In this exclusive interview with PREMIUM TIMES’ Oluwatoyosi Olawande and Aminu Adamu, Nigeria’s Minister of Health, Issac Adewole, speaks extensively on various issues and developments in the health sector, including the performance of the 2016 budget in the sector and what to expect going forward.
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PT: What is the ministry doing to forestall the strike threat by resident doctors?
ADEWOLE: We have met, and we are addressing the issues and a letter is going from the Permanent Secretary to the President of the National Association of Resident Doctors about what we have done on all the issues. Practically all the things have been looked into, some are key issues that are under our purview, some are key issues that will have no control over.
PT: What about the issue of their unpaid salaries?
ADEWOLE: I spoke to the Minister of Finance and Mr. President took a virement request to the National Assembly. It has been approved. The issue of November, December salary will be taken care of in the next few days, so that is the key element of their request.
PT: They spoke of worsening health indices
ADEWOLE: That is not true, that is very unscientific. I would have expected them to tell me the indices that have worsened since we came on board; none. You don’t even do indices every year, you do indices every 3 years, every 5 years. The next demographic and health survey in Nigeria is due in 2018. The last one was 2013, so how did anybody come with worsening health indices?
PT: They complained about dilapidated infrastructures in health institutions in the country.
ADEWOLE: That is also not true, we are working hard. If you look at the 2017 budget, there is a lump sum of money that we put there, about N12 billion, N11.7 billion of that is for upgrade of tertiary centres. And what we are doing is to partner with the sovereign investment authority to get some private sector money together so that we can grow the money and make sure we work on our health facilities.
PT: You heard about the recent unfortunate death of a corps member at an NYSC camp?
ADEWOLE: NYSC is not under us but immediately the death occurred, I called the Director-General and I said DG, I am writing to all the federal health institutions to look after your corps members. In addition, Mr. President has directed that we should bring a memo to the Federal Executive Council enrolling Youth Corpers in National Health Insurance.
PT: Still on resident doctors, they said their colleagues have not been paid salaries for 3 months in Akwa Ibom State.
ADEWOLE: The thing is that there is a problem across the country. The last time we spoke with Mr. President, I think about 24 states or so have not been able to pay salaries regularly. It’s a general problem.
PT: There is also the point about improper placement of doctors on entry point and non adjustment of their salary structure.
ADEWOLE: That is not true. Doctors are on CONMESS; CONMESS 1 to 7. Doctors who come back from NYSC actually start on CONMESS 2. They woke up and said that the entry point should be on CONHESS 9 and you are not on CONHESS.
That is what the Chairman of the Salaries and Wages Commission said, that if you don’t want your salary, say so and move to another one. You cannot stay in a salary scale and say they should give you entry point of another one.
Sometimes when your constituency fights, you ask them, do they really know what they are talking about? What you should ask for is that, maybe the entry point of your own, if you think it should be higher, we can work on that, ask us to look at it, but don’t say they must give you the beginning of another salary point because that is not what you need.
PT: What about pension deduction?
ADEWOLE: We have directed that they should deduct their money for pension, we don’t see why that should be a problem.
PT: When will there be white paper on training programme?
ADEWOLE: We are working on that.
PT: On non-payment of salary in some states…
ADEWOLE: We have no control. As I have said, I cannot force Akwa Ibom to pay you salary, it is not under our control. I cannot force Osun, I cannot force Oyo or any of these states that have financial hardship to pay you, we can only appeal to those states.
PT: What about the implementation of No Work No Pay Rule?
ADEWOLE: It is the policy of the land, it’s the law of the land. No Work No Pay is not my creation, it’s the law. You are free to go on strike but the law has to take its course, if you are on strike, then you don’t get paid. There is nowhere in the world where you go on strike and say they must pay you.
We don’t want strike, we will work hard to prevent strike and our job is to prevent strike. But we cannot but implement No work No pay rule.
PT: What is your roadmap and timelines for achieving your objectives in the health sector as a Minister?
ADEWOLE: We have a 4-year plan because this administration has a 4-year agenda and within the context of that agenda, we want to reposition the policy. We are working on that, it has been approved at National Council on Health, it is awaiting editorial input before we submit it to FEC for approval. Because, anything we do must be done within the framework of the policy, because the policy states what you want to do. This country has had a policy (reviewed) three times, in 1988, in 2004, this one is third one in the history of this country. Because we must have a roadmap, we can hold the policy and say look, this is what you promised to do.
Within the context of the policy, we want to do 4 quick things: improve on the policy environment; we want to improve on quality; we want to make sure that we care for the poor and the vulnerable – the president is so passionate about poor people, rural and vulnerable – and we want to prioritise health; and we want to begin the implementation of universal health coverage.
And when we talk about universal health coverage, it is a journey but it takes about 3 things. When you look at All Progressives Congress manifesto, it says that we will make health care accessible, affordable and qualitative. Those 3 means universal health coverage: that means you access health close to you, it must be of good quality and you must not look for money when you need it.
And that’s why we then say how do we deliver it? We must revitalise Primary Healthcare Centres. When Nigerians are sick today, because they don’t trust the Primary which has more or less collapsed, they walk into a Teaching Hospital or a Federal Medical Centre and say I have headache, I have skin rashes, I am having nausea and vomiting. And we say that it’s not what a Teaching Hospital or Medical Centre is meant for.
We want to reposition it properly so that it can sit at the base. We want a base which is the PHC, Secondary and Tertiary. Seventy per cent of Nigerians will access health at the Primary: those who want to deliver, those who have malaria, those who have diarrhoea and vomiting, those who have skin rashes, those who want to immunise their children, they don’t have to go to a specialist hospital. Twenty per cent will access healthcare, those who cannot deliver and need caesarean section will go to Secondary; accidents, bad cases will go there. Then the super complex cases like the girl with cystic hygroma, the liver cancer, cervical cancer, renal failure, stroke, will go to a tertiary centre. So within the lifespan of this administration, we want to reposition this pyramid.
PT: How well did the ministry perform with the 2016 budget?
ADEWOLE: For the first time in the history of this country, we gave 50 per cent of our capital allocation to the Primary Health Care Development Agency. It has never happened before. If you look at it, Mr. President submitted a proposal of N35 billion, National Assembly reduced it to N28billion and that drastically affected us. But even with that, we decided to prioritize, we said we must give priority still to primary healthcare. The total allocation for primary healthcare was N17.745 billion, so 60 per cent of our budget went to PHC, Primary Healthcare Development Agency.
That was why when they picked out that polio, all I did was to meet Mr. President and say Mr. President, we need money. He said what do you need? I said sir, we make provision for it in our budget, all you need to do is direct that it should be released. He said it should be released and the Minister of Finance released the entire N9.8 billion, 100% release. It has never happened in the history of this country.
The international community even said this has never happened before, that Health will release the entire allocation and that is why we have been able to do six rounds of immunisation of polio and WHO came and commended Nigeria. There are other things, if you look at the budget, apart from Polio, we had N1 billion for other vaccines.
PT: There was a reversal in Polio eradication in Nigeria.
ADEWOLE: It is wrong to say Nigeria is free of Polio when part of Nigeria was not accessible. And when they say there is resurgence of polio in Nigeria, I say where? Inaccessible area. The day you pick Polio in Kano, in Sokoto, Ibadan then I will say there is resurgence. So when you say under my beat, Polio resurged, No, it’s wrong. We’ve had 4 cases of Polio in Borno, all the four came from areas that were under control of Boko Haram.
When they say Nigeria was free of Polio, they should have said the free area or accessible area is free of Polio and it is still free of polio. We have not detected polio in Sokoto, Kano, Ibadan, Port-Harcourt, Abuja. We only picked 4 cases of Polio in Borno State, areas under Moguno IDP Camp, Murna Camp, and Gwoza. So that to me, scientifically, it is not resurgence. Resurgence is you have controlled it, it flared up.
We had no access to this place before. It is the security operations that enabled us to access them and that is why Mr. President said ‘Go and look for more, you might still find children who are not vaccinated before’. And if children were not vaccinated, they could develop polio and that is what happened. We did (immunization in) Borno State, we did five states and we did 18 states four times and we used soldiers to even vaccinate.
We worked with the Army, something that has never been done before and then we introduced IPV. The IPV is injection, you know oral polio will give about 4, 5 times because it is not as powerful as the IPV, but the IPV is in short supply all over the world, it is what we are introducing for routine immunisation. I directed that any IPV in Nigeria should be taken to Borno and any child that comes out, you are seeing, just give IPV because we may not see them again. Even if you give IPV once, you are sure you have given something.
PT: What are your immediate plans to ensure a transparent procurement process for 2017 budget implementation?
ADEWOLE: Well, the first thing is to say that we will continue to comply with the provision of the public procurement act, we would. Two, we would be transparent with our figures. I met the funders, even for 2016, this is what we have, we won’t hide it. When they brought the proposals for 2017, I did photocopy and gave to all the directors. I also insisted that the director of procurement must not advertise without getting the quotation from the director or head of unit. Because it’s the head of unit who is the technical person who knows about what you want to procure, they must contact them and our budget will be on the website
PT: In the 2017 budget proposal, 303.9 billion was allocated to health which represents below 6 per cent of the budget. Is the Nigerian government not committed to the Abuja Declaration of 2000 (15 per cent of annual budget to improve the health sector)?
ADEWOLE: Number 1, I am a doctor so I want more money in Health. But when you look at Health, what we need to do is to quantify money going into Health. How much are the states putting there, how much are we getting from donors, from outside funding?
In 2016, we have a World Bank loan of $500 million, that is about N140 billion that is going into Health. It is a loan from the World Bank, Nigeria will repay but we give it free to the states as grant to improve primary healthcare: improve immunisation, improve maternal health, improve child health, improve nutrition, improve immunisation, improve family planning, and take care of HIV. When you start taking it, we go and check your levels and we give you more money next year.
The Global Fund will spend about $1 billion over 4 years in Nigeria; that has not been captured. PEPFAR is working in some states, 32 local government areas on HIV, it has not been captured. DFID is supporting 950 PHCs in the North, to revitalise them, it’s not been captured. EU will rehabilitate 774 PHCs in 3 states in 2017. So when you look at health, health is not an orphan. I want more money in Health, I am not going to deceive you, but it is not that we are completely helpless. My strategy is that whatever we have, let’s use it well and ask for more.
For 2017, health recorded the single largest increase in allocation for capital. We have 79 per cent increase from 28 to 51 and we are assured that it will keep on increasing. When I discussed with the Minister of Budget, I tried to liken it to UBEC. UBEC is out of Education because UBEC is like NPHCDA, so maybe the solution is to take NPHCDA out of health so that people know that it is separate.
In fact, Bauchi is spending 16 per cent of their budget on health. So there are oasis of success and hope across the country. We will get there, I think part of the challenge in this administration, before now, we spent over 90 per cent of our budget on salaries. 2016 represents the first time Government is saying even if we are to borrow, let’s put money on infrastructure.
When you pay salary, even when you increase my salary, nothing changes outside other than my buying imported goods. But when you put money on railway, on roads, you know what will happen? I told my STA, I said once you put money in roads, it’s a capital project. You find drivers, they will employ more people, food sellers will come and sell food, by evening ogogoro people will sell ogogoro, by evening you find some small shelters, prostitutes will come there, you develop a new life, some people will open a small clinic to look after those who have accidents. So when you invest in capital, it’s like you are investing in the life of the country. And so 30 per cent is going to capital and it will change the dynamics of things. When the American economy was down, all Obama did was to fund infrastructure and turn the economy around in spite of being a black person.
PT: How well has the ministry been able to harness and redistribute the resources contributed by the international community, donor agencies and international NGOs in respect to health for the benefit of Nigerians?
ADEWOLE: Excellently well. You know the interesting thing about this country, the problem of health in Nigeria is the problem of equity. The maternal mortality rate of the educated Nigerian is just like that of Europe and America. Ninety-one per cent of educated Nigerians with at least secondary school will attend antenatal care. Twenty per cent of the poor ones will go to antenatal care, so that is why we just must target rural people, the uneducated people.
The Save One Million is to the poor. We are also using the RRI, the Rapid Result Initiative, it is for poor people. We are doing free surgery for poor people, some of them were given transport money, some were given money to go and start some business. The one I saw in National Hospital, they repaired the palate cleft, I looked at the child, the hair was fluffy, showing malnutrition and I said please ask her what work she was doing. She said she doesn’t do any work. I said will you like to sell a few petty-petty things? She said yes. I asked them to give her N50,000 to go and start selling something.
PT: How long will the Rapid Results Initiative last and what is the scorecard of the Initiative?
ADEWOLE: It will last the life of the Save One Million Lives, 4 years. We have the resources for the 4 years. So we are hoping every year, we will do 10,000 free surgeries. The whole concept of the RRI is to drive you. You set impossible targets. We did two series of workshops, invited the leadership of the ministry, media groups, some other people from outside, and said we want to do impossible things, touch the lives of Nigerians. What are the problems, set targets, they are impossible, when people hear it, they will say wow! That is the whole essence of RRI. It’s not simple and we do not expect to achieve 100 but we must start, drive people. Because if you don’t drive them, you won’t achieve. Usually we set 100 days, we said we will rehabilitate 109 PHCs, test about 50,000 women. We said we will do 10,000 surgeries, between June and now, we have done under 5,000. It’s because many of the CMDs didn’t even believe, until they saw money in their account. The aim is not to score ourselves but to keep moving and we will roll it on.
PT: Between 2001 and 2014, Nigerian Government spent about N32 billion on the construction and rehabilitation of primary health centres, comprising 687 health centres across the nation. However, our investigations as published on our PTCIJ web page show that a higher percentage are either abandoned or not in use. What are your plans to resuscitate them?
ADEWOLE: There are about 30,000 PHCs across the country, our own data. For this 30,000, only about 20 per cent are working or functional. There are 9,244 political wards in this country, for ease of functionality, let’s call it 10,000. If we can make the PHC work in each of these wards, that will enable us to deliver health to at least 100 million Nigerians. That will be a major achievement and that is why we are making that a cardinal issue in the life of this administration.
We are also looking at sustainable models. I went to visit one in Ibadan, at Ward 3 of Ibadan North local government. A private man, Kola Daisi, donated a building for PHC and every quarter, he was giving 200,000 naira, that is N800,000 per year. In 5 years, this PHC registered 18,000 people and has 21 million naira surplus in their account. It is being managed by his foundation, community medicine department of UCH and the community, they have a ward development committee. I sent the NPHCDA to go and look at this one. This model can work in any of our urban centres, that will reduce our burden of what to support in the rural areas.
I went there to personally supervise the PHC at Kunchigoro, Abuja. I invited the University of Abuja Teaching Hospital, their Community Medicine Department, I said NPHCDA go there. I am talking to General Electric to give us simple equipment, the phototherapy machine, the ultrasound came from General Electric. And I called Sterling Bank, Sterling Bank give me 5 million to this account and then I told the Minister of FCT I am renovating your health centre, because that is the one they picked in FCT, they picked them across the country, 3 per state and FCT, 109. We will do some shops behind there to make some money, the ward people will open an account, they will manage it, there will be joint signatory and we are hoping that if we can replicate this, using FM model because the issue is let them survive, because it is not every year that we will be putting money there. And so this is a model, working with Sterling and we are also working with rich Nigerians, you can take a PHC. I am appealing to National Assembly, a building does not constitute a health facility, don’t go and use your constituency money to put up a building and say it’s a facility. And that is what has happened. People have been building, putting building up, but that does not make it the health facility.
PT: What steps are being taken to accelerate tuberculosis case finding and treatment in rural areas in 2017?
ADEWOLE: I spoke to Eric Goosby, Eric Goosby and l, we’ve been working together. Eric Goosby is the special ambassador on TB in U.S.. And I told Eric, I said Eric you must support me, we have known each other for years. And Eric is going to support us. Apart from Eric, we have put money for at least 100 GeneXpert machines in 2017 budget, we are declaring 2017 as the year of accelerated case finding for TB.
The problem in Nigeria is that we can only diagnose about 20 per cent of the TB cases, the rest are out infecting other people. We have one of the lowest case detection rates in the world. So we are going to invest, we have about 300 machines, my vision is to find one GeneXpert in every local government, 774 that is where I am going, minimum. It is the new machine that has the better accuracy. But there is 100. In Abuja now we have about 300, so we will continue to improve, and make sure that we train more people.
PT: What caused the recent death of the health worker in Ogun State to Lassa fever? Measures to curtail an outbreak?
ADEWOLE: I got angry when I saw the report. It is unacceptable. The woman was there for almost 2 weeks on admission. I could not believe it could happen in a Federal Medical Centre. Because it is a nurse, they did not think of Lassa fever. It’s madness, they treated for malaria for 3 days, started giving her antibiotics, they thought it was infection, Ciprofloxacin. I read the report, I have constituted a high powered team to investigate and we will sanction them.
That is the unfortunate side of the success story against Lassa. Because of the jingle and everything, you say it’s gone down. Now we have been having sporadic cases, we lost a doctor in Asaba who died I think in Anambra. When it affects the health care provider, its more serious, every patient that that doctor or nurse treats is at risk. That is why we are worried when it affects the healthcare provider. It also tells us that even the hospital is unsafe. How can a Federal Medical Centre, you have malaria that is not responding, the fellow was vomiting, has diarrhoea and you cannot think of Lassa fever until Saturday? They then decided to do a test and of course the woman died the second day. I got angry, I was livid with the commissioner and I have asked the NCDC to investigate and certainly we will sanction them. What we will also do is to step up, to continue the surveillance, keep on making noise that once you have malaria that is not responding, you have diarrhoea and vomiting, you should think of Lassa fever or any other viral infection.
PT: Mental Health in Nigeria
ADEWOLE: What we have decided to do is to look at the mental health situation in the North East, deliberately as a policy and we are working in that area.