Improving Family Planning Services in a Developing Country The Case Analysis of Nigeria - Essay Example

? Improving Family Planning Services in a Developing Country – The Case Analysis of Nigeria Background Generally, family planning has lagged behind in Sub-Saharan Africa, relative to other parts of the developed world (Goliber et al, 2009). Nigeria is the seventh most populous nation on earth and if the trend continues as it is, Nigeria could become the world's third most populous nation by the year 2100, which is about 88 years away (Groth and Sousa-Roza, 2012). Nigeria has come up with some national policies on population. The current program is called the National Policy on Population for Sustainable Development. This was meant to reduce the fertility rate of about 0.6 children per woman between 15 – 49 in every five years by increasing contraception rates for people in this category from 14.6% in 2008 to 68.6% in 2035 (Goliber et al, 2009). This would be equivalent to an average 2.7 children in 2035 as compared to the current average of about 5.7 children per woman (2008 estimates). Previous strategies by various Nigerian governments have failed. The main reasons for these failures are Weak programming, Inadequate resources, Weak institutional framework, Lack of strategic planning (Federal MOH & UNPF, 1998). Socio cultural challenges like seeing children as a source of cheap labour and the scepticism of Muslim communities towards modern family planning methods have caused major setbacks to family planning (Renne, 1996; Avong, 2012). This paper will provide a practical approach in dealing with the lack of family planning services in a given Nigerian hospital, the University of Nigeria Teach Hospital, Enugu. This is a hospital that has a need to set up the rightful family planning systems and structures. However, due to the need for the attainment of serious ends and objectives, the entity does not have an in-house family planning clinic. This report will provide the blueprints which would include the option appraisal and a business case analysis. Part A: Blue Print Option Appraisal of The University of Nigeria Teaching Hospital, Enugu The University of Nigeria Teaching Hospital (UNTH) is a major health facility in Nigeria. It focuses on providing emergency healthcare and services for people. The focus on family planning is limited. Due to that there are major problems and limitations in the family planning clinic it runs. The clinic has no counselling services, poor diagnostic services, no pharmacy and laboratory. Figure 1 below shows the major problems with the operation of the clinic. Figure 1: UNTH Family Planning Clinic and its Problems Clearly, there is a problem with the collection of data from patients for the hospital (See Appendix 1). The lack of a laboratory and pharmaceutical facilities makes it difficult to take care of patients (See Appendices 2 and 3). Most of the people in charge of sensitive positions are not appropriately skilled. This is demonstrated in Figure 2 below. Figure 2: Healthcare Failure Mode and Effects There are different pointers that provide important linkages for the reason why this system has failed and needs to be improved. These are discussed into detail in Appendices 1, 2 and 3. Action Justification University of Nigeria Teaching Hospital remains a leading institution in Nigeria. Aside training the next generation of Nigeria's medical professionals, the institution is a centre for intense research and studies. Since the Nigerian government has shown interest in cutting down on the population, there is the need for the family planning clinic to be upgraded to a level whereby it can be used as a point for mobilising and treating patients accurately. There is therefore the need to change the current position and improve systems to be devoid of the various issues and limitations in communication, facilities and services. Objectives The main end is to provide the following objectives which would mark the success of the project: 1. An improved system of communication that enables patient diagnosis to be of a high standard and also link up to the healthcare professionals in the system. 2. Update of facilities and equipment to include a laboratory service and a pharmaceutical system 3. Integration of information technology systems and structures in the clinic. 4. Recruitment of new staff members to fill new vacancies that would come up and the training of staff members to meet the obligations of the new upgraded family planning clinic. 5. Restructuring of the capital base of the system. Option Appraisal The whole change that must occur in the family planning clinic of the UNTH must be strategic. Thus, we would look at the service model and then examine the business cases for various options. Primary Options Available: 1. Building a new facility for the family planning clinic 2. Refurbishing the existing clinic 3. Privatizing the entity to rebuild the clinic. Building Refurbishment Privatization Recording New system to be integrated Improved system to be put in place New owners would renew the current system Information System Acquisition and integration of new system that would link to the hospital's systems The existing system would be upgraded with new procurements and made to work more efficiently New owners would set specification and acquire them. Integration into the UNTH's system would be done by consensus Counseling Service A new counseling department would be set up from the scratch The current counseling services would be structured and centralized within the facility The facility would have to set up a counseling service that could be autonomous within the facility Recruitment of Staff The new facility would have to acquire new staff members who would be taken from the mainstream community inf the UNTH The current crop of staff would be improved and new staff members would be hired The private owners would have the right to hire and fire new staff members. They might be from within or outside. Training of Staff The new recruits would be trained on how to use the new equipment and run the system. The existing staff members would be encouraged to learn more and they would be trained to manage the upgraded facility. The private investors might have to hire trainers from within UNTH or elsewhere to help run the clinic. Diagnostic Equipment A new laboratory would be built within the facility to provide all the necessary diagnosis in-house. New facilities would be acquired and added to the existing stock of facilities. The private facility might need to get another specialized laboratory company to open an outlet in-house. However, coordination through electronic collation and transmission of information is a must. Pharmaceutical Services The pharmacy would be built in-house as part of the project. A pharmacy would be built in-house to facilitate services. The private owners could make arrangements with external pharmacies for the creation of a small outlet within the facility. Cost & Benefits The costs include the following: 1. Acquiring facilities to fill the premises: This would require a significant sinking of capital into improving the current clinic. This would include expansions and integration of relevant equipment. 2. Training of staff members: The doctors, nurses and other health professionals who would be included in this new facility would need to get up-to-the-spot training on family planning and understand what exactly they need to do at different points in time. 3. Renting the premises: The new clinic must give some degree of consideration to the owners of the premises to remain in operation. 4. Cost of paying staff members 5. Cost of equipment and running the equipment Benefits 1. The provision of specific health services to customers who need family planning services. 2. The building and concentration of core competencies in family planning services. 3. The creation of a classical case for replication in other parts of Nigeria and West Africa. 4. The alignment of the Nigerian government's policy of population control with the people in the area. Service Model. Figure 3: Proposed Service Model The service model must be adhered to if the new facility seeks to meet the required standard for the attainment of results that would improve the facility. The new facility would have a highly organized system that would include the frontline, back office and support services. The patients would report to those in the frontline wait and get all their data collected and sent to the back office and into the computerized IT system. This would link directly to the patient's history and factors. There would bring some organization which would naturally reduce waiting time. Information would be transmitted automatically and stuff would not be overburdened. Appropriate units would get their information and start acting before the patient gets to them. The patients would then proceed to the structured counselling unit where they would be heard and referred directly to a laboratory facility. Samples would be analysed instantly and results transmitted electronically through the new IT system. Relevant staff members who are trained to work efficiently would be called upon to deal with the new processes and provide solutions. The lab results can be check quickly and referrals would be made to the pharmaceutical unit. If the customer needs to come back again, s/he would start the process and the moment it begins, the case history would be made available to all the units of the facility. References Avong, H. N. (2012) “Perceptions of and Attitudes Toward the Nigerian Federal Population Policy, Family Planning Program and Family Planning in Kaduna State, Nigeria” African Journal of Reproductive Health Vol 10 (2) pp67 – 76 Bollen, K. A., Glanville, J. L. and Stecklov, G. (1997) Socioeconomic Status and Class in Studies of Fertility and Health in Developing Countries Chapel Hill: Carolina Population Center Federal Ministry of Health (Nigeria) and United Nations Population Fund (1998) Report of the National Population Policy Review, Nigeria Goliber, T., Sanders, R. and Ross, J. (2009) Analyzing Family Planning Needs in Nigeria: Lessons from Repositioning Family Planning in Sub-Saharan Africa Washington, DC: Futures Group, Health Policy Initiative Groth, H, Sousa-Roza, A. (2012) Population Dynamics in Muslim Countries London: Springer Nagel, P, Guiness, S. (2011) Social Geography London: Hodder Publications. Nkwo, P. O. (2011) “Privately-Owned Family Planning Services in Enugu Nigeria: Availability and Trends in Service Utilisation” Journal of Gynaecology and Obstetrics Volume 14 (2) pp697 – 702 Renne, E. P. (1996) “Perceptions of Population Policy, Development and Family Planning Programs in Northern Nigeria” Studies in Family Planning Vol 27 (3) (May – June) 1996 pp127 – 136 Appendix 1: Communication and Diagnostic Issues. Appendix 2: Diagnostic and HR Issues with System Appendix 3: Resource Constraints and Inhibitions Part B: Business Case Executive Summary This section of the research provides a critical business case analysis for the ranking of strategic choices and provide a strategic fit for the proposed changes to be made at University of Nigeria Teaching Hospital (UNTH). Three possibilities were examined in this case. The first was the building of a totally new unit by the UNTH. The second option is the upgrade of the current facility and the third option is to privatize the unit to an external entity. Different tools and techniques are used to evaluate the costs and benefits of the project. Through these processes, it is recommended that the UNTH should upgrade the current facility ahead of the other two options. Introduction & Background The current family planning clinic linked to the UNTH does not have a pharmacy department, structured counselling services and a modern laboratory. The project at hand is to create a system of treating at least 5,000 clients per day in aspects of family planning. The end is to provide a structured method of providing primary and secondary counselling services as well as some technical medical diagnostic services and treatment procedures on patients who need care in the area of family planning. Nigeria is the world's seventh most populous nation and it continues to increase at a rate that would make it the third most populous nation in 88 years from now (Appendix 1). Nigeria's economy is however suffering significantly and the government has sought to control the population. This effort has been limited by the social attitudes that the Nigerian people have towards birth control (Appendix 1).The government stated that the main problems involved weak programming, inadequate resources, poor institutional structures and the lack of strategic planning. Strategic Context The University of Nigeria Teaching Hospital is an exceptional institution that pioneers research and development in Nigeria. The hospital focuses on handling severe cases and treats emergency. This is due to the obvious lack of resources. The hospital has no structured plan for the provision of family planning services. Although they provide arbitrary counselling services, UNTH does not have the right structures for a structured or focused service delivery. Persons who need family planning services are referred to the community centre on a fire-fighting basis. This paper provides a structured system and method of instituting family planning services as a strategic business unit at the UNTH. It would provide a justification that provides a business case to complement the government's bid to control population growth. Project Scope and Objectives The current clinic in the community centre does not have structured counselling services, pharmaceutical services and a laboratory. From the current situation, there is the need for a clinic to be created within the University of Nigeria Teaching Hospital (UNTH) that would provide a structured, effective and efficient family planning service. This would provide conscious and well planned family planning service that could be mandatory for a certain section of the population like vulnerable youth and newly married couples. In doing this, the following objectives are sought: 1. The creation of a system for the coordination of health professionals and equipment for structured family planning services. 2. The maintenance of a commercially viable entity that can be funded by the project sponsors and kept running by the contributions of major stakeholders. 3. The system must be operational within a timeframe of 18 months and a budget of ?5 million and would draw on the human resource and resource pool of the hospital. Constraints & Critical Success Factors. Through these objectives the following targets are expected to be met at the local level: 1. The provision of family planning services to 5,000 people each day. 2. The maintenance of at least 5 entry points through which services would be provided 3. Direct linkage to different family planning programmes and other medical facilities in the hospital. 4. Provision of two classes of family planning counselling, diagnostic services and medical treatment services in family planning. 5. Reduction of the Enugu birthrates by 20% of the national average in the first five years of the operation of the hospital. 6. Appropriate and close monitoring of the treatments and procedures of patients. 7. Double the publicity of family planning services in the first five years. Strategic Options In order to create a system that would best meet the objectives and targets above, it is proposed that the following three options should be examined: 1. Building of an autonomous family planning centre linked to the hospital (BUILDING). 2. The Refurbishment of an existing central facility in the hospital (REFURBISHMENT). 3. Making it possible for private stakeholders to set up an entity (PRIVATIZATION) Project Scope This section would examine how feasible it would be to attain each of the three options that has been raised above. Option 1: BUILDING This would involve the building of a new family planning clinic within the UNTH. The entity would be ran independently and would be responsible for its own funding. This would lead to the creation of family planning and the soliciting of funds through some other external means other than from the coffers of the UNTH. Option 2: REFURBISHMENT This option would involve the ceding of the autonomy of the family planning clinic to the board of directors of the hospital. This would mean that they would have to refurbish one of the facilities of the clinic and source for staff from the hospital as well as the use of some joint services and overhead apportionment with the hospital to cut down on costs. Option 3: PRIVATIZATION In this case, the family planning clinic in the UNTH would be given to a private entity that would upgrade the current facility and include all the missing units of the facility. Through this system, the various centres would have the basic staff members who would provide primary and secondary counselling. Trained professionals who can do the diagnosis and the medical procedures would be appointed and they would work to ensure that the facility works to specification. Option Appraisal There would be the initial capital expenditure and the cost of running the centre. This could be estimated in different ways and methods to arrive at a clear conclusion. A. CAPITAL EXPENDITURE Option 1: Building Option 2: Refurbishment Option 3: Privatization Staff Contract Comprehensive: Shared with UNTH Acquired from UNTH at a full cost basis Equipment New Leased from UNTH Borne by owners Building Built from scratch Refurbish an existing UNTH structure Acquire an existing UNTH structure and refurbish it at the expense of owners Furnishing Acquire new furniture and fittings Acquire some additional furniture & fittings Borne by owners Initial Administrative Expenditure Set up new administrative structures Rely on UNTH for administrative systems Borne by external entity Aside the fixed costs above, there would be the need to acquire some variable products and services to keep the facility working. B. OPERATIONAL/TRADING COSTS Option 1: Building Option 2: Refurbishment Option 3: Privatization Staff Salaries Full cost on UNTH Partial Payment: Subsidy from UNTH Fully borne by private entity Equipment Maintenance & Depreciation Full cost on UNTH Full cost Fully borne by owners Recruiting of Staff Full cost on UNTH Subsidized Shared with UNTH Training of Staff Full cost Subsidized Shared with UNTH IT Support System Full cost Subsidized Full cost Administrative Services and costs Full cost Full cost Fully borne by owners Procurement Pay from different sources Receive at a subsidized rate from UNTH Fully borne by owners Rent (Actual/Notional) No rent Partial Rent Partial Rent Revenue Sources There would be different approaches to acquire revenue and earn money for the facility. This include the following: Option 1: Building Option 2: Refurbishment Option 3: Privatization Clients Over 50% Under 25% 50.00% UNTH Nil 25.00% 25.00% Nigerian Government 25.00% 25.00% Nil Donor Agencies 25.00% 25.00% 25.00% Financial Analysis A. CAPITAL EXPENDITURE Option 1: Building (?'000) Option 2: Refurbishment (?'000) Option 3: Privatization (?'000) Staff Contract 1000 200 1000 Equipment 1500 150 1000 Building 5000 350 2500 Furnishing 250 200 250 Initial Administrative Expenditure 250 100 250 TOTALS 8000 1000 5000 Aside the fixed costs above, there would be the need to acquire some variable products and services to keep the facility working. B. OPERATIONAL/TRADING COSTS Option 1: Building (?'000) Option 2: Refurbishment (?'000) Option 3: Privatization (?'000) Staff Salaries 2000 500 2000 Recruiting & Training of Staff 200 100 200 IT Support System 300 200 500 Procurement 1800 200 1800 Rent (Actual/Notional) 0 100 100 TOTAL 4300 1100 4600 Revenue Sources There would be different approaches to acquire revenue and earn money for the facility. This include the following: Option 1: Building (?'000) Option 2: Refurbishment (?'000) Option 3: Privatization (?'000) Clients 7000 500 '9000 UNTH 0 '1000 '1500 Nigerian Government '3500 '1000 '0 Donor Agencies '3500 '500 '1500 TOTAL 14000 3000 13000 Risk & Impact Analysis OPTION 1: BUILDING This refers to a major capital investment of ?14,000,000. The investment would be done in the name of UNTH who would hold the clinic in trust for the government and donor agencies. This would come with a higher degree of autonomy and independence. However, the financial commitment is enormous for a family planning centre in a developing country. This is because a country like Nigeria has limited finance to deal with its health problems. And family planning is more of a secondary element of the federal health budget. On the other hand, the revenue apportionment is quite problematic. This is because it is not realistic to levy ?6 million on clients who might see a family planning service as some kind of luxury. In a nation where family planning is seen as a detrimental activity to family financial gains, it would be difficult to raise as much as that from clients. The government is to pay ?3 million as subsidy whilst donor agencies are to pay a similar amount. This might be quite difficult. OPTION 2: REFURBISHMENT This option has a fairly balanced budget. It requires a very reasonable cost-sharing arrangement that would enable the UNTH to share the obligations with the new clinic. The UNTH would have overall control of affairs and yet, there would be some degree of autonomy which would enable the centre to work effectively. The cost sharing model is also fairly divided because it would enable all the stakeholders to get a win-win situation and a reasonable option. People who visit the centre can make a modest contribution whilst other stakeholders would make direct contributions. OPTION 3: PRIVATIZATION This option would involve giving out the hospital to a third party entity. In the normal capitalist mindset of the developed world, this is very feasible. This is because patients would pay for high quality services and enjoy good facilities. This would involve a high degree of management and control by the people in charge. However, there is a problem with the need to get customers to pay fully for the services they enjoy. This is because the private entity would seek to make profits and they are likely to make family planning services expensive. This is not positive in a nation where family planning is seen as a form of luxury. The need for government involvement to subsidize the clinic to make it free for the masses is necessary. Ranking of Services Against Objectives There were two rankings that were made, the financial and non-financial rankings (Appendices 4 and 5). Under non-financial rankings, Option 1 scored 57 whilst Option 2 scored 86 and Option 3 scored 59. This shows that Option 2 is the best. Financial rankings also showed that Option 2 costs just ?1,700 in present value. Option 1 is the most expensive with a PV of ?11,000 and Option 3 costs ?7000 in present value. The revenue recovery rates increase in proportion. Details are available in Appendix 5. Conclusion Option 2 scores the maximum points in all categories. It shows that the refurbishment of a new unit of UNTH as part of the wider organization is the best option for the creation of a family planning clinic with a structured counselling services, pharmacy and laboratory services. There are major cost savings as well as efficient systems of operations to meet targets. This makes it preferred ahead of the two other services. In spite of this choice, it is more important to promote and enhance the offering by conducting consultation sessions with the other stakeholders like the board of the UNTH to ascertain the final and most significant ways of attaining the objectives of this project. Prior to consultation, the following model identified in Appendices 3 and 4 can be used as the proposed service model and internal systems respectively. This would give an idea of how work could be done and completed and provide the blueprints as specified by Part A of this paper. References Avong, H. N. (2012) “Perceptions of and Attitudes Toward the Nigerian Federal Population Policy, Family Planning Program and Family Planning in Kaduna State, Nigeria” African Journal of Reproductive Health Vol 10 (2) pp67 – 76 Bollen, K. A., Glanville, J. L. and Stecklov, G. (1997) Socioeconomic Status and Class in Studies of Fertility and Health in Developing Countries Chapel Hill: Carolina Population Center Federal Ministry of Health (Nigeria) and United Nations Population Fund (1998) Report of the National Population Policy Review, Nigeria Goliber, T., Sanders, R. and Ross, J. (2009) Analyzing Family Planning Needs in Nigeria: Lessons from Repositioning Family Planning in Sub-Saharan Africa Washington, DC: Futures Group, Health Policy Initiative Groth, H, Sousa-Roza, A. (2012) Population Dynamics in Muslim Countries London: Springer Nagel, P, Guiness, S. (2011) Social Geography London: Hodder Publications. Nkwo, P. O. (2011) “Privately-Owned Family Planning Services in Enugu Nigeria: Availability and Trends in Service Utilisation” Journal of Gynaecology and Obstetrics Volume 14 (2) pp697 – 702 Renne, E. P. (1996) “Perceptions of Population Policy, Development and Family Planning Programs in Northern Nigeria” Studies in Family Planning Vol 27 (3) (May – June) 1996 pp127 – 136 Appendix 1 Facts About Nigeria's National Family Planning Structures Nigeria's current population is over 150 million and is the 7th most populous nation. The current birth rate is 0.6 children per woman between ages 15 – 49 years in every five years. All other things being equal, Nigeria's current population would make it the 3rd most populous nation on earth. Contraception use amongst Nigerian women between ages 15 and 49 in Nigeria is 14.6% (2008 estimates). This reflects to an average birth rate of 5.7 children per woman. The government's National Policy on Population for Sustainable Development aims at increasing contraceptive use from 14.6% to 68.6% in 2035. This would translate to 2.7 children per woman. Failures in previous strategies are attributed to Weak programming Inadequate resources Weak institutional framework Lack of strategic planning. Socially, Nigeria's illiterate masses see abundant children as a source of cheap labour and revenue. Some Muslim communities in Northern Nigeria view family planning as a way of reducing their numbers and political control. Appendix 2 Objectives & Options : Objectives The main end is to provide the following objectives which would mark the success of the project: 6. An improved system of communication that enables patient diagnosis to be of a high standard and also link up to the healthcare professionals in the system. 7. Update of facilities and equipment to include a laboratory service and a pharmaceutical system 8. Integration of information technology systems and structures in the clinic. 9. Recruitment of new staff members to fill new vacancies that would come up and the training of staff members to meet the obligations of the new upgraded family planning clinic. 10. Restructuring of the capital base of the system. Option Appraisal The whole change that must occur in the family planning clinic of the UNTH must be strategic. Thus, we would look at the service model and then examine the business cases for various options. Primary Options Available: 4. Building a new facility for the family planning clinic 5. Refurbishing the existing clinic 6. Privatizing the entity to rebuild the clinic. Building Refurbishment Privatization Recording New system to be integrated Improved system to be put in place New owners would renew the current system Information System Acquisition and integration of new system that would link to the hospital's systems The existing system would be upgraded with new procurements and made to work more efficiently New owners would set specification and acquire them. Integration into the UNTH's system would be done by consensus Counseling Service A new counseling department would be set up from the scratch The current counseling services would be structured and centralized within the facility The facility would have to set up a counseling service that could be autonomous within the facility Recruitment of Staff The new facility would have to acquire new staff members who would be taken from the mainstream community inf the UNTH The current crop of staff would be improved and new staff members would be hired The private owners would have the right to hire and fire new staff members. They might be from within or outside. Training of Staff The new recruits would be trained on how to use the new equipment and run the system. The existing staff members would be encouraged to learn more and they would be trained to manage the upgraded facility. The private investors might have to hire trainers from within UNTH or elsewhere to help run the clinic. Diagnostic Equipment A new laboratory would be built within the facility to provide all the necessary diagnosis in-house. New facilities would be acquired and added to the existing stock of facilities. The private facility might need to get another specialized laboratory company to open an outlet in-house. However, coordination through electronic collation and transmission of information is a must. Pharmaceutical Services The pharmacy would be built in-house as part of the project. A pharmacy would be built in-house to facilitate services. The private owners could make arrangements with external pharmacies for the creation of a small outlet within the facility. Cost & Benefits The costs include the following: 6. Acquiring facilities to fill the premises: This would require a significant sinking of capital into improving the current clinic. This would include expansions and integration of relevant equipment. 7. Training of staff members: The doctors, nurses and other health professionals who would be included in this new facility would need to get up-to-the-spot training on family planning and understand what exactly they need to do at different points in time. 8. Renting the premises: The new clinic must give some degree of consideration to the owners of the premises to remain in operation. 9. Cost of paying staff members 10. Cost of equipment and running the equipment Benefits 5. The provision of specific health services to customers who need family planning services. 6. The building and concentration of core competencies in family planning services. 7. The creation of a classical case for replication in other parts of Nigeria and West Africa. The alignment of the Nigerian government's policy of population control with the people in the area. Appendix 3: Service Model. Appendix 4: Non financial Option Scoring Scoring and Weighting of non-financial Point Option 1: Building Option 2: Refurbishment Option 3: Privatization Objectives WF BS WS BS WS BS WS Improve efficiency 3 2 6 5 15 4 12 Improve Communication 4 2 8 4 16 3 12 Improve speed 4 4 16 5 20 4 16 Improve quality of service 3 4 12 5 15 3 9 Improve equipment and structures 5 3 15 4 20 2 10 TOTALS 57 86 59 *Basic Scores (BS) ** Weighted Score (WS = WF * BS) ***Weighted Factor (WF) Appendix 5: Financial Option Scoring Scoring and Weighting of non-financial Point Option 1: Building Option 2: Refurbishment Option 3: Privatization Capital Required 8000 1000 5000 Operational Costs 4300 1100 4600 NPV 11000 1700 7000 Expected Revenue in 5 Years 14000 3000 1300 Read More