Nigerian American doctor proffer solutions for effective healthcare delivery system

April 7th, 2018

In this interview, Dr. Kenolisa Onwueme, a Physician in Maryland, Onwueme, who is recognized as one of the brightest medical doctors in the State of Maryland in the United States of America, gives insights on what the Nigerian, nay, African governments can do to get its health sector working right.

Nigeria budgeted almost N340.5 billion in 2018 for the health sector. In 2017, the budget for the health sector in Nigeria was about N340 billion. The USA on the other hand, plans to spend about $7 million per prisoner in Guantanamo Prison within the same period. Based on this analogy, do you think the major problem with healthcare in Nigeria is inadequate funding?

Having worked professionally in Nigeria I can address this with some familiarity. My sense is that the limiting factor is a lack of resource optimization. Funding may be a major problem but the resource under-utilization problem is a more insidious and overwhelming problem in my opinion.

Funding is certainly important and the fraction of the budget does reflect a governmenta��s level commitment as a corollary. However, I do not believe that inadequate funding is necessarily the limiting factor in Nigeriaa��s case or in the case of many developing countries for that matter.

Various health reports from the World Health Organization, and Nigeriaa��s ministry of health amongst others shows that many people still die every year of basic/common diseases in Nigeria and Africa. Do you think early diagnosis is a problem and how do you think that challenge can be addressed?

Early diagnosis is certainly a problem. I would clarify that early a�?correcta�? diagnosis may be the issue. There is a tendency to adopt empiric therapies with little diagnostic effort or pursuing biased diagnosis with prejudice.

Experts in the medical field opine that proliferation of low quality hospitals in Nigeria remain a big problem. Is that a challenge affecting healthcare in Nigeria and how do you think that challenge can be solved?

This is a tremendous challenge and one that I think has far region implications for the next 3 generations of Nigerians physicians. I think it will take that long to remedy some of the damage that has been done. The damage, if you will permit, is a cultural one, and the lack of quality is not necessarily structural or the absence of resources, but more functional and related to how the culture of medicine is practiced and executed.

It relates to how resources are managed and this would include human or labour resources, financial resources and intellectual resources. It has significance and poignancy for how trainee medical students are groomed through the process of becoming independent providers and stewards of Nigeria’s health system themselves.

What do you think we need to do to get health systems right and working in Nigeria and Africa?

This is a very open-ended question. I believe that will necessarily call for a multipronged approach. There is no simple answer. However, I do not believe that a listing of platitudes borrowed from development technocrats is an appropriate way to address this question.

I believe that the way to begin approaching some of the problems a country like Nigeria faces in the healthcare sector is again emphasis on optimizing resources that are already present. I believe this requires building scaffolds where they do not exist and strengthening of existing scaffolds if they are appropriate.

One can then layer the resources on a system that is optimized. This approach requires root cause and systems analysis of processes, or what I like to call process relays, in the healthcare delivery machinery.

For decades, Nigeria has not been able to get its health insurance system right. How can that challenge be addressed?

One of the most promising accomplishments of the previous administration was the National Health Insurance Scheme, (NHIS). For the first time Nigeriansa�� had a promise of health insurance and this attracted me to study how this could yield dividends.

A shortcoming however was that many of the programs targeted the middle class by structure, but though it has been acknowledged that a great deal of individuals were left out. Instead the mandate instructed informal sector workers to form community health insurance programs. In fact, my first adventure into Nigeriaa��s health system as a professional was to study the feasibility of this and work towards a proof or disproof of concept.

Accountability (for NHIS) is also an issue. Many of the health insurance companies became hugely profitable without delivering any care. For several reasons: at least for the first 3-4 years after it had been in force, many civil servants did not realize they had insurance.

Moreover, many conditions listed were not covered for care, and patients were still saddled with paying cash upfront before receiving care. One can debate the reasons for this (including insufficient a�?marketinga�? or advertising of the program by the government, but the net effect and hence report card is that it did not deliver as promised a�� a failure perhaps attributable to omission.

I am aware though there are those who believe there are failures due to commission as well. It may seem cynical but I believe that any honest analysis of outcomes now some 10 years after the program must consider, explore and address this as well.

What do you think can be done to encourage experts like yourself to come back home and help fix Nigeriaa��s health systems? What needs to be in place to bring people like you back home?

There are many facets to this. I know many like me who were genuinely committed to go into the battle of fighting for the future of Nigeriaa��s health care, and under huge personal sacrifice with costs to their family lives.

I know many for whom it became too frustrating or even unsafe. The best minds I know who made this journey were not in it for money or personal gain. And unfortunately, it appears we do not appreciate people like that. What would it take? Nigeria needs to court these brains. They populate the halls of the most prestigious institutions the world over. The nation can stew in its pride and decide it does not need the absconded diaspora. But it is to our detriment. What recruitment programs are there for these individuals?

Where do you see the future of healthcare in Nigeria in particular and Africa in general?

Ita��s a dismal future from my current vantage point if the professional culture issues are not addressed. There are some countries that seem to have gotten it right somehow. Rwanda, Botswana are two examples. But one can argue, correctly or incorrectly, that their small sizes make change and progress more manageable. But it also reduces your human and intellectual resource capital doesna��t it? So, I am not sure if that argument can withstand a deeper dive critique.

What do you think should be done by stakeholders that will attract serious investments in the healthcare development in Nigeria and Africa?

Accountability is imperative so that would be stakeholders can be more engaged. A non-profit organization I work with, the Obala Foundation, conducted an extensive feasibility project on establishing a 911 system in Nigeria in 2008. When we arrived for that project, one of the first things I did after charging my mobile card was to call the emergency access number listed in the instruction booklet/page of the card. It never worked. It does not exist. This was a slap in the face. A fallacy. Where is the accountability in that?

We reached out to the Federal Road Safety Commission (FRSC) and offered free help in designing a nascent Emergency Management System (EMS) but were rebuffed by its leadership then. We met with the representatives of a major mobile corporation but did not get past the first meeting because we could not tell them a�?what was in it for usa�?. Despite these experiences, which were no doubt demoralizing, we continued our study and completed it with devastating conclusions.

If you were to advise the President of Nigeria or the Minister of health on healthcare delivery, what would that advise be?

That would be accountability. Resource optimization, and more accountability.

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