Every organization requires a complex mix of a number of factors in order to function satisfactorily: Infrastructure by way of buildings that will contain the offices in which the operations of the organization will be conducted; finances to defray its expenses and of course human beings who will carry out the actual work for which the organization was set up. When we copy this observation over to the health sector, we note that we as doctors are familiar with hospitals, clinics, laboratories and medical equipment as being some of the infrastructure we require to practice our profession. Also, we need finances to purchase and maintain the equipment, pay for consumables, and run the expenses of the health facility. But over and above all this is the factor of the human beings who render services at the particular health institution. For it is their numerical strength, the quality of their services, the skills they possess as well as their professionalism that more than anything else, determines the quantity and quality of the output of that health institution.
But rendering services in the health sector is a very specialized business. Health workers often require several years of apprenticeship, training and retraining to enable them acquire the requisite knowledge for their calling, develop the appropriate orientation of empathy to the sick and imbibe the distinctive competence and character that are commensurate with their level of operation in the system.
The central body of the Nigerian Medical Association (NMA) has directed that for the 2006 Physician’s week, the keynote address should be on CAPACITY BUILDING: HUMAN RESOURCE DEVELOPMENT IN THE HEALTH SECTOR and this lecture, as I understand, is concurrently being delivered in all state branches of the association.
Let me therefore congratulate the central body of our association for being so thoughtful in its choice of a fundamental theme for the key note addresses. The number and aesthetics of a health facility are important and so are the equipment and consumables it contains. But nothing can replace or compare adequately in value, with the quality of the human resources with which that institution is endowed; resources that are slowly built and ultimately give that institution its form, character and status. Today’s lecture therefore will concern itself with the process of building competence in the health sector. It will follow the traditional pattern of evolving capacity for the preventive and promotive Primary Health Care, the curative secondary care as well as capacity building for the tertiary care that has responsibility for rehabilitation and manpower development. Its material context will be drawn largely from happenings in our state, the Rivers State, as that is the wish of the central body of our association. In addition and happily too, all three levels of care are available in the state. But before I continue any further, permit me to digress for a short while to comment briefly on this year’s Physician’s week, a time at which we as physicians are meant to reflect on our selves and on our services to humanity.
In this respect, what comes most readily to mind are the fresh challenges and opportunities that face us as a group of professionals. Global HIV/AIDS especially in poverty stricken developing countries, of which we are part, is decimating our population, disabling our work force, rendering our mothers widows and our children, orphans as well as reactivating age long tuberculosis over which we had thought we had claimed some victory. Indeed HIV/AIDS is seeking to reverse the gains we as health workers have made over the years in the care of the health of the community. The ubiquitous malaria parasite continues to confound us with its ability to develop resistance and so rendering itself liable almost exclusively to arthemesenin containing compounds, jettisoning the long cherished drug of choice, chloroquin, and calling for the use of impregnated bed nets. Prostate, breast, cervical and colorectal cancers are becoming epidemic while maternal and under five mortalities still remain the bugbear of our women and children. On the other hand, we must not let the import of the newly introduced Medical Insurance Scheme to escape us as through it we can extend our reach as health care providers while still ensuring that we are worthy of our hire. The recent inauguration of Medical Elders by our local branch is novel and timely. It is our expectation that it will be the responsibility of our elders to ensure that peace and harmony exist in our various theatres of operation. Some of our colleagues have continued to make us proud in governance and administration, areas in which not a few have condemned us as being ineffective and inept. Only a couple of weeks ago, one of us, His Excellency Dr. Peter Odili, the Executive Governor of our state, the Rivers State of Nigeria, received the highest honour that our parent body can bestow on anyone for his meritorious services to the nation. While we felicitate with His Excellency for that well-deserved recognition, as well as many others, we wish to assure him of our strong support for his course and our total commitment to the project of seeing him in Aso Rock, come May 2007, as the next Executive President of the Federal Republic of Nigeria.
The Current Status of Health Care Delivery in Nigeria
In order to understand and appreciate the environment in which health service providers operate in Nigeria, it is essential to carry out a brief review of the nation’s health care delivery system which is clearly laid out in the document National Health Policy and Strategy to Achieve Health for ALL Nigerians. This document indicates that Nigeria’s health care delivery is predicated on an integrated and coordinated three tier Primary, Secondary and Tertiary Health Care Delivery system.
Primary Health Care (PHC) as defined by the World Health Organization (WHO) at its Alma-Ata declaration of 1978, is essential health care which is based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community. It is the first level of contact of individuals, the family, and the community with the national health system bringing health care as close as possible to the people where they live and work. As envisaged in the National Health Policy document, PHC is the plank on which the health care delivery of the country is anchoured as it is expected to provide 70% of the health care requirements of all Nigerians. Although health is on the concurrent list in the Nigerian constitution, PHC is designed principally as a responsibility of local governments and it is to be practised largely in various health facilities in local government locations. Nigeria formally adopted PHC in 1986 and started with the establishment of model PHC services in 52 local government areas across the country. The coverage was then gradually increased until it covered all 774 LGAs in the country.
Secondary Health Care is curative and is the type of care that is delivered in many hospitals and clinics involving essentially, the treatment of diseases in individuals. It is designed as the responsibility of State Governments and is expected to take care of about 20% of the health care needs of the citizenry.
Tertiary Health Care is the advanced care of gravely ill patients in teaching as well as other tertiary health institutions involving their treatment and rehabilitation. It has the duty of training the personnel who would service the health system especially at the secondary and tertiary levels and also to carry out research on the health of the nation. The Federal Government has responsibility for tertiary care and also for enunciating the health policies of the nation. Only about 10% of the health care requirements of the nation are expected to be serviced at the tertiary care level.
These three systems do not work in isolation but are meant to be integrated so as to allow the free flow of users of the system from one level to the other through a well articulated referral arrangement without undue difficulty.
However, in actual fact, the health delivery system does not function in accordance with these laid down plans. So, instead of the ideal structure that has been described, the system operates in a very different manner. A citizen seeking health care has a range of health services open to him from prayer houses and traditional healers, to patent medicine sellers and private medical Practioners, to any of the health institutions in the government health sector. Recent researches in the health field suggest that 60% of health seekers first patronize non-government health providers; those who elect to use the formal health sector commence with any health institution they wish, oblivious of the hierarchical three tier structure. It was also found that the greatest failing of the government–run health system is at the PHC level where the referral system works very poorly due to a number of factors including lack of functional means of transportation as well as accessible roads and waterways.
Human Resource Development in Primary Health Care
Since the burden of success for the health care delivery system is placed on PHC, one would have expected that manpower development for the health sector would be robust and most elaborate for PHC providers. In many instances this is not so. However in the Rivers State, prior to the establishment of the College of Health Science and Technology, a number of institutions existed that had responsibility for the training of this cadre of health care workers. They included the School of Hygiene, The School of Public Health Nursing, The School of Nursing, and The School of Midwifery. These health institutions trained most of the nurses, midwifes, community health workers, village health workers and public health inspectors that rendered services under the framework of PHC in the 288 Primary Health Care Centres and some secondary health facilities in the state. In 2001 through an edict which was signed into law by the Rivers State Governor, the School of Hygiene became known as School of Health Technology and this new school together with many other similar institutions were then amalgamated into the College of Health Science and Technology. The College, now a formidable body with a Governing Council and Provost, consists of several training institutions including the School of Oral Health, The School of Dental Technology, School of Health Information Management, The School of Medical Laboratory Scientists, School of Midwifery, School of Nursing, School of Pharmacy and School of Public Health Nursing. Between 1999 and 2004, the schools under the College enrolled 5426 students and graduated 3405 as Nurses, Community Health Extension workers, Technicians, and Assistants. These graduates have been absorbed mainly into the various arms of the Rivers State Health service.
Human Resource Development in Secondary and Tertiary Health Care
Human resource development for secondary and tertiary health care is a very specialized affair which until recently was carried out in medical institutions outside Nigeria, mainly in the United Kingdom and United States of America. For instance the medical educators, clinicians, nurses and midwifes who taught and practised in the health institutions of the nation after independence were almost all trained abroad. This was true of the medical institutions of the first generation universities, of Ibadan, Lagos, Ife, Ahmadu Bello and Benin, as well as the general and specialist hospitals that existed at independence or were established shortly thereafter. The establishment of the National Post Graduate Medical College of Nigeria in the country in 1975 and the West African Post Graduate Medical College in the West African sub region in 1979 changed all that to an appreciable degree. The nurses also established a West African College of Nursing. These accredited post graduate institutions along with the 12 medical schools that are currently approved by the National Universities Commission, are now largely responsible for the training of most Nigerians who wish to pursue careers as medical Practioners or specialist doctors. Only few Nigerians still have their post graduate medical training abroad; still fewer do so for their undergraduate MB training. The trend is the same for nursing and midwifery. In the early years after Independence, most nurses had their nursing and midwifery training abroad, usually the in United Kingdom. As the university teaching hospitals got established in Nigeria, a number of nurses had the basic nursing training in the country but still travelled abroad for their midwifery training. Right now however, the majority of nurses have both the basic nursing training and that of midwifery here in Nigeria, including training for specialization in the various fields of nursing.
The General Hospital Port Harcourt and its sister institution, the Braithwaite Nursing Home, now Braithwaite Memorial Hospital are reputed to be some of the oldest secondary health care institutions in the country and in that respect, they predate the founding of the University of Port Harcourt’s twin health institutions of the College of Health Sciences and Teaching hospital. It was the General Hospital Port Harcourt that therefore commenced the training of pre-registration house physicians, a very important aspect of manpower development for secondary and tertiary health care in the Rivers State. When eventually the University of Port Harcourt’s two medical institutions came on stream in 1979, they gave a tremendous boost to the training of personnel that are needed to serve in the secondary and tertiary tiers of the health sector.
The College of the Health Sciences of the University of Port Harcourt offers instructions in medical education at all levels. It runs academic programmes from the bachelors to the doctorate levels in the basic medical sciences of Anatomy, Physiology and Biochemistry and also a Doctor of Medicine Programme, by research, in any of the disciplines that are taught at the College. These programmes ensure the training of medical educators especially in the basic sciences where such teachers are scarce.
The most sort after degree course of the University of Port Harcourt is the Bachelor of Medicine, Bachelor of Surgery programme which is run by the institution’s College of Health Sciences. This six-year degree course admits candidates with five credits at the General Certificate Education Examinations at the Ordinary level. Such candidates must also have good scores at the relevant Joint Admissions and Matriculation Board Examinations. The university admits about 100 students into this programme every year; of this about 60 graduate as doctors after six years of training.
Only two years ago, the senate of the university approved training programmes for bachelor degree programmes in Dentistry, Nursing and Pharmacy. The first batch of students admitted is few. When they as well as the subsequent batches that will be admitted, graduate from these newly approved disciplines, they will add to the available manpower for health care delivery in the secondary and tertiary tiers.
Another very important aspect of training that goes on at the University of Port Harcourt Teaching Hospital and also at the Braithwaite Memmorial Hospital is the training of specialists in the various disciplines of medicine, especially those in the clinical areas. The University of Port Harcourt Teaching Hospital is accredited by the two post graduate medical colleges that operate in the country to carry out post graduate specialist training for Surgery, Medicine, Obstetrics and Gynaecology and Paediatrics and partially so for training in the Pathological Sciences. The Residency programme that has been established for the training of these post graduate students, attract good doctors to the hospital who render services to patients while undergoing training themselves. Each year, no fewer than two candidates successfully complete their training from some of the post graduate programmes and so, over the years, a critical level of specialists who now serve as consultants to the teaching hospital while holding academic positions in the university, is gradually being built up. In some instances, the individuals concerned are persons who had had their undergraduate medical training also at the University of Port Harcourt, demonstrating the extent of success that is being achieved in the training of specialized and highly skilled manpower locally.
To support this local training of health personnel, the Rivers State Government has continued to approve in-service training of various cadres of health workers in the service of the state. It has approved overseas training in appropriate cases in line with its desire for an accelerated infusion of trained personnel into the health sector. This action, the government considers necessary in order to enable the state to cope with the innovative health care programmes that government has mounted and which are gaining in popularity with the citizenry. The Free Medical Care Programme (FMCP) which is targeted at two vulnerable groups of children less than five years of age and adults over 60 years and the Emergency Medical Services Programme. So far, 215,508 patients have been treated under the FMCP since the inception of the programme in May 2000. The programme has now been extended to the inmates of prisons, motherless babies home, homes for the elderly, disabled persons and ex-service men. As for the Emergency Medical Services Programme which was launched by President Olusegun Obasanjo in September 2000, it has so far handled 30,209 cases including victims of collapsed buildings and some persons from the sosoliso plane crash.
However, available evidence suggests that optimal services are not being obtained from care providers in government health institutions. Although this lack of efficiency is pervasive in the three tiers of the system, it is at the PHC level that it is most marked and correspondingly causes the greatest damage since PHC is expected to serve as the most important component of the integrated health delivery system.
Results of studies that were carried out by staff of the University of Port Harcourt in seven districts of Gokana Local Government Area in Ogoni land revealed that many PHC workers did not report for work when they should. There was a great discrepancy between the staff strength on paper and the personnel on ground. Many of the workers from cities out the LGA who were posted there, refused the posting and when they accepted, they often did not live there. They were often disillusioned and frustrated on account of poor working conditions. In some of the clinics that were visited, there were neither weighing machines for growth monitoring nor blood pressure machines for antenatal care. Furthermore, staff productivity was hampered by the deterioration of the structure of health facilities. They were not maintained. In a number of instances the roofs were rusty and leaking in several parts; the woodwork had been eaten up by termites and the plumbing works had rusted and so got blocked.
Other than these inadequacies which influence morale and performance, health workers themselves were found not to have acquired the necessary attitude of compassion and diligence which would have mitigated some of the problems that they had to contend with.
The human element apart, health care delivery is affected by a number of environmental and social factors like the physical surroundings, availability or otherwise of portable water, and transportation to mention but a few. For instance in many cities in Nigeria, there are no centrally organized treatment plants where human waste could be treated and disposed of hygienically. Virtually all houses in the cities contend with individual septic tanks dug close to the houses in which body waste material is stored. Although these tanks are sealed, they still constitute fertile breeding grounds for pests like cockroaches and rats. As for those who live in the rural parts of the country, disposal of human waste is through one of several approaches: disposal into streams and rivers, into adjoining bushes or into pit latrines. There is no organized system of domestic waste either. In the big cities, domestic wastes often litters the streets or are transported from one part of the city to the other until they are dumped at a point. The flaring of gas freely into the atmosphere with heavy atmospheric pollution is a common site in many parts of the Rivers State. All these add to the burden of disease and compromise the effectiveness of health care providers.
Well trained and skill full medical personnel are required to man the health care delivery system in order to promote good health, prevent disease and reduce morbidity and mortality. Although the available manpower is inadequate, its distribution is also uneven, the urban centres having a disproportionately higher concentration of trained staff than the rural areas making health services economically inaccessible to the rural populations, the poor and the needy.
Health workers need to be trained and retrained in order to enhance their professionalism. In addition they should be offered appropriate inducement so to accept postings to rural areas where may be needed. The emphasis that is currently placed on the training and improvement of the skills of health workers in the Rivers State is commendable. In this respect there is a need to work out modalities by which the training capabilities of the various institutions under the Rivers State Government and those of the University of Port Harcourt could be harmonized. Such an action would strengthen PHC in the state, and result in a more economical usage of the available manpower in the state.
CAPACITY BUILDING: HUMAN RESOURCE DEVELOPMENT IN THE HEALTH SECTOR – A Public Lecture. Delivered by Nimi D. Briggs. On behalf of the Nigerian Medical Association, Rivers State Branch In commemoration of The Physician’s Week 2006, Port Harcourt on Monday 23 October, 2006