FEDERAL MEDICAL CENTRE, ABEOKUTA: A CASE STUDY IN HOSPITAL

MANAGEMENT

Abstract

The Federal Government’s take-over of the Idi-Aba wing of the State Hospital, Abeokuta,
Nigeria, in 1993 provided a unique opportunity to introduce a series of management
interventions addressing structural inputs like personnel, equipment, logistic supplies and
additional infrastructural development and to institute processes that addressed clients’ rights
and the health providers’ needs in the context of improving the quality of health care delivery
in Ogun State. These series of interventions have validated the view that quality improvement
can dramatically affect service utilization. The major intermediate outcomes of these
interventions show a 300% increase in service utilization, a 34% decrease in hospital death
rates and an 8000% increase in hospital revenue generation reported by the end of 1999.
Details of the structural inputs, management processes, outputs and selected intermediate
outcomes are discussed in this paper.

Keywords: Quality of Health care, Hospital Management, Delivery of Health Care,

Clients’ perspectives, Providers’ perspectives, health Service Evaluation, Family Planning,
Bamako Initiative, Cost Recovery, Tertiary Health Care.

Introduction

The Nigeria National Health Policy1 defined the roles of the three tiers of government in
Nigeria as follows: primary health care to be provided by Local Governments, secondary health
care by State Governments and tertiary health care by the Federal Government. In
operationalizing this policy, the Federal Government decided to establish at least one tertiary
health institution in each State of the Nigerian Federation. In order to take advantage of this
gesture, the Ogun State Government, in 1993, invited the Federal Government to take over the
management of one of its secondary hospitals, State Hospital, Idiaba, Abeokuta, for the purpose
of developing it into a tertiary health institution. Hence, in April 1993, the Federal Government
took over the management of the State Hospital, Idiaba, Abeokuta, renamed it Federal Medical
Centre, Abeokuta and appointed a Board of Management, which included an
Obstetrician/Gynaecologist/Family Planning Manager as Medical Director.

In the last decade or so, there has been a lot of interest shown in quality improvement in health
care delivery. Development partners around the globe have introduced a variety of strategies
for quality improvement and have used different names like total quality management,
continuous quality improvement, quality assurance, performance improvement, continuous
assessment, facilitative supervision etc to describe key processes for improving the quality of
services. Furthermore, many studies have been conducted to determine the clients’ and
providers’ perspectives of quality2-5. From these studies a number of factors have been
identified as being influential in determining whether clients will or will not utilize a health
service 6-8. Some of these factors include the health provider’s attitudes, limitation of available
range of services, availability of drugs and supplies, fees policy of the service delivery point,
client waiting times and cleanliness of the facility. From all these, perhaps the most important
lessons learnt are those that have shown that when the perceived quality of health care service
increases, clients’ utilization and satisfaction of such services also increase, irrespective of
whether such services are free or are based on a cost-sharing policy9-10.

The take-over of the Federal Medical Centre, Abeokuta provided a unique opportunity to test
this hypothesis through the introduction of structural inputs and management processes that
were geared towards overall quality improvement in the facility. This report is a review of
these inputs, processes, outputs and the intermediate outcomes of these interventions in a 7-
year period. It is the authors’ hope that the lessons learnt, which are being shared, will go a
long way in assisting newly appointed Chief Executives of health institutions to effectively
manage their institutions for the overall improvement of health care delivery in Nigeria.

Material and Methods

The Board of management of the FMCA was in office for a period of 17 months only before it
was dissolved in September 1995. During the short period of its existence, the Board worked
with the management to put in a place a Strategic Plan for the gradual development of the
institution. Following the dissolution of the Board, the Top Management Committee of the
Hospital worked directly with the Ministry of Health officials to actualize the Strategic Plan
(Rolling Plan). Some of the activities under the strategic plan are described below:

Needs assessment

The primary purpose of the needs assessment was to determine the community’s and other
stakeholders’ expectations for the Federal Government take-over of the State Hospital. The
needs assessment began with meetings with the traditional leaders in Abeokuta, namely the five
Obas (Kings), traditional chiefs and citizens of the State. These meetings examined the
perceptions of the community about the quality of health care in the former State Hospital and
also enquired about the community’s expectations for its future development. A fact-finding
questionnaire was also administered to some members of the Ogun State Branchy of the
Nigerian Medical Association at one of their conferences. The major findings from these
meetings was that the community wanted the new hospital to become the apex of health-care
delivery in Ogun State, like Nigeria’s premier teaching hospital, the University College
Hospital (UCH) in Ibadan, offering a wide spectrum of clinical services for common ailments
and conditions. The community’s consistent reference to the example of the UCH led to the
management’s selection of this institution as the benchmark hospital for its development.

Management also met with all staff to exchange ideas on the expectations of the new
institutional mandate. The leadership of the University College Hospital (Prof. O. O. Ajayi,
Chief Medical Director, and Mrs. Pat Shenjobi, Director of Administration) was also invited to
meet with the management and staff of the FMCA to share experiences in the running of their
benchmark hospital, the UCH, Ibadan.

One of the most important findings from all of these consultations was the recognition of the
need to immediately expand the range of services being offered in the hospital to include, as a
minimum, the four basic medical disciplines, namely internal medicine, paediatrics, general
surgery and obstetrics/gynaecology and other relevant support services in the laboratory,
pharmacy and theatre. Prior to the Federal Government take-over, only internal medicine and
paediatric services were being provided on a limited scale at the hospital.

The Table below summarizes some of the findings of the needs assessment in the form of a
SWOT Analysis (Strengths, Weaknesses, Opportunities and Threats) of the Federal Medical
Centre, Abeokuta at its inception in April 1993.

Inputs

`The reporting period, April 1993 – December 1999 witnessed the injection of the following
structural inputs into the institution:

1. Establishment of a Management Organogram and a Local Board of Management and

Board Committees, top Management Committee, Hospital Departmental Tenders
Board, Medical Advisory Committee, Revolving Fund Committees and appointment of
Heads of Departments.

2. Significantly increased recurrent and capital budgetary allocations from the Federal
Government as shown in Fig. I below. Note however, the increasing proportion of
available funds allocated to recurrent expenditure due to increased salaries and wages,
increased cost of maintaining utilities and increased energy costs.

3. Hire of an additional 162 health workers, including Consultants (specialist physicians,

for each of the clinical departments) and senior administrative and accounting staff.

4. Improvement of the conditions of service of health workers as a result of increased

salaries and allowances periodically announced by the Federal Government of Nigeria.

5. Short-term reallocation of existing ward, laboratory and office spaces to create

administrative, accounting and basic clinical/laboratory services for internal medicine,
paediatrics, general surgery, obstetrics/gynaecology, anaesthesia, haematology, blood
banking, chemical pathology, physiotherapy and pharmacy,
Table 1: SWOT Analysis of the Federal Medical Centre, Abeokuta at inception in 1993.

Strengths
• 196 health care providers (6
physicians, 95 nurse-midwives, 8
pharmacy staff, 6 laboratory staff, 14
catering staff and 67 others)
• Fairly well-equipped modular
operating theatre
• Four ward blocks
• A 5th ward block converted into an
interim outpatient clinic department
• Functional Laundry and Catering
services
• Medical microbiology services,
including HIV testing
• Completed but severely vandalized
residential bungalows (6 in all)
Opportunities
• Federal Government’s commitment to
the development of tertiary health care
in Ogun State
• Community demand for quality health
care delivery in Ogun State
• Petroleum (Special) Trust Fund, with a
mandate to assist health care delivery
in Nigeria
Weaknesses
• Lack of 24-hour accident and
emergency outpatient services
• Lack of basic haematology, blood
transfusion, chemical pathology and
histopathology services
• No maternity services
• Lack of general surgical services,
inspite of existing operating theatre
• Shortage of medical staff (especially
specialists)
• Lack of other support services e.g.
radiological services, physiotherapy,
mortuary
• Very weak administrative set-up (lack
of senior administrative and
accounting personnel, inadequate
office space and management
information system)
• Inadequate pharmacy store
• Lack of a functional ambulance
• Inadequate funding
Threats
• Competition from existing
private/mission hospitals in Abeokuta
• Series of industrial actions embarked
upon by nursing staff
• Political instability resulting from the
June 12, 1993 Presidential elections

6. Dedicated space for 24-hours accident and emergency care services was created.

7. Construction of new buildings for outpatient clinic services, medical records services,
medical library services, reproductive health services and staff residential huildings.

8. Rehabilitation of existing Hospital Engineering Services buildings, Hospital Main Store

building, and residential buildings.
9. Rehabilitation of electricity generators to augment public power supply in order to
ensure 24-hours electricity supply.

10. Sinking of 2 water bore-holes to augment public water supply in order to ensure 24-
hours water supply.

11. Purchase of new hospital ambulance and new official vehicles to improve the
transportation system of the hospital.

12. Donation of an additional ambulance bus by the Petroleum (Special) Trust Fund set up
by the Federal Republic of Nigeria to support social services in Nigeria.

13. Rehabilitation of essential non-functional medical equipment and purchase of new

medical-laboratory equipment (e.g. electrocardiography machine, cardiotocography
machine, ultrasound equipment, blood bank, surgical instruments etc)

14. Donation of laparoscopic equipment by an international donor agency.

Fig. 1 : Subventions to the FMCA

(1993 – 1999)

Processes

Early in the life of the institution and as part of the strategic planning process, the hospital
managementnt organized an internal competition for the institution’s motto and logo. The
winning caption for the motto was “For Excellence In Service” and this was added to the
selected hospital logo.

Management went further to define the organization’s vision, mission and set goals which were
shared with all members of staff through handouts and handbills.

In order to emphasize a client-centered approach to health care delivery, posters spelling out
clients’ rights were pasted in strategic places all over the hospital while members of staff were
encouraged to improve their inter-personal relationships with clients/patients. Management
supported the continuous education programs of the Nursing department, which was designed
to improve the knowledge, skills and attitudes of nurses and ward maids for better client-
provider interaction. Privacy and confidentiality were given special consideration in all clinic
arrangements. The hospital environment was aesthetically improved through extensive
landscaping and horticultural development, in order to improve the clients’ perception of the
quality of the facilities. Maintenance of the hospital grounds was done through a contractual
agreement with a private horticultural company. Suggestion/complaints boxes were put up in
the service areas and clients were encouraged to give feedback to the management in respect of
the quality of services being provided.

In the area of human resources management, additional staffs were employed for all
departments of the hospital. Particular attention was paid to the hiring of consultant staff for
anaesthesia, internal medicine, obstetrics and gynaecology, paediatrics, pathology and general
surgery. Staff development activities included in-service training in injury control and
emergency services, perioperative nursing, AIDS counseling, sexually transmitted infections
(STIs) management, ophthalmic nursing, health management etc. Activities designed to
increase staff motivation included increased salaries and wages, timely and consistent payment
of salaries in the last week of each month, timely promotions of staff, institution of a car
refurbishment loan scheme, setting up of a cooperative society for the staff, provision of
official uniforms for all uniformed staff, establishment of a staff canteen and provision of free
meals to physicians on call duty.

Staffs were also allowed to form branches of their national professional unions/associations.
The leadership of these unions had periodic meetings with top management. Essential staff
(surgeons, anaesthetists, obstetricians and a theatre nurse) were provided accommodation on
the hospital premises.

In order to address financial management issues, financial consultants were hired to work with
the hospital financial staff to establish an accounting system. Special attention was paid to
internal control systems. The products of this exercise included an accounting manual and an
auditing manual. The Auditor-General’s office and the Federal Ministry of Finance later
approved both of these documents. The FMCA was subsequently declared a self-accounting
organization. The implication of this was that funds were then being channeled directly to the
organization’s accounts in Abeokuta, rather than going through the Federal Pay Office of Ogun
State.

The problem of stockouts in the pharmacy, theatre store, laboratory store and the catering
department, was improved throught he management’s adoption of the Bamako Initiative of
Revolving Fund systems for these areas. Hence, seed grants were given to the departments to
commence a Drug Revolving Fund, a Theatre Revolving Fund, a Catering Revolving Fund and
a Laboratory Revolving Fund. Separate accounts were opened for each of these revolving
funds and revenues from each service provided by these revolving fund systems were paid into
their appropriate accounts. A policy to restrict expenditure from the revolving fund accounts to
the originating services was put in place. Hence, for example, funds in the Drug Revolving
Fund Account could only be used to purchase drugs, while funds from the Laboratory
Revolving Fund Account could only be used to purchase laboratory consumables and
inexpensive laboratory equipment. Expensive medical/laboratory equipment were separately
budgeted for in the annual Capital Budgets and 3-year National Rolling Plans. These financial
interventions were based on one major assumption i.e. the Federal Government had the primary
responsibility to pay all salaries and wages of staff and to provide funds for the major
infrastructural development of the institution. For this reason, cost-recovery through the
Revolving Fund Systems was set at 110% of the original cost of the consumable supplies and
materials. The objective of the 10% profit margin was to cater for materials and supplies used
by poor patients and to counter the inflationary trend in the country.

As part of efforts to improve the electricity supply to the hospital, management refurbished two
existing electricity-generating plants and privatized their maintenance by signing a maintenance
contract with a private company. The terms of the contract stated that the company will
provide labour and minor consumables for the regular maintenance of the plants while
management will supply diesel oil and replace the more expensive spare parts as at when due.

The shortage of water supply from the public taps was augmented through the sinking of two
boreholes in the premises, one for the residential areas and another to supply the hospital
buildings. These interventions improved the water supply situation but did not completely
eradicate the problem.

Finally, to improve record keeping and the management information system, a new building
was constructed for the Records Department while a computerized system was put in place.
Both the manual and computer record-keeping systems were still being operated as at the time
of this report. Computers were also introduced in some selected departments for word-
processing, email services, accounting procedures and establishment of databases. To counter
initial staff reluctance to accept these systems, in-service computer appreciation training was
organized for staff. The demand for computers subsequently increased.

Outputs

The major outputs of these interventions include management and financial systems that were
put in place, approved accounting and audit manuals, annual budgetary estimates and work-
plans, completed FMCA sections of the 3-year National Rolling Plans, 5 new buildings and
many refurbished structures, expanded range of clinical services covering the basic medical and
support disciplines, 162 new staff hired, 152 staff promoted, and 73 staff sent to in-service
training.

Intermediate outcomes

The intermediate outcomes of the short and medium-term interventions reported above will be
evaluated from three viewpoints, namely patients’ attendance, inpatient mortality and revenue
generation.
Patients’ attendance

Figure 2 below represents a summary of patients’ attendance from 1993, when the Federal
medical Centre came into existence, to December 1999.

It can be seen that both the inpatient and outpatient attendance have increased by approximately
300% over the study period. The slight decline in inpatient admissions in 1994 was due to a 5-
month industrial action embarked upon by nurses. Overall, bed occupancy also increased
threefold from 22% in 1993 to 63% in 1999 (Fig. 3 below).
Inpatient morbidity and mortality

Fig. 4 below shows hospital death rates (per 100 inpatients seen), which have decreased by an
average of 34%.

Fig. 5 below shows an example of the disease pattern of inpatients at the FMCA. In 1997,
diseases of the genitourinary system (30.7%), complications of pregnancy and childbirth
(27.9%) and infections/parasitic infestations (16.5%) were the leading indications for
admissions. On the other hand, the major causes of death among inpatients were perinatal
conditions (16.9%), infections/parasitic infestations (18.5%) and diseases of the circulatory
system (10.7%)-see Fig. 6 below. For an institution set up to provide tertiary health care
services, the preponderance of infectious/parasitic diseases among patients seeking health care
services is an indication of the unsatisfactory state of primary and secondary health care
services in the State.
Revenue generation

Over the 7-year study period, revenue generated at the FMCA increased by more than 8000%
from a paltry sum of N198,000.0 in 1993 to over N17,000,000 in 1999 (Fig. 7). This revenue
was ploughed back into the originating departments to ensure sustainability of their services.
The concept of cost-sharing/user charges and revolving fund accounts introduced in late 1993
was largely responsible for this achievement. The departments that were responsible for the
major contributions to this revenue included Pharmacy, Pathology/Laboratory, Theatre and
Catering departments. Management maintained a strict policy that restricted the utilization of
all revenue generated in a department to that department.
 Discussion/Lessons learnt

The standards of public health services in Nigeria are generally perceived by members of the
public as being very poor. Phrases such as “mere consulting clinics” and “mortuaries” have
been used to describe many hospitals in Nigeria. Even providers of health care services,
themselves, have been generally dissatisfied with the perceived quality of care and have for
many years used their professional associations to demand increased government funding of the
health sector. Government, on the other hand, has often expressed the view that it is not just
increased funding, but the management of such funds that determine the quality of services in
the public health sector.

In this report we have been able to document that the proper utilization of increased input
resources can lead to an increase in the quality of services and, consequently, an increase in
service utilization as well as an increase in client/patient satisfaction, even when a cost-sharing
policy is being implemented. This finding validates the observations of other reports 11-14.

The major factors that are considered responsible for the improved quality of care at the FMCA
include the following:

• Setting up of a Local Management Team with the requisite authority to develop and
implement cost-effective interventions and to delegate roles and responsibilities to lower level
managers.
• Increased Recurrent and Capital subventions from the Federal Government to facilitate
infrastructural development.
• Establishment of sound administrative and financial management systems.
• Improved technical competence of health providers through the employment of
specialist physicians and the re-training of other staff.
• Expansion of the range of services made available to clients/patients
• Adoption of the Bamako Initiative in the establishment of Revolving Fund Systems and
retention of all revenues from such cost-sharing activities strictly for the operation of their
revolving fund accounts, leading to reduced incidence of stockouts in the pharmacy, laboratory
and operating theatres.
• Facility improvement through the construction of new buildings and refurbishment of
the older ones
• Adoption of a maintenance culture through staff training and the privatization of some
selected maintenance services (e.g. medical and laboratory equipment maintenance)
• Staff motivation interventions (e.g. increased salaries, promotions, annual merit awards,
provision of free meals to essential clinical staff on night duty).
Challenges

The FMCA faces many challenges for its future development if it sis to completely meet the
aspirations of the citizens of Ogun State. Some of these challenges include finding permanent
solutions to the erratic electricity and water supply from public sources, further expansion of
the range of clinical services to include dentistry, ophthalmology, otorhinolaryngology,
orthopaedic surgery and other medical sub-specialties, expansion of support services such as
radiodiagnosis and physiotherapy.

Other challenges include the development of a reliable and accurate system for the
identification of poor patients who cannot afford to pay for services and providing free services
for such patients, institutionalization of standards and guidelines for numerous activities
including written job-descriptions, and maintenance of transparency in management.
Continuous Quality Improvement must be the focus of future management if the gains made
over the last 7 years are to be sustained. Leadership must be encouraged at all levels and
service providers must continue to embrace the organizational vision of a center of excellence
in health care delivery.

Government, on its own, should set up a quality assurance unit in the Federal Ministry of
Health, without any further delay. The activities of this unit should be decentralized in such a
way that trained facilitative supervisors of the unit are posted to all the Federal secretariat
buildings in all States of the Federation. These supervisors should be properly trained in
quality improvement methods and should work with institutions to improve the quality
services. They should also act as liaison officers to identify problems that cannot be solved
locally by hospital staff, and refer/follow-up such problems at the FMOH in Abuja.

A potential threat to all of the above is the politicization of appointments to Boards of

Management, which may re-introduce an inappropriate interference in the day-to-day running
of the institutions. Experience from many older health institutions in the country has shown
that the perception of members appointed to such boards in respect of their roles and
responsibilities are usually at variance with that of management and government. This variance
tends to be more obvious in the area s of appointments and contract awards. Board members
must be tutored about their responsibilities and limitations. In particular, the chairmen of such
boards need to be constantly reminded that they occupy part-time positions, which usually
translates into quarterly meetings. Scarce resources earmarked to the health sector must not be
channeled into avenues for meeting political patronage.
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