MEZIESBLOG

• State-level Engagement

The Nigerian government inaugurated its National Health Act (NHAct) in 2014 to facilitate implementation of PHCUOR policy at all levels. Stakeholders in the Nigerian health system—specifically the National Council on Health (NCH) and Federal Ministry of Health (FMoH), which oversees implementation of the NHAct—held an emergency meeting in 2015 to appraise performance of the Act. A key objective during the emergency meeting was to agree on a more effective action plan for implementing the Act to improve health care delivery. Stakeholders in both public and private sectors resolved to set up some robust governance structures and mechanisms, particularly a constitution, to guide affairs of the newly selected members of the National Steering Committee, Technical Working Group (with its 5 sub-committees), and Technical Review Committee. respectively. At the NCH, state-level representatives declared their commitment to make significant contributions and ensure the NHAct achieves its purpose.

But findings show that their counterparts at the federal level have been more proactive. State-level facilitators of the NHAct have not been fully engaged to lead the ongoing implementation process and consultations. For this reason, impact of the NHAct at both state and LGA levels has been very low and insignificant with regard to delivering basic health care services which the NHAct promised.

The health program implemented in Anambra state aligns with the National Health Policy. The state has various health facilities to support delivery of quality health care. Some of the facilities are:

• State-owned tertiary health institution, the Anambra State University Teaching Hospital (ASUTH), Awka, which is however at a rudimentary stage.
• Federal teaching hospital, the Nnamdi Azikiwe University Teaching Hospital (NAUTH), which is located in Nnewi.
• Thirty-two (32) state-owned general hospitals
• Fourteen (14) mission hospitals
• One hundred and eighty-nine (189) maternity homes, and
• Over six hundred (600) private hospitals/clinics.

Each of the 21 LGAs in Anambra state has an equitable distribution of PHC centres totalling 210 and 166 health posts. In addition, the state has five schools of nursing and midwifery as well as a school of health technology.

Having analysed the commitment to implement the NHAct at both federal and state levels, findings show that Anambra state is a model for PHC delivery in Nigeria. Healthcare workers were evenly distributed across health facilities in Anambra state. Over 50 health facilities (nearly 95%) under review had nurses and midwives. But notwithstanding the efficiency in healthcare management in the state, some impediments to the Act were identified. All secondary and tertiary health facilities had doctors. However, only 6 PHC facilities (22%) had doctors. Community Health Officers (CHOs) were found in only 28 (51.9%) PHC facilities whereas secondary health facilities had fewer CHOs – only 7 (33.3%). When compared to secondary health facilities in, PHC facilities had more Junior CHEWs (JCHEWs).

Desk evaluations showed that Anambra state has no functional state-specific data system or health management policies on acquiring disease surveillance and notification (DSN) technologies. The available DSN system at the state, LGA, and health facility levels is not computerized. The facilities are not only understaffed but have inadequate office supplies such as desktop/laptop computers, printers, scanners, photocopiers or vehicles for transportation.

The observational checklist conducted on 55 health facilities in Anambra state to analyse level of technology use and preparedness for DSN showed that about 50 of health facilities reviewed (92.6%) function with facility records. All PHC and tertiary facilities use facility records. However, only 81% of the secondary health facilities use facility records. Interactions with focus groups, particularly heath administrators, showed that DSN officers (DSNOs) in Anambra state and the state epidemiologist face technology-based challenges. For example, they do not have the necessary health technologies for receiving and sending reports. Although the low technology adoption is related to poor funding, management-related issues make it difficult to create an enabling environment for process improvement and technology adoption. For example, a DSN officer receives monthly stipend less than ₦10,000. They do not have a reliable state-funded means of transportation for regular visits to the rural areas. Also, they do not have office supplies, including internet connectivity and ICT tools, for observing cases and sending timely reports to appropriate organizations or departments.

Problems related to funding, technology adoption and management make health care delivery a cumbersome activity. This explains why primary and secondary health facilities in Anambra state are relatively dysfunctional, unattractive and understaffed. Stakeholders in the state’s health innovation ecosystem organize regular workshops, but there is no provision for in-service training and health workers do not have educational support to boost their performance in health care delivery. Contrary to the NHAct action plan. This study therefore concludes that the Nigerian health systems need to show more commitment in the areas of workforce training, funding for health projects, facility/infrastructure development, standardized and remuneration for health personnel. Stakeholders in the health system should also collaborate to mobilize adequate human capacity in health management to implement innovative strategies that not only strengthen public awareness and trust, but provide quality, cost-effective, quality and accessible medical services. Technology diffusion in healthcare and the implementation of innovative health management strategies remain a key growth driver in the global health system. Therefore, concerted effort in these areas is required to revive the dysfunctional PHC system in Nigeria.

GUIDE FOR IMPLEMENTATION AND FUTURE SUSTENANCE

In recognition of the failure, an evaluation of the health care delivery policy shows there is urgent need for committee members to show more commitment towards providing accessible, affordable and quality health care. Stakeholders and state-level actors should also take ownership of the entire process to ensure equitable and transparent use of health resources. Further, the Health Sector Reform Coalition (HSRC) should partner with FMoH and its relevant agencies to facilitate engagement process at the state level.

Some of the key activities to enhance implementation of the NHAct at the state level include:

• Collaboration between FMoH and SMoH (and its agencies) to establish a state-level partnership/coordination forum similar to the Health Sector Reform Coalition (HSRC) to strengthen localization of the NHAct in all states.
• Training of state-level facilitators on the NHAct Implementation process, as well as the expected milestones and deliverables.
• Providing both financial and technical support needed for states to establish the necessary governance structures and policy frameworks similar to the federal-level structures in order to fast-track implementation of the NHAct.
• Empower every state to organize state-level Council on Health meetings where decisions on how to effectively localize key provisions of the NHAct can be taken. Deliberations and resolutions reached at the meeting should take cognizance of the unique contexts of each state.
• Empower each state to develop and adopt state-specific Health Acts which align with the NHAct.
• Support and sustain advocacy across the 36 states and FCT on the implementation of the PHCUOR policy.
• Support the establishment of State PHC Boards/Agencies and Local Government Health Authorities and enhance their eligibility to access the Basic Health Care Provision Fund (BHCPF).
• Ensure there are some effective accountability mechanisms for monitoring implementation of the NHAct in all states.

RESEARCH CONTRIBUTIONS

CONTRIBUTION TO THE BODY OF KNOWLEDGE

Anambra State Ministry of Health (SMOH) collaborates with various local and international agencies, NGOs and other coalitions to provide health care services to individuals and households within the state. The state government through its SMoH implements an all-inclusive strategic health plan to ensure institutionalized and effective supervision and implementation at all levels. This study on “Innovative Health Management Strategies for Enhancing PHC Delivery in Nigeria” contains a literature review of concepts and theories in leadership, health innovation, PHC administration and healthcare management models – including an analysis of current trends in global healthcare. An analysis of the Nigerian healthcare system shows there are few literatures on health innovation and PHC management strategies. This study therefore contributes to the conceptualization and operationalisation challenges in the health innovation ecosystem by addressing the limitations and even reducing gaps.

The research underscores the significance of investing in human capacity development, health technologies and an enabling infrastructure, as well as enhancing PHC process to create value for patients and all stakeholders. Previous scholarly works focused on descriptive analysis of the history of PHC in Nigeria, including PHC categories, guidelines, responsibilities, achievements and key challenges in the health system. None of the literature explored the link between health innovation and variables like efficiency, equitability and quality of care. This study was able to synergize theory and practice by providing insight into how trends in health innovation is boosting economic development in selected countries, and more remarkably, impacted positively on the quality and span of life.

Furthermore, an analysis of the Nigerian PHC system indicates that health workers at the federal level receive better compensations when compared to their counterparts (with same qualifications and experience) at the state and local government levels. Although the preferential treatment is justified based on the financial capabilities of the three levels of government, response from interviews show that employment for federal jobs is neither transparent nor based on merit. The study therefore suggests that an implementation of a standard salary scale and performance=based promotion for health personnel across all levels of government will, to some extent, foster sense of belong among healthcare workforce thereby increasing their level of motivation, engagement and productivity.

Nigeria has a high level of maternal and child mortality rate due to the poor health management strategies implemented at the federal, state and local government levels. This assertion is based on a fact that Nigeria has ample human and natural resources. The health development paradox lies in leadership capacity, specifically the ability of health administrators to identify country-level challenges and design effective interventions that guarantee positive health outcomes for everyone. On this backdrop, this study has both theoretical and practical relevance. Theoretically, it provides additional knowledge to the body of existing literature on healthcare management strategies and models implemented in selected developed and developing countries. With particular reference to rural communities, the study emphasizes the purpose and benefits of collaboration with health workers. Findings from the theoretical analysis will therefore serve as guide for advanced studies health innovation, healthcare management strategies and PHC delivery, which demands attention in the post-Coronavirus era.

Furthermore, this study will provide useful information on the factors that affect PHC delivery, maternal/childhood mortality and poor utilization of primary care facilities in developing countries. Using response from research correspondents based on their practical experience in the Nigerian health system, this study serves as a reliable guide for policymakers. It will also facilitate planning of relevant, persuasive and result-oriented action plan that will transform the professional level of health workers as well people’s perception and usage of primary health care services. Considering that this study investigated viewpoints from different level of health workers, recommendations based on the findings will significantly improve health management efforts, systemic resilience and academic practices.

CONTRIBUTION TO PROFESSIONAL PRACTICE

There is a wide gap between theory and practice as healthcare, and for this reason, research findings in the field are often diffused slowly into clinical practice. The implementation of research on healthcare management and health innovation is even a more cumbersome exercise due to the cost implications—including sociocultural, political and moral considerations. However, health administrators and clinical personnel do not just seek validation from empirical and non-empirical studies but consider research results and challenges encountered during implementation as a basis for more advanced inquiries. This academic paper elucidates how health systems, especially management personnel, can leverage innovative leadership and health technologies to improve primary care. Its contribution to professional practice is far-reaching because the content sheds light on the three key aspects of innovation—people, process and technology.

Considering that healthcare is problem=oriented and people-driven whereas doctors’ decisions are consensus-based and practice autonomous, there is need for knowledge-based implementation of systematic processes that have direct impact on human life. This study does not only contribute towards closing the evidence=practice gap, but it also adds to the growing body of knowledge on which actions are taken to improve the quality and span of life. This study therefore encourages best care practices and equitable distribution of health resources using proven healthcare management strategies and models of care.

As healthcare research continues to churn out new management ideas, new disruptive technologies as well as revised and more effective methods of disease diagnosis, treatment and control, the key issue becomes how to implement findings and automatically translate knowledge/tools into improved patient care. This study adds to the body of knowledge by closing the wide gap between the quality of healthcare that patients receive and the recommended practice. An example of the knowing-doing gap is found in Anambra state, where distribution of cadre of healthcare workforce at health facilities is inequitable. The state’s tertiary health facilities have a large number of CHOs, CHEWs and JCHEWs notwithstanding the fact that their training curriculum does not prepare them for challenges at that level. In addition to this healthcare management flaw, the CHOs, CHEWs and JCHEWs are not only supposed to function at the primary care level, but at least 60% of them should be in rural communities where there learning and experienced at required. These cadres of health workforce are specially trained, among other things, on data collection at the community and PHC facility levels where they are expected to contribute effectively to the overall disease surveillance and notification.

Lastly, the contributions of this study to the body of knowledge cannot be completed without emphasis on healthcare supervision which has been a weak, unproductive routine in Anambra state. The level of engagement among supervisory teams from WHO, UNICEF, USAID, SMoH and Anambra state epidemiologist is below standard because their monthly visit to primary and secondary health facilities which is supposed to offer on-the-job experience training, and particularly strengthen corrective measures, has made no significant impact on health care delivery. This has been attributed to lack of functional HMIS required for on-the-spot assessment of cases and timely reporting. On this premise, over 70% of health workers interviewed admitted they share mistrust on the validity of published health reports. This is so because data was not scrutinized at LGA level. Moreover, forms and logistics for supervising disease surveillance activities and providing feedback were inadequate. This study therefore helps to close the gap between management strategies and practical implementation that drives sustainable growth of the PHC system.

NOVELTY IN METHODOLOGICAL APPROACH

The data collection methods applied in this academic inquiry include both semi-structured interviews and secondary sources. While secondary data gathered from books, journals and webpages provided insight into relevant works on theories, concepts and practice, the primary sources of data comprising of health professionals at various levels and departments helped the author to gather first-hand, valid and verifiable information on the reality of PHC management in Nigeria. The author used non-probability sampling to select research participants (interviewees) who are either retired or currently working in the Nigerian health system (e.g. doctors, nurses, health administrators etc). Use of a semi-structured interview and secondary data sources were necessary to enhance the author’s understanding of challenges to healthcare management, technology diffusion and PHC policy implementation.

Generally, this research has proven that use of data collection methods, specifically semi-structured interview and secondary data, is a reliable, result-oriented decision while conducting explorative healthcare research. In line with implementation science, this study exploring various methods of implementing research into healthcare practice sets the pace for integrating research findings in policymaking through larger, planned and systematic initiatives. Accordingly, translational science (that is, using clinical knowledge to transform health outcomes) suggests approaches to bridging the gap between research and practice should mainly focus on implementation methods that promote information sharing and knowledge transfer, as well as the diffusion and dissemination of evidence-based knowledge to practice and decision-making in healthcare system—exactly what the author attempted to achieve with the chosen research methods.

LIMITATIONS OF THE STUDY

Challenges faced during the data collection period include:

 The distant locations of PHC facilities selected for the study. Some primary facilities are situated very far from residential areas in villages, most of which are not accessible.

 Lack of functional communication networks in several communities. Communication with research participants in rural areas was a challenge because some communities do not have reliable telecommunication networks. Some health workers living in areas without connection to the national electricity grid are sometimes unreachable because mobile telephones are not charged.

 In the era of communal crisis, kidnapping, armed robbery and political agitations, among other threats to life, visits to remote villages increase risks of attack. Safety concerns therefore deterred the author and research assistants from visiting some crisis-prone locations in Anambra state.

 Delays with getting approvals to assess facilities made it difficult to visit more locations during the research. Assessment was not conducted with facilities because approval was not received.

 It was quite difficult to secure appointments for interviews with the policymakers at both state and LGA levels because most of them do not reside in the communities they serve, and few do not have time for discussions with the researcher.

 A large number of LGA officials were not approachable. Some of them did not cooperate when requested to provide information on PHC management and relevant data due to the perceived confidentiality.

FURTHER RESEARCH

This study focused on the Nigerian PHC system to unravel mysteries surrounding its prolonged stagnancy and lack of innovation despite the huge allocations accruing from the federal government, including financial and technical support from local and international partners as well as various health development policies/programme initiated by present and past administrations. Having acquired detailed knowledge of the systemic issues mitigating against the PHC system, mainly at the state and LGA levels, the author would like to research further on how FMoH can achieve sustainable development of the Nigerian health system. This proposed research on sustainable business is appealing as the global health system reflects on the environmental, social and governance (ESG) impact of healthcare.

RECOMMENDATION

Based on the discussions in this chapter, the author argues that it is nearly impossible for the Nigerian government to institutionalize a sustainable PHC system unless every ward in all LGAs takes the following systematic steps:

• Exploit knowledge-based research to develop costed Annual Operational Plan of Action based on community diagnosis
• Prioritize the identified problems
• Assess available resources taking cognizance of the problems
• Utilise health resources in an equitable, transparent and accountable manner.

The Action Plans from all wards in a local government area approved the Local Government Commission should constitute the PHC Operational Action Plan. Accordingly, Action Plans from all LGAs in a state approved by the state’s PHC Board should constitute the State Operational Action Plan. The operational plans at ward, LGA and state levels should be financed by all relevant stakeholders in the health innovation ecosystem—in addition to allocations from federal government.

Based on the available workforce and infrastructure, state and local governments should collaborate in designating certain facilities for basic out-patient services while others are empowered with adequate staff and logistics required to provide 24-hour services. This will eliminate certain constraints to full compliance with the NPHCDA directives. It will also increase chances of meeting other clinical standards governing health care delivery across the world.

Policymakers should have a salary standard for health workers across all levels—federal, state and LGAs. Health administrators should understand the need for employee motivation and engagement, thus, there should be a program for recruiting talent and providing welfare support that lasts a lifetime. This will not only boost the attractiveness of primary facilities but forestall staff shortages. Staff motivation and engagement include the provision of standard accommodation, steady power supply, clean water and other incentives.

Government should also sign agreement with talent acquisition/training institutions and the National Youth Service Corps (NYSC) for deployment of relevant graduate students to areas with workforce challenges during industrial attachments and primary assignment respectively.

Delegation of tasks and authority should be encouraged among healthcare workforce in line with the existing task-shifting policy guidelines. This will expand the scope of services performed by lower-level cadres, thus, improving on-the-job learning for better service delivery.

The federal and state governments should maximize financial and technical support from NGOs, international agencies and other partners to provide infrastructure and technologies that strengthen capacity for disease diagnosis, treatment and control. Apart from improving clinical and out-patient experience, technology adoption requires change to new, innovative care management approaches that deliver seamless health care services at affordable costs.

Regular training programs should be organized for clinical and non-clinical staff at all levels across health facilities in the country, especially at the PHC level. Training based on knowledge and practical skills is not enough; the healthcare workforce should be trained to serve with respect, integrity and dignity thereby making primary care facilities more attractive for patients.

Lack of medical supplies was identified as a challenge to health care delivery in rural communities. Therefore, the federal, state and local governments should ensure that commodity logistics are consistently available. In addition, the governments should synergize with private sector organizations, donor agencies, NGOs and international agencies to distribute health resources according to needs. This will help forestall stock-outs of essential commodities like drugs and other consumables (e.g. cotton wool, iodine, test kits, needles and syringes etc).

Adequate monitoring and supervision as well as regular performance appraisals will also improve employees’ commitment to service and overall efficiency even in hard-to-reach rural communities.

Community participation has to be strengthened, too. Community structures at the ward and LGA levels can be leveraged to implement systematic supervision and feedback mechanisms that ensure public office holders and civil servants remain accountable in their actions.

QUESTIONNAIRE

Innovative Healthcare Management Strategies for Enhancing Primary Health Care Delivery in Nigeria

Questionnaire

SHARED GOALS The existence of explicit shared goals, collaboration in healthcare facilities, and coordination between primary and specialized care. Please rate the current situation in your organization with respect to the other level of care on a scale of 1 to 5	Lack of shared goals	Few shared goals	Some shared goals	A considerate number of shared goals	All aspects of care are covered by shared and consensual goals
PATIENT-CENTRED APPROACH Explicitly giving priority to the interests and preferences of patients in the interaction between levels of care favours collaboration and coordination between professionals working in the different levels. Please rate the current situation on a scale of 1 to 5.	In the interaction between levels of care, the interests and preferences of patients are not taken into account	In the interaction between levels of care, the interests and preferences of patients are taken into account on few occasions	In the interaction between levels of care, the interests and preferences of patients are sometimes taken into account	In the interaction between levels of care, the interests and preferences of patients are often taken into account	In the interaction between levels of care, the interests and preferences of patients are always taken into account
MUTUAL KNOWLEDGE Knowledge between professionals of each other’s values, specific competencies and focus with respect to care, as well as of the environment in which each other works, has an impact on the development of team spirit and collaborative work. Knowing colleagues personally is also helpful. Please rate the current situation in your organization with respect to the other level of care on a scale of 1 to 5	Lack of knowledge of the other level of care	Little knowledge of the other level of care	Moderate knowledge of the other level of care	Good knowledge of the other level of care	Excellent knowledge of the other level of care
TRUST Mutual trust makes inter-professional collaboration possible, reduces uncertainty and contributes to the formation of networks of multidisciplinary professionals focused on the needs of patients. Please rate the current situation in your organization with respect to the other level of care on a scale of 1 to 5	Lack of trust	Low level of trust	Moderate level of trust	High level of trust	Very high level of trust
STRATEGIC GUIDELINES The existence of guidelines issued by the corresponding Health Authority that promote collaborative work between professionals from different levels of care influences the coordination and collaboration between professionals in both levels of care. Please rate the current situation on a scale of 1 and 5	Lack of guidelines related to collaboration between levels of care	Few guidelines related to collaboration between levels of care	Some guidelines related to collaboration between levels of care	A considerable number of guidelines related to collaboration between levels of care	Explicit guidelines and strategies promote collaboration in all areas
SHARED LEADERSHIP Shared leadership between managers and clinicians at a local level allows for the development of collaboration between professionals and organizations. Please rate the current situation in your organization on a scale of 1 to 5	No shared leadership	Leadership is shared in few areas	Leadership is shared in some areas	Leadership is shared in a considerable number of areas	Leadership is extensively shared and promotes collaboration in all areas
SUPPORT FOR INNOVATION Collaboration requires changes in clinical practice and in the distribution of responsibilities for both primary and specialized care professionals. Such changes require innovation that may be disruptive or non-disruptive (i.e. may or may not be supported by your organization). Please rate the current situation in your organization on a scale of 1 to 5	No support for innovation	Little support for innovation	Some support for innovation	A considerable level of support for innovation	Strong support for innovation
FORUMS FOR MEETING For professionals of primary and specialized care to collaborate, they need forums, channels of communication and activities that enable them to come into contact with one another, discuss shared issues and establish links and agreements. Please rate the current situation on a scale of 1 to 5	Professionals are isolated and there are no forums for meeting	Few forums for meeting	Some forums for meeting	A considerable number of forums for meeting	Many forums for meeting
PROTOCOLIZATION The preparation and establishment of protocols clarify and makes it possible to negotiate how to share the responsibilities of each professional. Indeed, there are many mechanisms to formalize agreements and understandings between professionals in the two levels of care—specifically information systems, care pathways, protocols, and agreements between organizations or units etc. Please rate the current use of such mechanisms on a scale of 1 to 5	Lack of mechanisms in place	Few mechanisms in place	Some mechanisms in place	A considerable number of mechanisms in place	A systematic process is in place for establishing agreements
INFORMATION SYSTEMS The effective exchange of high-quality information between professionals in a system that facilitates collaboration and makes it possible to provide better care to patients. Please rate the current situation in your organization on a scale of 1 to 5	Relevant information from the other level of care is not available	Little relevant information from the other level of care is available	Some relevant information from the other level of care is available	A considerable amount of relevant information from the other level of care is available	All the relevant information from the other level of care is available

Please rate the current situation in your organization on a scale of 1 to 5
1 Shared Goals	2 Patient-centred Approach	3 Mutual Knowledge	4 Trust	5 Strategic Guidelines	6 Shared Leadership	7 Support for Innovation	8 Forums for Meeting	9 Protocolization	10 Information Systems