Fewer Hospitals, Better Healthcare: Why Akwa Ibom Needs to Shutdown Some Hospitals
A few years ago, my cousin, a talented artist, was found unwell in his room in our village in Akwa Ibom state. Nobody had heard from him in days, so there was naturally worry about his well-being. When he was found, he was in such a dire state that he had to be rushed to the hospital. Thankfully, a general hospital was only an 8-minute drive from the house. They hurriedly put him in a car and rushed to the hospital, only to be turned away because he was too sick. The hospital had only one duty doctor and a few nurses; they lacked access to resources to manage his dire situation. He was referred to another public hospital about 35 minutes away. He arrived there and, like before, was referred elsewhere again because he was too sick and they couldn’t manage him. He eventually ended up in a private hospital, where he deteriorated and passed on. He was only in his 40s with many unfulfilled dreams and left behind a single young child.
My cousin’s story is not a lone one. Many people like him go from facility to facility when sick, wasting precious time at poorly resourced locations like the general hospital in my village. It is one of many secondary facilities owned by the state that should be closed down, with all its services centralised to a bigger and better-resourced general hospital. This, as part of a broader centralisation strategy in the state should see 42 hospitals be rationalised to fewer than 30, with a concomitant investment in primary care. This would mean the state can concentrate on equipping fewer general hospitals better to deliver what they uniquely should, rather than diluting efforts to weakly support 42 hospitals. A similar initiative was undertaken in Denmark, where they reduced their hospitals from 42 to 21 and saw efficiency and care quality gains as a result.
Twitter was up in arms when I said I as much. I was called all sorts of names, labelled as biased, an idiot, etc.
What’s in a name?
General hospitals are not just a matter of nomenclature; they are meant to meet specific standards prescribed by the Medical and Dental Council of Nigeria.
The reality, however, is that our general hospitals are under-resourced and unable to meet this basic standard of three doctors to provide medical, surgical, paediatric and obstetric care. This is precisely what I discovered when I visited the general hospital in my village.
The Reality of Healthcare Access in Ini LGA
I come from Ikpe Ikot Nkon in Ini local government in Akwa Ibom state. The current estimations put the size of my LGA at just over 100,000 people. My state of Akwa Ibom has an estimated 5 million people living in an area of about 7,000 Sq Km, the 30th largest state by landmass in Nigeria and is mostly rural. Decent road networks within the state mean that it takes a maximum of four hours to traverse the entirety of the state. Unlike some other states in Nigeria, truly remote, unreachable communities in Akwa Ibom are rare.
In 2006, then Pres. Obasanjo commissioned a general hospital located in my village. I visited it in 2022 after my cousin died, and immediately understood why they referred him elsewhere; he would have died had they kept him there. I found a deserted hospital with a lone medical officer and a handful of nurses/ midwives. I spoke at length with the staff, who were candid about low patient numbers and the attendant deskilling they’ve suffered. On the rare occasion that patients attend, a referral elsewhere was the usual outcome. There weren’t functional medical specialities, no radiology, and minimal laboratory services, as you’d expect in a proper general hospital. In fact, the hospital was worse off than the local primary healthcare centre 20-minute walk away. If a person urgently needed hospital care, they’d be better off driving past this hospital rather than wasting precious time there.
Hospital overlap and duplication
Just up the road, about 20 minutes away, is another general hospital in Ikono LGA. First built in 1991 it was reconstructed and recommissioned in 2018. A further 35 minutes away from Ini LGA is yet another general hospital, Ikot Ekpene General Hospital, itself recommissioned by former president Dr Goodluck Jonathan. This makes 3 general hospitals about 35km apart, with a travel time by car of 40 minutes.
An hour away is Ibom Specialist Hospital, a tertiary centre built for 41 billion Naira, but infamous for being underutilised and now rotting away.
The people of my LGA have a plethora of hospital buildings to attend that would rival many European cities. Beyond my LGA, the whole state has over 355 public primary healthcare facilities and 42 public secondary facilities on record, yet the state’s healthcare indices tell a different story.
- Percentage of pregnant women with >4 antenatal visits - 65.10%
- Percentage of women using contraception - 19.80%
- Maternal mortality — 774 per 100,000
- U-5 mortality — 98 per 1,000
- Zero dose children — 13.90%
- HIV prevalence — 5.50% (We are the HIV capital of Nigeria!)
Buildings do not healthcare make.
How Nigeria’s Health System Is Supposed to Work
Primary care can address all the dire indices of Akwa Ibom's healthcare. In Nigeria, healthcare is broadly divided into 3 tiers, with facilities and responsibility accorded to each level of government. Hospitals are in the secondary tier.
Responsibilities often overlap (e.g., states co-fund PHC; some states run teaching hospitals), but key in this system is that the referral flow is designed to move patients appropriately between PHC, Secondary and Tertiary depending on the complexity of care required. This division and referral flow is to enable efficiency. For example, simple routine malaria should be managed in a primary care centre, while complex delivery requiring C-section should be managed in a hospital.
Most estimates are that 80–90% of care is delivered in the primary healthcare setting, while 5 -10% is in the secondary setting. When well-resourced and utilised, PHCs are meant to generate demand for secondary healthcare. Most people don’t know when they need secondary care; it’s the PHC generalist who alerts them to this and makes the appropriate referral. The usual Nigerian practice of walking into a general hospital for care is actually an inefficient aberration. Public health systems ideally should gate access and catalogue where the demand for secondary healthcare is. Policymakers can then site hospitals to plug gaps in demand. I’ve never seen data used this way to decide where to build hospitals. We put the cart before the horse, building hospitals for political reasons first and then (failing to) generate demand afterwards, while leaving them to rot.
What hospitals are built for in Akwa Ibom
Akwa Ibom State has 42 secondary care facilities under the care of a hospital management board that has a N9 billion budget. These hospitals made about 161 million in revenue in 2023. These figures and multiple anecdotes suggest that the story of underutilisation and under-resourcing in Ini LGA is repeated across several public hospitals across the state. The story is the same: the governor builds or renovates a hospital, gets the president to come commission, takes fancy photos, then abandons the hospital to become moribund. A future governor returns years later only to renovate and perpetuate the cycle. In the case of Ibom Specialist, Akpabio, the governor, now Senate president, who built and commissioned it, infamously had a car accident and had to be flown out of the country for care despite touting the centre as an antidote to medical tourism. Turned out that he commissioned a non-functional hospital. Watch out for when this place will be renovated for billions.
So let’s be clear on what hospital buildings in Nigeria generally represent: a photo op for politicians to falsely lay claim to delivering dividends of democracy. For them, a hospital building is a monument for campaign purposes and to win political favours, not to improve health indices. These capital projects also present a convenient route to siphon public funds via procurement fraud and kickbacks in a way that’s harder to obtain from investing in proper healthcare systems. Improving healthcare and the health of the citizens is an afterthought.
Learning from Denmark: Centralisation in Practice
Denmark is a European country with a population of around 5 million people. Coincidentally of similar population to Akwa Ibom but with seven times the land mass. In 2007, the country undertook a sweeping reform that reshaped its health system. The motivation was a highly fragmented hospital landscape with many small local hospitals spread across the country. These hospitals often lacked the scale and specialisation needed to deliver high-quality care. There was concern about inefficiency, duplication of services, and rising costs. Practice makes perfect in medicine, so the more cases doctors see, the better they and the system they work in are at delivering better outcomes.
A central goal of the reform was thus to improve quality, efficiency and outcomes via a more centralised hospital network. A move away from many small acute hospitals toward fewer, larger, and more specialised facilities. As a result, the number of hospitals fell from around 40 to just 21. Concomitantly, they invested in primary healthcare, prevention and health promotion. Over the decade following the reform, hospital productivity increased by more than two per cent per year while overall costs remained stable despite increasing disease burden. This combination of efficiency gains and financial control has been hailed as a success by many.
Similar experiences abound in lower middle income countries like India, Malaysia and Thailand where centralising of services and so-called ‘hub and spoke models’ led to gains in efficiency and outcomes.
An Improved Model for Akwa Ibom’s Healthcare
The combination of fragmented healthcare facilities that are under-resourced and underutilised, alongside poor health indices, suggests that a rethink in structure and operations is required to deliver proper healthcare. Learning from the Denmark experience, we need to invest further in primary care and health promotion. This would not be by building more facilities; we have enough to start with. What we need to do is go beyond noisy yet empty revitalisation projects to instead employ community health extension workers who roam the communities, taking healthcare to the people and generating demand for the PHC. This is the backbone of how we have been able to deliver encompassing immunisation campaigns and would solve 80-90% of healthcare needs.
The PHCs should be properly resourced and set up within referral networks to refer patients to secondary centres as appropriate. The secondary centres should be centralised so that, rather than a budget where boreholes and oxygen plants are built in 42 different sites with 42 different managers, budgetary and administrative efficiency can be derived from scale. More patients would attend larger but fewer centres and healthcare workers would be easier to recruit, train and retain as their skills are always sharp and being put to use. The state is small enough with good roads such that nobody would be more than an 30 to 45 minutes away from a good general hospital, even if half of the existing ones are closed down. Investing in proper emergency systems with paramedics to transport and stabilise patients will also be key to making this work. Should new hospitals be required, it will be a data-based decision guided by wait times, bed occupancy rates etc, not political photo ops.
The political economy would of course be a hard sell, who doesn’t like to cut the ribbon for a new hospital. Most rational health policy experts would however, struggle to disagree with the technical aspects of my position. The Denmark experience shows what’s possible if we move away from the “more hospitals equate better healthcare” paradigm. Less in this instance is more, and we should look to efficient ways to scale our healthcare.
