17th May, 2012
Dr. Olawale Lawal Oyeneyin, Consultant Gynaecologist/ Obstetrician and pioneer Chief Medical Director of Mother&Child Hospital, Akure, explains the success of the Ondo state government’s healthcare delivery
Q: What special interest did the government consider in setting up this specialist healthcare centre?
It was just a couple of weeks ago that the governor came to celebrate the second anniversary of this facility, which he commissioned on 27 February 2010, to commemorate his first year in office.
At the start of the Mimiko administration, we were already aware that there was an urgent need to overhaul the healthcare system in Ondo State. Moreso, the recent Nigerian demographic and health survey revealed that Ondo State had the worst maternal and child health statistics in the whole of the South-West. The governor, in all his wisdom, decided to concentrate on maternal and child health as the major pivot of the reform of the health system. No nation is taken seriously if it ignores maternal and child health. So much so that the United Nations came up with the Millennium Development Goals that identify improving child and maternal health as one of the goals to be achieved by the signatories – that is the MDGs 4 and 5.
So we came up with the Abiye Safe Motherhood concept, which was the name given to the Mother and Child care policy of the Mimiko administration. The Abiye was piloted in the Ifedore Local Government Area of the state in October 2009, in partnership with the World Bank. It was during the field surveys, baseline studies, that it became clear that there was a need for a dedicated facility to cater for mothers and children. Hitherto, we had specialist hospitals that were an all-comers affair, which took care of pregnancies, road traffic accidents, cancer, eye, etc. The desired impact was, however, not felt. So the governor came to change the system by setting up a facility dedicated to the child and mother. In fact, ours may well be the first purpose-built, 100-bed health facility dedicated to the care of pregnant women and children at the most affordable rate.
Its mission statement is to run an integrated maternal and child care facility fully poised to offer qualitative and critical interventions when required. This buttressed the mission statement, which was to develop an equity-based healthcare service that will provide universal access to the population. You can see the link. So, the Mother and Child came to serve as an apex referral facility for all complicated cases of pregnancies and medical illnesses of children under the age of five. The idea of the Abiye was to cause a paradigm shift by moving healthcare to the communities rather than expect patients to make their way to the cities. But in so doing, we realised that some patients would need to be cared for at the tertiary level when complications arise, which informed the idea of the Mother and Child. Whereas the Abiye programme is the umbrella programme for the state, in partnership with the World Bank, Mother and Child is an offshoot of the Abiye, but it’s wholly sponsored by the state government. And we give God the glory because we know that in terms of impact, as at 11 March 2012, we had registered and treated 38,899 patients out of which 21,256 were children under the age of 5, and 17,643 were pregnant women. As at that date, we had safely delivered 9,701 patients, which translate to almost 10,000 babies. And out of those deliveries, 1,541 were by Caesarian Section. We’ve been able to develop into a facility – perhaps the only one of its kind in Nigeria – that offers tertiary level services, that is, treating medical illness and performing surgeries 100 per cent free-of-charge to our patients. And this is regardless of social status, ethnicity or place of residence. We know that at least 20 per cent of people that come here are from outside the state. They troop to this edifice not just because the services are free, and are without any discrimination, but because of the quality of care they get. The governor created a sort of social integration – because you have commissioners’ wives, and company executives lying side-by-side with cleaners and artisans. And that, more than anything, attests to the quality of service provided here. We’ve also realised that when you compare our facility to other tertiary level facilities across the country, it appears from our evidence that we do more volume of work. We average about 20 deliveries everyday, with the minimal number of staff, at the least cost, with the best outcome. But we have to give the governor the credit for having the vision to support a project such as this. In a nutshell, that should give you enough insight into the significance of the Mother and Child Hospital, which is by now about the busiest in the South-West and one of the busiest in the country.
Given the sheer number of patients trooping here daily, can the government keep this facility running?
This has been a recurring concern. But I can tell you that within three months of setting up this project, the governor already set up a sub-committee on sustainability strategies to sustain the activities here beyond the Mimiko administration. It is clear to him that if you don’t make something an institution, it cannot outlive its pioneers. We knew we would have challenges running a state-of-the-art facility such as this. We also knew we would be inundated with the crowd you see now. We have mapped out our strategies, such that one, we invested in personnel. We knew we had a shortage of qualified staff. But you’ll agree me that the shortage of healthcare personnel is not an Ondo State problem, it’s not a Nigerian problem; it’s a developing world problem. We will never, it appears, have enough nurses, doctors, and other healthcare staff to cater for all our healthcare needs. But we can maximise the input of what they have, to achieve the outcome we desire. From the very beginning, there was a need to reverse the disenfranchisement, the poor attitude of healthcare workers, which, in a way, prevents people from coming to avail themselves of their services. So we introduced better emoluments, we introduced incentives based on key performance indicators for the staff to encourage them. We formed ourselves into a team and we allowed the nurses, who are more in number than the doctors, to take on hitherto traditional roles of doctors. We allowed the ward maids to take up hitherto traditional roles of nurses. And that we did without compromising safety because the prerequisite for doing that is that you have to institute what we call clinical protocols. They are a stage-by-stage set of instructions towards managing a patient to promote favourable outcome. What this does is that when a patient comes in with any form of condition, because the various staff have been trained on the protocols, they know what to do and this steps up the management of that patient. It is the delay in instituting interventions that is actually the bane of our society. Malaria is a treatable condition, you’ll agree with me. But our children are still dying from malaria because there’s a delay, either in the parents bringing the child to the hospital or in the child being attended to on arrival at the hospital. What we’ve done is to eradicate those delays, which, ultimately, reduces our own workload because you dispense of cases as they come in.
Also talking of sustainability, one of our biggest achievements in the Mother & Child Hospital is that we’ve been able to put a cost of care on our pregnant women and children. This means working out the cost of taking care of a pregnant woman from pregnancy, through delivery, to post-partum? We’ve been able to estimate, quite comfortably, that with about N5,000 – regardless of the mode of delivery or associated complications – you can safely take care of a pregnant woman. With N3,500, you can actually treat a child with common illnesses like malaria, excessive vomiting and diarrhoea, etc. So before you talk about sustainability, you have to decide what is your baseline. The governor gives us N5million and what he expects in return is 1,000 safe deliveries. Assuming we expect 5,000 women to deliver in a year, that translates to N25million to take care of them. That is aside overhead cost. You still have drugs, consumables and materials. Having taken care of the baseline, you can then talk of sustainability. We discovered that if every tax-paying adult in Ondo State, a population of roughly one million (out of about 3.4 million) pays N20 every month, that comes to N20million every month. You can then figure how many pregnant women you can take care every month by dividing N20 million by N5,000 . That gives you 4,000 women. This kind of deep thinking has been missing from Nigeria, where politicians throw money at the health sector, hoping that something good will come out of it. But if you don’t have a way of tracking, you can’t expect any fruitful outcome. In Ondo State, we have the formula that will ensure that if you put in “X” amount of money, you will get “X” amount of favourable outcome.
The other sustainability strategies are that we’ve keyed into the federally-controlled NHS, Millennium Development Goals, MDGs’ MCH Fund that was one of the benefits of the Paris Club debt forgiveness deal that Nigeria had. We also keyed into a research grant by organisations that fund medical studies and research. We also undertake the training of people who want to become safe delivery attendants. Our highly trained hands train them so they are able to replicate such experience in their respective health facilities. They pay a little for acquiring such experience. Those are ways we are able to generate revenue internally, so that we don’t depend solely on the government.
We also realise that we don’t want to overwhelm this facility, so the administration has built a second facility in Ondo town. It’s right at the Gani Fawehinmi Diagnostics Centre. It’s a much bigger edifice, but modelled after this one in Akure. So, we have two Mother & Child hospital outlets. What that means is that those patients in Ondo and its environs, who hitherto rushed down here, can now avail themselves of the one in Ondo. And the governor has promised that before the end of his tenure, we will have one in Ikare and another in Okitipupa. By the time you have four to five Mother & Child hospitals taking five thousand deliveries every year, spread over the whole of the state, you would have accommodated almost all the pregnant women in Ondo State. So those are measures envisaged in terms of sustainability and replication of the initiative.
You talked about giving out drugs to patients free of charge, how are you also able to sustain this?
One of the pillars of this project is that the governor set out to eradicate the out-of-stock syndrome common with free health services implemented by different levels of government in the country. For instance, a woman comes to a hospital with her baby suffering from malaria and she is told the drugs are not available. They are free, but not available. The woman has to go buy such drugs at the pharmacy. It defeats the purpose of “free” if the drugs are not available. We’ve instituted a unique drug procurement system that has eradicated the out-of-stock syndrome. And I emphasise the word “eradicated”. It is a model that others can copy from. Bearing in mind our principle of the “cost of care,” we relate directly with the drug manufacturers, the pharmaceutical companies. And because we buy in bulk, we get a significant discount. We’ve done away with the middle-men and that’s the solution to the out-of-stock problem. In our hospitals, if at all patients buy anything, they only buy consumables like sanitary pads, bleach and the like. But for the medical care and the drugs that’ll save your life, even blood transfusion, they are absolutely free. We set out to offer free health services and we are ensuring it is, indeed, free.