When accidents do happen, as they always will, at the very least the provision of at least one adequately staffed and resourced Accident and Emergency unit in every state capital will literally save thousands of lives. In Nigeria, children are perplexed when they grow up to realise that most ambulances they see on the road are not carrying emergency services as they are taught in school, but only appear on Fridays, carrying corpses to funerals This needs to be readdressed urgently. A good starting point would be to build up a pool of 2 – 5 ambulances absolutely dedicated to accidents and emergencies to each of the afore mentioned centres described. These as well as other practical solutions should be encompassed in a comprehensive emergency medical system for response, transport, evacuation and treatment of acute medical conditions and injuries at the state levels with a national emergency referral plan.

Emergency services and emergency planning are key areas – many of the recent disasters have led to unnecessary loss of life because the emergency services required were not in place. What does it take to ensure that every fire service has functional equipment and running water? This may have saved lives in the plane crash in Port Harcourt and more recently the petrol explosion in Lagos. One shudders as the economic costs of maintaining a Fire service, which at the best of times, fires being rare occurrences, are idle, and yet on the odd but urgent occasion when these do occur, those paid to respond cannot do so due to lack of water?

This leads to the question of health care services- where the question may be approached from two angles. In the first place, why is there no single world-class tertiary hospital in the entire country to negate the continued need to fly patients to South Africa, India or the United Kingdom? What exactly is the role the National Hospital in Abuja? Why is it necessary for a sitting vice president and the supposed front-runner in the presidential elections to be flown abroad for a knee strain and to treat "catarrh"? What needs to be done with the National Hospital in Abuja to make it meet these challenges? Anyone that has visited the centre knows it does not lack facilities yet, beyond the well-manicured lawns, why do we feel the same lackadaisical attitude so prevalent in our hospitals? Is it the absence of learning incentives through the lack of a comprehensive postgraduate training scheme for doctors in training? Is it the absence of a financial incentive due to the lack of specific health outcome targets tied to the huge financial resources being invested? If our most pre-eminent have no confidence in our premier health care facility, what can the ordinary Nigerian expect? The next president must create a genuine centre of excellence- if not for the sake of the ordinary man but also out of self-interest – it could save his life. Many will argue that this is not a priority but the creation of such a centre will raise standards in the provision of health services and therefore boost the general quality of services. In addition it can act as a magnet to draw highly qualified Nigerians from all over the globe as well as provide education and training to healthcare professionals within the country.

Looking more broadly at health services, it is immediately obvious that the majority of Nigerians obtain healthcare from the p

rivate sector-be it the roadside chemist or the fancy ten storey private hospital. Improving health services therefore must include restructuring the regulatory framework within which private providers of health provide care. There should be minimum standards for the opening of a health facility and these standards must be clearly communicated to the public so that they can make their own judgements. If members of the public know which banks to put their money in and which bus companies or airlines to use, they also have a right to know what standards they can demand from their healthcare providers. Chemists should be given minimal basic health training to recognize symptoms that they can manage and those beyond their capacity, which they need to refer. They can be issued licences which are regularly reviewed and which must be displayed in their shops. Public awareness campaigns should be carried out enjoining members of the public to demand evidence that their chemist has undergone the training.

Similar schemes should also apply to clinics and hospitals. If it is no longer acceptable for any group of people to set up a bank in Nigeria, why is it still acceptable for any post registration medical doctor to set up a clinic on his own? Is it not time yet for some minimum standards? These can be different for urban and rural areas, allowing for lower start-up resources in rural areas. Ministries of health must ramp up their inspectorate and approval services and carefully consider applications to open new private clinics. Perhaps restrictions should be introduced as to where new establishments are located- why for instance should there be a clustering of ten private hospitals or clinics in one street alone when many people in other areas lack access? By limiting the number, doctors and other healthcare workers will be forced to spread
care to where it is most needed. We acknowledge that there are complex challenges in getting more doctors to practice in the rural areas. There are however several options in providing the incentives to do this, as is being done in South Africa at the moment. However, none of these can be tried if we have no information on what the distribution of health care personnel is at present, stressing again the need for data.

Looking at the public sector, a lot of focus has been on increasing or improving buildings and facilities in government clinics and hospitals. Emphasis needs to shift from the numbers of buildings required to the quality of care delivered within the buildings. We suggest that most Nigerians will prefer going to a public sector hospital if they will not have to spend the whole day waiting to get a card, waiting to be seen by a doctor who might or might not turn up, waiting for tests, waiting at the pharmacy only for the customary ticks with a red pen on the items that are available, while the rest have to be purchased outside. Why is it no longer okay to take a sleeping mat to the bank, but still okay to take a mattress to the hospital? One possible solution would be for public hospitals to provide a high standard private wing services to draw in patients who would otherwise have gone to the private sector. The income from these patients can help subsidize care for others. Introducing minimum service standards should also be considered- for instance a target that all patients are seen within two hours could be introduced and communicated to the public. The media and the public can then monitor which institutions are meeting these targets, and hold the politicians accountable. These politicians will then put pressure on the hospitals, which would then lead to more efficient services for patients.