Professor Joseph Ana, Africa Centre for Clinical Governance Research & Patient Safety
The 12-Pillar Clinical Governance Approach to quality and safe healthcare was piloted in 2004 after a first ever comprehensive needs / situation analysis of the healthcare delivery system for the 3.1 million population of Cross River State, Nigeria.
The baseline assessment revealed a failing system plagued by appalling weakness across all indicators/domains for performance, safety and quality. Maternal, under-5 child, and infant mortality were 800 per 100,000 deliveries, 245 deaths per 1000 births, and 100 deaths per 1000, respectively. Sanitation, indiscipline, truancy, poor attitude and behavior of staff to patients, corrupt practices, frequent out of stock of essential medications, lack of basic and advanced equipment, erratic electricity and lack of potable water were contributing to these alarming statistics. There was no regular continuing professional development for staff to remain updated in their fields. Frequent strikes and inter-professional disharmony in the sector perpetuated the bad health indices, and until 2014, Nigeria had no National Health Act to provide a framework for improving its health system.
A response to address a weak health system
Since 2004, Health Resources International (HRI) West Africa has worked with public (state Ministries) and private facility owners to strengthen hospitals and reverse the trends described above. Our goal was to markedly improve routine immunization, reduce HIV prevalence in Cross River state, and improve staff attitude, patient satisfaction and care outcomes. We aimed to do this by introducing a new clinical governance approach. The National Council on Health formally approved our 12 Pillar approach at its meetings in Jalingo, Taraba State in 2006 and Abuja FCT in 2007, and recommended that other states should also adopt this approach. Three former ministers of health have consecutively declared that ‘Nigeria needs Clinical Governance’ of the type (12-Pillars) that we are promoting for training institutions, health facilities and policy makers.
A comprehensive approach to effective service delivery for developing countries.
The Cross River State Ministry of Health pilot in 2004/5 showed that the 7 Pillars of Clinical Governance, as described by Dr. Gabriel Scally and Prof Sir Liam Donaldson in the United Kingdom in 1998, could not be transferred to a developing country like Nigeria without essential contextual domestication. We found that five additional pillars (see below) were needed to ensure effective and sustainable quality of service.
The goal of the 12-Pillar Clinical Governance Approach is to reduce the disease burden, eliminate inequalities, reduce especially maternal and child morbidity and mortality, and increase life expectancy and quality of life across age and gender. The 12 Pillars approach is an innovative, evidence-based framework to deal with the chronic challenges in Nigeria’s health system. It uses contextual understanding and collaboration between all health practitioners, and all government and non-government stakeholders to optimize the health benefits of government policies.
Why 12 Pillars Clinical Governance for developing countries
The 12 Pillars are: *Policy/Law, *Funding Mix, *Infrastructure,*Equipment, *Utilities and Ambience, Clinical Effectiveness, Audit, Risk Management, Education and Training, Patient and Public involvement (PPI), Information and IT (ICT), and Facility and staff management. The asterisks highlight the essential five components are often missing in developing countries. By adding these to the original seven pillars, we created the 12-Pillar Clinical Governance Approach. Institutionalization of the Approach led to a Health in All Policy (HiAP) in Cross River State in Governor Donald Duke’s administration.
Why the policy matters
For more than 150 years, Nigeria’s health system has defied every effort to take it into the top league of global health systems, leading to unacceptable rates of maternal and child mortality rates and poor health outcomes for the population generally. Nigeria accounts for about 2% of the world population yet contributes 10% of maternal, infant and child mortality because of its failing health system. And although the HRI needs assessment focused on Cross River State, we know it is no exception to all the other 35 states and Federal capital Territory (Abuja).
Where the homegrown 12-Pillar Clinical Governance Approach has been introduced in Nigeria, whether in public or private health facilities, the positive outcomes have been rapid, including a stronger health system anchored on best ethics, professional conduct and practice leading to Accreditation and Quality Marker Awards, concomitant cost control and sustaining quality and safe care.
Reviews of an evaluation of the pilot (which were published in the book titled ‘Whole system change of failing health systems’) were positive. The pilot defined the 12-Pillar Clinical Governance Approach as a ‘comprehensive amalgam of context-aware processes that ensure quality and safe outcome in health care by protecting patients and supporting practitioners in tandem’.
The 12 Pillars approach recognizes that the health and well being of the citizen is influenced by factors beyond direct health intervention, including level of education, income, housing, work place conditions and ambience, infrastructure, culture and religion. In turn, these are determined by social, environmental, economic and policy factors. Government policies therefore have significant direct and indirect impact on the health of the population, including around issues relating to accessibility, affordability, disparity and equity. It engenders multidisciplinary and multi-sectoral collaboration to achieve better results.
BM.BCh (UNN), FRCSEd, FRSPH, JtCertRCGP-UK, DFFP (RCOG)-UK, DipUrology-UK, Cert.ClinGov.UK
AFRICA CENTRE FOR CLINICAL GOVERNANCE RESEARCH & PATIENT SAFETY
Fig.1 Credit: www.en.wikipedia.org, 7 Elements of Clinical Governance