Transcript The Future of Healthcare The Changing Role of Nigerian Hospitals September 2013 Enoma Alade,BDS,DDS,MPH(Health.

The Future of Healthcare
The Changing Role of Nigerian Hospitals
September 2013
Enoma Alade,BDS,DDS,MPH(Health. Mgt.)
 Nigeria
ranks 167 out of 176 on live expectancy with the average Nigerian
expected to live just 48 years.
 Every year about 53,000 women die at child birth which accounts for 10% of
the world maternal deaths from pregnancy and child birth related causes
while Nigeria represents only 2% of the world population.
 Over one million children dying before their 5th birthday
 Medical facilities are not evenly distributed across the country, with most
rural areas lacking basic facilities such as hospitals and clinics as well as
doctors and nurses
 5% of population covered by private insurance or HMOs
 Total Health Expenditure per capita is about $139 of which 63% is private
health expenditure, of which 95% is out of pocket
Source: http://www.africare.org/our-work/what-we-do/health/index.php

Healthcare Financing (2011)
◦ Gross Domestic Product per capita $2600
◦ Total expenditure on health per capita $139
◦ Total expenditure on health as % of GDP 5.3
SSA Country Comparison
Health spending as a percent of Gross Domestic Product,
2000-2011
12
10
8
6
4
2
0
2000
2001
2002
2003
Ghana
2004
2005
Nigeria
2006
Rwanda
2007
2008
2009
2010
2011
South Africa
Source: The Global Economy: research and Learning Tools for the Global Economy

The Federal Government Level – Federal Ministry of Health (FMOH)
◦
◦
◦
◦
Responsible for policy and technical support to the overall health system
Inter-national relations on health matters
The national health management information system
Provision of health services through the tertiary and teaching hospitals and national
laboratories
◦ Resource Mobilization and Evaluation
◦ Regulation of selected health services e.g. Radiology, Nuclear Medicine

The State Government Level – State Ministry of Health (SMOH)
◦ Responsible for secondary hospitals
◦ Deploying additional financial resources, regulation and technical support for primary
health care services
◦ Regulation of private sector facilities

The Local Government Level
◦ Responsible for primary health care delivery
◦ Support healthcare delivery efforts at the community level
World Health Organization. The Nigerian Health System


Private expenditure on health accounts over 63% percent of all health
expenditures
Geographic disparities exist: Overall, private hospitals accounted for
72% of the secondary health care centers
◦ 5% in the North-East
◦ 24% in the North-West zones
◦ 90% in the South-East and over 80% in South-West zones
World Health Organization. The Nigerian Health System
Estimated growth trends in the 10 most populous countries
millions
450
400
USA
Nigeria
350
300
Indonesia
Pakistan
+146%
250
Brazil
200
Bangladesh
150
Mexico
Russia
100
50
0
SOURCE: United Nations Population Division, Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects:
The 2010 Revision, http://esa.un.org/unpd/wpp/index.htm,Sunday, August 28, 2011; 12:59:25 PM, HMSH presentation during Anadach Webinar,2011
6
Million Visits/year
Projected Health OPD visits using South
Africa Targets
Projected Health OPD visits (SA current
public sector utlization)
Million Visits/year
Actual Health OPD visits at LASG facilities
0
10
20
30
40
50
60
Source: Lagos State, Statistics South Africa
70
Government Hospitals & Clinic
Private Hospitals & Clinic
Banking Sector
100%
90%
80%
70%
60%
50%
47%
40%
35%
33%
30%
20%
33%
31%
25%
18%
19%
15%
17%
16%
11%
10%
0%
No corruption
A little corruption
A lot of corruption
DK/Refused
Source: NOI-Gallup 4th National Poll
To the best of your knowledge, is there a treatment available that
helps people with AIDS live longer, or not?
Yes
No
(DK)
100%
90%
80%
77%
76%
70%
65%
62%
58%
60%
51%
50%
43%
36%
40%
30%
30%
20%
10%
24%
27%
26%
24%
23%
17%
12% 12%
15%
12%
6%
6%
0%
South West
South East
Source: NOI-Gallup 4th National Poll
South South
North West
North East
North Central
Nigeria
Poor health
outcomes
•
•
•
Triple burden
of disease
Poor quality of
health services
Lack of
protection from
financial risk
•
•
High maternal, infant and child mortality rates
Inequalities in health outcomes and utilization by socioeconomic status,
urban/rural and by regions across the country
Persisting vaccine-preventable diseases, such as Polio, Measles and
Meningitis
Rising non-communicable diseases
Significant burden of injuries and trauma-related deaths
•
•
Poor quality of health care services in public and private facilities
High rates of outward migration for health care services for those who
can afford it
•
•
Health insurance coverage is limited. Most payment remains out of pocket
National health insurance scheme currently covers only the formal sector.
Source: based on HMSH presentation at Anadach Webinar, 2011
Source: Interviews of 66 general physicians in 10 Nigerian Cities, Team analysis, Mrs Fola Laoye, Hygeia at the Nigeria Priave Health Care Summit
Most medical tourism cases reflect the increasing Burden
of Non-Communicable Diseases in Nigeria

According to the WHO Nigeria is one of the hardest hit countries with noncommunicable disease deaths and this is likely to rise
◦ Cardiovascular diseases account for most NCD deaths, or 17 million people
annually
◦ Cancer 7.6 million
◦ Respiratory disease 4.2 million
◦ Diabetes 1.3 million

A study assessing the prevalence of NCD admissions at the University of Port
Harcourt Teaching Hospital revealed 56% of medical admissions were due to
NCDs and the 3 dominant disease states were in decreasing order:
◦ Cardiovascular disease
◦ Diabetes
◦ Chronic renal failure
• obesity, worsening dietary changes, etc
Majority of NCDs share the same risk factors: tobacco use, inadequate physical
inactivity, the harmful use of alcohol, and poor diets and could be prevented
with proper health education and other interventions
Source: Nigeria Journal of Clinical Practice, 2008 Mar;11(1):14-7.Unachukwu et al.
Which is not surprising given the increase in Nigerians with
risk factors for NCD
More Nigerians are experiencing the
cluster of risk factors that predispose
them to non-communicable diseases
 It was found that patients may have as
many as five chronic disease risk factors:
-Smoking
-Alcohol intake,
-Sedentary life style
-Hypertension (160/95)
-Obesity
-Truncal obesity,
-Insulin resistance diabetes:
-hypercholesterolemia
(>5.2mmol/l)
-hypertriglyceridemia (>2.5mmol/l)

5 or
more
4 or
more
3 or
more
Percentage…
2 or
more
1 or
more
0
Source Ezenwaka et al, 1997
20
40
60
80
20% growth rate
Major Cardiac Disease Segments
• Coronary Artery Disease (HTN)
• Congestive Heart disease
• Ischemic with increasing prevalence
• Alular heat disease
• Arrhythmias
Source: Team Analysis
Lack of quality cardiology
services
in Nigeria is leading to drastic
increases in:
• Local referrals to the following
Nigerian centers
-First Cardiac Consultants
-UPTH
- UCH
-UNTH
-LASUTH
-National Hospital, Abuja
• International referrals e.g.
India, South Africa, Egypt
Total No of Cardiologists in Nigeria
Total required
India
UK NHS recommendations
Turkey
Upper Middle Class
Upper Class
0
Source: Interviews, team analysis
500
1000
1500
2000
2500
3000
• Prevalence of chronic kidney disease is estimated to affect about 30
million Nigerians
• Chronic renal failure is estimated to account for 10% of medical
admissions in Nigeria (200 to 300 patients/million) thus in Lagos you
would expect between 3,000 to 4,500 patients
• 40 renal centers in the country
• Only about 100 nephrologists in Nigeria
• 84 dialysis beds in Lagos with 84% in the private sector.
• There are probably less than 800 patients being treated by dialysis in
Lagos so there is likely to be a sizeable underserved market which may be
linked the high rates of uncontrolled hypertension (even in the middle and
upper classes).
Source: Nigeria Association of Nephrology, Abu –Aisha et al: Peritoneal Dialysis in Africa, Peritoneal International: 2010, Lagos State Government
Top investigations/procedures not readily available cited by the physicians
Dialysis, Intentional Cardiology, PET Scan, Vascular Surgery
Majority of the practitioners stated that between 40-60% of
patients require specialist intervention
Practitioners stated that about 12 % of patients requiring dialysis
79% do not know of any facility providing thrombolytic within 4
hours of stroke
Most local referrals are to Teaching Hospitals
Large variation in patients covered by Private Health Insurance
Source:Interviews,Team analysis
Typical specialty services include
the following clinical areas:
• General Surgery
• Dialysis
• Non-interventional
Cardiology
• Basic Orthopedic Surgery
• Neurology
• Basic Neurosurgery
• Gynecology
• Basic Radiology
Add-on or luxury services rarely
available/not available in-country
include:
• Laparoscopic procedures
• Interventional radiology
services
• Interventional Cardiology
• Organ Transplant
• Advanced Cardiothoracic
Surgery
• Advanced Neurosurgery
• Advanced Orthopedic
Surgery
Working Relationship
which may be
enhanced by referral
fees
Patient Request
Government
Agreements
Availability of Facility
Basis for choosing
referral center
Retainership
Agreement
Competence
Cost
Source: Interviews, Team analysis
Proximity
mm
Description of Major Providers
Capacity and Pricing
•200,000 medical tourists (70,000 from Middle East)
•Medical tourism estimated to grow at 30% per year
•Rapidly growing hospital chains – serving growing Indian
Middle Class
•Growth of Medical Tourism is regarded as a key strategy
by the Indian Government
•Key private sector providers include:
•Escorts Heart Institute and Research Centre
•Apollo Hospitals
•Workhardt Hospital (linked to Harvard Medical
International).
Top tier hospitals offer speciality services similar to the
US
•35,000 doctors of Indian Origin in the US –
increasing numbers returning to India after
speciality training to private hospital groups.
•For example, there are 3000 cardiologists
and 900 cardio-thoracic surgeons in India
compared to about 50 cardiologists in
Nigeria
•There are over 300 nephrologists in India
compared to under 100 nephrologists
•Rapidly growing hospital chains
mm
Overview
•Third largest chain in the world with
8500 beds in 54 hospitals in India
and elsewhere with 20 million
patients
•Apollo – New Delhi 200,000
patients annually with 9,500
international
•Increasing focus on Africa –
expectation that 10% of revenue will
come from Africa over next 3-5 years
Business Model
•JCI and ISO 9002 accreditation for
several hospitals
•Affiliated with Johns Hopkins and
Mayo Clinic
•No. of Nigerian patients increased by
150% in last 2-3 years.
•Allegedly pays referral fees to
Nigerian Doctors, visa ease
Clinical Offerings
•90% of physicians trained or
worked in OECD countries
•Offer similar spectrum of services
to Centres of Excellence in OECD
countries and other top tier Indian
Hospitals.
•Also provide electronic personal
health records
Payment Options
•Response to query on elective cases
within 48 hours
•Concierge services including helping with
visas, hotel, transportation, sight seeing
•Liaison with insurance companies e.g.
international SOS, CIGNA, BUPA
•Multiple payment options – TCs, Credit
cards, cash, wire transfer, foreign
currencies
“Famous patients include
Senator F. C Okoro - “I cannot
describe to you the dedication
to service, the efficiency and
the absolutely amazing
facilities you have here. For
me, not only is it far cheaper
than treatment in the USA or
UK, it is treatment that allows
me complete access to my
doctor.’’
Day Rate Private
Usually premium based on surgery ($150-500/day)
Day Rate General Room
Prices usually include shared room
Day Rate ICU (Intensive Care Unit)
N/A
Appendectomy
Not applicable
Hernia Repair
$2,800
Single Shoulder replacement (including implants)
$7,200
Knee replacement (single including implants)
$ 6,900
Myomectomy
N/A
Hysterectomy
$1,050
Cesarean Section
$1,200
Minimal Invasive Procedure (MIP) -Endoscopy
Diagnostic: $325
(MIP) Colonoscopy
Diagnostic: $375
(MIP) Laparoscopy
Diagnostic: $360 ; Surgery e.g. cholecystectomy
$1,800
Neuro Craniotomy
$7000
Dialysis per day
N/A
Kidney transplant
$20,000
Anesthesia
It is paid with the price of surgery
Registration
Included in pricing for elective procedures
In Patient
Included in pricing for elective procedures
Medical Consultation
Included in pricing for elective procedures
Looking at Nigerian urban hospitals over the next 5-10 years
Industry structure and economics
• Increased consolidation reduces
private sector fragmentation
• Industry remains profitable and
market growing so attract new
investors
• Relatively low barriers at the lower
end of the market
• More PPP arrangements
Patient demand
• Remain determined by GP referrals
• Growing demand for better quality
• fueled by income, awareness, disease
burden
• Price sensitivity is generally high
amongst lower and middle socioeconomic classes
Demand for
hospital
services will
continue to
increase
Competition
• Increased price competition esp. for
basic services
• Competitors differentiate on training,
services
• Greater international competition
including backward integration to
provide services in-country
External factors
• Growing numbers of the insured
• Increased disposable income
• Expanding health awareness which will
increase demand for services
• Falling international health prices for
elective care & new players in medical
tourism due to surplus hospital capacity
Changes in
demand
Demographics
Epidemiology
The public’s
expectations/m
obile phones
Changes in
supply
Technology and
knowledge
Workforce
Financial pressure
Broad social
changes
Globalization
Government reforms
Sectoral reforms
Health
Services
Adapted from Mc Kee, M.; Healy, J. 2002
Growth in Demand
• Major increase in personal wealth
driving patient demand for better
quality services
• Changing disease patterns e.g.
cardiology
• Increased use of specialty services by
physicians due to increased medical
education and increased influence by
physicians returning from the
Diaspora
• Resulting expansion of private
specialist services such as radiology
to address the needs e.g. Reddington
Hospital
Ability and Willingness to Pay
• Expanding private health care
expenditure - N546 billion in 2004 to
N1.2 trillion in 2008 (W.H.O)
• Expansion of health insurance
coverage in Nigeria which tends to
result in a per capita increase in use
of health facilities
• More organized private sector
companies offering HMO services and
expanding coverage of their
employees.
• Nigerians with a wide range of
incomes utilize specialty services in
country and abroad (~ $1 billion)
There are new players – both local and domestic responding to the increasing demand for quality specialty
services we believe this will become an increasingly competitive market in large urban centers e.g. Lagos, PH,
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Increasing allocation of funds to health
Improved regulatory environment
Training of hospital leaders in management
Clear Health Human Resource Strategy and Implementation
Training providers for the new environment, consider innovative
partnerships with international academic medical centers e.g. Emory
University/Addis Ababa University/Black Lion Hospital
Tap into the Diaspora resources innovatively – not just for delivery but
particularly for training and strengthening capacity
Focus on improving quality of care and improving patient satisfaction
Improving access to funds by private health facilities for improvement
Improved power situation
Continue to explore PPP arrangement but need to be assessed to ensure
that they are achieving desired goals
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Having clear vision and plan, identified competency areas
Focus on developing hospital as a business to ensure viability
Improve management systems to function effectively across various
areas e.g. Financial management, procurement, information technology
(IT), human resources, and administration
Leverage use of modern marketing techniques & innovative approaches to
health education e.g. mobile phones, lessons from the banking industry
Deliver patient centered care and encourage team approaches to health
care delivery
Performance improvement e.g. by encouraging improved staff morale,
clear financial incentives related to performance, use of SOP/protocols
Improve clinical skills and services that can be delivered to respond to
demand for new services
Consider focusing on delivery high quality care at internationally
competitive prices

The growth of outpatient service utilization is going to present the largest
change to hospital services over the next decade. Specialties expected to
boom include oncology (27 percent), general surgery (23 percent),
neurosciences (22 percent) and cardiovascular (19 percent).

A simultaneous decline in hospital inpatient services is expected.
Cardiovascular care will take the largest hit, according to Sg2, experiencing
a 27 percent drop in inpatient volume by 2022. From 1998 through 2008,
heart failure-related hospitalizations declined by roughly 30 percent.

The country's top-tier hospitals have tailored their specialty programs to
incorporate survivorship services, health education and therapy which are
now staples in patient-centered disease management e.g. Johns Hopkins
Breast Cancer Survivor Program
Source; Becker Hospital Review - Molly Gamble May 07, 2012

The odds of a hospital surviving on its own — without being part of this healthcare
ecosystem — are low, leaving many partnering, forming clinical affiliations,
merging or selling.

Hospitals are finding themselves in a game of consumerism catch-up. The
emergence of convenient, transparent and customer-centered strategies like ATMs
and online banking bears resemblance to telemedicine, for example.

American hospitals are likely to face a larger pool of competitors. For example,
even the country's most reputable and financially sound hospitals haven't been
immune to the competition of retail walk-in clinics in neighborhood CVS and WalMart stores.

Many physicians are quick to deem these care settings "as cheap, unworthy
competitors,” but hospital groups have responded. For example in 2009,
Cleveland Clinic partnered with CVS stores in northeastern Ohio and took over
nine of the stores' Minute Clinics, assigning a physician to each one.
Source; Becker Hospital Review - Molly Gamble May 07, 2012
Image: NXT Health
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