Chief Medical Director of Ekiti State University Teaching Hospital, Ado Ekiti, Prof Kayode Olabanji, tells ABIODUN NEJO why increased support from the government and a public-private partnership are required to maintain tertiary hospitals
Given the low budgetary allocations to health and the failure of state and federal governments to meet the standard every year, do you see hope for the country’s health sector?
It is true that against all hopes, the federal budget allocation this time round is about five per cent, which is far short of what the World Health Organisation and even the African Health Alliance, i.e. the nations in Africa, agreed to. However, there is hope for Nigeria. We have an abundance of human resources, so when we are considering things, part of what we also need to consider is the potential – the strengths that we have in the area of human resources. Many people are indeed emigrating, but it is also a testimony to the fact that we have well-trained professionals in all the areas and segments of healthcare. Because of that alone, there is hope. It is also believed that maybe as the governments are made to understand these issues and there is a change of attitude, there is hope.
Stakeholders talk of healthcare financing. What approach do you consider best?
World over, healthcare is expensive, you see that when there are campaigns in advanced countries. Healthcare financing takes a central issue as to who will be favoured when they want to deliver the votes. The things to look at include health insurance. We know the popular NHS Trust in the UK and most advanced countries. One of the problems of healthcare in this country is that we operate based on out-of-pocket expenses. Health financing is more than that because, as we said, healthcare is costly anywhere in the world. So, if we have well-organised health insurance that is made to capture all the citizens, it will contribute a lot. It is like pooling resources together and then using the funds as needed. We can start with civil servants, and we can then begin to extend it to others who are not in the formal sector until we can capture everybody. Once we can get everybody enlisted, there will be a good source of funds. That way, if you are travelling from Lagos to Maiduguri and not even carrying cash on you, you will not be afraid because if you need medical attention, you can easily get it in any accredited centre. That is one thing that this government should pursue. Most of what we do now is still limited to the formal sector. Even in the formal sector, it is not embraced by everybody; we need to be serious about that.
Are there alternatives?
As managers of health institutions, we can also look at various alternatives. The one in vogue is the public-private partnership to be able to finance healthcare in which the companies and various vendors get interested in certain aspects of hospital practice and they come in based on agreements and memorandum of understanding to finance on agreed terms and there are various methods like build, operate and own; build, operate and transfer; equipment placement, etc based on discussion and agreements between the various institutions and the vendors. This is another veritable alternative that can be used when it comes to healthcare financing.
The emigration of medical workers, popularly known as the ‘japa’ syndrome, has continued to be a menace to the extent that some hospitals shut some of their wards. What approach do you think governments at the federal and state levels should adopt to combat it?
The issue of emigration and the high rate of attrition of workers in the hospitals is very high. It is not just the healthcare sector, even in academia and some other areas, people are leaving in droves. For solutions, there are a lot of things to be addressed. We have to look at reasons people will have for leaving their comfort zones and going to other places where they are not treated as first-class citizens. It can be poor remuneration, the work environment may be not conducive in that you have received training but don’t have the right equipment with which you can practise and before you know it, you start losing your skills. So, most young and energetic people will want to go to places where they can actually be comfortable with good pay and lay their hands on good equipment. If we begin to address all these, people will likely stay back.
Do you think training more doctors can help?
In some official quarters, training more medical doctors has been mentioned. This problem cannot be addressed in the simplistic modality that has been prescribed. What affects the workers also affects the trainees. The doctors and professionals who are going are also part of the ones training the students. If people can hardly train 50 and you suddenly decide to expand your scope and begin to train 150, you are creating a problem. Before you know it, you may be producing charlatans. So, we should look in-depth at the problem and try to address it. Academics are also emigrating; I know many of the academics who are very dissatisfied because, for one reason or the other, there was a standoff with the government – eight months’ salary is being owed to them as we speak. With that, every slight opportunity, people are going. They are even going to smaller countries like Sierra Leone and Rwanda. If the trainers are moving and you say the few ones who are remaining, who are experiencing what we call burnouts because of fatigue and overwork, should have 15 students added to the five they are supervising that will not solve the problem. The thing is to look at all the problems and address them. I said it is a systemic thing, some people move because they feel insecure when you have insecurity in the land, and all these have to be addressed. What of all the municipal services? When I was young, in Ado Ekiti, I used to fetch tap water freely everywhere, but even in hospitals today, you have to generate your own water. What about power? Thank God for the government of Ekiti State which embarked on an independent power project to supply power, part of which we are enjoying now. All these are what contribute to people saying, “Let me go to where I can work and my head will settle”.
How has the emigration problem affected your institution and what steps are you taking to handle it?
There are two types of movement from EKSUTH – vertical and horizontal. The vertical one refers to those who move out of the country and that affects virtually all the institutions in the country. The horizontal movement is peculiar to maybe EKSUTH and some other state university teaching hospitals where the remuneration and the conditions of service are not up to what is obtained in the federal institutions, so we lose people in both ways. We have been struggling to keep replacing. The way it has affected us is this: even if you replace one for one, it is not exactly the same. You have a doctor who has been working here for the past 13 years, the skills, experience, hospital culture, the work ethic that they have imbibed, and the relationships they have developed with the clients make them better hands to handle situations. Even if you bring in today somebody with maybe a similar level of experience, it is not exactly the same because you cannot replace those experiences.
We presented this to the board led by Dr Adedamola Dada, and we have secured the approval to go ahead, those core clinical areas particularly doctors who will see the patients, nurses who will give the treatment, and pharmacists, those areas where we are worst affected, we have the mandate that once they leave, we can go ahead and replace. But it has been difficult doing that, particularly for doctors. Right now, we need doctors, anytime we see doctors we employ, we have our adverts almost on permanently. That is the way it has affected us, but we have not closed down the wards because we have that permission and we have been recruiting regularly, replacing those who exit. We have people to cover the wards.
What is being done to ensure that privilege is not abused?
Even the board knows that we are people who love and strive very hard to maintain our integrity. When we are given permission, we still weigh it with our subvention because if you brought in any worker, you would need to pay such worker. We don’t just do things indiscriminately, we have our statistics and we only replace them as needed. We give our report back to the board and the payroll is there. We make sure we do not overshoot. Our aim is for services to continue, if we are not careful and we bring in people that we cannot pay, then we will come to a complete halt because if the people don’t get paid, they down tools.
How are you managing your operations at EKSUTH, being state-owned?
For us, what we have done is that whatever the government gives to us, we are very prudent with it. We put all those things into salary payment, but it is not even enough, we still have to look for more. We operate a revolving funds system. Most operational departments have been encouraged and they have formed revolving funds committees which will include the professionals. For instance in Pharmacy, it will include the pharmacists, the accountants, the auditor, the procurement, those people from the store, they sit down and we give seed fund. With the seed fund, they buy drugs, medicaments, and all the consumables needed. We use these for the patients and we recover the money by charging to recover the cost. It is a committee thing and not subject to abuse. We meet regularly to review this. They do tendering, we follow all the rules. We meet together to review at the tenders committee meetings, we still take it to the board for verification. With this, we have devised a formula to share the profits which is in percentages. We leave the capital so that we can have something to continue to run.
Part of the profit goes to help us in the subvention account to be able to make our workers a bit more comfortable by adding to their remuneration. We also put money aside for capacity building, training, and accreditation. As a training institution, we are subject to accreditations from time to time from the various governing bodies and licensing institutions.
How do you take care of indigent patients?
We even set money aside for poor patients because this is a government hospital, some patients will be brought but don’t have anything – either they had been picked up as destitute on the streets, don’t have relatives, or people who had accidents brought in by the Federal Road Safety Corps or police. We set a percentage aside for them. What we do is to save lives, so if you don’t have money, we dip your hands into that purse to take care of such patients. All those things are already fixed. You can see in our institution that a lot of renovation work has been done and as we speak, there are plans to also improve both the internal areas of the ward and some of the facilities. We cannot but appreciate the governor, Biodun Oyebanji, who has been very gracious in this regard.
How effective has the PPP been at EKSUTH?
Our PPP arrangements have been working for us. We have several projects and operations under the PPP arrangement. The first one is renal dialysis where we entered into an agreement with the MTN Foundation which provided equipment, we provide manpower and we buy consumables from prescribed outfits. That is what we are using to maintain it. We are moving on to another one now because that one has expired. We brought in an endoscopy. Endoscopy is an investigation to see the internal organs or the alimentary canal, the gastrointestinal tract through light equipment with which you can see the internal parts. We are operating that one with Emzor Pharmaceutical Industries. They put in the equipment, we are using it and we are paying them from the proceeds.
Also, a company is coming to build hostels for us. We need accommodation which we have not been able to have for quite a long time, but now, we already have an agreement with the company that will come in, and build over 500-capacity bed space within the institution to accommodate students, interns, corps members and even serve as transit lodge for other categories of employees. We are also bringing in partners in the laboratories to help us with further equipping our laboratories. These are some of the PPP projects that we are doing. It is a big benefit. Part of the benefits is that such services are available and patients can access them. As professionals, we enjoy practising our trade when we have the equipment to practice. And it is one of the things that can attract one to stay. The students get trained because we can demonstrate in practice to all the professionals we are training so that they see such things. We are still negotiating on some.
Are you extending the partnership to individuals?
We have told people to bring in their MoU if they are interested in helping us. Of course, when we are running, the partners in most cases will maintain. So the profit that comes to us is the profit and that goes to the coffers of the hospital and government. Then the electronic medical records which we started before, but had to dismantle that old arrangement because the partners were becoming unresponsive, we are restarting very soon. In that case, our practice will be computerised, all the paperwork will disappear. That will help us also in the area of funds management. We are not saying there are obvious leakages, but you may not be able to rule that out and it will be minimised if not eliminated by the EMR. The advantages of PPP are many; you have good practice, you have better training and you enjoy your practice because you are doing what others are doing even outside the country and at the best of places.
I recommend PPP because it is the way to go right now. While we will still encourage the government to continue to give the best support possible, individuals and philanthropists can even come in because whatever you invest in health is an investment in our lives.
How else can Nigerian hospitals be made attractive to become destination places for foreign medical tourism?
That will be a summary of all that we have said. First, the workers must be well motivated. A nurse, a doctor under some pressure, or whatever it is will affect the patient who is being treated. Then, the hospitals must be well equipped with modern gadgets. The physical and the ambient environment must also be attended to. When you look at some health institutions and see the dilapidation, you will shudder and probably find it difficult to say you want to go there for treatment. Once you have that and the workers are well remunerated, they will stay. There is no treatment you want to go for in India, Singapore, America, or Britain that cannot be done in Nigeria. There is nothing that Nigerian doctors cannot handle because when most people go out, particularly to the US and UK, the chances that a Nigerian doctor will treat them are very high. In most cases, people go there and meet Nigerians there to treat them. So, if all those factors pushing our doctors to travel have been addressed and what would pull them back are put in place, the issue of medical tourism with all the capital flights would not arise.
