PREAMBLE: Though the health sector like most other sectors of Nigeria's economy is not immune from the challenges of the Nigerian system, I would say that the aggregate performance of Nigeria's health sector in 2013 was not remarkably different from that of 2012 despite some efforts made to address the challenges carried over from 2012. It was clear from the onset that the unsatisfactory amount allocated to the health sector in the 2013 National budget and the slow process of release of funds was not going to impact on the quality of health of Nigerians. The poor funding of the health sector manifested in the country's inability to give expression to some laudable initiatives in the health sector, including postgraduate Residency Training Programs.

It was however not all gloomy in the health sector in 2013 as there were some progressive developments like the eventual reconstitution and inauguration of the Medical and Dental Council of Nigeria (MDCN) and other Health Professional Regulatory Councils as a result of the agitations and committed efforts of the Nigerian Medical Association (NMA); medical professionals also led expert teams that undertook some highly skilled interventions such as Kidney transplantation, Stem cell transplantation, and Cardiac surgeries etc.

AGENCIES OF THE FEDERAL MINISTRY OF HEALTH:

NHIS: In the critical area of Universal Health Coverage for Nigerians through the National Health Insurance Scheme (NHIS), there were some developments, particularly the launching of more Community Based Social Health Insurance Schemes in various Nigerian communities, including the Federal Capital Territory. However, these efforts paled into insignificance considering that the Universal Health Coverage in Nigeria is still less than 6%. Perhaps the non-passage of the 

National Health Bill with fundamental provisions for financing the health of Nigerians, the long delay in inaugurating the Governing Board of the National Health Insurance Scheme (NHIS) as well as the inexplicable delay in appointing a substantive Executive Secretary of NHIS slowed down efforts at expanding Universal Health Coverage in Nigeria. Now that a substantive Executive Secretary for the NHIS has been appointed it is expected that the application of more innovative and social-based health financing mechanisms in 2014, together with strong commitment and transparent leadership of the NHIS Management, will propel the administrative wheels of NHIS in 2014 towards accelerating the enrolment of more Nigerians into the scheme as well as boost financial access of all Nigerians to a minimum healthcare package.

HIV/AIDS: Nigeria still has a lot to do in the fight against HIV/AIDS. It is imperative that the Director General of the National Agency for the Control of HIV/AIDS (NACA) and his management team learn from experiences garnered in 2013 to hopefully devise better strategies of securing improved results in Nigeria's efforts to combat HIV/AIDS in 2014. Besides seeking to improve the level of public education and access to anit retroviral medications by PLWHAs, NACA needs to do much more to reduce the significant level of mother to child transmission of HIV/AIDS in Nigeria.

Time has come for Nigeria to review her dependence on donor agencies so as to prevent the calamitous consequences of their eventual exit for whatever reason. I believe Nigeria is rich enough to make treatment of HIV/ AIDS truly free without relying on donor agencies. I therefore strongly advocate that Government should give a budgetary headline to TB and HIV at the hospital level if any meaningful impact is to be made in 2014 and subsequent years.

I also call on the Government to thoroughly investigate the complaints by PLWHAs about the FGN supplied combination drug---Nevirapine, Lamivudine and Zidovudine. If the drug is found wanting, it should be withdrawn immediately. NMA is prepared to make her informed contributions in this regard.The war against Tuberculosis (TB) seems not to be enjoying the momentum desired. Rather than the government to invest more on the active treatment of TB at the community level, they have found peace with investing funds (pre-eminently donor funds) in Multi-drug Resistance TB (MDRTB). An insignificant proportion of cases of MDRTB arise without first line drug management failure. There is therefore the need for agencies of government saddled with the responsibility of protecting Nigerians against TB to realize that the best weapon against MDRTB is effective prevention, early diagnosis and adequate provision of drugs for the management of Tuberculosis. 

Just like HIV/AIDS, treatment of TB deserves to be truly free.

RESEARCH: It is not surprising that there was no appreciable breakthrough in operational research. This may not be unconnected with the fact that Nigeria still has no strategic research policy, and probably does not consider research as a necessary tool for national development. In addition, investment in research by government, corporate bodies, and individuals is still at a low ebb in Nigeria such that potential Nigerian researchers and inventors are enveloped in a state of diffidence. Those who have the capacity to sponsor research in Nigeria do not believe in it. Although this is not peculiar to health but it is worse in the health sector. 

INFRASTRUCTURE AND EQUIPMENT: In terms of infrastructural development in the nation's health institutions, the year 2013 witnessed some efforts to upgrade existing federal health infrastructure and equipment with the aim of improving the capacity of the Federal Tertiary Health Institutions. There were also efforts by some state governments to upgrade their state hospitals. However, these efforts were not significant enough, thus leaving the aggregate performance in 

terms of public health infrastructural upgrade and development in Nigeria below par

Again, the private healthcare sector did not witness significant push in terms of health infrastructural development. The Federal Government of Nigeria through the President has accepted the proposal of the Nigerian Medical Association for the establishment of a Hospital Development and Intervention Fund (HDIF) which will help provide a platform for the establishment of world class health facilities in both the private and public health sectors. The NMA has called on the Federal Government to urgently give effect to the active development and implementation of the proposal in the year 2014.It is sad to note that the operational Magnetic Resonance Imaging machines (MRIs) in Nigeria are concentrated only around Abuja town and a few other areas in some parts of Nigeria. So imagine what it will take a poor man with a disease condition requiring an MRI investigation to access it. That is if he can even afford the exorbitant cost outside the associated cost of transportation, feeding and accommodation in a land he has no one to look after him.

MEDICAL TOURISM: On the issue of Nigerians still travelling abroad for treatment, it has become a status symbol for some, while for some others it is because of the ready availabilitof public funds to be spent. There are few germane cases. Nigerian doctors are doing a lot, and our people should have confidence in the system. It is better and easier to travel to Enugu or Ibadan or Benin to receive expert treatment than to travel all the way to Asia to receive the same services that are available locally.

PUBLIC-PRIVATE-PARTNERSHIP (PPP): The government needs to truly take matters concerning healthcare more seriously and allocate more funds to the health sector in addition to firmly instituting Public Private Partnership (PPP) arrangements in the hospitals/health institutions or the outright outsourcing of some services such as pharmacy, radiography, physiotherapy, e.t.c, so as to free funds for more critical services.

PROFESSIONALISM: In terms of Health Human Resource, one unfortunate feature witnessed in 2013 was the unwarranted bickering, agitation, professional territorial and sometimes politically motivated quest for equality with medical doctors, by some allied health professional groups and hospital support staff in Nigeria. This undoubtedly impacted negatively on health service delivery. ne hopes that in 2014 there will be greater harmony amongst the various healthcare workers in the public health sector with all stakeholders playing their role in a more harmonious way to ensure delivery of quality healthcare services to Nigerians.

Despite the challenges of health human resource in Nigeria, including the extremely hostile workplace environment, I must state unequivocally that medical doctors had profound positive impact on the health sector in 2013.

Nigerian medical doctors and dentists successfully undertook several high skilled medical and surgical interventions in 2013, amongst which were Cardiac surgeries and Kidney transplantation, as well as continued successes in Stem cell transplantation which witnessed a second successful cure of a 15 year old Nigerian student with Sickle cell Anaemia (HBSS), by a joint team of experts from the University of Benin Teaching Hospital, University of Benin and the Nigerian Medical Association's National Committee on Stem cell Transplant and Genetic engineering whose chairman, Dr. Godwin Nosakhare Bazuaye, a Consultant Haematologist (Pathologist) and Senior Lecturer with the University of Benin, headed the team of experts.

As part of our contribution to improved access to quality healthcare services in Nigeria, the Nigerian Medical Association (NMA), through its medical missions, offered free healthcare services, including surgeries, to over 250,000 patients in rural areas this year alone; the last outing for the year took place in Niger state in December, 2013. In this last outing, over 90 surgical operations were performed freely and at no cost to the patients.

The NMA also approved its Clinical Governance policy framework and work plan and inducted Zonal Clinical Governance leads to focus on issues of quality and safe care and the motivation of healthcare professionals in Nigeria. This policy implementation is already receiving great attention by development partners and the Federal Ministry of Health and holds a major key to the enthronement of improved quality healthcare delivery in Nigeria.

In the area of training and manpower development, the impact is unparalleled; the NMA welcomes the continued commitment by many Nigerian medical specialists in the training of Nigerian doctors at less than 10% of the cost of doing so abroad.Nigerian specialist doctors deserve very high commendation in this regard.If government is able to sanitize the health system, through the elimination of falsehood, thuggery, radicalized unionism and mischievous competitions by staff dissatisfied with their secondary supportive roles in patient care the doctors will do much more in 2014. There is a lot of distraction for the doctor at the moment which has resulted in preventable morbidity and deaths 

in Nigerian public hospitals. It can be stopped by government through the honest implementation of international best practices in hospital care for patients. It is the least the Nigerian government can do for the unsuspecting Nigerians. Indeed, there is urgent need for the enthronement of professionalism and international best practices in the healthcare sector, with the duties and responsibilities of the various healthcare providers clearly defined. Professionals should not claim to be able to do what is outside their professional training. It will help Nigerian patients in the hospitals.

NATIONAL HEALTH BILL (NHB): Though the efforts of both chambers of the National Assembly to re-present the National Health Bill for passage and hopefully, accent by the President are appreciated, the slow pace of processing of the bill leaves much to be desired. Indeed, the high hopes of Nigerians that 2013 will witness the delivery of a National Health Act that will enable vulnerable Nigerians (including women, children, the disadvantaged and the elderly) and those in the rural communities, to have ready access to health care facilities/resources, have dimmed.One prays that the National Assembly and President Goodluck Ebele Jonathan GCFR, will move faster to deliver this long overdue pregnancy, for it remains one huge debt they owe Nigerians. 

I cannot ignore the fact that whereas many other public/government parastaltals and banks are still wobbling and collapsing, the managements of most public and private hospitals in Nigeria survived the travails and extreme difficulties of the Nigerian system. This is an achievement in itself. But for the commitment of most of the chief executives, the impact of no water supply, moribund power supply, lack of good roads, suffocating poverty, high level of illiteracy, insecurity in hospitals and violent unionism would have buried the public sector hospitals in Nigeria. This success can only be traced to the professional training and exceptional discipline of the Chief Medical Directors/Medical Directors of the public sector hospitals.

For remarkable progress to be made in the health sector in 2014, it is important that the following challenges are concretely addressed:

(1) The low level of political commitment to healthcare by most governments in Nigeria, especially as depicted by the frequent travels abroad to seek medical care by political and public office holders, coupled with the poor healthcare funding and poor sectoral allocation/release to the health sector at various levels of government.

(2) Poor security and safety of healthcare workers in their workplace, and other Nigerians generally.

(3) Infrastructural and equipment deficits and dilapidation in the healthcare sector.

(4) Poor constitutional and legal framework for health in Nigeria, particularly the absence of a National Health Act that clearly defines the roles and responsibilities of the Local, State and Federal Governments with respect to the three levels of healthcare; as well as the roles and responsibilities of healthcare professionals.

(5) Poor funding and budgetary provisions for health; It is worrisome that despite the clarion call of the NMA for improved resource allocations to the health sector, the 2014 health budget is less than the 2013 health budget and far less than the stipulated 15% of the National budget as stipulated in the 2001 Abuja declaration of African Heads of State.

(6) Poor Health Human Resource Development plans, including poor recruitment of health human resource by all levels of government, poor capacity building and role definition, blunted job descriptions, uncompetitive wages, unsatisfactory working conditions and poor motivation of the health workforce; as well as the inequitable distribution of the health workforce.

(7) Worsening Mass poverty in Nigeria.

(8) Poor percentage lack of Universal Health Coverage for Nigerians;

(9) Pervasive quackery in the health sector;

(10) Weak Primary and Secondary levels of care with a weak referral system and the impact of the federal system of government on healthcare delivery;

(11) Poor data base, and poorly developed Information Communication Technology and Health Management Information System;

(12) Unbridled and indiscriminate advertisement of herbal and medicinal products on the electronic and print media;

(13) Unwieldy and unproductive number of Regulatory Councils in the health sector; with conflicting professional regulatory laws/Acts;

(14) Illegal prescription of prescription-only medicines by persons who are not licensed medical doctors, dentists or veterinary doctors, as well as chaotic and unregulated drug and reagent procurement and distribution.

 (15) Poor development of health-related infrastructure such as power, roads/transportation system, potable water, agriculture, housing and security.

CONCLUSION

The health sector of Nigeria in 2013 witnessed good and bad times in 2013. While there are viable solutions that can drive greater progress in 2014, includinginsulating the health sector from the vagaries and bureaucracies of the civil service by creating a separate Commission for the health sector as was done by removing critical sectors like the judiciary from the civil service, I am sanguine that with the expected passage of the National Health Bill, sincere and improved commitment by the political leaders to good governance and participatory leadership; 

coupled with the altruistic and constructive disposition of all health professionals, the health sector in spite of the poor allocation to health in the 2014 Federal budget may witness some improvements in the year 2014.

Dr. Osahon Enabulele, M.B; B.S, FWACP, MHPM

President, Nigerian Medical Association

Vice President (WAR), Commonwealth Medical Association

th 29 December, 2013.