Dr. Vincent Ogochukwu Okpala, the Hon. Commissioner for Health, Anambra State, had served in the capacity of Special Adviser to Governor Willie Obiano on Medical Facilities and Equipment. He practised as a physician in the United States of America since 2004. He had practiced as a psychiatric physician in Enugu, before he left for US. From US, he has done a lot of medical missions to Africa, organising healthcare delivery in different countries to help assess the healthcare system and give advice on how to change things around. He spoke to POLYCARP ONWUBIKO on healthcare delivery both at national and sub-national levels, in addition to his cerebral exposition on burning national issues.
GOVERNMENT both national and sub-national governments have been unable to set aside a minimum of 15 per cent of annual budget for the health sector as agreed by the African leaders at Abuja summit but could only manage to spend a paltry six per cent, how would you advise on that with respect to the deplorable state of healthcare delivery in the country?
We know that healthcare is not cheap. For healthcare to improve in any nation it has to be funded and it is not enough to say treat sick people without funding that mandate. In developed countries, a lot has been done with the healthcare system for them to get to where they are today and Nigeria have to do that.
So, setting that goal of 15 per cent annual budget to health sector was a highly ambitious goal but the question is, how can we meet up with that? You know the six per cent that we are seeing in different places is not acceptable and I think government actually has to do more.
But in a state where you have dwindling resources, it becomes more challenging. But there has to be more creative ways of engaging. One other thing you have to look at is that we have not seen healthcare as business. Whatever you don’t see as business has difficulty in thriving. We talk about medical tourism, we talk about capital flight, the truth about healthcare in Nigeria is that a lot of money leaves this system to the developed world where people search for healthcare. When they migrate for this healthcare, they pay for it, they don’t get it free.
They take that money that we don’t want to India, South Africa, US, UK and Germany. Those countries take that money from them. When you look at what leaves this system for medical tourism, you are talking about 40-60 billion dollars per annum. That is a lot of money; if that money is reinvested into the system as COVID has taught us, you realise that we can actually jumpstart the healthcare system and this can be achieved through effective budgeting. If government is mindful that this thing is to happen and funds it and creates ways of making things efficient, definitely we’ll get there. And the government I am serving actually has started doing that and it is a target we have set for ourselves, and I know that we will get there eventually.
The World Health Organization [WHO] recommended a ratio of one medical doctor to 600 patients but the Nigeria Medical Association, (NMA) said that Nigeria could afford a ratio of one doctor to 6,000 patients. Would you advise the government to award scholarship to medical students to beef up production of medical doctors and even para-medics?
The doctor-patient ratio in Africa is a problem. Coming back home to Nigeria is also a bigger problem even though compared to sub-Saharan Africa, Nigeria might be doing well when it comes to doctor-patient ratio but that is not good enough. Now, what can we do as a government to make the doctor-patience ratio look better?
It is not much about training as training is just one aspect. It has to be a multi-pronged approach to getting care of this. One is training; increased accesses to medical schools – have more medical schools, and then also, have more qualified people getting into training.
Now in Anambra State, that is why Chukwuemeka Odumegwu Ojukwu Teaching Hospital in Anambra State is where His Excellency is putting in great energy, putting resources to make sure we have our own doctors. Two, it is not just training; the other thing is also retention. After training, you have to retain them. Man is an economic animal. If you train doctors or healthcare providers and you don’t pay them well enough, they would want to leave the country to greener pastures. That is just the honest truth. So, they come out and compare their take-home pay when they stay 6-7 years in school and they see that their peers out there, comparatively speaking are doing better than they do financially, there will be that temptation to leave.
So what can we do as a government to retain the people that have been trained, what is there in the increased intra-mural practice?
We can create a situation where the physicians or the healthcare providers take more ownership of the place that they are working. Let’s take for example, you are working in a teaching hospital, you can design a programme where the doctor works a certain number of hours for government and the remaining hours for himself.
With that, they can be able to attract patients to the hospital and they can take a percentage of the revenue they are generating. Such intra-mural practices are being done in African countries like Ethiopia, because they had the same problem where you train doctors on scholarship and they leave the country for greener pastures.
What the Ethiopian Government does is to keep their license; sign a bond that after graduation, they work for government for the first five years after which you are on your own. For that five years, they work for government from 8 am to 4 pm; and from 4 pm to 8 am, they can work for themselves using hospital facilities and actually, there is a design whereby government makes money and they make money.
So, when you have that kind of model, you see that hard work is being rewarded. But when you choose to pay people a flat amount of money from whatever work they do, ultimately, what happens is that they don’t have any incentive to drive themselves and these are models His Excellency has actually charged us to look at to see if we can retain who we trained.
Also, there is need for more scholarships because if you have scholarships, there is chance that you will get more people for training. But the key thing is retaining them after their training not just having scholarships. With respect to paramedics, now we know that the Federal Ministry of Health is seriously moving to have para-medics trained and have them as recognised cadre in the medical field, so our state is jostling to be one of those states that will enjoy the benefits from that training. So, we can have a para-medical school in Anambra State that will help address the healthcare deficit and also address unemployment.
Going by the incessant industrial face-off between government and medical personnel, what do you think should be a pragmatic solution, even as some state governments cannot afford the salaries and allowances paid by the federal medical personnel?
With respect to industrial face-off between government and health personnel, it is actually quite pathetic. So, like I mentioned earlier, man is an economic animal. You train these individuals and they are working and they see that the salary is not taken them home, so what do you do? You realise that these individuals want to look for greener pastures and what do you do to keep them to increase their welfare as they buy from the same market like every other person? If they are not well taken care of, they will leave.
So it becomes a challenge, so the federal government tries to address these needs and then when you come to the state level, the state government may not be able to pay because of insufficient resources. Why can’t you fix these things? For instance, in Anambra State, before this government came into power, doctors were home 13-14 months on strike. Some of the things for which they went on strike have actually been addressed. They are now at the new salary structure and the scale of the new salary structure has also been improved upon. So, our goal is to get them where other persons are. It is one way to make people feel content with their job. Then too, the ownership I mentioned, job satisfaction. What can you do to improve that job satisfaction? If you create that model we mentioned, you go to work, you have a stake in this work, you don’t have only the salary, you have opportunities to go home with more while delivering a service. So, government’s role now is just to make sure that those facilities needed to work are provided so that those people will find it actually meaningless for him to open his own. Let me give an instance, you are a cardiac surgeon and working in a teaching hospital, you come in there, you have the nurses and other supporting staff to help you to do what you have to do, you have your TC Scan machines, ex-rays, etc to do your surgery and operating room. You are not the one paying the overheads, so you can bring your private patients to the hospital for a procedure. We will pay 20 per cent of whatever we are charging the patient.
If I add that on top, that you will be discouraged to open your hospital which means that you are taking the overhead, hiring new people and a whole lot of things and bringing partners and be there 24 hours of the day. So, you see that you don’t want to stress yourself so much as you are working in a teaching hospital where you have extra income as the harder you work, the extra money you make. So, that model will work so well.
It will also address the job dissatisfaction. So, these are things we want to experiment within the state. Now with respect to the state being able to pay, the state has to invest in hospitals and have the healthcare providers to be part of the work and make them have a stake in the job with respect to revenue generation and what they take home. That will be the best way to solve this problem because if you don’t give that service, that service goes to another person.
You have been at the centre of the ferocious war against COVID-19, how has Anambra State faired on the containment of the coronavirus? Could Governor Willie Obiano be given laurel for the efforts?
Well, we are still in the midst of COVID-19 pandemic and starting off from the pandemic, the state was ready right from the word go. We started our COVID-19 engagement in January 19, 2020, when we were fighting on two fronts, hitting on Lassa Fever and were hitting on COVID-19. With respect to COVID-19, we went through the four stages of public emergency: the stage of mitigation, the stafe of preparedness, the stage of response and the stage of recovery. The recovery is a mix bag. Now at the stage of mitigation, we early enough realised that this disease, looking at what is happening in other countries, if we want to stay at response stage, we might lose the battle because this is bringing big economies and big healthcare systems to their knees. So, we had to stretch our strength where we have comparative advantage and that was in mitigation to stop this disease from coming in. So, His Excellency, Chief Dr. Willie Maduaburochukwu Obiano went to town pushing us to make sure that the disease doesn’t come to Anambra State. We realised that Anambra State is not far away from Wuhan China, where this disease started. Why do I say that? Not far away by virtue of distance but by virtue of the fact that our people’s nature – they are highly travelled. You could have breakfast at Wuhan and dinner at the Main Market. So, our antennas were up, so we say people who are coming from there have to be quarantined and that happened in multiple occasions. We had to bring that mitigation measures and then ultimately, the disease came.
When the disease came, we were at the stage of preparedness. When it came to Nigeria, in Lagos and we say if our mitigation doesn’t work, what next? We get ready, and we got ready. We got our outstation centres ready, psyched people up to get ready. We started building capacity in infection, prevention and controlling, in case management and what have you. And eventually when the disease came, we responded appropriately from April 10, when we had our index case to date. We build capacity in a lot of areas, a lot of pillars, surveillance, contact tracing, risk communication, lab, case management and what have you.
So, it has been a roller coaster but looking back at what has happened, I thank God for the leadership of His Excellency.He remain the “Incidence Commandant” of this great pandemic. So, he has done marvelously well. I know he is my boss quite right even if he were not to be my boss; I will score him a super A1 plus 1 in the way he has responded to the pandemic.
There is impressive response of well-meaning Ndi Anambra to donate generously to the state government to alleviate the formidable impact of the pandemic. What does the state government intend to do with the humongous donations to improve on the healthcare delivery?
When this pandemic started, nobody planned for it from January 1, 2020, but when it came, the response was such that everybody had to chip in what they had; not just government. So, His Excellency called out to well meaning Ndi Anambra and they responded in kind and in many ways and there was an outpouring of support and that support actually is being utilised to provide for things in response to this pandemic and the key word His Excellency kept on is “there must be accountability and transparency” and all these things are being observed by the foot soldiers in response to the pandemic. And ultimately, by the time we are done, these things will still be made public. So, I thank ndi Anambra for the huge support and our people have a saying that “Ibu anyi danda”. So, with that support and with what the government has done, above all, we have been able to contain the disease in Anambra State.
You have done much in your brief period in the office in comparative terms, what legacy would you like to leave on health-care delivery in Anambra State when you leave?
I don’t know if I have done well or not but comparing the healthcare system to where I came from, I can say that we are digging from a very deep hole. We have to fill the hole before you start building; that is the truth but fortunately, I have a commander –in- chief who has health among his top agenda and he keeps pushing us to achieve. So, with respect to what I would like to be remembered, I will like to be remembered as that Hon. Commissioner who brought strengthening of human resources in health to the limelight, who made our healthcare providers to become aware that patients are human beings and should be treated with dignity and respect; who also showed that it was possible for healthcare providers to do things that people are leaving the state to go and get from other shores. So, if you are able to get these things organised in this state, and above all, the battle cry for short stay in this administration, in healthcare system in Anambra State hitting on those building blocks of the healthcare system to see if we can achieve or have a structure so that even if I am no longer here, there will have a system left behind that another person can build upon on sustainability. And when I talk about those building blocks, we are talking about service delivery, the availability of essential drugs, we are talking about health informatics, we are talking about health financing, we are talking about human resources for health, we are talking about governance and leadership, those six basic building blocks are all important. So, we are gradually nibbling at each of these blocks grain for grain, sand for sand, trying to build pillars so that by the time I leave, when you look back, you will say okay, a foundation was built at a point in time and people came to build on that foundation.
Crude oil price has suffered reverses going by the global pandemic which has adversely affected the economy, how would you advise the federal government on how to revive the economy to help small scale entrepreneurs to minimise job losses?
Nigeria actually can be looked upon as a banana republic. We depend on one source of income or revenue and no country thrives on that. You know the Danish element: that is when a country depends on once source of revenue. What it does ultimately sometimes is to generate a lot of adverse effects as things are not done the right way. Nigeria is actually before independence, before oil was discovered in the south-south, our palm plantations were doing great, the groundnut pyramids were doing great and the cocoa plantations were doing great, the cotton were doing great. It is on record that the first palm seedlings were taken from Nigeria to Singapore and Malaysia, and today, we see what these countries are doing. This has become the main source of revenue for their country while here, it is nothing and everybody is focusing on oil. It is not right. We need to be taught to be weaned from the nipples of oil. Even if we are depending on oil, we should start reinvesting in other things. Our people are highly talented, highly motivated and willing to work. People are well travelled, they learn a lot. Get electricity right, get our security right and then, you see investments flowing in here, you see peoples’ talents showing and bringing in revenues and small scale enterprises.
What make great countries great is the middle class. We are not looking at the middle class anymore and these small scale industries are the ones that were actually burgeoning the middle class but it is not happening in Nigeria. Until we wean ourselves of oil, reinvest whatever profit we are getting in those infrastructures that will drive the real sectors, energy and what have you, we would not get it right. It is just the simple truth.
So, with the prices going down, every other thing around it suffers too. This is time to use the opportunity of dwindling prices to look inwards. Are there expenditures you don’t want to make as individual that you can actually shop locally to take care of those expenditures, then do that. It helps drive the economy. I give you an instance; a loaf of bread that sold for a dollar has a lot of power. For a pragmatic economist, we look at that loaf of bread that is sold for N100. The baker makes profit from that loaf of bread from that N100, the baker makes a fraction of that N100, the farmer that grew the flower makes a fraction of the N100, the transporter that transfers the bread to the shop makes a profit from the N100, and government can now tax everybody, the baker, the driver, the shop keeper, the driver and the economy is moving.
We must focus on things manufactured locally and encourage our small and medium small scale enterprises and if we don’t, we can never get it right.
Going by the clamour for diversification of the economy by abrogating federal laws that inhibit state governments from venturing into some areas of economic policies and programmes, what is your take on restructuring the federation to reinvent the first republic federal system of government?
The federalism we are practicing is not the true federalism, which is the truth. One thing about federation and governance is democracy and the structure need to be dynamic; it is not cast on stone. That is why you see great nations like US; when they discuss the state of the union, keep on working on the union, it is not a finished product. Democracy should be dynamic. I believe that democracy is about people contributing their ideas, as the led form the leader by reacting and engaging in a dynamic way. It is a two-way traffic, that is where things like recalling people from the legislature and impeachment comes to play. So, if we truly practice democracy the way it should be practiced, we notice that the union is not yet perfect; the federalism is not yet perfect. If we look back, we would see that at a point in time in this country, there was a time when things were better, when we had thinkers. What we lack in the county are critical thinkers. Our education has not done us so much good because when you look at the system, we don’t encourage critical thinking in school.
So, we encourage more ‘route’ learning, so people come and recite and that is why we have potholes in the system where you don’t have civil engineers that can fix it using local means and it becomes a challenge.
Political scientists should look inwards and find out what is good for our system and not what works for Americans and other places but cannot work in Nigeria. So, we need to go back and reform the school system from childhood so that people become critical thinkers right from childhood. Let kids be raised to ask questions. Without asking questions, the system cannot improve. We should not shout on our young ones when they ask questions. In countries where they encourage critical thinking, the syllabus and curriculum is all designed around critical thinking, a problem-based learning and not theoretical based learning.
If we move to problem-based learning, then we will be problem-solvers. That is one thing that needs to be made right in this country in terms of raising the young in the way that they think about problems to solve. If we have problem solvers and you grow up solving problems, you see these problems; social, economic and scientific, you key into your problem-solving mode. And since everybody is thinking in the same line, you will be able to solve the problems.
How would you like the Anambra State government to position the healthcare delivery system to key into world standard with respect to Anambra Vision 2070?
The ultimate vision for the government for the state which His Excellency is driving will be that by 2070 [that is Vision 2070] Anambra State will be that state that will provide the best healthcare in Africa and beyond. It should be that state that somebody that needs medical help fly into Anambra. You go to that ward at the General Hospital, Onitsha, you realise that the person in that ward is somebody from Sokoto that came to get help and lying next to that individual in the private ward is somebody from South Africa that came for that special procedure that is done only in Anambra state in Africa.
And the next ward is that somebody that came from Egypt. We have that talent that can make it happen all over the world. Our sons and daughters adorn the best medical institutions across the globe. There is no hospital you go in US that hardly you don’t have a Nigeria, an Anambrian. And we give the best of service and best of care. So, the goal His Excellency wants for us is to get to that level because health, they say, is wealth.
There cannot be a truly wealthy nation without having a truly healthy nation and His Excellency has captured that vision and that is where he wants us to head to. So, we can be truly that state that has become the medical tourist heaven; such that if somebody has chest pain and you think that it is a heart attack, there will be ambulance responding to that individual in minutes, doing an ECG in the ambulance in minutes, diagnosing heart attack in minutes and heading to the emergency room of our good hospitals to get the best and that is where we are heading to.
I believe the journey has started gradually. At Amaku General Hospital, the diagnosis pavilion has the best machine in Anambra State and is a gradual build-out.
Refuse disposal has apparently become intractable all over the country. Having gotten past experiences overseas, what is your take on this formidable challenge?
It is said that cleanliness is next to Godliness; and you can’t be godly without being clean. Now, it is really a big challenge in Nigeria, a big challenge taking care of the environment. This also depicts a state of mind, when you don’t have a clean environment. There are many reasons why it happens here and that is why His Excellency launched Operation Clean and Healthy Anambra State (Ocha Brigade).
A lot of things went into having that done, and they are doing a great job to try to take care of things. Also, to key into his vision of cleanliness and healthy environment, it is work in progress. You see the state of beautification, it is a gradual work. The green areas are actually being established. Like Awka now, you see the flyovers, you see green areas coming up, the terrace areas around the government house. When you see the roundabouts and junctions, you see beatifications at Onitsha roundabout near DMGS, Ekwulobia roundabout, Amawbia bypass and other places where you see unique artistic impressions.
These are things that help to beautify the environment. When people start noticing all these things, they will start having that consciousness. When you look at those things, it brings down your blood pressure, it brings a kind of serenity into you, it brings calmness. So, that is what having a good environment does to you as a person; and above all, beyond government, the people will know that cleanliness is an individual thing, not just government. When you are in a vehicle and after taking sachet water, you don’t just throw it out but you put it in a basket; same for people walking along the road. So, if we build this consciousness among the people, we will have a clean environment. It is work in progress and it is a mandate which His Excellency has taken seriously.