Building a Solid Health Care System in Nigeria: Challenges and Prospects

The most significant ingredient of life is health. No wonder the oft–spoken slogan: “Health is wealth”, has remained evergreen in our memory. This is why inasmuch as life is the greatest gift of God to man, the provision of health care facilities is needed in superfluity in order that life may be sustained on earth. Unfortunately, in Nigeria today, the provision of health care facilities seems to be at low ebb as many Nigerian are vulnerably exposed to the danger of death. This situation gives the ugly impression that the political office holders appear to be paying lip service to their dauntless statements that health care facilities would be made available at every nook and cranny of the polity. Worried by this perplexing situation, the paper attempts to investigate the decays in the Nigeria’s health system and seeks to proffer ways which the populace can enjoy a healthier and


Introduction
Many countries are striving to keep pace with healthcare delivery because the sustainability and viability of any country's economic and social growth depends on the healthcare sector. This is because a nation of sick people would certainly not live up to its basic responsibilities. A keen look at Nigeria, presents an icky realization that what is required to meet up with this much needed health are either too few or altogether absent. Thus, there are so many untold stories, and statistics abound most painfully too, of mortality amenable to health care which could have been prevented. One wonders then, if Nigeria has any health plan at all.
The management of any health care system if it is to be successful, should be typically directed through a set of policies and plans adopted by the government, private sector business and other groups in areas such as personal health care delivery and financing, pharmaceuticals, health human resources and public health. The Federal government purportedly created the National Health Insurance Scheme in May 1999, but evidence showed that this as only fashioned to suit the government employees. The organized private sector and the informal sectors and probably the general public have no need of it.
In many parts of Nigeria, the afflictive conditions in which people live are enough to induce mental breakdown in many as there are in Nigeria. But as large as Nigeria is, there are but eight regional psychiatric centers and psychiatric departments and medical schools of twelve major Universities. The dire corollary of this is the fierce competition that has arisen between these formal facilities and faith healing centers that lay bold claims to remedy the situation for the mentally sick and others Once again, President Goodluck Jonathan recently lamented over a national challenge that is within his power to correct. Indeed, such lamentation is becoming his trademark. A few weeks ago, he had lamented that politicians were not delivering people-oriented dividends to the electorate. As if his programmes are people-oriented! The lamentation, this time, has to do with medical tourism that he said Nigeria has the highest number of people traveling out for in Africa.
Speaking at a presidential summit on Universal Health Coverage in Abuja, President Jonathan said we have suffered substantial capital flight to this development and that this is unjustifiable. We still have the largest number of people in Africa and the developed world, traveling out of the country to seek health services. The scale of capital flight lost to medical tourism is enormous, not justifiable, and needs to be speedily addressed for the survival and development of our local health practitioners and industry, he said at the event, at which he was represented by Vice President Namadi Sambo (Ejim,2014).
The issue is about primary healthcare which has virtually collapsed in the country. Quite characteristically, the president deluded himself by saying that we have made progress on the matter even though we are not where we should be yet. Unless the progress he was talking about was that made years ago, particularly under Prof. Olikoye Ransome-Kuti as health minister. Primary healthcare, like most facets of our life, collapsed long ago and the evidence is the preference for foreign medical attention by Nigeria's elite who can afford it. They do not have confidence in our medical personnel to handle even basic ailments, from toothache to headache, not to talk of more serious medical conditions. Many of our public officials, including governors-Sullivan Chime of Enugu State and Danbaba Suntail of Taraba State-have had cause to travel out for medical treatment in recent past. The president's wife is not exempted. This is nothing but a vote of no confidence in our medical facilities. But its solution is not beyond President Jonathan. What we expect him to do therefore, is to study the situation with a view to finding lasting solutions to it. What it calls for is action, not lamentation. This paper seeks to identify the indices of the Nigerian dying health system and suggest ways of building a solid healthcare system in Nigeria.

Conceptual Definitions: Health and Healthcare System
The World Health Organization (WHO) defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." This definition, no doubt, is bedeviled by concerted criticisms based on the use of the phrase "complete physical, mental, and social well-being." Some critics contend that no person could be in the state of "complete" health in the strict sense of the word. They argue that health is a matter of one's ability to adjust to one's condition. What it implies is that when an individual is not able to adjust to one's condition, that individual suffers from ill-health. Consequently, this adjustment is a matter of urgency and should be regular. This is because "achieving and maintaining health is an ongoing process, shaped by both the evolution of health care knowledge and practices, as well as personal strategies and organized interventions for staying healthy." Health may also be defined as "a state whereby one is not perturbed by either physical, or spiritual (mental) illness, or by injury of any kind." The underlying supposition of this definition is that man is a composite being with two complementing aspects-body and soul-either or both of which may be affected by ill-health. That is why as we talk about physical health, we should not lose sight of the fact that mental health is a necessity without which man's life will be atrophied. E can see why the WHO defines health as "a state of complete physical, mental and social well-being." Health has, therefore, to do with a person's well-being so long as he is alive, for a dead man cannot be said to be healthy. In order that the Nigeria population achieves its well-being in all its ramifications, certain health care facilities must be put in place.
As a matter of fact, we cannot talk meaningfully without addressing our minds to the health care and health care facilities. What then is health care? Health care is the provision of suitable environment which is aimed at the promotion and development of man's full potentials. It is simply "the identification of the health needs and problems of the people, and promoting them with the requisite medical care." Health care facilities are those basic equipment, stock of drugs, vaccines, portable water, constant supply of energy (power), medical record tools, ambulances for mobility of patients, solar freezers, availability of qualified health officers and medical personnel, etc., which make it possible for the improvement of the patients' healthy living. Health care facilities also include "hospitals, clinics, dental offices, out-patient surgery centres, birthing centres and nursing homes." In considering these facilities, it should be noted that the environment is an important factor influencing the health states of individuals. Here, we may mention three categories of environment, viz, natural, built and social environment. It is in the context of this environment that we consider the determinants of health. These determinants of health, like clean water and air, adequate housing and safe communities, good roads etc., contribute to good health, and as such, they are rightly to be include among health care facilities.

The Indices of Nigeria's Dying Health System
The health sector in Nigeria is in comatose. It is the reason why people who ought not to die often do so. Joel Dappa, publisher of Nigeria Today is still leaving with the scary memory of the poor medical attention at National Orthopaedic Hospital, Igbobi, Lagos that nearly cost him his life. He was rushed there when he sustained a fracture on his left leg from an accident. On getting to the hospital, it took an hour before he could be admitted. He nearly died. Dappa painted a sordid picture of facilities at the hospital to Newswatch Magazine (see Musau,2010). At the hospital, patients on admission buy everything namely syringes, drugs and hand gloves for the nurses, disinfectant, detergent and even bulbs for the wards. The same scenario of dearth of facilities and decay is replicated in many public hospitals across the country and even in the four designated specialist hospitals like the National Hospital that were supposed to be centres of excellence.
The health sector in Nigeria is deeply fragmented, with only a small fraction of the healthcare coming from a unified and organized center. The health ministry provides policies and regulations meant guide the implementation of healthcare, but this is mostly bureaucratic posturing that gets lost as you drill down to the core of healthcare practices in the country. Private hospitals provide at least 70 per cent of the healthcare in the country, with the rest coming from federal, state, local government, and even, community-funded health institutions.
Lack of basic amenities in the rural areas where majority of Nigerians are living has driven some to the urban areas. Probably deluded by this migration, the government ended up situating many of her infrastructures in the urban areas. this resulted in a spatial inequality with regard to situating health care facilities, thus abandoning a vast majority ho must still live in these rural places with little or no medical presence. Consider that the Federal ministry of health usually spends about 70% of its budget in urban areas where only a shabby 30% of the population resides, what an existential irony.
What is worrisome is that a lot of money has over the years been pumped into these teaching hospitals yet not much is there for Nigerians to rejoice about in their health care services. The absence of modern facilities in many public hospitals is linked to failure of successive governments to pay adequate attention to the health sector.
The federal allocation for the health sector is laughable in a country with no infrastructure to carry the most basic necessities such as steady power for hospital equipment (where available), good roads to transport patients to and from the hospitals, emergency medial service and personnel (if you dial 911, you're on your own), or even water for proper sanitation. The wards in some of the hospitals are so run down and bare they look like they would be sources for new outbreaks of diseases. To worsen the situation, allocation of funds never makes it through intact as the greedy leaders meant to utilize it for the welfare of the people pare it down to a small fraction of its original size.
Inadequate and obsolete equipment in Nigerian hospitals had over the years contributed to the exodus of Nigerian doctors and other health personnel abroad in search of better opportunities. Indeed, poor healthcare services in the country have contributed to increase in mortality rate in the country. This is basically why doctors, nurses, and healthcare workers in these institutions are paid a mere pittance not commensurate with the high level of stress and daily exposure to the diseases in the high level of stress and daily exposure to the diseases in the health centers. Some of them do not get paid for months at a time, when they are the frontline workers in the healthcare system as it is in Nigeria today. The suffering is real, a trip to LUTH, or any of such healthcare centers ill sober even the most jaded person. The queues are long, the equipment outdated, the facilities understaffed, the necessary medication is often lacking, and most of the patients cannot even afford the drugs or treatment.
The migration of health care personnel to other countries in search of greener pastures has produced a medical brain drain across Nigeria. Were it not so, why would a staggering 2,392 Nigerian doctors be practicing in the United states alone and 1,529 in the UK in 2005? And only recently precisely in 2010 another research showed that the figure has risen to over 5000 doctors in the United States, nurses of course not included. The crux here is that there seems to be no end in view. And unless our government determines and arrests factors responsible for this migration, she cannot hope to stem this tide, which has currently translated to a national emergency (Ejim,2014).
Statistics of health indices from international agencies point to the fact that at 50, Nigeria is still far from achieving the minimum required health standard. A recent World Health Organisation, WHO (2009), report shows that one million Nigerian children die at birth out of the nine million infant deaths recorded globally.
The most disturbing part of Nigerian health policy is the culture of government sponsoring public officials abroad for treatment instead of making provision for adequate health care for Nigerians. For many Nigerians, these acts have continued to expose the lack of commitment and sincerity of government towards tackling the issue of healthcare delivery in the country.
Saying that the Nigerian health sector is in shambles is tantamount to saying the sky is up above. This is the unadulterated truth, fact, reality, right-in-your-face, that Nigerians have to contend with, in addition to the other litany of inconveniences. Despite having some of the very best healthcare professionals in the world, the lack of development of the public healthcare system has eroded the little confidence the general population have in the Nigerian healthcare system. Even the leaders who ought to lead by example are most guilty of this lack of faith the in the Nigerian healthcare system, which is why they excel at flying themselves and their cronies to other countries with highly developed healthcare systems at the slightest sign of any health issues.
Why won't the average Nigerian follow suit? Those who can afford it go to industrialized eastern countries to get treatment for health problems, while those with smaller pockets go to places like India, with cheaper healthcare. It is very shameful that Nigerians have to go to India for procedures like kidney transplants, when we have some of the best and brightest physicians in the world. It is a matter of fact to report that Nigerian physicians are some of the best in the country. Yet, the same physicians would be seriously hampered and handicapped in Nigeria due to the lack of basic framework and infrastructure to support a sustainable and meaningful health sector.
According to the President of Nigeria Medical Association between 2012/2013, Nigeria lost more than $800 million on medical tourism. It can even be higher now. The NMA president told the TELL Magazine that his figures were derived from extrapolations from figures made available to him by foreign embassies in Nigeria adding that the country does not have official records of how much it loses to medical tourism (Adebayo, 2014:21).
Victor Ukut, a lawyer, is saddened about the poor state of facilities in the hospitals across the country which he described as 'mere consulting rooms". He would want President Jonathan to adopt the health policy of the late Sani Abacha which was premised on the importation of essential drugs for distribution to public hospitals through the Petroleum Task Force, PTF. His reason is that if the policy is revisited by the incoming government, it would go a long away in solving the problem of inadequate drugs which is the bane of many public hospitals in Nigeria. (Ejim,2014) Nigerians would want President Jonathan's administration to address the issue of facilities in the public hospitals. They also want him to revive the teaching hospitals so that they serve their primary purposes of being centres of excellence. Ukut said it was pertinent that the federal government stopped the culture of public office holders traveling abroad for medical check ups, at government expenses. He argued that if public officials realise that there is embargo on medical trips abroad, they would look inward to improve facilities in the hospitals in Nigeria.
The welfare package of doctors and other medical personnel's has been a burning issue in recent years. Early this year, public hospitals were paralysed due to strikes by medical doctors over poor welfare packages. Tokunbo Ola, a medical doctor, argued that doctors in Nigeria are the lowest paid. So, he would want President Jonathan to address the issue of doctors' pay by implementing a universal doctor's salary scale in order to avert frequent strikes by them. Doctors in Lagos had paralysed health services in public hospitals for over three months over the issue of new salaries.
It is axiomatic to posit that healthcare system in Nigeria began to deteriorate in the 1980s when our medical experts and other medical personnel left the country in droves in search of the proverbial greener pasture abroad. That was when our hospitals were no better than glorified consulting rooms. Two reasons accounted for this exodus; one was lack of tools for the doctors to work and second, we could not match the mouthwatering offers being made to them abroad, including countries like Saudi Arabia. Since there was no job satisfaction, it was only a matter of time for use to lose many of our consultants in the health sector to the countries where their services were better appreciated.
Successive governments have tinkered with some health policies in the past. For instance, Primary Health care was the cornerstone of the Ibrahim Babangida regime's health policy. Many Nigerians would want President Jonathan to pay more attention to primary health care which has almost gone into extinction. The present sad situation of the health sector in Nigeria, taking references from World Health Organization, United Nations Development Programme, the National Bureau of Statistics, National Population Commission and the Demographic Health Survey, can be further gleaned from these highlights: • • The under-five mortality rate is presently put at 157 children per thousand, meaning that 1 out of 6 children born die before their fifth birthday-half of this number actually involve those less than one year old. • Another points of interest have are the health indices that concern the adult female population, which is equally noted to be among the very worst in the world. • On the average, some 800 per 10,000 women die in Nigeria every year due to pregnancy related causes. In some regions, the figure is actually more than twice the quoted average. • Three quarters of all material deaths occur during delivery and the immediate post-partum period (Akinrogunde, 2011:1, 4). From the aforementioned, it is stating the obvious to point out that the prevailing picture of the health sector in Nigeria looks rather gloomy and very challenging. Unfortunately, these outcomes which jobs are continuously being lost and most families lacking the where withal to feed let alone handle personal and family health needs (Eme, 2008).
According to Yusuf, all intent and purpose, the figure is very realistic because you have all the factors contributing to mortality of human beings at early life still very rampant in Nigeria. Expatiating, he says: Deaths from preventable and non-preventable diseases are still very high, as well as deaths from accidents, and chronic illnesses like cancers. Look at maternal and infant mortality for instance, we are now the ors tint he entire world. I am quick to always remind people that the best way to assess the level of healthcare in Nigeria is to go to your towns and villages and look at the surroundings and see whether you ill find any healthcare facility. You hardly find any there.
Though Yusuf admits that people still live up to 90 years, but they are rather few. As much as he will like to admit that there are people who survive up to 90 years in Nigeria, but it is like living by chance. Anybody who is seriously sick in this country is doomed because our facilities quite unfortunately cannot take care of very serious illnesses. This is why you really cannot stop those who can afford treatment abroad to travel out of the country.
From the above explanations, we can posit that when the people are seriously sick, they die. And when the actuary officers collating these statistics visit such places, they do not find hospitals. And when they interview people in the neighourhood who report loss of their relations to either childbirths, deaths of children, or adults to road traffic accidents and what have you, they report 100 percent mortality in those areas at the long run.
Yusuf is particularly pained to admit that the nation's healthcare pines under the yoke of poverty occasioned by dearth of equipment under funding, inadequate personnel, lack of a legal framework, among other limitations, a development he says is symptomatic of the general malady in the system. We all have inherited a decadent society. We all have inherited a decadent society. We have allowed our country to slide and we are all at fault. So we all need to come together as one united body called Nigeria and take our destinies in our hands and move Nigeria forward Yusuf (2008) Like Abdul, Dr. Kingsley Kola Akinroye, the Executive Director, Scientific Affairs and Research, the Nigerian Heart foundation (NHF), believes the nation's health sector is in the doldrums, challenged by maladministration, lack of adequate infrastructure, paucity of funds, to mention just a few Yusuf (2008). While admitting the fact that a constellation of factors were responsible for the declining of factors ere responsible for the declining life expectancy of Nigerians, Akinroye cited the changing lifestyles of the people, lack of exercise, smoking habit of Nigerians, with about 4.7 percent rate of tobacco consumption, the highest in the world, among others.
Akinroye, who is the immediate past Vice President of the African Heart Network (AHN), however argues that the major challenge facing the health sector is the problem of human capital. Without mincing words, he says the crop of professionals in the sector is fast depleting, no thanks to hat he described as internal and external brain drain. His words: We are fast losing the number of our highly skilled hands that are suppose to be manning our health institutions. We have no a major problem of more internal brain drain than external brain drain. A lot of our colleagues trained with a lot of money are now finding their way into the fast economic sectors of the country such as oil companies, insurance, banks, communication.
The University of Lagos alumnus, who recalled that in his days it was fashionable for your doctors to desire to serve even in rural, areas persuaded solely by altruistic motives, lamented that nowadays most young doctors only want to work overseas where they are sure of earning salaries in many digits, to the detriment of the health sector. A senior medical practitioner in the Lagos State University Teaching Hospital (LASUTH) with more than two decades who prefers to be anonymous died one major factor leading to the decline of life expectancy rate in Nigeria is owing to socioeconomic factor.
Many people burn out more than what they take in. this means that a lot of people eat little food, small in comparison to the energy they exert out the body based on the nature of the job they do. In the general sense, that is malnutrition. This ought not to be. Your food intake should be more than what you burn out. On the dangers posed by poor dieting, she says "malnutrition leads to immune compromise" this is the state where the immune system of the body becomes weakened. When this happens, the system cannot fight against any disease attacking the body. Since the immune system in the body has been compromises vulnerable to any slightest infection. The end is death. This of course brings the subject of the decline in life expectancy ratio in Nigeria.
As a stop gap measure, she says the consumption of all kinds of junk food such as pastries, snacks should be avoided. All these junk foods accumulate in the body and cause what is known as sedentary: this is a situation here the hormones in the body are less active. The intake of these junks make the body hoard fats which can lead to stroke, paralyses and the end product is death. Eating fast food is not a display of wealth neither does it portrays affluence but it is an effective and perfect way of reducing one's life span, she says.
The harsh realities of economics combined with toil, inadequate nutrition, stress have all added up the average age as stated by the World Health organization which has been pegged to 47. From mere inference, with the poverty level which directly imparts on the living conditions of human beings being at a low, it is perhaps not too surprising. But hat is it really about the figures. Additionally, funding for meeting the earlier targeted Millennium Development Goals continues to drop and the realization of these goals becoming a dream. The World Bank (2008) has warned that the global financial crisis could become "a human and development calamity" for the poor countries urging do not nations to speedy delivery of money they have pledged and consider giving more. The puzzle then is: Where are the funds formerly pledged going to come from in the beehive of the current economic and financial meltdown?
Recently, the Global Find to Fight AIDS, Tuberculosis and Malaria announced that it is facing a $5 billion funding gap through 2010. There also has been an increase in new funding request for eligible nations, the demand being much higher than expected. To meet the demand, more money is needed than what is currently made available. In December 2008, the Global Fund grants were reduced by 10 percent, from $3.1 billion to $2.75 billion, although all program requests were approved. Recipients were asked to achieve the same goal with reduced funding through changes like cuts in overhead costs or funding lower cost options of pharmaceuticals (Akpo, 2009:33).
The fascinating inter-country economic and financial dependence places Nigeria in a very difficult poison as it is not left out in the global economic malady. The Nigerian government expenditure has become grossly affected as a result of recurrent fiscal budget deficits. The resultant poorer prognostic interplay is on health which forms a common denominator among the law, middle and high income earners and the under privileged in the polity. The

Health Implications and Challenges
In 1978, there were efforts to use health as the rout to socioeconomic development but this was followed almost immediately by fuel crisis, soaring oil prices, and the debt crisis of the early in 1980s. Mistakes were made in the international response to these crises when budgets were shifted away from investments in the social sectors, most especially health. The legacy of these errors is still being suffered by Nigeria today. History is about to repeat itself. The Nigerian economic climate and accompanying unemployment is likely to push more and more people into the poverty rolls. In the midst of all the crisis issues is often that people do not have access to health and even if they do, solutions to ailments are far fetched due to poor health sector funding from budget cuts. What is done in other sectors does not matter because one medical emergency, like the Avian flu recrudescence, can immediately destabilize not only family but a nation at large. Different things are needed by different families whether such families are lo, middle or upper income families. The bottom line to their needs is healthcare. With already established links between income, employment and good health, the loss of coverage heightens the possibility of grave consequences for Nigerians' health. Nigerians are changing their health behaviour as a result of economic stress. A rising percentage of Nigerians are failing to obtain needed health care and cutting back on prescribed medications. Job cuts are also tied to higher levels of anxiety, stress and depression as well as greater risk of death from suicide and heart disease. As household budgets are stretched tighter, many families are forced to make unfortunate cutbacks which could mean buying less expensive, often less nutritional foods and having trouble paying for household energy need which can result in poor health outcomes especially for the children. These effects do not occur right at once but we will start seeing the consequences if the economic crunch persists. Many of such health consequences will likely be the result of cutbacks in community health services, essential staff and funding coupled with the strain of attempting to meet increasing demands. The recession is totally destabilizing the safety net and health care providers are no longer able to meet the explosive growth in demand for health care from patients especially the less privileged. Patients are now presenting with more complex and expensive medical conditions, and specialists who regularly opened their doors to patients in need are no longer accepting referrals due to non-payment of medical bills. The implications include the underlisted:

Constitutional Impediments
The Nigerian Health System though has its inherent complexities and is unnecessarily cumbersome. For example, the prevailing system has outlined in the 1999 Constitution place health on the concurrent list, meaning that all tiers of government have a defined role / responsibility to play at providing for the health needs of the populace. Generally, it is noted that the primary level of health care delivery is taken as the responsibility of local councils; the secondary level of care is noted as the responsibility of the state governments while the federal government is in change of the tertiary level of health came delivery.
Of course, for multifarious reasons, the outlined responsibility above have a lot of intermingles with respect to who is in charge at certain levels of health care provision. For example, a number of state governments have their own tertiary health institutions like teaching hospitals, while the federal government itself has created a number of institutional intervention agencies to come in at the primary level of health care. It is however, disappointing that such tertiary levels institution within the primary purer of the federal government such as the teaching and specialist hospitals and centers are not truly centers of excellence as a number of them are far from in reality.
In Nigeria today, even the "expertise" is said to be available in respect of these so called centers of excellence are lacking in tools that make them truly worthy of being referred to as tertiary health institutions (see Adebayo, 2014).
On this, one ask that of what relevance is a tertiary health institution that is lacking in modern diagnostic tools like the CT scans and MRI gadgets among others. Consider the case of john Nwofia, a Nigerian psychiatrist living in Nashville, United States, US, whose younger brother was diagnosed with acute liver disease and perthyroidism in America in 2010. before then, Nwofia said he and other family members had tried unsuccessfully to get a diagnosis in Nigeria. Narrating his experience to an online health magazine, Nwofia said; My younger brother was diagnosed with acute liver disease and hyperthyroidism. We spent hundreds of thousands of naira doing one test after the other. My very good friend and colleague, Dr. Ezekiel Ogunleye, thoracic surgeon at LUTH (Lagos University Teaching Hospital), took charge of it. Every test he ordered had to be done at three different sites, including abdominal ultrasound and other laboratory tests. He explained that, "this is because he could not trust one laboratory and had to depend on two out of three laboratory and had to depend on two out of three laboratory results being close for him to use it. We got a CT scan but it was from an outdated 8-slice machine that was not sensitive enough. In the end we needed a test called a MRCP but we could not find a place in Lagos to get it done. The other option was for a procedure called ERCP but no gastroenterologist we knew of in Lagos could perform it. The other option was to open him up surgically in his almost moribund state to look for a cause, which by then we were worried it could be a tumour. We knew that his chances of making the surgery then were bad due to his state. We then made the difficult decision to fly him to the US. There, we had a 64-slice CT scan and MRCP and both were negative. All he had was an acute liver injury due to a commonly used anti-malarial. He responded well to high does of steroid and is now back home. He would have definitely died in Nigeria (Adebayo, 2014: 16).

Brain Drain
While it is conceded that the salary and welfare packages of the federal government employed health practitioners have improved considerably when matched with their counterpart in other sectors elsewhere, thanks to the doggedness of their agitations for improved emoluments, this alone will not avert the collateral trend towards brain drain outside the country of the appropriate tools to function effectively are not put in place.

Slow Implementation of NHIS
Another area of health care challenge is the role the NHIS plays . . . The National Health Insurance scheme which has been in place per enactment for more than 12 years now. To date, less than 5% of the populace had been keyed into the scheme, and that percentage comprise mostly federal government employees; very few state employees and organized private sector employees have signed on. The rest of the populace are not involved and there are no signs in view that there will be a radical change soon. Even the Presidency /MDGs office's NHIS free medicare programme initiated two years ago for pregnant women and under five children in some local council in 12 states is already faltering due to paucity of found. For the health insurance scheme, this balance sheet scream failure and not a crawling success as the operators of the scheme and the profiteers from it went the populace to believe.

Corruption
While the agitation for more funds is very sign relevant, many also posited that even when conceded that very little get appropriated to health sector than understand by desired, the budgetary allocation for this sector hardly get to the target layers envisaged during budget implementation. Most of these funds get embezzled by corrupt officials and their collaborating suppliers and contractors (see Ndenle Grang & Igbo)

Discussion of Findings
A number of points flow from the preceding presentations. The first is that prior to the global economic crisis, allocation to healthcare as a share of the national income in Nigeria fell far below the 2001 Abuja Declaration by African countries to commit 15 per cent of their national budget to health sector. Between 2002 and 2008, the sectoral allocation to health had oscillated between 3 and 6 per cent with the high point being in 2002, just immediately after the Abuja declaration. The crisis nonetheless resulted in a reduction in the sectoral allocation to health in relation to 2008 (the 2008 allocation was done before the crisis became pronounced). While it could be argued that the percentage drop in the allocation to the health sector in the 2009 budget is marginal in relation to 2008, it is to be noted that the drop broke a trend of upward movement that began in 2004 after a low in 2003. Also, given the contraction in the national GDP in the same period, the drop is more significant in real terms than the statistics show.
The second point to note from the above presentation is the diminution in the GDP of most countries in the African zone following the crisis. This brings into relief the dilemma of these countries in a global system in which they are utterly dependent on the 'prosperity from abroad' and are therefore highly vulnerable to the dynamics and the contradictions inherent in the global capitalist system. But even more telling is the World Bank projection that a decline in GDP of one or more points increases average infant mortality by 7.4 per 1000 births for girls and to 1.5 per 1000 births for boys (The World Bank cited in Adekanye et al, 2009:7).
The third point to note is that the global economic crisis appears to have impacted more on the HIV/AIDS subsector than any other social sector with global resource mobilization for the pandemic being in serious jeopardy. This is due, in large measure, to the dependence of countries of the SSA on external funding to combat the pandemic.
The fourth point is that contrary to the general expectation that the crisis would result in a drastic reduction in the quantum of Official Development assistance (ODA) from the world's industrialized and developed nations to the less developed nations, there was in fact a marginal increase in the volume of such assistance in 2009 compared to 2008. Ordinarily, this would have constituted a piece of cheering news by for certain implications that flow from it. One such implication is the contrast between the stability in the ODA flow from developed nations and the instability in the domestic revenue source of the recipient nations. It immediately raises concern over, for instance, how the leadership of these recipient countries, particularly in the African region would have hoped to carry on with the business of service provisioning had the global crisis persisted and the ODA eventually fizzled out? What safety nets are in place for the citizens of these nations to access in the event of a recurrence of such crisis?
Of more serious concern though is the implication of aid dependence for the recipient countries. The point here is that the primary responsibility for service provisioning in any country lies with the government of such country. Or put differently, it is the responsibility of such government to ensure that such basis services are provided. When such government fails in the discharge of this basic responsibility, or increasingly depends on other countries, or even multilateral agencies, to discharge this basic responsibility, the legitimacy of such a government is often called to question and, over time, the sovereignty of such a state is gradually under-mind and eventually eroded. Hence, the categorization of some countries as 'ungoverned territories'.
Environmentally, many citizens are yet to realize the health benefits of clean environments. The rate of both traffic and human congestion in our other big cities cry to the stake holders for immediate action. Environmental and noise pollution and general lack of sensitivity towards nature stares government in the face and the consequences of these or to show apathy. One insensitivities are always fatal. Just between March and June 2010, a series of lead poisoning in Zamfara state, Nigeria, led to the death of at least 163 people including 111 children.
The ongoing can only prove that the system has gone down, this house has indeed fallen, things have fallen apart. The worst demeanor to be put up by anyone concerned in this situation is to delay or to show apathy.

The way forward
Healthcare system in Nigeria began to deteriorate in the 1980s when our medical experts and other medical personnel left the country in droves in search of the proverbial greener pasture abroad. that was when our hospitals were no better than glorified consulting rooms. Two reasons accounted for this exodus; one was lack of tools for the doctors to work and second, we could not match the mouthwatering offers being made to them abroad, including countries like Saudi Arabia. Since there was no job satisfaction, it was only a matter of time for use to lose many of our consultants in the health sector to the countries where their services were better appreciated.
If therefore President Jonathan is sufficiently worried about the resources we are losing to these other counties as result of what is now referred to as medial tourism, he should do something about the appalling condition of our hospitals and give primary healthcare the attention it deserves. It is not enough to mouth transformation; it should be like a wind that cannot but be noticed whenever it blows. Our hospitals need to be upgraded, with state-of-the-art facilities provided; we should motivate our doctors and other workers in the health sector not only to retain those still in the country but also to make those who have left start to fell nostalgic.
From available statistics, many of our doctors out there are doing quite fine, which shows that the problem is not with them but with the environment. It lies within President Jonathan's power to make that environment attractive. This is far better than merely lamenting the situation.
The government in partnership with the citizenry must rise up to the current challenges facing the health sector. Failure to do so is an easy access to a disastrous consequence in the future.

Conclusion
Good public health is vital in any country, not only for the purpose of maintaining a healthy populace, but also as a matter of national security. A healthy country is a wealthy country, with a thriving human resource the country can invest in to move the nation to greater heights.
Saying that the Nigerian health sector is in shambles is tantamount to saying the sky is up above. This is the unadulterated truth, fact, reality, right-in-your-face, that Nigerians have to contend with, in addition to the other litany of inconveniences. Despite having some of the very best healthcare professionals in the world, the lack of development of the public healthcare system has eroded the little confidence the general population have in the Nigerian healthcare system. Even the leaders who ought to lead by example are most guilty of this lack of faith the in the Nigerian healthcare system, which is why they excel at flying themselves and their cronies to other countries with highly developed healthcare systems at the slightest sign of any health issues. This is basically why doctors, nurses, and healthcare workers in these institutions are paid a mere pittance not commensurate with the high level of stress and daily exposure to the diseases in the high level of stress and daily exposure to the diseases in the health centers. Some of them do not get paid for months at a time, when they are the frontline workers in the healthcare system as it is in Nigeria today. The suffering is real, a trip to LUTH, or any of such healthcare centers ill sober even the most jaded person. The queues are long, the equipment outdated, the facilities understaffed, the necessary medication is often lacking, and most of the patients cannot even afford the drugs or treatment.
Remote areas and rural communities are almost relegated to the background and have to fend for themselves. Some of these areas are not even connected to the national grid, and so have no power whatsoever. The federal government has no say in how states utilize their allocations, and cannot mandate them to spend a certain amount on healthcare, making it difficult to gauge the effectiveness of any campaign for improvement on a cohesive nation-wide level.
Also, the lack of medical intelligence nullifies any effort to identify sectors with disease outbreaks in a timely manner, to contain and treat incidences of infectious disease outbreaks, and reduce the frequent occurrence of such in the country. The manner of drug supply is also cause for concern. Most of the pharmacies in the country are not regulated, and even the tomato seller could also sell medication like pain killers, multivitamins, tetracycline, antibiotics and so on. A complete overhauling of the healthcare sector is long overdue and will help alleviate the suffering of the masses.