My address at the Scientific Conference and Ordinary General Meeting of the Association of Resident Doctors LUTH. August 2021

Protocol

It is a pleasure and honour to be invited as a keynote speaker at this scientific conference organised by the ARD. Pleasure because as an alumnus, LUTH holds many memories for me and this Old Great Hall in particular, contributed to shaping the foundation of what I have become as a doctor, words of wisdom from some of my old teachers such as Professors, Noronha, Okanlawon, Ebeabuchi, Olatunji-Bello, Adegoke, and the late Prof Adigun to mention a few were delivered in this room some 22 years ago.

2. It is an honour because amongst the multitude of qualified persons, you have found me worthy to be called upon. So, I take this quite seriously and hope that my thoughts, which are a culmination of years of my experience in the private sector, development space and now political arena, offer us an opportunity for reflection.

3. I must also say that despite the nightmare of getting to Lagos for this meeting, my regard for the association, the relentless pursuit by Dr Okerinde and the importance I place on the topic have weighed more significantly on me.

Making the presentation at the Scientific Conference organised by Resident Doctors in LUTH

4. Regarding the topic, I consider it a very germane one and most relevant at this time, given the challenges faced by the country and its attendant effect on the health sector. To reform the Nigerian Health Care Sector for a resilient (and I have included resilience because a good health system must have the ability to absorb and respond to unpredictable shocks in the short-term[1].) and sustainable (which I have defined as the ability to attain and maintain levers necessary to achieve desired levels of service coverage and financial protection in the medium-term) performance, we must first understand what the challenges truly are.

5. Understanding the challenges and being able to accurately diagnose them are a critical first step in enabling us determine what to do and how to go about doing them.

6. So, what are the challenges of the health sector?

Challenges

7. In one sentence, I have attempted to summarise the challenge of the Nigerian Health sector as a misalignment of our health system functions and goals. Conceptually, health system goals are categorised into three namely:

· Health — simply refers to improving and maintaining the health of the population

· Responsiveness — which explains how well the health system meets the legitimate expectations of the population for the non-health enhancing aspects of the health system[2].

· Financial protection — which makes it easy for you and I to sleep at night, knowing that cost of accessing care will not lead to poverty or our early demise.

A conceptual framework for achieving UHC.

8. Even before defining the health system functions, I’m sure you all can agree that as a nation, we are not performing optimally on any of the three goals listed here.

9. So, what are the health system functions and how do we tweak them to ensure we attain health system goals?

10. Broadly speaking, there are four health system functions namely: (i) Stewardship/Governance, (ii) Financing, (iii) Investments in human and physical resources, (iv) service delivery[3]. A high performing health system must maximise all four functions to enable it achieve the three (3) health goals earlier highlighted. Before I continue, it is important to say here, that there are several contextual factors (political factors, educational levels and income levels) outside of the health sector that could limit the attainment of these goals, but those are not exactly the focus of today’s discussion.

Investments in human and physical resources — Issues and Challenges in Nigeria

11. Optimising human resources for health requires that (i) Sourcing — the Country/State has enough, (ii) Distribution — Country/State avoids skewed health worker density by distributing available HRH across its geographical spread to ensure every household gets access to adequate care (iii) Productivity and Capacity — HRH is skilled and productive (iv) Incentives and Rewards — are timely and competitive enough to retain the best hands.

12. Interestingly, more often than not, the focus in Nigeria has always been about the first and last point. The data however points in a slightly different direction. Although we are far from the WHO recommendation of 10 physicians per 10,000 people, at 4 physicians per 10,000 people[4], Nigeria compares favourably with its peers when one looks at the availability of health workers. Ghana and Ethiopia both have 1 physician per 10, 000 people3. This indicates that while sourcing may be an issue, the bigger issue within the context of Nigeria is ensuring better distribution of existing workforce. Similarly, it is often said that the hospital staff are overworked, but when I use Ekiti as an example, in our busiest General Hospital, data indicates the average doctor only sees between 4–5 patients per day[5]. This is not peculiar to Ekiti, as the low numbers are fairly consistent across the country. Kaduna, Niger, Nasarawa, Abia, Osun and a few other States in which I’ve done some work for instance have similar levels of low productivity.

13. Regarding infrastructure, this perhaps is one area where a good number of States and the Federal Government have made significant investments. The challenge however as earlier mentioned is the misalignment between investments and the health system goals. So for instance, States and indeed the Federal Government ideally should focus more resources on improving infrastructure, availability of commodities and use of technology for health in existing facilities rather than build new ones.

Stewardship/Governance — Issues and Challenges in Nigeria

14. Stewardship, which refers to the role of government in providing vision, strategic leadership and use of performance management as a lever in strengthening the health system for the wellbeing of the population[6].

15. Given the federating nature of our country, both the Federal Government and States have a role to play in setting the vision and strategic policy for the sector. The National Health Act also strengthens the sector’s capacity to shape and define the sector’s future through the National Council on Health[7]. Fragmentation, duplication of functions and lack of clarity on a plan have however stalled the country’s ability to improve health system performance. For instance, there are grey and contentious areas in the roles and responsibilities of FMoH and NPHCDA in programs such as malaria and nutrition, which have a spill over effect at the State level.

Health Financing for a resilient and sustainable health performance — Issues and Challenges in Nigeria

16. A good health financing system must (i) mobilise resources; (ii) pool the resources mobilised together and (iii) purchase the services.

(i) Resource Mobilisation — mobilise resources adequately and sustainably. Adequately meaning that enough resources are raised to fund health service delivery and sustainably meaning that resources raised are prepaid and compulsory. As it stands, Nigeria’s current health expenditure per capita is $84[8], a figure much higher than that of Ghana and Ethiopia at $78 and $24 per capita respectively. The challenge however is the way this expenditure is raised. Only 16.5% of this expenditure is from the government whilst 72.2% is out-of-pocket[9]. This government expenditure represents one of the lowest in the world and has implications on the scope and scale of health services available to the population[10]. Relatedly, the high out of pocket expenditures indicates that a good number of households in Nigeria will face financial difficulties should they decide to use health services. Secondly, the conditions for a sustainable mobilisation of resources are absent in the country as we neither have a countrywide prepaid or compulsory system for generating revenues. The 1999 Act established the NHIS but did not make health insurance mandatory for Nigerians.

(ii) Pooling — which typically involves the accumulation of prepaid revenues for health so that beneficiaries can use a set of health services without having to pay the full cost from their own pockets is absent at a population level in the country. Pooling provides beneficiaries with peace of mind — the knowledge that, if they or their families fall ill, they will be able to use health services without financial hardship.

(iii) Purchasing — is the allocation of funds to obtain health services, both personal and population-based, as well as to secure system governance and operate cross-cutting essential public health functions. Purchasing can take the form of buying services or the inputs to produce them. Traditionally, our approach as a country to purchasing has focused mainly on allocating resources to service inputs such as drugs and consumables, salaries, infrastructure etc. This system of payment does not provide clear linkages between provider performance and health needs of the population. In most States for instance, the government procures commodities, pays health worker wages and provide somewhat, health infrastructure. Very few States, however, can explicitly define services actually delivered (at the right quality and regularity) in their health facilities and measure their performances. Although with the advent of State Health Insurance Agencies, most States have moved towards purchasing more strategically and using payment methods such as capitation and fee for service as incentives to achieve health system goals, these, still falls short of global good practice, in which multiple payment systems are blended and the inherent incentives within each payment system used in calibrating provider behaviour effects.

Service Delivery Issues and Challenges in Nigeria

17. Strengthening service delivery is crucial to Nigeria’s goal of reducing maternal and neonatal mortality and the burden of communicable and non-communicable diseases. It is an immediate output of the other three (3) functions, which I have discussed earlier. Unfortunately, we have made limited progress in service delivery. Maternal mortality ratio has hovered between 512 and 545 per 100, 000 lives births, between 2001 and 2018, Neonatal mortality remained relatively stagnant between 42 and 39 deaths per 1,000 live births between 1990 and 2018[11]. The poor outcomes are largely driven by low coverage rates of high impact health interventions. For instance, only 43% of deliveries in Nigeria are assisted by a skilled provider10. These figures are worse in the poorest households, where only 12% of births are carried out by a skilled attendant10. The low coverage in turn, is a direct result of the poor optimisation of the other three health system functions earlier discussed.

18. I have included under the service delivery function, the issue of public health emergency and preparedness. Nigeria has witnessed at least 2 disease outbreaks every year for the last 10 years, which presupposes that our plan of action should focus more on preparedness.

19. Having discussed the challenges and provided examples of where we have either fallen short or simply mis-diagnosed the problems, I’d now attempt to provide some practical solutions on building a resilient and sustainable health system using examples from Ekiti State.

Stewardship— Approaches from Ekiti State

20. To strengthen stewardship in the health sector, we focused on two main things –

(i) Visioning — In my first one month of assuming office last August, a 3-day health sector retreat was held to enable relevant MDAs review and redefine performance of the State health sector. Three key objectives of the retreat were:

a. To define, understand and agree on current challenges affecting effective and efficient provision of health service delivery;

b. To co-create solutions aimed at improving the quality of service delivery across all levels of care, whilst strengthening resilience of the health system;

c. To map out as well as prioritize interventions for immediate and long-term implementations

The retreat provided an opportunity for every stakeholder to understand their roles and responsibilities, areas of collaboration and specific deliverables they would be held accountable for.

(ii) Performance Management — We instituted this initiative, which is underpinned by four key steps namely; (i) Use of data; (ii) Regular review of progress; (iii) Implementation of corrective actions and (iv) Align on targets.

We have used this across multiple levels, with great success. For instance, I am personally involved and present in fortnightly meetings with the director level cadre in the ministry of health and quarterly meetings with the broader MDAs. Similarly, when the Covid-19 vaccine was deployed we set up a daily situation room, using the four key steps to measure performance. The result? We were the best performer in the country in vaccine deployment and received a lot of commendation from the Federal Agency.

Investments in human and physical resources — Approaches from Ekiti State

21. We recognised very early on, that our fiscal space as a State was limited and there was only so much recruitment we could take on. So, we focused primarily on redistribution, capacity building and rewards. At the Primary care level, where this time last year, 50% of our nurses and midwives were spread across only 5 of the 16 LGAs, we have redistributed our nurses and midwives within senatorial zones to ensure a more equitable access to skilled hands. We have also trained about 20% of our existing primary health care workforce, with more to be trained this year. We now also recognise stand out performances and celebrate birthdays of staff workers monthly. These non-financial incentives have been proving to be powerful motivators in the workplace environment.

22. Mindful that more needed to be done, we have recruited more than 20 doctors in last 1 year to support service delivery at the primary and secondary care facilities. We complemented these efforts by establishing a NYSC medical fellowship in which NYSC Corper doctors are actively encouraged to work in rural settings in Ekiti State. The fellowship was borne out of the realisation that in the past, more than 50% of corper doctors posted to the State relocated immediately after camp. Today, as I speak with you, we have managed to retain 99% of all doctors posted to the State since the advent of the medical fellowship.

23. Similarly, we have developed a program to utilise services of doctors at our teaching hospitals to complement the existing staff at our General Hospitals. This program aligns our goal of increasing utilisation in these facilities with incentive payments to the doctors by ensuring that doctors on the program get renumerated based on a composite number of patients seen.

24. Our investment in infrastructure has moved away from building new hospitals to modernising existing hospitals and providing the relevant equipment to work with. In addition, we have just developed a bill to set up our drug management agency. The agency, which will be capitalised with the sum of N80m at the outset will shift focus away from fragmented purchase of commodities and consumables to a more structured system that aligns with global good practice across the different supply chain functions.

25. With our investments in human and physical resources, data measurement and use become even more important. Consequently, we signed a partnership with Helium Health last week, to enable us collect, collate and synthesize health records electronically and in real time. The partnership also offers us the opportunity to digitise payment collection. This demonstrates our commitment to transparency and accountability.

Health Financing for a resilient and sustainable health performance — Approaches from Ekiti State

26. To set the State on the right path, and enable us match our ambition with our vision, we tripled our capital budget from N1bn to N3.2bn in 2021. In addition, we have deepened our public financial management processes by consolidating donor resources into our budget.

27. We have earmarked resources to fund a defined and explicit set of high impact services/interventions to be provided across the State. Working with global partners in the health financing space, staff at our Health Insurance Agency, recently undertook an executive course on health financing.

Service Delivery — Approaches from Ekiti State

28. Our primary objectives in service delivery focuses on increasing utilisation and quality of care at the front line. To achieve this, we have taken a three-pronged approach. The first, is the establishment of the enabling regulatory framework backed by law, to institute a process for standardisation, monitoring and accreditation of service providers in the State. The second is a policy on clinical governance and quality of care and the third is the introduction of continuous quality improvement measures at service delivery points.

29. We have taken advantage of the COVID-19 pandemic to strengthen our public health security. We have decentralised testing to 145 testing centres, the highest in the country, and improved our disease surveillance capacity to pick up early signals of possible outbreaks.

So what?

30. As you may have figured, our approach in the State focuses on laying the foundation for a resilient and sustainable health systems through a mix of immediate term interventions and programs whilst putting the laws in place to ensure that key programs are sustained long after the administration ends.

31. Our deliberate approach to utilising multiple levers across the health system functions in achieving our health goals have begun to yield some fruit. We have in the last 1-year increased confidence in the system. Anecdotally, there’s an increased interest in the use of health services by households in the State and latest data indicates that we have increased our immunisation coverage rates to 86%[12].

32. The journey to achieving our goals requires a thousand steps, but we have taken necessary actions, mindful that, like Johnnie Walker said, we must “keep walking” in the right direction.

33. Before I round off my address, I would like to touch briefly on the ongoing strike by the NARD. Whilst the issues raised are relevant, the effectiveness of strikes as a tool for negotiation are up for debate. As doctors, our approach to labour and other work related issues must focus on compelling and irrefutable arguments that provides opportunities to gain friends/sympathies across several industries.

34. Finally, I would like to thank everyone for listening and I do hope that this has been enjoyable and thought provoking for you all.

God bless

Dr Oyebanji Filani

Honourable Commissioner for Health and Human Services Ekiti State

Presentation of award of recognition by the association
With the Provost CMUL, President of the UNILAG ALUMNI association (Lagos Branch) and members of the ARD Exco
From L-R Dr Olowojebutu, Dr (Mrs) Fakile , Dr Adamson, Myself, Dr Oyedokun and Dr (Mrs) Eguavoen

[1] Christoph Kurowski et al 2020 — Health Financing Resilience Initiative

[2] Charles Darby et al — Strategy on measuring responsiveness WHO

[3] World Health Report 2000 — Improving Health System Performance

[4] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=NG

[5] Results from diagnostics carried out on health worker productivity in select General Hospitals in Ekiti State 2020

[6] Phyllida Travis et al 2002 — Towards better stewardship: concepts and critical issues

[7] National Health Act 2014

[8] https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD

[9] IMF World Economic Outlook 2018

[10] WHO Global Health Expenditure 2019

[11] NDHS 2018

[12] NPHCDA LQA Data 2020