Globalization of Health Care: Designing, Developing and ...

Globalization of Health Care /Waruingi et al. 1

ISSN 2159-‐6743 (Online)

Globalization of Health Care: Designing, Developing and Implementing a Just World Class Health System in a Frontier Market Macharia Waruingi1,2, Kerrie Downing1, Isaac Amos3, Shila Waritu1, Otobong Amos3, Susan Peiffer1, Tolu Ademodi1, Segun Agunbiade1, Uwemedimbuk Ekanem 1,4, and Fellows of Ustawi Research Institute’s Fellowship for Globalization of Health Care Abstract The focus of this paper is the approach to design, development and implementation of a world-class health care system (WCHS) in Akwa Ibom State, an oil producing state in South-South Region of Nigeria. We report the Ustawi Research Institute’s emerging paradigm for design, development and implementation of a WCHS in a frontier market. This report draws from rich experience gained in design, development and implementation of a world-class academic medical center developed on a master-planned medical city, and connected to a franchised system of ambulatory, tertiary care medical centers distributed in the state of Akwa Ibom, Nigeria. We used a qualitative method to gather inductive data from stakeholders of health and human development in Nigeria. The grounded theory design facilitated theoretical sampling of key concepts about state of health services in Nigeria. Comparative analysis yielded a grounded theory that a WCHS in a frontier market has three distinct structures: (a) a community engagement structure, (b) a payment structure, and (c) a health services delivery structure. The three structures are necessary subsystems of a complete system that form a comprehensive entity for health production in a frontier market. Planners, designers, and architects of health care systems and facilities must be aware of the working principles of the three necessary structures for community engagement, payment and health services delivery when designing, developing and implementing world class health projects in frontier markets. Keywords: Nigeria, Africa, Akwa Ibom, health; health care; medicine; health services; health finance; health law; health policy; health services design; health care quality

1

Ustawi Research Institute Center for Health Systems & Design, College of Architecture, Texas A&M University 3 Thompson & Grace Investment Limited 4 Uyo University Teaching Hospital Principal contact for editorial correspondence. Macharia Waruingi: [email protected] 2

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Fellows of Ustawi Research Institute Fellowship on Globalization of health include the following persons: Kerrie Downing A. Shila Waritu Zelalem Lome Ashley Ammerman Alice Lester Janine Cummings Charon Blaney Tolu Ademodi Ashley Granito Ammerman Segun Agunbiade Edidiong Udom Nene Adem Ekemini Usanga Ibanga Ekong Uwemedimbuk Ekanem Susan Peiffer Macharia Waruingi



Globalization of Health Care: Designing, Developing and Implementing a Just World Class Health System in a Frontier Market The focus of this paper is the discovery of elements critical to production and delivery of high quality, accessible, and affordable health services in frontier markets. In this paper, we report our effort to generate a theoretical model for high quality health services in a traditionally marginalized market. A qualitative approach helped to collect inductive data about design, development and implementation of world-class health care system (WCHS) in Akwa Ibom State, an oil producing state in South-South Region of Nigeria. Recent economic indicators qualify Akwa Ibom, and in deed Nigeria, as a frontier market that has registered phenomenal growth over the past five years (Berger, Pukthuanthong, & Jimmy Yang, 2011; Gail, 2011; Ty, 2013). Furthermore, Nigeria is projected to sustain an accelerated growth pattern in the foreseeable future (Bell, 2012, December; Nesbitt, 2012, December). The unprecedented rapid economic growth has converted the traditional notion of 3rd World to a new notion of frontier market. The switch from 3rd World to frontier market has caught many an unprepared global health practitioners by surprise. The unpreparedness of the practitioners of global health presents a unique problem in which the globalization of health care lags behind the general globalization of industrial manufacturing and consumer services such as mobile phones, and automobiles. High quality health services delivery systems such as preventative medicine and primary care clinics, general hospitals, and specialty medical centers are not emerging at any rate closer to any other business in the frontier markets. For example, phone companies are moving to put cell phones in the hands of nearly every adult in the frontier market. By January 2013, Nigeria’s Telecommunications Commission reported 110 million mobile phone subscribers in a country of 170 million people (Sotunde, 2012). Motor vehicle manufacturers are building manufacturing plants in frontier markets to provide the best quality cars to local consumers (Good & Hughes, 2002). Similar other manufacturing companies are opening a wide range of manufacturing plants in the frontier economies (Wessel & Gorlach, 2008). The mismatch between globalization of manufacturing and consumer service, and globalization of healthcare has left a large gap in health services in frontier markets, leading to a serious clamor for health services. Consequently, the demand for high quality medical services is enormous (Bradley et al., 2011; Couper, 2004; Patel, Gauld, Norris, & Rades, 2012; Tache et al., 2008). Meeting this demand places a tall order on practitioners of global health. At the heart of this tall order is the role of healthcare planners, healthcare architects, healthcare systems engineers, healthcare systems developers, healthcare systems implementers, and healthcare leaders. In this paper, we report our experience at Ustawi Research Institute to fulfill a certain aspect of this enormous demand for world-class health services in Nigeria, one of the fastest growing frontier economies. We attempt to respond to the following key questions: • •

How can we facilitate globalization of affordable and accessible, high quality health care to a frontier market? Reverse question: How can we create conditions for emergence of affordable and accessible, high quality care in traditionally marginalized market?

To respond to these questions, we first examine the concept of globalization to help anchor the idea of emergence of frontier markets. We then examine current state of globalization of health care to learn from its present working principle. In addition, we look at globalization of health to glean insight on _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


the questions that remain unanswered in conceptualization of global health in a planet of rapidly vanishing 3rd World. This aspect relies on the traditional conceptualization of global health as health services provision to dwellers of the 3rd World. Vanishing of the 3rd World as a defining principle, calls for re-thinking of global health practice in the context of globalization. Finally, we report the Ustawi Research Institute’s approach to the emerging paradigm for design, development and implementation of a world-class health system in a frontier market. This report draws from rich experience gained in design, development and implementation of a world-class health system designed on a master-planned medical city, and connected to a franchised system of an ambulatory medical centers distributed in the state of Akwa Ibom, in Nigeria. Background The problem of design, development and implementation of a WCHS in a frontier market relies on comprehension of the inner workings of globalization in general terms, and globalization of health care in specific terms. In this section, we examine the two terms (i.e., globalization and globalization of health care) as the central phenomena critical to comprehension of design, development and implementation of world-class health care systems in frontier markets. Globalization Globalization has become a central principle for business theory and practice as humans strive to connect with one another for economic and social reasons (F. G. Adams, 2008; de Sousa Santos, 2006; John, 2009; Peter, 1999). F. G. Adams defined globalization as “a process of market integration” (p. 155). Globalization as economic and social connection across the world has been growing for centuries. However, the present model of globalization fundamentally differs from the traditional notion as the pace of global integration picks a dramatic tempo secondary to inexorable acceleration of the speed of trans-border transfer of knowledge through the information superhighway. The dramatic tempo of knowledge transfer evokes a profound transformation of the global economic landscape. New patterns of trade and international specialization are emerging. Recent reports indicate that the pace of economic growth in the so-called 3rd World countries far outstrips growth in the socalled 1st World. In a complete departure from the traditional economic structure that had the 3rd World countries traditionally pegged as producers of agricultural products and raw materials, these countries are now the producers of completely manufactured products. Indeed, the rapid economic progress in the traditionally labeled 3rd World comes from intensive export of finished products and services, rather than raw materials. In an interesting turn of events, F. G. Adams (2008) reported that countries that “not so long ago were primarily producers of agricultural products and raw materials, far out on the periphery, are today core producers of manufactures, themselves drawing heavily on the world’s supply of raw materials” (p. 156). The growth in the emerging and frontier markets owes to the speed of communication; exchange of knowledge, goods, services; and transportation. The information and communications technologies help to resolve complex and large networks, and fuel monumental volumes of global transactions, dramatically changing the nature of trade. (Belton, 2010; Jiaming & Xun, 2007; Wang & Lo, 2007). This extreme connectivity has paved way for businesses to operate effectively in multiple and diverse geopolitical zones. F. G. Adams (2008) described the emerging ways of organizing global production and services delivery, where one company is able to manufacture products in many countries, and distribute the same products to distant countries the world over. Belton (2010) attributed the force of globalization to emanate from successive rounds of tariff reduction under the World Trade Organization’s (WTO) General Agreement on Trades and Tariffs (GATT) that lowered trade barriers on industrial goods down to comparatively low levels. Other forces fueling globalization include the cheaper transnational transportation of goods, and better logistics enabled by efficient information and communication networks facilitating transnational vertical and horizontal integration of global supply chain (F. G. Adams, 2008). The ability to send and receive money is critical to any form of trade. With advanced information and communications technologies, money instantly traverses national boundaries through electronic money sending and receiving systems that range from individual level remittances systems, real-time web_________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


based electronic billing and payment systems, and global interbank electronic funds transfer systems. Multinational banking organizations facilitate zero-cost remittances across national boundaries. The consequence of these events is the emergence of new ways of organizing business entities, regulations, economies, and human movement on a global scale. The increased economic connectivity has evoked profound geopolitical changes. Places traditionally classified as low-income developing countries are rising up and connecting directly to global capital and technical pool (Belton, 2010). Indeed, far beyond the emergence of these nations is the empowerment of the people local to them. The ensuing shift in power balance from the nation state to the individuals living in the nations has heralded a global rise in consumerism and globalization of the brand. Large multinational corporations are marketing their brands directly to consumers in all nations. Yawning Gap Even with the evident dramatic rise in tempo, globalization remains limited. While certain aspects of global integration are traceable back hundreds of years and have reached an advanced stage, others remain primordial, and others infantile, and many are far from conception (F. G. Adams, 2008). Globalization of health care, for example, lags far behind globalization of manufactures. As companies open up in new markets, their employees are left without access to health care services. Granted, medical services are local by nature. Most medical services require direct contact between the provider and the consumer. Certain medical services (e.g., invasive surgical procedures) are sophisticated and still very expensive to provide by remote means over the information superhighway. Granted, advances in science and technology in medicine could rapidly yield refined robotic surgeries carried out transnationally. However, such services are still very pricey, account for a large part of total expenditures, and cannot be directly traded internationally, at least for now. Yet, in the face of globalization of other industries and services, globalization of health care is inevitable. The local nature of traditional health care organization leaves health care leaders unprepared for globalization. The section that follows contains a brief look at globalization of health care to shed light on its occurrence and its drivers. Globalization of Healthcare Globalization of healthcare refers to the increasing globalization of the health sector (Craig & Beichl, 2009; Reading, 2010; Schroth & Khawaja, 2007). Traditionally, the health sector has been closed and nationally focused. Globalization of health care operates at three distinct levels of reality: (a) the level of the consumers of care, (b) the level of the health professionals, and (c) the level of the organization. Transnational Consumers At the level of the health care consumer is the phenomenon of the movement of consumers of healthcare for health tourism and medical tourism (Bateman, 2012; Christie, 2010; Leigh, 2007). Health and medical tourisms are two distinct forces that fuel movement of consumers across national boundaries in search of care. Carrerra and Bridges (2006) explained that health tourism is the “the organized travel outside one’s local environment for the maintenance, enhancement or restoration of the individual’s wellbeing in mind and body” (p. 449). Medical tourism, on the other hand, is the “organized travel outside one’s natural healthcare jurisdiction for the enhancement or restoration of the individual’s health through medical intervention” (p. 449). The major distinction is that health tourism involves restoration of wellbeing, while medical tourism involves restoration of health by medical means. The main drivers of both forms of tourism overlap to include the long wait times, high cost of elective procedures, and high cost of cosmetic procedures. Consumers travel to seek healthcare where they can find it. Consumers from low-income countries move to high-income countries to find care. African elite consumers have traditionally traveled to Europe and United States to seek care. More recently, tens of thousands of Africans travel to Asian countries such as India for medical care (Bisht, Pitchforth, & Murray, 2012; Sarojini, Marwah & Shenoi, 2011). Another recent phenomenon is the travel of consumers from developed countries to developing countries to seek care. Workers report a steady flow of patients traveling from United States, Canada, _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


Western Europe, and Australia to seek health care and medical care in India, Thailand, and Costa Rica. (Johnston, Crooks, Adams, Snyder, & Kingsbury, 2011; Johnston, Crooks, & Snyder, 2012). American, European, and Japanese consumers of care find new destinations for medical care in Singapore, Thailand, and Malaysia (Pocock & Phua, 2011). The growth in health tourism and medical tourism has raised concerns about health care equity. On one hand, the local people are not the target consumers of the medical and health tourism. As such, promoters of medical tourism create structures of delivery of care with little or no attention to the needs of the local people in the destination countries. The promise of financial rewards from health and medical tourism detracts local health providers from paying attention to the local people. The effect of the inattention to distributive, deliberative and social justices remains uncertain and unexplored. Johnston, Crooks, and Snyder (2012) observed from a cohort of Canadian medical tourists that the effectiveness of medical and health tourism to the care-seeking tourists is ill defined. Their research indicated that little is known about how medical tourists or health tourists decide to seek care in another country. Even less known is the effect of such decision on access to care among the local people in the destination country. Transnational Individual Providers Transnational migration of health professionals has historically been the main pathway of health services trade. (O. Adams & Stilwell, 2004; Dandona, 2000; Heard, 2000; Howie, Adegbola, & Corrah, 2005; Loefler, 2000, 2001; Lucas, 2000; Munoz, 2000). Professional migration followed colonial and linguistic ties. Physicians and nurses migrate for economic reasons such as better pay and financial security. Health professionals also move due to poor work conditions and/or the desire for opportunities that provide intellectual and professional growth (Adams & Stilwell). Transnational migration of health professionals has certain benefits such as remittances for origin countries and increasing healthcare workforce for destination countries (Adams & Stilwell). An additional benefit is the exchange and flow of healthcare knowledge and technology that takes place when these health professionals keep ties with their countries of origin. However, the migration of health professionals can create health equity concerns especially in developing countries, which suffer from the brain drain caused when health professionals leave. In addition, these countries lose the investment that they made when educating these health professionals as well as their potential contributions to health care field (Adams & Stilwell). Such loses also affect health service delivery because some areas may have inadequate health professionals and health services. Transnational Medical Systems At the level of the organization are private companies building hospital projects. For example in March of 2013, Johns Hopkins Medicine International (JHMI) signed an agreement with Sun Yat-sen University (SYSU) and affiliates in Guangzhou, China to create a long-term platform for exchanges among clinical and translational investigators, research professionals and administrators. The two organizations agreed to lay down infrastructure for world-class research in China. Under the agreement Johns Hopkins experts would travel to SYSU to teach courses and lead workshops designed to strengthen development of investigators and research professionals. These experts would also design a competitive fellowship program at Johns Hopkins for promising SYSU investigators and junior faculty members, and provide strategic and technical advice on a wide range of issues that include research infrastructure, operations, safety and governance. The agreement also provided seed grants for collaborative clinical and translational pilot projects that have the potential to develop into larger studies funded by industry or government sources in China and the United States. In another example, Partners Health Care System in Boston created Partners Harvard Medical International, with a mission to assist planning, design, and development of world class health services organizations. In one project, Partners Harvard Medical International helped to establish the tertiary care Maktoum Academic Medical Center in Dubai Healthcare City. In a different project, Partners Harvard Medical International facilitated development of a complex academic medical center in Pakistan. The academic medical center was a Pakistani Federal University of Health Sciences, masterplanned health care and teaching complex built on a 100-acre site outside Islamabad. Features of the medical complex included a 350-bed teaching hospital, and colleges of medicine, dentistry, nursing, and allied health professions, and world-class research facilities. _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


Another example occurred in 2001, when Cornell University and Qatar Foundation formed a partnership to create the Weill Cornell Medical Center in Qatar (WCMC-Q). The emergent WCMC-Q is world class medical facility providing teaching, research and health services. The WCMC-Q was first medical school in Qatar. Such transnational medical centers have been the domain of large well-endowed American health systems that target the elite consumers in the destination countries. Questions about effectiveness of such organizations in reaching the less-than-wealthy members of the society remain unaddressed. Although the transnational medical facilities help to introduce high-tech, high-touch medicine in the destination countries, they lack critical elements of structural equity that would ascertain social and related deliberative, and distributive justices for the local communities. Indeed, social, deliberative, and distributive justices are not the motivators for the emerging transnational medical systems. Implementation of high technology medical facilities that lack the critical elements of structural equity poses serious challenges for sustainability in the long term. This problem leaves a wide open question about how to implement world-class medical system that ensure deliberative, distributive, and social justice in emerging and frontier markets. Design, development and implementation of sustainable world-class health services in Akwa Ibom in Nigeria called for thinking about these critical elements of structural equity. Transnational Health Insurance Transnational health insurance involves selling health insurance products in multiple countries (Elnashar, Abdelrahim, & Fetters, 2012; Lotfi et al., 2011). In 2002, Blue Shield of California expanded Access Baja HMO, to form Access Baja Dependent Plan program that enabled eligible dependents of workers enrolled in a Blue Shield HMO or PPO health plan in California to receive healthcare coverage at home in Mexico. In Europe, a new European Union Directive on cross-border healthcare was passed in 2011. The EU Directive gives European citizens the right to access healthcare services in another European Economic Area (EEA) country as long as the treatment is medically necessary and is available under the NHS. It covers treatment in both state-run hospitals and by private service providers. Transnational Operations At the operational level of reality is the cross-border supply of services. One example is the use of new technologies for telemedicine, to provide health services across borders and to remote regions within countries, and between countries. Widening the range of possible telemedicine applications is the increasing accessibility of micro-sensors. Commercially available devices can currently measure glucose, blood pressure, international normalized ratio (INR) and numerous other laboratory parameters integrated with question-based algorithms. These devices are able to stream video from the patient’s home to a health care provider via the Internet. Telemedicine technologies facilitate consultations and second opinions, further increasing income and capitalizing on the expertise of professionals by reducing medical errors and insurance costs. Teleradiology and tele-pathology enable remote storage, image access and interpretation through the shift from hard copy to digital imaging, with the increased benefit of integrating results. As in-vitro diagnostic multivariate index assays (IVDMIA) becomes more common, molecular testing will be able to be done locally, with the resulting data being analyzed remotely. Gap in Effectiveness Globalization of health and medicine has had little impact on indicators of health (Kurjak, Di Renzo, & Stanojevic, 2010). In their paper, Kurjak et al. reported shocking information about the state of health in the world: every 3 seconds a newborn dies, and every minute a pregnant woman dies creating more than 10 million deaths every year. This unnecessary waste of life indicates an urgent need to discover effective processes for globalization of health care and medical services. Large U.S. medical centers are in an ideal position to export information, knowledge and technical expertise to the frontier markets. The process of effective globalization of such knowledge and skills from U.S. health care organizations to the frontier markets remains elusive. _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


Scholarly reviews about globalization of healthcare have consistently revealed significant gaps in knowledge about this phenomenon. Indeed, a process for mobilization of health services globally that can help to deliver safe care of greater quality to people in frontier markets remains elusive. The design, development and implementation of a world-class health system (WCHS) in Akwa Ibom state could help to define some of the processes that would facilitate the globalization of health care services in a frontier market. Indeed, the production of the WCHS could help discover the conditions for emergence of high quality care in traditionally marginalized market. The ultimate product would be a world-class healthcare system capable of provision of comprehensive care of good quality that is safe and affordable to inhabitants of a frontier market. Statement of the Problem The general problem is that of production and delivery of high quality health services that ensure the critical elements of structural equity in frontier markets. The system for health delivery in Akwa Ibom, a frontier market is in severe state of disrepair. Health services in Akwa Ibom are unsafe, of low quality, and inaccessible to majority of the people (Jacob & Akpan, 2009). The people of Akwa Ibom, afraid to use health services in the nation seek medical care in other countries such as India, South Africa, England, and United States. Indeed healthcare consumers in Akwa Ibom would be willing to pay more for better care, of high value with improved supply of drugs, better technical quality, better maintained health facilities, and shorter wait times (Ogunbekun, Ogunbekun, & Orobaton, 1999). Globalization of healthcare provides a major opportunity for increasing access to high quality affordable healthcare in frontier markets. At the same time, globalization opens economic opportunity for well-developed health care systems to export their knowledge and technical expertise to new markets. The specific problem is that the process for creating conditions for economically viable highquality care services in traditionally marginalized geopolitical locations in the frontier market is not certain. Literature is dearth on the structural features of a sustainable health care organization in a frontier market. Also lacking in literature is the conceptual framework for globalization of health care that health care leaders can use to as a guide to help them expand and establish successful health care organizations in the frontier market. We used a qualitative method to obtain inductive data from multiple stakeholders of health and human development in several sites in Nigeria (a frontier market), and United States (a developed market). Theoretical sampling procedures of the grounded theory design helped to analyze the qualitative data to generate key categories indicative of elements critical to successful sustainable establishment of a just health care organization in the frontier markets. Comparative analysis helped to generate a theoretical model for production and delivery of high quality health services in frontier markets. Statement of Purpose The purpose of this project was to discover elements critical to production and delivery of high quality health services in frontier market State of Akwa Ibom in Nigeria. This purpose pointed to a qualitative approach founded on the premise that humans access reality through social constructs (Kaplan & Maxwell, 1994; Myers, 1997). The qualitative method helped to obtain inductive data from multiple stakeholders of health and human development in several sites in Nigeria (a frontier market), and United States (a developed market). The objective was to engage the community in an inductive dialogue that would facilitate emergence of knowledge relevant to design, development, planning, and implementation a world-class health system in Akwa Ibom state. Specific communities engaged were Eket, the location of future clinical laboratories and imaging center for the world class health system; Uyo, the present location of a federal teaching hospital; and Afaha Obong, the future location of the world-class health system complex. Direct engagement of the three communities helped to shape many questions that guided further data collection. The emerging grounded theory design helped to explore the concepts about health shared by the stakeholders of global health and human development, and to formulate a theoretical model for design, development and implementation of a world-class health system in a frontier market. _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


Significance of the Problem This project is significant to the stakeholders of globalization of health care. Hart and Sharma provided a framework for identifying stakeholders of a comprehensive entity (Hart & Sharma, 2004). Stakeholders are of two categories: salient or core stakeholders, and fringe stakeholders. The core stakeholders are the visible and “readily identifiable parties with a stake in an organization’s existing operations” (Hart & Sharma, p. 8). Core stakeholders gain a seat at the table by virtue of their power, legitimacy, or the urgency of their claims. Examples of core stakeholders of the globalization of health care include the leaders of health care organizations, designers of health systems, health care planners, architects, engineers, hospital builders, governmental organizations, and non-governmental organizations. Other core stakeholders of the question of globalization of health care include manufacturers and suppliers of equipment used in healthcare organizations, community leaders in developed and frontier markets, other businesses, employees, and investors. According to Hart and Sharma fringe stakeholders “are typically disconnected from, or invisible to, because they are remote, weak, poor, disinterested, isolated, non-legitimate, or non-human” (Hart & Sharma, p. 8). Examples of fringe stakeholders of the globalization of health care include the adversarial, divergent, non-legitimate, the poor, the weak, the illiterate, the disinterested such as rural folks of countries characterized as emerging or frontier markets. Non-humans such as plant, animals, etc., occupying the frontier regions as their natural habitats, are fringe stakeholders of globalization of health care. Such non-humans suffer from the likely disruption of their natural habitat by increased human activity in new lands needed for development projects. Such fringe stakeholders are affected by globalization of health care but have little, if any, direct connection to the sponsors of development projects. Hart and Sharma indicated “fringe stakeholders may hold knowledge and perspectives key both to anticipating potential future sources of problems and to identifying innovative opportunities and business models for the future” (p. 10). Theoretical Underpinnings A second purpose for the project was to communicate to the stakeholders, the vision of creation of world-class health system in the heart of Africa. Effectiveness in communicating a vision is a function of co-creating, which in turn relies on the ability to put the last first. Co-creating Senge and colleague’s theoretical notion that co-creating is the most effective way for communicating a vision formed a theoretical basis for the procedures of the project (Senge, Kleiner, Roberts, Ross, & Smith, 1994). Co-creating arises from community engagement, which is paramount to building a shared vision (Issel, 2009). The strategy for community engagement must be well defined before the project begins. Involving the community leads to participation that empowers the local stakeholders and enhances “their capacity to assist in the assessment and their ownership of the data gathered and results produced by the assessment” (Issel, p. 125). Senge, et al. (1994) explained that five ways of communicating a vision determine the level of engagement of the followers: • • • • •

Telling, where the leader determines the vision and informs the organization; Selling, where the leaders determines the vision but seeks support of the people before moving forward; Testing, where the leader has an idea or two about vision but asks the people how they like each idea before proceeding; Consulting, where leader suggests the vision, but seeks creative input from the people before proceeding”; Co-creating, where leader invites everyone to think together about the vision they would like in the future.



Senge, et al. (1994), indicated that leaders who build their organizations by co-creating ultimately yield a powerful organization with highly engaged followers. Co-creating, because this process gives individuals ownership and input into the company’s goals. A well-communicated vision is a wellimplemented vision. Co-creating involves three major steps: (a) strategic analysis; (b) strategic formulation; and (c) strategic choice. Positive interdependence that relies on Nash's equilibrium is the key ingredient to co-creation. Some people like to refer to co-creation as co-operative collaboration. In implementation, members of the group work together to conduct a thorough strategic analysis. This involves a through market audit to gain a fundamental understanding of the strengths and weaknesses of the organization vis-a-vis the competition in the ecosystem of health systems. In strategic formulation, members of the group work together to identify all possible choices of health systems and their corresponding applications in an organization. In strategic choice, the members of the group make choices about which objectives to implement. At this point the implementation proper kicks in: members of the group set priorities on what to implement first, second, third...last. This priority plan helps to set the implementation goals, and then objectives for each goal. Putting the Last First The goal was to involve the community members to build a shared vision because when shared vision occurs, people excel and learn because they want to, not because they are forced. Co-creating results in better individuals, and a more productive, successful, and flexible organization. A sign of shared vision occurs when the language used changes from their project to our project (Senge, 1990). The objective was to carry community involvement through planning, implementation and evaluation of the proposed WCHS. This assessment involved communities directly affected by the implementation of the WCHS. Specific communities visited were Eket, the location of future clinical laboratories and imaging center, Uyo, the present location of the federal Uyo University Teaching Hospital (UUTH), and Afaha Obong, the future location of the WCHS complex. Direct involvement of the three communities helped to shape many questions that guided further assessment. The goal of community participation in this project was continual and permanent with a view to generate good quality understanding of the community members. Continued community involvement was critical to the establishment of opportunity for deliberative justice that is the centerpiece of ascertainment of health care equity in the WCHS. The general approach was to be informed by the Chambers’ (1997, p. 216) ten precepts and principles of participatory rural appraisal: 1.

Sit down, listen, watch and learn. Change behavior. Learn not to dominate, not to wag the finger, no to interview, not to interrupt. 2. Use your own best judgments at all times. Rely on personal judgment, not manuals and rules, fostering flexible and adaptable responses, and accepting responsibility. 3. Unlearn. Be open to discarding beliefs, behaviors, and attitudes, including many inculcated through formal education and rewards. 4. Be optimally unprepared. Enter unknown, participatory situations with a repertoire but without detailed preset program, so allowing for creative improvisation and open interactive process the course of which cannot be seen. 5. Embrace error. Be positive about mistakes. Do not bury them. Recognize, share and learn from them. Fail forwards. 6. Relax. Do not rush. Take time. Enjoy things with people. 7. Hand-over the stick. Facilitate. Hand over the stick, chalk or pen. Initiate a participatory process, and then step back, listen, and observe without interrupting. 8. They can do it. Assume people can do something until proved otherwise. 9. Ask them. Ask local people for information and advice, including advice on how they would wish outsiders to behave. 10. Be nice to people. Adopt the triple principle of Raul Perezgrovas. Rule No. 1, Be nice to people. Rule No. 2, Repeat rule No. 1. Rule No. 3, Repeat rule No. 2. This participatory approach was empowering to both men and women, and allowed them to share their knowledge freely (Chambers, 1997). Chambers’ observed that many professionals have the common prejudice that local people in villages “cannot and do not take long-term view of the professionals and the elites” (p. 175). On the contrary, local people living in villages were knowledgeable about the local _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


conditions, and willing to make huge sacrifices, just to eke out survival. The will to make huge sacrifices accumulates as massive tacit knowledge that can remain unknowable by an outsider who is unwilling to listen and learn. This project was founded on the theoretical principle that access to the crucial knowledge in the tacit dimension is reliant on absolute humility, putting the local people first. METHOD The purpose of this project was to discover elements critical to production and delivery of affordable and accessible, high quality health services in frontier market. This purpose pointed to a qualitative approach. The qualitative method helped to obtain inductive data from multiple stakeholders of health and human development in several sites in Nigeria (a frontier market), and United States (a developed market). Rather than looking at explicit data from a community, qualitative studies focus on understanding phenomena (Kaplan & Maxwell, 1994). Thus, qualitative research methods allow an indepth engagement with stakeholders (George, Freedman, Norfleet, Feldman, & Apter, 2003). The qualitative method was appropriate because data about the sustainable structures for health services delivery in a traditionally marginalized health care market are lacking. Qualitative approach allowed us to approach the stakeholders with an open mind, and open heart, and an open will to listen to their needs. The inductive approach helped to do away with preconceived notions of how health care should be organized. Such an open approach helped to entertain multiple points of view from a diverse group of stakeholders. The emerging grounded theory design helped to explore concepts shared by the stakeholders of global health and human development, and to formulate a theoretical model for design, development and implementation of a world-class health system in a frontier market (see for example, Brown et al., 2002, Glaser, 1998; and Goede & Villiers, 2003). Theoretical sampling procedures of the grounded theory design helped to analyze the qualitative data to generate key categories indicative of elements critical to successful sustainable establishment of a just health care organization in the frontier markets (B. G. Glaser & A. Strauss, 1967) Comparative analysis helped to generate a theoretical model for production and delivery of affordable and accessible, high quality health services in frontier markets. Grounded theory was appropriate because it helped to discover properties and dimensions of key categories of elements critical to sustainable entry into a frontier market. Data analysis involved coding of data to allow a new theory to emerge (Glaser, 1998). Coding consisted of naming and categorizing data, and required going back and forth to the data (Babchuk, 1997; Brown, Stevenson, Troiano, & Schneider, 2002). Thus, the processes involved constant review and re-review of the data to allow concepts to emerge (Goulding, 2006). Geographical Location Nigeria was the specific country of focus in this project. Located in West Africa, Nigeria borders Chad and Cameroon to the east, the Republic of Benin to the west, and Niger to the north. To the south lies the coast of the Gulf of Guinea on the Atlantic Ocean. Nigeria’s economic outlook is promising, and the World Bank reports it as a mixed economy that has already reached middle-income status. The country has an abundant supply of natural resources. In addition, Nigeria has an advanced financial, legal, communications, transport infrastructure. The stock exchange is active and picking up. According to the World Bank, Nigeria ranked 31 in global purchasing power parity as of 2011. This economic growth comes from oil exports, as Nigeria is the 7th largest trade partner with the U.S., supplying 20% of oil consumed in the United States. Oil trade notwithstanding, the country enjoys positive outlook from global financial sector. Citigroup projected Nigeria to have the highest average GDP growth in the world between 2010 and 2050. Accordingly, Citigroup classified Nigeria among 11 Global Growth Generators countries. This positive economic outlook renders Nigeria a great candidate for world class health services. Participants Participants in the study hailed from four distinct locations: Akwa Ibom state, Rivers state, CrossRivers state, and Lagos state. Majority of participants hailed from Akwa Ibom state (one of Nigeria’s _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


36 states, with estimated population between 4 and 5 million people. The Akwa Ibom state is located between longitudes 7°3 and 8°3 East, and latitudes 4°3 and 5°3 North. On the continent of Africa, Akwa Ibom State is in the coastal South-South region of Nigeria. Data Collection Data collection involved in-depth interviewing with stakeholders of health and human development in the states visited. The focus of the study was ten thematic areas (Table 1). Table 1 Ten Thematic Areas Type of needs assessed

Examples of Topics

Community needs assessment

Nutrition, infectious diseases, injury prevention, drugs, alcohol, tobacco, housing, oral health, violence prevention, chronic diseases, environmental health, mental health, occupational safety

Programmatic needs assessment

Allergy, asthma and clinical immunology; anesthesiology; cardiothoracic surgery; cardiovascular medicine; dermatology; emergency medicine; endocrinology, metabolism and clinical nutrition; family and community medicine; gastroenterology and hepatology; geriatrics and gerontology; hematology and oncology; infectious diseases; physical medicine and rehabilitation; medicine; nephrology; psychiatry and behavioral medicine; neurology; pulmonary, critical care and sleep medicine; neurosurgery; oncology; obstetrics and gynecology; radiology; ophthalmology; rheumatology; oral and maxillofacial surgery; surgery; orthopedic surgery; otolaryngology; pathology; transplant surgery; pediatric surgery; trauma and critical care; pediatrics; urology.

Facilities needs assessment

Physical plant, elevations, architecture, engineering, construction.

Technology needs assessment

Clinical technologies, administrative technologies, building technologies, health information technologies.

Quality needs assessment

Accreditation, Joint Commission International, International Standards Organization, Continuous quality improvement, Deming cycle, FOCUS-‐PDCA, Lean-‐Six sigma, risk assessment, risk mitigation.

Franchising needs assessment

Franchising, business models, collectivism, individualism.

Health care cooperative needs assessment

Equity: distributive justice, deliberative justice, social justice.

Governance needs assessment

Leadership, people, money.

Legal needs assessment

Legal structures.

Financing needs assessment

Capital acquisition, capital allocation.

The procedure for data collection from the participating individuals was co-creating open space large group processes (Waruingi, 2010). Data collection involved various types of open group processes such a direct interviews, focus group discussions. The emerging grounded theory design (B. Glaser & A. Strauss, 1967), helped to explore and isolate key concepts during the theoretical sampling of interview data from the stakeholders of global health and human development. Theoretical sampling involved careful line-by-line review of the interview notes seeking emerging concepts from each interview. The emerging concepts are used to determine the next plan of action, or where to focus additional interviews. The continued interviews allowed for a comparison of concepts identified from preceding interviews with concepts emerging from the current interview. The comparative analysis yielded key categories showing specific properties and dimensions.



RESULTS The purpose of this project was to discover elements critical to production and delivery of high quality health services in frontier market State of Akwa Ibom in Nigeria. Indeed, we wanted to know how we could use our design principles to create conditions for emergence of affordable and accessible high quality care in a traditionally marginalized market. Interviews with key informants identified huge need for medical services and health care in general that are in complete mismatch to other areas of development in the state. The major finding was that health care in Akwa Ibom state, and Nigeria in general has remained at the rudimentary level. The delivery system is completely inadequate to deal with local medical conditions. Majority of the people do not have access to care, do not seek care, or seek care in other countries. People Do Not Access Care Basic care is lacking across the state. Primary and secondary health care facilities are under-funded, under-staffed, and under-equipped. At the heart of this problem is the lack of an organized system to manage payment for health care services. Preventative health practices and medicine are also lacking with minimal attention to maintaining wellness. Health insurance organizations are few, and many selfemployed people without formal employment do not participate in insurance schemes. In-depth interviews revealed that primary and secondary facilities do not function well and are often lacking areas of greatest need. The bulk of primary care service takes place at the tertiary care centers, distracting the needed resources from this area. The effect is that the tertiary centers do not have resources needed for tertiary level services. Other services are also lacking, for example, at the time of interviewing, there was no neurosurgeon in the state. Patients needing tertiary care either die at home, or raise funds to travel to India, Germany, United Kingdom, United States, and other destinations for medical care. People Do Not Seek Care Many people do not seek care from the healthcare system. Health literacy and trust in the healthcare system is generally low. Many people do not have correct understanding of disease, the role of proper nutrition, lifestyle, and behavior in disease causation. Many people attribute illness to evil spirits and prefer to consult with traditional healers. People only show up at the hospital when they are quite ill or at the point of death. At such point, health care providers are unable to treat the condition effectively. One physician observed that although antenatal care and care for children under five is free it is still underutilized. Small children are so sick with malaria by the time the mother presents them to the health center; they are so anemic that even blood transfusions cannot save them. One provider recently completed a community study that revealed a high prevalence of the high blood pressure among the young people age 18 – 45. The cause of extreme prevalence of hypertension is unclear. People with high blood pressure do not seek medical care, a factor that might explain the high prevalence of renal failure in Akwa Ibom. Women with high blood pressure do not seek the freely available antenatal care either. One interviewee related a case where a pregnant hypertensive woman who had caesarian section in her prior pregnancy refused to seek prenatal care, because her church friends convinced her that prayers would help her. She went into labor at church, and as her church friends advised, she adamantly refused to go to the maternity. Her condition worsened, and passed into coma. By the time the church friends took her to hospital, she was in severe eclampsia. The baby had died in-utero. To save the mother, the doctor performed an emergency caesarian section to remove the dead baby. People Seek Care in Other Countries Most providers in the tertiary centers refer their patients to India for laboratory diagnosis, imaging, treatments, and surgeries. Common diagnostic investigations referred to India include genetic studies, and immunohistochemistry. Imaging works sent to India include CT Scans and MRIs. Some Akwa Ibom people needing CT scan and MRI are able to get tests in Port Harcourt and Enugu, both cities are _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


more two hours away by road. The imaging centers in these two cities are crowded, and have a long waiting list. Treatments sent to India include minimally invasive endoscopic surgeries, neurosurgery, open-heart surgery, and transplants. Gynecologic conditions sent include infertility cases, cervical, breast, ovarian, and prostate cancers. People needing recurrent tertiary care because of chronic diseases are in serious trouble, because they would have to travel to India very frequently. Although, some people can afford a trip or two to India, some diseases like renal failure require a higher frequency of visits with dialysis three times a week. Uyo University Teaching Hospital for example caters from at least 200 dialysis patients per month; patients needing three dialysis sessions times a week only get one session per week. Abstraction of Grounded Theory The results indicate an unjust health system in Akwa Ibom. Despite the extreme abundance of natural resources and exuberant economic growth in this frontier market, people do not have access to care, they do not trust the quality of care, and they seek care elsewhere. Given these findings we examined the data closely to discover the intrinsic story line. Comparative analysis of the expressed needs yielded the grounded theory that a just WCHS is a comprehensive entity with three sub-entities of (a) community engagement, (b) services delivery, and (c) a payment ascertainment (Figure 1). From this analysis emerged a grounded theory that: • •

the phenomenal structure of the world class health system in frontier markets has three distinct sub-entities; successful execution of the three sub-entities is reliant upon careful implementation of affordable pieces in a neat sequence, with regular monitoring and evaluation.

Figure 1. Phenomenal structure of a WCHS. The three elements are the subsystems of a world-class health system in a frontier market. The subsystems co-operate under an overarching umbrella organization providing business governance and oversight to ascertain complete justice of a sustainable design for a WCHS of a frontier market in a rapidly globalizing planet. Each subsystem serves a specified function to contribute to a world-class health system. The community engagement subsystem operates through a health care co-operative (HCC) with specified functions that forms the platform for deliberative justice. The payment subsystem operates through an organized health insurance scheme that forms an avenue for access to care, ensuring social justice. The delivery subsystem operates through a hospital system and the affiliated ambulatory medical centers that form the pathway for distribution of health and medical services, ascertaining distributive justice. Thus, the community engagement element helps to meet the deliberative justice, the payment element helps to meet the social justice, and the delivery element helps to meet the distributive justice. _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


Deliberative Justice The goal of a WCHS is to ensure community participation and empowerment. A WCHS must be conscious that community participation is the cornerstone of a sustainable health care system. As such, participation and empowerment of the community are central to the design of the world-class health services. The goal is to ensure creation of solutions that are grounded on local knowledge and work to improve the overall health and wellness of the entire population. Grounded solutions are relevant, have fit and working capacity in the local environment (Glaser & Strauss, 1967). A WCHS would ensure that the members of the local community are fully involved in shaping the health system through dialogue with local people. Deliberative justice is a character that focuses on policy formulation through dialogue. Dialogue ensures participation of all stakeholders in the design of the services that matter to them (Isaacs, 1993). According to Isaacs, the word dialogue is a combination of two words, dia and logos, that mean “meaning flowing through” (p. 25). The purpose of dialogue is to establish a field of “genuine meeting and inquiry, a setting in which people can allow free flow of meaning and vigorous exploration of the collective background of thought, personal dispositions, the nature of their shared attention, and the rigid features of their individual and collective assumptions” Isaacs, p. 26). Deliberative justice is the guiding principle of policy formulation for the benefit of the members of the local community. In the deliberative conception of justice, the legitimacy and value of healthcare decision-making will be enhanced if local people and community representatives take advantage of opportunities to engage in dialogue and discussion about matters of public concern. Deliberative justice conceives a just health care system as dependent upon processes of dialogue. Health care decisions are legitimate if they are the outcome of deliberative participation by those subject to them. In deliberative justice, people come together in a setting where, at their own choice, become conscious of the processes by which they form tacit assumptions and solidify beliefs. On this setting, people develop common strength and capability for working together and creating things together. In this way, the stakeholders of the WCHS effectively address through careful dialogue, the conflict between distributive and social justice in health care delivery, through a sustained collective inquiry into the processes, assumptions, and certainties that compose everyday experience. In deliberative justice policy-making must address each member of the community as someone capable of joining and contributing to a dialogue, and that each person is a potential agent of policy formulation decision. Deliberated policies decisions are representative as they are likely to be based on impartial rather than sectional perspectives. They have greater legitimacy and reduce the probability of recycling of majority rule. In addition, they express the value of public reason among free and equal citizens and institutionalize the idea that problems of collective choice such as health care should be resolved by dialogue rather than by force or manipulation. In a WCHS, an organized healthcare cooperative is the operational principle of the deliberative justice. The health care co-operative will enroll members of the local community, in a manner that will enable the less privileged people at risk to gain access to services provided at the WCHS. Community involvement and collaboration is the cornerstone for the efforts that a WCHS must make to improve community health through sharing the burden of the disease and engaging everyone as active participants in the health and wellness of the community. Evidence from the WHO indicates that community engagement is essential to programs addressing healthcare needs. Community engagement involves working to co-create solutions with groups of people such as farmers, small business owners, employed people, parents, and the unemployed without geographical limitations in the country. The idea of community involvement in improving health outcomes is not a new concept. In a traditional African culture, communities have always protected each other and supported their members. The modern era is not different from the past, but sharing and supporting community members takes a different form. The WHO defined the social determinants of health that necessitated launching primary health care across all sectors. The WHO’s concept of primary health care aligns with the African culture of sharing. This culture of sharing and supporting the less fortunate members enhances community participation in health care and health promotion. For the success of WCHS, community participation will play a key role. To increase community participation, progressive approach is required to bring community actors and systems into full partnership. Community _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


participation will involve the social welfare approach through the new health insurance system to enhance access to health care service without limitations by income. Like elsewhere, in Nigeria, there are millions of unemployed, under employed, small business owners, and the employed. The notion of world-class health is to provide high quality health care service across the sectors with affordable prices. And, this involves community engagement through ownership and sharing the financial burden of the diseases for sustainability of the services. Two forms of community engagement are manifest. The first form involves engaging the stakeholders affected by the health issues. The community defined in this way has been left out of health improvement efforts for many reasons including lack of health care service as the case in Akwa Ibom State in Nigeria. The second form involves the professionals as communities. The challenges may include the scope, scale, and urgency of engaging the entire community and the media through which community awareness raising can take place. The community engagement may require various approaches to promote engagement, which may include the use of community leaders, community organizations such as church or mosques, media such as radio, TV, Web site, posters, pamphlet, etc. To engage community, it is important to consider the perspectives of stakeholders on identity. In community development, the “I” which is how an individual thinks about oneself and the “me” how others see and think about that individual sometimes conflict. When the two agree, it results in shared sense of an identity. In Nigeria the multiple communities including families, workplace, and social, religious, and political associations think more about themselves (individualists) than in the past. Therefore, while community engagement is the key for the continuation of the planned WCHS project. Without encouraging the culture of collectivism within the modern individualistic society is impossible. The notion of WCHS is not to make a large benefit from the minority group or rich people in the country, but to increase access to all members of the community engagement, while maintaining sustainable and profitable services. Distributive Justice The health delivery system symbolizes realized access, the objective and subjective indicator of the actual process of seeking care, or the distributive justice. The realized access of the health and medical services by the population at risk is a major distributive justice component of the system. Realized access is a function of how well the delivery system in the WCHS would predict demand for care, and position itself to supply the demanded care by the population at risk. Ultimately, realized access refers to perceived value of the care provided. The distributive justice component is related to the needs of the individuals in the community and the WCHS’s response to those needs. Thus, the attributes and behaviors of each individual form the ultimate unit of analysis of distributive justice. As such, distributive justice at the WCHS will emphasize equity of medical care delivery, preventative medicine, and wellness to all the people of Akwa Ibom state. The WCHS will help to overcome barriers to distributive justice such as structural, financial, and personal determinants of access to health care. In addition, the WCHS will help to overcome challenges associated with the paying for medical care and use of clinical services by patients. Distributive justice is concerned with availability, organizing, and financing of health services within the delivery system and the utilization and satisfaction of members of the community who consume care in the system. Health care delivery system is the backbone for success. Even if community engagement and revenue is well maintained, if the service delivery system is not effective, customers start looking for other quality service providers. The services delivery for preventive, medical and surgical interventions require quality services. The delivery systems for preventive services may include health promotion activities such as education, vaccination, under-five or health children clinic, antenatal, and prenatal clinics. These types of approaches may take place at health care delivery points, at outreach programs, and post medical care as part of interventional approach. All nurses and physicians responsible must participate in the health promotion program. The most important approach is the primary or interventional delivery system. The question is what type, by whom, and where the services are delivered. The medical, surgical, maternal, pediatric, _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


laboratory and radiology services are delivered at the WCHS delivery centers. The providers are highly qualified Nigerian physicians, nurses, laboratory, and radiology technicians. Service delivery point is the place where consumers pay most attentions, and therefore the place where consumer satisfaction should be measured. More than the payment, quality matters for customer satisfaction. People do not mind paying for quality health care service and the service delivery is the key for customer satisfaction. This includes the length of waiting time from entry to the hospital or from triage to see the nurse and the physician, other quality measures such as mortality rate, nosocomial infections, pressure ulcers, pneumonia, and others. The WCHS in Nigeria will deliver its services efficiently and effectively compared to the other health care institutions in Nigerian. Overall, the WCHS brand must maintain modern laboratories, advanced equipment, an effective electronic medical system, and clean health care facilities. Most importantly, the WCHS brand should promise quality health care services and must run effective health care campaigns to raise health awareness issues for the community. Health campaigns should be developed in collaboration with community leaders in order to ensure effectiveness. In order to maintain quality, management must develop standards of quality. Franchise units will be held accountable for implementing these standards of quality. Management of the overall franchise must also include monitoring these standards of quality. Franchising In the franchising, the approach will be to delineate the delivery of ambulatory services from hospital services, to produce operational efficiency of the WCHS in Akwa Ibom state. In the franchise model, emphasis would be on promoting the creation of private outpatient clinics by individual franchisees. Such clinics would offer such as preventive and curative services. Hospitals would be reserved for sicker patients requiring inpatient care. Such triage will help to reduce cost while providing the most appropriate care possible at each level, and serve as a disincentive for providers withholding patients for maximizing financial returns. The idea is to shift the focus from the traditional illness model to a wellness model. Furthermore, this arrangement would discourage overutilization of unnecessary services, particularly hospitalization, which on average costs twice as much as outpatient care. The franchise model would encourage group practice creating economies of scale and better standards of care. Although this arrangement works better in urban/semi-urban locations, rural practitioners would also participate in the program to facilitate extension of the program to those areas. The franchise system is thus best adopted as part of a comprehensive that addresses the entire continuum of care. Social Justice The social justice component explicitly acknowledges the environmental determinants of disease. Environments include physical, social and economic. The physical environment in Akwa Ibom contributes to diseases incident to the local people. Factors affecting the environment range from tropical climate that encourages the proliferation of mosquitoes that transmit the malaria parasites, to extreme environmental pollution from the oil and gas industry. Factors affecting the social environment include the family and religious structures that determine how people demand and consume care in Akwa Ibom. Religious beliefs play a key role in how people think about specific illnesses, and the things they do to provide care to people suffering from diseases. For example, local people believe that people with epilepsy are possessed by a demon, or several demons. Factors affecting economic environment include the ability to produce marketable goods and services. Majority of the people of Akwa Ibom rely on subsistence cropping that has no commercial value outside of local consumption. Poverty is very high with 57 % of the people living below poverty line. Economic environment is closely tied with the physical environment. For example, the decline of mangrove forests in Akwa Ibom State is closely linked to poverty. In a WCHS, social justice is reflected in public health actions of health promotion within communities in Akwa Ibom. The goal of social justice is to contribute to improvement in health thus minimizing disparities among subgroups of Akwa Ibom population. For example, substantive equity would be _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


reflected in subgroup disparities in health. Procedural equity is the extent to which the structures and processes in the WCHS will lead to improved outcomes in health. According to Milio (1976), “behavior patterns of populations are a result of habitual selection from limited choices, and these habits of choice are related to actual and perceived options available” (p. 436). Thus by providing more and better options, it is possible to help the population change behaviors that are currently detrimental to their health.

SOCIAL JUSTICE

In a WCHS, the social justice works with the community as the unit of measurement, and is concerned with population health. Social and economic factors are key determinants of population health. Social justice calls for population health oriented perspective to designing and assessing production of health. Two ways that WCHS would address population health are the creation of an investment plan and a health care insurance plan (Figure 2). The investment plan will focus on economic development, while the health plan will focus on health promotion and disease prevention activities.

Investment Plan

Economic Development

Health Promotion Health Plan Disease Prevention

Figure 2. Functional structure of healthcare cooperative, the social justice ascertainment arm of a world class health system. Investment Plan. In a WCHS, an investment plan will enable members to participate through purchase of shares. The focus of the investment plan is economic development. A WCHS must be built with express intent to formulate innovative strategies for nurturing social and economic development of the local people. Members of the health care cooperative will contribute to a common pool of funds through purchase of co-operative shares. The co-operative then invests the pooled funds in revenue earning projects (a) directly into the WCHS, and (b) other suitable ventures such as food packaging plant. The healthcare cooperative then sells the packaged food to the delivery system, to local communities through local distribution networks, and to out-of-state, and international consumers. Prepaid Health Insurance Plan. In the WCHS, a Health Insurance Plan, a prepaid health-plan would engage in health promotion and disease prevention. The WCHS will engage in health promotion activities for its members. The completed needs assessment of this project identified many opportunities for health promotion such as health literacy, diet, exercise, healthy living. The healthcare cooperative will also engage in disease prevention activities such as vaccination against common disease prophylaxis, monitoring of the general health of the individual. The completed needs _________________________________________________________________________________________________________________________________ www.jghcs.info [ISSN 2159-6743 (Online)] JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 3, NUMBER 2, 2013


analysis published in module 4 of this project identifies opportunities for diseases prevention in Akwa Ibom. The Health Insurance Program will provide expanded access to health care for millions of Nigerians at affordable costs. For the WCHS, financing will be accomplished through consumer payment for the services through an established insurance system. The focus of the prepaid payment system is to increase access to health care. This also includes insurance for non-formally employed residents such as those whose income is dependent on subsistent crops. This community has no consistent income and their income depend on the weather condition (rain and drought) and the excess farming for sale or beyond for consumptions. Engagement of this group is important for two reasons; primarily to increase access to health care at the grassroots level, and secondly, for sustainability and expansion of the WCHS across Nigeria. For small business owners such as Motorcycle taxi drivers and others, cooperative payment system will be established. Deductions will be made either through the agency/organization or for individuals directly deposit the amount to the recognized bank. The other larger community includes employees working in the government institutions and in non-governmental organizations. Like in many developing countries, millions of employees in Nigeria have no health insurance. An engagement of this group is the key for sustainability of the WCHS project. The prepaid insurance program for employee groups should be made in system approach, where group engagement is made through the employer. Health care is a necessity and employees should be mandated to purchase for their wellbeing as well as for their families. This is also good news for employer organizations in Nigeria, because health individuals are more productive and the health system maintains health of their customers. Conclusion A just WCHS is a comprehensive entity with three sub-entities of (a) community engagement, (b) services delivery, and (c) a payment ascertainment. The three elements are the subsystems of a worldclass health system in a frontier market. The subsystems co-operate under an overarching umbrella organization providing business governance and oversight to ascertain complete justice of a sustainable design for a WCHS of a frontier market in a rapidly globalizing planet. Each subsystem serves a specified function to contribute to a world-class health system. The community engagement subsystem operates through a health care co-operative with specified functions that forms the platform for deliberative justice. The payment subsystem operates through an organized health insurance scheme that forms an avenue for access to care, ensuring social justice. The delivery subsystem operates through a hospital system and the affiliated ambulatory medical centers that form the pathway for distribution of health and medical services, ascertaining distributive justice. Thus, the community engagement element helps to meet the deliberative justice, the payment element helps to meet the social justice, and the delivery element helps to meet the distributive justice.



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