PREMIUM TIMES’ Ebuka Onyeji in December had an interview with Nigeria’s Minister of Health, Isaac Adewole, at his office in Abuja.
Mr Adewole, a professor, responded to questions on why the government is yet to fully implement the provisions of the National Health Act (NHA), a body of laws meant to govern the health sector.
Last November, this medium kick-started a series called “Dissecting the NHA”, in a bid to explain comprehensively the provisions of the Act and its non-implementation. The signing of the Act into law in 2014 after 10 years of consideration, birthed the argument over its implementation, which has continued, four years after.
In the interview, the health minister highlighted government’s plans on implementing the Basic Health Care Provision Fund (BHCPF), a major provision of the act for health funding which government, for the first time, included in the 2018 budget.
He also spoke about the crisis rocking Nigeria’s Health Insurance Scheme (NHIS) and why the scheme has not been able to cover the majority of Nigerians, 13 years after inception.
The minister also discussed government’s plans to bring back home Nigerian doctors practising abroad, among other issues.
PT: The Basic Health Care Provision Fund was added in the 2018 budget as mandated by the National Health Act. Why is the fund yet to be released and disbursed?
Adewole: We cannot just release the money without proper planning because if we put the money in the states and there is no template for using it, people will say it was wasted. The media will say BHCPF money was squandered. We have developed a 123-page manual.
What we have done is that we went to the states and did thorough jobs.
We are looking at the entire health system in each state and for the first time, we will do the whole 36 states and the federal capital.
The manual is a detailed assessment of the health system. It takes account of how many facilities a state is using because we just don’t want to share money. We want the money to flow from the central bank to the facilities. It should be the first time that a PHC will get money directly from CBN.
We now say for each state, give us the list of your needs, the PHCs you want to use. For example in Osun, 332 PHCs are benefiting. What is the condition of the 332 PHCs? How many can render 24 hours service? What do they lack in terms of staff, equipment, commodities and all? We will have detailed account of all this before releasing the money.
When you see the detailed manual we have developed, you will be amazed by the kind of work we have put in. We have developed that of Osun, Abia, Niger, Yobe, Borno, Edo and FCT. Seven states for the first roll out.
If we don’t do this and you send money there, it will be wasted. How this money will be shared are all in the manual. There is no challenge in getting the money released as many have said.
Last Friday (December 2018), we approved the guidelines that will guide the disbursement of the funds. It took almost us two years to get it ready and the president has agreed to flag off the implementation.
PT: Are you not worried the planning is taking too much time?
Adewole: I am not because we spent enough time getting things ready so now we can run and we are not only dealing with the Nigerian naira provided in the budget alone (N55b).
If you read the part of the act that made provisions for the BHCPF, you will see it is also talking about getting funds from local and international organisations and other sources.
We already have 20 million dollars from Global Financing Facility on ground. We have two million dollars from Bill and Melinda Gates Foundation. DFID (The Department for International Development) is putting 50 million pounds over the next five years. We are also meeting with the World Bank. There will be three accounts in CBN. The federal account will be for the consolidated revenue funds because we don’t want to mix funds with donor money.
Money will flow from the CBN to NHIS to NPHCDA to NCDC. It will flow from the Federal Ministry of Health, then from there to the states and from the states, it goes to the facilities through commercial banks.
We also asked them to open accounts in commercial banks. Part of the assessment is that they (state facilities and PHCs) have a bank account. If they do, who are the signatories?
PT: According to the act, 50 per cent of the BHCPF should go to NHIS. What are implementation plans?
Adewole: They (NHIS) have done their costing and we are going to do reimbursement. We need to clarify what it should cover. The 50 per cent for NHIS is going to work on the bases of reimbursement.
The manual is already on our website and it is clear on all the issues regarding the BHCPF. The planning, the monitoring and all, including taking care of emergency.
PT: According to the act, any hospital in Nigeria without certificates of standard, 24 months after the act is activated, is operating illegally. Why is it yet to be issued four years after the act was activated?
Adewole: The issue of accreditation is in two folds. We cannot temporary issue certificates of standard to health facilities at same level. We are supposed to work with the states.
We have set up the national committee on standard headed by Olusomi, a professor, and he is designing a template for accessing the facilities. What exactly are you looking for? What are you majoring? And everything has been done. What is left is for them to start working. We want to start with the federal first and thereafter we engage the states because health is on the concurrent list.
I am sure by January, the first set of accreditation will be done.
PT: Where are we on the revitalization of PHCs (Primary Health Centres)?
Adewole: For the 10,000 PHCs, at the last count, we have done 4000. My happiness is that state governments are keying in. Kaduna did 225, Osun did 332 so what we are saying is that with the new template and access to BHCPF we will be able to do the whole 10,000 in no distant time but there is no specified deadline.
PT: On brain drain, what are you doing to make Nigerian doctors practising abroad return home?
Adewole: We have a PPP (Public and Private Partnership) in the diaspora unit and that unit is working with doctors in diaspora to encourage them to come back through what we call the one-eleven.
What it means is to encourage them to come and work in Nigeria for one month and then work in their respective base for 11 months. While they are on leave, the arrangement enables them to come and work, as well as be with their families. They will support us and it will also be impactful so the association of Nigerian doctors in America are part of that arrangement.
We already put this on the 2019 budget.
We have already set up an MOU (Memorandum of Understanding). All we do is pay for their ticket home, move them around and give them some subsidised registration fee because part of the challenge is that if you have been away from the country for six years and you come back to practice, the MDCN (Medical and Dental Council of Nigeria) law says you must pay for those six years. So we are working with MDCN to allow them pay for only one year instead of six years because they are not permanently based in Nigeria.
It’s a type of waiver to encourage them to come home, which is why we are budgeting for that in 2019. They are happy about this arrangement and as we modernize our system, many of them will find it attractive to come on a permanent base.
PT: There seem to be so many internal crises in the health sector in your regime. What have you done so far to resolve them?
Adewole: What we have done is to solve the crisis. This administration should be credited for that.
PT: What about the crisis rocking the NHIS?
Adewole: I can tell you today that no Executive Secretary of NHIS has even completed a full term in office without being sacked or suspended, apart from Mohammed Dogo, the pioneer ES, so, it’s not just about this administration.
What has happened is that this administration is honest and open.
What has also made things open is the social media. Before now, if someone was sacked, you won’t even know, except it is captured on this newspaper the next day.
Social media has made information readily accessible and available. That has made things look as if it is only now that these things are happening, it used to happen before.
We are asking the presidential panel to take a more holistic look at the NHIS to review the act of the scheme. The act seems to have given so much power to the board.
The act also made insurance voluntary and that is why we are supporting the National Assembly to repeal the act and put in place a comprehensive package. Let it be comprehensive because it cannot be voluntary. There is need for a review of the act and it is going on.
The governing council, by that act, was given the power to do whatever is necessary to keep the scheme running.
If the council now thinks it is important to do anything to keep the scheme running, nobody can say no. That is why we say the act needs to be revised and be more specific. If you look closely, it is as if the council does almost everything there. The act is one of the major issues with the scheme. Why the act has not covered majority of Nigerians is because it is voluntary.
PT: But many believe the poor coverage is as a result of corruption and fraud in the scheme.
Adewole: When it is voluntary, it makes people not take it seriously. Our disposition as Nigerians, we don’t take our health critical. We don’t even treat our body the way we treat our cars. When we wake up in the morning, you have a car you clean it up. You test the engine oil, you test the water level etc.
Many people don’t treat their body as well as they treat their cars. When it comes to health, nobody wants to pay for health, we all want it free and that is why for us to make it free, somebody has to pay for it.
In the UK, the health insurance is there but it is being funded essentially, by taxation. What we need to look at in NHIS is, how do we put more money into health, put more resources together to take care of everybody and ensure maximum coverage?
PT: Where are we on vaccine production in Nigeria?
Adewole: For the first time, we are linking health to socio-economic condition.
We also made other strategic plans, such as support for Nigerian products. We got FEC to approve Vaccine production plant in Nigeria. This was something (that) for 12 years, previous governments could not achieve.
It was going back and forth and the president said, look get this done, and so we improved this plan and entered into partnership with May and Baker, the first indigenous drug manufacturing company in Nigeria, to develop a plan to produce vaccine locally.
Mind you, in 1996, Nigeria was producing vaccine and was even exporting it out of the country, so we said if we could do it then, why can’t we do it now?
We are working on it. We have set up the company and the federal government holds 75 per cent of the share. We brought the chairman and managing director, including three representatives from the government, who will be on the board. May and Baker have now developed a road map for vaccine production. Originally it was to start by 2020 but they came back last year with a well-arranged work plan and by 2020 to 2022 they will roll out the first vaccine.
The vaccine in Nigeria is coming at little or no cost, thanks to GAVI and they are saying Nigeria is a low-income country that has moved on to medium so we will exit their support.
We said we are facing some challenges so they said they will now extend their support for 10 years.
Over 10 years, they promised to give support to the tune of 1 billion dollars. But they said every year, you must increase your support for vaccine procurement by 10 per cent so that in 2028, Nigeria will be funding vaccine freely.
The implication is that the company may not find market in Nigeria for another four to five years, which is why we are talking to them because we cannot buy vaccine that is more expensive than what GAVI wants.
People will question – why are you buying at a high price when GAVI can give you at little or no cost.
We also recommend the issue of vaccine supply as an issue of national importance. We told them to work on vaccines not covered by GAVI or where we don’t even have enough.
I mentioned yellow fever, we don’t have enough vaccine for yellow fever in the world. Why can’t they make meningitis vaccine? We also gave them some tips as to vaccines they can concentrate on and meet international gap of supply.
PT: Why did it take so long to assent to the NCDC bill?
Adewole: It did not take a long time. What happened is that we looked at it internally and submitted the bill to Mr President and he approved. At the same time National Assembly is also working on a private bill and then we approached them and said, why not wait for our own and when they received it, they took over our own and subjected it to open hearing.
PT: It seems there is increased outbreak of diseases across the country. How has the government responded so far?
Adewole: We have increased our ability to respond quickly, with the number of surveillance exercise we have done. The test laboratories are now functional.
We now have a first class lab in Nigeria.
When monkeypox attacked, we diagnosed it in Nigeria, something that was not there before, so we have actually improved our capacity to diagnose, detect and report and we are now sending alert, something we never did in the past. You will see something like; dry season is coming prepare for Lassa fever, prepare for meningitis. That is the type of warning system we should have and we already have it.
PT: When are we going to be polio-free?
Adewole: By the special grace of God we are almost there. We will soon get there. We have done well and we will soon cut the tape. We will be the last country to have polio in Africa.
PT: What is the government doing to reduce the burden of cancer in Nigeria?
Adewole: We have two cancer machines at the National Hospital. We have assembled the one we met on ground and it’s now working. We secured the second one, we are training people on it because it is more advanced than the first one. We promise Nigerians that by January it will start treating people. That hospital will be the only one in Africa with two energy linear machines.
PT: How would you rate the ongoing HIV census?
Adewole: It’s the largest survey in the world. We want to accurately determine the burden of HIV in Nigeria. Hopefully, we will release the data of the survey by March and it will tell us where we are; if we are doing well with HIV or not.
We are working with our partners and we have been able to put close to 1.1 million people on treatment and we are committed to make sure every pregnant woman is tested for HIV so that we can regulate mother to child transmission of HIV in Nigeria.
Mr President has directed we put additional 50,000 people on treatment every year. We have also started a national treatment programme and Nigeria is the first in Africa to do so. We launched our treatment programme and we want to drive the vehicle, to make sure we remove user fee.