ABSTRACT
A good health financing system is crucial for the effective performance of a country's health system. Many health systems around the world, especially in lower- and middle-income countries such as Nigeria, grapple with perennial challenges such as chronic underfunding, wastefulness, and lack of accountability rendering these systems inefficient. Nigeria's health system faces additional extraneous challenges such as a huge and rapidly growing population, a stagnant economy, and worsening insecurity of lives and property. Furthermore, recent disease outbreaks such as the Ebola epidemic and the COVID-19 pandemic and an evolving disease demography evidenced by an increasing prevalence of chronic, noncommunicable diseases asphyxiate an already floundering health system. To address these challenges and to bolster its efforts in attaining universal health coverage (UHC) and meeting the targets of the Sustainable Development Goals, the Nigerian government launched a new health policy in 2017. A review of the health financing section of this policy shows a focus on improving funding for health care by all levels of government and guaranteeing affordable and equitable access to health services by all Nigerians, albeit with insufficient clarity on how these will be achieved. A more critical review of the country's health financing system also reveals deep-seated systemic issues. Its out-of-pocket payments for funding health care are among the highest in the world, with abysmally low government contributions to health. Successive governments seem to lack the political will to address these shortfalls. Critical gaps exist in the country's health laws, making it difficult to implement the strategies proposed in the new policy. Nigeria must strengthen its health laws to, among other things, mandate health insurance and provide adequate funding for the health system by the government. It should also formulate a dedicated, more precise health financing policy with specific, measurable aims targeting identified problems to enable it to attain universal health coverage.
ABSTRACT
Reviewing fluid balance charts is a simple and effective method of assessing and monitoring the hydration status of patients. Several articles report that these charts are often either inaccurately or incompletely filled thereby limiting their usefulness in clinical practice. We had a similar experience in our practice at Kettering General Hospital and conducted a quality improvement project with a goal to increase the number of charts that were completely and accurately filled by a minimum of 50% in a 1-month period and to reassess the sustainability of this improvement after 6 months. Data from baseline measurements showed that only 25% of the charts in the ward had accurate measurements, 20% had correct daily totals and 14% had complete records of all intakes and losses. We collected feedback from nursing staff in the ward on what challenges they faced in using these charts and how best to support them. Corroborated by evidence from the literature, we discovered that inadequate training was a major factor responsible for the poor quality of documentation in these charts. Using simultaneous plan-do-study-act cycles, we designed and delivered personalised teaching on fluid balance chart documentation to the nursing staff. Subsequent data showed remarkable improvements in all the parameters we assessed. For instance, the proportion of charts with accurate measurements increased by 55% and those with complete entries by 122%. Unfortunately, we were unable to demonstrate sustainability of these improvements as our second set of data collection coincided with the SARS-CoV-2 outbreak. In this project, we were able to demonstrate that simple and cost-efficient measures such as adequate training of nursing staff could remarkably improve the quality of fluid balance charts used in our hospitals. We suggest that this training should be included as part of the regular competency assessments for nurses and other healthcare staff.