“Health is everything. If actor die, film don finish”
– Engr. Chidi Izuwah Snr, at the 2019 Future of Health Conference
How do we begin to change the narrative about healthcare in Nigeria? This was a key question Dr. Ike Anya, Nigeria Health Watch Curator, wanted answered at the 2019 Future of Health Conference. “We have been talking about our Universal Health Coverage, we have been talking a lot about reducing maternal mortality and morbidity and improving health for mothers and the reality is that the more access we provide, we also have to be sure that what people are going to get when they get to those health facilities is good quality care,” he said at the opening of the conference, themed “Time to Focus on Quality in Healthcare: Improving Outcomes”.
“Good quality care is not necessarily about money, it starts from the gate of the facility; how the security man welcomes you, how the staff treats you, how clean the environment is. A lot of that is simply about treating and providing service in a way that we ourselves will like to receive care,” Dr. Anya said. He moderated the event alongside broadcast journalist & radio presenter Dr. Inya Ode.
How infusing quality can improve Nigeria’s health care system is what the speakers invited sought to unpack at the event, which is the fifth in the Future of Health Conference series.
The problem posed to Nigerians health by a lack of quality was surmised aptly by Dr. Ngozi Azodoh, Head of Special Projects, Federal Ministry of Health. “Ten to 15 percent of all deaths in low-and middle-income countries have been because of poor quality of healthcare,” she said, adding that, “Approximately 8.6 million people in low-middle income countries die each year from inadequate access to quality care. Out of the 8.6million, about 3.6million never got any health service at all, and 5 million die because of poor quality.”
Speakers on both days shared insights from various perspectives. Key areas highlighted at the conference included quality maternal health, partnerships, patient-centred care, inclusive healthcare, and quality in healthcare standards.
Dr. Mary-Ann Etiebet, Lead of MSD for Mothers, noted that for quality in healthcare to improve, “We need national leadership policies, we need local leadership and champions to make it happen on the ground. We need institutions and structures, like accreditation systems.” She said that while Nigeria contributes 23% of the deaths globally in maternal mortality, there has been remarkable work done in the country. “Earlier this year, teams in Cross River State — in partnership with Pathfinder International, reported that they have reduced maternal mortality rate by 66% in 3 years throughout the state”, she said. “Because of the work that they did, 90% of the women in that state are less than 2 hours from high-quality emergency obstetrics services. We have successes we can build on. Nowhere else in the world has experienced 66% reduction of maternal mortality death except for Cross River State. And that is what we should be proud of and work on duplicating it in other states as well as outside Nigeria.”
Partnerships were noted as key to driving progress and development in the health sector. Engr. Chidi Izuwah Snr., Senior Director General/CEO of the Infrastructure Concession Regulatory Commission in the Presidency, said “There are opportunities where we can work with the private sector to provide good healthcare, in the areas of power, waste management. These are the focus areas in Nigeria where we can bring in the private sector to improve healthcare for Nigerians.”
Quality Patient-Centred care
The focus on patient-centred care was a significant part of the #QualityHealthNaija conversation on both days. “The gaps in the health sector are wide and if we do not have the right attitude to disseminating services, we will be leaving many behind,” Dr. Amina Aminu Dorayi, Technical Director, Family Planning & Reproductive Health at SHOPS Plus, said during her talk. “We have trained about 48,000 CHEWs. And we have focused on patient-centred care not facility-centred care. We developed an app called TP STAA which helps register the patients and upload their details to be available anywhere they may go,” she said.
Dr. Adenike Odubiyi, Chief Medical Director (CMD), General Hospital Igede, said her team created a What’s App platform for their antenatal services, and dedicated staff to monitor it. She said the hospital is also collaborating with primary health centres to make sure they get good outcomes. “I want us to remember that when you talk of quality, you are talking of patient-centred care,” she said.
Dr. Olujimi Coker, Acting CEO & CMD, Lagoon Hospitals, said doctors and patients view quality healthcare differently. “As doctors we are more focused on outcomes, whereas the patients are more focused on the processes of care and to ensure that they are safe in the environment where healthcare is provided and we must not lose sight of this,” he said.
Quality in Inclusive Healthcare
Patience Dickson, Chairperson of the Women with Disabilities Initiative, began her #QualityHealthNaija talk by appreciating Nigeria Health Watch for putting her on the same stage with her colleagues. She made a passionate plea for a change to the way that healthcare workers perceive people living with disabilities. “People look at persons with disabilities as problems, weak, and helpless, as such, need welfare. They are often perceived by the medical world as sick and a burden,” she said, adding that this breeds low self-esteem, discrimination and stigmatisation.
Christian Aid UK Nigeria’s Country Director, Charles Emmamuzou Usie, brought in the perspective of the less privileged. He advocated for dignity and respect in treating everyone, and for equal opportunities for both the wealthy and the poor. “Many communities do not have health centres. And we are leaving millions behind, which is against the goal of the SDGs,” he said.
The perception that infusing quality into healthcare is an expensive process is one that several speakers worked to change at the conference. Dr. Coker spoke about areas in which hospitals could improve quality and one was in the area of infection prevention and control (IPC). “Infection control of course is extremely important, and this is one of the areas that you really don’t need a lot of money to provide quality healthcare,” he said, “Because soap and water is very cheap and the most effective way of preventing hospital-acquiredinfection is through effective hand hygiene, so I will recommend this to everybody.”
Quality Health Standards
The standards by which health services are provided are an incrediblyuseful quality improvement and measurement tools. Dr. Coker noted that the World Health Organisation (WHO) checklist launched in 2008 has helped reduce mortality by 50% and reduced 30-day morbidity by 45–50%, according to a study done in eight different countries. “So, there is no excuse for any operating theatre, not to use the WHO surgical checklist; it is simple, it is quick, and it is effective,” he said. Having quality medicines is also a key factor in infusing quality into health care, according to Dr. Chimezie Anyakora, Chief of Party of the Promoting the Quality of Medicine (PQM) program of the United States Pharmacopeia.
Dr. Obi Adigwe, Director General, National Institute of Pharmaceutical Research and Development (NIPRD) noted that especially in rural areas many people misuse drugs because they cannot read the instructions on it, and those who manufacture the drugs do not take the context where the drugs will be used into consideration. Dorothy Jeff-Nnamani said quality is not what happens in the four walls of the hospital but rather be evaluated according to the equity, safety, timeliness, patient-centeredness, and accessibility of care. “We need to start acting and reduce the talking,” she said.
SafeCare: Quality Improvement at work
At a Fireside Chat at the 2019 #QualityHealthNaija Conference, PharmAccess Foundation discussed SafeCare, a quality improvement methodology. Ms. Njide Ndili, Country Director of PharmAccess Foundation, said SafeCare is the first Internationally accredited Quality Improvement Tool, accredited by the International Society for Quality in Health Care (ISQua). “SafeCare is deployed to help move facilities along the quality improvement path, to help them improve their quality without any punitive measures,” she said in a SafeCare documentary.
The Foundation has assessed over 1000 health facilities in Nigeria, and some of them have scored as low as 15%, Dr. Ibironke Dada, Director of Quality at PharmAccess Foundation, said. SafeCare does capacity assessments to improve processes and procedures of health facilities. It looks at ways of automating processes by leveraging technology to improve operational efficiency when it comes to issues of licensure and quality monitoring, Dr. Dada said.
Pharm. Ibrahim Baba Shehu Ahmed of SafeCare said that their responsibility is “to set standards, ensure that those standards are followed, and were there are breaches, we enforce. Because of our activities, today we have in the register, about 25,000 registered pharmacists.” Dr. Abiola Idowu, Executive Secretary, Health Facilities Monitoring and Accreditation Agency (HEFAMAA) said they were able to create the online platform for the Agency and improve their processes and procedures thanks to SafeCare. “Currently, HEFAMAA has in its register 3,399 private health facilities and 335 public health facilities,” she said. Other speakers included Dr. Onyia, Dr. Adedamola Dada and Dr. Attahiru Bello.
Advancing Quality Maternal Health in Nigeria
The Maternal Healthcare Stakeholder’s Summit themed, “Advancing Quality Maternal Healthcare in Nigeria: What are the Missing Links?” took place on the October 18. Discussions were focused around developing strong relationships with key stakeholders working in the area of maternal care in Nigeria, generating recommendations for creating an enabling environment to improve quality maternity care in Nigeria. The conference aimed to propose innovative approaches to address key gaps in advancing the quality maternity care agenda, a central focus in the journey to achieving universal health coverage, delivering on Goal 3 of the Sustainable Development Goals (SDGs) and elevating women’s voices and integrating the local private sector.
The Honourable Minister of Health, Dr. Osagie Ehanire, opened the conference when he spoke about measures the ministry is taking to improve Nigeria’s quality of health care. “We are promoting the creation of an emergency medical system and patient transport system. In addition, we are open to exploring models that improve our primary health care like public-private partnerships,” he said, adding that, “Pertinently, we are improving the midwifery service scheme so that we can leverage on the wealth of experience of the retired midwives.” He urged that the outcomes of the conference be made available to the ministry “so that we can add this in improving the strategies for health care, especially at the primary health care level.”
Ugonna Ofonagoro, Head of Projects at EpiAFRIC, said at the stakeholder’summit that Nigerian culture “does a lot to children, especially the girl child. It loves them, teaches them but doesn’t respect or listen to them but they need to be listened to.” She noted that health workers need to have a non-judgemental attitude towards young women when they come to access health services.
Tariah Adams, Senior Communications Officer, White Ribbon Alliance, noted that when health care is responsive to the needs of people, it creates trust and better health care. “We reached 74,000 women through our campaign ‘What Women Want’. And they are seeking for basic things like wash, respect, medicine and information. Listening to women is important. Our health system should be structured in a way that listening to women is a part of the system,” she said.
Dr. Charity Chenge, Senior Program Officer at the Bill & Melinda Gates Foundation, said the government does not have to do everything. “We can leverage on the private sector to accredit and the government endorses. You can have all the money in the world, but if it is wrongly used, you will get nothing,” she said.
Abiola Nejo, Segment Manager, Women Young Professionals at Access Bank mentioned that the bank collaborates with the hospital and with individuals, and in 2015 started a maternal health service support scheme, which allows women to get a loan for infertility treatment as well other health care needs. “Earlier this year we had a partnership with General Electric (GE) where the hospitals could go to GE pick their equipment and pay the bank over time. The ultimate for us is that quality health care needs to be done in a sustainable manner,” she said.
Dr. Olamide Okulaja, Director, Advocacy and Communications at PharmAccess Foundation said his organisation is passionate about trying to facilitate quality healthcare services. “We look at the allocation of healthcare from government over the last 10 years, and the performance of that allocation it has not been too great. There was about NGN2.8 trillion out of pocket expenditure for health in 2019. So, there is a lot of money in the private sector and we need to include this sector because of its financial viability,” he said.
The maternal healthcare stakeholder summit was moderated by Temitayo Erogbogbo, Director of Advocacy at MSD for Mothers, and Dr. Ifeanyi Nsofor, Director of Policy and Advocacy at Nigeria Health Watch. Olubunmi Oyebanji, Programme Manager at Nigeria Health Watch, gave the closing remarks and call to action, highlighting that all hands needed to be on deck, and Nigerians need to be active citizens and not leave their health to the government. “We need to push for quality improvements in our primary health centres (PHCs) and health facilities so that no woman loses her life while giving birth”, she said.
If it’s not quality, it’s not health
Partners for the 2019 #QualityHealthNaija conference, all working to improve quality in healthcare in their various spheres, were; MSD for Mothers, the USAID-funded SHOPS Plus Project, development Research & Projects Centre (dRPC), who are implementing the PaCFaH@Scale Project, Society for Family Health, PharmAccess Foundation, Christian Aid UK Nigeria, Marie Stopes, and EpiAfric.
The consensus from speakers and participants at the 2019 #QualityHealthNaija Conference was that quality is the bedrock of healthcare. The need to go beyond discussion to action in order to ensure that the momentum created by the conference would not die was emphasised. Engr. Izuwah’s summary was apt. “The problems we face in our health care systems are not imposed on us by God, it is done by our actions and by our inactions and each of us here can collectively change the future of the health of our country; a healthy nation is a wealthy nation,” he said.