SUMMARY OF THE NATIONAL HEALTH ACT: IMPLICATIONS FOR HEALTHCARE WORKERS IN NIGERIA

SUMMARY OF THE NATIONAL HEALTH ACT: IMPLICATIONS FOR HEALTHCARE WORKERS IN NIGERIA

Written by

Onoka, Amara C., Omotola,Ngozi, Kelechi-Duruh, Ijeoma

Department of Nursing, University of Nigeria Enugu Campus, Enugu

Correspondence email: adiella914@gmail.com

Introduction

The 2014 National Health Act (NHA) is a bill that seeks to regulate and harmonize the Activities of personnel and institutions within the health sector in Nigeria (Enabulele & Enabulele, 2016). It was formerly signed into law on 31^st October, 2014 after almost a decade of debate by the former President of Nigeria Dr. Goodluck Jonathan (Adepoju, 2015). The NHA is the most debated health bill in Nigeria due to the many interests, agitations and desire for improvement of working conditions vis-à-vis remuneration, autonomy and participation in leadership positions among medical and health professionals. This paper shall review the 2014 NHA with special focus on:

1) Brief history of the NHA

2) The key players in the development of the Act

3) The parts and provisions of the NHA

4) Implication of the NHA to healthcare workers

5) Strength  and weakness of the NHA

Historical Overview: The NHA was first presented to the National Assembly in 2006 and was passed by the Senate in 2008, but not by the House of Representatives. In May 2011, it was passed by the House of Representatives and the Senate but was not assented to by President Goodluck Jonathan due to unhealthy disagreements and diverse interests of health professionals, religious and political groups.

The Nigerian Senate resuscitated the Bill in 2011; held a public hearing in February 2013 and passed the Bill on February 19th, 2013. The document was signed by the Clerk of the National House on 23^rd October, 2014 and by the former president in October 31^st, 2014 (Enabulele & Enabulele, 2016). The Act is published in the Federal Republic of Nigeria Official Gazette dated 27^th October, 2014. 

The Aim of the NHA is:

        i.            To provide a framework for the development and management of a National Health System for Nigeria.

      ii.            To provide a system that will regulate health services in the country and members of the system include both private and public sectors.

    iii.            To promote a spirit of cooperation and shared responsibility among all providers of health services in the Federation.

     iv.            To determine the rights and obligations of healthcare providers, health workers, health establishments and users.

       v.            It is also the first Nigerian law with clear provisions for the protection of the rights of the patients, ensuring their wellbeing, especially when they seek medical services at the nation’s various health facilities, in both the public and the private sectors.

Interest groups include

-          Medical doctors, under the aegis of the Nigerian Medical Association (NMA), The Health Sector Reform Coalition (HSRC), and the Health Reform Foundation of Nigeria (HERFON) were unanimous that when the Bill becomes law it would ensure access to affordable and specialized healthcare, and stop medical tourism and brain drain.

-          Other health workers under the aegis of the Joint Health Sector Union (JOHESU) and Assembly of Healthcare Professionals Association (AHPA) called on the National Assembly to reject the bill.

An overview of the National Health Act

The National health Act, 2014 is a 40 paged document published in the official gazette of the Federal Republic of Nigeria. The Act became operational on 31^st December, 2014 and is arranged in 7 parts which include:

1)      Responsibility for and eligibility for health services and establishment of the National Health System

2)      Health Establishments and Technologies:

3)      Rights and obligations of users and healthcare personnel

4)      National Health Research and Information System

5)      Human Resources for health

6)      Control of use of blood, blood products, tissue and gamete in humans

7)      Regulations and Miscellaneous Provisions

Part I: Responsibility for Health and Eligibility for Health Services and Establishment of the National Health System:

The aim of this part is to provide an all-encompassing framework that will regulate the Activities of healthcare providers within the public and private sectors, promote cooperation among all the players in the health system.

In sections 1-11, The Act

1)      Establishment of the National Health System: Provides for the establishment of the National Health system which comprise of the public and private health services, traditional and alternative health care providers as well as the ministries and departments at each tier of government.

2)      Functions of the Federal Ministry of Health: Stipulates the responsibility and roles of the different players in the Nigerian health sector. The Federal ministry of health has the oversight, co-ordination, planning as well as making budgets and presenting annual reports on the state of health of all Nigerians to the president and National assembly.

3)      Eligibility for exemption from payment for health services in public health establishment: Prescribes the  entitlement of all Nigerians to the minimum package of health services and the processes for the exemption of certain groups from paying for services in the public hospitals

4)      Establishment and composition of the National Council on Health: Establishes and stipulates the composition of the National Council on Health

5)      Functions of the National on Health: Lists the functions of the National Council on Health

6)      6 &7 Establishes and states the composition and functions of the Technical Committee of the National council whose duty it is to implement the plans developed by the Federal Ministry of Health

7)      Establishment of  the National Tertiary Health Institution Standards committee to oversee and set standard for tertiary health institutions in the country as well as undergo annual peer review

Part II: Health Establishments and Technologies: This part is provided by sections 12 to 19 and stipulates that:

(12) Classification of Health Establishment: The Minister for health shall classify health establishments and technologies based on their roles, function, size, location, nature, ownership etc.

(13) Certificate of Standards: Anyone (government, health agency, individuals etc) seeking to establish, construct, modify or provide healthcare services must do so after having acquired a certificate of standard from the approved government agency (Federal or state Ministry of Health)

(14) Offences and Penalties with respect to Certificate of Standards: Anyone who contravenes this law (24months after its enActment) shall be liable and shall be convicted by paying a fine of #500,000 or imprisonment for a period not exceeding 2years (if an individual) or both.

(15) Provision of health services at public establishments: The Minister shall determine the range of health services to be provided by a healthcare institution as well as how the revenue generated shall be used or allocated.

(16) Health services at public health establishments other than hospitals: The Minister with respect to the provisions of health services at public health establishments (state or federal) prescribe the minimum standards and requirements for the provision of healthcare services in health institutions as well as penalties in case of contraventions relating to traditional health prActices.

(17) Referral from one health establishment to another:  Any establishment that is not capable of providing healthcare services for which an individual visited is under obligation to refer him/her to a facility where such services will be provided.

(18) i&ii Relationship between public and private health establishments: Allows partnership between healthcare agencies (public, private &NGO’s) with the aim of ensuring adequate provision of healthcare services as prescribed by the minister.

(19)  i –iii: Evaluation of Services of health establishment shall be by the National tertiary health institution. All health care establishments are therefore expected to provide healthcare services as stipulated by the National council on health with regards to human resources, health technology, equipment, hygiene, premises and delivery of health services.

Part III: Rights and obligations of users and healthcare personnel

Sections 20-30 stipulate that:

(20 i-ii): Emergency treatment: No person shall be denied emergency medical services for any reason by a healthcare worker, provider or establishment. It also provides for a punishment of #100,000 fine or a minimum of 6months imprisonment or both for offenders.

21    (i-iii) Right of Health Care  Personnel: A health care personnel has a right to:

-          Be exempted from certain duties stipulated by an institution based on his health status.

-          Be protected from as well as minimally exposed to damage and disease transmission in the course of discharge of his/her duties.

-          Refuse to provide care in case of physical, verbal or sexual harassment by a user except where such user is a Psychiatric patient

Section 22 Indemnity of healthcare provider, Office of employment of healthcare establishment: Provides that so long as a healthcare personnel has not been found to be negligent, he shall be indemnified from any liability incurred in defending himself (in relation to provision of care) in any proceedings whether criminal or civil

Section 23: User to have full information: The Act stipulates that it is the duty of every healthcare provider to provide relevant information to users of healthcare facilitates about his/her:       

·         health status(except where there is substantial evidence that such disclosure would be contrary to the best interest of the user)

·         range of diagnostic procedure and treatment options

·         benefits, risk and consequences of any treatment

·         right to refuse health services and the implications of such decisions

Information should be provided to the user in a language and manner to ensure understanding.

Section 24: Duty to disseminate information:

The Act provides that every healthcare establishment (federal, state, local & public or private) must provide adequate information on display about the types of services available, the organization of health services, operating schedules as well as the rights and duties of healthcare providers

Section 25: Obligation to Keep Records: Provides that every head of health establishment must ensure (based on the archiving legislation) that a health record system is established and maintained.

26 (i-ii): Confidentiality: The Act provides that every information related to a user’s health status, treatment or stay in the establishment must be kept confidential except when there is:

-          consent of disclosure in writing by the user

-          a court order or law that allows disclosure

-          in case of a minor and anyone who is not able to give consent in that case his/her guardian

-          where non-disclosure poses a serious threat to the public

27-28: Access to health records: Provides that a healthcare personnel is allowed access to a user’s records only if such access is within the scope of his services.

A health care provider who has access to any information about the patient may disclose such information to other health care personnel only where it will help in facilitating the user’s treatment, for studying, teaching or research (with adequate permission of the relevant health research ethics committee) so long as no identifying information about the user is revealed.

29 (1-2) Protection of Health records:  Provides that:

-          The head of every health establishment is under obligation to establish a system of control of undue access to a user’s health records

-          Any person who fails to perform the duty of preventing undue access to user’s health records, who falsifies any record, creates, changes or destroys, make copies without authority or gains unauthorized access to any electronic device containing the user’s records etc. commits offence and is liable on conviction to imprisonment for a period not exceeding 2 years or to a fine of #250,000 or both.

Section 30: Laying of Complaint: The process of laying complaints shall also be made known to the user as displayed at the entrance of the health establishment, such complaints must be acknowledged and addressed or referred if not within the jurisdiction/scope of the establishment.

Part IV: National Health Research and Information System

Provides for the:

(31) Establishment, Composition and tenure of the National Health Research committee: The committee shall be established by the minister of health, membership shall consist of not more than 13 persons appointed by the minister to reflect federal charActer with their tenure lasting for three years after which they may be re-appointed, they are also permitted to vacate office by providing information through written letter or in case of permanent incapacitation or death.

32: Research or Experimentation with human subject: Must be carried out:

-          In a manner prescribed by relevant authority

-          With the written consent of the person after he has been provided with adequate information about the importance and risks associated with the procedure

In the case of a minor, such procedure   must be in the interest of the minor, written consent obtained from the parents and authority given by the National Health Research Ethics Committee

33: Establishment, Composition, Function and Tenure of National Health Research Ethics Committee:

-          Established by the Minister and shall be simply known as ethics committee

-          Membership shall consist of 15 persons one of which shall be the chairman, a medical doctor, a legal prActitioner, a pharmacist, a nurse, one representative each of the Christian and Islamic faith, a community health worker, one researcher in the field, a researcher in pharmaceutical field, a medical laboratory scientist and researcher in the field, a health record officer, a radiographer, a physiotherapist, 3 other persons one of whom shall be a woman with integrity.

-          Tenure  of members of the committee shall last for 3year

-          Some of the duties of the Ethic committee may include to:

c          Establish and regulate the Activities of health research ethics committees in institutions

c          Set standards and norms for conducting research on human beings and animals including clinical trials

c          Receive complaints and stipulate disciplinary measures in case anyone contravenes the provisions of the Act.

c          Advice the Federal and State Ministries of health on any ethical issues

Other Provisions in this part include:

35 Coordination of the National Health Management Information system

36: Duties of FCT as regards health information:

37 Duties of FCT Area Councils: Each shall establish and manage a health information system as a part of the national council

38: Duties of Private healthcare Providers: Each shall establish and manage a health information system as a part of the national

39: National drug Formulary and essential drug list and safety of drugs and food supply:  Provides for the listing of drugs to be known as Essential Drug list which shall be reviewed by the committee. The Act also encourages the indigenous and local manufActure of the items in the formulary.

40 National Health Insurance Scheme (NHIS): The National Council on Health shall ensure the widest catchment for NHIS throughout the federation

Part V: Human Resources for health

This part stipulates that it is the duty of the Minister to provide organs for:

41 (1 &2) Development and Provision of Human Resources in National Health System: Stipulates that the National Council shall develop policy and guidelines to monitor the; provision, distribution, development, management and utilization of human resources within the national health system.

42) Appropriate Distribution of Healthcare providers: following guidelines stipulated by the Minister and National Council in collaboration with the state ministries and local government.

43) Regulations relating to management of human resources in health system: The Minister in collaboration with the National council shall ensure/monitor standards of training based  on approval  by council, periodic re-certification programme through a system of continuing professional development, create new categories of health care personnel, identify shortages in skill as well as prescribe strategies for recruitment and retention of personnel within the national system and from anywhere outside Nigeria.

44 Plan for Manpower development:

45  (1-3) Industrial Disputes: Without prejudice acknowledges the right of all cadres and groups to demand for better conditions of service, it should be acknowledged that health services are regarded as Essential Service. Thus industrial disputes are not expected to last more than 14 days. In a situation where such has lasted for more than 14 days, the Minister is under an obligation to apply every necessary measure to ensure return of normalcy

46 Medical Treatment Abroad: Without prejudice to the rights of Nigerians to seek medical check-up, investigation or treatment abroad and anywhere within or outside Nigeria, no public officer of the government of the Federation or any part shall be sponsored for medical check-ups, investigations or treatment abroad at public expense except in exceptional cases under the recommendation and referral by the medical board with due authorization of the Minister or commissioner.

Part VI: Control of use of blood, blood products, tissue and gamete in humans

47 (1-3) Establishment of National Blood Transfusion Services (NBTS): The minister shall establish, regulate and maintain the Activities of the NBTS. States are expected to follow suit following appropriate law.

48 (1-3) and 49 (1-3) Removal of and use Tissue, Blood or Blood Products from Living Persons:

Stipulates that

c          Shall only be removed from a living person using the standard procedure only by the prescription of a medical doctor or dentist and after an informed consent has been obtained from the patient) or from his/her guardian if less than 18years (except in case of emergency.

c          It also prohibits the removal of tissues that cannot be replaced by natural process from a person less than 18years.

c          Shall be done only for medical purposes and not for commercial purposes or merchandise

c          Punishment: Contravention of the Act shall attrAct #1,000,000 or imprisonment for a period not less than 2years or both (in case of tissue) and #100,000 or imprisonment not exceeding one year or both.

50: Prohibition of reproductive, therapeutic cloning of Human kind:  The Act prohibits any form of genetic manipulation, nuclear transfer or embryo splitting for the purpose of cloning, import or exportation of human embryo.

Punishment in case of offence attrActs a minimum of 5years with no option of fine.

51: Removal and transplantation of human tissue in the hospital: As for blood and blood product.

Shall only be by a registered Medical prActitioner

53: Payment in connection with the importation or acquisition or supply of tissue of blood or blood products:  The Act prohibits any form of financial reward for such donation except for reimbursement of reasonable costs incurred by him or her to provide such donation.

Punishment: #100,000 fine or minimum of 1year imprisonment or both.

54-57: Allocation, Use of human organs:

The Act stipulates that a competent person who wishes to donate any part of his tissue or his body must state that in a will signed in the presence of at least 2 witnesses in which he should state the person (donee) or institution and shall only be used for training in a health institution, health research, treatment of another person etc and these should be carried out based on the regulation of the National Tertiary Institution Standards committee. The Act also allows for the revocation of that will at any time before his death.

55-57   Donation of human bodies and tissues of deceased persons shall be by the full consent of the donor stating the donee and the recipient institution. A donor also has the right to revoke his consent any time before the removal/transplantation following due procedure.

56 (1-2) Purposes of Donation of body Tissues: Shall only be for training of students in health sciences, health research, therapy, diagnostic and prophylActic substance.

58        Post-Mortem examination: Shall be carried out on a deceased if:

c          When the deceased person was alive, gave a consent in that regard

c          The parents, guardians, brother or sister gave an order (if the deceased is less than 18years)

c          To determine the cause of death

c          Only by the authorization of a medical prActitioner in charge of the health establishment in writing

Part VII: Regulations and Miscellaneous Provisions

(Sections 59-68)

Sections 59-63 Provides that the Minister has the power to:

-          Make other regulations necessary to facilitate the implementation of this Act

-          Establish the number of advisory and technical committees as necessary with consultation of the National council

-          Establish the National Consultative Health forum whose duties shall include; promotion and facilitation of interAction, communication and sharing of information on national health issues between representatives of the Federal Ministry of health, national organizations identified by the Minister and state organizations

64 Interpretations: Operationally defined the key words used in the Act eg appropriate authority, certificate, commissioner, death etc.

Blood product means any product derived from blood including circulating progenitor cells, bone marrow progenitor cells and umbilical cord progenitor.

A health care provider means a person providing health services under this Act or any other law

A health worker means a person who is involved in the provision of health services to the user, but does not include a health care provider.

Implications for Healthcare providers:

The NHA is a veritable tool to facilitate the provision of health care services in Nigerian with the main aim of achieving care Universal Health Coverage for all Nigerians through equitable delivery of health care services. It is therefore necessary that to achieve this goal, every healthcare provider in Nigeria must:

        i.            Have adequate knowledge of the provisions of the Act

      ii.            Collaborate with other members of the healthcare team in ensuring efficiency in delivery of health care services

    iii.            Understand that every Nigerian has equal rights to basic health care

     iv.            Ensure adequate academic, professional and political preparations to facilitate adequate representation in leadership positions

       v.            Provide care based on the provisions of the Act with a clear understanding of a user’s rights to confidentiality, full information in a manner s/he will understand, informed consent, emergency medical care etc.

     vi.            Understand the right of health care providers to refuse to provide treatment under certain conditions, be exempted from certain duties based on health status, to be protected from danger in the course of discharge of their duties and be indemnified in the case of criminal and civil proceedings.  

   vii.            Must participate in continuing professional development.

 viii.            Fully aware of guidelines relating to the transfer and use of blood products, tissues and body parts.

     ix.            Key into the approval of the Act to develop a public and private establishment; Private providers who have health establishments may therefore receive referrals from the public hospitals and to ensure accessibility and continuity of care.

STRENGHTS AND WEAKNESSES OF THE NHA

Strenght: The Act provides for:

        i.            A framework for the development and management of a National health system in Nigeria.

      ii.            A system that will regulate health services in the country whose members include representatives of both private and public sectors as well as providers of alternative medicine.

    iii.            Allocation of USER of health care services instead of a patient or client. Thus holds the user of healthcare services in high esteem.

     iv.            Protection of users of health care services through clear provisions for the protection of the rights of the patients, ensuring their wellbeing, especially when they seek medical services at the nation’s various health facilities (emergency medical care, information, confidentiality and allocation of tissues, blood and blood products, body or body parts and so on).

       v.            Protection of health workers by stating their right to safety in the workplace (and protection from abuse and harassment), right to agitate for better conditions of service within the provisions of the law and stipulates the provision of skeletal services in such situations.

     vi.            Obligations of health care establishments (Protection of the rights of health workers and users of health care services

   vii.            Adequate measures for the development, training of human resources and continuing professional development strategies for re-certification.

 viii.            Discouraged the incessant medical tourism abroad.

     ix.            Did not define/provide for any cadre of health workers to occupy Public and administrative leadership positions in the Health system (Minister, Commissioner): The Act defines a Commissioner of a state responsible for health and a Minister as a Minister charged with the responsibility for matters relating to health. This simply means that anyone who is qualified and is appointed by the President or state governor can occupy such position.

Weakness

1.      Although the NHA had as one of its aim as; to promote a spirit of cooperation and shared responsibility among all providers of health services in the Federation, it failed in any way to look at those issues that causes the numerous agitations among health care workers (especially that between NMA and JOHESU) some of which include:

-          Imbalance in government sponsorship of postgraduate studies (only for duty)

-          Lack of role definition among the health care workers

-          Leadership tussles of administrative positions in the health system; which cadre occupies the positions especially of Minister, Commissioner and Hospital administrator (who by definition must not be any particular cadre expect if such a person is qualified)

2.      Although the Act stipulated the obligation of health establishment to ensure the safety of health care workers, it is silent on the procedure for and punishment in case of breech.

3.      The silence of the ACT to stipulate regulations for sponsorship of post graduate studies among health workers, definition of roles, remuneration and especially the cadre of professional to occupy leadership position will continue to pose a threat to the health system. Thus strikes and agitations will continue to affect the co-operation and provision of heath care services in Nigeria.

4.      So much power was also given to the Minister for health as the sole determinant in establishment and appointment of committee members. Sections 9 and 33 of the ACT were the only sections where specific mention was made to include other cadres of health care professional thus the profession of the Minister may be a strong determinant of the appointees and committee members.

Summary

This paper reviewed the provisions of the 2014 National Health Act. It discussed extensively the implication of the Act to nurses as well as reviewed some of the strengths, weaknesses, opportunities, threats of the Act. Adequate knowledge of health worker and the will power to provide healthcare services based on the provisions of the Act is key to the achievement of the goals of this Act.

References

Adepoju, P. (2015). African Health: Nigeria’s New National Health Bill - the

beginning of another era in healthcare delivery. Retrieved on 15/05/17 from  http://africa-health.com/wp-content/uploads/2015/10/AH-Nigeria-edition-Jan-15.pdf

 Enabulele, O. &   Enabulele, J.E. (2016). Nigeria's National Health Act: An assessment of health professionals' knowledge and perception. Retrieved on 15/05/2017 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036296/

Federal Republic of Nigeria (2014). Official Gazette. No. 145 vol. 101. (Pg 139-172) Retrieved 15/05/17 from http://nigeriahealthwatch.com/wp-content/uploads/bsk-pdf-manager/1189__2014_Official-Gazette-of-the-National-Health-Act-,_FGN_1272.pdf