Professor Onyebuchi Chukwu served as minister of health under President Goodluck Jonathan before he resigned his appointment to run for governor in Ebonyi state in 2015. In this interview with PAUL OKAH, he says state governments pose a problem in the health sector. He also gives details of how he was able to combat the Ebola scourge and other national issues.
Health sector problems
Having presided over the health sector for four and half years, I will say the problem with the health sector is because it is fragmented and the commitment is not the same everywhere. State and federal health institutions are supposed to participate in the health insurance scheme, but it is still difficult for some states. Most of the health institutions in Nigeria are controlled by the state governments, but, as you know, not all state governments have the same commitment to health; so, everybody throws it back to the federal government. Take Ebonyi state, for instance. If you remove Alex Ekwueme Federal University Teaching Hospital (AE-FETHA), there is no other functional public hospital in the state. The others are mission or private hospitals. I was the one that made the then governor, Chief Martin Elechi, to start supporting the hospitals. If you put all the hospitals together that President Buhari is controlling today, there are not more than seventy; whereas there are thousands of hospitals in Nigeria: some owned by state or private individuals, while others are controlled by local governments.
So, state governments are a problem to us in the health sector. About 80 or 90 per cent of doctors in Nigeria are paid by the federal government. Some states are not even able to employ more than five doctors. The federal government says their only interest is tertiary care, but you and I know that tertiary care is for serious cases. That’s why the Primary Healthcare Development Agency, which is even supposed to be helping states and local governments, is not working. State governments could not fulfill their own part of the bargain whenever the federal government came up with any healthcare initiative schemes like SURE-P, Midwives Service Scheme and the others.
Incidentally, after Ransome Kuti, I am the minister that has served the longest. He served very long under military rule and was my teacher. However, under civil rule, I am the longest serving minister of health, because I served for four and half years. So, with all modesty, I usually tell people that I achieved more than my teacher Ransome Kuti as minister of health. With all due respect and responsibility, I don’t think any other minister of health has achieved more than me in this country, but the media is used to Ransome Kuti. He did well in primary healthcare. He was teaching us in final year when he became minister in 1985. He is the first Nigerian professor of primary healthcare and I respect him. But it was easy for him because he worked with the federal government under the military regime.
If the military government of Gen. Ibrahim Babangida took a decision or issued a decree, every state administrator must key in. But in a democracy, there are things President Buhari cannot direct state governments to do, especially with regards to health and education. You can’t compel any state governor to do anything about health or education in his state. You can only appeal to him. But in the military, you can easily remove any state administrator who disobeyed directives. That was the luck Professor Kuti had. Once he has spoken to Babangida and he gives his order, everybody from the state to the local government must obey. At that time, the health system was not as segmented as it is today, where you have different political parties at the federal and state levels that will tell you it is not in their manifesto. It is difficult to manage the health sector. Anybody succeeding now is doing a harder work, because it is more of advocacy: carrot and stick approach, like we did in the National Health Act (NHA).
In the NHA, we used the carrot and stick approach, because we were bringing money into the health sector. However, if state governments wanted to access the funds under the Basic Healthcare Provision Fund, they were required to set up their own primary healthcare agency and insurance scheme. That’s why governors were running around to set up healthcare centres and insurance agencies. We were not forcing them, but they were running after the money. NHA is a good one and was supposed to bridge the gap in our fragmented healthcare system.
Another issue is funding. States are not contributing. The law says that, at least, one per cent of the federal government money must be put into the primary healthcare. So we are taking care of it too through the NHA. However, the National Health Insurance Scheme (NHIS) needs to make it stiffer. I organised the first ever Presidential Submit as minister on Universal Health Coverage. Most of the things we passed there are what the immediate past minister have started implementing, to his credit. So, we are hoping we need to change the laws. NHIS is a voluntary scheme, but people hardly embrace insurance policies in this part of the world. Many people who have subscribed to the NHIS are basically federal government staff, because the law says 15 per cent of their basic salary will be deducted for that, otherwise they wouldn’t even have bothered. 10 per cent would be paid by your employer and five per cent by you.
Till today, that five per cent is a problem for people to pay. Yet, people will stay in their houses to say the NHIS has failed; when they are not even contributing. But, both as Chief Medical Director (CMD) of Ebonyi State University Teaching Hospital and Minister of Health, I saw the benefit of the scheme. I used the money from the scheme to carry out a lot of projects both as CMD and minister, because the money from the scheme was running into millions. Many of the big hospitals I commissioned as minister were from the NHIS. Even as a CMD, a woman whose husband was working with the federal government required multiple surgeries and seven pints of blood, but she did not pay a dime because she was covered by the NHIS. There is no way she could have afforded it as a middle level staff, but she was covered by the scheme. She had her HMO card and we were under obligation to treat her without demanding a kobo, so you can now see the beauty if the NHIS.
I also formed the Nigeria Centre for Disease Control; to be able to checkmate these problems. In a nutshell, we are not performing in the healthcare system because of the fragmentation. Countries that have a unified system are doing well. However, the NHA is helping. The National Council on Health (NCH) is now a legal body under the NHA. Any decision taken by the NCH is binding on state governments. Also, by the time I left office as the Minister of Health, Nigeria’s maternal mortality ratio had decreased from 545 per 100,000 to 350 per 100,000; under 5 child mortality had fallen from 157 per 1,000 to 94 per 1,000; infant mortality had reduced from 75 per 1,000 to 61 per 1,000 (National Bureau of Statistics 2012); and life expectancy at birth had increased from 47 years to 54 years (World Health Organization 2013). Of course, you know about the Ebola scourge I combated during the Jonathan administration as Minister of Health. I had to think out of the box when the disease threatened Nigeria. Details may form a topic for another interview that may cover pages, but the above are just some of my modest achievements and I received a lot of help from President Jonathan and other notable Nigerians to stop Ebola from spreading in Nigeria.
Buhari’s govt
Well, you know that I am in APC now and you don’t have to criticise your party. In terms of recovering so-called loot, President Buhari has done well, but corruption is not all about recovering loot. I am not sure we have done so well when it comes to the other aspect of fighting corruption. If you recover loot and set examples, like if you also prosecute people properly, seize their properties and jail them, then other people will see it as deterrent. That’s one way of fighting corruption, but that’s not the only way. I am not sure we have done too well with fighting systemic corruption. How do we stop policemen from taking open bribe, which is a shame to the country? Right now, every office you go to, people are asking for money openly. How do you stop ‘pen robbery,’ a situation where people in position of authority over-invoice things? There are areas we can still do better in the fight against corruption, despite the recorded success.
In terms of security, Buhari has done well in the fight against Boko Haram, but other forms of insecurity have escalated, especially kidnapping. The farmers, herders’ clashes have always been there, but it has also escalated. Maybe when he introduces his security chiefs, we can see how far we will go. I also think he should allow the state governors to promote this idea of state police. It is better for us.
In terms of economy, he has managed to stabilise the naira, though at a huge cost to the country. I am not an economist, but I think he has done well. It is good to float when you are productive as a country. Your production will increase the value of your currency. As someone who has interest in the economy and as part of President Jonathan’s team, N360 to a dollar is high, but it has been so for a long time. We must find way to encourage production. President Buhari has done well in piling up our foreign reserve, because of his prudence. He is not spending anyhow, but I am not sure we have done well in terms of job creation and empowering people. He has done well in social welfare, but that is for the short term. The long term is that people should be able to employ themselves and others.
Second term concentration
Number one priority is security. It is very important. I suggest he should work with people to make sure that state police is a reality. With the state police, a lot of these security issues will stop. The people in the state police will be the local people, so they will stop insecurity. I know it will work because nobody will like to kill his blood brother. For instance, if the Commissioner of Police is from Afikpo and is being ruthless with an Izzi man, the Izzi man will also be a commissioner of police and deal with the Afikpo man. That way, they will all know their families and will be careful about maltreating each other. The same thing cannot be said about a commissioner of police from the North who was transferred to the South. He can do anything, because his family is far away. I want President Buhari to put more efforts in human capital development, particular education. If Nigerians are intelligent, I believe it will strengthen our educational system, especially ICT. India, China, South Korea are doing very well in ICT. These are countries without many natural resources, but they have a lot of brains. Health can come after education, because it is also important. The fourth one is the economy. Many of the social ills will stop when people are gainfully employed. Government can’t employ everybody, so people should be job creators.
Ministers
Many of the ministers were able to deliver in the past, but I would have thought he should have mixed them up. There are people out there who are technocrats and not politicians and who I know will add value to his cabinet. I know that there is this argument that appointment must be within the party, but I am on the opinion that technocrats and politicians can be mixed either at the state or federal levels. Though there are some politicians who are also technocrats, those I can refer to as techno-polititicians, but there are pure technocrats who can give you fresh ideas.
Ministerial portfolios
My experience in politics as a minister was worth it. Due to my active involvement, I discovered we have a weak system. Many people are appointed ministers into portfolios they are not familiar with. The weak system leads to lawyers being appointed ministers or commissioners of different ministries; other than the ministry of justice. If you are not experienced as a commissioner or minister, people in the ministry will mislead you. The civil servants are always there, irrespective of whoever is appointed commissioner or minister. All you have to do is to have an idea of what you need to do and then issue the directives. You can see the difference when Mobolaji Johnson, a lady, was the Minister for Communications and what we saw recently in Buhari’s first tenure. That’s her area: she was already doing that before she was appointed minister. Her ideas and understanding of ICT were totally different, because she was an expert and an insider. It is not as if people appointed recently are not intelligent: they have to take time to learn and understand the intricacies in that sector and then listen to the advisers. Even when I was minister, I knew when someone was advising me wrongly. I have been there as a health expert and as an insider, so I have my brain to know when someone is advising me wrongly. Even in education, I am also an insider and I know what to be done for this country to wake up.
Only a few people like Dr Ogbonnia Onu were lucky to be given portfolios in their areas of specialisation. He is an academic, very brilliant, educated with a first class degree and was about becoming an associate professor when he left. He was given science and technology. For a technical engineer who is so brilliant, that is his area and he did very well. So, for a developing country like Nigeria, it is important for technical people to be given appointments in their areas, though they may be politicians. When we have a solid foundation, we can appoint non technical politicians to head ministries and it won’t really matter. For today, I am one of those who believe you should be an insider in any sector you are appointed into.
