Osagie Ehanire, Nigeria’s minister of Health, has over the time spent in office immersed himself in the efforts to build new structures to deliver quality health services to Nigerians. In this interview with a BusinessDay team led by Bashir Ibrahim Hassan, he tells the story of how Nigeria has stoutly responded to the COVID-19 pandemic and how Nigerians can have access to quality health care.
As Minister of Health, what are your plans and visions to reposition the health sector?
Well, what you must understand is that the person who won the election and got the mandate to run the affairs of this country is president Muhammadu Buhari, and it is he who has the vision and appoints people who help him realize his vision. And it is the minister who understands the vision and realizes it in a way that he approves, that meets his own expectation.
The minister develops vision for the health sector based on his understanding of the president’s own vision and it is particularly easy if the president’s vision tallies very well with the minister’s vision and there is a good synergy that helps to examine all the issues that requires attention, and that is what is going on in the ministry of health.
What were you doing before the pandemic in repositioning Nigeria’s health sector?
The vision we all have but haven’t realized, is the vision of Universal Health Coverage, to ensure that all people have access to health. Having access to health care means to first have physical access, being able to get there. This means you need facilities that people can go to, to get help when they are looking for help.
Secondly, having financial access, which means you can afford it or you have a mechanism by which your use of the health sector is paid for. And, there is the issue of the need to improve the quality of service. You know the health indices of a country are generally summarized by the World Health Organization (WHO) and also the Population Commission and department of statistics which, for example, tells us the maternal mortality, the under 5 mortality, the infant mortality in the country. And if you see that those figures are not good , it is because the health system has failed at the lower level, because most of the victims of maternal mortality will be the poor people in the rural areas and in the sub-urban high-density areas. So, if the health system has not worked well, that’s why you have high mortality rates and high rates of diseases and infections.
Therefore, the challenge is to rebuild the health sector generally, from bottom-up, beginning with integrating the primary health care into the traditional institutions that exist and the statutory institutions. We are working with the states and the local governments to ensure that a mechanism exists to ensure that we have human resource capacity to provide sustainable health service. This begins with providing the infrastructure that gives you the platform to deliver health services.
We have a plan, a model of primary health care centres, which we have set up. That model tells you what our primary health care centres should look like. In traditional primary health care centres, you have some people who resume maybe by 8 or 9 a.m. and they close by 3 or 4 p.m. Anyone who falls sick and maybe comes by 4 or 5, won’t find anyone.
Now, we have a vision of a primary health care center that has staff quarters, where the staff can work in shifts, so that you have access to health care round the clock, and can see a doctor or at least a nurse anytime of the day. And it is important for delivery because a lot of deliveries take place at night. But we have just over 30 percent of women who have skilled birth attendants at birth. The reason is that the facilities are closed when you want to deliver. So having physical access is important to creating that platform for improved health services.
The same goes for other routine health services in the health sector; immunization, health education, health promotion, and various measures for disease prevention. That involves talking to the citizens at that level, educating them on personal, domestic and environmental hygiene, because, if you are able to have a strong primary health care structure, you would have taken care of about 60 percent of the disease burden in the country, such as waterborne diseases, vaccine preventable diseases and vector diseases like malaria. If you can take care of all of them, you can also address the questions of nutrition at that very level. You will also be able to care of a good number of the problems that occur in hard-to-reach areas.
From there, you go on to secondary health care, which is under the state governments. It needs to be revived. At the moment, it is not functional in the country – only a few states have a good secondary health care structure. Also, while we are looking at one primary health care centre per ward, we are looking at one general hospital per Local Government. And the general hospitals should receive referrals from primary health care. This is where you can get the basic, minor intermediate surgeries done, like cesarean section, appendix etc. Only the very complex operations and treatments will need to go to federal medical centres or teaching hospitals.
What does it take to run these primary health care centres that you have just mentioned, based on this vision of yours?
First of all, look at the structure itself – you need to build it, or upgrade those that are built but not according to the model. Where they do not exist, they need to be set up and prepared.
Secondly, it takes human resources – the doctors, nurses, extension workers, laboratory scientists and the midwives who take deliveries and the various experts on different subjects; nutrition, eyes, ears, who do not need to be resident there but visit to attend to these issues. If you have a structure like that and functional, you have already laid a strong foundation for your health system.
The Nigerian Constitution sees the health system on the residual list. This means that it is not really assigned, but it is operated by all the tiers of government; federal, state and local government operate it together. So, the Primary Health care is operated by the federal, state and local government and the community is encouraged to participate in the operation of the primary health care to have ownership, to regard it as their own, look after it and protect it.
What about funding, how much does it require and when can we boast of having this permanent and strong health care system in the country?
We are looking for a total of about 9,800 primarily health care centres. We have just about less than half of them at the moment. So, we are looking at state governments, philanthropists, development partners, different clubs to help us build them. The model is there, so you don’t need to pay for an architect or anything, just build it. The state government will now employ medical personnel to run it and then you have a supply chain. As for the operation, the federal government started off with what we call the Basic Health Care Provision Fund (BHCPF), which is 1 percent of the Consolidated revenue fund to be distributed directly to the health care centres. This money is supposed to be supported with money from the state and any other sources for operations, medicines and all the various needs that they have.
There is also a component that comes from the National Health Insurance Scheme (NHIS), which was set up by the federal government to insure people and provide them with health care at a very cheap rate. This can be as low as N15,000 per annum and that sum covers any kind of treatment you may need. It might also include surgeries and the more people register, the easier it is to operate. So, we have started working on the basics for it and the law enabling the NHIS to make this health insurance mandatory is still being considered, so that, if it is mandatory, every person who is working or self-employed can at least afford N15,000 per year. During that period, you don’t need to worry anymore about health care, because right now, out-of-pocket expenditure for health is over 75 percent for Nigerians.
There are some people who don’t spend anything for a whole year, but the day they have a real problem, their whole account is emptied; they even sell things they have. That is what we call catastrophic health spending. They get financially ruined, if for example they have to undergo a serious operation. But, if you have a health insurance, you are financially protected in that the insurance will pay for your operation, pay for your treatment, and you don’t have to put any kobo on the table, provided you have maintained your membership with N15,000 a year, which is just over N1,000 per month.
What are the lessons learnt from the COVID-19 pandemic and it’s management?
There are many lessons. We all have routine resource mechanisms for diseases we know – for example, Lassa fever is a dangerous disease that occurs periodically, but because it’s occurs periodically over the years, we already know the pattern and know how to handle it. We know the signs and symptoms and we teach the public how to suspect Lassa fever and what to do. But, in the case of the COVID-19, it was a novel virus.
We don’t know how it behaves and nobody knew its features, even the means of transmission was at the beginning a guess work, Even to test it was guess work. It took some time before we could learn how to test for it and before we could get the reagents. Not all countries had the reagents and the laboratory machines needed. We did not have more than two at the beginning in the country, now we have about 80.
We have been able to boost our equipment and increase the number of people who know how to use the equipment. We have increased the number of laboratory scientists. We have increased the knowledge in Infection and Prevention Control (IPC). We have been able to purchase Personal Protective Equipment (PPE) and then to reorganize our public health structure. Public health is what affects everybody. The public health structure has benefitted a lot from learning about this dangerous disease. So, if anything like this again pops up in future, we already have experience and a good knowledge to start with, though that other ailment may have its own peculiarities. Others with very strong health care systems were overwhelmed by the number of sick people and that brought them to their knees. It’s not just that they did not have the answer or the treatment for the disease. All the beds were full; they had to transfer patients from one place to another and, at the end of the day, many of them could not cope.
And then the shortage of basic things like the mask, even big, powerful countries were short of masks and then you had a situation where all countries were struggling to get reagents, PPEs, masks and so on. A lot of manufacturing started in Nigeria. Many people are now manufacturing these PPEs, producing facemasks, sanitizers, and so on, in reaction to this outbreak; which is good for our country.
We have had just about 2,000 deaths, while some countries are having more than that in a day. Why did we not have much casualty as expected? From the beginning, we saw the havoc that this disease was doing in other countries, and we very early closed our borders and started contact tracing. We benefitted from the experience that the ministry of health in Lagos had, and they worked very well with us to track any new person who was coming in, particularly from high burden countries. And the president in his wisdom set up the Presidential Task Force (PTF) on COVID-19, which brought together all the ministers who are involved in any way relevant to the efforts – interior, humanitarian affairs, foreign affairs, among others. Remember this is an imported disease. This opened the door for any kind of financing we wanted. We got a lot of donations too. So, we were able to carry out a very rational approach to respond.
Was the coronavirus outbreak your worst fear for this country?
After seeing what was happening in other countries, we were hoping and planning that we would stop it from entering the country, but, what we were to learn was that this is a virus that transmits so easily from one person to another and difficult to stop. But immediately we learnt about it, we closed the airports. Only those in Abuja and Lagos were open and we were tracking every single person who came in. We gave them forms to fill to tell us their travel history. We took their temperature and gave them advice on what to observe.
Many people are now manufacturing these PPEs, producing face masks, sanitizers, and so on, in reaction to this outbreak; which is good for our country
Our own experience with AstraZeneca so far is that it has not had any side effects on any of our citizens that have been vaccinated
What is the position of the federal government on the Oxford-AstraZeneca vaccines?
The position of the Federal government is to observe our own experience with it, take note of the experiences of other countries and also observe the WHO advisory. Our own experience with AstraZeneca so far is that it has not had any side effects on any of our citizens that have been vaccinated. WHO has urged countries to go on using it, but, at the same time, we are closely monitoring other countries who are using it, the effects they are reporting and our decision is to continue to use it because we have not had any bad experience and because the WHO has given the green light to continue using it.
How many people have so far been vaccinated?
Over 8,000 and we have not had any adverse effects on our citizens. The 4 million doses of the AstraZeneca vaccines is just the first batch. There is more coming and vaccination is ongoing.
Where is Nigeria on the local production of vaccines and what is the plan for the N10 billion fund?
Local production of vaccines can be done in two ways, but first of all, you must have the infrastructure, you must have a vaccine production plant. You can produce in two ways; first, you get a licence from someone who has already got the formula, or you develop the formula yourself or sponsor the development. If you look at Oxford-AstraZeneca, it was developed by a group in Oxford and sponsored by AstraZeneca, who took on the production. Here in Nigeria, we have a vaccine company which is just about to take off. What we are looking for right now is technology transfer from a country that has the capacity to produce vaccines and wants to engage Nigeria in vaccine production. It’s called Biovaccine Nigeria limited, owned partly by private sector and partly by the federal government, but they are just beginning to set up.
What legacy would you like to leave after office?
It’s exactly what we set out to do from the beginning – to build a better health structure that works for the people, affordable and serves its purpose. We want to ensure that we are able to match the rest of the world in health technology and that our citizens develop confidence in the health system, because it is the lack of confidence in the health system that makes people go abroad for treatment.
Also, the health sector should be able to serve all Nigerians, including those in rural areas, the urban poor, who should not be denied health care because they have no money or because it’s too far away. So, the emphases are on availability, affordability, accessibility and acceptability of health care services. These will inspire confidence in the health care system.
What motivates you in doing the work?
The first motivation is the fact that I have been given a job and I want to make sure it is done well. Secondly, we are in a country where we are far behind where we should be in all areas, such as infrastructure and health care. Therefore, it is like trying to play catch-up with other countries and get to where we are supposed to be. I know that is what worries the president too. He sees the need to catch-up. A parable says “If you are far behind, you must run.” Indeed, those who are in front can afford to walk, but those who are far behind have to run.