“The world is not dangerous because of those who do harm, but because of those who look at it without doing anything” – (Albert Einstein)
Nigerian medical doctors at home and in the diaspora are doing their bits individually and collectively as well as in partnership with local and foreign investors to do something that might change the status syndrome of Nigeria’s healthcare. This effort is visible in the high profile publicity of private hospitals as well as in expressing the objective of expanding the horizon of national health economy in order to become competitive in the global health market. At different conferences and on the social media, the promotion of private healthcare as the pillar of hope and symbol of national healthcare delivery image is palpably persuasive to the point that it will inadvertently accelerate the displacement of public hospitals
Shareholders in the private sector are ambitious about enhancing the quality and productive capacity of private healthcare organisations through a growth strategy, hence the investment in modern clinical technologies and teams of suitably qualified, competent and highly committed multi-professionals across clinical, technical and management boundaries.
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In contrast to the hope and sense of pride being brought by the private sector, the public healthcare institutions have serious issues about staff commitment, low level of up-to-date clinical skills and competencies, lack of care and compassion. That explains the poor clinical outcome and low productivity often associated with public hospitals. Despite the facts, there are no questions about who should be held fully responsible and accountable for the leadership and management failures of public healthcare institutions and the unpleasant patients’ experience that undermines public confidence.
Several other Nigerians across different clinical and management fields are also making significant contributions towards a viable branded national health services development that will be effective in enhancing the philosophy of primary health care in Nigeria. In effect, there is a focus on ‘socio-entrepreneurial’ business model which is in contrast to the free market capitalist model that is literally behind the growth of private hospitals. The effort is directed at ensuring universal accessibility, affordability, diseases prevention, health promotion, patients/public empowerment and public financing of health.
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The goal of everyone irrespective of a preference for commercial or public healthcare is the achievement of well-developed quality health facilities in Nigeria and consistent achievement of better treatment outcome for patients. The challenge however lies on the financing of public health and access restriction due to ‘out of pocket’ payment. The mission statement of the Federal Ministry of Health reads; ‘To develop and implement policies that strengthen the national health system for effective, efficient, accessible and affordable delivery of health services in partnership with other stakeholders’.
Therefore, Nigerian government has a duty for financing public health and to source healthcare funding from the population on compulsory healthcare taxation for a defined class of people under the control of National Health Insurance scheme (NHIS). The working class and all income earners in full employment or self-employed will pay the healthcare tax on ‘pay as you earn’ (PAYE) formula. Standard for delivering healthcare will be set and both private and public hospitals can compete for block contract to meet public demand for listed range of medical conditions. This will promote market competition in a controlled market, not ‘free market’ and enhance public accessibility without the difficulty in out-of-pocket payment.
Health services outside the public financing list can be received at the private hospitals or the private wing of public hospitals and paid for privately. Health management strategists, health economists, public health doctors, general practitioners, nurses, therapists, lawyers, accountants and several other professionals appear to support this approach as it provides better choice and opportunities for the public and put the government in the driving seat as opposed to being misdirected by a single narrative of over-publicised importance of private healthcare.
Politicians and successive governments have made rhetorical statements about the importance of healthcare services in the country but yet none has proactively supported a distinctive Health System that draws clear line between the politics behind health policies and the corporate strategic initiative that drives healthcare planning, productivity and financial accountability. Similarly, there is no separation of roles between strategic business experts and the experts in medicine and clinical professions. Decisions about healthcare planning, priorities, financing, staff recruitment and development are often incomprehensible when analysed critically, especially in the context of public health and image, safety and patients/public confidence.
The government has persistently resisted the calls to redesign the organisational structure of the public health sector, and very importantly to engineer a paradigm shift in the corporate leadership and management of public hospitals. The emphasis is on creating permanent post of Chief Executives with a mandate to lead teams of intellectual think-tanks on the management board. It will take the team of people from different academic and professional backgrounds to develop long term strategic plans and make decisions that serves the best interest of the organisation. Contemporary hospitals and healthcare institutions don’t thrive well on the antiquated idea of four yearly political appointments of Chief Medical Directors (CMDs).
In the private sector, all parameters for patient quality outcome in service delivery is anchored on the fundamentals of business and economic principles which underlines the packaging, branding and promotion of products/services that are delivered to the patients/customers through the work of doctors, nurses and other professionals . The services should meet customers’ need/expectations, be cost-effective and quality assured through organisation’s legal accountabilities.
It is in society’s interest to have well established private hospitals to cater for a market segment and some medical conditions that may not be available under public healthcare funding. However, champions for profit orientated private sector must speak with caution and avoid demeaning the significance of public hospitals and public health institutions in Nigeria. It will be counterproductive to the success of the private hospital economy if reckless actions are encouraged with the aim to erase public health sector.
Disjointed health policies and their ineffective implementation; coupled with misconducts of clinicians that signpost vulnerable patients to private hospitals and clinics are open secret that is damaging public hospitals and the healthcare system. Capitalism in health economy is not the right model for Nigerian healthcare development. The government should take actions that will stop the ongoing run-down of public health sector and proceed to reviving the deteriorating public confidence in the nation’s healthcare system. Without a complete overhaul of the public health system, Nigeria’s disease, disability and death profile will take a pole position in world ranking considering that more than seventy per cent (70%) of the population is surviving on less than $2 a day.
The clinical services provided in the glorified private hospitals are limited in scope and are mainly specialists based medical and surgical conditions. The population that will suffer from the conditions and have the financial capacity to fund the cost is less than 3%. It is the same percentage that would otherwise travel abroad for medical tourism.
Private sector hospitals are unlikely to develop or expand services for casualties of emergency medical problems without an absolute government undertaking to pay the cost of treatment for victims of any category of health emergencies; especially road traffic and industrial scale accidents like bomb blasts, plane crash, fire/burns etc. Even where funding is agreed, the processes and procedures for claiming the cost must be simplified and flawless. The challenge in respect of the above is in a ministerial directive titled ‘Rejection and Refusal of treatment for Victims of RTA’.
In reference to the directive of the Honourable Minister of Health and a letter signed on his behalf by Dr Wadapa Balami mni, Director of Hospitals Services dated 24 November 2016 with ref. DHS/T/ER/DM007/1/110, there is an example of a typical government actions that is highly unlikely to be effectively translated into realistic outcome. Citing the National Health Act 2014 and the mandate of the 5th Pillar, it was stated that hospitals are mandated not to refuse treatment for accident victims on account of inability to pay. An aspect of the letter (paragraphs 4 and 5) lack clarity of purpose and would present challenges for the healthcare providers whose business is dependent on time and money.
The fact that identifiable accident victims are to be held responsible to make out-of-pocket payment for their own treatment highlights government negligence on its duty of care for the population. The instruction on how hospitals should draw the cost of treatment for unidentifiable accident victims explains the challenge that private hospitals will face as well as exposing a healthcare delivery policy that has no strategic foundation. In the first instance, both the law and the ministerial directive are silent on the ideal facilities and circumstances where and when medical emergencies should be delivered and the minimum level of skills and competencies the professionals must have in order to promote treatment and avoid complications. The law and ministerial directive centred on treatment in the hospital without indication of processes and procedures for rescue attendance, on-the-scene medical care and transportation of casualties to accidents & emergency (A&E) centres. Ambulance service is underdeveloped and grossly dysfunctional. The national emergency number ‘112’ may ring when called, but may not be answered by anyone thereby making SOS calls a hopeless effort.
There is a need to recognise the responsibility of Primary Health Care Development Agency in respect of ninety seven per cent (97%) of the population that are highly unlikely to have the ability to pay fully for medical treatment. That population will suffer from the 95% of the most common ailments that are prevalent in the country as listed in table 1 and the long term conditions that can be controlled with support in the community listed in table 2 (see tables below).
Furthermore, it is necessary to remember that the general economic environment has been compromised and many families have no means of earning income while several others are either low or middle income earners with many months of unpaid salaries, unpaid pension and these are contributory factors for cash-flow challenges.
The fear of out-of-pocket (OOP) payment for hospital bills is responsible for many households that don’t seek medical help at public hospitals. This often results in disease severity, complications and higher cost. The poor patients are therefore exposed as vulnerable victims of miracle makers, quack medics, insincere trado-medical people, mediocre private hospitals / medical clinics and self-medication, each of which could result in complications, disability or avoidable death.
Private hospitals are not better than well led and strategically managed public hospitals and both sectors should advance their services to meet the needs of the key targeted population.
It is time that the media should take a moral stand and be more critical in the analysis of the words and actions of the government, her agents in health management and others in clinical professions. There must be individuals to hold accountable for systems failures, wastage of public health finances and clinical malpractices in relation to international standards.
In conclusion, this article calls for unambiguous support for the development of a national healthcare system on the foundation of morality. The right to life must resonate the social contract that empowers elected government to protect the rights and dignity of the whole population, especially the weak and vulnerable. Political ‘will’ must be demonstrated to enhance the healthcare image and public confidence across the country. The health market has capacity for public and private healthcare services to function to their respective full potentials. The beautifully packaged poison-filled chocolate of sweet lies by ego-centrist elitist groups that encourages the destruction of essential public services must be stopped and the media must play its role. Just as public hospitals are under threat, while public education institutions are nearly out of fashion, , the diseases of the body and mind coupled with that of illiteracy are a time bomb that will kill off Nigeria unless honest government interventions are made right now, without any delay for another day
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