Often regarded as the longest-serving Commissioner for Health in Lagos State, Dr. Jide Idris had been a Permanent Secretary in the Lagos State Ministry of Health, before serving back to back in the administrations of Governors Tinubu, Fashola and Ambode, as Commissioner for Health.
Recently appointed as Director General of the Nigeria Centre for Disease Control and Prevention (NCDC), he speaks, in this exclusive interview with Healthnika, on Health Literacy; Health Insurance; Governance in the Health Sector; the need to mentor upcoming health practitioners and President Bola Ahmed Tinubu’s integrative approach to creating executive teams, among others.
EDITOR’S NOTE: This interview took place months before Dr. Jide Idris’ appointment as DG, NCDC.
Healthnika: You are welcome sir. We know your experience during your time in Lagos -the richest, biggest and multicultural state in Nigeria. We saw the way you fought Ebola and saved the whole nation from a big disaster. We know what you did with mobile cancer screening; we remember the ambulances you put on the streets of Lagos; we remember that you first started building the biosafety centre; in fact, you created about 578 Tuberculosis (TB) Centres to screen TB.
Unfortunately, that TB is still our problem, now; health infrastructures, everything…you have put a lot, more than twenty-five years in the public service, working in the field of Health. How did it start, sir? How did you start all these things? Did you come so prepared for all these?
Dr. Jide Idris: One, I was not the one that started it; I participated in the starting…because I came in as Permanent Secretary. There was a Commissioner for Health. There is no way any individual can do all these things on his own. Health is teamwork; in the health sector, nobody is an island. Two, it is good to have a vision of what you want the system to be. It is critical. That’s strategic. This is what we gained from Asiwaju Bola Ahmed Tinubu, when we came in: strategic thinking and long-term planning. When we came in, after about a year, they were calling him ‘Governor Go-slow’. I remember that. People are in a hurry to get things, they are not patient.
Part of that impatience is their lack of understanding of what strategy is. So, you can’t blame them. In the process of strategizing, when they said ‘Go-slow’, he was worried, because they did not understand what was happening. He wanted to do things properly, that would be sustainable. There were things, again, that absolutely reflected goings-on in the society… when he came in, he had mountains of refuse, you understand. We were having dead bodies all over the roads and we had to pick them….developing these things….some of those things, we had to use again, later, in building capacity, to also address bigger things, such as the Ebola containment. So, it requires vision, it requires precision planning.
You may have your vision; it also requires leadership and governance. It requires a good team and that’s why I said nobody is an island. Health is a complex thing, but it is a very necessary social need. It is linked to everything, the economy, development, everything. But you see, this is where our problem is. Many people don’t realize it (and) this is where literacy or illiteracy comes in; this is where education comes in. Health is more than clinical service. Clinical service is just about 20% of the Health Sector. There are other services, if not available, clinical service is a waste of time. Take, for instance, Cancer. The cheapest way is to prevent Cancer. How do you pass this information to people? Even with that information, how can they use the information to better themselves and the society? These are critical issues.
Healthnika: Yeah, talking about critical issues, sir, I remember you had in the past, discussed the health literacy project, in Lagos; how to actually deepen Health Literacy in Lagos; how to really pass information; how people can utilize the information to better their health and make good health decisions. Let us get a bit educated on that health literacy and where it is, now.
Dr. Jide Idris: Literacy issue was mooted, during that period, but it involves other agencies of government, not Health alone; it involves other professionals, not Health, alone. It’s information management and, just like the health worker, unless you are trained in that kind of thing, it can’t be effectively done. It involves changing mindsets. When we are saying emphasize profession, health promotion and all, yeah. These are aspects of it, but the processes of implementing this, if you don’t get the processes right, it’s a governance issue. In hospitals, for instance, if you want to treat patients, it involves clinical protocols; if I’m treating X disease, these are the processes: One, two, three. It’s a culture in many countries. If you are new, they have to teach you their protocols. So, when you start working there, you can’t deviate from that, because that’s what they use as basis to assess their quality of care. It’s a process. These are the things you don’t imbibe here. A lot of people over here don’t even understand what processes are.
Healthnika: So, in essence, health literacy is needed by even the practitioners (such as doctors) and the consumers of health services.
Dr. Jide Idris: How will the people have access to information? How do you increase access by the people, to information? Having created that access, how will the people themselves gather the information? So, improving on that information, again, is multi-disciplinary. It requires different stakeholders. The doctor is involved; the information person is involved, the community people are involved; the social (science) people are involved, (to) look at the social determinants of health. Culture. The culture here is different from the culture over there. So, if you want to pass information over there, you have to understand the determinants of those processes. How you do it in Lagos with one person is not the way you should do it in Niger state.
Healthnika: Still on Health Literacy; looking at the health burden in Nigeria, right now, especially looking at the indices, for instance, the gap between the number of health professionals (such as medical doctors) and the Nigerian population, the gap, if you ask me, is quite wide, based on available data. I think health literacy would help, in terms of what I will call preventative healthcare, where a lot of people already know what is good for their health, what to do and what not to do and whereby a lot of people who already have certain traditional and misconceived impressions ingrained in them, can now change their minds. Now, what kind of health literacy strategy should be put in place to bridge that gap, to reduce the health burden in Nigeria?
Dr. Jide Idris: We need to first understand what health literacy is. I have told you the key things about health literacy. Increase the people’s access to health information. It’s not only increasing the access. Even if you increase the access, how can the people themselves utilize that information? So, it’s beyond that. So, it depends on the kind of population you are talking to. If you are talking to people who are educated, yes, it may be easier. They can get the information through the easiest means of passing information, but they understand what you are saying; but what of the people in the village, people in the rural areas?
How can you pass that information to them? So, you have to find a way of addressing that and no single doctor can do that. Everybody is involved and that’s why, you need to look at one of the pillars of health, which is community engagement. If you don’t involve the community in what you are doing, they will either misunderstand you or misinterpret your intentions. It is when the community understands what you want to do, that they can now conform to what you want them to do. So, it’s a necessity and links to Health Security. What’s Health Security about?
A country should make provisions to promote the health of its citizens, to prevent the occurrence of disease outbreaks, especially in these economic conditions. In a situation where you can’t even prevent and the thing occurs, you now need to determine what it is, then you respond to it. It’s a continuum. The first one is promotion. The second one is prevention -health promotion and disease prevention. Now, have we imbibed this, as a country, as a people? Most of these things, we just say by mouth: lip service. We have a lot of work to do. We have issues, but there is hope, if things can be done properly.
And I go back again: the health sector is teamwork and if you want the team to work, you must have specific governance structures. Somebody has to lead. Luckily, we have good people at that level, now. But everybody is waiting to see. But to lead properly, you must have a structure in place: the governance protocols, policies, legislations, but how to implement these policies requires processes, procedures (decision-making procedures) and it’s at every level, even within the ministry, state, local government (and), even, the facilities. These things must be in place or somebody must be there to ensure that they are in place.
Healthnika: So, now, when one looks at Health Literacy, obviously it appears that even the literacy level in the community is a factor; it appears that non-engagement of the community is a factor.
Dr. Jide Idris: Okay, let’s look at it this way: we keep saying that if you educate a girl-child, you will have educated a nation. How well have we disseminated that information? Or how well has that information been imbibed in different states, different levels of affairs?
I also know that in some states, our culture actually goes against this (educating the girl-child). So, you need to break down these cultural barriers. For instance, our population is huge and you say, look, we have to do family planning. Good. In Lagos, here, they understand family planning. In some other places out there, they don’t like it! This is one of the issues we are contending with –cultural barriers to health literacy.
Healthnika: One would think that the faith-based organisations can also help to deepen healthcare. They have access to funds; they have the command of the people’s minds. How do we incorporate them?
Dr. Jide Idris: But they need to be regulated. Because even with the experience in Lagos, a lot of (ailing) people go to the faith-based institutions, get complications and die (or) it gets to a point where they now refer them to hospitals but by the time they get there, it’s late. That’s the reality. So, there is a role for the faith-based organisations to play, but that role needs to be regulated, because they still don’t know their limitations and, again, you look at the mindset of the people that “if I go to that place, I will be healed.”
People’s decision-making process in seeking health is still faulty. You see, finding solutions to all these issues is why we have think tanks, universities and research institutions, but it should not just be about carrying out research to get your degree. How do you now link that to policy implementation? How do we ‘meet gown with town?”
Healthnika: I like that. How do we meet ‘gown’ with ‘town’? Now, in your close to three decades of working in the health sector of Lagos State and transforming it before you left, in which area can you say, “Listen, I have come, I have seen, I have conquered; these are my impact, according to the vision we developed, collectively, with Asiwaju (Bola Ahmed Tinubu) and other successive governors, in Lagos State, back then?”
Which areas can you really say are impact areas? I am asking this question, because I am still coming to the key area of organizational memory. Let people see clearly that these are the areas of huge improvements; these are the areas of big limitations….
Dr. Jide Idris: I will disappoint you. Things were done, but I can also say that looking back, one of the things Asiwaju (Bola Ahmed Tinubu) wanted was sustainability. That was why he created that system, where successive governments included old functionaries, not just new people, but also seasoned functionaries from the previous administrations, who were part and parcel of policy development in the previous administrations. That system also included bringing in people from the outside (that is, the private sector) who would bring in their own private sector expertise, so that an administration is not starting from scratch, but can grow from previous foundations laid and develop based on those. But there were many things he did that were laudable. But, you see, the question is where are those things now?
Healthnika: Or how far have they been improved upon?
Dr. Jide Idris: In terms of infrastructure, well, they (successive governments in Lagos State) have been building on some, but on the other hand, maybe some of these are collapsing already. And, again, we operated in a different environment, back then. And, mind you, again, politics also has a role to play.
Now, I would say they increased the number of health workers up to a particular point, but again, the economic situation right now has compounded the situation –for instance, look at the Japa syndrome that has led to the rapid depletion of professionals.
Like someone explained, the Japa syndrome is not new. Rather, it’s a continuum. The people from Ekiti and Ondo (states), for instance, are leaving their economies, to come to Lagos, while the people in Lagos are leaving theirs and going elsewhere. So, something has to be done.
Now, in terms of programmes, we had a number of programmes related to health promotion and disease prevention, but how many of them have been continued? So, that’s what I said, that I would disappoint you, a bit. The whole issue still comes down to leadership and governance: the use of people as institutional memory. You can’t do things on your own. You have to use people and people must be ready to work together, to deal with these issues. Without some policies, we created many policies; without some legislations, we created legislations. But, then, all these policies and legislations need to be reviewed periodically, to reflect current realities.
In terms of infrastructure, you can see it. We increased the number of maternal and child health facilities we met; we increased the number of general hospitals we met; we increased the number of PHCs (Primary Health Care Centres) we met; teaching practice was developed –that was the LASU Teaching Hospital (LASUTH); the College of Health Technology was upgraded and the School of Nursing was rebuilt.
In fact, there was a time we were manufacturing basic things, if you remember. We were refurbishing hospital beds. There was a time we were producing prosthetics for disabled people. We started the ambulance services. I still recollect how we started the ambulance services. Apart from the state ambulance services, we made a decision with the local governments to also purchase their own ambulances to work hand in hand with the state government’s. It’s documented. At a particular point after that period, (successive Lagos State) government(s) just refused to fund the health sector. That was where the whole problem started.
Everything is documented. What are the challenges? We all know the challenges. Let’s start addressing the challenges now and to do that, everybody must work together.
Healthnika: We are not doing health audits, and that, for me….I’m wondering, because sometimes, when you do work and you intervene, you do some things, you want to audit –say, like “my activities in this past year, what have they resulted into?”
Dr. Jide Idris: Accountability. That’s an aspect of governance…
Healthnika: Now, what do you see? How is our Health System going, nationwide? We’ve seen that there are challenges with finance, and then, in terms of human resources for health, active pharmaceutical ingredients, etc.
Dr. Jide Idris: We all know the challenges. Everybody. So, I’m tired of talking about challenges. What do we do? Now, with the president, with Renewed Hope, there is hope, but to make that hope a reality requires serious work. There’s a lot of work to be done and it requires everybody’s hand being on deck. Everybody –ministry, state, local government, private sector, public sector, NGOs, education sector, everybody. Everybody must work along one line, not build anything in silos. So, it still boils down to leadership.
Healthnika: At different levels
Dr. Jide Idris: Starting at the federal, state and, if you look at the constitution, we keep on asking, “Where is Health in the constitution?” We will have many answers. It’s not on the exclusive list. Fine. Because the exclusive list is with the federal. But it’s not on the concurrent list, either.
Healthnika: Where is it? Is it at the local (level)?
Dr. Jide Idris: It says if you don’t have exclusive or concurrent, it’s in residual. So, that’s one of the grey areas that needs to be addressed.
I think that the major function of the health sector has to lie with the states and not that the federal will implement everything. No. They need to find a way of the federal working with the sub-nationals, to deal with this thing.
Healthnika: This three-tier system of healthcare that we have been working with for a long time, we seem not to be getting results from it. It appears government wants to talk about its own health system. The involvement of private-led healthcare is still not so deep.
Dr. Jide Idris: I don’t see anything wrong. Government should look at both public and private because we are all stakeholders in the health sector. I know that in Lagos State, for instance, the private sector receives more people than the public sector. On the other hand, in some other states, the public sector receives more people than the private. By the way, many states don’t even have serious private sector presence.
Healthnika: You have been a repository of institutional memory because you were there during policy formulation, implementation, evaluation….you were there all the while. How do you want to pass this information down to successive generations? I know that there is documentation somewhere, but at your own level, what is the heritage you want to leave for the upcoming policy-makers and implementers or for Nigerians?
Dr. Jide Idris: Everything is in that ministry, now and there were people that were left behind, but, again, I will take responsibility for certain things.
Healthnika: So, how are you…..What role are you playing now? You’ve risen beyond the state…. I am talking about the fact that your collective knowledge has gone beyond the state. How are you now dispensing that knowledge to us?
Dr. Jide Idris: You have to be careful in this environment because people might misinterpret your intentions, because in this environment, some people feel you have spent so long a time and they will tell you “What else do you want? Go and sit down”. It’s a common thing. So things like that actually prevent some of us from talking or looking. There are people who still come to ask for advice or recommendations. if you come, I will be forthcoming; if you invite me, today, I will be happy. And if you seek audience and they embrace you, it’s fantastic! But you can’t force…..In a normal society, people will fuse new knowledge with some continuity. This can even be seen in the university system, where retired or old academics are still part and parcel of that environment; they are still stakeholders in that system. So, it’s a leadership issue.
Healthnika: Looking at Health Insurance, sir, in other countries…in the West, it works well. The contexts are different and when the context is different, you need to look at the dynamics that will have a good fit with the context, to make whatever plans you have, to work. In the past few years, health insurance in Nigeria has actually undergone some changes, and it appears the government and other stakeholders are getting more serious about Health Insurance. But again, when you look at it, after much has been done, including policy-making, legislation, the establishment of health insurance firms, agencies and all that, it appears the benefits of health insurance are not yet trickling down to the ordinary citizens in Nigeria.
Again, when we talk about people who live in rural areas, you ask yourself, how many of them know health insurance even exists? How many of them know that there are certain things they can do and when they fall ill, it is easier for them to access healthcare? Those are the assumptions. How do we make health insurance in Nigeria more effective and more accessible?
Dr. Jide Idris: My first answer is this: we have brought or used technical people or expertise from the outside, be it the World Bank, the consulting firms, to put strategies together in solving our challenges. The question is, do their recommendations reflect our realities? That’s the first answer.
Many people don’t even understand what it entails or what healthcare financing is. Health insurance is just one aspect of that financing: mobilization of funds. There are many factors involved in the mobilization of funds. Many of them are political. Many of them are economic. Who mobilizes the funds? How do you pool the funds together? This is where insurance comes in: pooling of funds; pooling the funds together in an efficient way, to purchase health for the people who require health. It’s that pooling (of funds) that we have not gotten right.
Two, even though we have had health insurance law, for how many years now, the earlier laws or policies made health insurance voluntary and that was why we did not make any progress with health insurance well before now. Presently, we have made it mandatory. Yet, we also have issues, which are compounded by economic realities and that is why enrolment has not increased.
Apart from that, the governance structures have not been properly put in place. Right now, you have many people on the poor line that cannot even afford health insurance. And that’s why I say yes, you can say it’s contributory and, yes, people will contribute, but what is contributed is peanuts, compared to what is required.
Although you can increase the volume of people contributing, if you have proper laws and enforce those laws, because we have a huge population. But the bottom line is that government must fund that system, especially for the benefit of the poor.
Do we have the capacity to even manage the process? That’s why the public sector (government health agencies) and the private sector (Health Management Organisations) are having issues! We have to sit down and address these things and when you are addressing them, there should be no sentiments.
Again, there is the need to educate people. How many people understand what health insurance is? You cannot have effective health insurance, if the people don’t believe in it. You have to gain the trust of the people. This is where transparency and accountability come in. If I leave my money, what’s the guarantee that you are going to spend the money properly? That’s a governance problem. It’s not impossible, but it requires serious work.
Healthnika: What’s your big, hairy audacious goal for the health sector?
Dr. Jide Idris: I’m a retired man, though I still have passion for the health system, because it pains me to see things not going right. It’s also our responsibility to see that, at least, we guide people. Of course, we can still contribute to whatever….
Healthnika: Sorry sir, I interrupted you. I would like to ask….since retirement, what have you been doing and what are you currently doing?
Dr. Jide Idris: I am supposed to be consulting, but people are not even paying for the consultation. But what I see here again is that you need to…. I strongly believe that mentoring, especially of the younger ones, is key. This issue of leadership and governance, I believe, should be started right from medical school…. changing the curriculum.
Luckily, some universities are even training residents, now, in leadership and governance. So, I give one or two lectures on this to students at LASUCOM (Lagos State University College of Medicine) and the Lagos University Teaching Hospital. We don’t have a mentoring culture.
So, when the younger ones come up, we need to mentor them, so they don’t imbibe those things that might work against the development of the health sector. We need to pass on the experience to them. Also, I still do some research work.
Healthnika: Thank you for your time, sir. No doubt, the country still needs you.
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Interviewers: Dr. Tuyi Mebawondu and Dele Ogundahunsi
