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Pathways for enhancing performance of healthcare system in Nigeria

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Fatusi

Being text of a paper delivered by Prof. Adesegun Olayiwola Fatusi, professor of Public Health & Community Medicine, Obafemi Awolowo University (OAU), Ile-Ife, Osun State, during the 15th Sir Samuel Manuwa lecture at the 42nd West African College of Physicians (WACP) Annual General & Scientific Meeting in Kaduna, recently.

The concept and exploration of the “health system”
We will now turn our attention to the exploration of the concept of the “health system” to provide an appropriate context for the rest of this lecture. The notion of the health sector as a system is apparent from the common phrase, “health system”, but the events around us strongly suggest that it is a poorly understood concept both by the diverse bodies of health professionals and the political leadership in our dear country, Nigeria. From the piecemeal approach to health governance to the fragmented government-workers unions’ negotiations, the ever-contentious multiple public sector salary scheme, and the disconnect in the health professions, there seems to be very little of a “systems approach” to the health system’s operation in Nigeria. The account of the life of Sir Samuel Manuwa must challenge us all to deepen our understanding of the health system and to richly interact with the system so as to promote and enhance its performance, and ultimately to improve the health of our people. Without such knowledge and interaction, our practice of Medicine, no matter what speciality we are in, will be of only minimal impact. As Shine has posited, “The 21st-century paradigm is that of physicians who understand teamwork and systems of care in which they can provide leadership”. Clearly, we need to understand the health system well to truly be able to bring meaningful change to it.

The concept of the health system
What is the health system and what is its purpose? The interesting answer a student once gave me simply was: “a system that focuses on the health of the people” (I guess that he must have wanted to add the expression “of course” to his answer but for his respect for his teacher). Simplistic, no doubt, but useful in some ways as it clearly articulates the purpose of the system – ensuring the health of the people, not simply to put facilities in place, give drugs and offer treatments, or engage healthcare workers. The challenge with that definition (if we agree to call it a definition) is that it still leaves us with the two phrases we are trying to unravel: “health” and “system” and which I would want us to explore further. But first, let us draw on the literature to see some definitions of the health system.

Roemer classically defined a health system as “the combination of resources, organization, financing and management that culminate in the delivery of health services to the population. However, as the WHO has made clear, “delivering health services is an essential part of what the system does—but it is not what the system is.” The health system, as WHO defines it, consists of “all organizations, people and actions whose primary intent is to promote, restore or maintain health.” The Tallinn charter expanded on the WHO’s perspective by defining the health system as “the ensemble of all public and private organizations, institutions, and resources mandated to improve, maintain or restore health”. Thus, the health system is far more than the pyramid of health facilities and well-polished professionals who deliver health services. Health, as WHO puts it, is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. In a more operational sense, health can be defined as “a state of balance, an equilibrium that an individual has established within himself and between himself and his social and physical environment”.

To gain a deeper perspective of the health system, we will now turn our attention to the more intriguing concept of “system”. Systems are dynamic architectures of interactions and synergies. Systems can be best understood as an arrangement of parts and their interconnections that come together for a purpose. What makes the health system distinctive is that its purpose is concerned with people’s health. Secondly, the health system is an open system: “open” because it can be influenced by events outside it and the health of the people, which is its central focus, can be influenced by factors outside the health sector itself.

Thirdly, the health system is a “complex adaptive system”. This means that it is not a mechanical system – it does not operate on auto-pilot and neither is it fixed in its behaviour; rather, it is dynamic in nature and responsive to certain actions and several stimuli. Plsek and Greenhalgh defined a complex adaptive system as “a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions change the context for other agents”.

Implications of the system dynamics for the health system and its performance
What are the implications of viewing the health system from a system dimension point of view? That is the important and practical question we will now quickly explore. First, we must understand that every intervention in the health system – from the simplest to the most complex, has an effect on the overall system – and the overall system has an effect on every intervention. This is a fundamental mental model that we must employ in the consideration of any action within the health system. This paradigm of health systems approach is embodied in the concept of “systems thinking” – the art of studying the whole in order to understand the parts.

Systems thinking works to reveal the underlying characteristics and relationships of systems. As WHO has aptly pointed out, “Systems thinking has huge and untapped potential, first in deciphering the complexity of an entire health system, and then in applying this understanding to design and evaluate interventions that improve health and health equity”. In the words of Peter Senge “the art of systems thinking lies in seeing through complexity to the underlying structures generating change”. Systems thinking will help us as leading health professionals to get to grip with the complexity of the health system as well as to adequately prepare for consequences that might result from the interactions between many different health system actors and elements.

Also, from the perspective of an “open system”, we need to become more collaboration-conscious and break free from our classical “exclusive” and sometimes “stand-aloof” approach to health issues and health development matters. We need to increasingly and pro-actively engage with other actors within and outside the health sector, including the political space to build trusts, seek productive collaboration, and gain supportive partnerships for relevant health development agenda. Thirdly, knowing the nature of a complex adaptive system, we must seek to improve our understanding of the context of health challenges and interventions. We must study past, present and emerging pattern of behaviours to better understand the dynamics of our system, and seek to understand how the organizational structure within our systems influences behaviours and actions. Finally, we must increasingly prioritise the timely generation, dissemination and use of relevant and valid data to guide decisions and actions within the health system.

In essence, systems thinking and systems perspective can help us to make sense of, and potentially untangle the never-ending crises in the Nigerian health sector, particularly the unnecessary, bitter and counterproductive inter-professional rivalry that has periodically denied our people the much needed health care and imperil the health, longevity, and well-being of many of our co-citizens. Within the framework of systems thinking, for example, there is no “us” and “them” as all are part of the same system and thus responsible for both the problems and their solutions.

The architecture and goals of the health system
To round off our exploration of the health system, we will now discuss its architecture as well as its goals. The defining goal of the health system is to improve and protect health. In addition, the health system also has a number of other intrinsic goals: fairness in the way people pay for healthcare particularly to avoid catastrophic illness-related expenditure, responsiveness to people’s expectations with regard to how they are treated, and efficiency in the use of resources. The health system also has some intermediate goals, which are: “achieving greater access and coverage” and ensuring “quality and safety.”

To achieve the overall goals of the health system, there are six interacting sub-systems that constitute the building blocks of the health system. These are human resources, medicine and technologies, financing, information, service delivery, and leadership and governance (otherwise known as stewardship). It is important to note that the building blocks themselves do not constitute a system – just as blocks alone do not constitute a functional building. Rather, it is the dynamic interaction of the building blocks – the relationships between them and their influences on one another – that makes them into a system. Thus, when taken together in the full context of their dynamic interactions, these six building blocks constitute the overall health systems architecture. On the other hand, the health system architecture is also defined by its “people-centred” nature. As such, a well-functioning health system provides the platform for ensuring and improving the health of the people at individual, household and community levels.

Analysis of Nigeria’s Health System Performance And The Performance Factors
At this juncture, we will now examine the performance of the Nigeria health system in the light of the global goals of the health system. To do that, we will consider selected health level (or health status) and health equity indicators from the perspectives of the overall health system. We will also consider selected indicators in the context of the field of Family and Reproductive Health or Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health (SRMNCAH) due to the centrality of the field in the global health agenda as evidenced from recently expired Millennium Development Goals (MDGs) 4 and 5 and 6, and the Sustainable Development Goal 3 (SDG3).

Health outcomes
Health status and performance
Overall health system
The Ibrahim Index of African Governance (IIAG) produced by the Mo Ibrahim Foundation is an excellent starting point for the analysis of our health system’s performance. The IIAG is unarguably the most comprehensive analysis of governance issues in Africa, and health is one of the 14 categories covered. I must publicly admit that I am highly fascinated by the IIAG index as a genuine “home-grown” African development-oriented initiative. The 2017 IIAG assessed the health system performance of countries using a robust index incorporating nine key indicators.

In the IIAG health category, Nigeria ranked in the 45th position among 54 nations in 2016 with a score of 60.7 (over a total of 100), which is lower than the African average of 71.5. Our ranking is poorer than that of most of our less resource-endowed neighbours in West Africa. Compared to our 45th position, Capo Verde ranked in the 4th position, The Gambia in the 14th position, Senegal in the 15th position, Ghana in the 22nd position. Overall, among the 15-member nations of the Economic Community of West African States (ECOWAS), Nigeria ranks higher than only three countries –Niger Republic (46th position), Liberia (47thposition), Sierra Leone (49thposition).

Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health indicators
Towards the end of 2016, I had the privilege alongside a highly respected senior colleague and mentor, Dr. Sola Odunjirin (FWACP, Community Health) to undertake a review of Nigeria’s performance (2007 to 2016). We undertook that review as part of the baseline activity in respect of the task given to us by the Federal Ministry of Health and WHO office to lead the development of Nigeria’s first Integrated National Reproductive, Maternal, Newborn, Child and Adolescent Health and Nutrition (RMNCAH + Nutrition) Strategy; that new strategy succeeds the decade-old Integrated Maternal, Newborn and Child Health (IMNCH) Strategy launched in 2007.

Our review benchmarked Nigeria’s health system performance primarily against the targets set in various relevant national policy documents. Overall, we found that Nigeria achieved good progress in only 2.7 per cent of the 74 indicators reviewed but recorded worsening performance in 16.2 per cent of the indicators! Our findings also showed that we achieved low or insufficient progress in 41.9% of indicators, no change in 5.4 per cent of indicators while data were lacking regarding 33.8 per cent of the indicators to make an objective judgement (Figure 3). Two quick conclusions are obvious from that review exercise: (a) poor progress and (b) poor data culture.

The two conclusions are actually closely inter-linked: without data, we cannot judge progress, and we cannot recalibrate our efforts. As Osborne and Gaebler have noted, “If you do not measure results, you cannot tell success from failure; If you cannot see success, you cannot reward it; If you cannot reward success, you are probably rewarding failure; if you cannot see success, you cannot learn from it; if you cannot recognize failure, you cannot correct it” . These words clearly underlie some of the ironies of our health system… inadequate review and accountability, inadequate learning from previous experiences and, thus, repeated recycling of our mistakes (just as we are busy recycling political leaders without bringing their previous records into sharp focus)!

When we focused our attention on the 48 indicators for which data were available, the result showed progress in only 4.1% of indicators but worsening performance or retrogression in a quarter of indicators (24.5%). We also had low/insufficient progress in 63.3% and no change in 8.1%.

Health equity
As evidenced from the Nigeria Demographic and Health Survey (NDHS), of which the 2013 survey36 is the latest so far, there is considerable inequity in the access to and utilization of SRMNCAH services within our population. The 2013 NDHS result shows a consistent pattern of inequity between the rich and the poor and between the rural and urban-based population across various maternal care indicators – contraceptive behaviour, antenatal care, skilled birth attendants, facility-based delivery, Caesarean operation, and postnatal care.

For example, the proportion of pregnant women in the highest socio-economic class who had skilled attendance at childbirth was more than 10 times the proportion of women in the lowest socio-economic class who received such skilled services (86.2% vs. 7.4%). The proportion of urban women who received assistance at childbirth from skilled personnel was also more than double those in the rural areas where the majority of Nigerians live (68.2% vs. 25.6%). In the economic realm, the equity gap was not just between the richest and the poorest but consistent across the socioeconomic gradient.

Interestingly and disturbingly, an examination of the 2013 NDHS data also indicates that even when pregnant women access ANC services at health facilities, there are gaps in the package received by the rich compared to the poor (Figure 6). For example, whereas over 90% of the richest women had their blood and urine taken in ANC settings for relevant examinations, just slightly over half of the poorest women were accorded the same care in healthcare settings.

Thus, on the whole, the poorest women, who have a higher level of health vulnerability and higher risks for poor maternal and newborn outcomes, receive less of the essential health care package when they attend ANC in health facilities compared to their richer counterparts. The components of ANC received by pregnant women is not only a question of equity but also an issue of quality of maternal care.

A comparison of the 200337 and 201336 NDHS results also highlights a particularly disturbing trend of a widening gap between the richest and the poorest women in terms of the proportion that received key maternal, newborn and child health services (Figure 7) as the rich improved but the poor retrogressed. This finding has significant implication for the targeting of our services, the health service delivery approaches and the overall design and management of our health system.

Factors associated with health system performance and outcomes in Nigeria
To take our analysis further and deeper, we will now consider factors associated with Nigeria’s poor health system performance. Broadly, four major factors, in my opinion, explain most of the poor performance and rating of the Nigerian health system: (i) inadequate and inequitable access to essential services and high-impact interventions, (ii) sub-optimal quality of services, (iii) low level of health literacy and associated poor health-seeking behaviour of the population, and (iv) weak health systems stewardship. We will briefly examine each of these factors as well as the cross-cutting challenge of lack of trust within the health system.

According to 2013 NDHS36, more than a half (53.3%) of women 15-49 years reported that they experienced serious problems in accessing health care for themselves when they were sick; the most common reason given for the inability to access care was financial problem (42.0% of all women mentioned finance as a challenge). The problem was predictably worse among the rural-based and the poorest women. Indeed, among the poorest women, over three-quarters (75.7%) of those with healthcare access problem identified financial inability as an obstacle.

The second challenge is the quality of care. To have a peep into the quality of health services in Nigeria, we will briefly examine the findings from the analysis of Healthcare Access and Quality Index for 195 countries published in Lancet in May 2018 and that of the Service Delivery Indicators (SDI) study carried out in a number of African countries with the support of the World Bank. Nigeria ranked at 142nd position out of 195 countries on the HAQ index in 2016 index41. Nigeria’s score on the HAQ index is 41.5 on a scale of 0-100, which (or simply, 41.5%), which you will all agree with me is a failure mark in our medical schools, and in our fellowship examination will go with the appellation of “an abysmal failure”.

The result of the Service Delivery Indicators (SDI) study points to deeper quality challenges in the Nigerian health care system, including a low level of 37.3% diagnostic accuracy among primary healthcare workers. Among the five countries involved in the study, Nigeria’s diagnostic accuracy was the second lowest (Table 1). The diagnostic accuracy level in Nigeria (37.3%) was just half of that recorded for Kenya (74%)43. Adherence to clinical guidelines was also poor (31%), and only 17% of the health workers assessed were found to be managing maternal and child conditions correctly41. The study also reported significant deficiencies in virtually every area of key health systems input – human resources: 34% of health workers were absent from work; drug and supplies: vaccines were available in 76% of facilities and essential drugs in only 46% of facilities. Worse still, less than a quarter of the PHC facilities assessed in Nigeria had the required minimum infrastructure (23%), and minimum equipment (20%) level.

The third challenge is the low level of health literacy and associated poor health-seeking behaviour of the population. As the 2013 NDHS reported, for example, only three-fifths (60.6%) of pregnant women received ANC from skilled attendants. The majority of Nigerian mothers in this age and time still deliver at home: over three-fifths (63.1%) delivered at home, with the figure as high as 77% among rural women and 93% among the poorest women. The proportion of women who delivered at home is 90% or higher in Yobe (90%), Jigawa (91.4%), Sokoto (94.2%), and Zamfara (94.2%). As we have demonstrated in one of our publications, health-related attitudes, household factors and community characteristics all affect the maternal health-seeking behaviour in our country47.

As we had learned from the system approach, a shortcoming or challenge regarding one component or sub-system of the health system architecture affects the performance of the other sub-systems. To strengthen the health system, therefore, we must improve on all the six building blocks and manage their interactions in effective ways that would ensure improved, more equitable and sustained health gains for the people. The efficient management of the interactions of the building blocks is a stewardship function within the health system. Stewardship, otherwise also referred to as leadership and governance in the health systems literature, denotes the overall oversight of the health system and sets the context and policy framework for the overall health system and its operations. The presentation of the health system by WHO in a circular form with leadership and governance at the centre of its framework for health systems action makes the point quite well (Figure 8)21.

An often overlooked but extremely important factor that the “system approach” and the stewardship dynamics thrusts forward is that of “trust”. Trust plays a crucial role in the overall performance of the health system as the functioning of the system depends on the interaction of its parts, and the behavior of the diverse professional human agents is a key driving force in the dynamics of the complex adaptive system of the health sector. Without any doubt, trust is largely lacking among the various stakeholders of the Nigerian health system today – between the government and the health professional groups, between various health professional groups, between the public and the private sector, between the orthodox and traditional health system, and between the orthodox health workers and the Nigerian population.

The distrust of our health system is a factor that is responsible for many of the poor health-seeking behaviour of our population – including their preferences for less qualified traditional healthcare workers as well as spiritualists of various colours and shades including a host of charlatans. The distrust of our health system, health facilities and health practitioners is also a major factor driving the outward-bound medical tourism. To be candid with ourselves, it will be impossible to reverse the medical tourism trend without first rebuilding the broken down wall of trust between the healthcare workers, the health system, and the Nigerian population. The increasing distrust of the health governance and overall political system is also a major push factor in the new wave of migration of our doctors to the United Kingdom and other countries – and that is a sure threat to the future of our health system and training programmes, and must command our attention.

Addressing performance challenges and shaping the future
I will now focus my attention on the potentials for improving the health system. As a student of health policy and systems thinking, I very well recognise that there are no simple magic wands for the improvement of the health system and its performance. Simplistic solutions do not work, and piecemeal approach is not the way to go. Rather, we need well-thought-out plans that are context-relevant and implemented in a consistent, committed and sustained manner. There are seven key actions that I believe can serve as appropriate control knobs through which the Nigerian health system can be turned around for improved performance and outcomes. These are:
• Strengthen the primary healthcare system and prioritise universal health care agenda
• Strengthen the community systems and households’ health production capacity
• Scale up promising and high-impact intervention and strengthen their implementation
• Expand social health insurance coverage and strengthen financial protection
• Strengthen health workforce development and inter-professional relationships
• Improve health systems funding and accountability
• Improve governance, linkages and coordination across all levels

Time will fail us to discuss this seven-point agenda in details in this lecture, but I have endeavoured to discuss them in some details in the printed version of this lecture. I will only briefly touch on these outlined agenda here and emphasise two or three of them in particular.

Strengthen the primary health care system and prioritise universal health care agenda
PHC is the bedrock of our health system and we need to pay far more consistent, systematic, evidence-based and systems-driven attention to it. Efforts to strengthen our primary health care should also be with a strong focus on universal health care (UHC) in line with the vision explicitly indicated in our new National Health Policy. As WHO has stressed, strengthening the health systems is the only realistic way of achieving the health-related SDG targets, and the platform for achieving all of this is UHC56 (Figure 9).
Strengthen the community systems and households’ health production capacity
The community health system, defined as “the set of local actors, relationships, and processes engaged in producing, advocating for, and supporting health in communities and households outside of, but existing in relationship to, formal health”, must be strengthened if we hope to truly improve health systems performance as health is primarily produced by the people and their households – and not by the Ministry of Health or health professionals.

As I often emphasise to students in my master-level public health class in Strategic Leadership and Development Management, mothers are perhaps the most important and greatest health workers of all times. They are the health workers whose unquantifiable labour of love often maintain household members, particularly children, in good health through nutrition support, hygiene education and practice, emotional supports etc. Mothers are often the ones who make the primary diagnoses of illnesses; assess the severity and potential outcomes; select among available treatment options and providers; decide when to access the selected treatment option; as well as procure and administer treatments. Households are the ultimate producers of health, and mothers are the primary managers for the household production of health: this is a paradigm that the Nigerian health workers need to fully understand, embrace and tap into to improve health outcomes.

For optimal result, we must strengthen the capabilities of the households in terms of their resources, practices and values. We need to also strengthen the community health worker system and effectively practice task-shifting and task-sharing in line with our national policy. Furthermore, we must build and deepen trust and effectively engage with and empower communities to build viable and resilient community health systems with strong links to health and other relevant sectors.

Scale up promising and high-impact intervention and strengthen their implementation
The challenge of the health system in Nigeria is really not an absence of relevant initiatives or implementation of promising interventions. We have and have had several promising initiatives including “Making Pregnancy Safer” (MPS) and Midwife Service Scheme. Rather, the key problem is that there are pockets of promising initiatives that have not been taken to scale, or replicated with any significant degree of fidelity, and not sustained over time.

The National Health Act, for example, is a bold stewardship effort but since its passage in 2014, how far have we gone with its implementation? Moving forward, it is critical that programmes and policies be evidence-informed, well designed and implemented with a high degree of commitment. Programmes should also be well documented, rigorously evaluated and results disseminated widely to inform the design of future programmes. Finally, successful initiatives need to be scaled up and implemented with a high degree of fidelity and an innovative mindset.

Expand social health insurance coverage and strengthen financial protection
As far as the cost of medical services is beyond the level of financial affordability of most people, access to quality services will always remain a mirage for most Nigerians, especially those in the poorest socio-economic group. Moving forward, it is time to significantly re-engineer and rejuvenate our National Health Insurance Scheme (NHIS) and expand its scope based on careful analysis of the impediments and challenges and best global practices. There is certainly a lot that we can learn from a country like Rwanda where the mandatory community-based insurance system had achieved a coverage of over 80% (by 2015/201669). Rwanda has established an effective mechanism to identify those most in need of exemptions under the social health insurance, as well as “invested in a stratification process that has systematically identified poor groups to enable them to access all social programmes in the country, not just health insurance”69. If Rwanda can do it, “big brother” Nigeria should be able to do it too – but it will need Rwanda’s kind of strong determination, clear focus and high level of political commitment.

Strengthen health workforce development and inter-professional relationships
The health workforce is the lynchpin in the operations of the health system; without competent health personnel with a deep commitment to the objectives of the health system, and passion for a collaborative approach and teamwork, the health system can achieve very little. Nigeria has several challenges in terms of her human resources in health, particularly poor distribution, “brain drain”, and inadequate skills among others. But the challenge that I find most distressing is that of the repeated and endless industrial strikes and inter-professional rivalry that is gradually destroying the very soul of our health system. As one commentator sadly noted, “no part of public service in Nigeria has experienced more strikes than the health sector in the recent years”70. What a shame! Really, no health professional group has a clean hand when it comes to these strikes.

Without any doubt, the government has its own share of the blames with respect to many of the issues at stake in the strikes (if not the larger proportion of the blames many times). But one area of significant weakness and undue indulgence on the part of the government is the failure to apply the “no work, no pay” as stipulated in the labour laws. While applying such laws, which is also a matter of morality in a way, may not stop all industrial actions, it is likely to reduce frivolous ones to a minimum. Even at that, we must still work in trust to unearth the root problems with the view of evolving long-lasting solutions to the challenges of industrial action and disharmony within the health sector.

With its multi-professional nature, collegiality, mutual respect and trust are particularly important in the health professions and the health system – they are the invisible glues that hold the health team together and the catalysts that turn diverse professionals into solid and high performing teams. As Martin Luther King Junior rightly said, “we must learn to live together as brothers or we will perish together as fools”.

In line with the recommendations of the Global Commission on Education of Health Professional for the 21st Century, instructional reforms should be promoted in our health training institutions with a stronger focus on promoting “inter-professional and trans-professional education that breaks down professional silos while enhancing collaborative and non-hierarchical relationships in effective teams”72. Nigeria had a perfect model of such pre-service philosophy and approach in the original programme of the then University of Ife (now Obafemi Awolowo University) that is classically referred to as “Ife Philosophy” of health professions education. The “Ife Philosophy” focused on building “health teams …by providing a high-level common education in the medical sciences (for all health disciplines) for three years” and supported by other ancillary out-of-classroom activities73. I will always remember with great joy and nostalgia my experience as a student who was privileged to be trained under the old 7-year Bachelor of Medicine, Bachelor of Surgery (MBChB) training programme of the “Ife Philosophy”. I had the privilege and pleasure of sharing several classes over a three-to-four year period with colleagues in Dentistry, Nursing, Medical Rehabilitation and Environmental Health. Many classmates across diverse health professions from my university days have remained long life, trusted and highly respected friends and colleagues. As The Nigerian Academy of Science recommended in 2012, we need to re-examine such a model and re-engage appropriately with it in our various health institutions to promote the building of inter-professional trust and understanding from a foundational level.

As I draw the curtain on the issue of the health workforce development, I find it difficult to resist the temptation to make an observation on an issue that has continuously troubled me since my days as a resident doctor regarding our highly cherished training programme. As a body, the West African College has shown a remarkable drive in constantly reviewing its curricula and examination practices to increasingly align with global best practices. One main challenge that we need to seriously examine, however, is the low pass rate, which is far below what obtains in comparative training programmes in many other parts of the world. At an invited presentation that I made on postgraduate medical training at the Annual General and Scientific Meeting of the Nigerian Medical Association held in Ibadan in 201574, one poser I raised is: “high level of failure…. A thing of ‘pride’ or a matter of ‘concern’”?

As I highlighted in the said presentation, the lowest pass rate for any speciality in the residency programme of the Royal College of Physicians and Surgeons of Canada for the 2012-2014 period in respect of the first-attempt Canadian-trained candidates was 88.5%68. In fact, outside Public Health and Preventive Medicine, Neurosurgery with 89.9% pass rate was the only other one of the 41 specialities that did not have a pass rate of over 91%; four specialities actually had a 100% pass rate75. For the American Board of Internal Medicine, the pass rate for the first-time candidates for initial certification has steadily increased from 86% in 2013 to 90% in 201776. I need not tell you that the picture is radically different and the pattern diametrically opposite when we consider the results of our Fellowship examination and that of our sister bodies – the West African College of Surgeons and the National Postgraduate Medical College of Nigeria!

Curiously, the issue has hardly received significant attention in our discourse on the performance and the future of our postgraduate medical education in Nigeria77,78. To be fair to our younger colleagues, can we blame any bright, promising and ambitious young Nigerian physician who chooses the United States, Canada, Britain etc, as the place for postgraduate training solely on the prospect of examination success? The issue of low pass rates in our Fellowship examination certainly poses a challenge to the human resources in health development in our nation79 and the West African sub-region as a whole and has implications for the health systems performance Furthermore, whether we like it or not, this state of affair is beginning to induce some level of distrust in certain quarters.

While we must continue to preach and uphold excellence, this issue is one that we need to critically interrogate to see where corrections and adjustments are needed. Clearly, the fault is not and cannot be that of the College alone71, but as the leaders in this field of specialist training, it behoves us to take the lead in this matter and offer practical solutions that can change the present narratives. After all, the true essence of leadership is proactively and courageously addressing challenges and making a positive impact on people and systems.

Improve health systems funding and accountability
Budgetary allocation to the health sector in Nigeria has generally been poor and the government expenditure on health per capita on the low side ($34 in 2014)82. Clearly, there is the need for Nigeria to considerably increase financial allocation to health for improved outcomes and innovative efforts are needed to improve the generation of additional financial resources for the health sector. The provision of the Basic Health Care Provision Fund in the National Health Act provides an opportunity for an improvement in PHC funding, and its implementation needs to be pursued with vigour.

On the other hand, there is also no doubt that it is possible to achieve much more health improvement than the country had so far recorded if the financial allocation to the health sector had been expended for what they had been allocated for and if health spending had been as efficient as possible. Without any doubt, the high level of corruption and inefficiencies in Nigeria, which cuts across every segment of the health sector including the government, private sector as well as the domain of the international development partners, is a major challenge to achieving optimal gains from our current health funding allocations. We, therefore, need to also significantly increase accountability, reduce corruption, and improve healthcare spending efficiency.

Improve governance, linkages and coordination across all levels
Nigeria needs to take some key actions to improve the health governance and leadership. Firstly, we need to make sincere commitments to the implementation of our key policies, including allocating adequate funding to the implementation, ensuring suitable implementation structure, and monitoring and evaluating their implementation and the outcomes. Secondly, there is the need to improve coordination within the health sector, and across sectors to maximize the health benefits. The National Strategic Health Development Plan (NSHDP) provides us with a good platform and avenue to do that. Thirdly, the government needs to strengthen the monitoring of the health infrastructure and quality of services within the private sector and establish a strict system of regular and transparent accreditation. The fourth dimension is improved coordination and oversight of the activities of international development partners and the strengthening of the partnership frameworks.

Conclusions
A well-functioning health system is essential to improving the health and well-being of the population. The Nigerian health system has not performed optimally over the years with the result of unsatisfactory population health status and high level of health inequity. Yet, Nigeria has all it takes and the potential to improve her health system and health outcomes significantly. As a nation, we have the resources including a good number of highly qualified health professionals that include the Fellows of the West African College of Physicians. We also have necessary policies and policy instruments to drive sustained improvement of our health systems and actualization of our health agenda. In addition, we are not bereft of ideas or experiences in programme implementation from the several examples of innovative small-scale interventions that have been implemented over time.

Yet, we have a number of challenges – which have limited our progress over the years despite our rich potentials. These include a lack of sincere and sustained commitment, low political will, and inadequate accountability for results; these challenges manifest across all the health systems building blocks. The cross-cutting and underlying issue, however, seems to be a beclouding of our vision as to the purpose of medicine and healthcare and the goals of the health system, on the one hand, and the failure of the “trust” factor on the other hand. Without vision, as the Holy Book puts it, the people perish (Proverbs 29: 18). On the other hand, without a high degree of trust, there can neither be true partnership nor genuine and result-oriented collaborations that can effectively drive a purposeful and shared vision. The time to radically challenge our challenges is now; it is time to move forward and fully put our potentials to work for the health benefits of our population.

While there is no perfect recipe for the health system, as the “systems approach” has made clear to us. Yet, there are promising lines of action as we have discussed. These lines of action call for a renewal of our vision as to the purpose of the health system, which is to “improve health and health equity, in ways that are responsive, financially fair, and make the best, or most efficient, use of available resources”. Our health system needs committed and effective teams to achieve its goal… Multiple health workers from different professional backgrounds working together with clients and patients, families, households, caregivers, and communities to deliver the highest quality of care. As Chuck Swindoll, one of my favourite authors, stated in his book, The Finishing Touch, “Nobody is a whole team…We need each other… Isolated islands we’re not. To make this thing called life works, we got to lean and support. And relate and respond. And give and take. And confess and forgive. And reach out and embrace and rely. Since none of us is a whole, independent, self-sufficient, super-capable, all-powerful hotshot, let’s quit acting like we are. Life’s lonely enough without our playing that silly role”.

Without any doubt, we all need to rededicate and recommit ourselves to building a well-functioning and resilient health system with effective and efficient teams guided by a clear vision and a sense of mission: that task must start with us as members of the top echelon of the health profession. With all of my heart, I believe that it is possible with the right set of actions and commitment to rewrite the future of the Nigerian health system and improve the national health outcomes significantly. Indeed, I strongly believe that irrespective of our past, our future – the future of our health system and the health of our people – can still be written beautifully in gold.


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