Manifestations of Rivalry in Healthcare Sector in Nigeria and Solutions

Being the full text of a paper I delivered at the National Executive Council Meeting of the National Association of Resident Doctors in Katsina on Wednesday 4th of July 2018.

Let me begin by heartily appreciating the National Association of Resident Doctors of Nigeria for inviting me to be part of this august meeting. I am delighted to share this moment with you, bringing warm greetings from Lagos. In two simple words, I say thank you.

The residency programme for medical doctors in Nigeria, as we are well aware, developed its embryo as early as 1966. Thanks to Dr. J.O. Mabayoje who saw far enough to pursue the deliberate insemination of that idea into the broader topic of redirecting Nigeria’s developmental aspirations in line with the quest for national self-determination.

Today, Nigeria’s healthcare system has significantly evolved and the topic for which I stand here is one of such issues that require a clear approach to resolve. Once resolved, it should hopefully constitute a major landmark in the development of healthcare delivery in the country.

In dealing with Manifestations of Rivalry in the Healthcare Sector, a few questions come to mind, namely:

1. What are these manifestations of rivalry?

2. What are the causes (both human and material)

3. And, lastly, what are the solutions?

None of these questions can be swept under the carpet when a well-meaning resolution is the intention of any intervention, but in order to proceed properly with today’s assignment, I suppose it will only be proper to spell out a number of underlying concepts.

First is to understand what the outlook of a Healthcare system is. One definition holds that it “consists of all organisations, people from different disciplines and actions whose primary intent is to promote, restore or maintain health.” The simple, basic objective, derivable from our definition is fast taking the back seat in the light of the erosion of the binding tissues of unity and purpose-driven service delivery. The direct consequence of this challenge then are the innocent patients and by extension the rest of the recipients in the delivery of health services.

Second, I would like to draw attention to a 2010 intervention by the World Health Organisation regarding inter-professional collaboration. In its own words, inter-professional collaboration is a situation where: “Multiple health workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality of care”. This is essentially a situation where Health care professionals assume complementary roles and cooperatively working together, sharing responsibility for problem solving and making decisions to formulate and carry out plans for patient care.”

From the picture painted above, it can be understood that healthcare delivery is not the exclusive preserve of a single profession within the healthcare system. Second, it can also be said that a single-minded, mutually beneficial co-operation among all professionals in the sector is also not an option, if the system is going to optimize its potential. In short, the rivalry we see in Nigeria’s healthcare sector is an anomaly by every standard.

Sadly, however, it would appear that recent developments within the nation’s healthcare system have thrown light on a professional dichotomy between doctors and the non-medical practitioners. To the external observer, this could have passed for a family affair. But not so at this point. The rivalry is real and has festered like a sore, so badly that the whole nation has been forced to perceive its stench.

In reality, I may add that the mutual disaffection between these crucial providers of health services was in fact (and perhaps remains) deeper than the headlines and the TV screens portrayed.

Determined to make their statement clear, the Joint Health Sector Union, the umbrella body of all non-medical workers in the country embarked on an industrial action which lingered for 44 days before it was suspended on Friday, June 1, 2018. From papers available to me, a 15-point demand containing issues raised with the federal government as far back as 2009 was at issue. We may consider them here:

1. Internship: Immediate release of the harmonized scheme of service and circular on internship for nurses and midwives.

2. CONHESS salary review: Government agreed to the request of JOHESU to adjust CONHESS salary structure upward. The need for recomputed cost implications of the salary adjustment was taken into consideration.

3. Skipping of CONHESS 10: Immediate and full payment of arrears of salaries of CONHESS 10 skipping outstanding.

4. Payment of promotion arrears: Both parties agreed that payment of promotion arrears should be carried out.

5. Same scale promotion/re-designation: FMOH was directed to write a circular to all institutions to abolish further promoting people without advancement.

6. Employment: It was agreed that government should prioritise employment in the critical professional areas. Since government regularly employed resident doctors, other core professionals should be employed to boost human resources development for health.

7. Enhanced entry point: This was initially requested for radiographers and medical lab scientists based on enabling circular from the head of service. The agreement is that this should be done holistically to accommodate all other graduates of other health care professionals.

8. Appointment of CMD/MD: It was agreed that the Federal government will henceforth do advertisements in the appointments of head of health institutions in accordance with the law that establishes the health institutions without prejudice to any particular profession.

9. Heads of department: It was decided that universities of teaching hospitals cannot be separated from their teaching hospitals. The FMoH was directed to always accommodate the necessity of change in policy and guidelines as no policy should be seen as sacrosanct.

10. Specialist Allowance: The FMoH is to enlarge the three-man committee that is considering the eligibility for specialist allowance to accommodate two members of JOHESU.

11. Board appointment to Institutions: The final approval is being awaited from the President while FMoH should put more pressure to ensure board appointment.

12. PPP: If Public Private Partnership is inevitable it must not be any measure to impoverish Nigerians and send workers out of the job. All stakeholders must be mobilized and involved in planning and execution of the program.

13. Anti-corruption struggle at FMC Owerri: Those that are being punished as a result of strike action at FMC Owerri to be promoted to level up with their counterparts. The Federal Ministries of Health and Labour agreed to take up the issue of withheld salary to be discussed and settled internally.

14. Retirement age from 60-65: It was agreed that retirement should be adjusted as done for their counterpart in the Education Sector

15. Additional Demands: Need to urgently set up a collective bargaining agreement committee to look at the following allowances for JOHESU members, such as hardship allowance, administrative allowance, professional allowance, excess work load allowance, health and safety site allowance.

Both in tacit and expressed forms, these demands are borne out of a feeling of marginalization. And it may be fair to state, without taking sides, that a number of items contained in these demands carry some tone of genuineness and deserve urgent redress.

The persistence of the present reality, which mostly border on what JOHESU considers lopsidedness in the enjoyment of benefits in favour of medical doctors, is the bane of the rivalry.

Unfortunately, since Nigeria’s management culture does not particularly reflect global best practices in almost very sector, it becomes even more imperative why diligent attention ought to be paid to the issues in focus.

I must, without hesitation, commend medical doctors for the maturity with which they conducted themselves in the course of the 2-month long strike by JOHESU.

The federal government must realie that addressing the issue of rivalry is not just a matter of JOHESU vs. the NMA. That may not be the real issue at the end of the day. Rather, it is a sure credible path to reversing the nation’s appalling standing in healthcare.

Nigeria’s 187th position out of 191 health systems of countries ranked by the World Health Organization means the country’s healthcare system is only better than those of three countries: the Democratic Republic of the Congo, Central African Republic and Myanmar. While neighboring countries such as Ghana, Togo, Niger, Mali and Chad ranked better than Nigeria by taking the 135, 152, 170, 163 and 178 spots respectively, this report card reads like a document which, were it possible, should be hidden and never be allowed to see the light of day again. But not so. Such a response would turn a mere injury into a deadly sore. And since the government would primarily rely on the human resource component of healthcare delivery as primary drivers to improve the sector, it follows in my thinking that the human capacity component of the Nigerian health sector should be given a relevant degree of attention to urgently address what is by all counts not just a national emergency but also an embarrassment.

Health they say is wealth, thus the impact of a stable health care sector in Nigeria and Africa cannot be overemphasised.

Nigeria has a population of more than 180 million people. Infant mortality rate is estimated at 201 in every 1,000 live births. In 2015, maternal mortality rate in Nigeria was estimated at 800 deaths to 100,000 live births.

The health indicators for Nigeria are among the worst in the world. Nigeria shoulders 10% of the global disease burden and the country is making slow progress towards achieving the 2015 targets for the health-related SDGs. The Nigerian health sector is also facing major human resources crisis with maladistribution of the available workforce, and the increasing “brain drain” resulting in shortage of critically needed health professionals. The health sector recognizes that human resources for health are critical in the provision of quality health care. To address the current crisis, efforts are being made to re-position the public health sector to work in close collaboration with the private sector, development partners and all stakeholders to mobilise resources to develop and retain capable and motivated health workers. The Federal Ministry of Health developed a comprehensive National Human Resources for Health Policy in consultation with all the key stakeholders. A National Human Resources for Health Strategic Plan (2008-2012) was developed to operationalize the Policy. The strategies and activities in the Plan provide a framework to guide and direct interventions, investments and decision-making in the planning, management and development of human resources for health at the federal, state, LGA and institutional levels. The HRH strategic plan acknowledges the importance of stakeholder involvement in its implementation.

Itemised below are 10 challenges the sector is faced with and possible solutions.

1. Poor Funding

One of the major challenges of healthcare financing is unfair and unsustainable financing practice in healthcare services. Beyond the level of spending, the percentages of out-of-pocket expenditure or health insurance payment is very pivotal to the sector. The international best practice in healthcare financing is that whatever model of health financing that a country adopts should not prevent its citizens from accessing healthcare services. To a large extent, the implication of this international best practice is that out-of-pocket payment at the point of service delivery will have to be reduced to the barest minimum or be dependent on the ability of the patient to make such out-of-pocket payment. The preferred healthcare financing model should protect people from huge financial expenditure when they fall sick and also encourage healthcare providers to offer an effective mix of preventive and curative health care services. The high out-of-pocket expenditure on health care services in Nigeria is worrisome. This has gone a long way to further pauperise the poor masses. A survey conducted on the living standard of Nigerians indicates that out-of-pocket payment for health care services accounts for a significant percentage of household expenditure. Expenditure on outpatient care, transport to health facilities and cost of medication contributes a significant share of household expenditure in Nigeria

2. Lack of government interest

Most times the Nigeria government only get interested in what gives them lots of profit. When the government does not support or help in developing the healthcare system, it is definitely doomed to fail. The government should invest more in the health sector and give out loans to partnering organizations.

3. Dearth of medical doctors

It is not rare anymore to find a Nigerian always willing and ready to leave the country if the opportunity were presented. More than 40,000 of the 75,000 registered Nigerian doctors are practising abroad while 70 per cent in the country are thinking of taking jobs outside the country.

If new hospitals can be built, the existing ones taken proper care of, more medical equipment is supplied, a favourable atmosphere for doctors to work in, most Nigerian doctors would be happy to stay. Many Nigerian hospitals are responsible for needless deaths that could have been prevented immediately.

Nigeria is a great nation and is supposed to set standards for other countries to follow. We still have a long way to go concerning development and tackling health issues should be a nation’s top priority.

4. Lack of motivation of the health workers

This boils down to underpayment. When workers are not being paid enough for their service, they lose interest. This could even lead to a bigger problem as they may treat patients without courtesy.

They may fail to show up at work on time or even at all and may fail to treat patients in the best possible way. Doctors are life savers, if their lives cannot be saved, who will save ours? Their wages should not be something to joke with, they should be paid on time

5. Corruption within the NHIS

Even if corruption seems to be the order of the day for almost all the government sectors, the health of every citizen should not be something to take lightly. Mr Yusuf Usman”; the executive secretary of the NHIS said the NHIS as an institution had paid so much money to the HMOs from 2005 but that there was nothing to show for the expenditure. Fortunately, he has launched a campaign to get rid of the scheme of corruption, inefficiency and impunity.

6. Employment: In many public hospitals in Nigeria the patients’ health workers ratio is very poor many of the health professionals are over stretched thus there are reports of near death cases, because of the volume of work the health workers do on a daily basis.

7. Dilapidated structures and facilities

The current state of public and some private hospitals in the country is worrisome; also most of the equipment in the hospital facilities are outdated

8. Lack of access to health facilities

There are still many states in the country were access to health care facilities is a big problem. It’s one major reason we have one of the highest maternal and child mortality rate. Disease such has Lassa fever, malaria typhoid polio and more are still killer disease in the country. Bad roads to these hospitals still remain a challenge.

9. Misplaced priorities

Most hospitals are usually more focused on treating an illness rather than preventing it. Preventing diseases or illness or injury is the most least cost effective way to improve health, thus there is a need for enlightenment to encourage regular medical checkup.

10. Inadequate public enlightenment

Despite the corruption in the National Health Insurance Scheme (NHIS), health insurance still plays a vital role in any country’s healthcare development.

Nigerians who have heard of NHIS do not have a general knowledge of what it means or what it stands for. They hear insurance and quickly back out because they automatically assume it is something that is going to cost a lot. A very comprehensive explanation should be given to the public, the kind of explanation that has just one definition to everyone.

Of all the challenges stated above the issue of corruption in the National Health Insurance scheme and lack of motivation for health workers is a big concern because if Nigerians can key into the Insurance scheme health care will be more affordable for Nigerians.

There is also a need for harmony between health workers and the Nigerian medical doctors; this is necessary following the just-suspended health workers’ strike which was suspended after workers downed tools for more than two months to press home their demands. Their demands are yet to be met till date, while health workers are yet to receive April and May salaries due to the ‘no work, no pay’ introduced by the government during the strike. With this, one can guess there might be another strike

Possible solutions

I call it possible solutions because I believe in Nigeria and I know that we have all it takes to excel in every sphere of life.

1) Employ capable Health Care Practitioners

Hiring the suitable staff for appropriate work is the best way to make your organization serve the purpose for which it was set up. Therefore, employing highly qualified personnel to work in the public and private sectors of Nigeria’s health care industry will make it more useful and well managed.

2) Medical Insurance Coverage

Health care is a serious matter so introducing reforms, will ensure that government provides medical insurance for all public service employees, and pass a law making it compulsory for private organizations to give their employees medical insurance cover too.

3) Provide Incentives to Health Care Workers

Giving incentives to health care workers will motivate them to work harder, increase their passion to give their best and enables them to keep improving.

The following incentives can inspire them and create a motivating environment; special salary package, give them mortgage loans, leave bonus, overseas travel, car loans, improvement of off-hour duty pay, and then move staff around different departments and units to improve competence. The government should also yield to the demands of the Joint health sector union to prevent another round of strike which of course will be detrimental to the masses.

4) Provide Promotion Based on Merit

If you base staff promotions of public and private service on merit, it will make them very loyal and their morale would be at its highest peak. If this happens, health care delivery will experience a great boost.

5) ICT-Driven Operations

The waiting time between when a patient arrives in our public hospitals to when they are treated is unacceptable. If our hospitals are computerized, inputting, and retrieving patient details will be faster. If the hospitals are computerised, this will make public hospitals more efficient and help them treat more patients with less time. When this happens, both the patients and the doctors gain. This will be a major way to improve health care delivery.

6) Employ support staff

Employing support staff to add to the number of doctors and nurses is necessary if you wish to see smooth flow of work and service to the public.

7) Training Support Staff

Training more medical support staff is vital if the hospitals desire to run smoothly. Support staff should undergo training every year to infuse the tenets of the job in them and instill discipline amongst them.

8) Inspire a Sense of Ownership of the Hospital

If you hope to improve health care delivery, then you must instill the whole staff with a sense of ownership of the hospital, equipment, and property. Proper handling and maintenance of the few outdated equipment in the hospitals are necessary if you want them to operate at their best possible capacity.

9) Respect for Human Dignity

Hospital staffs are human beings so their propensity to misbehave is not in doubt. For proper handling of patients, it will be nice to give them training geared towards value for fellow human beings.

10) Strict Supervision of the Health Sector

The Federal Ministry of Health must be on its toes to supervise the sector properly. They must ensure all hospitals meet international best practice and standards.

Grade hospitals from good to great to determine the best and give awards to recognize them and to spur others to measure up. This has a way of improving health care delivery in the country.

11) Sanction

The axe must fall on erring hospitals that fall below set standards either by withdrawal of operating license, or payment of stipulated punitive fines to keep every practitioner in check.

Secondly, you must sack and prosecute all the quack medical doctors and health workers to prevent future occurrence.

Medical association and hospital management boards should be further empowered to discipline any Doctor, who commits a minor offence such as lateness to work etc.

12) Maintain High Standards

Our medical schools must observe strict standards to ensure doctors; nurses and other medical workers, pass the required exams before allowing them to practice.

There must be continuous training to keep them current with the latest procedures on a yearly basis.

13) More Private Hospitals

Government must make sure appropriate bodies check thoroughly before approving requests to set up hospitals. Continuous supervision of these hospitals must continue even after they begin operations.

14) Fund the Health Sector and Federal Universities

Making money available to Federal Universities and special grants for the Faculties of Medicine and Health Institutions will help them produce excellent doctors, nurses, and health workers. If the schools have requisite funding, brilliant doctors and support medical staff, will become the norm in the health sector and this will improve health care services throughout the country.

15) Provide Modern Equipment

It is a fact that most of our public health care facilities have outdated health equipment. This is a sorry situation, which must change if we wish to improve health care delivery in Nigeria.

We lose patients to simple medical procedures, due to lack of modern equipment.

Civil society, the Press, and concerned citizens must speak out to persuade government to replace old equipment in public hospitals to save more lives.

16) Sponsor New Health Insurance Bill

Civil Society groups should organize citizens to approach members of the house of Assembly, to pass a new health insurance act that makes it compulsory for both government and private employers, to create a new health insurance scheme for employees.

Both the staff and employer will have to contribute in a ratio of 30:70 percent to fund the program.

17) Health Maintenance Organizations (HMO)

The introduction of Health Maintenance Organizations (HMO,) has brought some innovations into the health care sector.

HMOs register employees into the scheme in the offices where they work. An Individual can register too provided they can pay the fixed monthly premium.

18) Improve Medical Curriculum

Improving the curriculum in our universities and health Institutions to include up to date subjects, will lead to the graduation of skilled doctors to run our hospitals, and this will improve health care delivery in Nigeria.

19) Replace Obsolete Laws

The legislature must pass new laws to improve health care delivery in our public and private hospitals. Outdated rules must give way to modern ones.

20) Make Some Public Hospitals Centres of Excellence

If private and public hospitals are to be better than they are presently, we must select some of our public hospitals, and upgrade them to centres of excellence, where the staff, equipment, and buildings can compare easily with the best hospitals abroad.

If we implement this policy, it will improve health care delivery.

21) Money for Health Ministry

In the 2018 budget 340.4 billion naira was allocated to the health care sector which is just 3.9 percent of the country’s budget. If the government wants significant change or progress in the health care sector making money available for use of the health ministry and monitoring the careful use of grants will help to improve health care delivery in Nigeria.

If you use the funds properly, this will ensure that there is medicine and constant power supply in hospitals and reduce the death rate of pregnant women and children in our hospitals.

Secondly, hospitals and health centers nationwide will have up to date equipment to save more lives.

22) Reduce Preventable Deaths

Government must intensify enlightenment campaigns through the Public Enlightenment Unit of the Federal Ministry of Health.

For example, informing people to keep their neighbourhoods clean and source of water free from contamination will reduce preventable deaths from diseases such as Malaria, Cholera, and Lassa fever.

23) Providing Money for Research

Terminal diseases such as breast and prostate cancer are difficult to manage in Nigeria. Government can provide money for our universities to conduct research to find a cure for these diseases.

Finding a cure here will not only improve the health care delivery in Nigeria, but also lift the country’s image amongst the global community.

Conclusion

As pointed out to me by a doctor in a tell-all revelation while I worked on this paper, some of the points used in defence of doctors maybe more personal in nature than otherwise. I opt to quote him here at once:

“When last was our lab results well reported by pathologists? Why should we not show our superiority by laying exemplary leadership through innovative thinking and research?.” Why don’t we award PhD in addition to fellowship as it is done in some clime, and yet deride BSc nurses who have double qualifications after finishing their Graduate course… Why would those who had done PhD insist others too must go through the same path…? …Why would pathologists be sharing call duty and call duty food with Lab Scientists only for the latter to now turn against the former? If you ask me… Where is mentoring or healthcare business management in our curriculum?…Why do consultants belittle residents as if they are not humans?… Why do consultants see MOs as good for nothing? And why do GPs see Consultants as rivals and try to pull them down in our General Hospitals? What is wrong with us? Why would those in headship of our tertiary institutions deride ARD that they were once part of? Why should ARD see MDCAN as evil? Why the rancor? Why the bickering? Why is there so much tumults among us in the Hippocratic brotherhood? Why can’t we be united? We allowed all these abnormality that is gradually becoming normal…. and we are losing our prestige…and our chickens are returning home to roost… Perhaps JOHESU’s inordinate ambitions should be a wakeup call for us all to sort ourselves out and put our house in order!!! If we don’t… This medical profession will soon become a shadow of itself.

Well, every day while I analyse issues on Journalists Hangout and try to contribute my own quota to the country, I realise through messages on social media and calls received during the programme that Nigerians want more and deserve more.

If we refuse to address the current challenges the health care sector is faced with, and proffer lasting solutions. Nigerians will continue to be medical tourists.

We must elevate the status of healthcare delivery to an essential service so that we can turn it into a service we can all be proud of, because it concerns all of us.

Babajide Kolade-Otitoju,

Head of News

TVC

Source

Wikipedia, Global health workforce alliance, National Health Insurance Scheme, Google,

Newspaper clippings, TVCN