By Simeon Mpamugoh
Executive Director of Trinity Healthcare Foundation, Dr Nseabasi Ekanem, is a pharmacist and public health expert, based in Abuja, the Federal Capital Territory.
Like most other patriotic citizens and healthcare professionals, his earnest desire is to see the government make and implement policies that will strengthen the national health insurance scheme. In this interview, he proffers suggestions on the way forward.
Talk a bit about yourself and how you came into public health as a clinical pharmacist.
I went into public health because of my interest in improving the health, well-being, and overall health outcomes of Nigerians and other Africans. I consider it important that my scope of influence will be better if I operate within the limits of public health rather than clinical health.
The difference between clinical and public health is that while clinical health focuses on the patient, public health focuses on the population and communities. The individual patient is impacted with clinical medicine but with the public health, it is the entire community that is impacted as a whole. So it was on the heels of that understanding that I decided to go into public health. And to give effect to this, I obtained my Master’s degree in Public Health from the Ahmadu Bello University, Zaria, Kaduna State, Nigeria. It was at the same time that I took a decision to start a non-profit organization, which clearly focuses on improving health outcomes through capacity building of healthcare workers, service providers, advocacies, policy and engagements with stakeholders in public and private private sectors. The idea was to ensure that both the private and public sectors are carried along with what is happening within the healthcare space. The lots of Nigerians can be improved through coordinated and holistic healthcare implementation strategies and this was the reason I established Trinity Healthcare Foundation. Currently, we operate in three states (Lagos, Adamawa, Akwa Ibom) and the FCT.
What basic areas of public health interventions are you involved in?
We provide multi-dimensional interventions. We engage the government with a view to seeing how we can inform policy making by providing sufficient evidence that shows that certain healthcare policies need to be reviewed in the interest of the public. We also provide evidence to show that the priorities and plans of the government align with the global best practices. So, we work with the Health, Education and Women Affairs ministries of the federal and state governments.
What can you say about environmental health in the country?
There is need to ensure that we create a safe and healthy environment. Our involvement in this started when we reviewed the World Health Organization (WHO) report on air pollution in Nigeria. We found out that Lagos ranked third in the entire world in terms of air pollution and that did not sit well with us because we understand that there is a whole lot of diseases that can result from air pollution, ranging from aggravated asthma, lower respiratory tract infection, down to chronic obstructive pulmonary disease, myoma, bronchitis and even lung cancer on the long term. We were given a priority to look at how we can sensitize the people. A couple of times we had to visit the motor parks to educate drivers on the need to work on their vehicles, to reduce emissions of toxic fossil fuels from their exhaust pipes. However, there is a limit to where some of these things can go, especially when a lot of these drivers are struggling to survive, and you’re telling them that there is an equipment they can use to filter out toxic fumes ridden with carbon monoxide. The person will tell you that he can barely feed himself let alone do that. The awareness is still ongoing. We have discussed with the Ministry of Environment concerning landfills. One of the things we talked about was that we should be able to make sure that we essentially coordinate waste management to ensure that landfills where these waste are disposed and incinerated are well taken care of.
Unfortunately when we moved round with a study we did in 2020 about disposing medical waste, we noticed that the disposal of pharmaceuticals, for instance, drugs, antibiotics and other kinds of medical devices such as syringes, needles and other hazardous medical waste, sometimes are done indiscriminately. Antibiotics, for example, percolate into the ground and plants absorb them and when we consume food from these plants, tubers or fruits, it has a way of exposing us to those hazards. We should try as much as possible to prevent it by having a good balance between the environment and animals. There is always an environmental component to some of the epidemics and infections happening in the last couple of decades.
You are on record to have said that organised healthcare financing will overcome the challenge of out-of-pocket payments. Please elaborate on this.
This was informed by an experience I had five years ago, when I provided service for a patient in my clinic. It was an acute accident and emergency case. The total cost of the medical bill was N400.000. Till today, I have not been paid a dime. Yet the patient keeps sending people to threaten me saying that if I keep pressuring him, he will have me killed. This was somebody, who submitted his international passport as a collateral but I didn’t bother to check the passport because I trusted him until later when I discovered that the passport had expired. Unfortunately, in international passports, you don’t get to see the house address of the person. The only thing I could reply upon was to call. Even the house address and next-of-kin in the register was also fake. So, I kept calling. In fact his case was almost fatal but I decided to help him because he sounded so desperate and I felt that life should come first before money. At the end of the day I got nothing. In this regard, the Bola Tinubu administration can come in by ensuring that the Mandatory Health Insurance Bill before the National Assembly is passed without further delay. The country’s healthcare system needs to be strengthened with health care insurance scheme. I give kudos to the current Coordinating Minister of Health And Social Welfare, Prof. Muhammad Ali Pate, for his system-wide approach to healthcare. He looks at the entire sectors of the economy in his approach to healthcare.
In Ghana, over 70 percent of the country’s population has been insured. And such scenario where you treat someone and he wouldn’t pay would not have a space in healthcare services. I was privy to this information because of the meeting I had with a senior official of National Health Insurance Agency of Ghana. An average Ghanaian lives on health insurance. What this means is that if he goes into a healthcare facility, he would access basic and minimum healthcare services without paying a dime from his pocket. So, out-of-pocket payment is a major bane of healthcare delivery and outcome in Nigeria. The government needs to pay priority attention to ensure that we improve and strengthen our national health insurance scheme, to block all the loopholes. We also need to capture more people into the mix because the more people in the mix, the easier it is to be implemented. In our federal system of government, there is a concurrence between the federal and state governments in terms of healthcare. So, as far as the federal, state and local governments are concerned, healthcare is on the concurrent list. It is not on the exclusive list and therefore not under the exclusive preserve of the federal government. It behooves the federal government to give it a priority by making it attractive.
How can states and local governments run an effective health insurance programme?
Most times when people have problems it is at the point where they don’t have money. But if they have an insurance cover, they will be able to access healthcare service without out-of-pocket payment. This restrains many doctors. A situation where a doctor for example is handling three to four patients who were not able to pay and he provides services and the patients still die. Who pays? The family tells him, “Sorry we are mourning our dead relation.” And they begin to fight over the release of the corpse? It doesn’t make sense. But if there is health insurance cover, everyone would be able to access healthcare without out-of-pocket payment. It is the principle towards achieving universal health coverage. We cannot achieve universal health coverage if Nigerians are not subscribed to an attractive health insurance scheme.
Nigerians must be made to see that when they subscribe, they can access healthcare service when the need arises.
I appreciate what the Chief Executive of the National Health Insurance Authority (NHIA), Kelechi Ohiri, is doing. He added some programmes into the National Health Insurance Scheme by including cancer treatment. But how many Nigerians are on the platform? If we have five people on the platform, it doesn’t give us any benefits. We need to ensure more Nigerians are captured in the platform so that they can access healthcare services such that if a patient walks up to a physician, he would be able to pick up the patient’s card and attend to him or her. It will engender the digitization of the process without NHIS card. Again, in some facilities in Ghana, they use thumbprint. You put in your thumbprint and your details pop up.
It was reported that not less than 18,224 Nigerian healthcare workers (doctors, pharmacists, laboratory scientists and nurses) were granted visas by the British Government in one year. What are your thoughts about the exodus of Nigerian healthcare workers to Europe?
Across the spectrum of human resource for health is the outward migration of trained and experienced professionals. Why? Because there are what we call the pull and push factors. The pull factors are the improved services and welfare that pull our clinicians like pharmacists and nurses to other countries in North America and Europe. In Nigeria we also have the push factors which are those factors that are pushing Nigerian doctors and other healthcare workers away. For example, healthcare workers in the light of inflation ask for very fair and moderate increase in their wage. In 2020, I went to some hospitals in the course of a survey in Delta State, in which a clinic had to pay for many tests for many children because they were important to know the problems and understand their pathology or diagnosis to be used to treat them. And the parents of the children didn’t have the money to run the tests. The clinician had to pay almost N100,000 for the laboratory tests. These are some of the things clinicians do and if not checked, in two to three months, they will go bankrupt. Yes! He has to do that because he doesn’t want the kids to die and no one can tell which of those kids could become the next Obamas or Obasanjos of this world.
Meanwhile, his colleagues in United States, Canada and United Kingdom are telling you that healthcare services are easily provided and all the patients have access to diagnosis and treatment and you, a healthcare provider in Nigeria is the one paying for the services. Sometimes, you go to the clinic and there is nothing to work with. You only read some things in the book. As a surgeon you go to the clinic using 1960 surgical tools that will not help your work proficiently. A lot of Nigeria’s medical personnel work on trial-and-error when it comes to diagnosis because the right diagnostic tools are not available. They feel frustrated everyday they go to the hospitals, they have to fan themselves because there are no air-conditioners, the environment is not conducive for work and patients privacy, because confidentiality is completely neglected. Sometimes you see five doctors in one consulting room and their interactions with patients are in the public domain for other doctors and patients to hear. Then there is the issue of remuneration. How much is an average Nigerian healthcare personnel asking for? Can it be compared to what obtains abroad? Anyone who visits Nigeria’s hospitals will see that doctors and nurses are under pressure to save lives every day. These are practical experiences that push our healthcare workers out of the country. And to halt it we need to improve the lot of the healthcare workers and the environment where they work, and you will see them happily providing the services towards the betterment, well-being and health of patients.
