Died Fixing Healthcare System


Dear Readers,

At a recent conference on health and health care in in Nigeria that held in London…Dr Seyi Oyesola asked the poignant question on what would happen to any of us if we had a medical emergency in Nigeria. The same question asked by Ernest Madu in his TED talk This story provides some answers. I am reproducing it verbatim as it appeared in “Thisday” as a public service. The piece speaks for itself on the tragedy of our country that has just experienced an era of 8 years of Oil selling at over $100 per barrel and how we have used this (or not) to improve the lives of our people.

Copyright belongs to This Day. All rights reserved. Distributed by AllAfrica Global Media (allAfrica.com).

Patrick Okigbo
4 December 2008

Lagos — Patrick Okigbo writes on the life and times of Dr. Enyi Okereke, a medical practitioner in diaspora who died trying to provide free medical services to the poor in Enugu State. Unfortunately, he died in a tertiary health institution that lacked equipment and drugs to save his life

Dr. Enyi Okereke had no real reason to be in Nigeria doing what he was doing when the cold hands of death squeezed life out of him. He could have stayed back in his villa in the United States to enjoy the results of his hard work. He could have been in the warm embrace of his loving wife who now has to journey through life without her soul mate. His children and grandchild could have surrounded him, as they joyfully expect the newest addition to the family. But he chose, instead, to be in Nigeria doing what he loved best – caring for the needy in our society. Dr. Enyi Okereke, physician par excellence, died in Enugu on November 11, 2008 of what is purported to be a heart attack.

Enyi, as he is fondly called was one of Nigeria’s top physicians in the United States. He was an associate professor of orthopaedics at the University of Pennsylvania. He was also Chief of Foot and Ankle Services at the University of Pennsylvania Health System in Philadelphia. Enyi won many prestigious awards including the 2002 Jesse T. Nicholson Teaching Award from the department of Orthopaedic Surgery, University of Pennsylvania.
He was named one of the “Best Docs” in 2004 and in 2005 was named one of Philadelphia’s “Top Docs”. Enyi held many leadership positions in many professional societies including serving as the 2004 secretary and 2005 program chair for the Philadelphia Orthopaedic Society. He served as the chairman of the New Jersey Chapter of the Association of Nigerian Physicians in America (ANPA). He was recently elected National Treasurer of ANPA.

ANPA represents the professional, political and social interests of the 4,000 plus physicians, dentists and allied health professionals of Nigerian birth, ethnicity or empathy in the United States, Canada and the Caribbean. ANPA’s vision is a healthier Nigeria in a healthier world and it seeks to achieve its vision through medical missions to provide free healthcare to the medically indigent in rural parts of Nigeria.

ANPA’s vision was Enyi’s vision. As has become routine for him, Enyi was in Nigeria with a team of US-based physicians to conduct free medical examinations and train student doctors in our universities. Enyi and his team were in a teaching hospital in Enugu imparting knowledge to medical students when he died.

The autopsy results are yet to be released; however, it is believed that Enyi suffered a heart attack. This is hard to believe because Enyi was very health-conscious. At 54 years, he still ran four miles every morning. He ate healthy, preferring salads to red meat and alcohol. It is difficult for anyone who knew Enyi to believe that a heart-attack would be the way he would exit this stage.

But that is beside the point. The point is that the heart attack happened in a teaching hospital in Nigeria, where he was surrounded by some of the best physicians in the world, but they could not save him. Why? The hospital didn’t have the basic equipment to provide alternative support for the heart while arrangements where being made for proper care. The hospital did not have the drugs needed to stabilise Enyi while arrangements where being made to fly him out of the country.

Both the Nigerian and Diaspora physicians looked on helplessly as life gradually drained from the body of an excellent gentleman. Enyi, a man with a passion to help the medically indignant became one himself because he found himself in a country that has squandered $350 billion in oil revenue but does not have the drugs and equipment found in every ambulance in the United States. Giant of Africa!

However, this story is not really about Enyi. Neither is it about my friend, a radio presenter in Enugu, who lost his wife and child a few weeks ago at childbirth. It is about the millions of Nigerians who die every year in this country for totally preventable reasons. According to the World Health Organisation (2004), of two million registered deaths in Nigeria, 1.43 million were as a result of communicable, maternal, prenatal, and nutritional conditions, 0.44 million from non-communicable diseases (such as cancer, diabetes, cardiovascular, congenital anomalies amongst others), and 0.13 million from injuries (including road accidents and other forms of violence).

We, as a nation, do not value our people. We do not value the lives of our people. We believe that people are dispensable. If not, why is it that we have not been able to fix the healthcare sector in Nigeria? Why do we delight in eating our own?

Scary Diagnosis
Enyi is no longer with us because of the challenges with Nigeria’s healthcare system. A review of these challenges can be quite daunting and with varied ramifications in terms of human capital, infrastructure, funding model, and policy. These challenges are compounded by other socio-economic challenges that are common across all sectors of the economy. A comprehensive and integrated healthcare strategy is needed, as none of these challenges should be solved in isolation. The government bureaucracy, as usual, has proved that it cannot solve these problems. It is time we turned to the markets to provide answers.

Human Capital
According to the World Health Organisation Country Cooperation Strategy for Nigeria covering the period from 2002 to 2007, Nigeria’s key health indicators have either stagnated or worsened. Life expectancy dropped from 1991 to 2000 by 10 per cent (48.2 years) for females and by 11 per cent (46.8 years) for males. This deplorable trend is consistent for infant mortality rate, under-five death rate, maternal mortality rate amongst others. The report attributes the trend to shortage of skilled medical personnel at the primary healthcare level. For instance, the report indicated that only fo
ur out of every ten primary health facilities provide antenatal and delivery services or have a midwife on location.

Nigeria is one of the major health staff exporting countries in Africa. According to 2008 research by C.J. Uneke published in The Nigeria Health Sector and Human Resource Challenges, about 20,000 health professionals are estimated to emigrate (legally) from Africa every year. Using 2002 data, about 21 per cent of this number comes from Nigeria. The data was not corrected for population size. However, the story is still poignant. Nigeria suffers severe brain drain as its medical professionals leave for greener pastures in foreign lands. Nigerian health professionals earn less than 25 per cent of what their contemporaries make in the developed world. Standards in our hospitals are so low that any medical professional desiring quality experience could be seduced by the facilities in the developed world.

According to the latest available data from the Federal Ministry of Health (1999), there are only 18,258 registered primary healthcare facilities, 3,275 secondary healthcare facilities, and 29 tertiary facilities shared by 140 million Nigerians (less the rich who can fly abroad for their own services). Although this data is ten years old, one does not expect any significant improvement in the numbers. It is important to note that the fact that a healthcare facility physically exists in a community does not mean that they operate. Most of these facilities are poorly equipped, lack basic diagnostics equipment, skilled human resources, and are usually in deplorable sanitary conditions.

Financing Model
The financing model is in two broad ramifications; development and delivery of health services, and payment for healthcare services. The financial resources for the development and delivery of health services in Nigeria come from government budgetary allocations, contributions from multilateral agencies, and the private sector. The Nigerian government spends a disproportionately lower percentage of its expenditure on healthcare than most nations.
According to the 2005 World Health Organisation report, per capital government expenditure on health was $14 compared to $32 (Ghana) and $2,861 (USA). In the same period, total expenditure on health as a percentage of gross domestic product was 3.9 per cent compared to 6.5 per cent (Ghana), 15 per cent (USA). Furthermore, the total government expenditure on health as a percentage of total government expenditure in 2005 was 3.5 per cent compared to 6.9 per cent (Ghana), 18.7 per cent (USA).

Nigeria did not fare much better on the World Health Organisation measures for individual contribution to healthcare. Out-of-pocket expenditure as percentage of private expenditure on health is 90 per cent compared to 79 per cent (Ghana) and 24 per cent (USA). This data shows the nascent state of health insurance in Nigeria. Patients bear the full and direct brunt of their medical expenses without any significant assistance from the company or institution they work for.

Nigeria’s national healthcare policy is based on a philosophy of social justice and equity. The policy is bureaucratic, cumbersome, and quite inefficient. The Federal Government is responsible for policy formulation, strategic guidance, coordination, supervision, monitoring, and evaluation at all levels. It is also responsible for operational roles such as disease surveillance, essential drug supply and vaccine management.
By the way, given the current governance arrangements, the Federal Ministry of Health does not have sufficient leverage over the State Ministries of Health to ensure compliance to the agreed policy. As a result, there is a visible gap between policy formulation at the Federal level and implementation at the State and Local Government levels. Herein lies the challenge. A government that cannot repair roads has assumed responsibility for the complicated management of healthcare systems and institutions.
Government, working closely with the private sector (owners of healthcare facilities, think tanks, health insurance providers and others), should develop policy for the healthcare sector. Monitoring of adherence to policy should (ultimately) be the role of the government, however, in the interim; the private sector should be involved in this effort. The profit motive for the private sector, which should be tied closely to the goals the government – which is to provide accessible healthcare to the populace, will ensure that the standards are maintained. Government cannot do it on its own.

Possible Cures
The real challenge, however, is not the intent of government to do the right thing for the people. Instead, it is the size of our bureaucracy and the absence of institutions and process that act as safeguards against inefficiencies and excesses. Given that most governments (even in more efficiently run countries) have shown that they cannot do better than the markets in terms of healthcare administration, it becomes imperative that Nigeria must redefine its policy to healthcare administration. The private sector must be allowed (indeed, encouraged) to lead development in this area.
Government’s role should not be in the provision of healthcare; instead, it should be to work with the private sector to ensure that policies are designed to meet the needs of consumers. By the way, bureaucrats should not design these policies. Instead, they should be designed by private sector operators with input from the regulators and bureaucrats to ensure that profit motives are not allowed to run amok. Research by Cato Institute, a liberal think-tank in Washington DC, shows that in terms of healthcare administration, markets are better than governments at cost-control. This is evident in private sector funded healthcare centres, and medical insurance programs that are available in deregulated markets.
For providing the patient funds, government can demand certain service levels including caps on tuition for students. The challenge for the school administration will be to ensure across-the-board efficiency that enables them meet the different conditionality attached to the facility. This can only bode well for society.
The National Health Insurance Scheme created by the National Health Insurance Scheme Decree No 35 of 1999 is a welcome development. The downside is its operation within the bureaucratic structures of government and its overly socialist leanings. Market driven health insurance programs have been more successful in other countries; however, they too run the risk of abuse if the profit motives of the insurance executives are unfettered.

Ultimate Price
As the Okereke’s commit their son to earth, one can only hope that his death will count for something more. Will it get the government to take a more critical look at the healthcare sector and seek pragmatic solutions? Will it shed more light to the plight of the medically indignant whose plight Enyi spent his life working to alleviate?
The Federal Government of Nigeria, under the leadership of President Umaru Musa Yar’adua, on behalf of the thousands who have received care from Enyi and all the other Nigerians physicians in ANPA, should confer a National Merit Award on this fine gentleman who died in the line of selfless duty to his country.

Enyi, journey well, my dear friend.


Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (www.epiafric.com), which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.

Discussion2 Comments

  1. Let us reflect ……..

    It was chilling and disturbing news to hear the death of an eminent physician, Dr Enyi Okereke on a mission to improve health services in Nigeria. May his soul rest in peace. I missed that story published by This Day and supposedly many Nigerians including health workers missed it too.

    The death has also provided an avenue to do some form of reflection by health advocates on the best strategy to engage Nigerian government on improved health services to the populace. I am not sure apart from the article written in This Day, the episode was given front news coverage by national dailies in Nigeria. This, informed us how the Print Media covers health news or makes a strong case to the government towards better services.

    Health to come back to the agenda at the federal, state and LGA levels, we need to innovatively engage the Print and to some extent electronic media in Nigeria. If we are expecting the policy makers to increase budgetary allocation and services to health sector without sustained advocacy and pressure, that might not happen, because it is not in their priority.

    Almost all the issues federal government puts much concern are being advocated and championed by Print Media and Civil Societies. In the health sector, there is great inadequacy of civil societies exerting meaningful and sustained advocacy and pressure and the print media have their own priority, when asked, they would tell you ‘Health news don’t sell’.

    Our policy makers hardly listen to news; don’t have access, neither understand articles published in Peer review journals, so far, Print Media and to some extent articles in popular websites serve the best medium to reach out to them in order to shape policies and raise the profile of health to get a better attention.

    A cursory analysis revealed that ‘there is no single opinion column’ in any print media in Nigeria that is dedicated to Sustained Public Health Discourse that engages policy makers and development partners on myriad health problems in Nigeria. This is the same in popular websites such as NigeriaWorld, Gamji, AmanaOnline, NigeriaVillageSquare to mention but few. (I stand to be corrected, if such columns exist ).

    Who will write such columns? Average journalist will not do it due to inadequate availability and accessibility to health information as well as grasping and understanding the subject matter to write analytical article. Those who are expected to do that are the health advocates and public health professionals who believe in the cause with flair to writing.

    We need to engage the print media and websites dedicated to Nigerian issues and regularly write as well as penetrate editorial board of Print Media houses to influence editorial policies. While I commend Diaspora Health Organizations that come to Nigeria on health mission, such missions need to be reform in such a way that it is not only about medical services to few individuals that can be reached at that point in time , the mission should also focus on engaging local civil societies in an innovative partnership that will lead to evidence based advocacy to policy makers for improved health services.

    Let us reflect please on this issue.

    Thanks and Godbless.

    Aminu Magashi Garba, MBBS, DLSHTM, MPH
    Kano, Nigeria
    Emails : GAmagashi@gmail.com, GAmagashi@chrnigeria.org

  2. This type of avoidable death is the reason why I complain bitterly about the mentality of Nigerian rulers and elite, which is to fly out for medical care when one is sick rather than fix the system. Dr Okereke’s unfortunate death is testimony to the fact that some conditions cannot wait for the 8 to 16 hour cross-atlantic flight. There has to be aggressive investment on the part of government to establish at least one state of the art center in each region of the country.

    This reminds me of the comments from a group of wealthy philanthropists who recently stormed the USA for a hospital fundraiser. One of the key donors invited from Nigeria mentioned in his speech that he understood the plight of people back home given their lack of access to standard equipment, and knowing how much he had to pay to use “a hospital owned by Russian doctors in Nigeria”. Well (I mused), even that Russian doc hospital may not have functional equipment because simple amenities like electricity and water are lacking, and access to modern medications is a nightmare. So, Russian docs/hospital or not, if you had a condition that required a prompt and highly specialized response, you were a goner. Indeed anecdotal accounts of Dr Okereke’s encounter with the Nigerian medical system suggest that some medications that would have alleviated his condition could only be purchased in….(drumroll) Abuja. Why not Enugu or any other urban center at a minimum?

    Seems like the one way to attract the attention of our rulers is to accost them with their own mortality, which realistically is not completely dependent on their ability to secure sophisticated care in South Africa or the west. If the medical system is not restored to a decent level, eventually many (wealthy or not) will fall victim to these blatant inadequacies.

    I did not know Dr Okereke, but what a shameful loss. Naija as a country should be ashamed that someone who was dedicated to bringing medical care to his countrymen eventually became a victim of the same monster he was fighting.

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