Saturday, 6 August 2011

The controversial clause in the "new" National Health Bill

The "new" National Health Bill is stuck in the presidency where it has been sent to be signed, as health sector professionals quarrel over a significantly flawed yet, trivial clause in the bill. This does more to illustrate the state of national thinking and dialogue, than anything else in recent national discourse. It is a pity that all the politics in Nigeria is tribal - and this is not just about the ethnic based "tribes" - but is also the tribes of professionals - doctors' vs pharmacists' vs nurses' etc. The tribes of "home grown" vs "diaspora" medical professionals. The tribes of "federal" vs "state", the tribes of "PDP" vs the "rest of the world", "public sector" vs "private sector".....all our politics is tribal! So the debate on the health bill is not about how it will best affect the health of the Nigerian people, no! There is actually no pretence about it - its just about the professional tribes, and how they are positioned to manage 80% of the budgetry resources on health spent on tertiary care at the Federal level in Nigeria. This is currently spent on our 17 teaching hospitals, 3 Orthopaedic Hospitals, 8 Psychiatric hospitals, one National Eye Hospital and 22 Federal Medical Centres around Nigeria. Until now each hospital has had its own management structures, with a super powerful Chief Medical Director.

The bill sets up an innovative structure called the "National Tertiary Hospitals Commission" to better manage this 80% allocated to tertiary care annually. Specifically the Commision is mandated in the new health bill to do the following (amongst others)

  • Establish minimum standards to be attained by the various tertiary health facilities in the nation and also to inspect and accredit such facilities;
  • Advise the Federal Government on the financial needs, both recurrent and capital, of tertiary health services and in particular investigate and study the financial needs for training, research, and services and to ensure that adequate provisions are made for these;
  • Set standards and criteria for allocation of funds from the Federal Government, monitor their utilization, source for grants as laid down by the Commission;
  • Collate, analyse and publish information in relation to tertiary health care services annually;
  • Monitor and evaluate all activities and receive annual reports from the tertiary hospitals, reward performance, apply sanctions and supervise annual peer reviews; 

This is all great stuff, and there is little to argue about, rightly so! Now the crux of the matter holding up the bill, has nothing to do with all this but simply on the Commission's leadership.  The new bill states that the "Executive Chairmanship of the proposed National Tertiary Hospitals Commission must be a; 
"Medical Director of the status of a Professor with a minimum of ten years working experience in a Teaching Hospital" 
This clause that limits the Executive Chairmanship to medical doctors in perpetuity has all the other health professions up in arms. Doctors argue that it is their traditional (read tribal) role to lead a medical team. The other health professions argue that they (their tribe) must also have a go at leading the commission. 

It is our contention at NHW, that this clause in the health bill is flawed, as it does not protect the best interests of Nigerians, and has placed tribal interests as belonging to a profession (a tribe of doctors), reaching an academic height (a tribe of professors) and having worked in teaching hospital (a tribe of public sector workers) - none of which ultimately guarantees a good leader and manager which the National Tertiary Hospitals Commission needs to fulfill its promise to the Nigerian people. 

Mr President - lead. On behalf of the Nigerian people, send the bill back to the Senate and House, let them remove the clause and open up the leadership of the commission to all those able to lead and manage, and let us move on to more important issues. The fundamental questions that we are not answering are -

- how best to organise and manage our health service
- how to fund our health service adequately
- how to balance the often conflicting demands and expectations of patients, staff and taxpayers
- how to ensure finite resources are targeted where they are most needed.

The health of our people should not be subject to tribal politics.

P/s declaration of a potential conflict interest - Chikwe is a medical doctor who believes that doctors should lead in the clinical management of patients! 


Ifedayo Adetifa said...

Chikwe,thanks for this well written commentary. I think inclusion of that clause is flawed. There is nothing wrong with leaving room for other professions, managers, business people to head a the National Tertiary Hospitals Commission considering its terms of reference. In view of reports (preliminary) from the US suggesting doctor-run hospitals outperform others, what is you take on the perennial debate over headship of our teaching hospitals?

Chikwe Ihekweazu said...

This response was sent to me directly - I think it will be of wider public interest.

Mr (or Dr) Chikwe is behind time in the affairs of the country. I guess he is outside Nigeria or probably not practising. I need to remind him that that the issue of leadership in the health sector is not about who can do it better. If this were to be the case then no one should actually contend with the doctor. We should actually be taking over PHCN, Banks, Nigeria shipping line, railway, aluminium industries, steel rolling mills and so on. None of these moribund industires were managed by any doctor. They were probably managed by BSc, MA or MSc and PhD holders in business management, Administration, Finance, etc. I am yet to be informed of any teaching or general hospital that completely closed shop since independence. In fact the day we begin to allow any person who is not a doctor to run our hospitals we would beging to witness distressed hospitals. May be many Nigerians have forgotten that between late 2003 and early 2005 foreign hospitals management experts known and called International Hospital Group (IHG) were contracted by the Federal Government under then President Obasanjo at a whooping sum of N600,000,000 per annum as management fees to manage National Hospital Abuja. Even though we did not like the idea of bringing the whiteman and paying a sum twice what was given to the rest of the hospital, we decided to give them a chance to see the magic they can perform in a system with zero capital allocation and 75% of salary from government. Guess what, "nwa diishi" was crying for money every hour, and wondered how we were able to keep services going on without money. I remember my MDCN Chairman then Dr JAF Momoh telling them to use their magic to go and get money from government since the black man did not have the magic wand. Their next plan? to close down dentistry, ophthalmology, ENT and scale down staff by 45%. Admin and maintenance were merged together. The cheapest of reagents (whether it was good or not) were used. I once asked the then Medical director Dr Neil Davidson, whether in UK he would allow anybody use a first generation HIV kit in 2004; he told me he was allowing it because there was no money to buy a better one. Before their arrival we were already using a fourth generation kit called Vironistika which he felt was too expensive to use in resource poor nation. The failure of IHG was so pronouced that government was forced to terminate a ten-year contract in less than two years to avoid further damage.

Remain blessed. Pray for Nigeria ALWAYS

Dr Kenneth C. Iregbu
MBBS, MSc, MPH, FMCPath, FWACP (Lab Med)
Consultant Clinical Microbiologist/Parasitologist &
Infectious Diseases Physician
National Hospital Abuja, Nigeria
234- 805 493 2992

Chikwe Ihekweazu said...

A continuation of the last comment....

The contest for leadership in the health sector by allied health workers is not about performance like I said earlier, but to "have access to national cake". I must admit that a few CMDs have forked up, but many have done well, from Benin to Zaria to Kano to mention but few. It takes a lot to run our systems, and in the case of health institutions, the doctor is the best trained and positioned to do so, and you do not throw away a winning team. Again an ally does not lead a force belonging to a force he is allied to.

If Chikwe is abroad he will confirm that even in those places that have non-doctors as chief executives the Medical Director takes all the decisions concerning clinical services; he employs, disciplines and promotes staff of the clinical division and decides the direction of services and manages the budget of the clinical directorate or division. The CEO is more of a facilitator than a manager. IHG structure here was the same. Mr Chadwick was the CEO but Dr Davidson was in full control of the Clinical Directorate while Ann Irani controlled the nursing services. These were the only two known members of the six-man IHG team. I can bet you that many of the staff never knew who those other men were until they left. No nation can afford to give executive power to a non doctor to control clinical services. God forbid.

Dr Kenneth C. Iregbu
MBBS, MSc, MPH, FMCPath, FWACP (Lab Med)
Consultant Clinical Microbiologist/Parasitologist &
Infectious Diseases Physician
National Hospital Abuja, Nigeria
234- 805 493 2992

Dockiee said...

The fight by other health professionals over the clause in the health bill didn't come as a surprise; infact it would have been a surprise if no dust was raised. This is borne out of the fact that the doctors who are supposed to be the head of the medical team have not been showing exemplary leadership in matters relating to the hospitals and the healthcare industry in general.The doctors usually find it difficult to carry the other professionals along when planning anything that cuts across board. When they finally have opportunity to sit on the table with our healthcare "colleagues" they engage themselves in exchange of words and show of power; they want to know who'll blink first. That's why they'll protest every move the doctors make, whether it's in the overall interest of the nation or not. A similar situation to what happened between the doctors and the Lab scientist is brewing between the doctors (community Physicians) and the community health workers (CHOs/CHEWs). The CHWs are trying to turn their program into a degree awarding program of about 5yrs duration, coming out with something like a Bachelor of Comm Health, and they are seriously working towards it; but instead of our Community Physicians providing leadership, say by drawing up their curriculum, setting minimum entry standards,regulating other standards before the degree can be awarded, they are busy fighting them and trying to block the move, which unfortunately have almost gotten NUC approval! Doctors should stop belittling themselves but rather should show exemplary leadership, this is the only way other healthcare professionals will have confidence in the doctors and won't be protesting every move we make!

Dr. Habeeb Salami
Clinician/Public Health Specialist

Anonymous said...

Chikwe, I regret this attack on your person and urge you to see the comment from Iregbu as one of those things holding us in Nigeria back where we award ourselves degrees and bask in the euphoria.

Dr Iregbu has demonstrated gross inexposure while he dreams of managing healthcare in Nigeria. I feel sorry for Nigeria

Please be aware that such people as Iregbu can be very dangerous

Anonymous said...

That Clause is nauseating to say the least.

Ken Nwosu said...

I can see from Iregbu's comments that he is not only an arch tribalist but a dinosaur. He confuses clinical leadership which Chikwe stated clearly is the preserve of the medical doctor with leadership of the health service. When will Nigerian doctors come to grips with the realities of 21st century health care and service provision. This parochial and clannish attitude as exemplified by Iregbu's comments indicates that health care professionals are all fighting to feather their individual hats and not the betterment of the health of every Nigerian citizen. Give me a break! I support Chikwe's submission that the President should send the bill back to the legislative body to look again at it hopefully with fresh eyes and remove all the clauses that are not fit for the purpose of optimal health care provision for all Nigerians. Let us for once get a national health policy issue right from the start. There is no need to rush the job and continue with a lopsided health care provision for Nigerians.
Ken Nwosu

Anonymous said...

In my opinion, that part of the bill that reserves the headship of the Tertiary Hospitals Commission to not just a physician, but a physician who is a professor, with years of experience in the tertiary hospital system, is flawed by all means.

First. Given the Nigerian factor, how do we expect someone who has benefited from a system clean up the same system. This clause excludes not just non-physicians, but physicians in the private sector, non academics and physicians with management track records who are not necessarily professors. Granted, like Dr Iregbu said that many CMDs have done well, what exactly is the rationale behind restricting the chairmanship of the commission in question to this group of individuals.

Secondly, although I am a Nigerian physician who did my post graduate clinical training in the US and currently practises in the US, and who also has some management training and experience, I do not believe that the headship of that commission nor the secretaryship of the FCT health board should be exclusively restricted to doctors alone. There is simply no basis for this in my own opinion. The best candidate with deep understanding of, and experience in a well run hospital or health system and with an excellent management/administrative track record and experience should be employed at any given point in time. If that individual happens to be a doctor, it is all well and good. If he or she happens to be a nurse or even an MBA, it's also all good. Yes, people argue that a pharmacist would not head a law body for example, but it's incomparable because clinical leadership is entirely different than administrative or management leadership.

The bill needs to be amended and the process needs to be expedited. The president should give this a lot of priority. People are dying.

Anonymous said...

it is very evident hat the clause is totally an act to disregard other professions.that aside, the most important thing is for the bill to be passed and implimented so that peoples lifes can be saved, issues of ammendment can be moved doesnt take been a medical personelle to know that clinical and managerial issues are quite different so either a doctor or pharmacist etc with needed criteria,stardard and has the health of Nigerians at heart works for me..GOD help us.

Anonymous said...

My colleague, Dr. Iregbu's comments are shocking to say the least. As Chikwe mentioned in his write-up even within the profession, there is a battle of attrition between 'doctor tribes'. What I resent is this 'entitlement' philosophy doctors have regarding leadership in all facets of the health sector. Guys, wake up and smell the roses...yes doctors may be smart (entry criteria for medicine used to ensure this), are repositories of so much knowledge (they are forced to cram and inbibe quite a bit in school) are absolutely the most qualified to take clinical related decisions BUT leadership, management or administration skills for successful healthcare delivery at all levels is not our exclusive preserv!!! And that comparison with banks, etc is not a valid one, that is an like comparing apples to oranges.

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Anonymous said...

Chikwe as much as you have raised valid points I believe Iregbu has some real concerns.In nigeria nothing is ever as it may preach an utopian state but the reality is that most if not all of those who are against the clause are doing that because of the perpetual struggle with medical doctors over every part of the health sector from office space to salaries to who heads the health team.Its interesting you state that doctors should head the clinical management but in nigeria and most of africa you have nurse,pharmacists,optometrists all claiming that role.The height of their actions the extension of courses in related health degrees from 4 to 6 years and changing their degree to phds!as if the difference between a doctor and a nurse/optometrists is the number of years in training!Finally please reply to Adetifa's comment on reports suggesting that doctor-run hospitals perform BETTER than others.Lets us be WELL informed not sentimental! regards,Concerned Lagos Doctor.

Anonymous said...

Please does anyone know where one can get a copy of the said Health Bill (for those of us outside Nigeria)? Much appreciated.

PS: Dr Habeeb, you hit the nail on the head. May God help us!!

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Anonymous said...

mr Chiekwe or what ever you are called you need to be updated with reality. We are not in a medeavian age when you pop something up and every one goes for it. How in the world will someone who hold only a degree in medicine say he should be given opportunity to lead. I don't blame you and your other medical colleagues. It is the government i blame because they are not well informed. They think the medical doctor is alfa and omega. Many of us who are opportuned to travel out of the country to carry out researches and stuf are aware of the fact that health administrators are committed to heading a tertiary health facility. It is only in this country you see fake people parade themselves as professors. Many of this people only hold an mbbs degree and then a fellowship diploma. How on earth will we sit down and allow people who are not qualified to lead the health industry. No wonder the health system in Nigeria is in a sorry state because un-qualified miscreants have taken over. There are medical lab scientists, pharmacists etc, with great achivements in medical sciences who have good outstanding degrees (Bsc, Msc, Phd) and international fellowships who also are holders of several international grants. These people should be allowed to lead. Lets stop playing politics with health. Medical Doctors have failed in delivering the services Nigerians need. They are the root cause of the many woes bedeviling the health sector today. They don't promote scientific and sound research because they are not academically qualified. They use the instrument of Chief medical director to oppress other health professionals. They encourage their younger collleagues to go into residence programs which is not academic and frown at other health professionals who seek to progress to Masters and Phd levels. These people (medical doctors) have basterdized the health sector and should be held accountable for it misfortunes. I challenge the 'professors' in medicine to declare their certificates. Many of these guys only hold a first degree, yet they parade themselves as professors. There is no country/health sector that can grow without a strong baseline for research. The reason why the health industries in the western world trived over the years is because they encourage research. Medical doctors in Nigeria should be ashamed of themselves. They are not reading and they are now intimidated and embarrased because other healthcare professionals are reading and getting good degrees. They should copy from their counterparts abroad who have Phd's and sound fellowship training. These Nigerian doctors are just politicians,they don't practice professionalism. I only pity the patients who are meant to be the highest stakeholders in health matters. Times shall tell because evil will not privail against good. God bless Nigeria

Majolagbe said...

Only in Nigeria is the issue of who leads the hospital a contest. who better if not the doctor. everybody is important including the security man, but because people feel inferior for the work they do, they best leave up by bringing up an unnecessary constest. but let it be known, no patient goes to the hospital to see a Nurse, pharmarcyst, Lab scientist or radiographer. everybody goes to see a doctor, even though the doctor may be the last person for you to see.
there can only be industrial harmony when other professionals in the health sector become proud of what can be achieved when they cooperate with the leader of the team.

Anonymous said...

Hmmm. God help us in Nigeria. The "my child must be a medical doctor" symdrome is almost hunting us. It doesn't cost much, I think everybody should go and become a medical doctor or better still vacate the other departments of hospitals for medical doctors only to operate. I remember the days when corses are been bought in some universities in Nigeria, pushing the well qualified but not financially bouyant ones to settle for the ally corses to medicine. We must learn to respect each other in this country. God bless Nigeria. Mr Edache.

Anonymous said...

Doctors are the PDP of nigerian health sector, who believed that only them know everything. Those days is gone sorry!

Anonymous said...

Why can't Nigerians have a debate without insults? Just make your point! This is a civil debate and yet some people feel it right to disrespect others "Anonymously"? Why can't you simply refer to the name and even go further as to say "whatever you call yourself". This does not qualify you specially as an astute contributor. It is simply disrespectful "whoever you are"

2) whether one exists in NIgeria or outside Nigeria, one is still qualified to contribute.
The simple case here seems to be that the NIgerians at the higher level are busy debating on who is to head the department/ministry; while the citizens at the lower end of the scale await a good standard service. The current state of the nation's hospitals is abysmal. People in the western world will not even trust to take their pets to some of our hospitals. I have never heard of anyone flying specially to Nigeria for treatment, instead you hear of people flying to Indian, US and UK?
3) Before we start debating on who is to head, can we stop and think of all the grassroot problems? I agree with disregarding 'entitlement' philosophy doctors have regarding leadership in all facets of the health sector.
The doctors should be busy thinking of the best ways to treat patients and not worrying about management issues. They should state all requirements for running an effective hospital and let good quality Managers (MBA specificalliy trained individuals), Marketinge experts and other skilled professionals aide them in the process of running the health sector. Doctors alone should not head the sectors. It should be a combined effort