Going home to die in Nigeria

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Mr Chukwu (not his real name) is a Nigerian who travelled to the United Kingdom, accompanied by his wife, a few years ago on a business trip. While on this trip, Mr Chukwu , who suffered from hypertension and diabetes, developed a cerebrovascular accident that led to a left-sided hemiplagia with some degree of dysarthria. This means that he developed a stroke that led to the paralysis of the left side of his body with some difficulty in making speech.
Following discharge from the hospital, Mr Chukwu  continued to receive medical care at a nursing home in London. When this misfortune sets in, he exhausted the money on him, including those remitted to him from Nigeria by family and friends. His wife resulted to doing early morning odd jobs, cleaning and the likes, to raise money so as to make ends meet. One day, at about six in the morning and while at work, Mrs Chukwu was arrested by the police and immigration officials for working illegally in the UK. It was discovered that Mr and Mrs Chukwu came to the UK on a six month visa that had expired. This visa did not permit either Mr or Mrs Chukwu to work in the UK. Mrs Chukwu was subsequently prosecuted and spent 5 months in jail. Not only this, she and her husband also faced deportation back to Nigeria.
Mr and Mrs Chukwu decided to contest the case – they were given rights of appeal. Their solicitor argued that deporting the couple to Nigeria amounted to passing a death sentence on Mr Chukwu. His reason was that Nigeria’s healthcare system is parlous, expensive and not easily accessible. He raised the difficulties Mr Chukwu would face in Nigeria in receiving adequate care of his complicated physical health. Mr Chukwu was duly assessed by a qualified and registered medical practitioner in the UK who listed his findings. These findings formed the thrust of the solicitor’s argument. However, a few weeks ago, the British immigration authorities responded. In their response, they said that they had conducted an investigation on the state of healthcare system in Nigeria, with special emphasis on the type of care Mr Chukwu was likely to receive. In the said investigation, they claimed to have spoken to two government medical practitioners in Nigeria. One was based in the Eastern part of Nigeria (where Mr Chukwu comes from) and the other in Lagos. They claimed that the two medical doctors concurred that Mr Chukwu would receive more than adequate care for his ailments in Nigeria. This is because the Nigerian healthcare system has been greatly revamped by the National Health Insurance Scheme (NHIS). They maintained that a very high medical ethics is now being practiced in Nigeria as, for example, only qualified nurses are allowed to administer Insulin in the treatment of diabetes, and the country can now boast of sophisticated medical equipment, courtesy of the NHIS. On the basis of the outcome of this “investigation”, the immigration authorities maintained that the deportation order on the couple stands. At this point, Mr and Mrs Chukwu’s solicitor decided to reach out to Nigerian physicians practicing in the UK, more so those with a recent experience of our healthcare system. He wanted to have the true picture of healthcare in Nigeria as he refused to be satisfied with an investigation that only involved speaking to two doctors in Nigeria.

Let me start by stating that I am a Nigerian and happen to practice medicine in the United Kingdom. I stopped practicing in Nigeria in early 2000 but also had a brief stint of a couple of months about three years ago. The above scenario was brought to my notice by a senior colleague who is well aware of my familiarity with the Nigerian medical system. The senior colleague sought to know my opinion on this issue. Many other Nigerian doctors were also contacted by the Chukwus’ solicitor. I remember that while in Nigeria, I was conversant with the noise about a proposed NHIS. Then it was more of a noise without anything concrete on the ground. When I went home about three years ago, I must admit to my blissful ignorance of the existence of a national health insurance scheme. If it was operational, I was not aware of this. No colleague brought its existence to my notice and there was nothing in my short private practice to indicate that Nigerians had a buffer programme to ameliorate the impact of the exorbitant and substandard nature of medical care in the country. Thus, I was perplexed by the outcome of the “investigation” by the British immigration authorities which painted a picture of Eldorado for healthcare delivery in Nigeria. Also, I need to mention that I have always been in contact with family and friends in Nigeria who partake of the available healthcare. No one remembered to inform me of the sudden transformation of our healthcare system. I felt I must have missed something big. I decided to conduct a little research.
I started by trawling the worldwide web. There abound lots of sources of information on the Nigerian NHIS. The NHIS was an idea that surfaced in the first republic when Dr Majekodunmi was then the Health Minister. However, it failed to receive the required support and went into premature coma. It was resuscitated again in the nineties and was eventually launched on the 15th October 1999. It was reported to have finally taken off sometimes in 2001. The concept as enumerated on the official website of the NHIS Corporate Office, Abuja, remains laudable. It was reported as a well thought-out and detailed programme that has the “most comprehensive benefit package” in the world. You can trust the Nigerian penchant for grandiosity! Somehow, I failed to glean the content of the so-called package from the information available on the net.

As at September 2008, the NHIS was said to have covered 2.7 million Nigerians (remember that there are over 150 million Nigerians). It was officially described as a social security system that guarantees the provision of needed health services to persons on the payment of token contributions at regular intervals. The government attempted to justify the necessity of individual contribution thus:
“The Government had initially provided ‘free healthcare’ for its citizens funded by its earnings from oil exports and general tax revenue. However, the global slump [ in oil prices in the 1980s greatly affected Nigeria’s major source of income. Government could therefore no longer afford to provide free health, and subsequently introduced several cost recovery mechanism like user charges and Drug Revolving Funds. Furthermore the introduction of the Structural Adjustment Programme in 1986 adversely affected the health sector allocation.”
In addition to the economic hindrances listed above, it was stated that the aim of the programme was altruistic, albeit redressing the general poor state of the nation’s healthcare services, the excessive dependence and pressure on government-provided health facilities, the dwindling funding of healthcare in the face of rising costs and the poor integration of health facilities in the nation’s healthcare delivery system. Obviously, the programme has received international support and co-operation as the World Bank, in particular, promised funding and the Ghanaian government has been motivated to implement something similar.
After the internet search, I decided to speak to colleagues on the ground in Nigeria. Unlike the British Immigration authorities, I spoke to more than two doctors that covered a very wide part of the country. My findings were very revealing but I would try and list those that are pertinent to the Chukwu’s case. These are:
1. The NHIS as currently obtained in Nigeria, mainly applies to civil servants. This is because a certain percentage of their monthly income is deducted to cover costs.
2. A civil servant is only entitled to treatment with his spouse and 4 biological children.

3. Currently, most states in the federation are NOT practising the NHIS. The scheme currently applies  mostly to Federal Civil Servants.
4. Lagos State, for example, does NOT practice it. The state practices Free Health for children less than 17 yrs and those over 65 yrs. However, this programme is limited in scope in terms of availability of drugs and other resources.
5. For those entitled to the NHIS, the programme is pegged. Pegged in terms of cover for costs of treatment. For example, cover for the treatment of Malaria is only 350 Naira. The Artesunate group of drugs are currently the drug of choice for Malaria. A complete package costs between 1500 to 1800 Naira. So, for anyone on NHIS, to achieve complete cure, the balance of payment has to be coughed out.
6. Generally, working class people are NOT covered by the NHIS. They pay for their services.
7. For operative procedures, written permission (paper or electronic) has to be sought from NHIS providers. This often times causes conflicts with emergencies, unless the affected patient can afford to pay.
Of course, the official NHIS website stated that the programme is targeted at various groups, such as rural community and the urban self-employed, but this is yet to materialise. With the present coverage of 2.7 million people and with the situational report from practising physicians, it is apparent that to date, the NHIS has not greatly influenced the state of healthcare in Nigeria. That particular state of healthcare does not merit repetition here; suffice it to say that it is an uncaring system that spells early end to the grievously sick. With this in mind, I wondered at the type of doctors that gave an aura of Eldorado to the British authorities. The answer was obtained from those on the ground.

The information obtained from my colleagues in Nigeria did not just flow without hesitation and reluctance. It was professional fraternity that thawed the ice. Ostensibly, doctors in some states had received government directives warning them of instant dismissal if found criticising or making disparaging comments about the programme. The instruction was always to portray the programme in good light. However, my medical colleagues agreed that for Mr Chukwu to be returned home in his present state without access to adequate funding, instant death seems to be the prognosis. Even with a full pocket, the care needed by Mr Chukwu is still better sourced outside the country. So much so for our much orchestrated NHIS.

Before we go any further, may I firmly affirm that it is the duty of a responsible and responsive government to provide qualitative, adequate and affordable healthcare for its citizens. The case of the Chukwus serves as the pivotal for a reflection on the continued sad state of our healthcare system. It is amazing that for a programme that was launched in 1999 and took off in 2001, the coverage is still a mere 2.7 million Nigerians and specifically those who can make monthly contributions from their salaries (hence civil servants). This brings the sincerity of this much touted programme into question. The argument that it is still at the infantile stage may not hold, not after nine years of launching.
The concept of some form of insurance to support widespread delivery of healthcare is not novel to Nigeria. However, the model we seemed to have copied, modified and implemented, is not populist in concept and almost elitist in implementation, hence the problem with widespread coverage. It is imprecise and pejorative in concept and almost narcissistic in implementation. The obvious constraints that would forever limit the success of this programme stare at us in the face daily. These include:
Absence of an acceptable population census. An acceptable census holds the potentials of providing essential demographic information that would have been vital at the planning and implementation stage of this programme.
Pervading lack of industrialization with associated economic poverty.
Lack of an efficient and corruption-free taxation system in the country. Take away some Islamic countries where it is a taboo to tax citizens, Nigerians are probably one of the most under-taxed people in the world. A good taxation system would provide  needed fund to ensure the generalisation of the health insurance scheme and also introduce needed quality.
The multiplicity of insurance providers. This is of concern as it could lead to massive exploitation and lack of structural control and uniformity. A more structured and streamlined corps of providers might probably be the best.

Nigeria as a nation has to learn to divorce the delivery of healthcare from its perennial political problems. Saving Nigerians from preventable deaths through the provision of an effective and comprehensive healthcare is as important as moving the nation forward via an equitable, just and practical political formula. The health of a nation is intricately tied to its wealth. A healthy people make a healthy nation. Sadly, in this wise, Nigerians can be said to be sick.

Back to citizen Chukwu, the London-based solicitor is trying to marshal his argument on the situational facts on the ground as compared to the outcome of the British authority who spoke to two frightened medical practitioners out of about twenty-five thousand practicing doctors in Nigeria. I am a Nigerian and sincerely love my country. I did not set out to epitomise the British healthcare system as the panacea to all. Unfortunately, as things still stand, Mr Chukwu is most likely to meet a certain death if he is returned to Nigeria.

Let me conclude by saying that this is not a deliberate attempt to undermine the British authorities on the way and manner of conducting their immigration policy. Rather, it is a lamentation of the chaotic system that obtains in Nigeria, especially one that has contributed immensely to the legion of economic and health migrants in the British society.
CSN: 2612-2008-00-29

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