In 2015, Nigeria and several other West African nations pledged support to achieve Universal Health Coverage (UHC) by the year 2030 in line with achieving the Sustainable Development Goals (SDGs).
Basically, this means that we promised the United Nations (UN) that all individuals and communities within our Nation would receive the health service they need without suffering financial hardship in achieving this. Have we succeeded or are we anywhere near success? I believe the answer is quite glaring.
In achieving this lofty goal of Universal Health Coverage, like so many of the OECD countries have, and like other African Countries are gradually attaining to, there is so much to do. However, working on achieving UHC without integrating Quality Health Care as a fundamental part to achieving this desired outcome is both a time and money waster. Poor quality healthcare has been discovered to be responsible for 15% of overall deaths in low and middle income countries and imposes costs of up to US$1.4 to US$1.6 trillion each year in lost productivity. Definitely not something to be trifled with.
What Exactly Is Quality Health Care?
This is the extent to which health services provided to individuals and populations is able to increase the likelihood of desired health outcomes and be consistent with current professional knowledge. To achieve this, services must be safe, effective, timely, efficient, and equitable and people centered.
Global State of Healthcare Quality
The importance of quality healthcare globally can clearly be depicted by using countries like Sierra Leone, and Liberia as case studies, both preceding and following the Ebola outbreak. Its outbreak emphasized deficits in a skilled health workforce both in the health facilities and communities, lack of financial mechanisms which compromised provision of quality service delivery and allowed the epidemic to proliferate.
Are Health Services Effective?
Ineffective health services usually occur due to lack of adherence to evidence based guidelines. This may be due either to a lack of knowledge of these guidelines or non-compliance to them. Worldwide, there are issues with effectiveness but none as glaring as what we have in Africa. For example in Kenya only 16% of providers correctly diagnosed all five patient cases that were presented in clinical illustrations to assess provider knowledge. In Nigeria no studies have been done but even the basic recommendations by World Health Organization (WHO) which advocates non treatment of febrile illnesses as malaria unless we have a positive RDT (rapid diagnostic test) result is not adhered to. This causes health care providers to miss early diagnosis of cases like Lassa fever and other febrile illnesses.
Are Health Services Safe?
Patient harm is the 14th leading contributor to the global disease burden, majorly falling in low and middle income countries. This usually leads to an increase in the financial burdens of diseases, due to management of adverse events, and results in decreased confidence in the health sector. Adverse events range from medication injuries in short term care to pressure events in long term care. Issues of safety are widespread in our Nigerian health sector and are rife in reports all over the news and social media. They range from forgotten gauze packs during surgeries to wrong prescriptions and misdiagnosis of patients both in the public and private sector. Proliferation of fake and substandard drugs is also a major factor.
Are Health Services People Centered?
Respect, care and also community engagement in decision making are key foundations in a people centered health care delivery system, and it differs between High and Low and Middle Income Countries(LMIC). This is especially reflected in our maternal health care delivery system where women frequently complain about a lack of effective communication between their health care provider and themselves with respect to their health care plans and outcomes which leads to a high proportion of deliveries outside the health facility and contributes to poor outcomes in the maternal mortality rates especially in Nigeria. Communication in a language that people can understand along with clear explanations and compassion go a long way in patient’s perception of the healthcare system.
Are Health Services Timely?
Nigeria makes a perfect case study of the inadequacies of the public health care system. In an outpatient service in Northern Nigeria service users waited for 60-120 minutes for only registration and an additional time to see the service provider. In Benin, Edo State, average waiting time was 173 minutes and in UCH 73 minutes. In countries like Ethiopia waiting time was as long as 149.2 minutes, while in countries like Canada we have an outpatient waiting time of 30 minutes or even less in other OECD countries. Reasons for long waiting time are commonly due to low man power in most of the clinics and poor infrastructure.
Are Health Services Efficient?
Efficiency usually looks at costs. Both under treatment and overtreatment have associated cost implications. The 2010 world health report estimated that 20-40% of all health sector resources are wasted for example, in India the rate of antibiotic use for acute diarrhea which is usually self-limiting was 43% in public facilities and rose to as high as 69 % in private facilities.
Similar problems definitely exist in Nigeria with widespread overtreatment with antibiotics by both the doctor’s prescription and those gotten without a prescription over the counter.
Is There Equity?
There’s no country anywhere in all the world where health services are equitable. However, a lot of geographical inequity exist for example with regards to cancer of the cervix. In 2015 nearly 270,000 women died from cervical cancer with 90% of them being from LMIC. This striking disparity based on location highlights that a woman’s risk of dying from cervical cancer is driven largely by where she resides. Despite advocacy for screening of women aged 30 and up, only 12.24% of women aged 16-60 years have done this in LMIC as against 72% in High income countries. Rates were 13.7% in Africa and 5.7% in Asia. Similar stories occur in the case of breast cancer with 80% of women surviving in high income countries as against 60% and 40% respectively in low income countries.
Restructuring the Nigerian Health Care Sector to Achieve Quality Health Care
According to the WHO Nigeria is rated 187th out of 191 countries in terms of health care delivery. Under 5 mortality still stands at 120/1000 live births, maternal mortality ratio at 800/100,000 live births, life expectancy at 52 years and a patient doctor ratio of 2500:1.
The above statistics clearly depicts the necessity for the restructuring our health system not only to increase access but also to increase quality. We are currently at ground zero, so it’s easier in my view to incorporate quality into a developing system as we go up rather than into a fully formed system. It would be essential to learn not only from the successes of already established systems, but also their failures.
For the health sector to evolve, changes must be made in the following just to name a few:
- Health Care Financing
As at 2001, Nigeria along with other members of the African Union, committed to increasing the percentage of their national budgets to healthcare to 15%. The highest realization of healthcare in the Nigerian budget was 5.95% as at 2014. As at 2020, this figure has declined further to about 4.5% of the proposed national budget.
Three years ago the federal government launched the Basic Healthcare Provision Fund (BHCPF), finally funding it in 2019 with disbursement to 15 states and the FCT. The aim of the BHCPF is to ensure healthcare availability to the poorest of the poor in Nigeria. The functionality of this program would be assessed over the coming year and increased awareness must be given to both the staff and the people of the availability of this funds for healthcare to ensure its success.
There’s the need to revitalize primary health care centers with adequate funding and monitoring of disbursement of funds to ensure proper utilization.
- Human Resources
Most conspicuous is the mass emigration of health workers from the country. The ideal patient to doctor ratio recommended by the WHO is 1:600, Nigeria currently lies somewhere in the range of 1:2500 or worse with disparities between the Northern and Southern regions of the country. This paucity in human resources especially up north significantly affects our health indices and are a major contributor to the figures emanating from our country.
We need to address the ongoing brain drain with respect to human resources and invest in capacity building of staff with modern curricula. In the same vein, reduce staff turnover in order to curb losses after capacity building via addressing relevant staff needs, and ensuring proper reimbursement.
Lack of basic infrastructure especially at the PHC (Primary Health Care) level is a key problem that needs to be addressed. As at 2011 there were 30,098 PHC facilities in Nigeria. Twelve percent (3992) of these were secondary and one percent (83) tertiary. Only 20% of all PHCs are functional at one time across Nigeria. Several PHCs lack basic electricity/ backup generators, ambulance services and good sanitary or waste management systems just to name a few.
The development of health information systems and continuous monitoring and evaluation of facilities and their quality of care need to be encouraged.
- Essential Drug Supply
The revolving drug fund which was supported by the PTF and other agencies is currently practically nonexistent. With most primary health care centers lacking the basic essential drugs, most patients who visit the health centers are not given drugs because they are unavailable thereby reducing the sense of efficiency that a patient gets when he/she visits. Secondary care centers fare only slightly better occasionally failing to have supply due to the unwillingness of pharmaceutical companies to extend their credit facility due to nonpayment of debt. This exposes patients to patent pharmacy stores and quacks who worsen the illness state by the sale of fake and substandard drugs.
- Political Will
In addition to low budget allocations, disbursement is usually about 70% of what was allocated and frequently about 70% of that goes to recurrent expenditure of which salaries are a major part, leaving only a little for capital expenditure.
Strengthening political will to make health care a priority. This would ensure increased budgetary allocations towards healthcare, a strong economy cannot be built without a healthy workforce.
In conclusion, one of the key markers of an economically developed nation is a healthcare system delivering quality healthcare. Though Nigeria has a long way to go, a journey of a thousand miles surely begins with one step. Quality Healthcare is achievable.
Dr Olanlesi Osadiaye is a Public Health Physician and Resident Doctor in The Department of Community Health and Primary Care Lagos University Teaching Hospital. With a Masters in Public Health , she has her interests in Adolescent Health, Health management, Disease surveillance control and response.