Doctors as managers of healthcare resources in Nigeria: Evolving roles and current challenges

Abstract

Over the years, medical practice in Nigeria has evolved in scope and practice, in terms of changing disease patterns, patients' needs, and social expectations. In addition, there is a growing sentiment especially among the general public and some health workers that most doctors are bad managers. Besides drawing examples from some doctors in top management positions that have performed less creditably, critics also harp on the fact that more needs to be done to improve the training of doctors in health management. This article describes the role of doctors in this changing scene of practice and highlights the core areas where doctors' managerial competencies are required to improve the quality of healthcare delivery. Areas such as health care financing, essential drugs and supplies management, and human resource management are emphasized. Resources to be managed and various skills needed to function effectively at the different levels of management are also discussed. To ensure that doctors are well-skilled in managerial competencies, the article concludes by suggesting a curriculum review at undergraduate and postgraduate levels of medical training to include newer but relevant courses on health management in addition to the existing ones, whereas also advocating that doctors be incentivized to go for professional training in health management and not only in the core clinical specialties.

INTRODUCTION

The Nigerian health care system, like in some other developing countries, is bedeviled with poor health indices and service delivery to majority of the population.¹ The Nigerian public health system is characterized by grossly ill-equipped facilities ² as well as inadequate and poorly-motivated personnel.³ These problems are linked to poor management of resources across levels of care in the country.²

Over the years, medical practice in Nigeria has evolved in scope and practice, as there is now a changing perception of the role of doctors from being solely a healthcare provider to that of an all-round professional with administrative and managerial responsibilities.⁴ Contemporary doctors may have to take up responsibilities that include but are not limited to clinical, teaching, research, leadership, and managerial roles in the line of duty.⁵

The ability to perfectly blend these roles is the foremost attribute of a first-rate doctor, and this is a crucial asset when viewed against the backdrop of scarce human resource for health required for quality healthcare delivery.⁶

As professionals in the lead,⁷ doctors have the traditional responsibility to coordinate activities of other members of the health team toward effective patient care at the three different levels of management such as operational (low), tactical (middle), and strategic (top). However, there is this growing sentiment especially among the public and some health workers that most doctors are bad managers.⁸,⁹ Besides drawing examples from some doctors in top management positions that have performed less creditably, critics harp on the fact that doctors' training is deficient in health management.¹⁰,¹¹

This criticism has challenged the traditional thinking of doctors as leaders of the health team, a managerial role they should presumably find less difficult. This changing paradigm also stresses the necessity of enhancing doctors' professional capability not merely to maintain their status as health team leaders, but to address problems in the overall context of health system's perspectives (health system refers to people and institutions carrying out actions whose primary functions are to improve health).¹² This article describes doctors' role in this changing scene of practice and highlights the areas where doctors' managerial competencies are required to improve the quality of healthcare delivery.

AT WHAT LEVELS OF MANAGEMENT CAN DOCTORS MANAGE HEALTHCARE RESOURCES?

Though one may be tempted to think that for a doctor to be a manager of resources, she/he must occupy a middle or top management position. This is untrue because being a manager entails taking responsibility for the efficient use of resources to achieve objectives effectively.¹³ Doctors' day-to-day activities such as planning surgeries, supervising colleagues and other health workers fall within the realm of operational or “low-level” management. A doctor is engaged in middle-level management when she/he assumes such leadership positions as chief resident, consultant, and head of the department where she/he translates policies into tasks to be carried out by those under their influence. This middle-level is also called tactical or administrative management.¹³ The top level of management, otherwise called strategic level management, is concerned with policy formulation, strategic decision-making, and resource allocation among others. Doctors in such positions as Ministers, Commissioners of Health, Members of Hospital Management Boards, Chief Medical Directors, etc., operate at the top management level. Being a good manager of healthcare resources is essential for all doctors and more critically, those aspiring to venture into private practice as this fosters sustainability and profitability.

RESOURCES TO BE MANAGED

Resources to be managed by the doctor can be summed under the “3Ms” of management-manpower, money, and materials. Manpower resources are said to be the most important aspect of healthcare systems.¹⁴ For a doctor to deliver high-quality service, it goes beyond mere clinical expertise, it entails appropriate skills in human relations, and inter-and intra-professional relationships and conflict management.¹³

The ability to make wise decisions about money is one of the attributes of a good doctor. In a resource-poor setting like ours, where about 68% of the population are poor with a purchasing power parity of <$1.25 a day;¹⁵ this attribute comes to bear in offering sustainable, cost-effective treatment options for patients, improvisation, reducing overall wastages in the health sector, and improving access to care.

Materials to be managed are quite varied and may include medical supplies, consumables, equipment, and drugs among others.

Time is also a resource that must be well-managed by doctors.¹⁶ Proper time management is essential for high-quality health care delivery as patients experience less waiting time, colleagues, and other health workers experience less job-related stress as tasks are done promptly without impeding the work of others.¹⁷

PERTINENT ISSUES IN THE MANAGEMENT OF HEALTH CARE RESOURCES IN NIGERIA

Health care financing and funds administration

One of the major areas where the managerial roles of doctors can be better deployed is in healthcare financing. Doctors must be advocates for better funding of the health sector and also play leading roles in the efficient management of health funds.

Presently, most African countries including Nigeria, do not meet African Union 2001 Abuja Summit's recommendation allocation of at least 15% of their national budgets to health.¹⁸ Apart from government annual budgetary allocation to health, other major sources of health care financing that must be explored include earmarked taxes, out of pocket payment, health insurance (social, private, and community) scheme, and grants and aids from donor agencies among others.¹³,¹⁹

Accountability, probity, and transparency must be the watchwords while handling funds. Managers of the various levels of health care system in Nigeria (primary, secondary, and tertiary) must be ready to account for monies released to them or generated as internally generated revenues. In addition, doctors as major stakeholders in the health sector should further advocate for the scale up of the National Health Insurance Scheme for better coverage particularly with regards to the people in the rural communities in order to achieve universal health coverage.

Management of essential drugs and other health commodities

One common phenomenon in public health facilities across the country is the “Out of Stock syndrome.”²⁰,²¹ This refers to nonavailability of essential drugs or products within a health facility for whatever reason. This seriously affects the quality of healthcare delivery to the people in the community bearing in mind the popular aphorism that “where there is no product, there is no service.” Patients bear the brunt of this managerial inadequacy; as they are forced to procure drugs of doubtful quality from patent medicine shops outside the health facilities.²²

With a good understanding and practice of logistic management of health commodities and concept of drug revolving fund (DRF), health managers can make “Out of Stock syndrome” a rarity. Awell-functioning logistic system can improve health services tremendously by enhancing quality of care and improving cost effectiveness and efficiency.²³

The DRF; defined as a system whereby initial capital (money) investment on drugs are replaced with the money collected from sales of drugs as developed jointly by the UNICEF/WHO through the Bamako Initiative in 1987 offers a practical solution on how to manage drugs and essential supplies.²⁴,²⁵ Doctors as managers alongside other stakeholders are expected to make the right decisions. The types of decision that need to be made include how much to charge, who to exempt, etc., The DRF scheme has been adopted by many sub-Sahara African countries,²⁶ though there are challenges such as pilferage, high operating cost, and payment default among others.²⁷

Human resources management

Human resources management (HRM) has been defined as “the integrated use of systems, policies, and practices to plan for necessary staff and to recruit, motivate, develop, and maintain employees in order for the organization to meet its desired goals.”²⁸

The doctor as a manager needs to understand that the right people (human resources) are the most important resources required for the attainment of organizational goals. It is equally important to fill positions on the organizational chart with the right people and to create a work environment, which will ensure that people work harmoniously as a team toward organizational goals while also accomplishing their own personal goals.²⁹

There are a shortage and uneven distribution of healthcare personnel across various regions in many developing countries.³⁰ Besides there is an unhealthy rivalry among various healthcare professionals in Nigeria; this has nearly crippled the public health system following repeated industrial actions and agitation for parity with the doctors by other health professionals.³¹ These and many other issues have made the health sector an “atypical customer” as regards effective utilization of HRM interventions.²⁸

ROLES OF THE DOCTOR AS A MANAGER

While taking responsibility to efficiently manage resources, the following processes are important for doctors:

Planning

This entails setting organizational and team goals. It also includes setting objectives that are meant to be achieved. This role involves allocating resources and time frame for the set goals.¹³,³² It is good practice to anticipate and reduce risks as well as including indicators to assess how well the objectives are achieved.

Implementation

Refers to the process that ensures the activities are carried effectively, efficiently, and responsively. This aspect of the managerial process is very relevant to medical practice because it entails leading (which is the traditional role of the doctor), organizing, controlling, and ensuring appropriate staff mix.¹³,³³ Leading is a managerial skill needed by doctors to motivate their colleagues and other health workers with a sustained zeal to deliver qualitative healthcare. For doctors to lead effectively, they require excellent communication skills.

“Organizing” skill is expected from doctors, and it entails being able to arrange and coordinate human, financial, material alongside information resources to achieve desired goals.³⁴

As part of controlling functions, doctor-managers must perform supervisory tasks to ensure that work gets done according to plan. They may be required to set standards (for example in patient care) monitor this and provide feedback to staff for adjustments.

Staffing is the fourth aspect of the implementation process that ensures that the appropriate human resources needed to achieve set objectives are available.³³

Monitoring and evaluation

This is concerned with the assessment of the progress made as compared with earlier plans, and how well objectives have been achieved with the sole aim of improving health systems as a whole.¹³,³⁵

ATTRIBUTES OF A GOOD DOCTOR-MANAGER

The following are important attributes a good manager must develop as espoused by the foremost management expert Senge.³⁶ They include:

Personal mastery

This emphasizes personal learning and growth. Adoctor who seeks to be a good manager of resources should continually expand his ability to create the results she/he wants in his/her practice. There are many fields of knowledge besides core clinical disciplines that doctors must acquaint themselves with. Atypical example is Information Communication and Technology, a tool that has the capacity to provide information needed to improve treatment decisions, assist hospitals in providing better quality of care, and make government more responsive to citizens' health needs.³⁷

A good doctor-manager is one who knows his area of deficiencies and constantly seeks knowledge in the pursuit of his goals. This attribute underscores honesty and creating a balance in one's life, especially between work and other personal issues. For example doctors should continually strike a balance between work and family, focusing on work at the expense of the other will surely affect one's productivity and managerial effectiveness.

Systems thinking

This refers to the ability to see interrelationships among processes, different activities, professional groups, etc., rather than a static view. Application of systems thinking is a pathway to identifying and resolving health system challenges.³⁸ A tree does not make a forest, and as such having a system view will enable the doctor-manager to appreciate and value the contributions of different health team members.

Mental modeling

This concept borders on interpreting realities and visualizing what needs to be achieved. Adoctor with good managerial skills should be innovative and have a mental picture of what should be done to improve the well-being of both patients and the system within which she/he practices. In line with changing realities, doctors should continually have a clear projection of how to satisfy health needs of patients and improve the health status of the population as well as working with other stakeholders to achieve this. More so, it has been established that teams with shared mental models have better performance.³⁹,⁴⁰

Team building

Being a leader of the health team comes with the responsibility of aligning and developing the capacity of team members for optimal service delivery.⁴¹ Teambuilding has profound effects on systems performance.⁴² However, building a formidable health team requires a lot of team learning. Good communications skills as well as the proper perception of each team member as colleagues working together for optimal healthcare delivery is essential. The managerial skill of the doctor is not complete without being able to make sure that his team (the most vital resource) joins forces with him/her in the delivery of high-quality healthcare.

Shared vision

This quality helps to obtain the commitment of others toward a vision aimed at solving certain challenges.³⁶ Shared vision has been reported to be a very good predictor of organizational success.⁴³ It engenders a shared set of operating values and creates a sense of shared purpose and identity. Having a shared vision is necessary if the problems in Nigeria's health sector must be solved. Ashared vision is one that other team members can adopt and literally “own” as against vision statements that are often thrust upon team members.

Having all the aforementioned attributes will contribute to make a doctor well-adapted for carrying out effective managerial roles, in and out of the line of duty.

CHALLENGES DOCTORS MAY FACE AS MANAGERS OF RESOURCES

An obvious challenge that was earlier emphasized in this article is that the training of doctors on health management can be improved upon, although it has recently been added to the medical curricula at both undergraduate and postgraduate levels.⁴⁴ There is the need to further stimulate the interest of doctors in health management. For instance, doctors need to be fully conversant with civil service rules and apply this in their daily professional dealings.

Tight work schedule and work pressures could constitute a challenge to the doctor who manages resources. The busy schedule of caring for patients may leave little time for dispensing managerial responsibilities effectively. A major challenge is the perception that the Nigerian health system has a poor reward system as good managerial expertise is not getting the due recognition it deserves. Major emphasis is placed on acquiring clinical expertise only while other skills are generally perceived as being of lesser importance.

Intra-and inter-cadre wrangling is a major challenge to doctors who manage resources; moreover, the ability to tackle this will determine how effective the doctor performs as a manager. Already, some professional groups are picking up disputes, challenging the traditional notion of doctors being the leader of the health team, while also agitating for wage parity with doctors.⁸

The changing scene of practice in terms of shifting disease patterns, patients' needs, and social expectations has a great potential to task the managerial skill of the doctor. Dwindling health sector funding sector coupled with an increasingly diverse health workforce mix also pose a challenge. The doctor must be well-prepared to tackle headlong the issue of corruption in the health sector which is a reflection of the wider Nigerian society.

Recommendations

There is the need to do an assessment of the managerial training needs of medical doctors. An objective needs assessment is required so as to know which areas and to what extent capacity building should be deployed. Consequent upon the needs assessment findings, appropriate themes in health management and administration should be integrated into the medical curricula at the undergraduate, postgraduate levels in addition to current ones. In addition, relevant training modules to improve the managerial skills of the doctor should feature regularly in the Continuing Medical Education series for doctors and as of necessity, they must familiarize themselves with pertinent management issues affecting their practice for example; patient-focused approaches, policies and civil service rules, health economics, data-based decision-making, conflict management, program management, human resource, and financial management among others.⁶,²⁸

For doctors to develop an interest in health management and even pick up careers therein, a supportive environment must be provided. Certificate courses in management should be recognized such as other certificate courses related to medicine. Once management courses are duly recognized either for promotion or appointments, doctors will be incentivized in this regard.

It will be a great idea to see more doctors routinely pursue postgraduate degrees in health management, carry out research in managerial issues affecting health and proffer home-grown solutions to them. In addition, an evaluation of the effect of health management research output on health policies and overall system performance would be appropriate in the medium term. This is the sure way forward to address our nation's nagging health sector challenges. An appropriate reward system should be in place for doctors with exemplary managerial and leadership skills. This will surely bring out the best in the doctors who manage resources at all levels in the health system.

CONCLUSION

In conclusion, for the doctor to be relevant in the scheme of things in today's health sector and in the nearest future, she/he must continually assert and fulfill his leadership roles. This responsibility does not start when doctors assume top management positions; it starts from the day they take the Hippocratic Oath and start managing and coordinating resources toward patient care.

Furthermore, for the nation's parlous state of healthcare to improve, much emphasis should be placed on ensuring high-quality human resource for health. A major step in this direction is to ensure that alongside clinical expertise, doctors are appropriately schooled and skilled in managerial competencies. This will make them “five-star doctors,” and this will improve health service delivery and promote harmony in the sector.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.