TQM STRATEGIES AND HEALTH CARE DELIVERIES: LESSONS FROM NIGERIA

Olawale Ibrahim Olateju Department of Business Administration and Management Technology Lagos State University, Lagos, Nigeria.

Raheem Olasupo Akewushola Department of Business Administration and Management Technology Lagos State University, Lagos, Nigeria.

Oludare Tolulope Adeyemi Dimension Consult Limited, Lagos, Nigeria

ABSTRACT We examine the TQM Strategies and health care delivery in Nigeria, and the various means of measuring service quality. Nigeria continues to suffer outbreaks of various diseases cholera, malaria, cerebrospinal meningitis, measles, yellow fever, Bird flu e.t.c., all these diseases combine to cause high morbidity

and

mortality in the population. To assess the situation this paper looks at the relevant indicators like Annual Budgets by Government, Individual’s income, the role of Nigerian Medical Association (NMA) and various health care agencies vested with the sole responsibility for elaborating standards for products and processes in Health care Delivery .

The paper also examines the implication of Government Budget estimates on the Life expectancy of an average Nigerian. The findings necessitated the need for the government to seek support from WHO to assist in strengthening the health care system by advocating and providing technical support to health sector reforms.

Keywords: Health, quality, hospital, clinic, sanitation, mortality, malnutrition, poverty, medicine.

1. Introduction

justice and equity. Primary Health Care

The organization of health services in

(PHC) is the cornerstone of the health

Nigeria

It

system. The policy provides for a health

includes a wide range of providers in both

is

pluralistic

and

complex.

system with three levels: primary, secondary

the public and private sectors: private for

and tertiary. The policy also spells out the

profit providers, NGOs, community-based

functions of each tier of government and

organizations, religious and traditional care

provides

providers. The National Health Policy (1998)

advisory National Council on Health chaired

is based on the national philosophy of social

by the Federal Minister of Health (the

132

for

the

establishment

of

the

Minister of State for Health and State

training nurses, midwives and community

Commissioners of Health are members).

health extension workers (CHEWs). The

Other organs set up by the policy include the

LGAs provide basic health services and

State Health Advisory Committees and

manage

Local

Committees.

normally the first contact with the health

Their potential has not yet been fully

system. Some parastatals exist within the

realized. As part of the health sector reform

health system. The National Agency for Food

process, there is a need to review the

and

functions of these organs in order to

(NAFDAC), National Primary Health Care

maximize

their

Development Agency (NPHCDA), National

National

Health

Policy,

is

responsible

Government

government

Health

use.

According

to

the

the

federal

Drug

PHC

facilities

Administration

Programme

on

which

and

are

Control

Immunization

(NPI),

policy

Nigerian Institute for Medical Research

guidance,

(NIMR) and National Action for Prevention

coordination, supervision, monitoring and

and Control of AIDS (NAPCA) were created

evaluation

to deal with priority health issues. WHO

formulation,

for

the

strategic

at

operational

all

levels.

It

responsibility

also

for

has

disease

(2007).

surveillance, essential drugs supply and vaccine management. In addition, it provides

2. Statement of Problem

specialized health care services at tertiary

The Organization of Health service in

health

Nigeria

institutions

(university

teaching

is

Pluralistic

and

complex.

It

hospitals and federal medical centres). These

includes a wide range of providers in both

serve

the

the public and private sectors. Private for

secondary health facilities. At the lower

profit providers, NGOs, community based

level,

organization, religious and traditional care

as

referral

the

institutions

states

and

LGAs

for

share

responsibility for health care. States largely

providers.

operate secondary health facilities (general

provides for a health system with tree levels:

hospitals and comprehensive health centres),

primary, secondary and tertiary. The policy

providing mostly secondary care and serving

also spells out the functions of each tier of

as referral level for the LGAs which provide

government

the

establishment

essential

National

and

Health

provides

Policy

for

the

of

PHC.

decentralized

health

Council on Health (the Minister of State for

structures of the federal government are in

Health chaired and State Commissioner of

the states, while those of states are in the

Health are members). Other organs set up

LGAs.

operate

by the policy include the State Health

tertiary facilities or specialist hospitals.

Advisory Committees and local Government

While the federal government is responsible

Health Committees. Their potential has not

for the management of teaching hospitals

yet

and medical schools for the training of

functions of these organs maximize their

Operationally,

doctors,

Some

the

elements

The

the

states

states

build

are

and

responsible for

133

been

of

fully

the

advisory National

realized.

Realizing

the

use. The problems identified by this work

expenditure and recurrent expenditure on

are listed below;

the life expectancy of an average Nigeria because the life expectancy at birth depends

1.

The

Government,

various

participants,

public-private

the

on the activities of the various participant in

partnership

the health sector.

(PPPs) that have been bestowed with the responsibility

of

providing

health

care

Operationalization

delivery have no clear composition and

The degree of health care delivery depends

documentation and therefore, there is need

on the direction and composition of the

to

and

private, public and international bodies

direction in order to carry out effective

understand

their

composition

bestowed with health care delivery, vital

evaluation of their activities. It is also

statistics record, activities of the regulatory

necessary to established the extent to which

bodies

the composition and direction is comparable.

allocation. This illustrated as follows;

2.

HCD = f ( PPI C+D + VS + RP +RB + RE + µ)

The sectorial performance vis a vis

and

parastatal

find allocation and industry expectation in a

Where

TQM model cannot be ascertained.

HCD = Health Care Delivery

3.

The

contribution

of

the

PPI

various

C+D

and

= Private Public and International

activities of the regulatory bodies and the

bodies composition and direction

parastatals on health care delivery cannot be

VS = Vital Statistics

ascertained.

RB = Regulatory bodies

4.

The

various

participants

in

the

resources

RS = Parastatals

health sector have not address the vital

RE = Resource allocation ( budget estimate)

statistics, in health care delivery. This has

In order to access the level of Health Care

led to improper planning and evaluation of

Delivery the study identifies access to health

health care delivery, vital statistics has not

care delivery, manpower training in health

been well documented, consequently leading

care delivery and the life expectancy of an

to improper planning and evaluation of

average Nigerian.. This is illustrated as

health care delivery.

follows; LE = f (PPI C+D)

3. Limitation of Study

LE = f (VS)

This study examines the TQM strategies and

LE = f (RP)

health care delivery in Nigeria. The study

LE = f (RB)

identifies manpower training, activities of

LE = f (RE)

the

study focuses on this variable only

Regulatory

bodies

and

parastatals

bestowed with health care and the life

MT = f (PPI C+D)

expectancy of an average Nigerian. This

MT = f (VS)

study

relationship

MT = f (RP)

between the budget estimate on capital

MT = f (RB)

only

considers

the

134

}

This

MT = f (RE)

Nigeria. A working document has been

AH = f (PPI C+D)

developed for the revitalization of the

AH = f (VS)

implementation of primary health care as

AH = f (RP)

part of government stewardship role to reach

AH = f (RB)

the MDGs.

AH = f (RE) Where

Health service management is decentralized

LE = Life expectancy of an average Nigerian

at the three tier levels. In addition, some

MT = Manpower training

States have Health Management Boards

AH = Access to health care delivery

which is responsible for direct service delivery while the Ministry focuses on policy

4. The National Health Policy and

formulation,

Strategy

monitoring

This

policy

to

achieve

health

for

all

standard and

setting

evaluation.

and

Community

Participation is strengthened through the

Nigerians was promulgated in 1988 and

Village

revised in 2004. The policy document was as

establishment of VHC is emphasized in the

a result of several consultative processes,

current Health Sector Reforms. National

incorporating views from stakeholders and

Health Policy (2004)

Health

Committees

(VHC).The

reflecting new realities and trends in the National Health Situation including regional

5. Public-Private Partnerships (PPPs)

and global initiatives such as NEPAD and

for Healthcare in Nigeria

the MDGs. The main policy thrust focuses on

The

National

services

Health

Management;

System

National

and

for and

improved

health

expanded

delivery

programs

is

Cares

particularly acute in developing nations like

Resources; National Health Interventions

Nigeria where diseases are having a major

and

Services

delivery;

Health

its

call

Health

impact on the health and quality of life of all

Information Systems; Partnership for Health

National

people across all the sectors. Under serviced

Development; Health Research and Health

areas of developed countries also suffer from

Care Laws.

inadequate community health programs and have similar burdens and needs. Based on

A National Health Reforms Agenda is being

these, it has become imperative that there

implemented to carry forward the health

should

strategies

Economic

Partnerships (PPPs) towards sustainable

Empowerment and Development Strategy

healthcare delivery systems, as enunciated

(NEEDS),

in the maiden National Health Summit held

of

New

the

National

Partnership

for

Africa

Development (NEPAD) and the MDGs.

be

levels

of

Public

–Private

in Abuja, 1995 (Abuja Declaration).

Primary Health Care continues to be the

Public-Private Partnerships have become

cornerstone

critical frameworks through which some of

of

health

development

in

135

the elements of Health Sector Reforms are

Finally, the essential role of the public sector

gated worldwide. Over the years, it has

in PPPs is to define the scope of business, to

become

good

specify priorities, set targets, and specify

healthcare delivery systems had to be

performance standards against which the

structured and driven under the purview of

management of the PPP is given incentives

trans-

or

to deliver. The essential role of the private

collaborations of different dimensions which

sector in all PPPs is to deliver the business

are

the

objectives of the PPP by offering higher

such

value-for-money to the public sector than

arrangements. In a sense , Public-Private

could be achieved by public sector provision

partnerships have to do with insights and

alone. Francis, O.O.(1998)

increasingly

sectorial

dependent

environment

on

and

obvious

that

partnerships

the

nature

objectives

of of

practices touching public private sector relationships in ensuring regional or even

6. Nigeria's health sector reform

global health quality outcomes and the

The seed for the current health sector reform

conceptual aspects of such relationships,

underway in Nigeria was sowed sometime

including the function of the key players in

back in the year 2000 in the early days of

collaborating to make these partnerships

President Obasanjo's first term in office. For

achieve

reasons not entirely clear, the reform could not

their

set

goals.

be initiated during the president's first term. An additional disparity between PPP and privatization is that the extent of PPP

Objectives of the reform:

business (and hence it’s latent capacity for

Objective 1 - Expand and strengthen primary

turnover)

contractually,

health care services throughout the country.

rather than by market forces alone. Normal

Objective 2 - Eradicate, eliminate and control

private

childhood and other vaccine preventable

are

constrained

incentives

still

apply

in

the

management of a PPP, such as the need to

diseases

earn an adequate return on capital, but the

immunisation activities.

business risk is, in effect, partly regulated by

Objective 3 - Integrate and strengthen all

virtue of the constraints defined in the terms

disease control efforts and health promotion

of the contract. In addition, with a PPP, the

activities into health care at primary care

public sector pays for services on behalf of

level.

the general public and retains ultimate

Objective 4

responsibility for their delivery, whereas the

problems through the provision of family

private sector’s role is limited to that of

and reproductive health services including

providing an improved delivery mechanism.

the

In the case of privatized utilities, ultimate

incidence

responsibility

Objective 5 - Reduce environmental and

for

service

delivery

is

transferred to the private sector.

through

necessary of

adequate

routine

Address the demographic

services STD

and

to

reduce

HIV

the

infection.

occupational health related morbidity and mortality.

136

Objective

6

-

Rapidly

resuscitate

and

These fourteen objectives now form the core

improve the services of secondary health

of Nigeria's 2004-

care to serve as an effective referral for PHC.

2007 health sector reform agenda. Johnson

Objective

7

.D (2000)

diagnostic

and

-

Improve

investigative,

treatment

capability

of

tertiary health facilities to serve as an

7.

effective apex referral system to all health

Administration

facilities in the country.

SERVQUAL, a standard instrument for

Objective 8

measuring functional service quality, is

Ensure the attainment of the

Servqual

and

in

Health

valid

goals and objectives of the National Drug

reliable

Policy (NDP), which focuses on self- reliance

environment and in a variety of other

in essential drugs, vaccines and biologicals

service industries.

through local manufacture and an effective

SERVQUAL

drug administration and control system.

administrators

Objective 9 -

also

in

the

Care

provides

with

a

tool

hospital

hospital for

the

Protect the public from the

measurement of functional quality in their

harmful effects of fake drugs, unregistered

own organizations. Deficient scores on one

medicines and processed foods.

or

Objective 10 - Ensure that the support given

normally signal the existence of a deeper

by donors, NGOs and UN agencies is

underlying problem in the organization.

provided within the framework of the

For example, assume that SERVQUAL

national

more

SERVQUAL

dimensions

will

plans.

indicates that patients do not perceive

Objective 11 - Broaden financing options to

hospital employees as being willing to

expand and improve access to affordable and

help. The low score on this aspect of

adequate health care to a majority of

quality may be symptomatic of deeper

Nigerians.

problems that center on the organization's

health

policy

and

Objective 12 - Strengthen policy formulation,

ability to hire and retain high-quality

general

employees,

management,

financial

to

evaluate

and

reward

to

provide

Likewise,

billing

management, and planning capacity of the

superior

Federal Ministry of Health and parastatals.

adequate

Objective 13 - Strengthen the capacity to

inaccuracies

develop, implement, monitor and evaluate

staffing problems that prevent insurance

evidence-based

claims from being filed promptly and

planning,

national

programmes

health and

policy,

performance, training. may

or

be

symptomatic

of

payments from being recorded accurately.

activities.

Perhaps to accommodate the interests of new parties to the reform, the following set

Therefore,

of

added:

contributions to the health care industry

Objective 14 - Institutionalize managed

will be its ability to identify symptoms and

competition, public- private partnerships

to

and

examination of underlying problems that

new

objectives

National

has

Health

been

Accounts.

137

provide

one

a

of SERVQUAL's

starting

point

major

for

the

inhibit the provision of quality services.

Healthcare Organizations (JCAHO). For

The measurement of patient expectations

the long-run success of a health care

as well as perceptions provides a valuable

organization, both functional and technical

dimension of insight into the process by

quality has to be monitored and managed

which the quality of health care service is

effectively.

evaluated.

Administrators

understand

the

areas

should in

which

8. Nigeria leads fight against "killer"

expectations are particularly high so that

counterfeit drugs

the service delivery process can be tailored

Nigeria has been at the forefront of global

to meet those expectations (Parasuraman,

efforts to fight counterfeit drugs since Prof.

Zeithaml, and Berry 1985). Similarly, in

Dora Akunyili took over the National

order to identify and correct service quality

Agency for Food and Drug Administration

problems quickly, administrators should

and Control (NAFDAC) in 2001. Prior to

understand patients' perceptions of the

2001 Nigeria was ranked as one of the

quality

of

service

mannertin

which

the

most corrupt countries in the world, by

and

Transparency International. Before her

perceptions are balanced. In addition, the

assumption of office , staff abused their

scale can also be used to measure the

position to extort money from honest

views of hospital managers and employees

manufacturers at the same time as taking

as they think patients perceive the quality

bribes from counterfeiters in return for

of the service. This can be done easily by

access to the Nigerian medicines market.

changing the instructions portion of the

Akunyili told the Bulletin (World Health

scale. Hence, the existence of another

Organization

potential

gap,

delivered

and

expectations

gap

level

of

the

corruption we had in 2001 cannot in any way be compared to what we have now. It

can

has decreased to almost zero. But it is still

assessed

between

"The

provider's view and the customer's view, be

the

2007):

and

monitored

(Parasuraman, Zeithaml, and Berry 1985).

a

Finally, it should be pointed out that

completely."

SERVQUAL

is

cannot

rule

it

out

measure

The Nigerian agency is now a key player in reducing the manufacture and distribution

manner in which the health care service is

of counterfeit medicines in West Africa. It

delivered

However,

has the support of the Food and Drug

functional quality in a health care setting

Administration and the Environmental

cannot

accurate

and Occupational Health Science Institute

diagnoses and procedures. Such technical

at Rutgers University in the United States

quality is the focus of research that is

of America, among other regional and

being

international agencies including WHO.

be

the

to

We

functional quality only (defined as the

to

designed

problem.

sustained

conducted

organizations, Commission

patient).

by

without

a

including for

number the

Accreditation

of

Joint

Her efforts have led to increased public

of

awareness about counterfeit drugs and

138

tougher surveillance at Nigerian customs.

Teaching Hospitals, Specialized Hospitals

She says that the number of fake drugs in

and Federal Medical Centres

circulation

in

Nigeria

has

been

substantially reduced, although she and

8.2. Regulatory Bodies

everyone else involved in fighting the

Nigeria Medical & Dental Council

illegal trade admit how difficult it is to

Nurses & Midwifery Council of Nigeria

quantify

Pharmacy Board of Nigeria

the

problem

and

therefore

measure their success. Still, there is plenty

Dental Technologist Board of Nigeria

of anecdotal evidence that her measures

Health Records Officers Registration

have had an impact: shopkeepers no longer

Board of Nigeria

dare to sell counterfeits openly for fear of being

reported

to

the

authorities.

Research Methods

Criminals behind the trade have left

To examine the effect of the activities

Nigeria and set up business in other

embark upon by the stakeholders in the

countries, she says. Now governments

health sector on the life span of an average

across West Africa are working closely

Nigerian,

with Nigeria to crack down on the illegal

secondary sources such as the Central

trade. World Health Organization Bulletin

Bank of Nigeria Annual Reports. The data

(2007). The milestone achievement by

used covered a period of 14 years (1990 –

NAFDAC

2003).

could

be

traceable

to

the

data

were

gathered

from

attention given to this sector by the

The method of analysis was based on

present administration, the support of the

Correlation

citizenry and efforts by the stakeholders in

expectancy and Budget estimates. Bar

the sector. Below are various Parastatals

chart and line graphs were also used to

and regulatory bodies established by the

show the relationship between Budget

Government and stakeholders all aimed at

estimates and Life expectancy.

improving the health sector.

Regression analysis was used to show the

Coefficient

between

Life

relationship between the budget estimate 8.1. Parastatals

and life expectancy.

Primary Health Care Development Agency

Model Specification

(NPHCDA)

LE = Ao + X1RE + X2CE + Ut

National Health Insurance Scheme (NHIS)

Where LE =Life Expectancy (Dependent

Nigerian Institute For Medical Research

Variable)

(NIMR)

RE = Recurrent Expenditure (Independent

Nigerian Institute Of Pharmaceutical

Variable)

Research And Development (NIPRD)

CE = Capital Expenditure (Independent

Regional Center for Oral Health Research

Variable)

and Training Initiatives (RCORTI)

Ut = Error Term

139

Table

1

:

Below

government

shows

budget

federal R

estimates,

R2

Adjusted

Std

R2

Error of

(Recurrent of capital expenditures) and

the

life expectancy at birth, years.

YEARS

Estimate

Model

RECURRENT

CAPITAL

LIFE

EXPENDITURE

EXPENDITURE

EXPECTANCY

0.647

0.419

0.321

1.1716

II

AT BIRTH (YEARS) 1990

401.1

257.0

54

9. Results and Findings

1991

619.4

137.6

51

The coefficient of determination R2 is 0.241

1992

837.4

188.0

52

1993

2331.6

352.9

52

1994

2066.8

961.0

52

expenditure accounts for 24.1% of the

1995

3335.7

1725.2

52

variation in the life expectancy of an average

1996

3190.0

1659.5

53

1997

3197.2

2623.8

53

1998

4860.5

7123.8

53

1999

8793.2

7386.8

54

2000

11612.6

6569.2

54

2001

24523.5

20128.0

54

which indicates that the RE explains 41.9%

2002

50563.2

12608.0

54

of the variations in the life expectancy of an

2003

33254.5

6431.0

57

which shows that the CE the current

Nigerian within the time of the study.

The coefficient of determination R2 is 0.419

average Nigerian.

Source: Central Bank of Nigeria annual Reports (2004)

Using the Spearman’s correlation coefficient, the value 0.644 indicates that there exist a

Figure 1: Federal Government Budget estimates and life Expectancy at birth

linear

correlation

between

total

expenditure

coefficient and

life

expectancy. The increase in life span is not as sharp as one would expect compared to

60000 50000

the increase in the Budget estimates of the

40000 30000

health sector.

20000 10000

03

02

20

The Regression analysis shows that the

20

00

01

20

99

20

19

97

98

19

19

95

96

19

94

19

93

19

92

19

19

19

19

90

0 91

Budget Estimates and Life Expentancy

Federal Government Budget estimates, and Life Expectancy at birth

positive

Years

percentage

of

contribution

of

capital

expenditure and current expenditure is less Model Summary

than 40%, which is significantly very low compared to normal expectations.

R

R2

Adjusted

Std

R2

Error of the

The standard error of the estimates is

Estimate

greater than half the value of the estimates X1 and X2. This shows that the estimates are

Model I

0.491

0.241

0.178

1.3394

140

not statistically significant at 5% level of

setting cannot be sustained without accurate

significance for a for a two tail test.

diagnoses and procedures. Also, efforts by various

Government’s

Parastatals

and

The implication of the above findings is that

regulatory bodies to improve health care

the minor changes expressed in the life

deliveries is impressive and commendable.

expectancy of an average Nigerian may not

Health reforms embarked upon by the

be due to the gradual increase in budget

President Obasanjo’s regime have greatly

estimates for recurrent expenditure and

revived the ailing sector.

capital expenditure. The changes may be as

However, the efforts made by authorities in

a result of health reform embarked upon by

charge

the administration of President Olusegun

impressive and commendable, but it should

Obasanjo

be sustained and improved upon.

and

stakeholders

in

also the

various

efforts

by

sector

aimed

at

of

healthcare

in

Nigeria

are

improving the health care deliveries in

References

Nigeria.

Central Bank of Nigeria, Annual Reports, 2004.

10. Conclusion and Recommendation

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Public health systems vary in different parts of the world, depending upon the prevalent

Public-Private Partnerships (PPPs) for Healthcare in Nigeria: The Awakening Possibilities. Retrieved 25th May 2007, from www.ex-designz.net

health problems. In the developing world like Nigeria, where sanitation problems and

Facilitation Skills for Public Healthcare Professionals: An Introduction. Retrieved 25th May 2007, from www.ex-designz.net

limited medical resources persist, infectious diseases are the most significant threat to

Olateju O .I. and Adeyemi, O. T. (2007) “Measuring Service quality of Health Management in Nigeria” Environmental Behaviour Association of Nigeria, Lagos.

public health. Public health officials devote resources to establish sanitation systems

Parasuraman, A., el tal(1985) "A Conceptual Model of Service Quality and Its Implications for Future Research." Journal of Marketing 49, pg. 41-50.

and immunization programs to curb the spread of infectious diseases, and provide

World Health Organization Bulletin (2007), “WHO Country Cooperation Strategy: Federal Republic of Nigeria”.

routine medical care to rural and isolated populations.

SERVQUAL's

major

contributions to the health care industry will be to identify symptoms and to provide a starting

point

underlying

for

problems

the

examination

that

inhibit

of the

provision of quality services. Finally, it should be pointed out that SERVQUAL is designed to measure functional quality only (defined as the manner in which the health care service is delivered to the patient). However, functional quality in a health care

141