Nigerian physicians in the Diaspora recently converged on Las Vegas for the annual scientific session of the Association of Nigerian Physicians in the Americas (ANPA). Tokunbo Adedoja writes on the issues raised by some of the physicians as responsible for the precarious state of the Nigerian health sector.
Why is the Nigerian health system in spite of the huge resources – human and material – that the nation could boast of still in a parlous state? Why is the nation plagued by a dearth of world-class medical centers? How can the health sector be revamped and become attractive for big players in the private sector? What steps should be taken to halt the brain-drain in the health sector and attract Nigerian physicians in the Diaspora back home? Should public office holders be barred from seeking medical help abroad as a way of forcing them to address the problem in the health sector? These were some of the questions raised by THISDAY with some Nigerian physicians residing in the Americas during a three-day scientific session in Las Vegas recently.
Interestingly, many of the Nigerian physicians in the Americas, some of who manage flourishing health centers and several others who are playing important roles in leading health institutions in their host countries hold strong views on the state of Nigerian health system, and how the sector could be revamped. Even though their views were as divergent as their numbers, they were unanimous on the fact that Nigeria’s health sector should not be in the state that it is, and something urgent must be done to salvage the situation.
Michael Etomi, medical director at Fresenius Home Dialysis in Charlotte, North Carolina, and vice-president, Metrolina Nephrology Associates, also in Charlotte, believes that funding of the sector “is grossly inadequate.” Noting a report that indicted Nigeria as one of the countries that spend the least per individual for healthcare, Etomi said government must improve on the funding of the health sector if it desires a corresponding improvement in the facilities and quality of service. Achieving this, Etomi said, requires the will and education, not only of the Presidency, but also of the National Assembly, adding, “We have to be able to help and guide them. It is not sufficient for our leaders, civil servants to be able to go abroad to get healthcare assistance and not to realize that they are responsible for making it happen in their own country.”He reasoned that, technically, if senior government officials were barred from seeking medical treatment abroad, they would likely be forced to focus on improving the medical facilities at home. He however, quickly added that he would not mandate what anybody would want to do with him or herself privately.
Etomi, who is also the President of Association of Nigerian Physicians in the Americas (ANPA), made up of physicians and dentists of various healthcare specialties in the public and private sectors across North, Central and South America – however said the private sector had a role to play in revamping the nation’s health sector. On its part, he said ANPA would focus on improving Nigeria’s tertiary health system by working with groups and corporations towards facilitating the building a world-class tertiary hospital in the country. The tertiary hospital, which would be a private venture, would have specialized personnel and facilities for advanced medical investigation and treatment. Noting its partnership with United States Agency for International Development (USAID) to help reform the curriculum in Nigerian medical schools, Etomi said ANPA had also taken the bold step of signing a memorandum of understanding with the Ministry of Health and the National Primary Healthcare Development agency (NPHCDA), which focuses on five specific areas – education and training, health-related research, service delivery and skill transfer, quality assurance in healthcare delivery, and private sector investments in the health sector.
The Associate Dean for the Office of Global Health and Associate Professor, Department of Surgery at The University of Texas Southwestern Medical Center in Dallas, Fiemu Nwariaku, said “The difficulty is more than medicine. It is governance, its leadership, its management, its corruption and all the things that plague our society.”Noting that Nigeria had a history of excellence in medical care, institutions and medical training, he recalled that the nation used to have some of the best medical institutions on the continent. “If you look at the history of some places like University of Ife (now OAU), University of Ibadan, University of Lagos, these universities and teaching institutions actually trained other Africans in the region who went back to start their own medical schools,” he said. But those institutions have also witnessed years of decay. This, he said, was not peculiar to medical schools as such questions had also been raised about law schools, engineering schools and architecture schools. “So we suffered as a nation, several decades of terrible, crumbling educational institutions in all professions, and medicine suffered from that,” Fiemu said, listing inadequate funding, corruption and absence of a signed healthcare bill that would provide a road map, as some of the causes. “Even where there is enough funding, there is a mismatch of funding”, he said, noting that federal tertiary institutions get more funding than the local government areas.”But the disease burden is higher in local government. So, does that make sense? The best doctors and nurses go to the federal medical centers and teaching hospitals, but the bulk of the population resides in places where they rely on primary healthcare and not federal. So there is a mismatch of funding”, he said.
In his view, “getting back to where we were 50, 60 years ago, requires working on the infrastructure, the hospitals, the buildings, the equipment and the training of people who work there.” On whether foreign medical treatment by senior government officials should be banned, Fiemu would rather align himself with the Federal Ministry of Health’s pronouncement that state funds would not be used to send public officials overseas for treatment. Arguing that healthcare was a “very private and personal thing”, he said some of those who go overseas for healthcare do so not necessarily because they could afford it, but also because some of them would want their privacy preserved in places where they would remain anonymous. “Telling people not to seek medical help anywhere if they have the funds, is like overstepping the bounds of government, “he said.
Ola Ayodeji, a Kidney specialist with the Peninsula Kidney Associates in Hampton, Virginia who said he had been away from Nigeria for some time, described healthcare, in this day and age, as capital-intensive. He suggested that either government or individual’s partner together or doctors pull resources together so as to be able to afford to put together excellent world-class centers. On whether banning overseas medical treatment for senior government officials would help improve Nigeria’s health system, Ayodeji said he would not advocate restricting access to highly needed care, “because when you have a medical problem, then it becomes a personal thing, you want to survive, whatever it takes, wherever you can get the care, whatever you have to pay.”
Ajovi Scott-Emuakpor, a Professor at Michigan State University, who had trained generations of Nigerian physicians, agreed that “Nigeria is filled with talents and there is no area of medicine that you will not find Nigerians that are super talented.”Why then is the health sector in the state that it is? The question about Nigerian healthcare system is all in the culture of the country, Scott-Emuakpor said, adding, “Nigeria’s culture does not favor the promotion of excellence. Nigeria’s culture favors the promotion of not only mediocrity, but it promotes material possessions.”For that reason, he said physicians that are talented and knowledgeable, but not greedy, are excluded from the mainstream of decision-making. Recalling that he gave the keynote address to the 50th anniversary of Nigeria Medical Association (NMA) where he highlighted some of these issues, Scott-Emuakpor said ANPA could, in a sustained and persistent manner, infiltrate the mindset that had set the nation back and promote some excellence.
On seeking medical treatment abroad, the Lansing, Michigan Area Pediatric Oncologist and Pediatric Hematologist would however not support placing a ban on public officials from seeking medical treatment abroad because in a democracy, individuals must be free to make choices. Noting that those who seek medical treatment abroad were a very insignificant proportion of the Nigerian populace, he said the bulk of the Nigerian population could not afford even to travel out of their local government areas to the headquarters of their states to seek medical care, let alone leave the state. “Those are the people we are interested in. We are not interested in the technocrats and the bureaucrats who have the money to travel abroad. We are interested in the masses. How we can bring proper healthcare to the masses that needed it most, he said.
Potomac, Maryland-based Charles Afam Obioma, a gastroenterologist, who runs three surgery centers, said, “a lot of us who are here have intent of going home if we find the appropriate way of doing it,” but added that the high cost of land and security were the main reasons why Nigerian physicians abroad who were willing to return home and build world-class medical centers could not do so. Citing his own experience, Obioma, who noted that he had many VIP patients in Maryland, said he had been looking for land in Abuja to build an ambulatory care center where some foreign-based specialists would practice and train people. “We can’t afford the expensive and exorbitant money that you pay for land in Nigeria and still be able to afford to build an appropriately sized medical center with the state of the art equipment.”Describing security as another major issue, Obioma, who trained at the University of Lagos before going to New Jersey Medical School, raised a poser: Are we going to be safe when we come in? “Recalling a sad incident, he said: “The chief of orthopedic surgery, one of the doctors that used to go with us to do medical missions in Imo State, he had a heart attack (in Nigeria) and he died. He was the chief of orthopedic surgery at the third biggest medical school in the United States, University of Pennsylvania. “A thing that we could have taken care of here. That is part of the security that we are talking about. Are you able to get quick emergency care? Of course, we stopped going to my state, Imo, this year because of the amount of kidnapping. These are the kinds of things that retard our progress, not because we don’t want to but we have road blocks.”The gastroenterologist also noted the problem of electricity to power the state of the art medical equipment that would be brought in, but quickly added: “even at that we may even buy generators but security is important.”
Washington DC-based President of Foundation of Combined African Medical Mission (FCAMM), Olabisi Jagun, said Nigeria could not be said to lack qualified physicians, some of whom had slowly been finding their way back home to see how they could help revamp the system. She however said government needed to make health a priority, “because the health of a nation determines the wealth of the nation.” Jagun noted that the budgetary allocation to health was abysmal, not only at the federal level, but also at the state level. Summing up what should be done, she said: “We need to also take care of the different aspect of health. The preventive aspect because a lot of what kills the people are preventable. Like 70 per cent of the illnesses in Nigeria are preventable. We need to focus our attention in that area. “Also it would take resources to rebuild our health institutions – primary, secondary and tertiary. There is also need for capacity building to close the gap in knowledge, whether at the nursing level or the physician level, we need to bring the knowledge up through continuing medical education. In medicine, you need to always constantly update your knowledge.”The FCAMM president aligned herself with the view that public officers must be barred from traveling abroad to seek medical help, saying that would make them concentrate on how to raise the standard of health care delivery in Nigeria and standard of the facilities.
California-based Nkem Chukwumerije, who is the Physician-in-Charge, Division of Hospital Medicine Kaiser Permanente Medical Center, said implementation of strategic plan was the problem of the Nigerian health sector. “Nigeria has developed a lot of strategic plans on medical facilities but implementation is the problem. I think the way out is to get the right leadership that does not just plan but also tries to get the outcome, “he said. Chukwumerije would not align himself with the view that public office holders should be barred from seeking foreign medical help abroad. He said the choice of health care provider should be a personal affair and individuals should have the choice of picking the best physician from any part of the world, as long as state funds were not used.
Nevada-based Charles Folashade, and author of “Controlled Drugs Prescribing Laws”, described the state of Nigeria’s health sector as a microcosm of the development in the whole society. “We are a corrupt society. Everybody thinks of himself. Those that are healthy and are in power are only thinking of the amount of money they can amass. When you are healthy, you don’t think that you will be sick, you don’t think about other people around you that are getting sick,” he said. He noted that one of the fundamentals of any nation that is going to develop or aspiring to develop is good health, adding that until the nation realizes that apart from food and shelter, healthcare is the most important component of any economy, it would go nowhere. Citing as example, he said US spends the biggest part of its money on healthcare because it knows that “a healthy citizenry is a productive citizenry and a productive citizenry means more money to the state, more money for the government, and more money for everybody.”Folashade, who had not been to Nigeria since he left the country in 1988, also lamented the difficulties Nigerian physicians abroad who attempt to go back home face. Quoting from the experiences of others, he said, “people like us when we go back and we want to contribute, we are seen as outsiders. They make life difficult for us. If I go back and want to work in UCH, from what I have heard from others, they think you are there to take over.” The Ibadan-trained physician, while noting that Nigeria lacks strong medical laws, said, “I think what we need to do is to encourage Nigerians in the Diaspora to come home and develop what we have.”
A cardiologist at the Cardiovascular Clinics in Anniston, Alabama, Osita Onyekwere disagreed that funding is the problem of Nigerian health sector as there are many Nigerians that are even richer than some small countries. Onyekwere who is a specialist physician in Vein care and aesthetics at the Vein and Vascular Laser Institute and Aesthetics also in Anniston opined that if some of these Nigerians could pool resources together, they would come up with world-class facilities. According to him, the problem of the Nigerian health sector had its roots in culture, corruption, insecurity and infrastructure. “One of the problems is that our people don’t respect our resources, he said, adding, “Nigerian culture is such that if something is from overseas, it is believed to be better than something that is homegrown.”On infrastructure, he said: “People who had tried to put up something in Nigeria have told me that there is an upfront, maybe 20 per cent overhead just for running a generator to generate electricity, and if you have to put it on top of what you have to pay people to protect you somehow, that is another 10 per cent of your gross revenue. Right of the board, you are already rolling a 30 per cent overhead to set up a clinic, and then everything else is on top of that. ”He said even at that, he would like to go to set up something in Nigeria, but the security issue was a huge impediment. He added, “It has become profitable to kidnap doctors in Nigeria. Somebody like me, I have four children that need me. I can’t afford to go to Nigeria and get kidnapped just because I want to help other people. It just doesn’t make sense.
For Nnamdi Maduekwe of the American Board of Psychiatry and Neurology, State of New York Office of Mental Health, the political will to effect changes is what is needed.”Our leaders do not have the political will for the changes that are needed in the medical sector”, he said, adding, “Some of our people don’t even need the government money. They just need the political space that encourages people to bring back the money, to bring back whatever money they have to invest in the system.”
On his part, Okey Okuzu of Instrat Global Health Solutions attributed the state of the health sector to the unwillingness of physicians to adopt technology and the limitation of their experiences.”So collectively, as other places advance in technology, we are not embracing those technologies and it is hard to become that center of excellence. If you lay upon that, the complexities of the Nigerian system of governance, then that exacerbates the impact,” Okuzu argued.He however added that things were changing “because we are getting better governance and we are starting to see innovations coming from outside Nigeria and giving Nigeria’s opportunities to embrace those innovations, we will see a lot of improvements.”