Looking more broadly at health services, it is immediately obvious that the majority of Nigerians obtain healthcare from the private sector-be it the roadside chemist or the fancy ten storey private hospital. Improving health services therefore must include restructuring the regulatory framework within which private providers of health provide care. There should be minimum standards for the opening of a health facility and these standards must be clearly communicated to the public so that they can make their own judgements. If members of the public know which banks to put their money in and which bus companies or airlines to use, they also have a right to know what standards they can demand from their healthcare providers. Chemists should be given minimal basic health training to recognize symptoms that they can manage and those beyond their capacity, which they need to refer. They can be issued licences which are regularly reviewed and which must be displayed in their shops. Public awareness campaigns should be carried out enjoining members of the public to demand evidence that their chemist has undergone the training.
Similar schemes should also apply to clinics and hospitals. If it is no longer acceptable for any group of people to set up a bank in Nigeria, why is it still acceptable for any post registration medical doctor to set up a clinic on his own? Is it not time yet for some minimum standards? These can be different for urban and rural areas, allowing for lower start-up resources in rural areas. Ministries of health must ramp up their inspectorate and approval services and carefully consider applications to open new private clinics. Perhaps restrictions should be introduced as to where new establishments are located- why for instance should there be a clustering of ten private hospitals or clinics in one street alone when many people in other areas lack access? By limiting the number, doctors and other healthcare workers will be forced to spread care to where it is most needed. We acknowledge that there are complex challenges in getting more doctors to practice in the rural areas. There are however several options in providing the incentives to do this, as is being done in South Africa at the moment. However, none of these can be tried if we have no information on what the distribution of health care personnel is at present, stressing again the need for data.
Looking at the public sector, a lot of focus has been on increasing or improving buildings and facilities in government clinics and hospitals. Emphasis needs to shift from the numbers of buildings required to the quality of care delivered within the buildings. We suggest that most Nigerians will prefer going to a public sector hospital if they will not have to spend the whole day waiting to get a card, waiting to be seen by a doctor who might or might not turn up, waiting for tests, waiting at the pharmacy only for the customary ticks with a red pen on the items that are available, while the rest have to be purchased outside. Why is it no longer okay to take a sleeping mat to the bank, but still okay to take a mattress to the hospital? One possible solution would be for public hospitals to provide a high standard private wing services to draw in patients who would otherwise have gone to the private sector. The income from these patients can help subsidize care for others. Introducing minimum service standards should also be considered- for instance a target that all patients are seen within two hours could be introduced and communicated to the public. The media and the public can then monitor which institutions are meeting these targets, and hold the politicians accountable. These politicians will then put pressure on the hospitals, which would then lead to more efficient services for patients.
Another important area for consideration should be the question of medical education and specialist training. Is the current curriculum fit for purpose? Should it be reviewed to make sure that the doctors we produce are the doctors we really need? Have changes in the prevalence of diseases and the roles of doctors been reflected in their training? How much managerial training are provided for medical doctors who suddenly find themselves appointed as Chief Medical Officers (effectively CEOs) of large teaching hospitals with budgets running into billions of naira and staff strengths of close to a thousand in some instances. How have the Medical and Dental Council of Nigeria, the Nigerian Medical Association, and the Nigerian Universities Commission worked together in preserving the quality of medical training in the ever-increasing Nigerian universities?
A more aggressive approach towards cases of clinical negligence should be combined with provision of opportunities for continuing professional development. The legal profession, the courts and the media also have a role to play in ensuring that patients are not short-changed. Doctors and other healthcare workers need to be held accountable and these institutions must do this. This can only be realistically achieved if the role of the Medical and Dental Council of Nigeria is strengthened. Self-regulation should be preserved as the first line of enquiry. The Medical and Dental Council of Nigeria has a major role to play in ensuring that standards are maintained in the private and public sector.
To achieve all this, 3 issues are key:
1. Leadership. To implement the issues raised requires a visionary committed team that understands the issues and is passionately committed to change. That this has happened in other sectors of the economy is not in doubt. It is time that this approach was brought to the Nigerian health system. Sometimes it does take a single, motivated and skilled individual at the steering wheel.
2. Money. It will require money, lots of it! In many parts of the country, there has been an absolute collapse of the health care infrastructure and anything other than an emergency injection of funds immediately will not be helpful. While there is a need for an absolute increase, innovative funding mechanisms (such as the NHIS) need to be further explored and nurtured to maturity. With political stability, we believe that the investments will keep flowing into profit-oriented sectors of the economy. This is not necessarily the case for sectors such as health and education where financial returns cannot be the primary motive, yet these areas are imperative for national development.
3. You. When next your neighbour dies from measles, during child birth or even in a car accident, rather than conclude it is all as “God wanted it”, we should spare a few minutes to think and maybe act on the failings in the system, the missed chance at vaccination, the inadequate antenatal care or the non-existent emergency services that might have prevented these deaths. The only alternative would be to conclude that God really has a problem with us Nigerians; why else would he let so many of us die from causes no one else is dying from?
The way forward:
-The new government should urgently put a process together to identify 10 health priorities: (e.g. Childhood immunisation, Maternal care, Access to emergency services, Prevention and care of HIV&AIDS, Environmental sanitation, etc)
-These priorities should be in the public domain. It is the people who elect (or for that matter, don’t bother to elect or indeed challenge) people in office. In many countries, elections are won and lost on health issues. Just as we demand for electricity, good roads etc, we have a right to basic minimum level of health and health care and must learn to ask for this.
-These priorities should all be data driven. No matter how rudimentary, we need to set up, resource and sustain an information management system for health and healthcare management data. This is the only way of measuring progress.
-As a matter of urgency, we need to assess, map and categorise existing health infrastructure and personnel and set up a mechanism to track and manage these over time.
-The entire health system is in dire need of bold, innovative strategic management.
These are ambitious pointers. We do not expect immediate success. Positive change is often painful and will face resistance and often resentment. There might be strikes, and people might die. But it cannot be business as usual. Our health is our greatest asset. Without good health, little else is possible. With a clear agenda, good leadership, a good implementation plan, and a good team with the requisite health and managerial skills these can be achieved.They start might be slow, some will stumble, then over a year or two, there will hopefully be significant improvement.
Ike Anya wrote this piece on behalf of the Nigerian Public Health Network; a network of over 100 Nigerian Public health professionals around the world.