Thought Leadership

Health in Vision 20: 2020 and the National Health Bill

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We have blogged severally on the National Health Bill, on the strange process it has gone through, the intrigues in both houses of parliament in the past few years including retreats in Ghana. Our understanding is that the Bill has now been ratified by both houses and is with Mr President awaiting signing.

Over the past few months, the Federal Government, led by the office of the Vice President has brought together eminent Nigerians to draft a document to guide the implementation of its Vision for Nigeria to be one of the world’s 20 leading economies by the year 2020. We reached out to the eminent colleague that led on working group on health for the Vision 20:2020 Document (which you can read in full here). We asked him on how his work was tied up with the new National Health Bill awaiting signing. We got a most amazing reply. Most amazing!. Reading his email correspondence reproduced below with his kind permission. He agrees like we suggested that Nigerians have a right to know how their demoracy works!

Dr Shima Gyoh, the chair of the committee on health for Vision 20:2020 did not see a copy of the National Health Bill until their last day of sitting.

Dear Chikwe,

Attached is my submission to the FMOH on the National Health Bill (NHB). As you noted in the report of the Health Schematic Group of Vision 20, 2020, our persistent efforts landed us a copy of the National Health Bill at the end of our work. I read it overnight and presented the attached “Problems with the NHB” to the group, but they correctly said our time was up, and the members did not have the privilege to go through the document and then discuss it as a group. Since there was not going to be an extension of the time, they did not want to be involved in doing emergency work on such an important document.

None of the “distinguished” members of the Health Schematic Group had previously seen, not to talk of participating in producing the document; the only member that was familiar with it was the representative of the Federal Ministry of Health. I was alarmed by the omissions and commissions in the documents, and the indications that it might have been produced without wide consultation within the health sector. Following a dispute as to whether the copy of the NHB which I reviewed was authentic, the Minister sent us a copy from his office, and it was identical to the one reviewed.

I was informed that it was too late to recall the Bill. My opinion was that rules and regulation are made by human beings, and nothing should be beyond change if it is to serve the public but contains serious deficiencies. I therefore sought to cause a re-think by submitting this document to the Minister, urging him that if this was really the final and authentic copy of the document we were hearing has been passed by both houses and was awaiting Presidential signature, it should be quickly recalled for urgent reconsideration.

Since I have not yet received a reply, I can only pray about it, meaning I have given up, and simply hope that the much taunted NHB is something much better than what I had seen and reviewed. Copies of it should have been widely available to the public at the stage of public hearing, long before the final debate on it. Yet even at our Group, getting a copy was no easy task. Our democracy is quite peculiar!

Kind regards from

Shima K Gyoh

Chairman, Health Thematic Area,

National Technical Working Group

The analysis presented below are personal, and I alone should be blamed for its shortcomings. The Health Thematic Group did not have time to go through it, but they unanimously felt that the Bill could do with more consultation. My own work on it was rushed, and not as comprehensive as I would have liked it to be. It is my strong belief that if the Bill goes through in its present form—granting that the version I have reviewed is the final form, it would create more problems and a demand for its amendment would come sooner than later. Shima K Gyoh

Primary Health Care Development Agency.

The Bill does not create a Primary Health Care Development Agency (PHCDA). Section 11 establishes a Primary Health Care Development Fund (PHCDF) which cannot be confused with an Agency because

1. The sources of the fund are spelt out in Sections 11 (1) and (2).

2. However, clause (4) of Section 11 suddenly begins to talk of the PHCD Agency, which is nowhere established in the Bill.

Can the PHDCF be converted to PHCDA? Not really for the following reasons:

1. The Established PHCDF does not have membership because it is only a fund, and cannot be both an agency and a fund, and there is no list of membership or of functions that can be proper for an Agency.

2. Conversion of the PHCDA into a fund-disbursing body would be disastrous for the health care in Nigeria. The Government, like the WHO, is emphasising that PHC must be greatly strengthened to constitute a good foundation for our health services. The function of PHC in the health care development in Nigeria is very crucial, and the Health Committee of Vision 20, 2020 is making strong recommendation to that effect. The Agency should be involved in full-time PHC activities.

Under the leadership of Professor Olikoye Ransome-Kuti, the FMOH embarked on setting up PHC units (posts, clinics, health centres and CHC) in the States as templates which each State could replicate to cover its entire territory. The FMOH naturally gave more attention to States that were slow in implementing their PHC services, thus achieving a more uniform performance all over the Federation. Because of the importance attached to PHC, the Ministry, which had several other functions, decided remove PHC out of its multiple commitments and delegate it to a new body it created, the PHCDA, which would devote its full time to the task without other distracting duties as was the case in the Ministry. This principle for creating the PHCDA might perhaps have been modified with time, but the parastatal should never be turned into a money disbursing body. The confusion of its name with Fund in the Bill is a serious mistake that should be immediately corrected before it becomes law, especially as the proposed legislation will benefit from wider consultation.

Federal Capital Territory PHC Board

Section 12 establishes the Federal Capital Territory PHC Board with membership and functions. Problems are:

1. There was no need to multiply the cost and lengthen the process of administration by establishing a whole Board just for PHC in the capital territory. A Committee of professionals would have done.

2. Nowhere in the membership of the Board is qualification and experience in PHC
demanded. It consists of just technocrats with experience in accounting. Yet the Board is to “ensure coordination, of planning, budgetary provision and monitoring of all PHC services in the FCT.

The National Council on Health

Section 5 creates the National Council on Health (NCH). The following aspects need reconsideration:

1. Each meeting of the Council requires enormous work: gathering memoranda from the States, debating them at the Top Management Committee of the Ministry to determine the correct policy to adopt, and again at the meeting of the Technical Committee of the NCH when it is presented by the originating State. There are many challenges in trying to do this properly, as any person with responsibility of organising the NCH meetings should know.

2. Section 5 (3) provides that the NCH meets at least twice in a year. The NCH is a large and expensive meeting. The Ministerial Committee has about 58 members and the Technical Committee about 150. When one adds up the secretarial and other staff, one gets a minimum of 300 delegates. There are serious problems doing the job properly even when the meetings are held annually. If they are to be held every six months, both the States and the FMOH would abandon everything else and concentrate on NCH affairs. Policy matters do not require such frequent meeting. The meetings should remain annually, and the law should only provide for extra-ordinary meetings to satisfy the occasional need.

3. The private sector which is reputed to provide from 40% to 70% of services depending on the part of the country, is severely under-represented at the Technical Committee. Even if one includes the religious health organisations, their total representation would be only 3 out of 150, about 2%. If we are serious about the public private partnership, the private sector should be allowed fuller participation at the stage of policy formulation.

National Tertiary Hospitals Commission

Section 9 creates the National Tertiary Hospitals Commission which not only takes over some of the functions of the Federal Ministry of Health; it also subsumes nearly all those of the Hospital Management Boards. Is this commission really essential? What value does it confer on the system?

i. It is another administrative body that would need offices, office equipments, secretaries, vehicles and highly paid staff that would greatly absorb the scarce resources and multiply the expense of administration without significant added value.

ii. It is a serious delay “middleman” stage that would convolute bureaucracy and delay issues because the hospitals would no longer be able to get direct and quick access to the Minister on grounds that the commission should be consulted first.

iii. The Hospital Management Boards are also Bodies Corporate that can sue and be sued. Why this additional exposure to litigation? Why create a powerful body that is not directly in charge of the hospitals, and open up another avenue of likely conflict with the Management Boards?

Research or Experimentation with Human Subject

On health matters, only a person’s doctor can give reliable, professionally competent and acceptable advice. Therefore, if any human being is going to give informed consent to participate as a subject on research or trial of any sort, he or she should do so only after his or her doctor has studied the protocol and can advise on the possibility of adverse sequelae both in the short and long term. The advice, though not perfect, would be expected to be better than that of any other person, especially those involved with the proposed research.

Yet Section 33 of the draft bill nowhere provides for this. Section 33 (1) (b) says “… with the written consent of the person after he shall have been informed of the objects of the research or experimentation and any possible effect on his health.” This does specify anyone to do the explaining, and the research team would fill this vacuum.

The draft should be amended to require the family doctor of the propositus to not only explain things, but to be an obligatory witness to the written consent.

Unfortunate Legal Requirements

Legal Blood Donation: Section 50 (a) states “A person may not remove tissue, blood or blood product from the body of another living person for any purpose unless it is done (a) with the informed and written consent of the person from whom the tissue, blood or a blood product are removed granted in the prescribed manner and (b) in accordance with the prescribed conditions by the appropriate authority.” This provision is going to kill any attempt to set up blood transfusion services in the country. If you ask blood donors to first sign a legally binding agreement, they are going to be suspicious that you are about to do something that might harm them, and you are seeking a legal escape from the consequences. Suppose they ask the doctor, why must I sign this, what would be the answer? This provision should be deleted.

Section 53 (b) (i) Provides that the written permission of the medical practitioner i/c of clinical services in the hospital is required before an organ is transplanted from a living donor to a living recipient. This introduces unnecessary complication to a relatively simple process. The consent for the operation signed by the donor, the recipient and the operating doctors provides sufficient legal requirements to do the operation without convoluting the bureaucracy.

Section 56 (3) provides that “an organ shall not be transplanted into a person who is not a Nigerian citizen or a permanent resident of the Federal Republic without authorisation of the appropriate authority in writing.” This again is unnecessary convolution of bureaucracy already noted in Section 50 (a), and 56 (3). Once the health services of Nigeria become good, there will be an influx of many patients from other countries, just like it is happening with India. Consent documents signed by the people involved will not be improved upon by introducing third parties that might complicate matters and cause unnecessary delay and controversy.

Section 7 (2) (k) The FMOH decided in the 90s to abandon the phrase “Specialist Hospital” because it was used to mean many different things; the majority of people understood it to mean “a hospital where there are specialists.” The more accurate phrase “Specialty Hospital” meaning a hospital that deals with only one specialty should be used to describe such institutions, e.g. orthopaedic, psychiatric or eye hospital.

The National Health Bill 2008: More Consultation Needed

Finally, the Health Thematic Group of the National Technical Committee of Vision 20, 2020, consisting of experienced top players in the health sector from various specialties was surprised that, while their members had all heard of the National Health Bill 2008, none had had the opportunity to read it, and none knew for sure what its provisions were.

Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

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