Healthcare investors generally take a fancy to Nigeria. Africa’s most populous country has a growing middle class and will one day finally put some distance between itself and South Africa as its largest economy. The petrodollars already flow freely into healthcare. But no one has bothered to keep them in the country: not the existing fragmented private sector, nor the government, which has other priorities – President Buhari has been treated in London, after all! So, surely, all that’s left to do is fly in, start a JV with a local partner, consolidate and cut off the medical tourism leak at source?
There are many trying to do just that. Clare Omatseye, CEO of the Healthcare Federation of Nigeria, told us the 1,800 beds in three PPPs currently under construction in Abuja were just the tip of the iceberg. Saudi-German Hospitals want a hub and spoke centred on hospitals in Abuja, Kano and Kaduna. Abraaj, Ciel, Pathcare, Dr Agarwal’s and Lancet – experienced operators and investors that specialise in emerging markets – have also targeted the market. In short, this vision of Nigeria – a solid long-term prospect – has its believers.
Where are we now?
Nigeria is not quite there yet. The existing landscape is characterised by small private hospitals of no more than 100 beds each, often in converted houses, a few high-end tertiary care centres in the commercial capital of Lagos and the odd primary care chain. Regulation is poor – charlatans staff up to 95% of hospital labs claims The Medical Laboratory Science Council of Nigeria (MLSCN). The public sector offers primary care centres and university hospitals, but they lack equipment and staff. Just 4% of the population is insured despite a national health insurance law that’s been around since 1999.
The problem in Nigeria, John Adesioye, CEO of Utopian Consulting, explained to us, is that the lack of primary care overwhelms secondary care. Patients get treated too late and at the secondary care level when a community nurse could have solved the issue earlier. Without prepaid healthcare people tend to wait and a poorly regulated market offers little confidence to the consumer.
The system is also fragmented: primary, secondary and tertiary care nod their caps to different leaders: primary is governed by counties, secondary the regions and tertiary is central government’s responsibility. This creates silos. Adesioye complains it’s difficult to even get community nurses trained by doctors operating in secondary care hospitals.
A landmark health bill was passed in 2014 that aimed to replace dysfunction with effective and universal healthcare: The National Health Act. Legally, it should fund vaccinations, the maintenance of primary care facilities, and staff formation, with half the money directed to the National Health Insurance Scheme (NHIS) to cover vulnerable people, and the rest to primary care. It’s paid for – again, at least according to the law – by 1% of the government’s consolidated annual revenue, which would amount to US$193m in 2016, topped up with donor contributions and local government revenue.
The NHIS’s website is vague about its precise benefits, although the government would ideally like to reduce infant and maternal mortality we hear. That could be because each state is being encouraged to set up its own scheme. “Each state will decide on how to run it and what works best, but everyone will have an NHIS card, there will be some co-payment and freedom of choice of provider,” says Dr Wale Oyebanji, Consultant at Anadach Consulting. He believes the policy is hampered by the lack of data for targeting: they don’t know who are the low earners so they can cover them.
Click the table below to download our spreadsheet of Nigeria’s largest healthcare players.
Where to?
This is the current reality, and an uncertain future arrives through a violent macroeconomic climate antagonised by the Central Bank of Nigeria’s somewhat creative use of economic theory.
It’s possible that the Health Act could revive public primary care, spread access rapidly, tighten regulation creating a competitive market with patients able to choose between public or private facilities and draw foreign investors with medical tourists and expat doctors alongside. Nigeria’s size would force suppliers to open local offices and turn into a healthcare hub within the highly populated West African region. GE and Philips, for example, appear to be betting on this scenario by investing in the country.
Or – the money will not go to healthcare. The poor will not save for healthcare through social health insurance, or through general taxation. Fighting Boko Haram will take political precedence in the face of falling oil revenues. That means patients will probably skip primary care and instead overload the public secondary care system. Foreign investors will change their mind about Nigeria, and the investment in infrastructure needed to attract foreign doctors back will not be forthcoming. So rich Nigerians will keep going to India and South Africa, or eventually Ghana.
Getting to option one means overcoming a number of challenges. There are investors looking at the market as we’ve seen, but private equity wants both big bets and fast returns. Nigeria offers neither. There are few platforms available and building infrastructure, which is sorely needed, takes time. Many sources complained to us of power and water shortages; the solutions can’t just be ordered in. And then there’s a broken foreign exchange market.
“There has been some activity,” a sceptical Adesioye admits. “But, right now, there are huge issues with infrastructure. Many people want to come into the market. But how many people are ready to commit the funds to build a hospital? How many will recruit the personnel?”
Government support and a transfer of risk would help, and in the number of large and ambitious PPPs, that radically alter the state of the country’s tertiary care, it looks to have arrived. Monetary policy is now also more decipherable and that should allow the currency to level out at an attractive bottom, free up foreign exchange markets and, the optimists predict, turn the economy around.
But Obesioye claims the interest rate – 18% per annum – offered by The National Sovereign Investment Authority (NSIA), which is bankrolling the PPPs, is not sustainable. “They forget how much training goes into every aspect of healthcare; it should be funded as a social enterprise.”
The geography of Nigeria is another issue: There are six regions that vary between Muslim and Christian, urban and rural and rich and poor. “You can’t expect the same returns in Gombe as in Lagos,” says Adesioye. “There should be different rules for each region; if they want investment in poorer states they have to take some of the risk.”
Either way, without further reform to the system’s foundations, in the shape of insurance and primary care, the PPPs will struggle to find business. And the early signs are the government will not deliver on its Health Act-promises.
Edwin Ikhuoria, Nigerian representative for the One Campaign NGO which works to end poverty and preventable diseases, told Nigeria Health Watch: “The 2016 budget proposal by the Federal Government seems to move the health sector away from the aspirations of the National Health Act passed in 2014. The intent of the new law was to correct the lopsidedness in the funding of the primary health care system in Nigeria and aimed at providing the bridging funds needed to create a resilient health system. The current proposed health budget does not allow for this impetus to take place.”
Nigeria budgets for healthcare like a miser gives to the poor: it spends far less than the average for sub-Saharan African countries and the 15% of budget funds targeted by the Abuja Declaration. Rwanda is in another league: it grants of 18% of its national budget to health compared to Nigeria’s 6% – and its population with 12 years more of life expectancy than Nigeria feel it. Most of Nigeria’s states do not generate much revenue and can’t make up the gap.
Oyebanji says the 10,000 primary health centres policy has now been reversed; it was a hasty choice that he puts down to inexperience in the new minister. The new more pragmatic approach is to ensure that there is one in each district and to build from there. There is better news on insurance.
Oyebanji tells us Lagos State is going to make its health insurance scheme mandatory. “They are on the verge of that already and once it’s finalised things will kick off.” Cross River State has similar plans we hear. “Lagos state has been busy,” says Awosika. “And as the major metropolitan area, where it leads others follow, so we can hope it’s a sign of things to come.”
The existing insurance market, which competes to participate on the NHIS, is overly competitive, says Awosika, as it fights over the meagre formal sector offering. “There is a lot of potential in PHI, and I would even go so far as to say most insurers are not adventurous enough, but they are stuck in the corporate sector. The opportunities are elsewhere.”
Awosika argues the government should get out of the way and allow the private insurers to take over. “Then we would see phenomenal growth.” Oyebanji believes getting coverage up to 70-80% of the population, and bear in mind the division and tensions that exist within Nigeria, is achievable.
Anywhere but Nigeria
Perhaps the major issue in Nigeria is its leaky border. The best estimates say there are 30,000 doctors in the country. There are 3,000 Nigerian trained doctors in the UK and more than 5,000 in the US. Around half the medical graduates from the college of Medicine at the University of Nigeria are to be found practicing abroad ten years after graduation. Yet Saudi-German says it wants 80% of the workforce at its hospital to be natives.
Odesioye is a member of Nigerian Physicians in America, and he claims the desire to return to Nigeria and positively impact its healthcare system is widespread. What’s stopping them? It used to be taxes: Nigerian expats had to pay back licensing fees for every year they’d been abroad. But now it’s a fixed fee, and the issue has migrated to proving continued educational development, and the quality of facilities. “We think the more hands we can bring to bear the better. But, at least there is finally a diaspora desk at the Ministry to try and streamline these processes.”
Egbe Osifu-Dawodu, founding partner of Anadach, says the desire to positively impact Nigeria amongst expat physicians is widespread, but less want to return. Decreased demand for foreign physicians in the UK – the Health Secretary recently announced a policy to boost the number of native doctors – and the fact it’s becoming harder to specialise should help. But it’s harder to convince Nigerians working in the US, where they are better paid, to return.
The government’s 2016 budget proposal allocated Naira 257bn (US$814m at current rates) for health. So it’s staggering that more than US$3bn, at least according to Omatseye, is spent by Nigerians on healthcare abroad each year.
Alex Alexander, CEO of Ciel which has invested in Hygeia, told us in January why the group is targeting hospitals specifically: “Outpatient centres and health insurance are key to healthcare systems, but only hospitals will prevent patients flying out of the region. The continent also sees too many doctors leaving for career purposes, and we want to develop skills within Africa.”
Both medical tourists and doctors want decent facilities. Patients would always prefer to remain at home close to their families; it is finances and the lack of options that drive them abroad. The falling Naira should also have similar effects to the demise of the rouble, which has kept Russians out of Switzerland. However, Oyebanji has a word of warning: “Definitely, the drop in the exchange rate means a lot of people are looking for alternative measures. But there are often no facilities in Nigeria: for example, we don’t have good quality cancer care so even if you want to stay here you can’t find it.”
Our Analysis: Hospital groups across the world have long profited from Nigeria’s version of the natural resource curse – the paradox that countries with an abundance of natural non renewable resources – like oil – tend to have less economic growth.
But there is no inevitability to this – healthcare services are less amenable to international trade than oil. It was put to us that reversing the flow of doctors and patients depends on private sector investment – the state has a poor reputation with the diaspora. If this is true, should it be a priority for Nigeria?
One might argue the tastes of Nigeria’s rich, seeped in oil wealth, no longer cohere with what is feasible for the general population. And, if so, the government would be wasteful, or worse, to grant the bargain – tax breaks, loans and non-interference – the private sector wants for moving in. Why replace the segregated healthcare system of medical tourism with a domestic one? Is the typical South African, who struggles to access his country’s private healthare system, much better off than the typical citizen of Nigeria, which has none?
The answer is somewhere between a version of trickle down healthcare, where the odd bed is made available to the poor, and the benefits of investment in high-end healthcare to the Nigerian economy and society through follow-on benefits to the wider healthcare system. Hospitals will train doctors who will pass on knowledge to nurses; PPPs may have quotas for affordable patients; private operators may move towards more affordable services. It’s also probably true that should the NHIS take off, capacity will be needed from both the private and public sectors, to avoid overcrowding. However, none of this means Nigeria is wrong for focusing on primary care and asking tough questions of prospective developments.
So far, investments in PPPs aside, state support has not been forthcoming. But Oyebanji has faith: “From the body language of this government, they are ready to work. Within the next three years there will be dramatic change; there are a lot of moving parts in motion.”