Minister of Health, Prof. Isaac Adewole reveals the challenges in the health sector, what the government is doing about them and why he did not resign his position following the position of President Muhammadu Buhari on the crisis in the National Health Insurance Scheme
The health sector is a very important aspect of the economy as it has to do with the well-being of the people. How difficult has it been managing this critical sector?
It has been very interesting and taxing. The sector spans research development, policy-making and service delivery, with different agencies, parastatals and departments under the sector focusing on different elements. As a minister, I provide the sector with strategic leadership and stewardship. From a service delivery point of view, I engage regularly with the departments to ensure programmes are being implemented according to plan. I receive updates from the Nigeria Centre for Disease Control on emergency responsiveness to disease outbreaks and work with other sectors to collaboratively address the social determinants of health. I also interact with heads of tertiary health institutions to ensure that we fulfil our mandates. I also interact with Nigerians who nurse grievances and seek assistance.
Since you assumed office as the minister, what would you describe as the most difficult decision you have made or the toughest part of your job?
The toughest part is managing people and the most difficult decision was explaining to Mr President why a polio-virus case was detected in Borno State. Luckily, he demonstrated total understanding and provided unparalleled support. He directed full release of N9.7bn budgeted for polio eradication. This was the first time Nigeria would release the total amount of money appropriated for any health challenge. Being a former military man, he understood the challenges of delivering services in a conflict zone.
People have always described the health sector as a troubled one and that no substantial progress has been made over the years, in terms of infrastructural development? Why has it been difficult to surmount the infrastructural deficit in the sector?
The currency for measuring the health sector should be the coverage of health indicators and not infrastructure. In this regard, we have done a lot but can do more. Our routine immunisation coverage (Penta 3) for instance, has gone up to 57.2 per cent from 48 per cent in 2015. We are distributing more long-lasting insecticide-treated nets to reduce the burden of malaria. We recorded a drop in the prevalence of malaria from 42 per cent to 27 per cent.We are completing the abandoned Cancer Centre at National Hospital, Abuja and have installed the High Energy Linear Accelerator (Cancer Radiotherapy Machine) that was in the crate for three years. Since installation, we have been treating 80 to 100 patients daily at the cancer centre. We also acquired a second machine through the generous support of SNEPCO. This should become operational soon. Work is going on at the University College Hospital, Ibadan and Ahmadu Bello University Teaching Hospital, Zaria, where we are building bunkers to house high energy linear accelerators to offer cancer care to Nigerians. I have visited University of Benin Teaching Hospital, Benin; ABUTH, Zaria; Federal Teaching Hospital, Ido-Ekiti, among others to inaugurate upgrades and newly completed projects. We have completed the Central Laboratory at Gadua (Bauchi State) and inaugurated two ultra-modern warehouses in Abuja and Lagos. These are additional to our signature projects of making 10,000 primary health care projects functional across the country.
Nigeria and two war-torn countries (Pakistan and Afghanistan) are the only ones that have failed to tackle the scourge of polio. Do you not sometimes find things like this embarrassing?
No one is happy about the current situation. It however must be said that the delay in declaring Nigeria polio-free, arose from the detection of a polio case in the conflict zone in Borno. Since then, we have redoubled our efforts and no case of wild poliovirus has been detected in Nigeria in the last 30 months. We are cautiously optimistic that this will remain so.
Nigeria is also said to have the highest maternal mortality rate in the world, and people have said Nigeria has no business being on that level, especially with the level of its skilled manpower and resources. Is this not discomforting?
A bit of correction, Nigeria does not have the highest maternal mortality rate in the world. We acknowledge that our indices have not been great, but we have instituted several interventions to address this. For instance, the Accelerated Maternal Mortality Reduction programme is aimed at rapidly reducing the MMR in states with the worst mortality rates. Also, the Basic Healthcare Provision Fund and the Saving One Million Lives initiative would help bridge the gap in access to high impact maternal interventions aimed at reducing mortality.
About three years ago, you inaugurated the one primary health care centre per ward programme. For how long will the public wait for the government to cover the remaining 10,000 wards after its inauguration at Kuchingoro Ward of the Federal Capital Territory by President Muhammadu Buhari?
The programme is ongoing and we are happy with the progress. Almost all the states have now identified their one primary health care centre per ward and are at different stages of revitalisation. We have, through the support of partners and other options, revitalised over 4,000 PHCs mostly in rural areas and we are still counting. Many states such as Kaduna, Kano, Niger, Borno, Edo and Osun are taking on the initiatives
It has been observed that a large number of patients in the tertiary hospitals should have visited primary and secondary health facilities instead, but the reverse of that has put enormous pressure on the teaching hospitals. What is the way out?
We are aware of this and we are putting in measures to reverse this. One of the measures is the Basic Healthcare Provision Fund, which guarantees that services delivered at secondary care facilities must be based on appropriate referrals. Also, the PHCs revitalisation programme is specifically targeted towards this.
On the NHIS coverage, what percentage of coverage did you meet on the ground and how much have you added?
We are concerned about the low coverage. With the BHCPF, we hope to rapidly expand access to millions of Nigerians.
Looking at the amount of money Nigerians spend on medical tourism yearly, why is it difficult for the Federal Government to set up a multipurpose medical facility that can take care of the medical needs of Nigerians, especially on issues of cancer and heart-related problems?
This is of utmost concern to the President Muhammadu Buhari administration. We have worked hard on this and have started seeing the results.
Why is it that Nigeria could not buy many of the required machines to save the lives of citizens, because there are times that only one or two will be working out of the seven in the country?
The National Hospital now has all it takes to treat cancer cases. We have two high energy LINAC machines that have capability to treat 200 patients per day. Many Nigerians who went to Ghana and India for treatment are coming back as it costs about 20 per cent of the cost of treatment overseas to get treated in Nigeria.
The President once frowned upon medical tourism but he has continued to do that himself, especially when the State House clinic is not in proper shape after allegedly gulping billions of naira. Shouldn’t there be a law that would bar public officers from travelling abroad for treatment?
Public servants, like every other Nigerian, should be able to seek care anywhere they are comfortable with. Don’t forget also that individual preferences mean people may have personal doctors they are used to. In addition, some were treated in the past and may require follow-up. We are also very secretive about our health and medical history. Most Nigerians die after a brief illness.
I honestly believe it is part of their rights in as much as public funds are not used. In instances where the capacity to treat locally is lacking, then public servants may get support from government for funding.
The health sector has suffered low budgetary appropriation over the years, despite the glaring needs in the sector. Are there no other ways the ministry could generate funds or other ways it could meet its obligations to the Nigerian people?
There are, and we are working on it. Together with the Ministry of Finance, we are exploring some innovative ways to expand the fiscal space. For instance, we are considering the sin taxes and telecoms levy. There are plans to encourage private sector participation in healthcare financing by developing investment case for health. The initiation of Basic Healthcare Provision Fund and the operationalisation of Saving One Million Lives initiative are designed to expand the fiscal space.
In the past, it was gathered that people came from outside the country for surgery, but now it’s Nigerians that run to other countries for treatment. How did Nigeria’s health sector degenerate to the level it is?
Poor funding in the past contributed to this, but that is gradually changing now. The government has earmarked the sum of N55.1bn for the Basic Healthcare Provision Fund. Also, the teaching hospitals are now being supported to improve their performance management in a manner that ensures continuous quality improvement of services and skills training. However, I must point out that not all Nigerians go on medical tourism. A lot of our people seek care at home and they have good testimonies about our healthcare system.
After the National Health Insurance Scheme boss, Prof. Usman Yusuf, was reinstated by the President, following his suspension amid corruption allegations and obvious insubordination to your office, many Nigerians who know you and what you stand for thought you would resign. Why did you not resign?
People who understand what leadership is all about cannot but understand why certain decisions taken by a superior authority should be respected. I saw it in that context. My appointment is a call to service and not an opportunity to compete with my boss.
After his reinstatement, the President only said he should learn to work with his boss. People feel the President took sides with Usman. Did you feel bad about it during that period?
As an insider, I did not (feel bad).
And how was your working relationship with him before he was eventually suspended?
We worked together and amicably to improve the coverage of healthcare services.
Recently, the Presidency said the board lacked the power to suspend the chief executive of an agency. In your view, would you say the minister should be armed with such power since you head the supervising ministry?
Once boards are constituted, a minister’s role in supervision becomes minimal. The issue of the powers of the minister is secondary. Broadly speaking, the NHIS Act would need to be reviewed to enable the organisation to carry out its functions optimally.
Recently when you were asked about the stress doctors go through for their housemanship, you said not all of them would be specialists and that some of them could go into farming. People feel that comment was not good enough as it seemed to undermine the aspirations of those doctors. Do you stand by that statement?
The point I was trying to make was lost in the context. Firstly, there are differences between medical schools and residency programmes. As at today, we produce more medical graduates than the available residency slots. This simply means the demand is greater than the supply. Recently, a teaching hospital interviewed 850 potential applicants for 120 slots. It is also important to note that as at today, the Federal Government’s spending on health is disproportionately tilted to tertiary care, which makes additional investment in tertiary care and by extension residency difficult.
I would also like you to note that the expansion of slots for residency has implications on civil service wage and vacancies declared in authorised establishments have to be approved by the civil service commission. Similarly, the Federal Government is the single largest employer of resident doctors as there are limited private tertiary facilities.
My point about doctors maximising their vocational skills and potential was based on these realities above and certainly not meant to slight my hard-working colleagues or Nigerians at large.
Some of the doctors are asking why you would say that especially when you didn’t go through all that as a budding doctor as some people before you had made things easy for you. Do you have a feel of their plight?
I was making a case for the development of entrepreneurial capabilities to reposition doctors for the 21st century labour market.
That said, I completely understand the constraints, frustrations faced by medical doctors seeking residency slots and we are working hard to increase the slots. For instance, we are actively encouraging private sector investments in tertiary care that provide more opportunities for specialist training. We are also working on reducing the extended stay of those who have finished the residency programme but still hang on.
Some people see it as an admittance of failure on the part of the Federal Government because they feel government should be working on ways to bridge that gap. What is the solution you are proffering to the shortage of placement for housemanship and residency training?
There is no shortage of placement for housemanship. What is creating the bottleneck is the inability of states to pay the right wages to doctors. We are commencing central placement of housemanship with effect from 2019. The central posting of other health professionals will follow thereafter.
When you came in, you promised to do something about the plight of cancer patients, many of who put their hopes in one or two machines in the whole country when small Morocco has many of them. Why is it that government presents itself as incapacitated as Nigerians suffer from cancer and are still dying needless deaths?
Like I mentioned earlier, we now have two fully functional machines at the National Hospital, Abuja capable of treating 200 patients per day. We have ordered for more machines and we are upgrading the teaching hospitals across the country to be able to provide adequate care. We will continue to do everything to alleviate the challenges associated with accessing quality care.
There seems to be a surge in the incidences of cancer and heart-related ailments. Some people have tied it to lifestyle and some other reasons. As a doctor of many years, what is responsible for this rise?
A number of reasons are responsible for these. Like you have rightly said, lifestyle is a factor. One other thing to note is that we are hearing about it more now because there’s more data out there and also because of the interconnection arising from the use of multiple social media platforms. We have also improved our diagnostic capabilities. Cancer is also essentially related to ageing. We expect the burden to increase as our life expectancy increases.
We have been talking about Lassa fever for many years and nothing has changed in the year 2018. Why is it so difficult for Nigeria to deal with this and many other vaccine-related diseases after so many years?
Lassa fever is a disease deeply rooted in the environment. We have improved our understanding of the disease and capability to diagnose and treat it. We are sending out alerts and warning messages to Nigerians about the threat and I can assure you that research for candidate vaccines is in top gear. Global warming could be contributory to low level transmission during wet seasons.