A while ago we invited colleagues that had an informed view on health issues in Nigeria to share this via this blog. Maybe, just maybe we can force some attention to the health sector. Maybe, together we can bring about, and in some cases be the change we seek. Maybe, just maybe we can raise the quality of the debate on the critical issues that face our country above the narrow and parochial arguments that dominate our media.
Enjoy this piece sent in by Felix - powerful, articulate, engaging - a must read.
By Felix Abrahams Obi
Abuja, April 2010
Since the recent reconstitution of the Federal Executive Council by the Acting President, Dr. Goodluck Jonathan, the cyclical war of attrition among healthcare professional associations has once again resurfaced. The President of Nigerian Medical Association was alleged to have made statements purporting that only medical doctors have the requisite skill and expertise to head the Ministry of Health by reason of their six years of university education. The Pharmaceutical Society of Nigeria and other ‘allied health professionals’ on the other hand have contested the position of the NMA president and his members on the grounds that only the best candidate is worthy of leading the ministry.
Each contending group seems to vehemently defend its position armed with seemingly infallible logic based on skewed premises. The battle rages on with each group being more passionate about protecting their own professional interests without engaging in any meaningful dialogue with each other for the common good. But health professionals should bear in mind that what is at stake is the promotion of health and the provision of health services to over 140 million Nigerian citizens and foreigners rather than the preservation of professional ego and parochialism.
This unhealthy contention over the headship of the health sector among health professionals seems far more pronounced in Nigeria. It dates back to medical school where it is believed that the ‘most intelligent students’ are admitted into the university to read medicine while the seemingly second-rated students are admitted into the ‘allied health professions’, and these departments also serve as ‘dumping grounds’ for the ‘non-intelligent 300 level medical students’ who couldn’t pass their ‘2nd MB’ exams to proceed into the clinical years. These off-loaded ex-medical students unwittingly are forced by unfortunate circumstances of their exam failure to become undergraduate students of professions they hitherto were made to see as second rate and inferior. Thus they join the other side of inter-professional rivalry and the vanity of ego-sprucing during and after they leave the university. Upon graduation from medical school, the battle ground thereafter shifts to the turf of the hospitals, clinics and health centers where the system is structured to reinforce the already polarized health sector. So who is to take the blame for this unhealthy and unnecessary bickering within the health sector and in whose barn does the battle spoils accumulate to rot away?
Since only medical doctors used to have the exclusive right to the title ‘Doctor’, other professions have tried to bridge the gap as well. The optometrists run a 6-year long program and graduate with ‘Doctor of Optometry’ and wouldn’t let medical doctors enjoy that right. Pharmacists and Physiotherapists are working assiduously to phase out their current 5-year long undergraduate programs to upgrade them to be in sync with the already popular ‘Doctor of Pharmacy’ and ‘Doctor of Physiotherapy’ programs currently run in USA. And if their efforts scale through the Nigerian Universities Commission, will medical doctors raise the bar by phasing out the MBBS programs or lengthen the years to preserve the comparative advantage in length of training?
A careful analysis of undergraduate and to some extent postgraduate medical education in Nigeria and most countries across the globe shows that there are a lot of deficiencies in terms of knowledge base and requisite skills vis-à-vis the reality in the health sector. For instance, medical training is strictly based on the ‘Biomedical Model’ derived from the ‘Germ Theory’ whereby focus is on using biochemical agents (drug therapy) to fight the bacteria, virus or other unwanted organisms that invade the human body. And where there is compromise in the integrity of the anatomy of the body by way of trauma or genetic abnormalities resulting in malfunctioning or disability, the ‘almighty surgery’ comes to the rescue, complemented by chemicals infused into the body. Interestingly, almost all the knowledge and skills most health professionals acquire in medical school are tailor-made to ‘fix’ the medical, surgical or psychiatric and other conditions of the ‘patient’. Since patients basically are ‘treated’ within the walls of a hospital or clinic, the health professionals worldview is by default circumscribed to be limited by the walls of a hospital.
While undergoing training in medical schools, health professionals by reason of their curriculum have limited contact with the wider university community. The glorious white coats make them appear like gods to the other students from the arts, humanities, and sciences and sundry faculties. Consequently medical and other health professionals end up being holed up in their tiny world of patient care bereft of knowledge derived from other fields; making them stand the risk of being one-tracked and ‘narrow-minded’ but intelligent individuals. Unfortunately this sequestration which started in Nigerian medical schools continues till today, with little or no influence from the outside and wider world after graduation save those who get ‘delivered ‘by renouncing the health profession for the more lucrative sectors such as the oil and gas, banking/financial services, insurance, advertising, telecoms and IT etc. They realize that medical knowledge is not omniscient indeed!
The pharmacists want to prove that they are experts in drug production, prescription and therapy; without which the doctor’s omnipotence is deflated. The laboratory scientists guard the laboratories from any intrusion by the hematologists and pathologists who are empowered to certify their diagnostic tests. The radiographers keep watch over the entrance to x-ray rooms in the same hospital. As if that is not enough, the nurses by default rule and reign in the wards over every other health professionals because the patient indeed is their own share of the polarized clinical turf. The physiotherapists in their own right guard and protect their own part of the kingdom of health sector. And the non-medical professionals within the hospital setting also seek for their own relevance and significance, thus adding to the already polarized milieu. But the battle doesn’t end at the hospital mind you!
With the concentration of power at the Federal Level, the entitlement syndrome takes pre-eminence and the status quo of power play that holds sway in the hospital arena is sustained at the Federal Ministry of Health. So medical doctors want the headship conferred on them at the hospital level to remain sacrosanct while the other health professionals battle to wrest it from them. In fairness to other health professionals, doctors have always dominated and occupied the top management positions in the Federal Ministry of Health, and have served as the Heads/Directors of the Departments of Public Health, Family Health, Planning Research and Statistics, Hospital Services, Special Duties except the Department of Food and Drugs which a Pharmacist heads, and the non-technical Department of Personnel and Accounts.
But is the matter really about headship alone? Where then is the interest of the common Nigerian whose health needs are being underserved by the current health system which is dysfunctional and weak? If this battle is about entitlement and getting a share of the juicy position of Health Minister with its accompanying benefits, aren’t health professionals being selfish in this unbridled quest for power? If medical doctors have always managed the nation’s secondary and tertiary hospital facilities, doesn’t the sorry state of our hospitals reflect some degree of inefficiency on the part of those that manage them? And by extension, are the units managed by other health professionals working at their optimum best?
Let the truth be told to all and sundry, the training of medical doctors and other health professionals in Nigeria have little or no management component. Though health professionals are thoroughly groomed to provide clinical care, however we all know that clinical care is a microcosm of the larger and more complex health care services delivery system. Thus being an expert in clinical care doesn’t translate into expertise in management nor the visionary leadership needed to run a system as complex as the Ministry of Health. And those who have worked within the public health policy and management sector know that having a hospital or university experience is not enough to steer the health sector through the reforms and change so needed today.
Recently, I had an engaging discussion with a surgeon who has over 20years clinical experience, and currently serves as the Chair of Medical Advisory Board (CMAC) of one of the nation’s Teaching Hospitals on the issue of Health Management. Being a sincere and godly man, he admitted his inexperience about the theory and practice of management until he was given the appointment. Determined to bridge the knowledge and skills gap, he has invested time and personal resources, taking actionable steps to acquire as much knowledge and expertise on management as possible. His passion is palpable and he wants to devote the rest of his career developing and expanding his expertise in health management. Appalled at the lack of managerial skills among his medical colleagues, he has started sensitizing his colleagues on the need for managerial training.
Some medical schools abroad have taken strategic steps to reform their curriculum to be in tandem with global trends. For instance, some medical schools in US offer dual degrees such as MD/MBA, and several Management Schools now have an MBA in Health Services Management or Masters in Health Economics, Policy and Management. Some offer Interdisciplinary Graduate programs that give medical professionals the opportunity to expand their world view as these incorporating courses in the humanities, arts, social sciences, behavioral sciences, law, economics and management. Often times, health professionals who undertake training in management and public health policy lose interest in clinical care as they begin to see health from the Social Model perspective (the bird’s eye view point) reckoning that health is far bigger than taught in our medical schools . The WHO in recent years has recognized this by promoting the concept of ‘Social Determinants of Health’ taking into consideration the fact that health is influenced and impacted by variables and factors outside the control or purview of the health practitioner. Does the clinical expertise of doctors or other healthcare experts give them any control over the social, political, economic, cultural, religious, technological and other factors that impact on health?
If Health Professional Associations are honest and humble enough to put away professional pride and haughtiness which smacks of self-conceit and delusion, this lingering war of attrition among them will become history. And in this age of broadband internet services, patients and laymen now have as much opportunity to the hitherto reserved knowledge which made health professionals revered as gods. And with the pushing to the public domain of the concept of ‘rights-based approach to health’ the power of health professionals over the patient or general public has been eroding by the day. The general public no longer cringes at the idea of demanding their health rights and are quick to go to law courts or use the media to press their case.
Besides the golden era of late Professor Olikoye Ransome Kuti who envisioned the 1988 National Health Policy and promoted Primary Health Care, the Health Ministry was more or less in limbo until post-1999 when Sector-wide Reforms under the NEEDS were pursued. It was a Health Economist, Prof Eyitayo Lambo who revised the National Health Policy in 2003/2004 having served as the arrow head of DFID-sponsored ‘Change Agents Program” which was used to engage Obasanjo’s Government on the need for reforming the health sector. Through the Change Agents, the first National Health Bill was prepared and sent to the National Assembly for approval and baring the political intrigues in our federal system of government, the Bill would have be passed into Law by now. As Minister of Health, Prof Lambo once again revitalized Primary Health Care and merged National Program on Immunization (NPI) with National Primary Health Care Development Agency (NPHCDA). He spearheaded the2003-2007 Health Sector Reform Program and the formulation of sub-sectoral policies in the areas of Public-Private Partnerships for Health, Health Management Information System, Health Promotion, Health Financing, and Human Resources for Health, HIV & AIDS, Malaria Treatment Policy, among others. Though the formulation of policies is not enough in themselves, but it is a known fact that no government, organization or entity cannot function without a clear course of direction which policies provide.
It was upon this foundation that erstwhile Health Minister Prof. Babatunde Ostimehin built upon by mobilizing the resources of Government and Partners to develop the unified National Strategic Health Development Plan (2010-2015) which feeds into the Vision 20:2020 strategy. What we need now is a Health Minister who has the leadership and managerial ability to deploy the human and material resources available within and outside the country to realize the set goals. He/she should be able to galvanize rather than increase the friction among the feuding professionals. We should downplay sentiments and political correctness in this matter and whosever the cap fits best should be given this privilege of bearing our health burdens. This verbal wars and entitlement syndrome have done us no good!
(Felix Obi is a Physiotherapist and Health Policy/Management Professional who works with an International Donor Agency in Abuja and can be reached via firstname.lastname@example.org)