Rebuilding trust in the Nigerian healthcare system
There are many concerns about the current state of healthcare in Nigeria. Instances abound of unnecessary fatalities in our hospitals for a plethora of reasons, most of which can be attributed to one root cause: the lack of a mandatory requirement for quality assurance in the healthcare space. Available indices show how poorly Nigeria is performing when compared with her neighbours: our life expectancy is lower while maternal and infant morbidity rates are higher than other Sub-Saharan African countries. Over the years, failed policies as well as inadequate funding has led to poor working conditions and failing infrastructure, and this has led to catastrophic brain drain in the medical professions over the last 40 years. It is a sad fact that in Nigeria, only the well to do enjoy a standard of healthcare delivery comparable with other Sub-Saharan countries. The rich and well-connected attend to their ailments abroad, spending over $1billion annually on medical tourism with Europe, North America, India, South Africa, and Dubai being their preferred destinations.
Things were not always this bad. From the 1950s to the 70s, the University College Hospital (UCH) Ibadan was a world-renowned centre for medical excellence. Indeed, senior members of the Saudi royal family were brought to UCH for major operations. The wife of the, then Head of State in the early 70s, Mrs Victoria Gowon chose to have her first child at Lagos University Teaching Hospital. Many foreigners, drawn by our equable climate as well as the sterling reputation of our healthcare system, elected to come to Nigeria for treatment, effectively becoming medical tourists to the country. The glory years of the past and restoring Nigeria’s reputation as a centre of excellence in the healthcare space can be achieved by mandating hospitals to adopt Total Quality Management (TQM) principles.
Healthcare is a service and like all services it must meet the needs of the consumers. Consumers generally know what they are buying and can decide that a certain product or service is not meeting their needs and as such, choose not to patronise the provider of that good or service. This is not the same with healthcare in Nigeria. The only requirement to be a provider of healthcare services is a license to practice from the Medical and Dental Council of Nigeria (MDCN) and the systems currently in place are not effective in ensuring that the service that is provided meets the needs of the consumer. This is particularly important as the consumer generally does not have the same level of information as the medical provider which prevents him from being a meaningful part of the decision-making process. This information asymmetry is being changed by almost universal access to information on the internet and healthcare consumers are demanding more. Furthermore, social media also provides an opportunity to hold medical professionals accountable and disseminate information if they if they feel they have been short changed. Healthcare providers have the responsibility to ensure that the service they provide is safe, responsive, and caring if we are to rebuild trust in healthcare in Nigeria and these can be achieved by the implementation of TQM. This will to the benefit of both the consumers of healthcare as well as the providers.
Total Quality Management (TQM) is a management framework based on the belief that an organization can build long-term success by having all its members, from low-level workers to its highest-ranking executives, focus on improving quality and, thus, delivering customer satisfaction. The philosophy of TQM is continuous improvement, or Kaizen (a Japanese term meaning “change for the better” ) and It focuses on process improvements over the long term, rather than simply emphasizing short-term financial gains. The 8 cardinal principles of TQM when applied to healthcare are: customer focus, recognizing that patients are customers; integrated systems, ensuring coordinated activities in the hospital; employee involvement, obtaining total commitment of all employees; the process approach, which provides consistent and predictable outcomes through a system of aligned processes; and continuous improvement, which involves the logging of serious adverse effects and definition of corrective methods. Evidence based decision making from analysis of data; the establishment of effective communication channels; and a strategic and systematic approach to managing interrelated processes all contribute to overall improvements in organizational capabilities and performance. Implementing TQM improves patient safety in several ways: operational efficiencies are increased, errors are reduced, and cost effectiveness is increased, freeing funds for training and equipment. TQM facilitates prompt identification of the causes of poor performance and provides remedial measures to correct any anomalies while it’s proactive, rather than reactive, approach to problem solving guarantees customer satisfaction and loyalty.
Clinical Governance as a concept is the United Kingdom’s approach to TQM. It was introduced in the 1990s and provides a framework through which National Health Service (NHS) organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. Clinical Governance aims to set clear standards, monitor implementation, and publish results with periodic inspections by regulatory bodies. All healthcare organisations must have a clinical governance strategy. It is based on seven pillars: Clinical effectiveness, Risk management experience, Patient experience, communication effectiveness, resource effectiveness, strategic effectiveness and learning effectiveness. These seven pillars function within the fundamental principles of system awareness, teamwork, communication, ownership, and leadership.
TQM and Clinical Governance aim to achieve the same objective of assuring the quality of care that is delivered to the consumer. TQM is a generic management concept that applies across all product and service organisations but Clinical Governance as a concept is specific to healthcare. The UK further supports the implementation of Clinical Governance by setting up the National Institute for Health and Care Excellence (NICE) with the specific mandate to improve outcomes for people using the NHS and other public health and social care services by producing evidence-based guidance and advice for health, public health and social care practitioners as well as developing quality standards and performance metrics for the providers among other activities. In addition, the Care Quality Commission (CQC) was set up as an independent regulator of health and social services in the UK to make sure healthcare service are safe, effective, responsive, caring and well led. They do this by monitoring, inspecting, and regulating services to make sure they meet fundamental standards of quality and safety, and they publish their findings, including performance ratings, to help people choose care. They also have a mandate to act where they find poor care with the objective of helping the organisations improve the standard of care that they deliver.
There needs to be a big shift in Nigeria, and we need to embrace the philosophy that medical practitioners are service providers and patients are consumers of healthcare and such they have rights. Indeed, the publication of the patients’ bill of rights (PBOR) by the Federal Competition and consumer protection commission (FCCP) is a step in the right direction but the FCCP needs to do more and work with the medical regulatory systems such as the MDCN to provide an integrated regulatory framework to protect the consumers of healthcare. The regulatory framework needs to expand beyond the licencing of medical practitioners by the MCDN. There is a need to investigate the setting-up of organisations such as NICE to produce standards as a reference point for practitioners. The regulation of health services and hospitals in Nigeria is under the State Ministry of Health and some states such as Lagos state have gone further and set up agencies such as the Health Facility Monitoring and Accreditation Agency (HEFAMMA) and while this is a welcome development, there is more to be done to model HEFAMMA along the lines of the CQC. These changes will not happen overnight but the adoption of TQM principles and their application to Clinical Governance, by improving the patient’s experience and the employee’s working conditions, will contribute immensely to the restoration of trust in Nigeria’s healthcare system.
