Health Inequality in Nigeria: a complete absence of conscience and common sense

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Introduction - As a prelude to the issue of the fundamental right to affordable quality health care services in Nigeria, it is necessary to note the development of social contract theories and essence of natural and legal rights (see, Hobbes, Locke, etc). This article will explore the concept of human rights, government formation and the

possible consequences of continuous denial of the rights of the citizens to quality health care by those that are elected into government offices, or gained access to power on their own wild strength.

It would highlight the key issues that revolve around social contract and inalienable right of man, the political context of health inequality in Nigeria and then provide suggestions for better ways forward.  

Social Contract and the Inalienable Right of Man

Irrespective of academic debates on the subject of right of man, history favours the argument that man has a natural relationship with animal, except for our level of reasoning hence the imputation of conscience and common sense which are factors that inhibits a man’s inherent instinct to kill, destroy or devour like animals in the wild. 

Government is known to have evolved from a man’s natural state, which is the state of the jungle. A life in that state was described by Thomas Hobbes as nasty, brutish and short. In that jungle which Nigeria is degenerating into, life is a continuous struggle and survival is of the fittest. Now in Nigeria, people live as if in an environment of constant war; characterised by kidnapping in the South, bombing and shooting in public places in the North. Above all, everyman has become a law onto himself with intimidation and oppression weighing down from the top and toughest to the low and weakest. It is a vicious circle.

Social contract fundamentally aimed to safeguard the right of the individual within a society who among themselves agreed to take a collective form of sovereignty. It is on this thinking that John Locke asserted that neither the head of the sovereign nor the members should be above the terms of the social contract. This means that none is above the law of the collective form of a society.  The individuals must retain their judgement of how their rights are respected in order for the sovereign to be maintained. Locke argues that the determination to fight to get what one is entitled is not just a matter of right, but a duty to God.    

John Locke wrote, "…we are all qualified, entitled, and morally obliged to evaluate the conduct of our rulers. This political judgment, moreover, is not simply or primarily a right, but like self-preservation, a duty to God…”. 

The theory and principle of John Locke were incorporated into the American constitution on their declaration of independence. The section  reads,

"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.--That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed, --That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute new Government, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Safety and Happiness." 

The fact that Nigeria is a creation of colonialism by the amalgamation of the respectively thriving ethnic and regional entities in 1914 by Great Britain and not by agreement to live together does not weaken the essence of social contract theory. In a democracy as it is supposed to be, every Nigerian is entitled to quality healthcare and education as a basic right to the nation’s social benefit. With every right comes responsibilities and it is the duty of the sovereign head (the government) to educate people about their responsibilities to pay tax and support the development and maintenance of public infrastructures like healthcare services, education, roads, water and electricity etc. The failure of the government is due to the reliance on oil and looting of the income from natural resources mainly from petroleum mined from Delta region of the country. 

Every civil society maintains the system with tax income and trade. It is the tax that enhances the society’s capabilities for developing and maintaining the social system for providing essential public goods and services. Without the commonality, every house will be a hospital, each rented room will be a classroom, and every pathway will be owned by one person. For water, as it is already, each family will have its ‘well’ or ‘borehole’. Self-protection community vigilante groups will graduate into arm struggle with the corrupt law enforcement agencies.

Nigeria has degenerated into the natural state and the fittest are those in government. Judging by the conduct of many and the processes of election and selection, campaigns are characterised by blood, tears and finger pointing. Only a few cares about the governed, but often their voices are quickly silenced by the devourers in the system. As a result, there is disillusionment and mistrust across the country. Majority of the citizens are hugely disempowered by lack of education, knowledge and information and are therefore subjected to accept the gloom and doom around them as the fate of the Blackman.  

The truth is that the replacement of conscience and common sense with brutish strength and criminal approach to civil governance led to the audacious breach of contract within the social contract theory. The current atmosphere of civil governance in Nigeria can be described as a ticking time bomb which has the potential to explode in a mass revolution either in violent disintegration of the union or in forceful protection of votes that can guarantee unrestricted access to affordable quality healthcare, education for the children, good road, clean water supply, electricity for homes, industry and food preservation, safety and security, and general comfort and happiness. 

The Political Context of Health Inequality

The health service delivery in Nigeria in the 70s had a system that was aligned with the British model. Every Nigerian then, irrespective of status and location had access to quality healthcare facility with qualified doctors and nurses. While the British model (the NHS) continue to undergo changes and making continuous improvement, the Nigerian healthcare services has deteriorated in all ramifications. 

The deterioration can be explained from the rough data of brain drain of doctors, nurses, allied health professionals and medical tourism. In addition, the statistics for infant and maternal death rate shows that Nigeria is only better than two poorest countries that are locked in endless war. Disease, injuries, disability and death of young people due to barriers for accessing affordable healthcare are too high and clearly documented by international organisations like the Wold Health Organisation (WHO) United Nations (UN) World Bank etc. 

Since 1999 when democracy was restored in the country, the statistics of politicians that have travelled abroad for medical treatment is eye watering. Many travel for things as simple as treatment for common cold, knee ligament strain, general check up to more serious conditions such as cancer, kidney disease, heart bypass surgery, stroke etc. The cost of the travel for the public officers and their aides as well as for the related treatment is paid for with public fund. Ngozi Okonjo-Iweala, Honourable Minister in Obasanjo and Jonathan’s governments provided that foreign medical treatment cost the public N30billion per annum. This no doubt can go a long way in building value in the services delivered locally in Nigeria.

In contrast, the statistics for the preventable and avoidable complications and deaths among the ordinary citizens is astronomical. The doctors are dismayed by the lack of conducive environment to practice their profession. Nurses are denied the opportunity for carrier progression and job satisfaction. The rest of the health professionals have their various tales of unhappiness of working with improvised materials and dilapidated equipment. 

The public who are the greatest victim are unaware of their right that is being brutally undermined by the political system which has deliberately or ignorantly embraced American model of health service delivery and their free market capitalism which left 16.3% of its (American) population without health insurance and so with no access to healthcare services.  

America is the world economic leader and has mass employment opportunities for its resident population. Many Americans have health insurance through their employers. In contrast, Nigeria has over 42% of its population unemployed. According to Christie [CNN online] the percentage of people in America who had health insurance through their employers fell to 55.3% in 2010. This has shown a downward trend, with 56.1% the year before and 64.1% in 2000. Elise Gould, Director of Health Policy Research for the Economic Policy Institute, a Washington-based think tank, stated, "As the job market remains weak, Americans can no longer depend on their workplace for consistent affordable coverage," (Christie). 

Obama’s effort to put a human face on the beast image of capitalism with regards to the unfairness of the American healthcare insurance system was vigorously resisted by the demon called capitalism. This demon has engulfed the Nigerian policy makers who themselves hugely benefited from the socialist-based health economy and education system of the 70s.

While the level of employment has lowered in the USA, in Nigeria it is on a free fall. Osalor  [Online], writing on youth restiveness, pointed that the National Bureau of Statistics (NBS) has put the figure of unemployed Nigerians in 2011 at 23.9 per cent, up from 21.1 per cent in 2010 and 19.7 per cent in 2009. How NBS got its statistics is not known considering the nature of disjointed information sources in the country. This assertion by Osalor was reiterated by the Minister for Agriculture, Dr. Akinwumi Adesina who painted a gloomier picture about the upward spiral of unemployment in the country. Dr Adesina highlighted that unemployment rate is growing at 11 per cent yearly, and that “Youth unemployment rate is over 50 per cent.

The NHIS has failed as a social policy due to the typical bad implementation strategy that is predominant across the sectors of national economy. According to Alliance for Health Policy and systems Research (WHO 2012) only 4% of the population, which is 6.6 million out of 167 million Nigerians are registered. NHIS has now existed since 2005 and yet has such abysmally low uptake. The reason is because it covers those in federal government employment. So far only two states (0.7%) of the 36 states have shown interest in the NHIS scheme. Cross River adopted the policy in 2007 and Enugu State in 2010. 

The beauty of the NHIS is that it was built on social policy and it was promoted to provide national coverage. The evidence shows that there is nothing national in the NHIS (Eboh 2008) and the implementation grossly undermines the right of every citizen of Nigeria to the essential social good under the social contract. With NHIS targeting the employed, what is the fate of the unemployed, the elderly that has higher percentage of chronic conditions, the infants and school age children and pregnant women? Nigerians want to work but the employment opportunities have been seriously compromised by systems failure, insecurity of lives and properties which scares off investors, limited creative and innovative ideas for job creation among the leaders.  So being unemployed is not by choice. The system should protect the interest of the weak and vulnerable members of the society.

Rather than counter health inequality, the NHIS has compounded it. Furthermore, health inequality is greatly expanded by the key players in the system who, principally are the politicians, the health professionals and the private providers, including many Nigerians and foreigners trooping in to set up private hospitals, laboratories, and other services, most of which are not subjected to any quality control or function up to internationally recognised minimum standard. Fake drugs are everywhere and pharmacies dispense all forms of medicines with or without prescription. Consider the recent report about the death of a young female master’s degree student who was doped with the drug ‘rohypnol’ purchased from a qualified pharmacist who ought to observe the standard of the pharmacy profession.  Medical equipment imported into Nigeria are those mostly no longer being used in the foreign countries because of advancement in technology. Nigeria with its wealth (in holistic description), continue to seek a third best position in the world with increasing dependency on other countries for health, education and technical support. 

It is due to the poor control system of healthcare delivery and implementation policies that a vulnerable patient had his two kidneys removed for a complaint of fever (Edeh 2012)  and a young woman lost her life following a caesarean section that led to a severed artery and unauthorised removal of her fallopian tube (Aboyade 2011).

The regular industrial actions by the medical professionals have never been directed at highlighting the degrading environment of work and difficulty with working to international standards and competitiveness. Instead, the professionals emphasises on pay and incentives for which there is easy patronage while the status quo of a bad operating system sustains.

Under this climate of weak and severely compromised health and hospital services with associated underclass professional skills and competences, the lives of vulnerable Nigerians are being wasted. Most of the injuries and deaths suffered in the hands of health professionals are avoidable and preventable and the country has no clear processes for learning from incidents. 

Had there been any remnant of conscience and common sense, our politicians will feel the guilt and the government will bear the burden of the failure. Similarly, the health professionals will submit to the scope of their competence and guided by the desire to save lives and not to endanger it.

Health inequality is defined in Nigeria by the degree of medical tourism of people in government and the 160.4million (96%) Nigerians who are excluded from the national health policy called NHIS. 

Way Forward

There should be an acceptance that the system is failing the people and the injuries and deaths unnecessarily affecting 96% of the population are avoidable and preventable.

Proper system of checks and balances should be introduced and health institutions should develop on strategies for sustainable corporate leadership, financial accountability, social entrepreneurial management model and competitive business strategies. The current hierarchical organisational structure needs to be flattened and the endemic inter-professional rivalries need to be turned into corporation, collaboration and partnership.

The public need to empower themselves to remind the politicians that their political fate are determined by peoples vote under the social contract. Through this relationship, public can enforce their demand for quality and affordable healthcare when campaign time comes.

The power of the government to make laws and regulate the system in order to carry out its primary duty of protecting the lives and property of its citizens/population is enormous and must be seen to be exercised. The first approach to overcoming the challenges in effective healthcare delivery is by introducing health service strategic management system and ‘think-tanks’ into the health industry. This will be a move away from the medical model and a sick and treat approach to policy initiatives that has undermined visible progress in developing viable primary health care in the country. 

There is a need to have a clearly identifiable government body that is responsible for health and social care development, strategic planning and decisions about the nation’s healthcare challenges. Their core duty is to have the statutory power to advice the Minister of health as well as provide policy directives that guide the service delivery strategies at the respective healthcare institutions across the country. This body is proposed to be named, “Federal Health Service authority FHSA)”. The diagram below shows a model of Leadership for Nigeria’s Health and Social Care Services under the FHSA. The FHSA should be answerable to Parliament and responsible to the Minister, Ministry of Health who in turn should be answerable to the voting public. 

Very importantly, the government should create a National Institute of Health Service Management and Leadership (NIHSMAL) to train graduates that can focus on health planning and development strategies, industry competition at local and international levels, the general health economy and global market, analysing models for financing health, service analysis, design and redesign, corporate management and leadership, procurement and supporting professional development etc. 

David Eboh BA (Hons) Health Service Management, LLB (Hons), PGDipHE, MBA

Health Management Consultant

Author, Strategic Concept for Managing Health Care in Nigeria

Motivational Public Speaker

President: Nigerian Association of Health Service Managers and Consultants (NAHSMAC)

School Governor

This email address is being protected from spambots. You need JavaScript enabled to view it.

www.nahsmac.org,

 www.nahsmac.com

References

Aboyade, F. (2011) When is Medical Negligence? THISDAYLIVE 09 Aug 2011 

Alliance for Health Policy and systems Research (WHO 2012) National health insurance scheme in Nigeria: an analysis of constraints and enabling factors to adoption. [Online] Accessed from: http://www.who.int/alliance-hpsr/projects/uninigeria_ufc/en/index.html 

Christie, L, (2011) Number of people without health insurance climbs. CNN Money [online] Accessed from: http://money.cnn.com/2011/09/13/news/economy/census_bureau_health_insurance/index.htm

Eboh, D. (2008) National Health Insurance Scheme: A model for realistic change in healthcare delivery in Nigeria. Nigeria Village Square Jan. 31 [Online] Accessed from: http://www.nigeriavillagesquare.com/articles/david-eboh/national-health-insurance-scheme-a-model-for-healthcare-delivery.html

Edeh, S. (2012) Quack at Work: Abubakar Goes For Fever Treatment, Doctor Removes His Two Kidneys, Vanguard, August 19 

Driver, J. (2009) "The History of Utilitarianism", The Stanford Encyclopedia of Philosophy (Summer 2009 Edition), ( Edward N. Zalta ed.), [Online] Access from: http://plato.stanford.edu/archives/sum2009/entries/utilitarianism-history/ 

Hobbes, T. (1660 ) Leviathan 2 (Graham, A. Rogers, Ed.) University of Virginia, Thoemmes Publisher 2003 

Locke, J. (1690) Second Treatise of Government (C.B. Macpherson.Ed.) Indianapolis Hackett Publisher, 1980

Osalor P. (2012) Youth Restiveness and unemployment in Nigeria: The way out part 1, Vanguard Nigeria,  May 28, 2012 [online] Accessed from http://www.vanguardngr.com/2012/05/youth-restiveness-and-unemployment-in-nigeria-the-way-out-part-1/




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