INTERVIEW WITH DIRECTOR OF BORROMEO HOSPITAL
ONITSHA, ANAMBRA, NIGERIA
FJA: Francisco J Agraz, J.D., Treasurer and Director, Catholic League for the Poor of Nigeria, Inc.
DIR: Rev. Fr. Izunna Okonkwo, PhD., Dip HMA
Director, St. Charles Borromeo Specialist Hospital Onitsha
[Rev. Fr. Okonkwo has a PhD in Theology and Religious Studies, Belgium. He also earned an advanced post-graduate certificate in Health Care Management and Administration, from St. Joseph’s College, Brooklyn, New York. He joined the Health Directorate of the Archdiocese of Onitsha in 2014 and the Archbishop asked him to assume management duties at St. Charles Borromeo Hospital that same year.]
Interview recorded in Onitsha, Nigeria – December 3, 2016
DIR: My title is “Rev. Father” and I am Director and CEO of St. Charles Borromeo Specialist Hospital Onitsha.
FJA: Thank you for agreeing to see me today. Fr. John and I have met with the Archbishop during our brief visit to Onitsha. He recommended that we should visit with you, to learn how the St. John Borromeo hospital is managing healthcare issues in this area. I recognize you have many pending matters in administering such a busy institution, and appreciate your allowing me to ask about your operations with a goal of helping our project. We hope to raise 20 to 30 million dollars so we can design and build a new hospital that will be located on donated property in Okoti-Odekpe. We would like to be able to express to possible donors and foundations the nature of what is needed to provide efficient, modern healthcare services for the rural poor in Nigeria.
DIR: Here at St. Borromeo Hospital we have a goal of looking for areas where we need to improve. We will do whatever we can in our effort to provide best quality care to our patients. Look there, at our Mission Statement: “We emphasize quality, accessibility and affordability.” We don’t compromise in this. And the Archbishop doesn’t play with anything what has to do with quality. We have a plan for next year and subsequent years to upgrade the quality of services we are rendering to our patients here. And we also have plans to upgrade our services to meet standards as a teaching hospital.
FJA: As I mentioned, our goal is to raise as much as 30 million dollars from private donors and foundations, worldwide, probably mostly within the United States. As part of our efforts, we have to show a business plan stating our mission, goals, how funds will be used, concept design and intended use of the actual building, and – this the reason for visiting you – we need to provide data showing why there is a need for a new hospital in Okoti-Odekpe. We have a presentation explaining what we know at this stage of our campaign, which was presented to the Archbishop and the Legal Counsel for the Archdiocese. Now it is a privilege to be able to speak with you – and to ask for your help in gathering data and statistics regarding the state of at least one medical services provider in this region. In my research I find governmental Ministries might have such information, but statistics are of a general nature usually providing overall national numbers with very few, if any, local details. And often the reports easily available to me are many years old.
But you are more intimately acquainted with the current situation regarding provision of medical services, in this area – the region where we hope to build the new hospital. Actual budgets regarding what it takes to run a hospital in Onitsha would be helpful. Yet, at this beginning point we are seeking to gain an understanding of resources used and a sense of the type of patient loads and types of medical services needed in this region.
DIR: I think when one wishes to create a budget or estimate of costs – what it would take to build a hospital – there are certain benchmarks one has to consider.
FJA: One hundred and thirty beds.
DIR: Then one has to consider what departments.
FJA: Three operating theaters… MRI… new equipment, not used…and we are talking about a hospital pharmacy…some 28 rooms for doctors….a three story main building designated as D&T&A (Diagnostic, Treatment and Administrative), mechanical/maintenance, storage areas, a receiving and waiting room for patients and families. The operating theaters will require installation of hospital-rated elevators. Then, in addition, two wings containing the 130 hospital beds will also be built, connected by corridors to the 3-story D&T building. Each wing will be only two stories. One wing will be designed to care for post-surgical and other medical patients. The second hospital wing will be dedicated other exclusively for psychiatric patients. The reason for the wings having only two floors is primarily for maintenance purposes. And secondarily, the second story floor would be utilized, as required, for staff and community education meetings and as training salons. Certain areas will be reserved for temporary living quarters for visiting physicians and other medical/technical personnel. As needed, selected family members of psychiatric patients might be allowed to use temporary living quarters as medically determined for patients’ welfare and treatment. Of course, it is not yet decided as to the number and layout of patient rooms and nursing stations and other similar areas.
DIR: These are the matters we would have to look at before I could tell you what it would take. And, remind me how much money you are thinking of raising?
FJA: As I said, our preliminary estimates are in the range of 20 to 30 million dollars. But remember, that is only to design and build the facility. The actual budget for construction may result in needing a smaller amount, based on actual building cost efficiencies we expect to encounter here in Nigeria. Again, I emphasize, we are thinking only of designing and building. As to running the hospital, that would be up to the Archbishop, as he makes decisions about who and perhaps a local community council in the Okoti-Odepke community that would make suggestions to the Archbishop concerning what areas to focus on.
DIR: Let me calculate a few things. I am looking at the lab rates, and all that involves. When you are talking about building, are you including the equipment that you expect to be used?
FJA: At this point in our design and planning, we are looking at helping with some of the heavier initial expenses by assisting in contacting certain Houston area organizations who are able to provide hospital supplies are minimal costs. But not all. Equipment would be extra. But again, I must emphasize, we are looking at design and build costs only.
DIR: Well, in my own case, I am here as a Manager, you know, more of an Administrator. But you will need to talk about hiring architects, and what we in Nigeria call Quantity Surveyors in order to get a good idea of the cost implications. We need to look at:
- size of the building,
- quality of materials,
- hospital elevator requirements, so, what kind of elevator,
- quality of beds.
- treatment of sewage and hazardous wastes, and
- making certain of a reliable and continuous source of water.
- Ensuring a reliable source of electricity is critical for a hospital.
Regarding electricity, will you design the hospital to use alternative energy sources like solar power or will the primary source of power be the National Electrical Power Supply – the Nigerian electrical power distribution grid. You must consider the need for and required capacity of standby power generators. Here at St. Charles Borromeo, we use standby power generators most of the time, which means having to assure ample storage space for and assuring for a reliable supply of diesel fuel. Speaking of diesel, cost is a big factor. There is the problem of inflation. Last year we budgeted for 85 Naira per liter, but the actual cost has risen to 185 Naira per liter, that is 100% increase in the price of diesel. Also, construction costs may rise unexpectedly. These are the variables one has to consider before beginning a project. I have lived in different parts of the world and have noticed cost increases elsewhere are not as dramatically high as they have been here.
So these are the things a person has to consider in budgeting, if one wants to begin a construction project. The architects and Quantity Surveyors will look at the plans and tell you their estimates for Nigeria.
Then, as far as purchasing equipment, factors to be considered are the sources – will you buy direct from the company? Or through an intermediary?
FJA: We are acquainted with that area, and know of certain non-governmental organizations who can facilitate the transfer of what I will call “gently used” but modern, technical medical equipment in very good operating condition. These pieces occasionally become available for forwarding to you when major medical organizations decide to replace a perfectly good medical appliance with a newer version. I am speaking of – and I am not an expert in this area – but I have heard mention of the availability of MRI equipment, CT scan devices, and X-ray machines.
DIR: We have been thinking of acquiring a new CT machine. I recently inquired about the price and learned it would cost $435,000 USD ($170,000,000 Naira). That’s for a CT scan machine. I am not sure of the exact amount, but an MRI machine would cost over one million US Dollars.
FJA: Speaking of buying equipment and supplies. Where do you buy them from? Locally, internationally?
DIR: Most of them from different parts of Nigeria, where the local distributors and representatives of foreign supply companies are based. For example, our CT scan machine, made by Toshiba. Their representative is in Lagos. As we speak, it is broken down. We called the representative in Lagos and asked how much the repairs will cost. In our own assessment, their quote for repairing the machine was on the high side. So we tried to contact the company Toshiba directly. They referred us to their representative in Nigeria. So, things like that are what we have to deal with. If we can gain direct access to the company it would bring down the cost. You know, at times you do not know the person you are communicating with.
FJA: Now, turning to the subject of patient care services at this hospital, what is the level of hospital care we are talking about – advanced primary, or secondary level care?
DIR: Here at St. Charles Borromeo Specialist Hospital Onitsha, in certain areas our position is strategic in terms of the medical care that we provide. We have at this time working with us:
- 46 Medical Doctors
- 22 of our physicians are Consultants [Note: A Consultant Physician in Nigeria is a senior doctor who practices in one of the medical specialties]
- We also train doctors here. We have 6 House Officer doctors [Note: In Nigeria House Officers are provisionally licensed doctors who have completed their medical school requirement and now must work for at least one year in an accredited hospital in order to qualify for a medical doctor license.]
- 135 Registered Nurses
- Some have double qualification ratings (e.g, general nursing and mid-wife certification)
- 100 Subsidiary Nurses
- Community Health Extension Workers (i.e., not yet fully-certified Registered Nurses)
- Health Care Attendants
FJA: Can you now talk about the “bricks and mortar” medical facilities at this hospital?
DIR: We have four major surgical theaters at St. John Borromeo Hospital. But they are not sufficient. We are planning to build a new, ultra-modern major surgical theater. That would increase the number of operating tables we have. This hospital also has three additional surgical areas within what we call an Emergency surgical theater.
We have plans for an ultra-modern OPD Complex (Out Patient Department). We want to relocate administrative offices into more functional administrative offices at the OPD. Our administrative staff still works in temporary administrative offices, which unfortunately have been “temporary” for too many years.
FJA: Can you share with me the number of functional hospital beds at St. John Borromeo Hospital as of today (December 3, 2016)?
DIR: We have 230 functional beds.
FJA: And would you please describe, generally, the physical hospital buildings? One story, two story, three story?
DIR: The hospital wings have one floor only. The small original hospital building that you see out front, facing the parking lot, has two stories. The new OPD building will have two stories.
FJA: Will you now share some statistical data about the programs and patient catchment at St. Charles Borromeo Hospital?
DIR: As of the time I came on board
- These are the number of patients who came to us for treatment during the six month period between January and June 2016.
- Admissions: 2,257 patients
- Ob-Gyn: 781 deliveries
- Surgeries: 641
- Outpatient cases (OPD): 22,838
- Casualty clinic cases (i.e., Emergency cases)
- Antenatal clinic cases (ANC): 4,591
- Newly registered patients (patients not seen before) 5, 032
- X-ray Department: 2,054
- Eye clinic: 1,117
- Physiotherapy Department: 2,203
- Dialysis: 301 sessions, an unusually low number of sessions because we had problems with our dialysis machine. Some patients were referred outside. During an average six-month period we treat approximately 80 patients per month (80 x 6 = 480 sessions).
FJA: Rev. Fr., this hospital is obviously very busy. In Onitsha, are there other hospitals? Can you please describe the number and quality of healthcare facilities, clinics, hospitals, or specialty hospitals?
DIR: In Onitsha, to be frank, there is no other hospital that does what we are doing – no other facility can provide the range and quality of healthcare that we provide at St. Borromeo Hospital. Not even the Nigerian government hospital. In terms of functionality, we do not see anyone else doing what we do. In terms of magnitude, that is, the departments we have in our hospital, the only other hospital that approaches what we do is the other Archdiocesan hospital, Holy Rosary Maternity Specialist Hospital.
As you drive along the streets of Onitsha, you may see signs directing you to a “hospital.” But these are usually single-doctor primary care clinics. Certification standards are not easily enforced, so a healthcare professional, perhaps not even a medical doctor might run a facility and call it a hospital. But it would never qualify as multi-departmental, well-staffed healthcare facility. Strictly speaking those are not true hospitals – perhaps single-bed first aid stations, sometimes associated with a locally owned pharmacy and other times operated by a physician’s private practice. Regretfully here in Nigeria we do not have the strict regulatory distinctions in that area so anyone can put up a sign and say they are a “hospital.”
FJA: Now, Rev. Father, my final series of questions, have to do with financial matters. Can you give me a broad overview of how this hospital operates with regard of sources of income and expenses? Grants from the Archdiocese? Subsidies from the government? Payments from patients? And perhaps insurance company payments?
DIR: I began my duties as administrator and CEO of this hospital in July 2015. Since that time we have not received any monies from the government in terms of subsidies.
FJA: Are there government grant programs from the federal or state governments with a goal of subsidizing healthcare facilities, and more specifically, multi-department hospitals such as St. Charles Borromeo Hospital Onitsha?
DIR: The federal government does not provide subsidies. But the state governments do have programs to assist organizations that provide healthcare for Nigerians. In the past, Anambra State has collaborated in the construction of healthcare facilities generally, not just our hospital. We just do not get federal money for healthcare purposes from the federal government.
- As you approach the entrance to our hospital you will see an example of that – the International School of Nursing. The greater percentage of money used to erect the building came from Anambra State, not the federal government.
- Then, we have staff quarters for the doctors – that is residences we are able to offer to doctors while they practice with us which were built several years ago with financial assistance provided by Anambra State.
- Also, the CT scan machine we current operate was purchased with subsidies from the state government.
FJA: Operational expenses?
DIR: Internally generated revenue. Which means, payments from patients who ask for the services we provide here. And, often we do receive charitable donations by third parties to help offset the expenses incurred by indigent patients. For example, just yesterday, we had visitors who donated funds to our hospital. One of our visitors was the wife whose husband holds a high rank within the Nigerian military. The lady was being shown around the city by the wife of Willie Obiano, Anambra State Governor. The wife of the military officer had gifts for our patients, and the wife of the Governor pledged to donate funds to help pay for certain indigent patients she met during her visit.
FJA: So, again, generally, at the end of the year, if there is a deficit, who makes up the deficit? Are there other financial mechanisms in play?
DIR: Well, this will be my first full year as hospital’s CEO. Since we work in six-month accounting cycles. So, I can tell you the figures for the first two six-month periods that I have been here. And I can tell you that, thanks be to God, we did not end up in the “red.” But we still have a lot of building plans and development issues that we need to handle. You are probably wondering “why are you not ‘in the red.’”
FJA: OK. I will ask you, why did have you not suffered financial deficits the last two financial periods?
DIR: Well, first, not much has changed because Nigeria is in recession. And, when it comes to money, especially health care management, it is generally believed that a lot of things are being wasted. And, that is one of the things I learned when I began my post graduate studies [in healthcare management]. Experts all over the world show statics of healthcare waste. And that is all over the world, not just in Nigeria, not just in the United States, all over the world. But once they recognize the problem then we turn our focus on waste reduction. That is, on how to reduce running costs.
So, after a few surveys we put a few strategies in place to reduce our running costs. That enabled us to save some money. It was money that was being utilized inappropriately. We stopped spending for certain items. We considered more closely what we buy, how we buy, and when we buy as well. I wanted to start learning when the best time was to buy.
FJA: You have been very kind in taking the time from your busy schedule to speak with me. Do you have any final thoughts?
DIR: It has been my pleasure to be able to share these facts with you. You are very much welcome to Nigeria. I thank you for the initiative your group has begun, to bring a welfare package and help for Nigerians. Healthcare is like a big ocean, a big sea, you know? No single individual can meet all the demands of providing for healthcare needs of people. So, as they say, “the more, the merrier.”