First Eleven Providers Patting Health Care: Fierce Elements for Professor Pate’s Headship’s Cure

 

Figure 1: The first eleven providers of healthcare in Nigeria - culled from Dr. Adetolu Ademujimi’s archives at Sartorius Resources

Nigeria’s healthcare system is a beehive of both real and quasi healthcare services that requires compelling political will & actions to effect remedial interventions as part of Health System Strengthening (HSS) measures. The gigantic buildings clustered as Federal Government-owned Teaching Hospitals and Federal Medical Centers (FMCs) across the country are minute proportions of the hundreds of thousands of seen and unseen facilities offering varying forms, scope, and quality of healthcare services to the estimated 220 million population of Nigerians.

The narrow approach by successive administrations that leads Federal and subnational governments to focus country-wide healthcare interventions solely on ‘typical’ hospitals has left weak results in its trail partly because it does not take into cognizance the fact that healthcare is a commodity influenced by the multiple factors of demand (religion, culture, proximity, affordability, service-rating etc.) and supply. It is not surprising, therefore, that the administrative elements of sectoral funding, policy formulation & implementation, regulatory frameworks, human resource development via welfarism-related & capacity-building initiatives, monitoring & evaluation structures, donors/partners-seeking effort, and reform-oriented activities are typically, exclusively, and erroneously directed at public hospitals. This systemic omission needs to be redressed with data-influenced decision-making, going forward such that the high morbidity and mortality records from some of the non-conventional members of the first eleven elements patting healthcare supply would pointedly stimulate precise administrative actions for or against them.  

Until a heavy downpour of rain forced me to hibernate at a retail outlet within the popular auto-part market at Ilesa garage in Akure on a fateful day and engage in a forty-minute-plus conversation with six vendors within the complex, I couldn’t imagine the extent of the high demand for healthcare in places other than the conventional hospitals by a retinue of the Nigerian populace. My disbelief was taken to an all-time level when all six adult traders, estimated to be within the age bracket of 25 and 45 years, categorically (though ignorantly) informed me that a traditional bone-setting center and not the regular hospital, is the “ideal” place to manage a bone fracture in Nigeria. I was bewildered by their first-time conviction, after my enlightenment sermon as a medical doctor, that the Accident & Emergency (A&E) unit of a General Hospital is not only to stabilize and suture wounds incurred from an accident but the proper place to commence the management of skeletal fractures in accordance with established standard clinical protocols. Of course, they admitted that several persons who seek the services of traditional bone-setters have poor outcomes, summarized in their own language as “bent hands & legs and wound wey no dey heal quickly” after recovery, which are medically termed mal-union and delayed wound healing.

The latter part of this eye-opening interaction that occurred few days after the inauguration of Senator Bola Ahmed Tinubu, GCFR as the President of the Federal Republic of Nigeria had my interactive audience highlight the other six healthcare providers whose services they often court and patronize even as urban inhabitants and workers, before the next four conventional healthcare facilities were mentioned. I began to imagine the scenarios in rural areas where more than 80% of Nigerians work & live and the highest incidences of unregulated and pretentious healthcare practices occur every minute.

Permit me, therefore, to humbly present to Nigeria’s recently appointed cerebral Coordinating Minister of Health and Social Welfare, Prof. Ali Pate, the first eleven suppliers of healthcare services at the subnational levels in Nigeria, with the first seven arguably being the most patronized, and yet, the high offices of the country’s health authorities in Abuja that he now leads, do not, or rarely reach.  As for the private-public healthcare dichotomy, the cumulative daily patronage of private providers of healthcare by Nigerians is arguably higher than the aggregate utilization data of public hospitals on a day-to-day basis. Also, I am certain that President Bola Ahmed Tinubu would be shocked to see the results of a commissioned survey by his office today to ascertain the proportion of Nigerians who receive primary care services in non-conventional places other than Primary Health Care (PHC) facilities. A large proportion of medical injections, consultations, wound dressings, maternal deliveries, family planning services, pregnancy abortions etc. occur in dirty corners within the outlets of several Traditional Birth Attendants (TBAs), Faith-Based Birth Attendants (FBAs), traditional bone-setters, chemist shops/patent medicine sellers and traditional herbal homes.

That said, what are some of the critical challenges posed to the country by a section of the top seven providers of the first eleven contained in the diagram above? These include but not limited to;

• outright medical quackery or criminal activities;
• out-of-purview/extra-jurisdiction services;
• large-scale incompetence and low-quality services;
• increased morbidity (risks of other illnesses such as transmission of HIV/AIDS, hepatitis B & C, disabilities, drug interactions, Vesico-Vaginal Fistula etc.); and
• increased mortality (death)

Are there reasons adduced for the comparatively low demand for healthcare services at the last four conventional healthcare clinics, as relayed to me during my unforgettable encounter with those automobile parts’ traders? Yes! In no particular order, they include but are not limited to;

• non-flexible payment methods for healthcare commodities & services;
• prolonged waiting time at service points;
• prolonged walking time between scattered service points within the same healthcare facility;
•  judgmental & sundry ‘nasty’ attitudes of many conventional health workers; and
• recent spate of attrition of health workers (mostly Doctors and Nurses) in response to the socioeconomically induced Japa (relocation abroad) wave in Nigeria that has left many hospital workers to render pressured, poor & perilous services to healthcare-seekers. Regrettably, Japa has further encouraged the first seven to boldly step forward, more than ever before, in filling the gap.

Consequently, to effectively intervene in the supply side of healthcare, the following are some concrete steps recommended for Professor Pate’s headship of the health sector in-country regarding the first eleven that continually stroke healthcare or its semblance in Nigeria.

1. Taking a stance: Through the National Council on Health, the Minister for Health would do well to lead the country to take a stance regarding the ‘continued existence’ or ‘critical proscription’ of traditional birth homes, faith-based birth centers, traditional bone-setters, traditional incision centers and traditional herbal homes. If these facilities are to stay, their scope of services should be expressly defined or re-defined in a policy manual to set clear operational limits and wide publicity of the contents of the operational guidelines. The country’s poor referral system within the health sector would also need to be strengthened to ensure these facilities can intentionally, promptly, and correctly refer clients to conventional hospitals. Likewise, the quality of in-facility trainings and attendant certificates & practice licenses offered by many private hospitals to their staff who are then referred to as auxiliary “nurses” requires scrutiny and a national position. The country has been too evasive on these subjects to the detriment of human lives and overall health indices.

2. Decentralization: That health is on the residual legislative list of the 1999 constitution of the Federal Republic of Nigeria (as amended) doesn’t alter the fact that our current dysfunctional Federal system tactically places too much “legal, geographical, administrative, political, and economic” powers in the hands of the Federal government at the expense of the States (refer my book released in 2022 titled DIAL 811: DEFT OR DAFT?). This unfair constitutional posture makes it extremely difficult for the subnational governments to intervene more than they currently do in healthcare. Yet, these first eleven are physically situated within the States. For these reasons, relevant Federal government ministries, agencies or offices (e.g., Office of the Minister for Health, National Primary Health Care Development Agency, National Health Insurance Authority etc.) require frequent engagements with their State counterparts (Forum of State Commissioners for Health, Forum State primary Health Care Development Agencies, Forum of State Health Insurance Agencies, respectively) to take and implement timely decisions on critical healthcare delivery subjects pertaining to the first eleven.

3. Regulation (monitoring & enforcement): The approach to ensure effective regulation of these first eleven suppliers of healthcare in Nigeria is not for the Federal Government to create more agencies. It also doesn’t mean hiring more personnel, procuring thousands of automobiles for expensive supervisory visits from Abuja, or incurring exorbitant costs on airline tickets, per diem & hotel allowances by its officials for regulatory/supervisory travels to 36 States. Effective regulation simply means re-establishing clear guidelines for the operations of healthcare providers, effective publicity of these guidelines among stakeholders & the public, mustering the will to implement sanctions (including prosecution and proscription) when guidelines are flouted and deploying relevant ICT tools (CCTV cameras, electronic apps etc.) for cost-effective and remote monitoring of activities conducted within these facilities. Specifically, owing to the gap in identification, a window period for mass enlisting/mapping of Traditional Birth Attendants (TBAs), Faith-Based Birth Attendants (FBAs), Traditional bone-setters, Chemist shops/Patent Medicine sellers and traditional herbal homes should be announced and the following recommended supplemental actions instituted by State governments in that direction;

• issuance of registration numbers;
•  request for ‘compulsory’ designated facility phone numbers & gadgets (not personal phone lines);
•  publication of phone directories of these facilities (electronic publication is preferred) and regular update of the listings by State Ministries of Health;
• erection of unique colour-coded signboards for each category of these eleven facilities;
• reforming and reinforcing (through legislations by State Houses of Assembly, electronic gadgets, and budgetary provisions) the Offices of Medical Officers of Health within the 774 Local Government Areas (LGAs) across 36 States and Federal Capital Territory (FCT) to provide strong local leadership & coordination over these non-conventional healthcare facilities; and
• empowerment (through legislations by State Houses of Assembly, electronic gadgets, and budgetary provisions) of Ward Development Committees (WDCs) in each political ward across the 774 LGAs to conduct routine supervisory visits to each of these facilities and provision of audiovisual feedbacks/reports to the respective Offices of Medical Officers of Health across the country.

4. Training: Compulsory trainings (knowledge & skills transference and update) in accordance with operational guidelines that define the forms, scope, and quality of healthcare services to be offered by respective healthcare providers should routinely take effect. Beyond the usual technical skills, training modules on soft skills such as medical customers’ relations for conventional health workers can be offered as short-term courses by various Colleges of Health Technology (public & private) ‘littered’ around the country.

5. Infrastructure support for General Hospitals, PHC facilities and Private healthcare facilities: The current level of infrastructure decay in the mentioned facilities are such that the morgues in many General Hospitals won’t let the dead rest in peace. For instance, Special Purpose Funds – SPFs (and not new agencies) may be created/allocated to directly support the States in the massive and urgent upgrade of infrastructure at secondary healthcare facilities (General Hospitals, State Psychiatric Hospitals, State Specialist Hospitals etc.). Through high-level advocacy by the Office of the Coordinating Minister of Health & Social Welfare to the Governor’s Forum to encourage intentional & efficient use of hospital-generated revenues, strategic private sector investments, partners’ & donors’ support, philanthropic promotions and public (community) involvement, at least 50% of PHCs and secondary healthcare facilities can have the following over the next four years;

• designated phone numbers & gadgets (not personal phone lines) that would strengthen inter-hospital communications and referrals;
• State-published phone directories of these facilities (electronic publication is preferred) and regular update of the listings;
• Electronic Medical Records (EMR) system with requisite training of all frontline clinical staff to use same;
• Solar power mechanisms to reduce exorbitant running costs incurred majorly on energy;
• Solar Direct Drive (SDD) cold chain systems for vaccine storage;
• Laboratory, radiology, dental, eye, mental health, and physiotherapy facilities particularly in secondary healthcare centers; and
• Staff quarters (units of one-room apartments) for healthcare workers welfare.

These critical infrastructure interventions would enable both primary and secondary level healthcare facilities effectively offer to Nigerians, the five forms of health services prescribed under Universal Health Coverage (UHC) – promotive, preventive, rehabilitative, curative, and palliative care. Private hospitals and diagnostic centers should also be considered for similar support including soft loans with single-digit interest rates.

In conclusion, it is my hope that by year 2027, it shall be said that our highly revered and experienced public health expert-cum-coordinating Minister of Health & Social welfare, Prof Ali Pate, has indeed ensured Health System Strengthening (HSS) by leading the central and subnational governments to remarkably intervene in ‘curing’ the first eleven providers patting healthcare in Nigeria.

Dr. Adetolu Ademujimi is a Medical Doctor, Health Financing Specialist, Author, Reformer, Public Policy expert and Social entrepreneur who can be reached in Abuja via adetoluademujimi@gmail.com