Fixing Nigeria’s healthcare through innovation.

We are in trouble.

The healthcare system in Nigeria is a disaster.?

It’s arguably one of the worst in the world. Data from the World Health Organization, WHO shows that Nigeria’s life expectancy of 55 is one of the lowest in the world, and only at par with three other countries - The central African Republic, Lesotho and Chad. Moribund medical facilities and run-of-the-mill healthcare infrastructure abound. Qualified medical professionals are scarce - they are either consulting with some of the top private hospitals or have sought greener pastures abroad (They have “Japad”). The doctor-to-patient ratio is off-putting, 1:6000, that is one doctor treats 6000 patients in Nigeria. In South Africa, the ratio is 1:4000 while in India, with a population of 1.3 billion (more than six times the population of Nigeria), the physician-to-patient ratio is 1: 854 better than the WHO’s recommended ratio of 1:1000.?

The Nigerian government's healthcare spend according to the 2021 budget breakdown was 516 billion nairas, which comes to 3.7% of GDP. Cuba with a quarter of Nigeria’s GDP spends 10% of its GDP on healthcare. For the records, Cuba though a poor country has one of the best healthcare systems in the world. Its infant mortality bests that of the US, 4.3 even its life expectancy rivals that of the US.?

While there is no direct correlation between the physician-patient ratio and life expectancies of countries, this data from the World Health Organization suggests that an appreciable ratio does impact the quality of life of citizens of a country. For instance, data from the World Life Expectancy suggests that Cuba with the highest physician per 10,000 patient rate of 84.2, has a life expectancy of 77.8 while Norway with a physician per 10,000 patients rate of 50.5 has a life expectancy rate of 82.6. See data here. ?

In like vein, Norway has the highest number of doctors and nurses in the Organization of Economic Co-operation and Development (OECD) countries. According to data from the World Bank in 2018, there were 29.16 doctors per 10,000 people. In the same year, 2018, Norway had 4.82 doctors per 1,000 people and 17.81 nurses per 1,000 people. The data is on the website of the World Economic Forum.

Nigerians don’t have access to quality healthcare because they are poor

Without saying too much, most Nigerians don’t have access to good medical treatment as and when they need it. A few years ago, Dr Ajayi, managing director of the Nordica Fertility Centre, Lagos alluded to this fact as a panellist at a Standford Africa Business Forum. This is how he puts it: Access is still the greatest challenge to health care delivery in Africa. Fewer than 50% of Africans have access to modern health facilities. Many African countries spend less than 10% of their GDP on health care. Also, there is a shortage of trained health care professionals from Africa because many of them prefer to live and work in places like the U.S. and Europe.

The corollary is that most Nigerians don’t visit hospitals. Economic reason is the elephant in the room. They can’t afford it since they have to pay out of their pockets. According to data emanating from the World Poverty Clock, 69,977,160 Nigerians live in extreme poverty, representing? 32% of the population. So, it is just the norm to find these Nigerians abusing drugs with reckless abandon. They will either patronize local drugstores which are usually staffed with “rookie” and inexperienced pharmacists who can hardly give accurate prescriptions or patronise sellers of local herbs which they can buy and prepare based on the prescriptions of the sellers.

Quacks abound in the healthcare value chain

There is also a preponderance of quacks in the healthcare value chain. This BusinessDay article contains the frustration of a Nigerian medical doctor on social media: ?A patient with a slow pulse was advised by a doctor to drink Coca-Cola to bring it up. A patient who was bleeding from the anus for 18 months was receiving blood transfusion with no tests until an endoscopy revealed much later that the patient had cancer, by then it was too late. A patient was told she had diabetes and was receiving treatment as a diabetic for 12 years only to find she was never diabetic. A doctor without any formal surgical training was alleged to have performed a complicated bowel surgery on a patient who died in the operation. A patient bled to death after a doctor carried out a renal biopsy without a simple medication history that would have revealed that the patient was on aspirin, a blood-thinning agent. A doctor administered a dextrose drip on an unconscious patient without first checking if the patient was diabetic – the patient never woke up. Another was diagnosed with bone tuberculosis by just touching a patient’s jaw without doing a single investigation and had planned to remove the patient’s jaw. The patient was saved when she sought a second opinion while abroad and was found to have a benign lymph node.”?

Failure of the National Health Insurance Scheme

It is well documented that the National Health Insurance Scheme (NHIS) has not achieved the objective for which it was set up, to remove the burden of Nigerians paying their medical bills out of pocket. Unfortunately, it is not anywhere close. The coverage of the NHIS is ridiculously low, 0nly 4%. That is, only 4 out of 100 Nigerians have insurance coverage. It is no surprise why the life expectancy of Nigerians is one of the lowest in the world. A child born in Nigeria today is only expected to live up to about 60, other things being equal. Data from World Health Organization, WHO indicate people are living longer globally, the average life expectancy in the world is now 73.??

Similar figures of life expectancies in countries with the similar moniker, developing countries, such as Nigeria, especially those within Africa, show they are doing far better.? Morocco, 77.21, Tunisia, 77.17, Kenya, 67.21, Zambia, 64,41, Ghana, 64,48 and Cameroon, 60,1. Outside Africa, Moldova, 72.18, Indonesia, 72.14, India, 70.19, and Bangladesh, 72.29. In 2018,? the World Health Organization, WHO ranked Nigeria 178 out of 192 countries in life expectancy

Nigeria’s child mortality rate is also poor. For every 1000 births, 65 babies die compared to 33.6 in Kenya, 28.9 in Rwanda, 28.8 in South Africa and 18.8 in Egypt. Also, our death rate of 12.8 is the highest in Africa compared to our African siblings- South Africa, 9.8, Egypt, 5.8, Rwanda, 5.8 and Kenya, 5.7. Nigeria’s per capita expenditure of $215 on healthcare is too low. South Africa spends $1,086, and Egypt $495. It is clear, that we can’t even hold a candle to the UN’s recommendation of 15% of GDP. There is no need to over-flog this matter, Nigeria needs to spend more to improve the well-being of its people. In any case, Nigeria’s population is not slowing down.

In the last decade, Nigeria has added roughly 50 million more people, more than the entire population of Canada, 38 million, yet Nigeria spends $1.o7 billion on healthcare which is less than the 2.4 billion budget of St and Thomas, a government hospital in the UK visited by Nigeria’s elites.??

The corollary is that if the government increases spending on healthcare, from the current 3.7 of GDP to about 10% over the next decade, it would likely lift Nigeria’s life expectancy from the current 55. Perhaps, a trader in Ojuwoye market, Lagos, a petty trader in Abakaliki and a private school teacher living in Warri, would be able to access quality and affordable healthcare. In other words, the health and living conditions of Nigerians would likely be better.?

As shown in the figure above, life expectancy improves as the health expenditure per capita of countries increases. Said differently, people live longer in countries where the governments spend more on healthcare. So, the UN’s recommendation makes sense. As you would observe from the figure, one useful insight is that life expectancy is one of the key indicators of the economic status of a country. Data from the Organization for Economic Cooperation and Development (OECD) shows that the US tops the list of countries that spends heavily on healthcare with a stunning $11,076, Switzerland is second with $8,000 while Germany and Norway rounded out at number three with $6,600. Incidentally, these four countries are some of the wealthiest countries in the world, according to World Atlas.

Money matters but it isn’t everything

Money matters. But not all the time. While it is generally true that the wealth of a nation correlates with the quality of its healthcare. That we have seen from the examples of the US, Switzerland, Germany, and Norway. So, the corollary is that if a country can get its economic policies right, it can improve its healthcare system significantly.????

In a way, one may be tempted to say, “money answers all things”, a verse of the Holy Scriptures that has been twisted out of context to satisfy the lust of the lazy and get-rich-at-all-cost greedy generation. Money is important, but throwing money at every problem oftentimes makes the problem worse. A few days ago, while chatting with a friend, this same issue came up, though under a different context, startup success. Nothing ruins a startup company faster than having too much to spend especially when it has yet to discover who its real customers are, I mean, it has not nailed down the segment of the market that would readily buy its products as well as stay loyal to it. No real data on product-market fit. I am no killjoy, but all these rounds of funding, whether series A or B or C, whichever, are an inflammable fuel that would blow up many of these startups. According to research by Harvard senior lecturer, Shikhar Ghosh, three-quarters which is about 75% of startups don’t return the investor’s capital.

Now, back to our discourse, my point is, money is not enough. You know, some parents including myself believe sending children to “Ivy League” schools where school fees are in the six to seven figures would not only help ground the child academically but also improve their confidence and general outlook on life. Though few parents would admit, the real motivation for sending children to expensive schools is that they would be able to rub shoulders with the children of who is who as well as position them for success in their careers and in life generally.?

Expensive schools are not necessarily better afterall

But I am beginning to have a rethink, a few years ago, about three or so, we moved accommodations, so our children had to change their schools. Nothing serious since it is still the same school but just located in another part of town. Experience taught us otherwise. The performance of my children nosedived, it was clear the standard of their new school though under the same name and leadership was far lower than where they were coming from. Their average performance which was something in the region of 90-95% just dipped to less than 80%. We were pussyfooting, not willing to change their school since my daughter was already in our final year. But we got the reality check when they went for their new school’s entrance test. My son’s score was horrible. Even my daughter whom we all thought was an “efiko” or a “bookworm” just did fairly well. Change was therefore inevitable. It took extra classes and additional homeschooling to get them back to winning ways. What’s more, we are paying much less than we were in their former school. Money matters, but others thing matter too.

What can the healthcare sector learn from the telecom space?

Again, money is important, but money doesn’t answer all things. My experience as a strategy and innovation consultant has proven to me time and time again that the core essence of innovation is to help customers get their jobs (whatever it is that is their pain points) done, better and cheaper.? My preference is what you probably know so well.?

A few years ago, you would recall, when the global systems mobile communications, GSM, “touched down” in Nigeria, it was sweet relief for many poor Nigerians who had desired to own a telephone someday, which by the way was a status symbol of success, at the time. According to data from the NCC, the total number of telephone lines, commonly referred to as (nought nine nought, 090) prior to GSM was a paltry 500,000.?

Fast forward to twenty-something years later, according to data emanating from the NCC, there are 297.2 million connected lines out of which 187.2 million lines are active. It is really a good place to appreciate the former president Chief Olusegun Obasanjo and the hard work put in by the Bureau of Public Enterprise led then by Mallam Nasir El Rufai, the current governor of Kaduna state.

The introduction of GSM technology was a game changer that democratized communication for Nigerians. By the way, GSM technology is a standard developed by the European Telecommunications Standards Institute to describe second-generation digital cellular networks used by mobile phones and tablets. Before GSM, analogue telecommunication systems such as the Advanced Mobile Phone Service (AMPS) and Total Access Communication System (TACS) were commonly used in the US and UK respectively.? Believe me, and you know too only most Nigerians could not afford the “nought nine nought” except the very rich and top business professionals.?

Glo, the equalizer

So, GSM was more or less the equalizer (seen Denzel Washington’s movie with the same title?), the leveller that perhaps bridge the gap between Nigeria’s rich and poor. Suddenly, Chukwudi, a businessman, who sells food items in Owerri, could transact business with his customers located in Aba, Enugu, Onitsha, Maiduguri and Lagos just by dialling their phone numbers on his mobile phone without having to travel down or use a proxy.?

But then, even though life was getting better for Chukwudi, the cost of the phone calls was rather high and was now eating into his margin. Many subscribers demanded that the three major networks review their billing system specifically to move from minutes billing to per-second billing. The two forerunners, with yellow and red Pantone colours, appeared tone deaf until Glo came, introduced per second billing. That game-changing act is perhaps one of the epic moments in the history of telecommunications in Nigeria. The same company pioneered SIM “giveaways” in Nigeria. The outcome was that its subscriber swelled up by millions.?

Glo like Denzel Washington in the Equalizer empathised, connected and defended the ordinary people with the introduction of the per second and so many Awoof promotions. For me, without saying so much, it is perhaps the only true innovative MNO in Nigeria. What’s more, the per-second billing helped Chuckwudi lower his overheads and hence boost his profit. The political will to do the right things is what is needed not just money.?

source: guardian.com

It is no rocket science that Glo’s heroic action played a major role in the growth of the telecom industry.? Telecom is perhaps the most productive non-oil sector of Nigeria’s economy. Between 2019 and 2021, the sector grew 2.5%. As you can see in the figure above the sector added 11.39% to the GDP in Q2 of 2019, in Q2 of 2020, it contributed 14.3% and 14.42% in Q2 of 2021. Data from the World Bank indicates that the sector contributed 10.6% of the GDP in 2019 valued at $448.1billion.?

Behold the orange in the banking industry

My point exactly is that there shouldn’t necessarily be a tradeoff between value and price. Said differently, it is possible to deliver value without necessarily making it very expensive. Guaranty Trust Bank, GTB, delivered a masterstroke a few years ago when it introduced the zero balance, a scenario where a customer can open a bank account without necessarily a minimum amount of deposit. Perhaps, it stole a sheet from Glo’s trade secret. That was how it forayed into retail banking, as I write, GTB has one of the largest customer bases in Nigeria.?

Although its self-acclaimed moniker “customer service bank” is now questionable, GTB brought a lot of innovations to banking in Nigeria. I won’t forget how I used to queue for hours each time I wanted to help my mum collect her salary at one of the old-generation banks. Each time, I had to show my ID card, and since I wasn’t working at the time, I had to use the ID of my church. But these days, I don’t need to, I do transactions without using my ID. Since my data is already with the bank, all it needs to do is just access it whenever I want to perform any transactions. It might sound so ludicrous nowadays but if you banked like 20 years ago, you would appreciate what banks like GTB, Zenith, Stanbic IBTC, and Standard Chartered did, and how they leveraged the power of technological innovations to change the banking industry in Nigeria.

The rich also cry, disparities in the US healthcare system

The US as you have seen above spends more than any other country on healthcare, $11,076 per individual. Yet, its healthcare system reveals faultlines of various proportions. It may surprise you that a lot of US citizens cannot afford to access healthcare since many of them don’t have the insurance that can pay for it.?

Dr Ola Brown (@flydoctors) alluded to this fact in her article. She recalled how her cab driver while in the US told her that he had to seek medical treatment in Mexico because he couldn't afford the one in the US. According to this article, a lot of disparities exist in the US healthcare system, people who don't have health insurance are being made to pay more before getting medical treatment. NPR/ProPublica reported that some Nonprofit hospitals go as far as suing their patients for defaulting on their payments. There was this case of a Nonprofit, Heartland that sued a couple, demanding 10% and 25% of their monthly incomes. The report states that this is a worrying trend across many states in the US.?

Necessity is the mother of innovation

Size matters in competitive strategy. But “bigness” can be both strength and a liability. Without saying too much, Cuba is a very poor country compared to the US. While the US boasts a GDP of $23.99 Trillion, Cuba’s GDP is only $107.40 Billion as of 2020. You know the country is a communist country, meaning everything including businesses is state-owned. While the country might not be the economic gateway of the world, Nigeria and the US can learn vital lessons from Cuba.

It is well known that Cuba has one of the best healthcare systems in the world. My research revealed that the country’s impressive track record is connected to the determination of its former leader, Fidel Castro, to succeed at all costs not minding the US trade embargo. So, the country has learnt to do much with less.?

Here are five innovation lessons Nigeria can learn from the communist country.

1. Focus on preventive medicine

You know, travelling uncharted paths can be hard. But when left with no alternative, breakthrough ideas often emerge. It is a proven fact that most prosperous economies including the US focus their healthcare dollars on treating diseases. Without saying too much, this would help the radiology and diagnostic industries as manufacturers would be able to produce newer equipment for consumption.?

Cuba, on the other hand, focuses its resources on preventive medicine which is low-tech but requires a lot of education and enlightenment. The truth is, innovation as defined by Schumpeter is a new combination of old information, ideas or facts. The poor country may not be “techy” but it is getting the job done. How do you know? Outcome. Cuba has a better record of infant mortality than the US, 4.3. That is, for every 1000 births, only about four infants die. The US with all its spending has an infant mortality of 5.7.?

Nigeria can tear a sheet from the experience of Cuba, it is not only polio vaccination that requires sending health workers to churches, mosques, communities and poor neighbourhoods. Malaria kills more people than HIV/AIDs. In 2020, Nigeria had the highest number of deaths from malaria, according to the World Health Organization. Out of the estimated 627,000 deaths, 602,000 were from Africa with Nigeria topping the list, 39.1% followed by the Democratic Republic of Congo, 13.2%.

It bears repeating that Nigeria needs to create a massive awareness of the dangers of malaria as a potential killer. The ministry of information and communication should liaise with the National Orientation Agency to create sensitization and awareness campaigns on both the traditional (broadcast, print) and social media all year round.

2. Promote a community-led healthcare system??

Every family has a visitor and a team of nurses in Cuba. Families get at least visits from their doctors and nurses, every week, this would undeniably help to detect and discover new medical conditions before they become emergencies that might lead to early deaths. It was during a medical outreach organised by my church that the high blood pressure of one of our members was detected. It was a lifesaver, only God knows what would have happened if that medical outreach had not taken place. It is a known fact, that Nigerians hardly do medical checkups, such visits can lead to early detection of conditions which can be addressed promptly and cheaply too. My sister died a few years ago due to the late detection of a tumour in her womb. Imagine if a family doctor had been calling frequently, he could have discovered it before it got to a death situation.

3. Spend more on healthcare

Cuba spends 10% of its GDP on healthcare.

Nigeria’s GDP, $448.10billion, is almost four times that of Cuba’s. While I agree that Nigeria’s current financial situation is really bad and that squeezing additional funds for healthcare would be tough.?

Nigeria needs to do something about its recurrent expenditure. In 2021, Nigeria’s government allocated N5.6 Trillion for recurrent expenditure which equals 41% of its total budget of N13.2Trillion. If you ask me, that is extremely crazy. It is clear Nigeria is borrowing to live, which is tantamount to eating its tomorrow today. So, the question is where would the money for funding healthcare come from??

The government must prioritize the lives of its citizen above all else. Cuba is not a rich country, but the country places premium value on the health of its citizens. I believe, that whenever there is a will there's always a way out. It is clear, that increasing the budgetary allocation is not really an issue it is the political will to do so. Oftentimes, you and I find ourselves in some tight situations and we just have to prioritize including making sacrifices that are sometimes unpalatable.?

A few days ago, I took my children out shopping for the incoming new school session. Ordinarily, I could have spent the money on something else, but because I prioritized the needs of my children, I had to make the sacrifice not minding the difficulty it would cost me.?

If the salaries of senators and house of representatives can be slashed by about 10-20%, that could help a great deal in addressing the abysmal lack of funds in the sector.?

In this article, Prof Itse Sagay claimed that senators and house of representative members are the highest paid in the world. If it is true, a senator earns about $1.7 million (N850 million at N500 to a dollar), while a house of representative member earns $1.45 million (N725 million, at N500 to a dollar). So, my proposal is even too mild, maybe 50% of their salaries should be used to fund healthcare.?

4. Creatively fund healthcare?

Thinking out of the box is not a cliche, it is a recipe for success for developing nations whose backs are against the wall. Cuba, knowing it has to find a way to fund its healthcare invested in creating medical “missionaries” in the diaspora, there are over 50,000 Cuban medical doctors spread across the globe that remit 50% of their income to their government.

According to this website, the revenue generated from these ambassadors is in excess of $ 8 billion. Who says Nigerians in the Diaspora wouldn’t want to do similarly? This is what Abike Dabiri should be doing, in addition to defending the rights of Nigerians in the diaspora. A Pew Research shows that there are 348,000 registered Nigerians in the US, that is excluding those who are not under the radar of the US government. In 2017, Nigerians living in the US remitted a total sum of $6.2 Billion to Nigeria. Imagine, if the government has a firm policy in place that take 50% % of all remittances, that is a cool $3.1billion. My point is, that there are creative ways the country can solve the puzzle of its financial strait.?

5. Invest in focused innovation hubs

Nigeria has the largest number of innovation hubs in Africa. I have written about this before, but it bears repeating that the way Nigeria can get out of this economic quagmire is to build a robust innovation and entrepreneurship ecosystem. Thankfully, digital technologies are helping developing nations like Nigeria to sidestep the stepwise movement associated with the first, second and third industrial revolutions.?

The government should channel resources in form of investment to fund innovation, especially in the healthcare sector. One way to do that is to establish is to invest in community-led innovation hubs scattered across local government areas that can spur innovation at the grassroots.?

I know the Bank of Industry has been doing some terrific jobs, but the government can do more. Besides, money is the last thing that is sometimes needed when tackling social problems. Right-brain thinking is often the first requirement. My suggestion would be that the Bank of Industry creates a special funding scheme targeted specifically at innovators in the health sector. Call it Healthcare Innovation Intervention Fund (HIIF) or something, but my point is that such interventions should be well-focused.?

For instance, Brian Turyabagye and his business partner, Olivia Koburongo, created a biometric smart jacket which quickly and accurately detects pneumonia. Pneumonia kills about 500,000 children under 5 including 25,000 Uganda children) in Sub-Saharan Africa every year, according to the World Health Organization.? The background story to this is that Olivia Koburongo’s grandmother had died due to a wrong diagnosis - doctors diagnosed her with malaria while indeed she had pneumonia. By the time, the truth was revealed, it was too late, that was the motivation behind the biometric smart jacket. When in use, the child wears the device which would be connected to a mobile phone via Bluetooth, which sends the medical data to the mobile phone for further insight by a doctor. This grassroots innovation is the likely outcome of such innovation hubs.?

Secondly, just like India, Nigeria needs to have a National Innovation Strategy (I have written about this in my previous post) which would coordinate all the innovation activities of startups and entrepreneurs and also ensure public and private collaborations. In order words, the startups with innovative solutions from these government-sponsored hubs, can readily create prototypes, test them with real customers, get feedback, design formidable business models as well as have the opportunity to be acquired by private sector organizations in the same healthcare space.?

This is similar to what South Africa is doing which has resulted in the creation of a robust and innovative healthcare sector powered by digital technologies. The point is, that such sector-focused can help unleash tech startups like Healthtracka, Ubenwa,? Medsaf and Lifebank.

Summing up, Nigeria’s healthcare is currently in a crisis, and the indicators are scary. High infant mortality, 65, the not-too-good life expectancy of 55, high death rate, lack of highly skilled medical practitioners and all. What is clear is that a step-by-step, linear approach to problem-solving won’t hold any water, what is needed for the hour is radical, intuitive, ceiling-smashing right-brain thinking.

While it is true that the health sector is underfunded and needs loads of cash, what is also true is that money is not the only ingredient it needs to make things better. The US with the reputation of being the country with the highest health expenditure per capita in the world has people in it who cannot afford to pay for their medical treatment. Yet, it is spending 11,076 dollars on each citizen annually, about N5.5 million (how many Nigerians have that kind of health insurance cover?).?

The National Health Insurance scheme has failed, it has a 4% coverage. That’s not good enough. But Nigeria can learn from the sterling success of Cuba, a poor country with a big heart for its people. Cuba has proven that a country’s political will is far bigger than the size of its treasury. With a GDP of $107.32b, the country has marshalled its intellectual resources to create one of the most advanced and envied healthcare systems in the world even beating the US on certain fronts. So, if anything, Nigeria can learn five critical lessons that can help turn its moribund healthcare system right side up. This includes investing in low-tech preventive medicine, promoting a community healthcare system, increasing healthcare funding, creatively funding healthcare and investing in focused innovation hubs. It goes without saying that innovation holds the key to unlocking the true potential of Nigeria’s economy as well as the well-being of Nigerians.