Enhancing healthcare regulation in Nigeria: Ensuring safety and sustainability

This article explores approaches that will enhance patient safety and promote health system sustainability with healthcare facility regulation in Nigeria. Great strides are being made with healthcare development. However, ongoing dissatisfaction is expressed by the extensive use of alternative medicine, religious bodies, self-medication, and the amount spent on outbound medical tourism. Despite the increased number of healthcare regulations, unsafe practices continue, including considerable quackery resulting in patient harm. This article discusses Nigeria’s current healthcare regulatory framework, emphasising the need for a National Healthcare Facility Regulation agency.

Why is industry regulation important?
The objectives of regulating an industry include ensuring product and service safety, quality, and fairness and maintaining stable and competitive markets. Industry regulation has transformed many industries in Nigeria, ensuring that consumers are well served and that the industry is viable for continued investment. The banking, telecommunications, and pension industries are notable industries transformed by strategically applying regulation. The private healthcare industry can also be transformed, creating broader access to safer, quality, and affordable healthcare for all Nigerians.

Current state of healthcare regulation in Nigeria
The National Health Act of 2014 (NHA 2014) outlines the structure of healthcare regulation in Nigeria. The Federal Ministry of Health is responsible for developing national health policies. The State Ministries of Health supervise public and private health facilities within their jurisdiction. The Federal Ministry of Health regulates federal facilities within the state. Local Government Health Authorities provide and maintain primary healthcare within their domains. The National Tertiary Health Institutions Standards Committee (NTHISC) has been inaugurated to improve the governance of the health systems in federal tertiary hospitals across the country. The National Health Act mandates the establishment of regulatory bodies like the National Primary Health Care Development Agency (NPHCDA) to regulate primary health care delivery. The Nigerian Patient Bill of Rights (PBoR) is an important policy that protects patients’ rights within the Nigerian health care system.

State regulation of healthcare facilities
The National Health Act of 2014 mandates state health ministries to oversee private and public healthcare facilities within the state, ensuring quality and safety. Some states have taken the initiative by establishing dedicated agencies to monitor and accredit these facilities. Notably, the Health Facility Monitoring and Accreditation Agency (HEFAMAA) in Lagos State and the Yobe State Health Facility and Health-Related Facilities Inspection Agency (YOHFIMA) exemplify this effort. Significant progress has been made, but resource limitations challenge the effective fulfilment of their mandate. Nevertheless, these agencies’ unwavering commitment to upholding necessary standards is crucial in safeguarding public health in their states.

Why does Nigeria need a national healthcare facility regulation agency?
Healthcare facility regulation in Nigeria presents significant opportunities to strengthen our health system and build public trust. The initiative requiring all health facilities to secure a certificate of standards is an important step toward quality assurance. Additionally, the newly formed National Tertiary Health Institutions Standards Committee (NTHISC) diligently oversees tertiary facilities, which marks a positive advancement in our healthcare landscape. Establishing a National Health Facility Regulation Agency (NHFRA) will further enhance our healthcare system. This agency would effectively regulate non-tertiary health facilities, addressing critical issues such as patient safety and treatment effectiveness, which will improve treatment outcomes, build trust in the healthcare system, and improve the health-seeking behaviour of Nigerians. It could also tackle access to care and affordability issues in healthcare across Nigeria.

Furthermore, the NHFRA could address industry fragmentation and promote equity in the distribution of health facilities. We can create a more robust healthcare system by aligning with existing regulations. Moreover, the NHFRA could serve as a central data collection and analysis hub, which is vital for crafting and implementing informed policies. Sections captioned (i-ix) below outline the other significant improvements that NHFRA could contribute to transforming Nigeria’s healthcare landscape.

i. Implementation of the certificate of standards
The NHA 2014 plays a crucial role in ensuring the quality of healthcare services nationwide by introducing the requirement for a certificate of standards. This legislation mandates that public and private health facilities secure this certificate to operate legally. The absence of a National Healthcare Facility Regulation Agency is why this has not been implemented.

ii. A clear definition of a hospital
A hospital is a complex, multidisciplinary institution, uniting various medical departments like emergency, surgery, and cardiology under one roof for integrated patient care. This cohesive structure fosters collaboration and resource sharing among specialists to optimise healthcare outcomes. While the system can be defragmented, where services operate separately, we will focus on its integrated nature, emphasising the synergistic and holistic approach essential for efficient and effective medical treatment.

Establishing national standards in Nigeria’s healthcare system presents a fantastic opportunity to enhance hospital quality and effectiveness. Hospitals are complex buildings that must be designed and built for purpose. Patient safety, accessibility, infection control, emergency preparedness, integration with multiple departments, and effective information management systems must be built into the design to assure quality healthcare delivery. The National Health Facility Regulation Agency will have to define standards for Nigeria, and licenses will only be awarded to those who comply with the standards defined.

iii. Reducing the cost of healthcare delivery.
i) A focus on outpatient care
Most healthcare services can be effectively provided in an outpatient setting without hospital admission, as the World Health Report 2008 indicates. Integrating services within these outpatient settings will likely enhance healthcare delivery and address a broad spectrum of patient needs, as highlighted in the Global Strategy on Integrated People-Centred Health Services for 2016–2026. In Nigeria, the prevailing perception of hospitals is that they are facilities designated solely for the admission of individuals who are ill.This mindset considerably elevates the costs associated with primary care.

ii) Asset-light clinics for primary care
Asset-light clinics are an innovative approach to healthcare, minimising physical infrastructure and capital needs. By focusing on essential services, these clinics lower overhead costs and can expand rapidly into underserved areas, providing affordable primary care and improving accessibility. A successful model relies on collaboration with hospitals for seamless patient referrals. To support this shift, thoughtful adaptations in regulatory frameworks and incentives like tax breaks or grants can encourage the establishment of clinics in rural communities.

iv. Expanding access to healthcare facilities.
Healthcare investments often concentrate in affluent areas of cities, as these communities can typically afford a wider range of services. This trend has led to an oversupply of facilities in certain regions, resulting in overcrowding and challenges to the financial sustainability of these facilities. Regulatory measures could be implemented to encourage collaboration among healthcare providers rather than competition to address this issue. The certificate of standards requires healthcare providers to obtain approval before opening new facilities. This system would ensure that new hospitals are created only when there is a demonstrated need to meet the healthcare demands of the community. Additionally, fostering partnerships between hospitals and asset-light clinics can optimise resource utilisation and improve service delivery. This integrated approach reduces competition and contributes to a more comprehensive and efficient healthcare network.

v. Driving patient safety and effectiveness of therapy
Regulation plays a crucial role in enhancing patient safety and the effectiveness of therapy through several key approaches. One important aspect is establishing minimum safety and quality standards for healthcare providers, facilities, and products, ensuring that essential patient care criteria are met. This can be achieved through licensing, accreditation, monitoring, and reporting patient outcomes and adverse events. The data collected helps identify trends, errors, or areas that need improvement, allowing for proactive measures to enhance the quality of care. Regulations also promote adherence to evidence-based clinical guidelines and best practices, ensuring that therapies are effective and grounded in current scientific knowledge. By requiring ongoing education and training for healthcare professionals, regulations ensure that providers remain updated with the latest advancements and safety protocols. Finally, regulations hold healthcare providers accountable for their actions, fostering a culture of transparency that prioritises patient safety and continuous improvement.

vi. Differentiate a medical practice from a hospital
The evolution of private healthcare in Nigeria has resulted in most practitioners needing to provide the infrastructure to practice their profession. A practice is usually an outpatient setting that allows a doctor to practice his profession. The infrastructure level deployed may vary, but there are usually no admission facilities for overnight care. In the absence of regulatory control, what should be a straightforward practice often transforms into a larger hospital model where patients are admitted for overnight care without meeting the standards of a hospital. This is usually done to enhance the revenue potential of the facility. This lack of regulatory scrutiny has led to the proliferation of facilities labelled as hospitals in Nigeria. A hospital’s size and scope differ significantly from a medical practice’s. Hospitals are substantial investment vehicles that typically exceed the resources of a typical individual doctor. The certificate of standards will support this initiative to distinguish between a medical practice and a hospital.

vii. Making the private healthcare industry attractive for investments
The Federal Ministry of Health usually focuses on developing the public healthcare sector. According to available data, the public sector meets less than 30 percent of Nigeria’s healthcare needs, while the private sector provides over 70 percent of Nigeria’s healthcare needs. This Business of Health in Africa, published by the United Nations Industrial Development Organisation (UNIDO) more than 15 years ago, promoted investing in the private sector as a route to African healthcare development, and many funds, such as the Africa Health Fund (AHF), were created to support this effort. Unfortunately, the initial exuberance has waned (Why Investors Are Ignoring African Healthcare).

These challenges need attention from a national regulatory agency. It will be important to understand the forces that shape the industry’s attractiveness for funding and strategically employ regulation to reshape the industry.

viii. The current regulations focus on healthcare professionals rather than healthcare facilities:
The Medical and Dental Council of Nigeria licenses medical doctors and dentists, while other councils like the Nursing Council and the Medical Laboratory Science Council regulate various professionals. Given the complexity of healthcare facilities that employ multiple professionals, a single council cannot effectively oversee all activities. For instance, laboratory services involve pathologists, laboratory scientists, and nurses. While these existing agencies are working and must continue to be supported, a National Healthcare Facility Regulating Agency is needed to register facilities and focus on patient safety and service effectiveness without negating the existing professional registration system.

ix. Driving consolidation and collaboration within the private healthcare industry.
Regulation can be a powerful driver for consolidation and collaboration within the healthcare industry by establishing a framework that encourages partnerships, integrates resources, and enhances efficiency. Insights from South Africa’s large hospital groups, such as Mediclinic, Netcare, and Life Healthcare, provide valuable lessons: Regulations can incentivise healthcare providers to collaborate through measures like tax breaks, streamlined licensing for joint ventures, and grants for integrated services. These advantages encourage stakeholders—investors and practitioners—to work together. By enforcing standardised medical practices and technologies, regulations facilitate smoother mergers between smaller providers and larger entities, thereby improving resource sharing. South Africa’s large hospital groups have prospered in regulatory environments that balance competition and collaboration. Nigeria could adopt similar regulations to ensure fair competition while promoting partnerships that drive innovation in healthcare delivery.

Conclusion
Every Nigerian has the right to access safe, effective, and affordable healthcare. The government is responsible for strengthening healthcare regulations and building trust in the healthcare system. I have discussed these issues in three previous publications (all referenced above with the hyperlinks). The government has set up a committee to establish a National Health Care Regulation Agency, and my objective with this essay is to reaffirm the necessity for such an agency.

Exciting times are ahead as we unite under a national vision to achieve universal health coverage (UHC) for every Nigerian by 2030. UHC embodies the promise of safe, effective, affordable healthcare for all, and this goal has been the heart of our discussion. Establishing the National Healthcare Facility Regulatory Agency is challenging yet rewarding, reminding us that “Rome was not built in a day.” This journey will call for our patience, unwavering determination, and an understanding that change unfolds gradually. Collaboration and consensus among all stakeholders are essential in this dynamic process. We must engage healthcare professionals, government entities, and the public, ensuring everyone feels valued and invested in building a strong foundation. This vibrant, collaborative spirit will help us enrich our agency’s growth with a rich tapestry of perspectives and expertise. Prior important laws have set up several credible and practical regulatory bodies for various sectors of the healthcare industry and the professionals working therein.

However, there remains a gap, and this new regulatory agency will work in tandem with existing regulations at both the national and sub-national levels to provide an effective framework to support the healthcare system. Moreover, let’s embrace our role as catalysts for positive change by emphasising improvement through training and development rather than punitive actions. By focusing on growth and capacity-building, we position ourselves as passionate advocates for enhancing our healthcare system. By embracing these principles, we set the stage for a resilient, adaptable healthcare agency dedicated to health and well-being. Together, we’re paving the way for a national healthcare system that is not just functional but genuinely effective, thriving on patience, teamwork, and a shared vision of empowerment. The future looks bright, and I am thrilled about what we can achieve together!

Dr. Richard Ajayi (FRCOG, FWACS, C.Dir) is a healthcare leader and entrepreneur with over 25 years of experience in obstetrics, gynecology, and healthcare management. Committed to transforming the medical sector in Nigeria and Africa, he focuses on advancing patient care and driving innovation in healthcare delivery.