5 “Provocations” of Healthcare Quality Reform


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n the four decades since he made his impassioned statement at the dedication of the Hubert H. Humphrey Building on the 1st of November 1977, the quality of healthcare provided to these groups has remained a benchmark not just of the moral credentials of any government, but also of its stewardship of the human capital and cultural legacy bestowed upon it by previous generations. Any nation in which children die needlessly, where the few who survive to old age suffer unduly and those in material, social or physical need go unsupported is a nation contribute meaningfully to the development of his fatherland, preferring instead to offer criticisms of a country now totally alien to him, from a comfortable and seemingly unassailable distance.

In response to this I plead, as you might expect,“not guilty as charged”. I have, over the past year or so, had the opportunity to contribute and the privilege of giving back to the continuing medical education of practitioners in Nigeria. This has so far, been an incredibly fulfilling experience in itself and I fully intend to continue over the coming years.

The moral test of any government is the way it treats those in the dawn of life – the children,those in the twilight of life – the elderly, and those in the shadow of life – the sick, the needy and the handicapped.
Hubert Humphrey Jr. (38th Vice President, USA, 1965 – 1969) destined in its current state, to make very
little progress.

By any recognised measure of socioeconomic progress, citizens of the Federal Republic of Nigeria have been considerably underserved and disadvantaged by a series of patchy and generally low-quality healthcare provision
standards made available to them over the years. An estimated US$1 billion is spent annually on health tourism for conditions that ought to be treatable at home, a situation which in most aspirational and well-ordered societies would quite rightly be considered a national disgrace.

So far this might read like the habitual polemic of a privileged lucky brat, who having benefited from the best of education and professional training locally available at the time, makes his way to the United Kingdom, obtains
postgraduate qualifications and refuses to Indeed, the purpose of my deliberate mischiefmaking in the first few paragraphs of this article is to ignite the burning platform from which to consider the potential solutions to rapidly improving healthcare delivery and the quality of health outcomes for the deserving people of our great country.

In the sections that follow, I will be using relevant concepts and models to adduce arguments for how through contextually applied global solutions with local adaptations,Nigeria can begin to surmount the numerous barriers that confront it with regard to improving health care quality.

I will attempt to do this through a series of 5 “provocations”, which essentially are suggestions about what needs to be considered in seeking to improve the quality of healthcare provision in Nigeria.

1. Adoption of nationally agreed definitions of quality in the Nigerian health care context

While it is true that various relatively unsatisfactory definitions exist for health such that a universally acceptable definition of health quality is problematic, other health systems around the world have grappled with the same or similar issues and managed at the end of a formative process of development, to come up with workable definitions of ‘quality’ in health.Lord Ara Darzi came up with a definition that works for the National Health Service (NHS) in the UK and which could perhaps be adapted in suitable format to satisfy the precise requirements of the Nigerian context.

In his reckoning, quality in health has 3 central components, namely – patient safety, clinical effectiveness and patient experience. In essence, patients and their relatives can judge the level of healthcare they receive based on these (measurable) parameters. In the interest of brevity, I will not go into much detail on this,
but will attempt instead to link these 3 components to essence of the 2nd provocation.

2. Government has to provide an enabling legal and policy environment for delivery of high quality care

This will of necessity involve explicitly championing high quality care through legislative enactments that mandate minimum standards of governance and safety controls at all levels of care provision whether private and
public healthcare.

Furthermore, borrowing coinage from yet another US politician, the present list of ‘known-unknowns’ in terms of numbers of health care providers, patient safety incidents,professional malpractice litigation, costs of common health interventions and their outcomes will need to become ‘knownknowns’.This will require concerted effort to
bulk up the academic disciplines of public health and epidemiology, health economics,medical statistics, etc.

The possibility of establishing national, regional and state inspectorate infrastructure will become increasingly accompanied by the need to empower such quangos to make necessary recommendations and changes on ground.

Setting-up clinical networks and case registers are essential building blocks for agreeing quality standards and providing mutual support for practicing healthcare professionals. Finally, a clear approach to promoting improved patient safety and mechanism for sharing the learning from adverse and untoward clinical (and administrative) incidents is essential to preventing a re-occurrence of similar incidents in the future.

3. Public health education programmes from cradle to grave aimed at increasing the health llteracy level of the average Nigerian

Owing to a prevailing culture of entrenched socio-economic inequality, there is a compelling case for majoring on prevention strategies in order to reduce the financial burden of health care for the least able to pay.Achieving a desirable state of increased population literacy and health awareness will also have the effect of undermining deep-rooted, dysfunctional systems of paternalism and power distance,largely dependent on preservation of hierarchy
and false economies of knowledge inherent in the doctor-patient relationship.

4. Strengthening of the legal basis for seeking redress when detriment is experienced by patients as a consequence of medical negligence

Indeed, the possibility of losing professional licenses and the closing down of sub-standard medical facilities must be kept under review in order to prevent unscrupulous medical practitioners from taking advantage of lapses in
regulation and governance standards to set-up shop within the system.

5. Recognition and reward of quality healthcare standards

Recognising and rewarding clinicians and care delivery providers for delivery of high quality care will incentivise and promote higher professional standards and innovative care practices throughout the sector. Such an
awards system is likely to have the desired effect of driving up clinical practice standards with attendant consequences for patient outcomes.

In Conclusion

Quality in health care delivery is an enduring and difficult issue to master, especially in the context of developing countries such as Nigeria, with multiple and intersecting challenges and problems. Having said this, few
things should be assigned more strategic importance than the health and wellbeing of the people of any nation. There is a very important saying – “our people are our destiny”. It stands to reason therefore, that the challenge
confronting society regarding the quality of healthcare offered to its citizens is indeed a pertinent and existential one.

Returning to my introduction regarding the remarks made by the late Hubert H. Humphrey at the dedication of the building commemorating his achievements as the 38th vice president of the united states in 1977, it is interesting (or perhaps simply apt) that this edifice was soon afterwards to become the headquarters of the United States Department of Health and Human Services (HHS). His oftquoted comments at an interesting time in the history of his country serve to remind us of the essence of our existence and our responsibility as care givers in society.

In the next few articles, I will delve deeper into a number of issues relevant to improving quality and healthcare delivery standards at the practitioner-patient interface.


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6th May 2018

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