Functionality and Efficient Services Delivery in Nigerian Hospitals

 It was with great pleasure that this author accepted the book author’s request to pen a general view on the title of this important book, Functionality and Efficient Services Delivery in Nigerian Hospitals. This title is appropriate and reflects a conscious effort by the author to galvanize efforts towards strengthening much of Africa’s health system using the Nigerian health system and its hospitals as a template.

A cursory look at the title of this book may suggest that our hospitals (Nigerian hospitals, in this instance) are not working to deliver the expected efficient and quality healthcare services to their clients and patients. This deduction is similar to what seems like a general public perception that hospitals in Nigeria are not working.[1] Indeed, the poor state of hospitals is said to be one of the factors promoting outward medical tourism, characterized by frequent foreign medical trips by Nigerians, including top political and public office holders.

The above deductions and impressions notwithstanding, it is important to state at the outset that the situation may not be that gloomy, particularly as there are some hospitals in the public and private health sectors of Nigeria, nay Africa, that are still holding their own despite the perennial challenges besetting them. Some watchers may even argue that in the face of the general decay in Nigeria’s public institutions, her public health institutions, including her public hospitals, seem to have fared better than some other institutions in the sustenance of their critical responsibility and mandate for healthcare service delivery.

In developing this chapter, the author leveraged their practice experience as a medical doctor and Consultant Family Physician, experiences as a Health and Civil rights activist, involvement in the processes that led to the enactment of Nigeria’s National Health Act (NHA), and the practical leadership experiences within health systems at local, state, national, continental, and international levels. This is particularly true, having served as President of the Nigerian Medical Association (2012–2014), President of the Common Wealth Medical Association (2019–2022), and President of the World Medical Association (2022–2023). 

In Nigeria, there are all types of hospitals. The earlier and latter chapters in this book describe hospitals that may be described as small, medium-sized, or large – this attribution is a rough description and uses physical size as the only determinant. The type and level of services that a hospital provides, its location, and the size of its clientele are immaterial as far as the contents of this chapter are concerned. A primary care hospital may occupy large grounds, while some tertiary health care facilities are small in size.

 In a typical hospital, nearly everything of significant interest—both living and non-living—relates to humans. The non-living things include the building (if it is a small hospital) or the buildings (if the medical facility is a large hospital at one site or a chain of hospitals in multiple sites). The other constituents of non-living things are the moveable, and installed and immovable equipment of diverse sizes and numbers. Living things are usually considered plants and animals. Plants could be a problem and could also be of great aesthetic value in the hospital setting, as this book shows in some of its chapters. Human beings come under the animal kingdom classification and are considered to be at the top of the ladder in that kingdom. Non-human animals are part of human existence, but they are not considered in this book as the medicine that applies to animals is veterinary medicine. In a characteristic hospital of any size, the consideration or focus is humankind.

This book is about human beings who are unwell and need to be given attention by other human beings (and gradually assisted by robots) to achieve restoration of health, prevention of disease, or promotion of health. In summary, one set of human beings needs help; another set of human beings provides help.

The development and management of hospital facilities should follow a systematic process, including, at a minimum, conceptualization, planning, design, construction, maintenance, provision for growth, and security considerations. This chapter is designed to cover these aspects. The contents are not exhaustive but are adequate to demonstrate considerations, challenges, and successes in achieving functional and efficient medical facilities management.

The idea behind this Chapter, “Getting the best out of hospital employees,” is the reality that there are many hospitals in Nigeria that do not lack patients, but what they lack are hospital employees who, for one reason or another, do not or cannot give the best to their employers or patients. When and where this happens, the physical edifice of the affected government hospitals and the smaller facilities owned by individuals and organizations exist mainly to pay salaries and to “stay open” to the public. The clientele dwindles over time and such medical facilities become abandoned where the negative and unprogressive trend is not stemmed. Since it is difficult to repurpose a purpose-built hospital, particularly large hospitals (government or private) become liabilities rather than the assets they were intended to be. This scenario is presented first with the purpose being to discourage any employer or investor from allowing this to happen to them, their business, or social services project. Unquestionably, the best asset that any hospital has is the human resources. How to get the best out of hospital employees is consequently the best objective of any hospital, its management officials, and owners/proprietors.

Interestingly and almost peculiarly, a reasonably large hospital in Nigeria, in addition has features of a hotel, restaurant, bank, typical office or institution, school, land transportation outfit, and more. Hospital employees or personnel are, therefore, not only the core healthcare professionals like doctors, nurses, pharmacists, laboratory scientists, and medical records personnel but also administrative personnel, lecturers, teachers, security personnel, cooks and restauranters, janitorial staff members, employees of banks that have outlets in the hospital premises, drivers, and more. Sadly, carrying along sixty percent of these personnel does not give the institution a pass mark in the minds, eyes, words, and social medial postings of patients and their family members. This is because a patient may feel impressed right from the hospital’s entry and exit gates just because of the treatment that they receive the first time or every time they have cause to go to the hospital. On the other hand, they may become disgruntled at the point of entering the compound of the hospital or anywhere in between there and their leaving the hospital – and this could be the handiwork of one hospital personnel or more than one such employee. Despite the training that hospital employees (core personnel or support staff members) receive during training in their various schools, their attitude towards clients and the level of service they render are generally based on the individual. This chapter is to show that it ought not to be so; it should be institution alized. Every hospital must establish the standards on which it wants its employees to function and, at the same time, know and remember that the treatment it gives to its employees goes a long way to determining what services it can extract from these employees. The immediately preceding sentence simply means that if employees’ salaries are withheld for months, indiscipline is condoned, time for work is flouted with no consequences, leaders fail to show good examples, there is harassment in the workplace, fairness in handling personnel matters becomes an unnoticed or irrelevant “man overboard,” there is lack of training and employees’ progression in the workplace is irrational or inexplicable, or retired employees are not paid their benefits for months or years, it becomes very difficult to obtain from employees that commitment to work that is integral in rendering excellent services naturally.

One of the reasons for choosing Bowen University Teaching Hospital as a “case study” in this book is that it is a quintessential example of a hospital that started not with the aim of making profit but to render medical services to a poor and, at the time of its inception, a rural community but somehow survived the intricacies of medical practice in Nigeria and, today, is rendering primary, secondary, and tertiary healthcare services. The services of this hospital attract patients from nearby communities and nearby states in the South-Western geopolitical zone of Nigeria.

This is an interesting story with ups and downs, periods of uncertainty and joy, periods of support and virtually standing alone to believe in itself – and most importantly, periods of taking “a leap of faith” that has taken it to an enviable league of a tertiary hospital that trains medical students, postgraduate (resident) doctors, and undergraduate students in nursing.

The story of Bowen University Teaching Hospital should encourage any hospital irrespective of its ownership to aim for greater heights and to believe that when medical services are rendered from the mindset of running a marathon race and concomitantly satisfying their patients and communities consistently, only the future can tell what a hospital with a humble beginning can become. 

The University of Uyo Teaching Hospital (UUTH), Uyo, is not one of the first-generation teaching hospitals. The story of this hospital is included in this book because it is a story of hope – hope in the sense that with determination, despite humble beginnings, something good, useful, and great can be obtained from something that appears small at the beginning. UUTH was not even conceived as a Teaching Hospital, but the foresight in setting it in a strategic location seems to have made the hospital attractive enough to the Federal Government of Nigeria to convert it into a Teaching Hospital of its university called the University of Uyo. This hospital has adequate grounds that have been fenced to provide security and discourage any form of encroachment. Physically, the hospital has not fully occupied the space available for the small initial hospital. Although it is not as established as the original teaching hospitals, UUTH has achieved a lot and, has weathered many storms and is still standing and getting stronger. It is the only teaching hospital in Akwa Ibom State (an oil-producing State in the South-South geopolitical zone of Nigeria.) The presence of this hospital has helped address the healthcare needs of residents in the 31 local government areas in Akwa Ibom State.

The purpose of including Mother and Child Hospital is to show how a private hospital can provide essential and targeted medical services to patients who reside near and far from it. Mother and Child Hospital is neither a small nor a large hospital but, being a medium-size medical facility, it sits comfortably in-between these two types of hospitals. Like many small and medium-sized hospitals that are set up primarily for profit in addition to rendering medical services, this hospital is situated in the mainland part of Lagos State which is suitable for easy physical access to and financial affordability for its target population – mainly the middle class. The hospital started as an obstetrics and gynecology cum pediatrics outfit and has maintained this target as its clientele.

The story is brief and it demonstrates that any focused medical practice that operates with excellence and patience eventually makes a mark on its patients and patients’ relatives. The word of mouth by beneficiaries of medical services in any hospital, especially in private hospitals, is so important that it can make or mar an upcoming or an established hospital. This hospital has been on the right side of history and patronage of its patients. Following the example of this hospital is a recipe for comprehensive success.

“Small hospitals” is an expression that many prospective and current proprietors and operators of hospitals might avoid using. This is understandable in a country where it is believed that the bigger, the better. The author deliberately used this expression to buttress the point that “Small” is not synonymous with the quality, significance, or nature of service that a hospital provides. The purpose of using “Small” is also to encourage doctors and non-physician investors to take seriously the prospect of establishing and operating hospitals that are small in comparison with the usual and commoner expansive hospitals, space-wise. To write this chapter, the author conducted a detailed analysis from a search of hospitals and discovered that even the World Health Organization (WHO) and the various governments in Nigeria acknowledge and advocate “small hospitals.” In Nigeria, the government allows “Small hospitals” to be sited in remote areas, rural areas, semi-urban areas, urban areas, state capitals, and even the Federal Capital Territory. This alone shows that there is, indeed, a place for “Small hospitals” in Nigeria – and, by extrapolation, in other developing countries of the world.