Dr Joshua Ndom Giyan is the chief medical director of Federal Medical Centre, Keffi in Nasarawa State. It took him more than mere human energy to turn around the abysmally rated medical facility to an enviable standard healthcare Centre with state-of-the-art service delivery. The quintessential medical expert tells AGBO-PAUL AUGUSTINE, in this interview, what the federal government must do to stop medical tourism.
The health sector has been characterised by industrial actions lately. How do you access the sector under the present administration?
In accessing the sector under this administration, I will say the fortunes of the sector are going down. Definitely, if you have industrial actions bedevilling a system, it cannot be improving. If there is an industrial action in whatever sphere, it means the system is very low. On general comment concerning that, most of these industrial actions have not been needful, and when you look at what happens during strike, it is not actually that these people are fighting the people who cause their grievance. That’s the funny thing. If the unions are fighting government, who is government? Are we talking about the Ministry of Health, federal government or management? In many of these strike actions, how many of them suffer the setback in terms of inability to access medical care. None of them. In fact, those in federal government who are sick run outside the country to take medication. I’m not scared of mentioning it because it’s public secret. Even myself as a medical director, if I travel out of the country, I access care and I tend to think that there is a misfire.
The unions want to attack those that they are aggrieved at and then end up attacking very helpless masses who are the tax payers who have nobody to help them. I think it has a moral issue. Is it right to actually do that? There is a way to address the issue, which include dialogue, writing of petitions to government, meeting the press and carrying placards to the government and show them you are not happy. But do not attack the helpless- those that you already have contract with to take care of.
They came in, submitted themselves and some of them cannot help themselves. Then you have what it takes to keep them alive and you abandon them on the bed. Some of them put off the generators, cut off power to life-giving sustaining machines to these poor patients. That means you are sentencing them to death. No skeletal services and you now begin to wonder what we are doing. Whatever political undertone, it is not right to kill people just because of grievances against top officials? In this centre, those Unions have stood at the gate, stopping their members from coming in. They’ve locked the offices to ensure that those who are not on strike will not have access to equipment to save lives. They even told some patients at the gate that they are on strike. Those who ran to hospital thinking they are at the right place will say, ‘thank God we arrived the hospital’. Where did they go? They just go to die? This is the highest level it has reached.
Even when members of the striking unions fall ill they try to seek medical attention elsewhere because they don’t usually have the heart to treat their own during strike action. There was a time up to seven staff died during strike action. It doesn’t make sense. When you are fighting the enemy you try and provide help for your own people so that you can stay alive. Having reached this level, I want to declare that the issue of strike action is not only on welfare issues. We just use welfare as camouflage. Usually, there is political undertone and some have realised it and some have not. At the end of it others that just followed will now realise that they were just deceived into the strike action and at the end of it, damage has been done. I want to call on the Civil Society Organisations and the press to please speak on behalf of the voiceless because I believe that I have a voice, the leaders have a voice, government has a voice and they have a way of debunking allegations. They tend to launder their name, but the poor masses have nobody to speak on their behalf and instead of trying to help those in position to clean their name and advertise what they are doing, the masses need our help more. Let’s speak for them, they are the taxpayers, and they have nowhere to go.
Earlier, you talked about medical tourism, which has been a source of concern to many Nigerians. What, in your view, is scaring people from visiting our local hospitals?
In Federal Medical Centre, Keffi (FMC), we had a private project called SERVICOM, which is service-improving project in the general outpatient department. We were made to understand that there is what we call patient satisfaction. If patients are not satisfied, they go away; they go to seek for alternative means of sorting out issues. That is just it. And what are the drivers of patients’ satisfaction? Too much waiting time and patients get frustrated while waiting. Another one is the attitude of the workers. Very terrible attitude among health workers also drive patients away. Some people even prefer to go home and die. Another one is getting the services they came for. If they came to have surgery and at the end of the day you pick one or two diseases to their condition, they have not obtained their services, or they came, had an operation, and instead of getting better, they become worse; or if you keep postponing the surgery, they become really dissatisfied.
Another one is information. If a client does not get the services needed, somebody should please explain to the patient, calm his or her nerves, then explain to him or her why you could not render the needed services. Promise the client he or she can get the services needed the following day, or you can say ‘the doctor is not available now; he will come in two hours’. If a client comes for treatment that will not yield perfect result, he or she should be told if the treatment would not give total recovery. That is information. If a patient has that, he is already satisfied; he or she would want to come there next time. I interacted with a patient and the patient told me, ‘Doctor, nobody has explained to me like this before. How can I be seeing you anytime I come?’ I was happy, but I felt disappointed also that as simple as information is, people are not receiving it.
We now talk about expertise. That’s one of the major thing people run to hospitals outside the country. If you are diagnosed of an illness and they tell you they will operate on you and they operate on you and the next day you are discharged, it shows a lot of expertise, and this is related to equipment as well as training of the specialist. So, all this satisfaction you find them outside the country.
Talking about universal health coverage, can you tell us how much of health care delivery the Federal Medical Centre Keffi has delivered to Nigerians in the last one year?
We have come a long way. I was able to reverse the trend of patients leaving the centre for private hospitals and now they want to come back here. The number of our patients per day on average increased five times in the general outpatient department through the small research we have been doing. In 2007 when we did the baseline it was just an average of about 57 patients coming to DOPD on a daily basis but now we have reached between 200 and 250 because of the satisfaction. That means it is not capacity alone but the services have improved and patients are longing to come here. We now have patients coming in from Abuja and within the neighbouring states for care.
We have successfully convinced our patients through SERVICOM ideals by implementing the SERVICOM ideals. Patients have seen that they are really satisfied; some of them have made good comments. One was published in one of the papers. He came here and was really surprised. He said he thought he could only get this kind of thing outside the country. One called me and was praising the system. I told him to send me an email and he did. He is a lecturer at Nasarawa State University. So, you can see that we are touching the lives of these people and they are really appreciating and showcasing it. Then we are going down to the rural areas; our out posts are springing up now so that we will be able to touch the lives of those in rural areas.
If you talk about the last one-year, we have been able to move our records to electronic. Moving our records to electronic means we don’t have any missing patients’ record again. That’s one of the things that can lead to loss of life and disrupt patients’ care. Our electronic medical record that started in 2015 is ongoing and there is no problem with it. One area we have been able to improve our services to our clients is constant power supply, which we were able to get through partnership with Sumtotal. We had the installation of 200kv solar power so we can have 24-hour power supply for our patients. In those days that we had black out, you know what it does to the psychology of the patients.
In the last one year, we have really reached the level we can say patients are satisfied with our services. On the issue of attitude and the issue of out of stock, we are trying to do clean up in that area. I believe with what we have done, the provision of our healthcare to our patients will be at optimum. When you talk about the universal healthcare coverage, it goes beyond everybody and access to the care. And that’s why I talked about rural outpost. If we are able to perform that, the common person over there will have good services.
There is this general problem of dwindling resources, especially at the national level. You mentioned that your clients have increased over time. How have you been managing the hospital within the circumstance of poor finances?
If the capital provisions are not coming, what we are sure of is the salary. Salaries have been paid but you know some allowances have been delayed. We thank government that salaries are being paid. When it comes to provision of equipment and tools to work with, that has been really a challenge and we are all aware of the dwindling fortunes of oil in the country, which we have been depending on.
Government has opened other means of meeting the needs that is called public private partnership (PPP). Government does not open the chance for them to invest and have money locked up, and then we will be starving in the midst of plenty. We should score the government high for introducing PPP. This entire breakthrough we have had is from partnership. It was not something that government provided with capital. The solar power was partnership. In fact, they also have another one, the mortuary, which can accommodate 60 bodies per chamber; this is partnership. An individual will go into agreement and do it and then we will be paying from the resources. Up till now we have not finished. We pay from what we have been generating. We want to thank those who partner with us. We are also planning to go into partnership in other areas like building our theatre and others. Even in terms our drug supplies, we don’t buy drugs. We go into Memorandum of Understanding (MoU) with the drug suppliers. You can see that they just bring the drugs and we sell the drugs to the patients, collect the money and pay them. You can see that with that leeway, we have been able to provide services because we should not just sit down, cross our hands and say ‘there is no money, we can’t do anything’. That’s how we have been able to do it.
When the government notices that you are making effort, you tend to find favour. When the House of Representatives Committee on Health visited us they were so happy with the progress. We now have the justification to ask for help and there is high hope that they will be able help us to do one or two things. Also minister of Health was also here and he was happy with what we did in this area and that has opened a better horizon for us to continue.
Shortage of manpower has been identified as a major challenge in the health sector. How can the situation be improved to deliver quality service to Nigerians?
You can classify manpower into two- the actual number and the useful number so to say. If you have a host of staff, how many of them are actually working and contributing to the system? In fact, you may even have some that are being paid by government and all they do is to pull the system down and the system survives despite their negative influence. Some staff could be truant, some for selfish interest to prevent the services from going on.
Like I said earlier, when workers go on strike, why do they stop those who are not on strike from taking care of patients? If it is total number, we have total number. Almost every health facility has the total number that is needed and some critical experts, and with the local arrangement, experts can actually move around and provide expertise and they also succeed in training people locally. Even on the expertise, we are engaging in training them, and that’s why we have embarked on residency in this centre. We also do internship to prepare those fresh medical graduates to have their practicals before going for NYSC. We are doing residency in five critical areas: Family Medicine, Obstetrics and Gynaecology, Paediatric, Surgery (Internal medicine). We are discussing with a view to starting residency in Dental Surgery, Radiology, Ophthalmology and even Public Health.
What will you say are your significant achievements since you took over the headship of FMC Keffi?
When I assumed office, the centre was one of the worst FMCs. We just had a fire incident that burnt the administrative block and all valuable documents-personnel, admin, account and others. It was considered to be an electric spark that led to that. Many people considered it as sabotage. It was a fire that even affected neighbouring places. It was investigated and we found out it was an electrical fault. You can imagine taking off on that kind of situation. My goal was to ensure that records are kept securely to prevent any fire inferno in the future. But even if there is any fire outbreak, because one can’t have everything you needs, all the documents should be protected. So, in any new structure we built, we ensured fireproof cabinet or strong rooms are provided. If you go to our admin block you will find every office has that. So, you learn from experience. I also had the goal set to ensure that we standardise operation. Every department comes out with standard operation from every individual disease. Another goal was to train staff for experts care; we also retain doctors because we had doctors coming in and going. Like I said we have been able to start residency in five areas. So, with that doctors rush in. In fact, we are rejecting doctors now; you can see we have been able to attend to that.
Then documentation and reporting; if you do not record whatever you are doing, anybody who comes starts new. So, we decided that every department should produce monthly report, then annual report. We have been able to produce from 2008 to 2015 and then publish our annual report. That’s a big accomplishment anybody can refer to and that has also disciplined staff to know that you don’t just do things; you document them. Every department has a secretarial staff with computers to ensure they keep data. Then the electronic medical records of patients; we were losing so many patients’ records with their attendant’s effects. But now there is no more loss of patients’ records.
Talking about infrastructure, every building at our centre has been renovated, and we have built new structures to provide space. We have also gone a long way in that, that’s also a goal we have attained. One of our mandates is research. We have been able to create a research unit, and we have scientific officers. In fact, we are going to have annual scientific conference next year. They will address accessibility to patients’ care. We have a plan to build a structure that will have a research unit so that we can play the leadership role we are supposed to play as a tertiary health institution in Nasarawa State and its environs. So, that’s a goal we have attained. We have had seminars, invited some renowned persons to come, many papers have been presented and many research works are ongoing.
Do you have the number of the outposts of health centres that have been opened by your hospital?
By reason of our residency, one of the requirements of is to have outpost. We have MoU with two private hospitals in Akwanga, Ola and ERCC, Alushi. We send our Residents there to see patients and by so doing they train. A patient in Akwanga that wants to access care at FMC Keffi can as well go there and access care. Now we are liaising with Nasarawa State government; they have handed over a primary health care centre in Toto local government area, Gadabuke Primary Healthcare Centre, to FMC Keffi. We have done feasibility studies on that, we have taken over and we are working on doing some renovations so that full fledged activities can go on there. We are also into discussion with another centre in Doma LGA towards starting an outpost there. We have discussed with government intensely and we are looking for another one in Wamba. We tried to get that of Mararaba but I think another centre took that up. With this spreading, we send our staff there instead of adding here. There are one or two others, but this are the ones I can mention.
What is your take on the level of implementation of universal healthcare coverage in Nigeria?
We have the concentration of the health care providers in the federal tertiary hospitals. Even the private ones are concentrating on urban centres because everyone is trying to survive. We have secondary ones, which is the general hospitals and comprehensive centres. You go there and you see one doctor and usually a doctor who is just a general duty doctor. You go to primary healthcare centre where the majority of citizens of this country access their care that is accessible to them, and they see that there is no doctor. The highest that happened in time past is to send a midwife to go there. So, what led to that? You find that there is no equitable distribution of the health and manpower resources. And it is just policy that can change that. Once you are able to uplift the standard of the PACs to a level that the doctor can stay there, what else do you need? Just structures that we can provide. You need power, internet, equipment and security so that you will be able to stay there and work and everybody will come there.
So, where did those resources come from? There is a way funds can come. How about the NHIS? The NHIS is only in the federal sector; even in the states, there is no provision. Some states are just introducing it and you now go to the individual, may be primary healthcare system, where someone who is not even a worker can provide some money. Except we reach that level, there is no way we can reach the universal healthcare coverage. And all those people that have no access to care will just be hoarding disease and incubating it for the other ones that have accessibility. I think we are far from universal healthcare coverage in Nigeria and those critical steps have to be taken.
What are the major challenges facing FMC Keffi that you want addressed by the government?
Shortage of fund is a major challenge to us; otherwise, if you give me all the needed funds, I tell you, the centre will be drawing patients outside the country. We have discussed that and we are making efforts for individuals to help. So, those who have the money and feel like helping should come. Definitely if you come in and invest here you are paid gradually and if it is a yielding venture you are paid with time, it may take longer and that will be your community service development. The second major challenge is corruption. It is something that is endemic in Nigeria and President Muhammadu Buhari is on top of the situation in fighting it.
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