INNOVATIVE HEALTH MANAGEMENT

“STRATEGIES FOR ENHANCING PRIMARY HEALTH CARE DELIVERY IN NIGERIA”

ABSTRACT

Introduction: Governments all over the world are increasingly introducing new Primary Health Care (PHC) management strategies to enhance clinical process and improve quality of care. In Nigeria, health professionals are implementing various health development initiatives to strengthen the health system towards achieving sustainable health outcomes for individuals and households in rural, semi-urban and urban areas. Yet, many health administrators, policymakers, and healthcare personnel have no ideas about which strategies to implement during this development process. The author provides insights into concepts (such as healthcare management, health innovation and digital health), including an analysis of current strategies being used, the challenges, and what has to change for Nigeria to revive its dysfunctional PHC system in accordance with standards set by the World Health Organization (WHO).

Methodology: The research strategy adapted to gather information, analyse data and present research results includes: (a) case study (c) grounded theories (d) survey and (e) action research. A non-probability sampling was used to gather unbiased and reliable input from volunteers (employees in the health sector) and care users in rural communities.

Conclusion: Evidence-based research indicates that development towards a sustainable health and wellbeing system is a complex and time-consuming process that requires unwavering commitment to improving people, process and technology. Establishing a functional healthcare system demands policy changes and adequate investment in education, research & development (R&D), as well as responsible leadership. Therefore, the success of PHC systems is not just a result of establishing robust country-specific health policies; it is also influenced by applying the right health management strategies at the right moment throughout the development process.

LIST OF ACRONYMS

ACMQ: American College of Medical Quality

ACOs: Accountability Care Organizations

AI: Artificial Intelligence

AIDS: Acquired Immune Deficiency Syndrome

ANDI: African Network for Drugs & Diagnostics Innovation

AU: African Union

BCG: Bacilli Calmette Guerin

BHCPF: Basic Health Care Provision Fund

BLS: Bureau of Labour Statistics

BMGF: Bill and Melinda Gates Foundation

CDC: Centres for Disease Control & Prevention

CHEWs: Community Health Extension Workers

CHIP: Children’s Health Insurance Program

CHOs: Community Health Officers

CMC: Christian Medical Commission

CMS: Centre for Medicare & Medicaid

COVID-19: Coronavirus Disease 2019

CRM: Customer Relationship Management

DH: Digital Health

DHPs: Digital Health Platforms

DPT: Diphtheria, pertussis, tetanus

EC: European Commission

EHR: Electronic Health Record

EU: European Union

EUA: U.S. Enterprise User Administration

FBDE: Full Benefit Dual Eligible

FDA: U.S. Food & Drug Administration

FDIs: Foreign Direct Investments

FFS: Fee-for-service

FGN: Federal Government of Nigeria

FHPs: Family Health Practitioners

FMoH: Federal Ministry of Health

GDP: Gross Domestic Product

GPs: General Practitioners

HA: Health Administrator

HAIs: Health-Associated Infections

HIPAA: Health Insurance Portability and Accountability Act

HIV: Human Immunodeficiency Virus

HLA: Health Leadership Alliance

HM: Healthcare Management

HM: Healthcare Management

HMOs: Health Maintenance Organizations

HSRC: Health Sector Reform Coalition

HW: Health Worker

ICT: Internet Communications Technology

IMF: International Monetary Fund

IoT: Internet of Things

IT: Internet Technology

ITU: International Telecommunication Union

IVR: Interactive Voice Response

KEMRI: Kenyan Medical Research Institute

LGA: Local Government Area

LMICs: Low- and Middle-Income Countries

LMX: Leader-Member Exchange

LWF: Lutheran World Federation

M&E: Monitoring and Evaluation

MDGs: Millennium Development Goals

MedPAC: Medicare Payment Advisory Committee

m-Health: Mobile Health

MNCH: Maternal, newborn and child health

MOH: Medical Officer of Health

MSS: Midwives Service Scheme

NAFDAC: National Agency for Food and Drug Administration and Control

NAFDAC: National Food and Drug Administration and Control

NASRDA: The National Space Research & Development Agency

NCC: Nigeria Communication Commission

NCDC: Nigeria Centre for Disease Control

NCDs: Non-communicable Diseases

NDHS: National Democratic Health Survey

NDHS: Nigeria Demographic and Health Survey

NEPAD: New Economic Partnership for African Development

NGO: Non-Governmental Organizations

NHI: National Health Insurance

NHMIS: National Health Management Information System

NHP: National Health Policy

NHS: UK’s National Health Service

NICS: National Immunization Coverage Scheme

NIMC: National Identity Management Commission

NIMR: Nigerian Institute of Medical Research

NIPRD: Nigeria’s National Institute for Pharmaceutical Research and Development

NPHCDA: National Primary Health Care Development Agency

NPHCDA: National Primary Health Care Development Agency

NPHCDA: Nigeria Primary Healthcare Development Agency

NPI: National Programme on Immunization

NPPS: Nigerian Pay for Performance Scheme

OPV: Oral Polio Vaccine

ORT: Oral Rehydration Therapy

PCMH: Patient-Centred Medical Homes

PCP: Primary Care Provider

PHC: Primary Health Care

PHCUOR: PHC Under One Roof

PHPs: Public Health Physician

PORSDCORB: Panning, Organizing, Staffing, Directing, Coordinating and Budgeting

R&D: Research and Development

ROI: Return on Investment

RPM: Remote Patient Monitoring

SIHI: Social Innovation in Health

SMEs: Small & Medium-scale Enterprises

SRM: Strategic Roadmap

STDs: Sexually Transmitted Diseases

TAM: Technology Adoption Model

TCF: Tulsi Chanrai Foundation

THAs: Traditional Health Attendants

TSA: Treasury Single Account

TWGs: Technical Working Groups

UHC: Universal Health Coverage

UK: United Kingdom

UNFPA: United Nations Population Fund

UNICEF: United Nations Children’s Education Fund

UNZIK: Nnamdi Azikiwe University

USAID: United States Agency for International Development

VAT: Value-Added Tax

VA: U.S. Department of Veterans Affairs

VHA IE: U.S. Veterans Health Administration’s Innovation Ecosystem

VHWs: Volunteer Health Workers

WCC: World Council of Churches

WHO: World Health Organization

WHOAFRO: WHO Regional Office for Africa

CHAPTER ONE

1.0     INTRODUCTION

Health refers to the state of being free from illness or injury (McSherry & Douglas., 2011). According to Carless and Douglas (2018), good health simply highlights complete emotional, physical and social well-being.

Health is wealth. As a positive concept, it emphasizes personal and social and personal resources—as well as physical capacities (Goldman Schuyler et al., 2016). Healthcare therefore exists to help people enjoy optimal state of health, but this objective is prone to various economical, socio-political and cultural challenges (Plianbangchang., 2018).

On this premise, global health is the understanding of healthcare in an international and interdisciplinary context, and it entails the study, research, and practice of medicine for the purpose of improving health as well as healthcare equity for everyone around the world (Seçkin et al., 2018). Global health initiatives, thus, transcend medical boundaries to exploit opportunities in non-medical disciplines—such as cultural studies, economic disparities, epidemiology, environmental factors, public policy and sociology, among others (Lueddeke., 2020). The World Health Organization (WHO) is one of the frontline agencies focused on advancing global health. Government administrators, non-government organizations (NGOs), researchers and leaders in different fields are also contributing towards the actualization of WHO’s Millennium Development Goals (MDGs), which include: (a) eradicating extreme poverty and hunger (b) reducing child mortality (c) improving maternal health (d) combating HIV/AIDS, malaria and other diseases (e) ensuring environmental sustainability and (f) developing a global partnership for development (Hassall., 2020; Remedios et al., 2020).

To achieve these goals, WHO relies on partners providing support for national efforts by (i) establishing global health care norms and standards, as well as guidelines for prevention and treatment (ii) providing necessary technical support required to implement guidelines in every country (iii) analysing social and economic factors that influence attainment of health goals and (iv) highlighting the broader risks and opportunities for both national and global health systems (Orhun., 2021). But despite huge efforts from the global institution—such as assisting national authorities to develop and implement health policies/plans; helping governments collaborate with development partners to align external assistance with domestic priorities; as well as gathering, storing and disseminating relevant data on health to improve national budget on health and monitor progress—there’s need for more investments in community health (Schweer Rayneret et al., 2021). Challenges from the COVID-19 pandemic however proves that every country is vulnerable to health crisis no matter the effectiveness of innovative health management strategies and level of disaster risk preparedness (Osland et al., 2020). Apart from the Coronavirus, which infected millions of people worldwide, other public health problems in 2021 include: mental health conditions, alcohol and substance abuse, food safety, healthcare-associated infections (HAIs), heart disease and stroke, HIV, prescription drugs overdose, as well as nutrition, physical activity and obesity. These public health concerns are a reason for the institutionalization of Primary Health Care (Shroff & Jung., 2020).

Innovation is the solution to modern-day healthcare management (Browne et al., 2017), and PHC systems around the world must either embrace innovation for higher productivity and sustainable growth—or remain stagnant, and eventually, lose their relevance (Best et al., 2012). In recent decades, healthcare has experienced different forms of innovation designed to enhance quality of life and improve life expectancy—thanks to more effective use of diagnostic and therapeutic options. But since COVID-19 and its socio-economic implications on every country, healthcare organizations have faced unexpected challenges to upgrade quality of service, lower cost, and eliminate waste. For these reasons, innovation has become a major focus (Cherry et al., 2020).

As global economies worsen, health workers maintaining high standard of service or sacrificing their lives to save others will not be enough. Thus, the healthcare industry needs far-reaching changes driven by innovation in management. But despite the urgency, policymakers must understand that innovation is not given for the asking of it. There are many forces driving the need for innovation. For example, recent trends in healthcare show that the traditional encounter-based care delivery approach has been upturned by increasing demands from retiring ‘Baby Boomers’ and the skyrocketing cases of chronic ailments (Janice et al., 2017). Additionally, there’s shortage of healthcare workers and/or key providers. Costs of medications and therapeutic care are too high, and most healthcare givers are poorly trained, thus, incapable of adapting to a fast-paced work environment. A constantly decreasing budgetary allocation to the health sector in most countries also hampers growth of health systems. These factors, together with other socio-economic forces, buttresses the fact that a shift to innovative management is necessary in healthcare (Carvalho et al., 2020).

While the WHO is addressing global health concerns, countries have different approaches to managing national health. The Federal Government of Nigeria (FGN) launched its Primary Health Care plan (PHC) in 1988 as a local approach for delivering quality, equitable and affordable healthcare services to communities—in line with WHO guidelines (David-West & Nwagwu., 2018). PHC is well-rooted in Nigeria’s National Health Policy (NHP) and has been the bedrock of the nation’s health system (Olukoga et al., 2010). Data from WHO shows significant decline in child mortality rate as well as a remarkable leap in life expectancy at birth. Per capita government expenditure has also increased, with fluctuations since 2008, when FG invested a record-high amount in the health system. Healthcare budget in 2019 was nearly ₦1.2 billion. But the problem is: PHC in Nigeria has performed below expectations despite the national and international support. Studies show that most health infrastructure/facilities are dilapidated and poorly equipped. Additionally, health workers are not adequately trained, and salaries are either owed by the three-tier government or delayed—a sad situation which doesn’t enhance output. On the part of health administrators, there’s also a problem of corruption, abuse of power and gross incompetence. Some of these setbacks are responsible for the continued poor health ranking of Nigeria in comparison to other countries in sub-Saharan Africa. And a workable solution is urgently required to improve healthcare as the nation risks failure to attain its 2030 Sustainable Development Goals (SDGs). This buttresses the importance of innovative health management strategies (Shroff &Jung., 2020).

For example, recent data from the Nigeria Demographic and Health Survey (NDHS) show that mortality rates caused by preventable diseases, despite low, have remained. Moreover, a large number of low-income earners are facing challenges of childhood diseases since the 2016 economic recession (Osakede., 2021). The 2018 forecast from NDHS on Nigeria’s healthcare is disheartening, and it supports the call for immediate adoption of tested-and-proven innovative healthcare management strategies. A study of the data highlights the undeniable reality that only 3% of Nigerians (aged between 15 and 49) have access to health insurance. The infant mortality currently stands at 67 deaths per 1,000 live births—which means that one out of eight children in Nigeria will most likely die before they are 5 years old. Further, neonatal mortality rate (i.e. a probability of dying in the first month of life) is at 39 deaths per 1,000 live births. According to a 2018 data from NDHS which was recently analysed by the United Nations Children’s Education Fund (UNICEF), indicates 25% of Nigerians still practice open defecation; only 39% of households in rural areas practise improved sanitation, and this poor hygiene level is a probable cause of deadly infections and death. Perhaps, the poor sanitation index is why many Nigerians still account for around 25% of the global Malaria challenges despite national and international interventions spearheaded by WHO. This research will examine community health in Nigeria for the purpose of proffering innovative health management strategies that can improve delivery of health care.

1.0.1 BACKGROUND OF THE STUDY

Nigeria is a West African country which shares its border in the West with Benin Republic, Northeast with Chad, East with Cameroon and Niger in the North. Its Southern coast is located at the Gulf of Guinea in the Atlantic Ocean. In the aspect of primary healthcare (PHC), Nigeria is still unable to attain goals of the Alma Ata Declaration four decades after its inclusion in the health policy. Provision of basic healthcare for the citizenry has also been an unrealistic objective. Although successive governments have made some appreciable efforts to improve quality of primary healthcare in the country and make health services available in every community, the current state of the national primary healthcare (PHC) system is still below acceptable standards, especially when compared to other developed countries of the world. This appalling trend is mystifying because CDC (Centres for Disease Control & Prevention) and PHC partners are regularly providing technical and programmatic expertise to eliminate or control vaccine-preventable diseases through immunizations.

Additionally, CDC in collaboration with a host of international partners and donor agencies, has rallied support for the polio eradication and measles pre-elimination activities in Nigeria—some of the major health programs that could have shaken coffers of both federal and state governments. Financial and technical support from foreign agencies have also facilitated performance of field activities such as campaign planning, monitoring and supervision, including acute flaccid paralysis surveillance and outbreak investigations, as well as outreach to nomadic populations, special projects, research, and data management support. One of the frontline programs “the National Stop Transmission of Polio Program” recently expanded service centres to improve the delivery of routine immunization services across northern states of Nigeria. Basically, CDC and MOH have collaborated in health emergency response, particularly some repeated outbreaks of vaccine-derived polio and other vaccine-preventable diseases. But these giant successes have been overshadowed by the poor image of PHC system in Nigeria—except in Anambra state, which is considered the centre of innovation in health care.

For example, vaccines prevent about 2.5 million deaths among children aged below 5 years of age, but despite the huge efforts from CDC and PHC partners, studies show that 1 child dies every 20 seconds from a disease that could have been prevented by a vaccine. The fundamental problem is not corruption among government/health administrators per se. Other areas of concern include inaccessibility/ignorance among healthcare users and or lack of fund to oil the wheels of PHC system. Additionally, Nigeria simply lacks a country-specific health management strategy capable of streamlining health services according to their needs and economic strength of the intended healthcare users. The trend is totally different in Anambra state. Dr Vincent Okpala (the Anambra State Commissioner for Health) on 1 April 2021 applauded a team of researchers at the Nnamdi Azikiwe University (UNIZIK) for their contributions towards advancing technology-driven healthcare services through Social Innovation in Health (SIHI) – an agency conducting studies on healthcare innovation for the purpose of providing solutions to the Anambra state health sector. The fluidity of healthcare management in Anambra, and the state government’s focus on adopting innovative strategies, are a reason why more than 30,000 residents were able to receive COVID-19 vaccines—at a time when most states have not received vaccine allocations. Generally, Anambra state takes centre stage in Nigeria’s healthcare initiatives. It has significantly improved diagnostics through research and innovation and is therefore considered a model for healthcare management and PHC services.

On this backdrop, stakeholders in Nigeria’s health sector should adopt exploit innovative health management strategies to effectively reform the national PHC system, as well as reposition the sub-sector to become an effective and reliable tool for improving national health indicators. This has become necessary in recent months. Thanks to improved diagnostic and therapeutic options, the global healthcare has experienced an influx of strategic ideas fashioned to improve quality of life and extend life expectancy. Therefore, the Nigerian health sector can’t afford to remain stagnant or deteriorate further.

Since the COVID-19 pandemic, a large number of healthcare organizations have faced unprecedented challenges to upgrade quality of products, reduce risks to consumers, improve accessibility to health services, increase efficiency, eliminate waste of resources, and significantly reduce costs. Moreover, innovation has become a major focus in many countries once again—Nigeria inclusive. It is therefore unarguable that the global healthcare industry is on the edge of massive change, but the underlying impact on PHC systems will differ among countries (Nwagwu & Akeem., 2013).