was more than 70%. In comparison to Sierra Leone’s 58.3%, Ethiopia’s 58.4% and Senegal 41.8%, Nigeria is far behind on percentage expenditure on public health services.
This means that the government has not been very keen on the health of her citizenry beyond lip service and propaganda for a very long time.
The passion to have a healthy citizenry must be the priority of our government, if not PPP is like an irresponsible husband asking outsiders to come manage his household. PPP is not an escapist route or deliberate obscurantism.
Let me further buttress this assertion: the per capita expenditure on health for the average Nigerian degenerated from less than USD5 to as low as USD2 compared to USD34 recommended by the World Health Organization,WHO, (WHO, 2007).
It will surprise you to note that the average cow in the European Union earns between USD1.4 to USD2.9 daily as subsidy. The mean is approximately USD2.2; but a Nigerian has USD2.2 spent on him/her annually on health services. The average cow in the European Union (EU) is therefore earning more than the lowest-paid worker in Nigeria monthly as subsidy.
You will, in a short while, see how much our politicians earn compared to European and American Politicians, with better health facilities and services.
EXPECTED BENEFITS FROM PUBLIC PRIVATE PARTNERSHIP (PPP) IN THE HEALTH SECTOR.
- Financial inflow from the private sector like the World Bank, Rotary Club International, Bill and Melinda Gates Foundation, Carter Foundation, The Kuwait Fund and UNICEF.
- Institutional developments by private individuals like the world class hospital being built in Umuchukwu, a sixteen-storey hospital in Orumba South LGA of Anambra State by Dr. Godwin Maduka. It will turn that community to a medical city when functional. It will ease the burden of getting spaces for residency programs.
- One would anticipate better managerial skills transferred from the private sector.
- Another is better staff behaviour in PPP hospitals instead of the present lateness, loudness, lousiness, and aggression by nurses, midwives, and surgeons.
- Meritocracy should replace mediocrity in appointment of personnel.
- Less corruption and sharp practices.
- Better working environment.
According to Ogundipe (2005),
- Mortuary services, have been working well on PPP basis in some hospitals.
Now, I must state very emphatically that for PPP to work in Nigeria, the following must be in place, take place, and examined concurrently.
A. INFRASTRUCTURAL DEVELOPMENT
1. Regular Electricity
Countries like Ethiopia, Kenya, and Madagascar that are less endowed than us have regular electricity supply. Even Sierra Leone is now generating electricity from bagasse—a waste product from ethanol production from sugarcane—by Addax Company in Makeni. Meanwhile, we are flaring gas instead of generating thermal energy with smaller turbines.
We have not even harnessed the abundant solar and wind power in Nigeria. Surgeons are currently doing surgeries with rechargeable lamps and illumination from android phones.
The cost of diesel to run generators and the frequent breakdowns of the generators is a major overhead cost in all our institutions.
I strongly suggest that electricity to hospitals, schools, and military installations should be subsidized.
2. Water supply should be adequate and regular, even from public mains.
3. Good transport network system
Good roads will prevent delays in bringing patients to hospitals. Also, it will ease the stress of health personnels to get to hospitals.
I once saw a child in a long traffic jam from Okokomaiko to Mile2 in an ambulance, one hot afternoon. I felt so bad.
4. Paradigm shift in religious practices
Our denominations must stop building cathedrals that are hardly used most days of the week and build more health facilities.
Baptist, Presbyterian, Methodist, and Catholic Churches overseas, are major stakeholders in the health sector in countries like the United States of America and Germany. I was reliably informed that the Catholic Church owns several hospitals in Germany, including where my son is doing residency in Orthopedics.
We had missionary hospitals at Eku, Ogbomosho, Shaki, Iseyin, Onitsha Ngwa, Abak, Onitsha, Ihenu, etc.
5. There must be a strong industrial base.
A nation that cannot produce cotton wool, drip-sets, injection needles, injection fluids, etc., in large quantities for her nearly 200 million citizens, cannot benefit from PPP. This is because she will import nearly everything and will be short-changed and remain parasitic.
We must, therefore, deliberately put policies to attract pharmaceutical and medical equipment manufacturing companies to Nigeria.
6. Subsidized insurance scheme
In Germany, there is a compulsory health insurance scheme for everybody, which is partly subsidized by government to reduce the premiums for the poor, and private insurance for those with higher premiums who can afford them. Maybe we should forge out a workable formula for Nigeria.
B. ELITE CAPTURE AND THE IRON LAW OF THE OLIGARCHY
According to Sola Ogundipe, Clifford Ndujihe and Emman Ovuakporie, writing in the Vanguard newspaper, stated that according to a member of House of Representative; Henry Archibong, PDP, Akwa Ibom, that the budgetary allocation to procure equipment for the State House clinic in 2015, 2016 and 2017 appropriation Acts, were the sums of N3.94 billion, N3.87 billion, and N3.12 billion respectively for upgrading and provision of necessary drugs and equipment.
Within the 36 months, what the 16 teaching hospitals collectively got for capital projects were: N1.142 billion (2015), N3.333 billion (2016), and N1.94 billion (2017).
According to Archibong, in spite of these huge budgetary allocations, the clinic lacks necessary facilities such as syringes, drugs, and equipment needed to save lives.
The State House clinic had 17 ambulances; how many does University of Benin Teaching Hospital, UBTH, have? Despite the N1billion budget, our president still went overseas for treatment and his wife said there was no “panadol” in the State House clinic.
To show how perverted our values are, N123 million was budgeted for catering equipments and materials in the President’s kitchen. This is different from that of the Vice President. He is to spend N17 million for cutleries in 2018, as if they are disposable every year.
In Aso Rock, food stuff and catering materials gulped N360 million in 2016, meanwhile Nigeria’s premier Teaching hospital—University College Hospital, Ibadan—got N230 million for capital projects. To feed crocodiles, birds, and wildlife in the presidential villa took N36 million, while N63 million—25% of the budget for capital projects in UCH—was for cooking gas only in Aso Rock.
N94.5 million was spent for bullet proof tires for the president and others in 2017. And I ask, “On which road are they going to drive those cars?”
C. SECURITY VOTES
Security votes are not meant to be accounted for by governors, they are as follows:
Imo States: N4 billion annually,
Enugu State: N600 million monthly = N7.2 billion
Akwa-Ibom State: N1.5 billion monthly,
Rivers State: N1.5 billion monthly,
Delta State: N2 billion monthly, that is, N24 billion annually × 4 years = N96 billion, N96 billion × 2 terms = N192 billion.
Maybe I’m too stupid to understand some issues in this country.
According to an anonymous sources, a Nigerian Senator earns 8 times as much as an American Senator and more than 3 times the American president—who pays for his food in the White House apart from “State dinners”.
These are people with better health facilities than us. These are people in whose countries our leaders go to treat headache.
A Nigerian Federal Legislator earns 2 times as much as a British Parliamentarian.
In 4 months, the Senate President and the Speaker of The House of Representatives earned 6 times what the British Prime Minster earned in a year. That means they earned 18 times combined what the British Prime Minister earned. Remember our president just came back from the UK where he went for medical treatment.
D. SALARIES AND WAGES
We must pay our health workers well if we value health.
A Cardiothoracic Surgeon in America earns USD292,777 annually; some earn up to USD400,000 annually, more than the US president. My classmate earns USD1 million annually.
Michelle Obama, as a hospital Administrator, was earning more than her husband as a Senator. In 2006, her salary was USD273,618 from the University of Chicago Hospitals as Vice President for Community and External Affairs while her husband earned USD157,082 as a Senator – “values”.
A REVIEW OF TWO RECENT PPP HEALTH PROGRAMMES
1. The Akwa-Ibom “World Class” Hospital
The N41 billion Akwa-Ibom “world class” hospital shut down after just 2 years. The foreign partners—Cardiocare Ltd. from India—discontinued the contract based on poor funding. Cardiocare was alleged to have absconded with N300 million. People complained that their services were poor, the management was poor, fees were very high especially for that part of the country, even though government gave diesel free. It did not enjoy much patronage from within and outside Akwa-Ibom state.
Only one church roof that collapsed in Uyo crippled the hospital. They did 80 surgeries, had over 100 in-patients and 300 out-patients and gave a bill of N294 million.
The hospital was hurriedly commissioned in the Nigerian way and was not well equipped. The modular theaters were not yet complete. The Dialysis Section was not working and the government had no supervisory role. The present governor is not interested in it. That is Nigerian mentality for you!
2. The Abiye Project in Ondo State
According to Olusola Isola (PhD), Governor Olusegun Mimiko had a PPP with the World Bank and Globacom.
Maternal mortality reduced to about 47% with 96% increase in live births; 26% reduction in child mortality.
According to Dr. Mimiko, Commissioners’ wives and drivers’ wives were giving birth in the same hospital. The World Bank has recommended it as a model for Africa.
- Low level of telephone coverage in some areas
- Women who delivered refused to return the handsets given to them.
- Shortage of personnel.
- It was driven by financial assistance from World Bank.
- Mr. Akeredolu, the present governor, is complaining that a debt portfolio of N220 billion was left behind with N9 billion in the treasury.
Sustainability might become a problem.
As laudable as PPP is in enhancing health care delivery in Nigeria, it cannot on its own become a solution, especially with a kleptomaniacal and morally insane elite political class we have in Nigeria.
There has to be a political reorganization to reduce the burden of the political class on all other aspects of our society.
We must value the health of our people and have the right values and priorities.
God bless Delta State.
God bless Nigeria.