Assessing Health Infrastructure in Nigeria and Bridging the Gap

This is the first of a series of articles tackling some of the gaps and thoughts raised from the Lagos Health Summit 4.0. These include health infrastructure, digital health collaboration and regulatory frameworks amongst others.

Nigeria has an enormous healthcare problem and as a practising medical doctor in sub-urban Nigeria (Ogbomoso), I have lived, first-hand experience of these issues — from health financing where the vast majority of Nigeria’s mostly-poor population are one illness away from poverty and the majority of illnesses are covered by out-of-pocket payments to health policy, where until recently, the mental health legislature was guided by the Lunacy Act. However, a striking, rarely-spoken about aspect is the (lack of) health infrastructure.

Health infrastructure refers to the physical facilities that make care accessible; laboratory, training, and other support facilities; reliable supplies of pharmaceuticals and other materials; trained staff and professional training systems; and mechanisms to distribute resources and expertise. This, summarily, refers to the value chain and all input needed to get healthcare to the final consumer in Nigeria.

Progress: The lay of the land

While there is no single metric that assesses the availability and effectiveness of health infrastructure in Nigeria, the following stand out in assessing the gap that needs to be filled for proper health care delivery:

A. Bed space: As at 2004 (the latest data available), Nigeria had 0.5 beds per 1,000 people. This is far below the WHO recommendation of 4 per 1,000 and less than other countries at a similar level of development. According to the Nigeria Health Sector Market Study Report, Nigeria requires 386,000 additional beds and $82 billion of investments in healthcare real estate assets to reach the global average of 2.7 beds per thousand people in 2019.

Source: World Bank Open Data; Visualisation: O.C. Olorunfemi using Tableau

B. Pharmaceuticals: The National Drug Policy was formulated (1990) and revised (2005) with the aim of manufacturing the majority (70%) of Nigeria’s medicines’ needs via local manufacturing. Paradoxically, 70% of medicines consumed in Nigeria are imported into the country as at today.

C. Medical imaging: Over 60% of X-ray equipment in Nigeria are obsolete and are between 10 to 60 years. As at 2018, there were 183 CT scanners in the entire country and three (3) states in Northern Nigeria — Kogi, Kebbi, and Zamfara — had no CT scanner installed. Nigeria has only 58 MRI machines.

Source: Organisation for Economic Co-ooperation and Development; Data Visualisation: O.C. Olorunfemi using Tableau

D. Import-heavy health economy: According to the International Trade Organisation, despite an estimated market size of $94 billion for medical devices, diagnostic and laboratory testing instruments, all $94 billion are sourced via imported goods with zero goods being exported.

Problems: Obstacles in our way

A. Government- “Macro-economic”:

Factors extending beyond healthcare may be considered the single biggest contributory factor to the dearth of adequate health infrastructure in Nigeria. Nigeria is said to be the 131st hardest country to do business worldwide and institutionalised delays in the ease of doing business makes the Nigerian landscape a living nightmare for private consortiums and individuals willing to do business.

Source: World Bank Ease of Doing Business rankings; Visualisation: O.C Olorunfemi using Tableau

This means that a Big Pharma company looking to establish a local plant must consider relative security, access to locally-sourced raw materials, constant electricity supply amongst others before establishment. This is before consideration of the difficult-to-source foreign exchange or import-duties paid on the health consumable imported into the country.

B. Government — “microeconomic”:

At the Abuja Declaration in 2001, African governments promised to invest at least 15% of their respective national Budgets into healthcare. However, 22 years on, Nigeria is still yet to achieve this with 4.93% (N1.07 trillion) of the budget being allocated to the Ministry of Health (FMOH) in the 2023 budget — a shortfall of 10.1%. Of this, more than half (58.6%) goes to recurrent expenditure like salaries while 41.4% funds capital expenditure like health infrastructure gravely needed.

C. Minimal private investment:

Due to a myriad of factors as listed above, investors remain reluctant to fund private health. This limits access to healthcare for an existent, albeit shrinking, middle-class.

Plan: Possible ways forward

1. A thousand effective NGOs, private institutions do not have the impact of a fully functional FMOH. This can only be attained by increasing the funding of the FMOH, with a view towards an exponential increase in the portion spent on capital expenditure. Proper implementation and follow-up are also key aspects of this 3-tiered process.
2. However, the betterment of the heath sector cannot be achieved without an improvement of the larger Nigerian context. For health indices to improve, fundamental issues affecting the quality of life of Nigerians — security, electricity amongst others — must improve. This will in turn increase purchasing power for the average Nigerian while increasing investor confidence enough to boost local production of health infrastructure. Tax breaks should also be given to manufacturers in order to encourage local production of health consumables.
3. While the local economy is given enough time to “breef” and thrive, access to health infrastructure can be made even easier. This can be done by giving Import Duty Exemption to importers of health equipment. Private investors should also be encouraged to work towards the establishment of heathcentre chains, either in isolation or in public-private partnership with the three tiers of government.
4. Involvement of government and international parastatals in funding for infrastructure: Over the past few years, specific measures have been taken to provide access to liquidity for private institutions. This include the N100 billion credit support intervention for the healthcare industry provided by the CBN; ECOWAS Bank for Investment and Development (EBID)’s $215.9 million commitment to heath, and the African Development Bank’s Strategy for Quality Health Infrastructure in Africa. However, awareness, participation and utilisation can be improved while public awareness on the progress so far made known.

In conclusion, the state of health infrastructure in Nigeria stands at a critical crossroads. While there have been commendable efforts to improve and expand healthcare facilities across the nation, significant challenges still persist. However, amid these challenges, there is room for optimism. The growing awareness of the importance of a robust healthcare infrastructure, both from the government and the public, signifies a positive shift towards change. Collaborative initiatives involving public and private sectors, along with international partnerships, have the potential to inject much-needed resources and expertise into the system.

For sustainable progress, it is imperative that Nigeria prioritizes long-term investments in health infrastructure. By addressing foundational elements, Nigeria can pave the way for a stronger, more resilient, and accessible healthcare system that caters to the needs of all its citizens.

In the coming years, the success of Nigeria’s healthcare system will depend on the collective determination to overcome challenges, the willingness to adapt and innovate, and the commitment to ensuring that every individual, regardless of their location or socioeconomic status, has access to quality healthcare. As Nigeria strives for a healthier future, it is the synergy of efforts and the unwavering dedication to improving health infrastructure that will ultimately define its success on this crucial journey.