Governance of the Health Sector And Enhancement of Productivity
Special Committee on Health. CHS. OOPL, ABEOKUTA.
By Nimi Briggs, University of Port Harcourt.
In the recent past, a few health related events in Nigeria have served as fillip and given the country some cause for a little cheer. The Ebola Virus Disease (EVD) in West Africa, happily now in its twilight, is reported to have killed over 11,000 in Liberia, Sierra Leone and Guinea alone1 aside from the devastation, sorrow, misery and dreadful disruption of human activities that became the lot of those who survived or escaped contracting the disease. Considering Nigeria’s large population (estimated as 170 million) and the propensity of Nigerians for frequent local and international travels, it would have been difficult to phantom the scale of catastrophe and human desolation that would have been the case had this infection of mass destruction been allowed to establish a foothold in the country when the late Patrick Oliver Sawyer imported it on 20 July 2014 from his native Liberia. The First Consultant Medical Centre, Lagos, the Federal Government as well as the Governments of Lagos and Rivers States rightly command the nation’s respect and gratitude for the way they, their employees and agencies rose to the challenges posed by that grave danger at the time. Also on 24 July 2015, Nigeria recorded a one year period without a confirmed fresh case of poliomyelitis infection. This happy event prompted the World Health Organisation to directly declare to the country’s President, Mohammadu Buhari in September 2015, that the transmission of live polio virus in Nigeria has terminated2&, 3. The organisation did so as a prelude to deregistering the country from an ignominious list of global live polio transmitters – a humiliation which Nigeria shared with Pakistan and Afghanistan. Also, Nigeria, like many others, is currently appraising its performance in the 15 years (2000-2015) pursuit of the United Nation’s Millennium Developing Goals (MDGs), including the health related ones even as it signed up for active participation in the next 15 years (2015-2030), in a new set of 17 Sustainable Development Goals (SDGs), again from the UN, designed to transform our world and protect our planet. Nigeria was unable to meet any of the benchmarks set by the world body but the country recorded some improvement in a number of its health indices especially in those of < five mortalities (from 140 to 117 deaths per 1000 live births), maternal mortality ratios (from <1000 deaths to 630 deaths per 100,000 live births), HIV/AIDS prevalence (from 5.2% to 3.4%) as well as malaria infection rates (from 60% to 45% in < 5 children).
However, as welcome as these achievements are, they cannot be interpreted as emanating from a robust national health sector which many agree is largely dysfunctional and characterised by defective governance. Access to public health institutions, where they exist and at all function, is difficult and inequitous. Such institutions are badly administered, poorly funded and bogged down, more often than not, by incessant industrial actions from a multiplicity of Trade Unions that have effectively held the system to ransom leading to poor productivity by staff and loss of confidence by the citizens.
On its part, the private sector provides both orthodox and traditional health care. Although less burdened in the manner of that of the public sector, private health care remains largely unregulated in Nigeria. Thus, the infrastructure, quality of staff, standard of care provided, and user fees in private health institutions differ widely in both orthodox and traditional health care delivery settings. The net effect of these deficits in the public and private health care delivery systems is that Nigeria cannot be said to have really established a properly run, well-integrated and functional health delivery system that satisfactorily addresses the health needs of the generality of its citizens, despite the multiplicity of recommendations and efforts in the past. However, there appears to be some silver lining in the sky. The National Health Bill which was signed into law by Mr. President on 9 December 2014 contains directives through which some of the most pressing issues that have been responsible for the dismal performance of the sector could be addressed. Also the clamour by concerned citizens for the institutionalization of Universal Health Care underpinned by Primary Health Care, to drive the sector, if heeded, could go a long way in ensuring a Health Care Delivery System that should truly serve the needs of all Nigerians in a holistic manner.
This paper will review the health sector governance structure that currently exists in Nigeria, pointing out its weaknesses, including how those weaknesses lead to poor productivity, gross inefficiency, system paralysis and patient dissatisfaction. It will examine aspects of the National Health Bill as well as Universal Health Coverage that could be used to enhance better governance of the system and then make recommendations that will enhance the setting up of health policies, their implementation and the process of holding health workers accountable. Properly implemented, these steps could lead to improved governance of the sector.
Governance structure (see schematic diagram on page 8).
The “National Health Policy and Strategy to Achieve Health for All Nigerians” which was launched in 1988, was the first well-articulated document that defined a comprehensive structure for health care delivery in Nigeria. The document, the health policy it espoused and the structure is wished to put in place, were all designed “to make available to all citizens a level of health that will permit them to lead socially and economically productive lives at the highest possible level through the provision of effective and affordable health services at all levels”. It is this policy which was inspired by the 1978 World Health Community Alma-Ata Declaration of “Health for all by the year 2000” and the structure that emanated from it, that has survived till this day, albeit with some modifications.
In essence, governance is effected through an integrated 3-tier health delivery system of primary, secondary and tertiary care at the local, state and federal levels respectively. Primary Health Care (PHC) is to serve as the bedrock of the system and is to be universally accessible to all individuals and families in the very communities where they live and work. The Local Governments have responsibility for PHC and are to establish Local Government Health Systems that would operate at the village, district and headquarters levels. To strengthen the PHC system, a Primary Heath Care Development Agency is set up to take charge of the overall management of all PHC activities. The states-based Secondary Health Care System is to be run by state Ministries of Health. Operating mainly through General Hospitals, the secondary health care system is to offer curative services in support of PHC. In the same vein, tertiary health care is primarily concerned with the provision of highly specialised services, including the training of health care providers, through teaching hospitals and other tertiary health institutions in support of the primary and secondary care levels. The design of the entire system is such that it should operate as an integrated complex in which patients are referred to higher levels of care as the need arises and a feedback system ensures information flow back on the fate of referred patients.
The responsibility for the operations of these three tiers of health care rests with the Minister of Health, the State Commissioners of Health and the Supervising Councillor for Health at the local governments respectively. These persons are in turn appointed by Mr. President, the Governors of the respective states and the Chairmen of the various local governments. Mr. President also appoints the chief executives and members of boards of tertiary health institutions just as the State Governors do so for the secondary level health institutions and the chairmen of local governments, the supervisory councillors for health.
Despite the good intentions implicit in the described structure, the actual working of the system is far from ideal as governance at all levels is poor. PHC, the bedrock of the system is deficient at the local government levels in many states thereby failing to provide the anticipated broad base at which not just disease prevention and health promotion activities are expected to flourish but also the platform that addresses about 90% of ailments that are reported to the health sector. The governance and supervision that PHC is expected to provide over the village and district health centres is absent in many places let alone the sieving and demarcation of categories of ill patients. Thus, the structure remains almost moribund at the base. Furthermore, the secondary and tertiary institutions are also inadequate, ill equipped and staffed by poorly motivated workers who frequently resort to industrial actions for varieties of reasons. So, there are problems also at those two tiers of care. Referral of patients from a lower to a higher tier is nominal due to absence or inadequacy of needed support – management, means of conveyance, paramedics and equipment. Attendance at health institutions along the three tiers is therefore haphazard instead of hierarchical as envisaged in the original operational structure as patients attend any health care institution of their choice outside the prescription of the system. The net effect of all this is that the institutions virtually work in silos with little inter connectivity. Additionally, both the orthodox and traditional care of the private sector are not integrated into the main stream health care delivery system and little effort is made to ascertain what goes on there. Sadly, available evidence suggest that the private sector – orthodox and traditional – constitutes the initial port of call of many who seek health care in the country.
The National Health Bill, 2014.
Regulation and management, both of which border on governance, are two important issues, among others, which the National Health Bill, 2014 is designed to address among public and private providers of health services. The Bill rests the responsibility for the production of clear policy guidelines for the operations of the National Health System with the Federal Ministry of Health led by the Honorable Minister and through him, the state Commissioners of Health. The Bill provides for a National Council of Health as the highest policy making body to be chaired by the Honorable Minister and in which State Commissioners of Health and others are members. Furthermore, the Bill establishes a number of Committees – Technical Committee, National Tertiary Health Institutions Standard Committee among others, that are to regulate and control structure, staffing, standards of service rendered and enforce adherence to policy and guidelines. The Bill lays emphasis on the coordination of health services rendered by the federal government with those rendered by the States, Local Governments, Wards and private health care providers so as to establish a comprehensive health care system. In doing this, the Bill allows the Federal Ministry of Health, or any state ministry or local government or public health establishment to go into agreement with private practitioners, private health establishments or non-governmental organisation in order to achieve any of the objectives of the Bill.
Universal Health Coverage.
The spirit of the National Health Bill 2014 is to explore all possible avenues to extend quality health care to all Nigerians at affordable cost. This can be done through Universal Health Care which seeks to provide access to basic and functional health services in a sustainable manner to all the people but without unbearable financial burden on them. It also includes proactive and promotive activities, together with education on lifestyle choices that are designed to enhance healthy living and so reduce the chances of ill health with their cost consequences. It is intended to provide everyone, especially the poor, with the opportunity for a healthy life as a fundamental right as improvements in health contribute directly to human development and economic growth, just as those who are unable to work can get pushed into or descend further into poverty. It is for these reasons that UHC is being seen as the greatest public health tool of the 21st century.
Governance of the Health Sector and Enhancement of Productivity.
Recommendation 1 (Policy formulation)
Establish a bottom up approach for harvesting information on which health policies will be predicated. Ensure that persons to drive health policies at all levels are well-informed health experts and professionals.
1. Conduct health talks in local communities and obtain peoples’ concerns on health issues. Sieve, categorise and forward same to be complied and tabled eventually for discussion at National Council of Health meetings.
District health workers, District heads. State Ministries of Health. Federal Ministry of Health.
2. Define and collate health concerns from communities and evolve health policies based on these concerns as well as global issues.
National Council on Health. Federal Ministry of Health. State Ministries of Health.
3. Ensure that health policies are well understood and publicised widely including doing so in local languages.
Federal and State Ministries of Health as well as those for Information and Education.
4. Avoid political considerations in the appointment of Minister of Health and State Commissioners of Health. While Commissioners of Health could come from other health professionals, that of the Minister of Health should be a seasoned medical doctor.
Mr. President. State Governors.
5. In the same vein, great care should be taken in the appointment of Medical Directors for secondary and tertiary health institutions. They should all be experienced physicians.
Mr. President. State Governors.
6. Management Boards of Secondary and Tertiary Health Institutions should contain experienced well-meaning public spirited individuals.
Mr. President. State Governors.
Recommendation 2 (Policy Implementation)
Establish clear guidelines for policy implementation.
Guidelines for the implementation for each health policy should be clearly stated including the accountable officer. Where possible, the time for the implementation of the policy should also be stated. For instance, the abrogation of obnoxious health habits like smoking, time for eradication of each vaccine preventable childhood disease, provision of pipe-borne water, proper treatment and disposal of faecal waste and others.
Federal and State Ministries of Health, Directors of Secondary and Tertiary Hospitals as well as their board members.
Establish a computer based monitoring system to track progress in implantation of health policies as well as a system for initiating immediate corrective actions when things begin to go wrong.
Federal Ministries of Health and Communications as well as State Ministries of Health and Information.
Correlate guidelines to avoid duplication and to determine pathways for future health care. For instance, policies on Non-Communicable disorders, infectious diseases, cancers, congenital disorders and so on.
FMOH and State Commissioners of Health.
Teach rudiments of health policy in Health Science at secondary school levels.
Secondary School Principals.
Recommendation 3 (Accountability)
Hold officers to account for failure of governance.
The Hon. Minister of Health, State Commissioners of Health, Directors and Chief Executives of health institutions should all receive Work Descriptions and Financial Instructions on what is expected of them.
Federal Government, State Governments. Management Boards.
Officers should be held accountable for failures in administration that lead to loss of life, walk outs, strike actions by staff through quarries, suspensions, retirements, dismissals and even prosecution.
. Federal Government, State Governments. Management Boards.
Officers so disciplined should be blacklisted and prevented from holding any other responsible positions.
Set standards for quality of care and operational levels for tertiary health institutions and carry out periodic visitations and accreditation exercises as centres of excellence for major disease conditions as is done for universities by the National Universities Commission.
Federal Government, State Governments. Management Boards.
Federal Ministry of Health and Standards Certification Committee as envisaged in the 2014 National Health Bill.
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Encourage staff to give of their best to the health sector through improvement in work environment, prompt payment of salaries and emoluments, training, and recognition of outstanding staff. In the same vein, punish indolence and truancy.
Allocate sufficient funds for the health sector and judiciously expend such funds to ensure that public health institutions are well equipped and have the basic tools that professionals need for their training as well as carrying out their work effectively.
FMOH, Federal Ministry of Finance, National Assembly, State Commissioners of Health, Boards of Tertiary Health Institutions.
Lay strong emphasis on maintenance culture in all public health institutions.
Boards of Health Institutions.
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Sponsor staff to attend in service trainings as well as local and international conferences to update knowledge and improve moral.
Boards of health institutions.
Put a reward system in place, including financial reward that would openly recognise staff that have done well – productivity award on a productivity day.
Boards of health institutions.
Reduce the number of recognised Trade Unions that currently operate in the national health sector and stringently apply the “no work, no pay” rule when union members go on strike. Furthermore, ensure that training periods are appropriately elongated by various examining bodies to reflect the times trainees were out of work and on strike. Chief Executives should hold regular dialogues with unions to keep abreast of management actions. Also they should dialogues to diffuse tension so as to prevent strike actions.
FMOH and State Commissioners of Health. Boards of Health Institutions, Medical and Dental Council of Nigeria, National Post graduate medical college, West African Post Graduate Medical College and other regulating bodies.
Government should not enter into agreement with staff unions for payment of emoluments for which there is no cash to support. Furthermore, governments should avoid going into direct negotiations with trade unions especially on issues involving funds. This should be left to the Boards, who are their employers to handle.
Federal and State Governments. Boards of Health Institutions.
Recommendation 5 (Coordination and Integration)
Properly coordinate activities at the primary, secondary and tertiary levels of care including the establishment of effective referral system. Integrate orthodox private health care as well as traditional care that has proved efficacious into main stream of health care delivery system.
Renovate, equip and staff all PHC centres so as to get them to function satisfactorily. This may involve some increased stipend to encourage staff to work in far flung rural communities. Also, to encourage patients’ attendance, health care at the PHC level should be free of charge. Similarly, equip, renovate and staff the other two tiers so that they too can run efficiently.
Primary Health Care Agency, FGN, State Governments
Provide the needed support for a referral system to function efficiently – means of specialised conveyance by land and sea, emergency equipment, trained paramedics, drugs and put responsible staff of the hospital to man this aspect of work.
Boards of Hospitals.
Use services of orthodox private health care providers to boost health care coverage under UHC and thereby integrate them into main stream health care delivery system.
Federal and State governments.
Encourage research on traditional medicines and traditional health care in universities and research institutes. Incorporate those that are efficacious into the National Health Care System.
Federal and State Governments. Universities, Research institutes.
This paper is one of a number being put together at the instance of the Centre for Human Security of the Olusegun Obasanjo Presidential Library on the health sector in Nigeria – a sector, which on account of its parlous performance has attracted concern and voluminous publications. Among the many issues that are generally believed to be responsible for the dismal performance are inadequate funding, poor governance, frequent strike actions and dilapidated infrastructure. This paper addressees only the issue of governance and advances the Recommendations as its forte. Thus, the recommendations are put in a tabular form in which each recommendation is followed by a series of activities to be effected to address the recommendation. In that way, the recommendations are action oriented and an implementer can run with them. They are not exhaustive but are sufficient to kick start a series of actions that could result in a more coherent governance of the health sector.
Nigeria’s health sector needs a coherent and well-articulated governance structure that would harness the combined efforts of all care providers, ensure optimal function and utilization of the system and motivate staff to render quality professional services to all its citizens. That this has not been the case has been partly responsible for the poor health indices of the country and the frustration that drives many to seek health care in foreign land at great expense. It is expected that the recommendations in this paper if implemented should go a long way in addressing aspects of the governance issue.
A Schematic Diagram of the Current Governance Structure.
Ebola Outbreak in West Africa. Case Count as at October 14, 2015. www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa-counts.html
Polio. Nigeria has stopped Polio. WHO says. The Wall Street Journal. September 25, 2015
WHO removes Nigeria from Polio Endemic List. www.who.int/medcentre/news/releases/2015/nigeria-polio/en/