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Destination Universal Health Coverage: Can PPPs be the vehicle to get us there?

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PharmAccess Foundation’s journey in PPPs has shown significant promise and evidence of the organisation’s successful partnerships can be seen in the revitalised primary health centres in Lagos and Delta State. Photo source: PharmAccess Foundation

The best stories of growth in Nigeria have been private sector driven – whether it is in telecommunications, financial services or in infrastructure. So, why have we not felt the impact of the private sector in the health sector, especially on the frontlines of primary health care (PHC)?

Almost everyone in Nigeria has directly or indirectly experienced the catastrophic impact of emergency out-of-pocket expenses on healthcare. We can no longer keep on doing the same thing – and hope for different outcomes – it is time to think differently and do things differently. It is time for strategic private sector engagement.

We all agree that the desired destination is Universal Health Coverage (UHC), i.e. ensuring that everyone in Nigeria has access to quality healthcare. As defined by the World Health Organisation (WHO), UHC means that “all people and communities can use the promotive, preventative, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship“.


Image credit: Nigeria Health Watch
Countries that have made significant progress in reaching this goal have health systems that include functioning primary healthcare, with a trained health workforce, access to essential medicines and the requisite technology to perform their roles. Sustained financing is also available to the health system and the entire population irrespective of their economic status has access to quality health services. However, in Nigeria, how do we achieve this goal given our mixed and fragmented health system that encompasses the private and public sector? How do we ensure that no individual or family is impoverished by catastrophic health expenditure?

The current state of the Nigerian health sector
The Nigerian health sector has suffered from chronic underfunding, 72.24% of current health expenditure is out-of-pocket, leaving patients to bear the burden of funding their own healthcare. This has led to sub-optimal healthcare delivery with many of our health indicators below national targets and international standards. Eighteen years after the Abuja Declaration where African Union states pledged to allocate at least 15% of their annual budget to health, Nigeria continues to default. Low budget allocation (and it is reducing rather than increasing) has crippled the Nigerian healthcare system in many ways. We forget that a healthy population is truly the best insurance we can have for our economy to thrive. Several studies have shown that investing in health leads to economic development.

If primary health care provides whole-person care for health needs throughout one’s lifespan, not just for a set of specific diseases, why do we neglect PHCs in Nigeria? Why do we still have wards that have no functional PHCs? Why do Nigerians visit secondary and tertiary health facilities for illnesses that should be treated at the primary level? This is likely because the primary healthcare system has failed them.

The important role of the private sector
There are competing demands on Nigeria’s national budget and health has not been given sufficient priority, leaving it underfunded. In a recent speech by Christine Lagarde, Managing Director of the International Monetary Fund (IMF), she stated that the Nigerian economy will struggle due to low revenue generation, given the country’s tax-to-GDP. This will have implications on the country’s ability to direct sufficient resources at the health sector and there is little hope that more funds will be made available to strengthen our already weak health infrastructure.

The role of the private sector is therefore critical in enabling improved access to health for all. It is clear that our public health system faces limitations, as it is not able to meet the healthcare needs of the population. The private sector, however, has the capacity to provide the technical efficiency required to deliver health services. Engagement of the private sector has, therefore, become critical as with the growing population in Nigeria, the public health sector is overcrowded and slow to innovate. Many initiatives have been tried to bolster the health sector and public-private partnerships (PPPs) in healthcare have emerged as a possible vehicle to enable the advancement towards UHC.

Yet, this is not an easy space. It is littered with failed projects and lost investments. It requires extensive thought leadership – an area that we at Nigeria Health Watch partnered with PharmAccess Foundation to address through a recent health policy dialogue.

PharmAccess Foundation – Systems transformation through PPPs 
The private sector can play an important role in strengthening health systems in Nigeria. Through their expertise and capacity and PharmAccess Foundation has an integrated approach that focuses on the supply side of healthcare delivery, not just the demand side. The health policy dialogue on the 11th April 2019, organised by PharmAccess Foundation and Nigeria Health Watch, titled Disrupting health care – PPPs as a model adoption for health system strengthening in Nigeria” highlighted PharmAccess Foundation’s journey in revitalising primary health care centres in Lagos through PPPs. This is not PharmAccess Foundation’s first foray into PPPs, the organisation had worked with Hygeia Community Health Care and the Kwara State Government on a PPP to develop the Kwara State Community Health Insurance Scheme, with the aim of providing affordable access to quality healthcare through the introduction of subsidised health insurance.

 
“Quality is not a pass or fail process in our own books. It is about improvement”, Ms. Njide Ndili, Country Director, PharmAccess Foundation. Photo source: PharmAccess Foundation
The selection by PharmAccess Foundation of primary health care centres to revitalise first involved a geo-spatial mapping of existing facilities in Lagos. In the process, it became evident that there were many non-functional primary health care centres which still received an allocated budget to run. The PPP model adopted by PharmAccess enabled greater access to finance to enable the revitalisation of primary health centres – the frontline of healthcare access for more Nigerians. Realising that health facilities have struggled to access finance due to the stringent requirements put on them by financial institutions, PharmAccess established the Medical Credit Fund (MCF), which places money within the banks as guarantees, with the purpose of helping private healthcare facilities to access affordable finance and PharmAccess supported with capacity development. The effort as Ms. Njide Ndili, Country Director, PharmAccess Foundation, explained, was to provide loans at single-digit interest rates, compared to financial institutions with interest rates as high as 24%, making repayments easier and anchored on a model of sustainability.

“All health PPP projects must consider dimensions of quality including technical competence, access to services, effectiveness, safety, efficiency and continuity”, Dr. Ibironke Dada, Director of Quality at PharmAccess Foundation. Photo source: PharmAccess Foundation
In providing loans, PharmAccess Foundation also ensured that the healthcare services provided by such facilities met a minimum quality standard. To support the revitalised health facilities, PharmAccess Foundation introduced SafeCare, the only quality accredited standard for resource restricted countries like Nigeria. SafeCare standards were developed with Joint Commission International (JCI) and facilities receive their accreditation from the Council for Health Service Accreditation of Southern Africa (COHSASA). “Quality is not a pass or fail process in our own books. It is about improvement”, Ms. Ndili said while discussing SafeCare. “All health PPP projects must consider dimensions of quality including technical competence, access to services, effectiveness, safety, efficiency and continuity”, Dr. Ibironke Dada, Director of Quality at PharmAccess Foundation pointed out.

“Trust drives financial services. Trust drives lending. Trust is capital for the doctor and equipment supplier”, Mr. Olufisayo Okunsanya
Business Development Director of the Medical Credit Fund. Photo source: PharmAccess Foundation
Challenges funding healthcare in Nigeria
What drives the lending system? Trust. Trust. Trust. Trustworthiness matters in all financial transactions; healthcare transactions are not excluded. At the policy dialogue, Mr. Olufisayo Okunsanya, Business Development Director of the Medical Credit Fund, explained how trust is key between all stakeholders and in its absence, lending does not occur. “Trust drives financial services. Trust drives lending. Trust is capital for the doctor and equipment supplier”, he said. In addition, when looking at the challenges in funding healthcare in Nigeria, the inconvenient truth is that the government cannot fund the infrastructure requirements of the health sector. The bulk of the federal government’s expenditure is spent on recurrent expenditure leaving little for capital expenditure.

“To ensure that adequate domestic resources are allocated to the health sector, dedicated analytic, policy, and advocacy efforts are required”, Dr. Olamide Okulaja, Director of Advocacy and Communications at PharmAccess Foundation. Photo source: PharmAccess Foundation
If Nigeria is to adequately fund its health sector, we need to view healthcare not as an expense, but as a business. According to Dr. Olamide Okulaja, Director of Advocacy and Communications at PharmAccess Foundation, financing is not the only solution to solving Nigeria’s healthcare problems. He said that we would also need to have systems that are in place to absolve financing and continually justify its release. “To ensure that adequate domestic resources are allocated to the health sector, dedicated analytic, policy, and advocacy efforts are required”, Dr. Olamide added. The role of the government in this mix is to ensure that they create the enabling environment for the private sector to support the running of primary health care facilities. They should be regulating and providing governance in healthcare and let the private sector use their expertise and competence to deliver healthcare.

Healthcare needs to be seen as a business and only bankable ideas get funding. With PPPs you cannot do collateral borrowing and so the healthcare provider is borrowing against the future cash flow that will come from the business. This provides reassurance for the financing organisation for the loan will be repaid. We all have an enlightened self-interest, so it is in our best interest to fix healthcare in Nigeria and look for solutions outside of traditional government financing to address the funding challenges in healthcare.

Case study – Toronto Hospital brings healthcare to the Polobubo Community
How do you provide health care for a community left out of the health system for many years? That is the story of Polobubo, in Delta State, one of the most remote hard-to-reach communities in Nigeria. With a population of about 75,000 inhabitants, the community had until recently no access to healthcare due to their extreme isolation and remoteness.  Accessing Polobubo through its closest town Warri, requires a 3hr 45mins boat ride, travelling with a 200-horsepower double engine speed boat, through the Niger Delta creeks, and across the Atlantic Ocean.


“We are breaking boundaries and getting healthcare to areas no one will dare”, Dr. Emeka Eze, Toronto Hospital. Photo source: PharmAccess Foundation
The high maternal and infant death rates would have continued in Polobubo if not for the intervention of the Delta State Health Insurance Scheme delivered through a PPP model consisting of PharmAccess Foundation’s Medical Credit Fund’s Access to Finance framework, the Bank of Industry and Toronto Hospital, in Anambra State. A successful approach, the model had registered 2,639 enrollees who pay an annual premium of N7,000 and attended to 3,990 cases, including caesarean sections, minor surgeries, appendectomies in the Polobobo health facility, within two months of operation. All of these and many more success stories would not have been made possible without a PPP. “We are breaking boundaries and getting healthcare to areas no one will dare”, Dr. Emeka Eze of Toronto Hospital said.
Also Read Health For All: Achieving Universal Healthcare Coverage in Nigeria | Adaku Efuribe

Now what? The Scalability of the PPP model in healthcare
In the 2019 health budget, about ₦50billion has been allocated for capital expenditure. Clearly, this amount is unable to cover the infrastructure gap in the healthcare industry and cater for the health needs of Nigeria’s burgeoning population of almost 200 million people. Can PPPs fill the gap in health funding? The government does not trust the private sector due to fear that they will put profit before performance, however, there appears to be a sea change. For the first time in Nigeria, two state governments are releasing funds to the private sector to revitalise some of their healthcare facilities. This is a testament to the political will in Lagos and Delta State to partner with the private sector.


The PPP model registered 2,639 enrolees who pay an annual premium of N7,000 and attended to 3,990 cases, including caesarean sections, minor surgeries, appendectomies in the Polobobo health facility, within two months of operation. Photo source: PharmAccess Foundation
In 2017, the federal government flagged off its Primary Healthcare Revitalization Programme, announcing its target of revitalising 10,000 PHCs in Nigeria. Recently, the Minister of Health, Prof. Isaac Adewole, however, said that the government has only been able to revitalise 4000 PHCs. Could financing be a major hindrance to achieving the FG’s target? Perhaps this is an opportunity for the private sector? In joining the PPP vehicle, the words of Mr. Olufisayo during the policy dialogue, come to mind “If you want to be a good public-private-partnership candidate, do not come alone. You have a better chance if you collaborate with others. The strength of the pack is the wolf, and the strength of the wolf is the pack”.
 
The first panel at the policy dialogue focused on financing healthcare projects. Photo source: PharmAccess Foundation
The ability to scale up PPPs needs to be driven by government policy, regulation and political will, critical enabling conditions for the successful implementation of PPPs. This was seen with the partnership between the Lagos and Delta State governments and other stakeholders; the public sector commitment was evident. Dr. Olaokun Soyinka mentioned during the policy dialogue that “Government needs to advocate within government”, and so promoting the benefit of PPPs. Evidence of a successful PPP model, as Engr. Chidi Izuwah pointed out, was Garki Hospital, in Abuja, the first ever public-private partnership in the Nigerian health sector.

Under the stewardship of Prof. Chris Bode, the Chief Medical Director at the Lagos University Teaching Hospital, a state of the art Cancer Centre was commissioned in partnership with a consortium that included the Nigeria Sovereign Investment Authority (NSIA) in February 2019.


The second panel at the policy dialogue focused on creating synergy for PPPs to strengthen primary healthcare delivery. Photo source: PharmAccess Foundation
PharmAccess Foundation’s journey in PPPs has shown significant promise and evidence of the organisation’s successful partnerships can be seen in the revitalised primary health centres in Lagos and Delta State. So, opportunities to scale up PPPs this model is encouraging in the absence of more funds being directed at the health sector.  The role of the government is critical and as public funds are increasingly being invested in the private sector, we are slowly pushing ahead in the journey towards Universal Health Coverage.

A detailed report of the policy dialogue will be made available. Please contact [email protected] for further details. If you would like to watch the live coverage of the event and see photo highlights, kindly visit our Facebook page. To view some of the presentations from the event, click here

Health

Universal Health Coverage: Local action driving universal achievements

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The world has never been as aligned on a common global health priority as it is now on universal health coverage. It is a global imperative for cohesive societies and economic prosperity. A consensus has existed since 1948 that health is a human right, and the call for health for all has been a lingering voice since 1978 at Alma-Ata. But there has never been such high advocacy as there is today with the current call for universal health coverage with access to essential services for all without financial hardship.

The United Nations High Level Meeting on 23 September 2019 in New York may be the climax of this building advocacy. Despite this celebratory moment, there remains a real fear that the political endorsements, high fives, dinners and numerous side events, will bring little change for half of the world’s population, living in Malawi, Vietnam, Somalia and other countries. This includes large numbers of people living in developed countries such as the United States who still do not have full coverage for essential health services.

As the world converges in New York this September, many issues will need to be prioritised. The UHC2030 movement, through its various multi stakeholder constituencies and wide-ranging consultations, has identified six key areas of focus. They start with political leadership beyond health and commitment to health as a social contract. Health is the foundation for people, communities and economies to reach their full potential – and the achievement of universal health coverage is primarily the responsibility of governments.

Governments ensure that people’s health is a social contract, noting that achieving universal health coverage is essential for inclusive development, prosperity and fairness. It requires political decisions that go beyond the health sector.

Second, half the world’s population is left behind. That includes the poor, migrants, criminalised populations and women. Health is enshrined as a fundamental right of every human being. Universal health coverage is key to reducing poverty and promoting equity and social cohesion.

Local action driving universal achievements

Extending geographic coverage and reaching the most marginalised and hard-to-reach populations are essential to achieving positive health outcomes. For real action in all communities, governments must commit to report disaggregated data for the official statistics compiled on the Sustainable Development Goals in order to capture the full spectrum of the equity dimensions of universal health coverage.

The third priority is to ensure that governments create a strong, enabling, regulatory and legal environment that responds to people’s needs and builds institutional capacity, so the rights of people and their needs are met. There is no debating the fact that governments bear this primary duty under the International Covenant on Economic, Social and Cultural Rights.

The fourth call is to uphold the quality of care by building health systems that people and communities trust. That starts with primary health care as the backbone of universal health coverage. It is best achieved through creating confidence in public health systems that respond to people’s needs and deliver desired outcomes.Where private health services are required, leadership should come from the public sector.

The fifth call is for leadership through public financing and efficiency by investing more and investing better through sustainable public financing and by harmonising health investments from all players including development assistance and the private sector. Governments must adopt ambitious investment goals for universal health coverage and make progress in mobilising domestic pooled funding towards existing targets, such as 5% of gross domestic product or the African Union’s Abuja Declaration of 15% of government expenditure. This funding should be equitable and driven by the need to reduce impoverishing and catastrophic out-of-pocket expenditures for communities.

Furthermore, development assistance for health should reduce fragmentation and strengthen national capacities for health financing.

Finally, and in line with SDG 17 on the need for partnerships – and in recognition of the fact that health can only be achieved by a whole-of-society approach – countries should take active steps to engage non-state actors more meaningfully. In providing clear direction from the public sector, civil society and the private sector, they too can shape the universal health coverage agenda.

As in many other sectors, there is no one-size-fits-all answer. Solutions for each country must be tailored to that country’s particular context and population needs. The international community and global health partners should unite to support all countries to build a healthier world. The UN High Level Meeting in September must therefore reach high enough to mobilise political leadership but local enough to drive meaningful country action.

Githinji Gitahi joined Amref Health Africa as the group chief executive officer in June 2015. He is also a member of the Private Sector Advisory Board of Africa CDC, the Global Health Investment Advisory Board, and of the World Health Organization’s Community Health Worker Hub. Gitahi is co-chair of the UHC2030 Steering Committee, a global World Bank and World Health Organization initiative for universal health coverage. Gitahi has a doctor of medicine degree from the University of Nairobi and a master’s in business administration from United States International University.

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GE Healthcare Advancing Universal Health Coverage in Ghana

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GE Healthcare’s Eyong Ebai, General Manager West Central & French Sub-Sahara with Hon Alexander K. K. Abban Ghana’s Deputy Minister of Health, Farid Fezoua President & CEO GE Healthcare Africa and Sulemana Abubakar, CEO GE Ghana during Ghana Healthcare Dialogues event. Source: GE

A key highlight of the event was the unveiling of GE Healthcare’s new budget-conscious ultrasound system, the Versana Essential

ACCRA, Ghana, June 12, 2019 – GE Healthcare has kicked-off a two-day “Healthcare Dialogues” event in Ghana, bringing together public and private sectors’ industry stakeholders including policy makers, healthcare professionals, decision makers, academia, investors and financing institutions to drive conversations around innovative sustainable healthcare solutions to help progress Ghana’s Universal Health Coverage (UHC). Under the theme of Elevating Healthcare through Collaborations, key topics to be discussed include Structuring Innovative Healthcare Financing Solutions; Ghana’s Vision for UHC; the Future of Radiology with Artificial Intelligence (AI); Healthcare Technology Innovations, among other topics.

Also Read HealthPoint Promote Health Inclusion For Widows And Orphans In Nigeria

A key highlight of the event was the unveiling of GE Healthcare’s new budget-conscious ultrasound system, the Versana Essential. It has excellent image quality and can be used by obstetricians and gynecologists, family and general practice physicians, and clinicians in a number of other specialties, making healthcare accessible to promote maternal healthcare in Ghana.  It also comes with local product and clinical training backed with GE’s solid aftersales service to help healthcare professionals gain comfort and proficiency with the system to enhance patient care.

“Promoting health for all is key in accelerating Ghana’s vision for Universal Health Coverage,” said Eyong Ebai, General Manager, GE Healthcare West Central Africa & French Sub-Sahara Africa. “Through collaborations, continuous investment in sustainable healthcare solutions and capacity building, GE Healthcare will continue driving access to quality and affordable healthcare in the region.”

Ghana has been recognized for its commitment to address barriers to health care services and attainment of UHC by 2030 by providing formal support to its vulnerable population through its National Health Insurance Scheme (NHIS).  In 2018 https://bit.ly/2ZnK1yV, NHIS had increased to about 11 million people from the 1.3 million memberships at inception in 2005, representing 38% of Ghana’s population. In addition, the healthcare system engages over 4,000 public and private providers and accounts for about 85% of its internally-generated fund.

“We are proud to host the GE Healthcare Dialogues in Ghana and provide a platform for the industry stakeholders to advance the country’s healthcare agenda,” said Sulemana Abubakar, CEO GE Ghana. “This is a testament of our role as a global leader with local presence, to drive better outcomes for people in the markets in which we operate.”

GE started its operations in Ghana in 2010 with only 5 employees and has grown to 100+ employees currently 90% Ghanaians, with two offices in Accra and Takoradi. Through strategic partnerships and localization commitments, GE is supporting co-creation of solutions to tackle key challenges in Healthcare, power and oil & gas to help improve life for the people of Ghana. GE Healthcare in collaboration with the Ministry of Health and the Ghana Health Service is also training and equipping healthcare professionals at the primary healthcare level with over 500 portable ultrasound machines across 125 of Ghana’s 216 districts. As a result, 1.5 million expectant Ghanaian women are expected to benefit from the initiative by 2020.

GE.

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Engaging community healthcare workers in addressing primary healthcare crises in Nigeria

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Image credit: VON

We are currently facing a primary healthcare crisis in Nigeria and speedy intervention is needed to salvage and enhance access to health care for our ever growing population.

Community health workers have the potential to enhance primary care access and quality, but remain underutilised in Nigeria.

A WHO report by Uta Lehmann and David Sanders from the School of Public Health University of the Western Cape, says;

‘The use of community health workers has been identified as one strategy to address the growing shortage of health workers, particularly in low-income countries. Using community members to render certain basic health services to the communities they come from is a concept that has been around for at least 50 years. There have been innumerable experiences throughout the world with programmes ranging from largescale, national programmes to small-scale, community-based initiatives’ (Evidence and Information for Policy, Department of Human Resources for Health Geneva, January 2007)

It is common knowledge that  we do not have trained physician associates or assistants in primary care facilities to support medical doctors in providing primary care services; rather what we have in some  communities are quacks, people parading themselves as medical doctors with no medical qualification what so ever.

But I don’t see any reason why we should not welcome the idea of training physician associates or assistants to fill in the gap for medical staff shortage, when other developing and developed countries that have better healthcare systems do have them.

In Nigeria we do not have enough doctors per population or geographical area, This is the time to train up more community health care workers as this would help in the much needed awareness creation and community based interventions for  managing long term conditions, reducing childhood illnesses due to lack of immunisation. Trained birth attendants will also help reduce maternal mortality and community nursing care will reduce infant mortality.

In a typical medical centre in the UK for instance, healthcare assistants, advanced nurse practitioners, health trainers, clinical pharmacists or prescribers, work alongside doctors to provide patient centered care. This helps to reduce the work load on the doctors as these other clinicians and allied health workers have enough training and experience to manage long term conditions and participate in triage system.

In the UK, a lot of research has been done and there are calls to increase the health work force in the National Health Service (NHS) through the utilisation of community-based lay workers.

Below is an extract from a research published in the journal of Royal society of medicine curated by Dawn O’Shea:

‘’Introducing a workforce of community-based lay health workers in the NHS could address current general practitioners (GP) workload demands, while improving clinical outcomes, according to research published in the Journal of the Royal Society of Medicine.

In the 1960s, programmes in the US funded members of the community provide a bridge between patients and health care providers. By facilitating appointment-keeping and increasing medication compliance, community health workers improved access to and quality of health care, while reducing costs.

In Brazil, community health workers receive basic training in disease identification and monitoring, immunisation, screening and health promotion. They support patients with medication adherence and chronic disease monitoring and liaise proactively with GPs and practice nurses…..

The authors conclude that systematic integration of community health workers at scale in the NHS could be an effective and a rapidly implementable approach to the current primary care workload crisis’’.

(Hayhoe B & al.  | J R Soc Med | 4 Oct 2018     from Dawn O’Shea | UK Medical News | 8 Oct 2018)

Another important area where the community healthcare workforce could be utilised effectively is emergency care or first aid. In most public and private places in Nigeria, there are no ambulance or paramedic services; having well trained community first aid responders would go a long way to save lives in times of emergency for example; cardiac arrest, collapse, and respiratory distress. Having a health unit manned by well-trained first aid responders in all public places like markets, motor parks etc is highly essential.

Healthcare provision anywhere in the world is capital intensive but we can start from the basics; we can reduce the burden or costs in secondary healthcare provision especially in our public hospitals if we lay more emphasis on patient health education and encourage people to engage in healthy living and self-care. Integrated healthcare practice at all levels is an efficient way of providing patient centered care where every member of the healthcare team contributes their quota.

Community healthcare workers are well placed to offer advice on healthy living and self-care in the language people of a specific demographic area would understand.

Hypertension, Chronic Kidney Disease, Type 2 diabetes mellitus, malaria, HIV/AIDs are among the diseases that could be prevented or well managed through patient education and lifestyle advise.

The role of health education cannot be overemphasized. For instance, there is still some form of stigma around epilepsy in some areas in the country; where people who are epileptic are believed to be possessed by some sort of evil spirits, in an unfortunate event of epileptic fits in public places, patients are not well cared for and objects like spoon etc. are inserted into their mouths in the believe that it keeps the airways open, this could be a choking hazard and has made recovery time worse for some patient. Community healthcare workers could perfectly fill that gap of providing basic health education and public health enlightenment.

In conclusion, addressing the primary healthcare crises in Nigeria is no mean feat, but we need to look at the issue holistically, it involves a multifaceted, public and private partnership, but the Government has to lead on this through the inaction of relevant laws and provision of training programmes, monitoring and evaluation etc.

Without health, life is not life; it is only a state of languor and suffering.     

Francois Rabelais

 

Author:

Adaku Efuribe

Clinical Pharmacist/UN SDG Advocate

 

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