Empty Promises: The Bane of Health Sector Reform in Nigeria

Editor’s Note: This week’s Op-Ed comes from Chiamaka P. Ojiako, a lawyer and health equity advocate. On this Democracy Day 2019, she writes about the negative impact of inadequate political commitment on successive attempts to achieve sustainable reform in the Nigerian health sector. She makes the case for structures and enforcement mechanisms that hold the incoming administration accountable for commitments to health sector reform.

“Promises are like crying babies in a theater, they should be carried out at once” – Norman Vincent Peale

A recent report bemoaned the absence of a health agenda in the 2019 Nigerian presidential election race, and it prompted me to recall the several empty promises that candidates made during the 2015 election cycle and the early days of the past administration. The most striking was a declaration made by President Muhammadu Buhari in 2016, that he would stop government officials from using public funds to seek medical care abroad. This instruction was supposed to apply especially to medical conditions that were treatable in Nigeria.

The President then subsequently traveled to London, allegedly using taxpayers’ money, on 5 separate occasions during his last tenure, for several medical issues ranging from treating an ear infection to other unknown ailments. In 2017 alone, President Buhari spent about 103 days in London, receiving medical attention, thereby missing an opportunity to change the narrative through leadership by example.

In 2018, Nigeria Health Watch in collaboration with NOIPolls conducted a survey to find out the voting priorities of Nigerians in the run-up to the 2019 elections. The results revealed that 86% of respondents polled mentioned health as one of the issues that mattered the most to them. This suggests that the average Nigerian considers health to be a priority yet it was not a top debate topic in the campaigns by all the parties at the recently concluded election.

The Nigerian government repeatedly prepares an agenda for the health sector with little or no corresponding action. These agendas are like cheques that always bounce except that charges accrue for bounced cheques but they do not seem to accrue for our leaders who issue empty promises. Where there are no consequences for the breach of a commitment, the chances of complacency or failure to act are more likely. Citizens’ demands for health sector reforms thus remain a plea and not a demand because no cost accrues to the politicians who promise to address them, when a breach occurs. The citizens bear the cost of these unfulfilled promises and poor prioritization of health, as evidenced by the poor health they experience as evidenced in Nigeria’s poor performance on several global health indices.

An important factor that allows successive Nigerian governments to maintain a non- committal attitude towards fulfilling health commitments is the people’s low expectations. Many Nigerians are indifferent to the government’s health agenda because of prior disappointments by past leaders. In 1999, Chief Olusegun Obasanjo signed the National Health Insurance Scheme (NHIS) Act when he was president, to make healthcare accessible and affordable for all Nigerians. About 13 years after its establishment, it is still almost impossible to get an accurate figure of the number of Nigerians that are covered under the scheme. However, the suspended NHIS Executive Secretary, Prof. Usman Yusuf, in 2017 mentioned that the scheme covered a mere 1% of Nigerians. Why have we not held an agency that has woefully failed to deliver its mandate, accountable? Perhaps many Nigerians are not even aware of the existence of such an agency and the few that are aware do not expect much from it because of their distrust for government-led initiatives.

Undoubtedly, Nigeria is excellent at making paper commitments that never see the light of day. In 2001, Nigeria was one of the countries that signed the Abuja Declaration, pledging to spend no less than 15% of its annual budget on the health sector. 18 years later the commitment is still unmet. Last year, the budgetary allocation for health only just reached four percent (4%) after a successful campaign for the appropriation of the Basic Health Care Provision Fund (BHCPF) as provided for in the 2014 National Health Act. Of the four percent, only a fraction was disbursed, and that was close to the election period. Our government needs to understand that political commitment goes beyond being signatories to treaties, conventions, and creating numerous policies.

Meanwhile, Rwanda has achieved tremendous improvements in its health indices primarily because of the strong political commitment displayed by their leadership in efficiently coordinating foreign aid and other aspects of their health sector. Not only have these efforts led to an implementation of a sustainable health financing mechanism, it has also set up evaluation mechanisms to monitor implementation. Their emphasis on accountability led to the dismissal of the Health Minister in 2016 and the entire staff of a division at the Rwandan Biomedical Centre in 2018. This lends credence to the importance of enforcement mechanisms for fulfilling commitments geared towards health sector reform. Isn’t it high time we began to put stricter measures on the performance of our leaders?

Although political commitment is essential, other factors such as human resources, research and financing, are equally important for successful health sector reform. However, political commitment precedes all of them. While the country waits earnestly for political commitment, the private sector is still a key stakeholder that can drive efficiency and quality through competition. The recently formed African Business Coalition for Health is refreshing because it involves African business leaders engaging with governments to improve health access and achieve better health outcomes. More of such public-private partnerships providing solutions for a sustainable health sector reform are welcome.

Now, President Buhari has been re-elected and his administration will serve Nigerians for another four years. We need the Nigerian Government to make clear commitments to reform the Nigerian health sector. Commitments that would not only be signed on paper or read out in a speech, but commitments that would be followed through for the good of the people, with clear outlines of what actions will be taken if the commitments are not met.

Efforts should be made to sensitize Nigerians about their right to health and what clearly quantified improvements they should expect from the government. With this, citizens and appropriate bodies would then be able to hold the government accountable in the instance of a breach. The Saving One Million Lives program is proof that incentives work, as governors were motivated to produce results. Also during the campaign to eradicate polio, the National Primary Health Care Development Agency (NPHCDA) held politicians at every level liable for the vaccination coverage of their respective communities. These commitments were successful because the NPHCDA held them accountable and reprimanded those who did not fulfill their obligations. If the carrot is good enough then the stick is equally necessary.

As we mark another Democracy Day, stakeholders in the health sector should refuse to be left out of the “Next Level” commitment made during the recently concluded election campaign. The quality, access and effectiveness of our health and healthcare affects every one of us. We must stop celebrating mediocre attempts at governance and demand for accountable leadership so we can enjoy the highest level of health regardless of class, sex or creed.

Chiamaka P. Ojiako is a lawyer and health equity advocate. She finds the complex nature of health care issues and the absence of a uniformly adaptable solution or model stimulating. She is the Executive Director of Health Equity Advancement for Africa.

How can government and civil society make it easier for citizens to measure progress against their commitments in health? What sanctions and incentives can be used to encourage politicians to keep their promises? We would love to hear from you.  To Mr President and the newly elected governors and other elected officials, we encourage you to share your plans for improving health over the next four years with us here at Nigeria Health Watch, to help us and your citizens celebrate and challenge your performance over this period.