Against the backdrop of incidence of quackery in the medical profession, Professor Muhammad Aminu, president of the Medical and Dental Consultants Association of Nigeria (MDCAN), in this interview with FUNMILAYO AREMU-OLAYEMI, explains the rudimentary criteria for the establishment of hospital among other issues. Excepts;
Can you give us details about the regulatory framework in Nigeria regarding who can establish a hospital and the key agencies involved in the approval process.
The establishment of a hospital is generally in two government-sponsored or government-owned hospitals and private or public-private hospitals. There are regulations governing the establishment of a hospital and it must be by a registered medical practitioner of at least five years standing. It must be a doctor registered by the Medical and Dental Council of Nigeria (MDCN), which is the regulatory body that is established to regulate the establishment and the practice of medicine in Nigeria. It is established by the law and it is an organisation that is responsible for the registration and licensing, renewal or re-licensing of fresh and existing medical practitioners on an annual basis. So, for somebody to establish a private hospital, that person must be registered by the MDCN and the registration is in three categories. There are fresh doctors that graduated and are to do their internship or what you call housemanship. That is what you call temporary registration and it is a registration with which a newly-qualified medical doctor is allowed to practice and supervise for two years. And from there, if he has satisfied the requirement, he gets what is called a permanent registration. Unless that medical personnel or medical officer has committed any offence that will make the council delist him, that means he can practice as far as that certificate exists.
There is also another form of a category whereby expatriates who are registered somewhere else, and those who have additional qualifications can also be given temporary registration, which will be given to them and renewable every two years. So anybody who should establish a medical, private medical practice or a hospital in Nigeria must have a permanent registration of five years standing. Thereafter he can register the hospital and continue to practice.
There are also regulations as to what space; you cannot just go and get a stall in the marketplace that is busy, that is congested. When a person wants to have a private practice, he or she must get a decent place and there are basic requirements of what the hospital should have. And even the hospitals are of different categories. There is a clinic where patients come to be seen and then prescriptions are given without admission, there is a full-fledged hospital that may have different arms: wards, theatres, laboratory pharmacy and some other facilities that a hospital should have. These are the basic requirements of establishing a hospital in Nigeria.
Can individuals who are not in the medical field establish a hospital?
Yes, individuals can establish a hospital, but it should be in partnership. But no hospital is going to be registered just because someone has the money or has the facility or has the property and then he will just go to the regulatory body and say register a hospital for me. He must have been in partnership with a qualified medical doctor who is of that standing to do that because no hospital is registered without the certificate of a qualified medical doctor.
Are there specific licenses or permits that need to be obtained before establishing a hospital in Nigeria?
Yes, there are many. One, depending on what kind of hospital you want to establish, there are regulations. First, you need to register that as a company in some cases with a CAC so that it becomes an entity that can sue and be sued. Secondly, you must follow all the due regulations for establishing a hospital from the particular location or state you are going to establish the hospital. For example, in Kano, we have the Private Health Institution Management Agency. It is an agency that is responsible for that and the faster you do, you go and take the form of intent that you want to establish a hospital and this is the name you want to give the hospital. Then they will search from their archive and ensure that there is no other hospital registered with that name. And then they will also submit all your certificates for verification. Through the director of medical services of the state, you will get in touch with the Medical and Dental Council of Nigeria to ensure that the certificate is actually from them, certified from them and also that the medical personnel that is using a certificate to register the hospital is not under any investigation or has not been convicted by either a law court or by the MDCN Medical Disciplinary Committee. So, after that certification, they will now come for an inspection to see the location, the facilities you have, what you intend to do there, if you have the requisite qualifications and also the list of your proposed staff to ensure that all of them are also registered by their own regulatory body.
For example, nurses by the Nursing and Midwifery Council of Nigeria, medical laboratory technologists by the Medical Laboratory Science Council and pharmacists by the Pharmaceutical Council of Nigeria, just to ensure that your members of staff are also licensed to practice their trade. So having done that and they are satisfied with your location, then the process of registration will start, they will issue a registration certificate and then you can commence your medical practice. This is the summary of the process.
Are there any specific guidelines or standards such as infrastructure requirements, staffing ratios or equipment standards that a potential hospital founder needs to adhere to?
Yes, it depends on whether someone is going to establish a clinic, that is an outpatient clinic or the person is going to establish a full-fledged hospital. So a full-fledged hospital should be equipped with a requisite number of staff and a requisite number of basic equipment that can handle basic emergencies and should also have a way of ensuring that they have a referral system because, at every point in time, patients may require further referral to other places. So, on the facility, the space, depending on what you want to do, if it is a clinic, you will need to have at least two consultation rooms, a procedure room, pharmacy store equipped with air conditioning to ensure that the drugs are in the adequate ambient environment and also to ensure that the patients that are there will have adequate resting well-ventilated place so that they can be comfortable while they are there and also to prevent the spread of communicable diseases.
If it is a hospital, the hospital should at least have two or three wards for male and female patients and probably a children’s ward and then should also have a pharmacy, a place for the laboratory where basic things can be done because there are some investigations that you must have an accredited lab to have them done. Similarly, you need to have a procedure room and if it is surgically based, then the surgery and the labour room also have the specific equipment that need to be there. So, these are the basic setups of the basic minimum standard hospital.
In addition, there should be adequate qualified staff that will be there. For example, a hospital must have at least two nurses on shift and then many other basic requirements that the hospital should have in order to ensure safe practice but at any point, if there is recognition that a patient requires higher or further care, then that hospital should be able to refer to the next higher or more equipped hospital.
What are the roles of the Medical and Dental Council of Nigeria, especially in ensuring quality healthcare in new hospitals?
Nigeria operates a concurrent system of government whereby the MDCN regulates the standard of practice and the qualification of the medical practitioners in Nigeria while state agencies, the state ministry of health, the Director of Medical Services and then in states that have agencies like some states have Private Health Institution Management Agency, some states have private health institution registration units, under the ministry of health, they have their basic requirement which differ from state to state. But in all of them, they must have ensured that those basic requirements I highlighted earlier.
So usually, MDCN is more concerned with the registration of qualified medical doctors, ensuring that they have updated their education, ensure that they renew their licenses every year and ensuring that no patient has suffered from the activities of that hospital.
So, if a patient or any other concerned person has a complaint about how a patient is managed sometimes they appeal or they send a complaint to the MDCN which has an arm called the Medical Disciplinary Committee, which has the rating of a high court. So, what they usually do is that you give all your evidence, they call the medical doctor, and they have someone in that level of practice to review what was done for that patient to ensure that it is of the standard of care or if there any fault found in the care of that patient. So, from there they invite the practitioner and they can discipline that practitioner either warning this practitioner if it is a very mild offence or sometimes if the practitioner is at no fault, they acquit the practitioner or they can suspend the practitioner ranging between six months to one year, suspend them from medical practice or sometimes they delist that person from the register of medical personnel and that means that the person will not practice medicine for the rest of his life.
What is the typical timeline for approving and establishing a hospital in Nigeria from application to operational status and does the NHIA play any role in the accreditation of hospitals at all sir?
It depends on the preparedness of that person and the knowledge of the requirements of establishing the hospital. If that person has made adequate preparation and has everything on the checklist up to standard, then it shouldn’t take time. Then, choosing the name of the hospital, for example, if someone has chosen the name of an already existing hospital that is a source of delay and then if somebody doesn’t have all the requirements or is choosing an inappropriate place then that may also cause a delay in the registration. Different states have their requirements so fulfilling them on time makes it easier but in all, it can be as quick as one month if you have everything or it can be delayed depending on what was highlighted during the visit to inspect the facility. If there are things that need to be modelled, to be changed or to be altered then the person has to do that, no matter how long it takes before the person is registered and is allowed to practice. The NHIA, what they do is that they have their basic requirement to accredit a hospital to the standard of taking care of NHIA clients so they have their clients and have the standard of care that they expect any hospital that should take care of their clients should have “XYZ” and then depending on whether the hospital is going to operate primary care or secondary care or even tertiary care that is expected. For primary care the requirements are lower; you need to have basic medical officers that would cover 24 hours and then you have basic facilities, pharmacy, laboratory and consultation places and admission rooms. Then you must have a Theatre and Labour room these are basic standards that will take care of their primary care patients. But if you want to register for secondary care you need to have a specialist in those areas where you intend to offer that special care services. So, they have their standard and it is basically for their client service provision.
Are there any incentives or benefits offered to individuals or organizations that establish hospitals in underserved or rural areas in Nigeria?
The issue is that this is a major problem. The only thing that I know of Kano State, if you want to establish a hospital in a rural area like in Kano State, about 87 per cent of all private hospitals are in the city and about half of the local government does not have private health care facilities. But I know that if you are establishing a hospital outside the city then you feel just about a token about one-tenth of the registration fee to ensure that people are encouraged to go to underserved areas and provide additional services in addition to what the government is providing.
Can you provide insight into common challenges or obstacles individuals may face when establishing a hospital in Nigeria?
The commonest challenge that private health care providers are facing are multitude in Nigeria. One, you have to provide every other service to make the hospital work, you have to provide water, electricity, security, you have to provide every other thing, that is one major issue. The cost of doing business, especially medical practice is on the high side. The second major problem is multiple taxation. There are taxes normally even by the law that should be by the federal government, some by state and some by local government. Even at that, you see the state and local government sending the medical practitioner taxes that if he is to pay everything, it’s like they are asking him to close service and government agencies at different levels should know that whoever established a private practice to provide services is actually assisting the government to increase the care of his own populace and therefore assisting the government to achieve his mandate because health care provision is a basic human right everywhere. There is a high need for the government to ensure that these multiple taxations that are discouraging medical practitioners that some are contemplating closing and some have even closed. Because you are likely going to think about closing. All that you do, you are only working for the government because of that multiple taxation. Thirdly, there is no basic or deliberate effort to fund private healthcare facilities with soft loans because everything you want to buy that is hospital-related is exorbitantly priced. So, for you to establish a standard you will spend so much to establish the hospital and then you wouldn’t be able to charge as appropriately as somebody who is just establishing a shop for something else because you are providing what is termed in court to be social services but every service in a private setting is paid for. So, there is a deliberate effort that needs to be made by the government to provide loans for hospitals to upgrade or set up so that there will be effective health care services by these hospitals so that they can assist in decongesting the government settings so that both will be beneficial to the population that the government is serving. We also recommended earlier that the government should establish a health bank which eventually was signed by the previous government pray that the current government will establish it so that it will be a low or no-interest banking service so that people can get capitalized and can do more specialized services, and they can employ more so that the population will be served with a better health care, and Nigeria can be a hub with the manpower that is being looked after from all over the world if government can assist people to establish standard hospitals in Nigeria then it can become a hub where people from come from all over in such of health care just like it was happening before. So that we can reverse the medical tourism that is happening which is affecting our economy.
Can you give a figure of hospitals that are not accredited in Nigeria?
It is difficult to do so the accreditation, when you talk of accreditation, depending on what accreditation you are talking about. There are various levels of accreditation; There is the accreditation to practice or to treat patients, if that is the case then there is no hospital that has the registration that is not accreditd to practice. But there are unregistered hospitals and those ones you know you can’t have a figure for them, it only takes the surveillance of the registration agencies in the state from time to time go out and look for those places and close them. Likewise, there is accreditation for the training of various cadres of health care workers, those are done by the regulatory agencies. MDCN regulates registration for undergraduate medical education likewise there is accreditation by various agencies as to whichever service the hospital is providing. So as far as that is concerned, all the registered hospitals are expected to have been accredited to practice at that particular level they are operating, but for those that are registered, it is difficult to have a figure that one can say okay these are the numbers because they are practising illegally and probably in hidden places.
What is the penalty for not duly registering your hospital and practising in Nigeria?
The penalty is that one, it is a criminal offence. Secondly, it depends on whether the person is qualified to practice medicine and is practising medicine, Thirdly, whether the person is registered by the medical council to practice medicine, otherwise, the hospital once identified that it is unregistered, should be closed and then the person or the operator prosecuted.
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