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Health care delivery: Imperatives for change

THE Nigerian healthcare delivery system is a source of concern to all  because of the needless deaths of citizens and the capital flight that the health sector has come to represent in our time.

While the wealthy routinely fly out of the country to seek medical expertise, the middle class struggle to access the few private healthcare centres in the country and the poor are left at the mercy of poorly managed healthcare centres manned by poorly committed, ill motivated healthcare workers of all types or quacks.

Overtime, Nigerians have depended on the Healthcare professionals to proffer solutions to the various challenges plaguing our healthcare delivery system but unfortunately, the health sector has become atomistic and is perpetually at war with itself and thus have almost abandoned their core mandate of attending to the healthcare needs the nation. Most often, rather than seek reengineering of the system, they are at war over personal emoluments.

Most often, workers down tool in this sector for their own need and comfort, recourse to improving the system is only used as rhetoric to mask their original claims. It is therefore important that we put a call to government to look closely at our healthcare delivery system and address the issues squarely. The personal emoluments of the healthcare providers are crucial but improvement can only be obtained from a holistic review and implementation.

The Healthcare sector is meant to service the society and ensure that the populace, as much as possible, is in the state of health to effectively drive the engine of national development. What we find today is a healthcare system which rather than service the nation is preying on its citizens and pauperizing our national economy either consciously or unconsciously.

Current Health architecture

Nigeria being a three tier state, constitutionally charges each tier with a specific level of responsibility in the health sector. The Local Authorities are responsible for the Primary healthcare which ought to be the management of local dispensaries, environment sanitation/protection and routine immunization,s etc.

The State Governments are supposed to be responsible for secondary healthcare system i.e. the General Hospitals, Health Centres and similar healthcare delivery systems while the Federal Government is expected to concentrate its efforts on the tertiary and apex referral institutions such as the National Hospital, the Specialist/Teaching Hospitals and the interventionist Federal Medical Centres.

The reality on ground today however, is that the local authority delivery systems are non-existent. The dispensaries and Health Centres managed by the Native Authorities in the 60s and Local Authorities in the 70s are non-functional.

In other words, the first level of healthcare provision and prevention of diseases has been rendered non-existent. The implication of this is that all the patients who should have been attended to at this level either move to the next level (the secondary level) or seek self-medication or rely on quacks. Recent Newspaper reports indicate that only 2,500 of 30,000 Primary Healthcare Centres nationwide are functional. Thus, diseases that could have been arrested or prevented at that level are left to fester sometimes metamorphosing into an epidemic on national dimensions.

Furthermore, the NPHCDA is funded by the Federal Government from its own share of the Federal Revenue Allocation. This unsustainable arrangement is what the country is currently operating and has even been further expanded to include support for some traditional birth attendants and midwives nationwide.

With the clamour for increased revenue allocation to the State Government, funding for this Agency may be one of the casualties of a reduction in the Federal Government spending whenever revenue review takes place. The implication of this on primary healthcare delivery is scary.The State Governments are expected to be saddled with the efficient running of the Secondary healthcare facilities such as General Hospitals, health centres etc. Surprisingly due to gross dereliction of responsibility, many General Hospitals in the State are ill equipped, ill-staffed and ill maintained.

Recently, a State in the Middle Belt of Nigeria shut down ALL its General Hospitals supposedly for renovation for almost three years. The whole state had to depend on the only Federal Medical Centre in the State Capital for its healthcare delivery . This necessitated the Federal Centre embarking on outreaches to the three Senatorial districts at huge costs to the Federal Government.The hardship experienced by the citizens of that poor state is better imagined. Our political system does not sanction leaders for mismanagement of this nature and thus encourages maladministration underpinned by arrogance. There should be a way to sanction leaders at state levels who display this type of nonchalance to the welfare of their own people.

The Federal Government has largely borne the burden of servicing the healthcare delivery system of the country. From providing primary care and environmental sanitation in the Local Council Areas to servicing the Secondary level care of the State by building Federal Medical Centers in the States. The consequential effect of this is that Federal funds which should only have been spent on tertiary level care in the Federal and Teaching Hospital is dissipated and inadequate to procure and properly maintain the apex level clinical equipment in these tertiary level hospitals.

If the exodus of our compatriots for medical care to India, Egypt, South Africa, UK, USA, Germany etc. with the attendant loss of forex is to be stemmed a major restructuring of the nation’s healthcare Architecture must take place (Infact, the current economic situation in our country has made the review of our healthcare delivery system more imperative as the cost of seeking alternatives outside the shores of this country is now prohibitive even for the rich!).

Ordinarily medical tourism ought to be the pre-requisite of the affluent but contemporary experience has shown that neglecting to seek medical attention outside the shores of this country could mean pronouncing a death sentence on yourself.

Under the current economic climate, the government has no choice than to revamp the health system while tackling the economy and infrastructural challenges. Some of these changes do not require funds but a revision of strategy.

Nigeria healthcare professionals are among the best in the world and would deliver given the right atmosphere. The right atmosphere should among others include a review of the organogram of the healthcare institutions, adjustment of the management pattern of the hospital and expansion of the clinical training program of doctors to include salient management concepts and equipping for managing a multidisciplinary enterprise such as a hospital.

The policy that allows for medical personnel in public services to run parallel hospitals whilst still in public service needs a rethink. This policy has done more harm than good to the healthcare delivery system in this country. The initiators probably meant well and needed to address certain nagging issues at the time it was granted. The implementation has been abused and the ordinary citizen are helpless as diversion of patients, absenteeism and extortion has taken over this policy no matter how well intentioned it was at conception.

There is an urgent need to review and allocate specific responsibility in patient management as it concerns the Consultant, Doctors, Residents, NYSC Doctors, Nurses and Midwives. The manpower input of these professional ought to be thoroughly monitored in order for it to achieve the desired objective. Whereas the payrolls of the hospitals are loaded with these experts, the actual delivery of services leaves much to be desired.

Drugs availability is an age old challenge in the system. With the number of pharmaceutical manufacturers in Nigeria and the NHIS support, there is no reason why baseline medication should not be available at affordable prices for the populace throughout the country.

The pharmaceutical drug distribution system both in the public and private sector needs to be re-organized by the government and made efficient. Government should take the lead in this direction. Drugs and medicaments donated by multinational agencies need to be monitored and directed to the areas of need when they still have adequate shelve life. The role of Government Agencies in the Ports on donated drugs leaves a lot to be desired. The Government Agencies at the nations Ports should co-operate with the health authorities to ensure that donated and even imported medical equipment and drugs do not waste away at the ports when those in need of their applications are dying in droves.

Government should define the structure of the nation’s healthcare Architecture possibly through a constitutional amendment. Healthcare responsibilities should be clearly defined between the three tiers of government. And each tier should be encouraged to perform its role. When support is lent by other tiers, it must be as an intervention and temporary. Each tier should be encouraged to play their constitutional roles

The National Health Insurance Scheme should be expanded and made to function as a health insurance body for the entire populace. The experience gathered since inception is now enough for them to deploy nationally. Government should decentralize control of healthcare facilities. The federal ministry of health should be concerned with enforcement of regulatory control and providing enabling environment for investment in the Health Sector.

Healthcare procurement is specialist procurement. Government hospital must not procure medical equipment without adequate sustainability arrangement. In this wise, biomedical engineers and technicians should be employed and deployed to the hospital to arrest the constant breakdown of equipment.

Some equipment must not be owned by the hospitals or government at all. Such equipment of high capital value should be obtained on a public, private partnership (PPP) arrangement with the manufacturers. Nigerian patient population is huge enough to generate a fast and good return on investment.

Government resources should only be spent to ensure that the vulnerable are not left out due to financial incapacity. Finally, the health sector is definitely not the only one needing a thorough analysis and re-organization but it is the most potent in terms of its adverse survival index on the populace. If we must survive and exit this recession, the working class must be healthy enough to be productive and grow the economy.

I do hope that those who are in the position to act will consider all or part of this discussion as a contribution to our quest for national transformation.

All hands must be on deck if we must navigate and turn around the economy of our country for good.


Samson A. Opaluwah, an engineer, is a former Director in the Federal Ministry of Health and ,The National Hospital,  Abuja.





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