Health workers should be removed from general salary system – Senator (Dr.) Ibrahim Oloriegbe
In this exclusive interview with Health Insurance Today Magazine, Senator Dr. Ibrahim Oloriegbe, Chairman, Senate Committee on Health for the Ninth Senate shares his mind on critical issues in the health sector, the nation at large and his personal achievement during this four-year tenure in the senate.
HITM: Congratulation sir on the successful completion of your tenure as Chairman Senate Committee on Health. How will you describe the journey so far?
Senator Oloriegbe: Well, so far so good. I give gratitude to God for his favour and the privilege I have to be elected as a senator representing Kwara Central to serve this country in the last four years. The little I will say is the much I have been able to do particularly in the health sector and generally to the country in the various roles I played while in the Senate.
HITM: Indeed, it has been quite an impactful tenure that you had particularly relating to the health sector and also beyond. So in your own opinion, what were the major challenges facing our healthcare system and how has your committee helped in addressing those challenges?
Senator Oloriegbe: Well, the Nigerian health sector faces challenges in virtually every pillar of the health system. Health-financing is one of it where we do not have adequate resources allocated to health, from the budget perspective. We have high level of out-of-pocket expenditure (about 70%), which means many people pay for healthcare at the point-of-service. They have to get the money themselves because there is no prepaid system. That is why we have come up with the new National Health Insurance Authority Act to be able to address the gap in financing. So one of the key reforms in that Act is to make health insurance mandatory for all residents in Nigeria. By this, it means that everybody living in the country, when the law is fully implemented, must have basic minimum package of health insurance. If you say that, the question will be does everybody have money? The answer is no because the proportion of people that are in paid formal employment are fewer than even those that are in the informal sector and then we have those that are the vulnerable groups.
So because we have identified the vulnerable groups, the law also now provides for vulnerable groups fund which is estimated that about 83 million people of our population are vulnerable. They are vulnerable because they are not able to pay and then the government has to pay their premium. So, this is to address that. But of course we have challenges in terms of service delivery, infrastructural deficits, lack of equipment, and so on. On this wise, in the last four years, through the various projects, we have been able to make some infrastructural additions but we are not yet there.
Of course, we have a major issue in the health human resource, with a lot of Nigerians, particularly the clinical staff (doctors and nurses), leaving the country. This is also called brain drain or what we call the japa syndrome. Now, it is a major affliction of the sector because it is a double jeopardy. We are not producing enough and the little we are producing, majority of them are leaving the country. This is one we have not been able to solve. But it is an ongoing process because the solution is beyond the health sector. It is not all within the health sector. For instance, when you talk about salary, the health sector cannot unilaterally fix salary for itself. Health sector salary is within the global civil or public service salary system. One of the things we are advocating, because of the critical nature of health workers, is to remove them from the global salary system and let them have enhanced remuneration for them to stay back in the country.
We also have the issue of working environment which is internal to health and external to health. Working environment will include providing health workers with appropriate equipment and infrastructure to work. That is within the health sector and will require allocating more resources for health. But the external environment includes insecurity, which is a general problem in the country. Health workers, because they are elites, leave because of insecurity where they work. This means the government has to address the issue of insecurity. Working environment again includes the families of health workers. Are their children able to go to good schools? Do they have water? Do they have access to other social amenities? These are things that make people to leave but addressing them is something that is an ongoing process. It will require allocating more money to the sector.
The current budget, maximally, we have achieved only about five to six percent when the Abuja Declaration of 2001 (by African Heads of State) says 15% of the national budget should be for health. Until when we get that resolved, of course, we have to go on. In terms of service delivery, there are issues of linkages between the primary, secondary and tertiary health care. That is the referral system. It is weak, particularly as 80% of our health problems are primary health care based. Primary health care service is allocated to the local government. The local government does not have the capacity to solve it and the state has to make some inputs. Same with secondary health care where many states, or let me say generally at sub-national level of the country, are not meeting up their responsibility. Everybody looks up to the federal government.
You see that we have teaching hospitals and federal medical centres across the country addressing issues that are not tertiary in nature. They address issues that are more of primary and secondary levels because of inadequate functionality at those levels. These are some of the challenges that besiege the sector and which we are trying to address.
HITM: As a follow-up to that sir, you had once recommended remuneration equilibrium as a way to discourage migration. During your tenure, did you make any proposal to the government on this and if you did, would you want to let us into it?
Senator Oloriegbe: No, no, we did not make any proposal specifically. It is a general thing. It is a discussion. We did not say “equilibrium”. If you say proposal, of recent, we talked about the enhancement of CONMESS (consolidated medical service salary scheme) which is the medical salary scale and of course the CONHESS (consolidated health service salary scheme) which is for the other health workers. But as I said, mostly what happens is that if you have to do that, it is within the context of the general salary system because Salary and Wages Commission will say that there is a limit to what the people can earn. We have made the proposal to government but it has not been approved.
What we said sometimes ago was that within the system in the country, the NNPC, NIMASA and some other agencies of government have specialised salary for their people. But because these agencies are classified as Government-owned Enterprise (GOE), they are not part of the core civil servant salary. We want health workers to be in that situation as well. But the government will have a problem with that because they may say what happens to other people? Teachers will also ask for it. Other people too will ask for special salary.
HITM: Still talking about the issue of funding, I am glad that you refer to the Abuja Declaration of 2001 when African heads of state came together to say nations of Africa should allocate minimum 15% of their total annual budget to healthcare. We know that we have not done much as we have hovered around four to five percent in the last few years or so. So what efforts are in place, especially by the National Assembly, to ensure that going forward we improve on budgetary allocation to health?
Senator Oloriegbe: The allocation system in Nigeria is not solely within the national assembly purview. The budget, which we call the money bill, is the only bill that you cannot initiate from the National Assembly. It must be initiated by the executive arm because they know the quantum of funds they have and money is allocated based on their policy priorities. The allocation system in Nigeria is what we call the “envelope system”. Although the National Assembly has the “power of the purse” as they say, because we do budget, but it is always within the envelope. This is because there is always a discussion with the executive arm and they say this is what we give priority and allocation.
The challenge we have had, however, is that we do make case for extra allocations where there is a negotiation between our committee and that of appropriation. Unfortunately, we have had very little success because in the past four years, as one that has been here, security has been a major problem. Majority of the money of the government goes to address security. In fact, we do have supplementary budgets almost every year to address specific security problem. Just like I said earlier about the brain drain and human resource, if there is no security, you cannot do any other thing. This has been the challenge. But despite that, I must say, within the last four years; one of the things we achieved is additional budgetary allocation to health. One is the Basic Health Care Provision Fund.
When we came on board, it was under capital budget. That made it discretionary. But we have been able to move it to statutory allocation. This means it is now 100% disbursed. One percent of Consolidated Revenue Fund of the Federal Government goes for that. That has added more money to health in an indirect way. During COVID-19 pandemic, we were able to get additional resources in the health budgets for years 2020 and 2021. It was beyond the envelope system but a special allocation. This helped to put more infrastructures in place. We were able to develop a lot. All our teaching hospitals in the country now have at least three facilities – isolation centre, molecular laboratory and intensive care unit (ICU). These were not there before. This was as a result of extra money that came into health. There are also grants and loans which government seeks. If all these are captured, they all increase the amount of money available to health sector.
HITM: Typically from what we see, these funds, sizeable as they may be, we realise that a chunk of it goes to recurrent expenditure, not so much to capital. You have alluded to some capital expenditure that the government had undertaken particularly around the COVID period. Are there ways by which the National Assembly works with the Executive to ensure that we allocate more fund to capital projects across the health sector where we can see more impact?
Senator Oloriegbe: Two things I want to say here. One is that the amount of money health gets for capital is a proportion of the total capital expenditure allocations in the entire budget. Two is that the recurrent expenditure, particularly as far as health is concerned, is critical because if you look at health budget, I think it is only probably education that has more recurrent than health because of salaries of health workers. Despite that, we say funding is not enough. It is huge money. For example, in this last budget, about N400 billion is for payment of salary. And the overheads part of it is because of the number of institutions under health. Though it may look small but if you add it together it becomes a substantial amount.
The two factors that are “fighting” are, one, the total amount of money available for capital expenditure generally will determine what is available to capital expenditure for health. Two, when you come to health, the recurrent is critical because whatever infrastructure and so on you put in place, you need human being to operate it. What we are doing in the National Assembly is that when the budget comes, we negotiate with the appropriation committee and with some of our colleagues to pull other resources from other sections into health for some projects. Those projects will now add more to transform our health sector.
Having said that, I think in the last two years or even if not within the last four years, I am aware that there are some special interventions. Example is the Nigeria Sovereign Wealth Fund which is doing special interventions across the country. Part of the special interventions include building mega diagnostic centres. They are doing this investment in all the six geo-political zones including building of specialised cancer treatment centre. This is increasing infrastructure and they are also doing this for some of the hospitals using that fund. These are extra ways of getting more resources for infrastructure into the sector.
HITM: We have a new government now in place, government of President Bola Ahmed Tinubu. What will be your suggestion to this new government in the health sector?
Senator Oloriegbe: The new government campaigned on certain manifesto which contains what it wants to do on health. Those are the things I think it should do. They include increase of budgetary allocation to health to 10% in the immediate and to 15% over the next four years. Also it wants to improve infrastructure generally as well as putting 50 million Nigerians on health insurance. These are part of the commitments in the manifesto of the government. It should address the issue of brain drain through improved remuneration. It should provide enabling environment for health workers including provision of car and housing loan.
These commitments are in the Renewed Hope manifesto. There is also the issue of Nigeria’s preparedness for health security and pandemics. So what I will say is that the new government should implement what is contained in its manifesto.
HITM: Of course you were instrumental to the enactment of the NHIA law. Give us a background, what were the shortcomings of the old law? Why this new law and how much of the shortcomings has this new law addressed?
Senator Oloriegbe: Well one of the major issues with the old law was that it was just a scheme that was more tailored to and focused on the formal sector employee, particularly government employees. It did not address health insurance directly in the country. Secondly, it did not make health insurance mandatory. It was voluntary. That is why we have not been able to scale-up our coverage.
That has been addressed. Thirdly, now that it is mandatory, you have to address the issue of people that are not able to pay premium. That is why we created the vulnerable group fund in the new law. The other one is capturing the sub-national level, i.e. the state health insurance. We saw there was no legal framework that connects the federal and state institutions together.
Of course, the state health insurance came about because of the Basic Health Care Provision Fund but there was no legal framework. The new law has now defined the role of NHIA and the relationship between the States in terms of regulation and so on. But there is still an issue, which is still in debate. That is, based on historical experience, NHIA engaging in both regulation and implementation. This indicates that it is not strictly a regulatory body as it is regulating the system and also implementing the Federal Government formal sector. People felt that it should not play that dual role.
So except you want to create another agency, which is not part of the recommendation, to say, remove the implementation part (Federal Government scheme) and give to another agency, say Federal Civil Service HMO so that NHIA will remain purely regulatory and regulate all the players in the sector. That is it.
HITM: The last four years have been quite impactful for you and you are bowing out in glorious and glowing colours. What are your reflections in your role and achievements? Are there things you would rather do differently?
Senator Oloriegbe: As a human being, you learn lessons. But I think it has been wonderful in the last four years. Perhaps, you are only aware of the NHIA but I sponsored 15 bills; 11 of them were passed by the Senate and four have been signed (assented to) by the president. That is quite unprecedented! One of the ones I am happy about, after the NHIA, is the Mental Health Act. Hitherto, there was no legal framework that looked at mental health. You know health is defined by the WHO as not only absence of disease but complete physical, mental and social well-being. Physical health is what all the other laws are talking about. The social well-being is within what you do in the economy but the mental health, which is a major issue, had no legal framework. I am pleased I sponsored that bill also. It has been signed by the president. Through that bill, a department has now been created in the Federal Ministry of Health. We hope it will be implemented.
Related to the mental health law is one of the bills I sponsored for the establishment of a neuro-psychiatric hospital. When I came on board, we had federal neuro-psychiatric hospitals across the country but there was none in the North Central zone where I come from. None in any of the six states. Now, we are able to establish one in Kwara State. It is fully functional now with all the compliments of staff and infrastructure. It is one of the legacies and I am happy looking back now. Of course, there are several other landmark infrastructures that I took to my constituency over the last four years.
Outside the bills, motions and laws, in terms of constituency outreach, I have quite a number of things that I have been able to do. So when I look back, I think I will still repeat what I have done the same way and maybe do them deeper. Because of the background I came from, I classify my constituency outreaches. I have been able to touch all the sectors, education, health, electricity, water and roads. In terms of education, I supported several schools with building of classrooms, ICT centers, gave scholarship and gave educational materials. In health, it is not only the establishment of the psychiatric hospital.
There is one other hospital that I facilitated. We constructed a comprehensive health centre and I got the federal ministry of health to adopt it as an outstation for University of Ilorin Teaching Hospital as an emergency centre. This is because it was built along the express road linking north and south, around Bode Saadu-Ogbomoso Road. The facility is fully functional now with staff, equipment and so on. Also, I was able to provide functional equipment to about 15 primary health care centres. I held medical outreach every year for about three years consecutively and each year, we cover between 2,500 and 5,000 people that benefited from free care.
HITM: That is wonderful, congratulations! How does Senator Dr. Ibrahim Oloriegbe relax?
Senator Oloriegbe: Well, I read books. I read biographies. I watch television and I go on vacation.
About Post Author
