Budgetary Allocation to Health: Shame of a Nation

The lack of commitment on the part of the federal government of Nigeria to increasing the budgetary allocation needed to improve the health of Nigerians remains a disturbing one. Recently, it was reported that Nigeria earmarks 3.5 per cent of its national budget to the health sector. With the well documented intrigues surrounding the release of budgetary allocations, no one is even sure if all the earmarked funds are ever gets released, and if released what percent is spent on services or lining pockets. With this level of allocation, Nigeria ranks just above Burundi in Africa in budgetary allocation to health. It is shameful that a nation that ten years ago hosted African Heads of State and Government at a conference in Abuja and led in the pledge for governments to allocate at least 15 per cent of their national budgets to health does not even allocate a paltry 5 percent of its budget to care for the health of its citizens. According to Ademola Olajire, a Nigerian and the Director at the Social Affairs Department at the African Union Commission, only six countries have achieved the target set in Abuja. It sure must break Mr. Olajire’s heart to provide such information that gives Nigeria a black eye. The six countries, namely Rwanda, Botswana, Republic of Niger, Malawi, Zambia and Burkina Faso that have passed the 15 per cent mark are all less endowed than Nigeria. Leader of Africa, who are you leading.

Did someone say “Cry my beloved country”, oh no I am the one who said it. As a healthcare professional, the healthcare infrastructure in Nigeria breaks my heart every time I think of it. As one of my colleagues said “because we all have parents and relatives in Nigeria who depend on this healthcare system and cannot afford to fly them out to countries with better facilities every time they fall ill, we cannot fold our hands and watch without doing anything.” The question is what can we do as non-politicians to force the hand of the government to allocate more resources to delivery of healthcare services to Nigerians? At a National Association of Resident Doctors’ roundtable in 1987, Nigerian physicians were called out for forgetting the “Hippocratic Oath” and not insisting on receiving needed resources when they become commissioners or ministers of health. It will be recalled that the late Professor Olikoye Ransome-Kuti extracted a committment from Babangida before he accepted the position of Minister of Health that the resources needed by the ministry will be provided to ensure that programs are implemented. He remains the only minister in recent memory to have done this. He got most of what he wanted albeit during a military regime.

In an interview with The Guardian after delivering a speech at the on-going Conference of African Ministers responsible for Finance, Economy, Planning and Economic Development in Addis Ababa, Ethiopia, Nigeria’s Minister of Health Professor Onyebuchi Chukwu said “funds allocated to security and the electoral system, among other competing needs in Nigeria, might have robbed the health sector of much-needed higher allocation in the budget.” The minister’s statement does not provide any succor to many Nigerians who still rely on government provided healthcare. In addition, the minister’s assertion that government's per capita expenditure on health was rising steadily and it's about $20 contradicts independent sources including the Africa Public Health Info which puts the figure at $10.

This is not surprising as anyone following the political debates and campaigns in Nigeria would have noticed that none of the candidates at the local, state, or national levels including the presidential candidates have mentioned or articulated any strategies to improve the health of Nigerians or arrest the decay that is the Nigerian health infrastructure. As the elections are conducted, winners announced, and executive councils formed, it is time for the Nigeria Medical Association that have done a good job of insisting on physicians running the ministry of health to go a step further to insist on improved allocation to the health sector and preventing its members from accepting health commissioner and minister positions as a form of protest if government allocation is not increased. Professor Olikoye did it and it still can be done if the focus is on the overall interest of Nigerians and not on holding a political position. When it is all said and done, physicians are going to be reminded that they presided over the decay of the Nigerian healthcare system.

The African Woman: A Priority in Medicine?

Researchers link preparation of smoked fish to lung diseases! For my fellow fanatics, this recent article in The Guardian will undoubtedly be a disheartening revelation of the hidden cost behind the savory goodness that is smoked fish. My initial thoughts after reading the title were admittedly, selfish. My mind skipped through the numerous pulmonopathies that I have encountered during my first year in medical school. I ranked the diseases in order of severity, hoping that the punishment for my affair with smoked fish would be selected from the bottom of the list. As I read further, I soon realized that I was not the subject of article. In this case, the unfortunate victims of lung disease are the manufacturers of smoked fish – predominantly women (“manufacturers” because the things that these women do to smoked fish are nothing short of magical). The Togo-based study suggests that these women who are “constantly exposed to smoke, heat and burns, during the process are at high risk of developing chronic chest and respiratory infections or disease."

As I sympathized with the women from the article, my thoughts led me to the broader topics of feminism and the empowerment of women. March 8, 2010 was the 100^th anniversary of International Women’s day, a global celebration of the political, economic and social achievements of women. Using the Togolese fish smokers as a take-off point, I thought about women in Africa and what I believed was an on-going struggle to empower them. My mental exercise soon turned into a “Google” exercise as I realized the inadequacies of my knowledge base about African women. In the course of my search, I stumbled upon an inspiring article: Empower Women to Realize the African Dream written by Obiageli Ezekwesili, the World Bank Vice President for the Africa region. From the piece, it’s clear that the African woman has come a long way over the last few decades. Progress is evident in the worlds of business, politics, education and medicine. However, as Mrs. Ezekwesili reminds us, “the feminization of poverty still remains acute.” Women bear the brunt of the African situation, standing at the front line in wars against malnutrition, overpopulation and discrimination. Equality and gender issues have seen some improvement, but we still have a long way to go.

Women in Nigeria proudly show a hand-painted banner for peace

Of Mrs. Ezekwesili’s points, I was struck most considerably by those that highlight the things medicine is NOT doing for our women. “One in 20 girls born today in Angola, Mozambique, Liberia and Sierra Leone will die in childbirth. An African woman is 25 times more likely to die during labor than a European woman […]; three young women are infected with HIV/AIDS for every young man in Africa; [and] girls still face genital mutilation in 28 African countries.” Like most others, the medical sector is doing a miserable job as regards protecting and providing for our women. I’m in no position to criticize the field, or to recommend things that we can do to advance women’s rights in Africa, but I do know that we can do much better. So even as we remember International Women’s Day and take our hats off to the women who make life worth it, I ask that we make it a priority to empower the women of Africa through medicine. Our mothers, wives, daughters, sisters – our women – are our “hope, strength and opportunity.” Let’s play our part to make sure they are always treated as such.

Reasssessing the Notion of a "Brain Drain"

The idea of a drain hardly ever evokes a positive reaction especially in the context of the siphoning of intellectual capital from developing countries. The impact of the “brain drain” phenomenon has been hotly debated in development circles, particularly in relationship to the flight of health care workers who emigrate from countries facing incredible public health challenges. This has been discussed previously on the ANPA blog here and here. Outside of the usual culprits – corruption, bad governance, and the like – some are wont to place the blame of Nigeria’s health care struggles on the backs of doctors and nurses who participate in destabilizing the healthcare infrastructure by abandoning the country. Nearly one in ten Nigerian physicians practices in the United States or Canada. To add insult to injury, reports surface indicating that foreign-trained health professionals in developed countries, at times, outperform their home-grown counterparts – begging the question, why have we (Nigerians) not benefited from the fruits of our labour (that is, educating such professionals)? One may come to conclusion that while developing nations invest resources into the training of its professionals, developed nations are unfairly poised to reap the benefits of such harvests. However, this line of reasoning requires a serious rethink. In full disclosure, I must admit that I am a somewhat biased, since I am a product of Nigerian intellectual refugees, and would not wish it any other way. But, I cannot help but highlight a number of incorrect assumptions made by the above argument that may debunk the notion of the brain drain as the critical destabilizing force in Nigerian healthcare.

I’ve struggled with how best to say this without being offensive, but, the idea of that the Nigerian government has and continues to lose out on its investment into the training its healthcare force, is, quite simply, laughable. Investment, ke? When overall health infrastructure spending falls at a paltry 4% of a nation’s total budget, one can only imagine that how much less is “invested” into training the healthcare force – in terms of financial assistance for education and future career support. For the overwhelming majority of Nigerian physicians practicing both in Nigeria and abroad, the heavy lifting of such support primarily rested on self, family, benevolent communities and non-governmental organizations. Furthermore, the American Medical Association reports that more than half of African born physicians practicing in the United States spent a significant portion of their educational careers at American universities and hospitals.

While doctors and nurses play an irreplaceably essential role in a nation’s overall healthcare, one must remember that the success of any national healthcare system depends on far much more than its healthcare workers. The World Health Organization identifies a number of key components of an effective healthcare system, of which, interestingly, health care staff play a merely supporting role. Of chief importance are, again, good governance and financing, but also functioning information systems, diligent public health surveillance and access (to be distinguished from availability) to essential drugs and technologies. While the desire to return home and practice medicine in Nigeria remains a strong desire for many a Nigerian physician in the US, packing up and re-inserting oneself into a virtually non-existent health system may prove frustrating to both healthcare provider and patient. It goes without saying that organizations such as ANPA have and continue to contribute to the welfare of Nigerian patients and some Nigerian physicians in America, have in small groups, given back to their homelands, whether in financial assistance, educational support, or short-term projects. Though not yet quantifiable, doctors in the West may be contributing far more than they could have while in Nigeria and a mass exodus back to Nigeria, may prove counterproductive, particularly in the absence of policies and structures. It is critical, therefore, to reassess what is actually being drained and what the consequences are of haphazardly reversing that process.

ANPA Leadership Secures Waiver of Back Payment of Licensing Fees for Nigerian Physicians Practicing Outside Nigeria

In a landmark decision, the Medical and Dental Council of Nigeria (MDCN) has agreed to waive the requirement for back payment of registration and licensing fees for Nigerian physicians who have been in practice outside Nigeria. The news of this agreement was conveyed to the ANPA members by its President, Dr. Fiemu Nwariaku today. The President said the MDCN decision was conveyed to ANPA representatives by the Registrar of the Medical and Dental Council of Nigeria during the recently concluded signing of the MOU between ANPA and Federal Government of Nigeria in Abuja.

Prof. Roger Makanjuola, Chairman MDCN

Before now, foreign-based Nigerian physicians were required to pay back registration and licensing fees whenever they requested for certificate of good standing, often needed to register or obtain licenses in their countries of practice. The fees in some instances may be for over twenty years as was the case for one of my colleagues who recently moved to Chicago and had to obtain an Illinois license. Many have condemned the payment of fees for a period during which one is not practicing in the country as exploitatory and punishing. The granting of this waiver is therefore a welcome relief. The waiver according to the Dr. Nwariaku is contingent on the Nigerian physician being able to demonstrate that they have been and continue to be in good standing (dues paying) in their current location. Practitioners who wish to renew their licenses will however be required to pay renewal fees for the current year of practice.

Former ANPA President, Dr. Julius Kpaduwa

ANPA Blog has learned that the Chairman of MDCN, Professor Roger Makanjuola, was swayed by representation made on multiple fronts by ANPA, pleading the case for thousands of diaspora Nigerian doctors who are eager to contribute to their homeland. Former ANPA President, Dr. Julius Kpaduwa, raised the matter at the the July, 2009 retreat with the Ministry of Health attended by the the health minister, Professor  Buchi Chukwu. Furthermore, ANPA Blog pestered Professor Chukwu with the issue during our interview with him in the fall of 2010, and extracted his promise to present our case to the MDCN.

 In his message, Dr. Nwariaku said: “ANPA has worked hard to secure a waiver of the requirement for back payment of medical license renewal fees for physicians and dentists who have been out of Nigeria for some time. We strongly argued that this was a major barrier to the desire of Nigerian trained physicians and dentists living outside Nigeria, to resume practice (fully or intermittently) in Nigeria, and that this regulation worsened the critical shortage of a skilled healthcare workforce within Nigeria.”

This decision by the MDCN couldn’t have come at a better time as the Nigerian government struggles to attract diaspora doctors to contribute their skills to the development of the country. In addition, the long drawn issue of whether Nigerian physicians practicing outside Nigeria need to obtain temporary licenses when they go on medical mission trips can be put to rest. With this agreement, obtaining a temporary license will be much easier for foreign-based Nigerian doctors who want to spend time back home providing care for our citizens without the back payment of fees hanging over their heads like a sword of Damocles.

I salute the hard work of the ANPA leadership in securing this waiver and join the President in applauding the current leadership of the MDCN for making right the wrong that has been perpetuated over many years.

Update from ANPA President

ANPA President, Fiemu Nwariaku

March 3, 2011
From the Office of the President

Dear Colleagues,

As promised, I would like to use this opportunity to provide you with updates on the activities of our organization. Much has happened since our strategic retreat in Houston in November. I am pleased to announce that the much awaited memorandum of understanding (MOU) with the Federal Ministry of Health in Nigeria was signed on February 14th 2011. Some of you may recall that the initial MOU signed 6 years ago did not result in any significant activity. As a result the current leadership of the FMOH assembled a meeting of stakeholders in Abuja, last July. During that meeting, the decision was made to renew the MOU, but make it active by convening a joint technical committee (JTC) which will become the effector arm for the MOU.

On February 14th 2011, the Hon. Federal Minister of Health signed the MOU and commemorated a fourteen-member JTC. Represented on the JTC, were ANPA, MANSAG, FMOH, Medical and Dental Council of Nigeria (MDCN), Nigerian Medical Association (NMA), National Institute of Medical Research (NIMR) and the Committee of Chief Medical Directors of Tertiary Hospitals. Our organization was represented by Past President Kpaduwa and myself. Also present from ANPA were Drs Igho Ofotokun, Vincent Idemyor and Abdulkareem Lateef.

Dr. Nwariaku and Hon. Min. of Health, Prof Chukwu, sign MOU 

The JTC held its first meeting that day, and began the work of identifying priorities that match the resources of ANPA and MANSAG. The next meeting is scheduled for late March 2011. ANPA proposes to focus on Maternal/Child Health and Emergency Medical Services (EMS) as the initial priorities. Our organization will then leverage our technical expertise and resources to address these priorities. We believe that this is a huge step by our government, and will rely on our members to deliver on our promises. I will continue to keep you abreast of the JTC activities as they pertain to our organization.

Secondly, ANPA has been fortunate to secure financial and logistical commitment from the Health Systems 20/20 project of the U.S. Agency for International Development (USAID). As part of this project, ANPA has offered to provide technical assistance to facilitate the revision of medical school curricula in Nigeria. With assistance from the Medical and Dental Council of Nigeria, the National Universities Commission (NUC), NIMR, the Diaspora Desk of the FMOH, and the University of Ibadan, the Hon. Minister for Health also inaugurated a committee to serve in an advisory role to the regulatory bodies in Nigeria, whose responsibility it is to revise the medical school curricula. This group also had a very successful meeting between February 15th and 18th 2011. Represented by Drs Igho Ofotokun, Vincent Idemyor and myself, our organization provided perspective on the American medical training. During that meeting, the decision was made to assemble the relevant materials to assist the NUC, MDCN and interested medical schools in Nigeria to begin the long process of curriculum reform. This process will likely take months to years; however we have been fortunate to secure the commitment from USAID and other partners for the duration of this project. We believe that this will be an important long-term investment to rebuild and strengthen the health care sector in Nigeria.

On the home front, preparations are underway for the next Annual Scientific Convention in Chicago. As usual, Professor Scott-Emuakpor and his program committee have put together a solid program. With a powerful theme of Maternal and Child Health, we will certainly attract significant attention from the public and private sectors. The projects described above will require significant financial commitment from our organization. As such, I hereby seek your assistance to begin making the calls to your friends, family, partners and acquaintances that are in the position to provide such assistance, both here and in Nigeria. Our organization will need a lot of financial support for many of these important activities that are underway. We all strongly believe in the activities of our organization to improve healthcare in Nigeria. We now need to communicate that need to our network of sponsors. I strongly believe that our organization can be a positive force for good in Nigeria. However we will need all hands on deck to accomplish this goal, and will need to convince other organizations about the importance of our work. The coming months are likely to be an exciting time for our organization. I will keep you informed as these activities evolve.

Warm Regards

Fiemu E. Nwariaku
ANPA President