“Activating the Other Hand: Towards A Citizens’ Approach to Healthcare Delivery” Chukwuma Charles SOLUDO, CFR

The 26th Annual LAPO (Lift Above Poverty Organization) Development Forum, 2019 on the Theme: “The Nigeria Healthcare Dilemma: The Way Forward” held at the International Conference Centre, Abuja: 22nd October, 2019

I: Introduction

Let me thank LAPO for the honour to chair its 26th Annual Development Forum. In that capacity, let me also join the organizers in welcoming all of you to the Forum. The theme of the Forum: “The Nigeria Healthcare Dilemma: The Way Forward” draws attention to a very critical pillar of national transformation. As the saying goes, health is wealth, and hence a healthy nation is a wealthy nation. You are the experts on the subject—policymakers and regulators, NGOs and CSOs, health and insurance practitioners, government officials and legislators, health researchers and Think Tanks, development partners, organized private sector, etc. Beside an interest in development economics and concerns as a citizen, I must confess that this is a subject that I know very little about. It is said that it is better to keep quiet and let the audience think that you are a fool than to open your mouth and confirm it. I should therefore respect myself and keep quiet rather than expose my ignorance by dabbling into a subject that should be better left for the experts. I am glad that we have as keynote speaker, a renowned expert on public health.

In this short introductory note which I hastily scribbled last night, I try (as a layman) to draw attention to a few issues for you, the experts, to take into account as you deliberate and fashion out ‘the way forward’. I have entitled this chairman’s opening remarks: “Activating the Other Hand: Towards a Citizens’ Approach to Healthcare Delivery”

In most conferences and development fora, the recommendations or action agenda dwell essentially on “what government should do”. For most issues, especially those bordering on social actions/outcomes such as healthcare and which also depend on behaviour and lifestyle of citizens, an often neglected missing link is the action agenda for the individuals and non-state actors such as the community, the religious organizations (churches and mosques), social and cultural organizations, professional associations, corporations, NGOs and CSOs, etc. Our thesis is that by often focusing almost exclusively upon government action on matters such as healthcare, we have been clapping with one hand and expecting a loud sound. It is time to active the other hand— the Citizens’ United Action for Healthcare (CUAH)! LAPO observes that “government expenditure on health is only 25.15% of all the money spent on health across the nation… and that healthcare delivery in Nigeria has experienced progressive decline due to multifarious challenges that have beset the health sector for decades”. While government expenditure on health (like other sectors) needs to be ratcheted up and its facilitation and regulatory functions strengthened, serious attention at fora like this one, should also focus on how to maximize the latent potentials of the “other hand”— individuals and non-state actors—in reversing what LAPO identifies as the “progressive decline” of healthcare delivery in Nigeria.

II: Unpacking the Healthcare Statistics for Effective Intervention

Nigeria’s healthcare statistics are as scary as its poverty and unemployment statistics. Using the average life expectancy as summary indicator of state of health of a society/country, it is evident that a strong correlation exists between the level of poverty/inequality and the state of health. The global rankings of per capita income vis-à-vis average life expectancy of countries illustrate this point. Studies have shown that poverty is both a cause as well as a consequence of poor health. This point should be self-evident. However, a careful examination of the country statistics will suggest that healthcare status is not always and everywhere a matter of just money (size of income per capita or poverty). There are enough African examples to buttress this point. For example, while Nigeria Africa’s largest economy with per capita income of about $2,000 has a life expectancy of about 54 years, several poorer African countries (on per capita terms) have far higher life expectancies: Rwanda (68.75 years; $825); Ethiopia (66.33 years; $790);  Eritrea (66.08 years; $1,100); DR Congo (60.48 years; $500), etc, etc. It is important to understand why an average Rwandese (with about one-third of the average income of a Nigerian) manages to live about 15 years longer.

Furthermore, average or aggregate national statistics are useful in many cases, but for effective intervention programmes, we must carefully unpack the averages or aggregates. Spatial and demographic distributions of healthcare can be critical. In other words, when one churns out the statistics on Nigeria, someone might rightly ask: “which Nigeria are you referring to?”— are you referring to Lagos, Bayelsa, Anambra etc or are you referring to Sokoto, Katsina, Adamawa, Jigawa, Kebbi, Bauchi, Gombe, Zamfara, etc? Evidently, unpacking the healthcare statistics by state will reveal more about the prevalence of certain diseases or challenges by state and even by sex and age groups. Another country that probably mimics Nigeria in terms of having multiple enclaves within the same country is South Africa—with per capita income of $6,600 and yet with ‘average’ life expectancy of just 63.87 (far lower than Rwanda or Ethiopia which have lower than $1,000 per capita). The White South Africa is clearly different from the black South Africa. In these circumstances, a one-size-fits-all response package will definitely be inappropriate and ineffective.  Differentiated and targeted responses might be the way to go.  

Healthcare delivery is a multifaceted agenda. In the Western countries, it is noted that the great improvements in life expectancy especially in the 20th century had more to do with better nutrition, clean water and sanitation than merely the transformations in medical facilities. New-born deaths may have as much to do with poor medical facilities as with the health/nutritional status of the mothers. If (as one of the NBS household surveys showed), some 32% of the population then were food-poor, and probably living in inhuman conditions with poor water and sanitary conditions, it is not difficult to draw conclusions about their health status—regardless of the availability and accessibility of health facilities. Of course, we know that access to standard health facilities is a key issue.

Individual lifestyle as well as superstitious and religious beliefs are critical in the overall healthcare delivery. “You are what you eat” is a famous quote. My wife says that the secret to a healthy living is: “Eat clean, exercise dirty”!  Yet, a serious pushback says that “one thing must kill a man”— as an excuse for mostly dangerous indulgences. Check out the drug epidemic among our youths, the reckless drinking and smoking habits of many, the addiction to processed foods, as well as lack of adequate physical exercise by most or resistance to periodic medical check-ups even for those who can afford such. Most people probably underestimate the impacts of superstitious and religious beliefs on healthcare delivery. In a society where many have abdicated a sense of personal responsibility and every challenge, including ill-health, is caused either by the devil or bad people, and there are enough religious people to diagnose every sickness as coming from the devil or “sent by bad people or the enemies or even family members”, healthcare delivery faces peculiar challenges. Many people afflicted by HIV or cancer or even malaria/typhoid, pneumonia, measles, etc have been told by their religious mentors that they were suffering from “spiritual attacks” and therefore needed spiritual rather than medical treatments.  In the circumstance, miracle/magical healing centres are growing faster than hospitals/health clinics—with thousands if not millions dying as a consequence. Critical immunizations have been known to have been resisted in many places on account of superstitious beliefs and unfounded propaganda. The list is long. The point here is that you, as the experts, have your job cut out for you as you try to fashion ‘the way forward’.

III: The Road Ahead and the Road Not Travelled

As chairman’s opening remarks, I must resist the temptation to pre-empt our expert keynote speaker. He will take us through the solutions—the way forward. Mine are a few nuggets—footnotes.

For starters, it needs to be emphasised that we have never lacked great ideas especially in relation to public health. I recall the great works of late Dr. Olikoye Ransome-Kuti in public health delivery while he was the Minister of Health. Chapter Two of the 1999 Constitution contains Nigeria’s socioeconomic and political rights and among other things mandates the State to ensure that “there are adequate medical and health facilities for all persons”. It is argued that the provisions of the Chapter—Nigeria’s goals for Eldorado—are non-justiciable and thus cannot be enforced. The UN Sustainable Development Goals (SDGs) number three envisions that by 2030 all countries should “ensure healthy lives and promote wellbeing for all at all ages”. There are about 13 specific targets to meet this goal. From all indications, Nigeria is set to miss the targets and the SDG goal on health except some dramatic and systematic reforms are initiated and sustained from now until 2030. To tackle healthcare challenges at the roots requires decisive and comprehensive war on poverty, inequality, illiteracy or poor public health education, nutrition, water and sanitation, as well as provision of adequate and accessible public health facilities and insurance schemes.

A starting point in the design of new interventions is to understand why a plethora of earlier programmes and policies failed or remain largely unimplemented. Second, it needs emphasising that health is on the Concurrent list of the 1999 Constitution of Nigeria as amended. It is thus the responsibility of the Federal and State governments. Some critical components such sanitation ought to be the responsibility of local governments. Both states and local governments constitute about one half of the consolidated public sector expenditure in Nigeria. Many analysts miss this point as they focus primarily on the activities of the federal government (sometimes even inappropriately comparing the expenditure of only the FGN to the combined national expenditures of countries that are unitary states). What is required for effective public healthcare in Nigeria is consolidated national (rather than federal) public sector intervention. It will require extraordinary regime of coordination between the FGN and the 36 states for effectiveness— the only way to ensure that you clap with two hands in respect of public sector intervention. Whatever the content or context of the healthcare delivery system, there must be a deliberate strategy to mainstream smart technologies and ensure accessibility.

Education is key to effective healthcare. The Constitution provides for free and compulsory primary education, as well as free secondary education. It is our view that primary and secondary education (with appropriate new curricula for public health) should be made compulsory in Nigeria especially for girls. Qualitative education for our girls holds the critical key to unleash Nigeria’s developmental momentum. As the saying goes, the hand that cradles the child rules the world. Any society that subjugates its women and fails to maximize their contributions to national development is akin to an airplane that flies with only one engine. Such a society will always underperform and remain underdeveloped as it struggles to clap with only one hand. Some 42% of our population are between ages 0 – 15 and largely under the care of their mothers. It is difficult to see how we can sustainably solve the problem of maternal, new-born and child deaths or even pragmatic population control without the empowerment of girls/women through qualitative education and jobs. With a structured public health education programme, all radio and TV stations in the country could be required to devote at least two hours a week to public health education. Agencies such as the National Orientation Agency could find a new purpose to be actively alive again.

Finally, we suggest that what is required is a collective response, and not just a government response. Public policy cannot be effective without a vigilant and demanding citizenry.  Individuals and non-state actors account for some 75% of healthcare expenditures—according to LAPO. A sustainable strategy of the future is how to mobilize this dominant but latent force to transform the delivery system. Our NGOs and CSOs should go beyond advocacy and become champions of transparency and accountability in healthcare expenditures. Put differently, the NGOs and CSOs should organize to become the value-for- money auditors in the healthcare delivery as part of their citizen duty. Many analysts simply quote expenditures on health as if the major issue is the absolute amount. Our view is that the problem is both the size and efficiency of expenditure on public health— but more so about efficiency than size. It is possible that much of the even miniscule expenditure does not reach the intended beneficiaries. If, for example, the value for money audit reveals an efficiency rate of, say, 40% (some believe the figure might be far lower in many cases), then merely doubling the efficiency rate to 80% is equivalent to doubling the size of the expenditure. So rather than dissipating energy campaigning for percentages of expenditures devoted to healthcare, citizens and organized groups should also focus even more so on value for money in the sector, as well as holding practitioners accountable for poor service delivery.

Furthermore, we must think through how to mobilize our churches, mosques, traditional and professional institutions as forces for good in healthcare delivery. These constitute the largest fora to reach the largest segment of the population. Most of the leaders in these organizations will easily understand and cooperate. But some, especially some of the magical/miracle centres which feed upon the Siamese challenges of the most vulnerable—poverty and ill-health—might feel challenged. However, the conversation must begin and ultimately, the dominant force of science and reason will triumph over superstition and ignorance. The summary point is that once the citizens become conscious of the fact that they will only get the quality of healthcare they persistently demand for, and conscientious leaders emerge to organize and mobilize action for change, the healthcare delivery system won’t be the same again. At the individual levels, income inequality is very high in Nigeria. We need to design a structure of incentives for the richest 8% that probably controls some 90% of private wealth to systematically invest in health and education. Besides, it is in their enlightened self-interest to do so!

With the above opening remarks as chairman, I hereby declare the 2019 LAPO Development Forum open!

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