Saturday, 26 May 2018

NHIS Has Failed Because Doctors Hijacked Scheme – Akintayo


Olumide Akintayo is the immediate past President of Pharmaceutical Society of Nigeria (PSN). In this interview with CHIOMA UMEHA, he speaks on the challenges of leadership, inter-professional crises in the health sector and the way forward for effective healthcare management in Nigeria. Excerpts:
 Health watchers have continued to complain of poor NHIS implementation. What is responsible for this?
The original aim of the National Health Insurance Scheme (NHIS) is to bring quality healthcare to the doorsteps of every Nigerian and above all, streamline the role and responsibilities of all healthcare providers. At the point of commencement, the medical doctors introduced in-house laboratory and pharmacy facilities and smuggled into the scheme global capitation where a doctor can carry out laboratory test and stock and dispense drugs without the intervention of the experts in that field.
Doctors also issue and dispense same prescription especially, in the private health facilities. The only reason why NHIS has not met its goals almost after 12 years is because the doctors hijacked the scheme and sidelined other healthcare givers. Today, we have a lofty scheme being driven by only doctors at the detriment of the patients.
Non–implementation of job evaluation of Federal Ministry of Health/Head of Service document for health workers
A job evaluation committee of the Federal Ministry of Health and Head of Service of the Federation (HOSF) was set up in 2007, under Professor (Mrs.) Adenike Grange as Minister of Health, primarily to assess and evaluate how each health professional adds value to patients care. The report brought out a lot of salient things that would have addressed issues of professional wrangling and wages of healthcare workers once and for all, but the medical doctors worked very hard for the non-implementation of the report because it did not favour them.

Nominations and appointment of Minister for Health, conditions of service, salaries, promotions, among other issues have remained controversial ones among professional players in the sector. What is the way forward?
On each event of ministerial nominations and screenings in the country, the Nigeria Medical Association (NMA) has often taken a narrow and discourteous position that one of its own must be appointed at the helm of the Federal Ministry of Health (FMOH) claiming that this was a global practice.
The NMA in a particular dispensation under the President Goodluck Jonathan’s administration threatened that it would ground the health sector if its position was not adhered to. This conceited stance has perennially polarised the health sector, which has culminated in the formation of the Assembly of Healthcare Professional Associations (AHPA), and the Joint Health Sector Unions (JOHESU) to agitate for the rights of other health workers in Nigeria.
Sections 147(1) & (2) of the 1999 constitution of the Federal Republic of Nigeria are very clear as to how Ministers are appointed. Section 42 (1) a & b also compels a right to freedom from discrimination on the basis of Community, Ethnic Group, Place of Origin, Sex, Religion, Political Opinion etc.
This is contrary to what obtains in other countries – United States of America (USA); Kingdom (UK), Japan, Botswana, among others.
It is important to state that the headship of the Health Sector is not vested in medical doctors contrary to the claims of the NMA. A Minister of the Federal Republic of Nigeria is a political appointee whose duty is purely administrative.
There is also discrimination in the salaries and wages in the health sector as well as illegal and unlawful strikes by doctors which have sent many patients to early grave.
The issue of imbalances in the directorate structure of the Federal Ministry of Health (FMOH) is also worrisome.
Others are unprofessional and hostile disposition of doctors to the team approach; poor implementation of National Health Insurance Scheme; non-implementation of job evaluation document of Head of Service of the federation/federal ministry of health; unlawful appointments in regulatory agencies of government; poor implementation of interventionist health agencies; establishment of the post of Surgeon-General of the Federation, among others.
Agitations over what the activists have described as unlawful appointments in regulatory agencies have been rife in the sector. What is the true position?
The National Agency for Food Drug Administration and Control (NAFDAC) was established by Decree 15 of 1993 and the establishing statute provides for the appointment of a Director General/Chief Executive Officer. Section 9 (1) of Decree 15 of 1993 gives a condition precedent for the appointment of the D.G. of NAFDAC which states to wit, “There shall be appointed for the agency by the President Commander in Chief of the Armed Forces on the recommendation of the Minister, a Director-General (DG) who shall be a person with good knowledge of Pharmacy, Food and Drugs.”
The immediate past DG of NAFDAC is a doctor who specialises in Neuro-pharmacology. It is a matter of commonsense that the DG failed to meet the condition precedent in Section 9(1) as he does not have the requisite training to have a good knowledge of Pharmacy – a recognised profession in healthcare.
Since the major areas of regulation cut across pharmacy, food and drugs at NAFDAC how can the DG who is not lawfully qualified to regulate these core areas be conversant with day to day running of the agency?
Again, Nigerians are denied the expertise of the pharmacists in drug assay and quality assurance.

What about poor implementation of interventionist agencies and effective healthcare management in the country.
Most of the interventionist health agencies like National Programme on Immunisation (NPI), National Agency for the Control of AIDS (NACA), Roll Back Malaria (RBM) etc. are populated by medical doctors and they have very poor drug procurement and management systems because of non-involvement of pharmacists.
In fact, at a point some doctors styled themselves ARV doctors at National Agency for the Control of AIDS (NACA) because doctors were dispensing ARV drugs after diagnosing and prescribing the ARV drugs.

What is the way forward?
Instances abound of glaring misinterpretations of provisions of Decree 10 of 1985 now Cap 463 LFN 2004 and the need arises for these lapses to be redressed. For instance, that the law specifies only the Clinical and Administrative Departments cannot be enough reason to subsume all health professionals under the head of the clinical department, especially when the existing Civil Service Regulations recognise university graduates as persons who can reach the apex of the civil service via GL 17 or equivalent.
In view of the difficulties envisaged in the promulgation of another law, we suggest appropriate interpretation of this law within three months, while within one year Cap 463 LFN 2004 should be reviewed and subsequently repealed.
You are an advocate of limitation to professional calling. Can you give further explanations on this?
Every provider must be reoriented to limit his output to only areas of core competence.
The propensity of doctors to feel they can annex the professional and statutory duties of some other health workers, while others cannot encroach into medical practice is the foundation of mutual mistrust displayed by care providers.
Specifically, government must obey court judgments compelling it to respect the autonomy of Medical Laboratory Science as a professional calling.
In this regard, pathologists cannot head laboratories, optometrists cannot be subservient to ophthalmologists, radiographers must be made to paddle their canoes independent of radiologists to fulfil their destinies.

How can private sector potentials be harnessed to address healthcare needs of Nigerians?
In 2001, the various Heads of Government of different African states met in Abuja and resolved under what is now popularly dubbed the Abuja Declaration that National Governments should dedicate 15 per cent of their budgets to healthcare.
Despite being a signatory to this declaration, the highest that has ever been dedicated to health since 2001 by the Federal Government is a meagre six per cent of National budget in 2012.
We as healthcare provides must continue to critically evaluate healthcare expenditure as a percentage of Gross Domestic Product and the analysis paints a very dangerous picture.
I have observed that over 88 per cent of health budgets are dedicated to only recurrent expenditure. Out of this huge cost a whopping 82.5 per cent is dedicated to only personnel expenditure.
Of the total cost reserved for healthcare, staff emoluments of about 61 per cent is gulped by salaries of sometimes an over-bloated core medical staff in Federal Health Institutions. Unfortunately, what has played out in recent years is that over 50 per cent of total health budget is dedicated to paying only one cadre of personnel in healthcare – doctors.
The unfortunate scenario depicted above is one of the reasons why healthcare infrastructure remains in limbo and endeavours which facilitate research and development are completely comatose in an ever dynamic health sector in the global arena. One is compelled to call on the Federal Government and indeed government at all levels to see an urgent need to drastically reduce the unproductive recurrent expenditure invested in personnel emolument of some clinical staff which can be diverted to fruitful capital projects as well as research and development initiatives.
Specifically, this forum must adopt a call for a privatisation of some level of clinical services especially at Out-Patient Department at all levels of care (primary, secondary and tertiary) in Nigeria. This approach will entail bringing in tested private sector players (private hospitals) to take over the running of some services in public sector hospitals in Nigeria. In some areas where service might be in higher demand, doctors might be hired on locum basis as we have seen been successfully implemented by some state governments.
The advantages inherent in this model are numerous as it checkmates the obvious propensity to embark on strikes perennially by those who should provide services, but do otherwise.
The age-long strength of the private sector in the area of service delivery would be felt maximally in the health sector which continues to misfire at the detriment of the consuming public.
Government can dedicate more funds to revamp infrastructure and equipment of secondary and tertiary levels in particular. The Nigeria Institute of Pharmaceutical Research and Development (NIPRD) as well as Nigeria Institute of Medical Research (NIMR) would also be beneficiaries of this process as substantial votes to these institutions would ultimately re-position healthcare in Nigeria.
For our sector – pharmacy, the process offers Nigeria the unique opportunity to join the League of Nations which are self-sufficient in the manufacturing of consumables, essentials drugs as well as exporters of Active Pharmaceutical Ingredients (APIs) and Pharmaceutical grade raw materials. This becomes imperative when we reckon that the global pharmaceutical market is now an impressive $1 trillion dollar business which is growing at an annual rate of seven per cent.
With Nigeria currently providing about $1 billion dollars of this global market at an annual growth rate of 10 per cent even when we do not do much of primary production of drugs and consumables in Nigeria, a wisely discerning health administrator should look at the immense potentials new investment in the pharmaceutical sector offers an economy already overburdened by avoidable and excessive personnel overheads in clinical services.



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