The international assessment of our state of health is nothing to write home about, although it may not be viewed with the same level of dismay and disappointment because once in the rot the sense of smell disappears.  It is even more disappointing considering the amount of resources invested in healthcare as well as for publicising the seven Points Agenda of President Umaru Musa Yar’Adua. Children are dying before their 5^th birthday from diarrhoea, cholera, dysentery, malnutrition and abuse syndrome. Mothers are also dying from childbirth while the youths have resigned to an average life expectancy of 48 years from preventable illnesses and accidents. Public hospitals/health institutions are preferred as last choice for healthcare services after churches and traditional healers. While the above remain obvious and in dire need of change, the powers that be are yet to be seen in contrite mood reflecting on global trends in order to pursue policies that centres on how best to realise benefits for the public against working purely for the interest of the professionals. It is on this principle that literates and illiterates; press and politicians, clerks and clergy retain the notion that no one is better placed to head the health ministry, hospitals and other healthcare institutions apart from medical doctors.

Sustaining the above wrong notion is harmful to Nigeria hence this article is written as a follow up to another publication in the Daily Independent on 19^th and 20^th November 2008 titled, “Shifting the Paradigm of Leadership in Nigeria’s Healthcare Management”. The  aim is to drive a debate on:  (1) “Whether career progression for doctors should be in management which is at the detriment of patient care and medical research” or (2) “Whether management of hospitals and health institutions is better left in the hands of people that are primarily educated, trained, mentored and solely committed to management of healthcare services”.

With the appointment of Professor Babatunde Osotimehin as the new minister of health, whose experience and international exposure appear to place him in a position of advantage to understand better our poor state of health and unacceptable deplorable structure and system of the nation’s hospitals and health centres which are crying for change, not just in the frontline service delivery and equipment, but most fundamentally in the leadership and management. The change has to be introduced by members of the most resistant groups whose attitude to satisfying public needs of unhindered access and affordable quality healthcare and national health image run secondary to their professional  ego, greed, arrogance and ignorance.

Without a visible reform of the public hospitals, particularly with regard to service delivery and management systems, the privileged in the society will continue to travel abroad for medical care and treatment. Many of such medical tourism are funded by public finances and that is a resource which could have been better utilised in bringing our healthcare institutions to international standard by introducing corporate management into the healthcare industry. It is all about training people and giving them the right skills, knowledge and experience to lead this specific aspect of the economy. The opportunity it will create would diversify leadership approach against the current monopolistic medical model that has been a impediment to innovation and creativity in advancing the business of healthcare services, global recognition of local clinical research, patient empowerment and consumer (customer) satisfaction. The archaic ideology about power – interest in the politics of the industry is detrimental to good inter-professional relationship, multidisciplinary co-operation and collaboration and knowledge sharing. It is also a barrier to positive career progression and knowledge expansion.

Just like the stated medical tourism, Prince Charles Dickson wrote about Nigeria’s public education system where he noted the high number of the leaders’ children that are studying abroad; especially in Europe and North America. There are some travelling to Ghana and South Africa. The concern is that Nigeria with her massive human and natural resources have ignored the opportunity of becoming a global player like Cuba, Brazil, Ghana, South Africa, etc in championing excellent quality public health and education system not only for local population but also for international fee-paying customers. Instead, we take pride in sojourning in foreign nations with mix-feelings; both of the enjoyment of the good of that country and the suffering from prejudices and vulnerability to oppression. Health and education are among the most important institutions that connect the citizens to their governments. In the developed world they are fundamental election determining factors.  

Nigeria being a country of praise singers where people are given recognition for jobs that are badly done or doing things badly outside of one’s area of core knowledge and skills, the public have developed a subjective mind to accepting the mismanagement and unaccountability of the nation’s health service industry as that of unquestionable duties of doctors, who by themselves prefers authoritarianism against partnership collaboration, co-operation, shared learning and knowledge exchange and arrogant refusal to recognise  the importance of the other members of the multidisciplinary health professional teams. 

 With so many professionals in the health industry and within hospitals, there are several clinical management positions among which are, chief medical director, director of different clinical directorates such as medicine, surgery, obstetrics & gynaecology, paediatrics, psychiatry etc. Positions for nurses include chief nursing officer, clinical service managers, matrons etc. Furthermore, you also have other allied medical clinical services with related management positions. In order for anyone to be able to function effectively and efficiently in any of the above listed positions, he or she need to be supported to undergo appropriate management and leadership training, development and mentorship programmes. Training as a clinician is a different ball game from training as a manager. The core skills for managing people, resources and productivity are significantly different from the skills for treating patients and conducting medical research. In a broader term, corporate responsibilities for managing a health institution cannot and must not be combined with the responsibility of managing clinical segment or directorate.  For this reason, a doctor who sees his/her career future in management should go through management training, obtain the relevant qualification and put away his/her stethoscope for boardroom meetings and responsibility for organisational development or failures. Running clinics and attending boardroom meetings by the same people are a fundamental problem for developing Nigeria’s healthcare industry and the system of qualitative management.

The title of a job tells a big story about the role of that position. With regard to the primary role of the person occupying such position, criteria for achievement is always paramount. The difference in the tile between a chief medical director and a chief executive cannot be clearly seen or imagined due to ignorance. With a chief executive, anyone with the right skills, experience, knowledge and determination can maximise their potentials in that role, irrespective of the person’s background.  You do not need to be a doctor to lead or manage hospitals, healthcare institutions and the ministry of health. The debate is not about doctors managing medical directorate and their flock of patients just as only nurses should be leading and managing nursing services and pharmacists should be leading and managing pharmacy departments.

Lack of management training is a problem and a big barrier for realistic reform and transformation of the systems of leadership in the health sector. It is also the reason for slow or absence of progress in clinical care and customer services. There are many people highlighting this view and I have raised it in my letters to Senate President, David Mark, Speaker House of Representative Dimeji Bankole, members of the national assembly and President Umaru Musa Yar’Adua. I expressed the point on NTA programme ‘Platform’ in Lagos. I wrote about it in most of my published articles which can be accessed online by typing my name in google search engine.  See also my book, “Strategic Concept for Managing Healthcare in Nigeria where there is illustration of the appropriate management structure.  

In the western world where our people export resources to purchase medical care, the hospitals and healthcare institutions are allocated huge budget for investing in management training of the relevant workforce across career and professional boundaries, especially those aspiring for leadership and management positions.  The institutions, for example in the United Kingdom, from the ministry, hospitals and community services are headed by Chief Executives and teams of Directors and General Managers. They comprise of people from different fields; e.g. management consultants with degrees in health services or hospital management, economics, finance, accounts, psychology, history, law, medicine, nursing etc. Most have MBA qualification to prepare them for thinking and functioning like a manager against parading non-business concepts in corporate boardroom where clinical matters only revolve within the orbit of the broader healthcare business issues.

Drawing the distinction

A doctor’s primary function within the community of healthcare professionals include; diagnoses, treatment, research, training of students and  junior doctors and managing area of clinical practice. That of nurses include caring for patients, meeting all prescribed clinical needs, managing wards and clinical areas, including quality and complaints, clinical research in nursing and training of students and junior nurses. The above is applicable to all the clinical professionals.

However, in core corporate management, the responsibilities are different and much broader. The chief executive and executive board of directors primarily focus on the corporate accountability in the management of finance, investment and productivity (profitability), people management, continuing assessment of society needs, development of appropriate healthcare services to meet those needs, product (service) marketing, building and promoting organisational image, fundraising, employee training, continuous personal and career development of employees, continuous service improvement, development and proactive implementation of excellent policies for sustainable quality assurance processes and excellent customer (patient) satisfaction. These are not exhaustive list of duties of a chief executive and board of directors. They are also not the type of responsibilities of a doctor or medical director. The outcome of the corporate ideas and decisions are however translated to the frontline patient care by clinical and non-clinical employees who function as one team in the name of their organisation; for their good and general of the society that they are employed to serve. Based on that, everyone takes pride in doing what they are trained to do best. The cleaners, porters and gatekeepers, office clerks and technical staff will earn their respects just like the doctors, nurses, pharmacists, medical laboratory scientist, therapists etc.

Change is not an embraceable idea for those that it would most affect, but if you continue to do what you have always done badly without the change, you will continue to get the same unsatisfactory result. In the case of healthcare in Nigeria, the public will continue to suffer while the rich keep their option for medical care abroad. If hospitals and healthcare institutions would be brought to the management and clinical standards of the rest of world where citizens have a social contract with their system of government; and leaders understand their responsibilities to serve the interest of the population, reform and change management in the industry would not be a mountain of challenge that cannot be overcome. Change is good as in the world of business; change will ever remain constant and so need to be viewed positively. While some people might be worried about change, it is important to point that change on its own is not a problem. The usual challenge is the process of change management, which if dealt with in the best way by skilled and experienced management consultants; people’s concern would quickly evaporate without any notice of the background to their initial fears.

Following the breakdown of the stereotype about race and politics, which have seen the ascension of Obama into the Presidency of the United States of America; it is time to equally breakdown the stereotype which has seen doctors dominate the leadership positions in the nation’s healthcare institutions, from ministerial, commissionership to chief executive positions. With this we can then have a management board and leadership team from diverse background and projecting diversified ideas for managing our healthcare system. In the contemporary world of constantly emerging challenges in healthcare market, it is important that the door of opportunities is left open for the right and bright stars to shine, not merely on the basis of being a medical doctor, but on the merit of appropriate training and development for leading and managing those challenges. 

The laudable 7 points agenda of Mr President in my opinion fundamentally lies on the foundation of a viable system of excellent healthcare and quality education which is publicly provided with ease of access and affordability to all the population of Nigeria. The economy would not blossom without healthy humans steering the ship to the anchor of hope through knowledge and relevant experience.

It would be a welcome idea for media interest and sponsorship of this debate, which I would be very keen to participate in. I would not hesitate to support the change management process should the government pay attention to the need for shifting the paradigm and rebalancing the talents that could maximise success in the transformation of the nation’s healthcare delivery system. It is a responsibility of diverse intellectuals and not a ring-fenced job for doctors.

In view of the above, application shall be made to the appropriate government authorities for registration of National Institute for Health Service Management. Graduates from all backgrounds, current managers in health ministries and hospitals, clinicians and people aspiring for management career in healthcare services are encouraged to indicate interest for membership by sending email to: info@mebodmanagement.com with CVs attached. There is no fee following early interest. Training needs assessment shall be conducted and appropriate training programmes will be developed to bridge knowledge and skills gap, introduce general leadership and management competences and standard for assessment. This is a way forward, but an open debate would be welcomed.

David Eboh –  BA (Hons), MBA, PGDipHE,. MIHM, AfCIPD, (LLB (Hons) std @LSBU))

Chief Executive and Health Service Management Consultant, Mebod Management Ltd

deboh@mebodmanagement.com, info@mebodmanagement.com

Note: Mr David Eboh studied Health Service Management and was sponsored by National Health Service (NHS) Modernisation Agency (England) for a six months NHS leadership and management training programme for aspiring BME managers. He lives and works in the UK. He was chairman of BME Network and Project Manager at Queen Elizabeth Hospital, Woolwich London. .David lectured and led a course across University Hospital Lewisham and University of London. He believes that the dream and desire for western excellence healthcare delivery system can be translated into Nigeria/African realities. Where there is a will there will be a way. 

Robot  # 1 | 24.01.2009 23:37

The international assessment of our state of health is nothing to write home about. Public hospitals/health institutions are preferred as last choice for healthcare services after churches and traditional healers. While the above remain obvious and in dire need of change,many people retain the notion thatmanagement of our Healthcare institutions is sole duties of medical doctors. Thisarticle aim to challenge that notion and to intiate a public debate. ...Read the full article.