By Prof. Ben Udoh


Abstract
The health sector in Nigeria is faced with numerous problems arising from bad governance, government and leadership. Tupocracy if introduced as a form of government in Nigeria, would surely address most of the challenges which have their bedrock on corruption and greed. Tupocratic government demands that the top has a model - a guiding policy principle of leading by positive example. A tupocratic leader leads the followers by exhibiting good examples that would not tolerate or allow the rots in the nation’s political and health policies to continue. A good healthcare delivery system policy usually starts from the top and gets down to the common man in the villages and its environs. Leadership by example (tupocracy) would solve most of the numerous challenges being faced in the health sector in Nigeria today.

1. Definition
• Tupocracy is a system of government involving people who lead by positive example based on transparency, integrity, altruism, patriotism and godly character which is worthy of emulation by their colleagues and followers. Tupocracy is one word for leadership by example, coined from two Greek words, tupos (example, pattern, model which is worthy of emulation) and Krateia (government, leadership, rulership or administration), in the family of Democracy, Autocracy, Aristocracy, etc. This system of government was invented by Dr. Godwin Akpan Amaowoh, a Nigerian Clergyman, in 2006 as the brainchild of his doctoral dissertation at Nigeria’s foremost institution of higher Education, the University of Nigeria, Nsukka, Faculty of Social Sciences.
• This is an efficient system of governance in that it goes a long way in terminating common vices that compromise good governance. One of the major challenges which the world is facing today is the absence of good leadership. This has precipitated poverty, social unrest, insecurity, instability, war, ethnic tensions, criminality, corruption dissatisfaction and despair among the citizenry and other crimes in the land and in many nations. The answer to this dilemma is found in Tupocracy which is rightly predicated on the age-old axiom that “example is better than precept.” Based on this, the Tupocract says, “Emulate me in all things”.

This system of government maintains that positive change starts from the leader and flows down to the governed. The governed find it very easy to follow suit when the leader has taken the lead. Tupocracy has been viewed as the bedrock for the success of other systems of government because it nurtures sincerity and commitment among the leader and the lead. For instance, the beauty of Democracy, as a world acclaimed political doctrine, lies in Tupocracy. For this reason, Tupocracy has been recommended to be adopted as the handmaid of Democracy, without which Democracy becomes “Dem all gracy”, meaning, “Governance by insane people.”

• In Health Care Delivery System, this system of government is so much needed for optimal growth and efficiency in services to the general public. Tupocracy when put into practice preserves the hierarchical structure of any healthcare system. Starting from the topmost head down to the least leader in different units of the system as the need for demonstration of leadership by example is paramount in the health sector.

• In our country today, corruption and neglect of duties are the major banes of success of our health care systems. The leaders pay little or no attention on the healthcare needs of the governed, but rather places personal gains and aggrandisement over everything. This ill attitude leads to crack and eventual collapse of the system. Tupocracy ensures transparency, integrity and moral rectitude in governance/leadership which are bedrock for a thriving healthcare system.


Governance or leadership should not be an all comer’s affair. This underscores the need for careful selection of suitable leaders in every position of authority. The truth is that governance should be for people whose lifestyles are worthy of emulation whether they are Presidents, Heads of healthcare Delivery Systems, Governors, Legislators, Judicial Officers, Ministers, Commissioners or Chairmen of Local Government Areas, Council[ors, Mayors, Police Officers, Military or Paramilitary Officers, traditional Rulers, Heads of Schools, Managers of Industries or Religious Leaders.

2. The feature of an ideal Health Care Sector
The constitution of the World Health Organization (WHO) which came into force in 1948 defined health as a state of complete physical, mental and social wellbeing and not merely the absence of diseases or infirmity 1

Three key information are apparent from the WHO definition. (i) Health connotes the absence of any disease or infirmity. (ii) Health is a state that allows the individual to adequately cope with all demands of the daily activity. (iii) Health is a state of balance: and equilibrium that a person has established within self and between self and the social / the physical environment. The implication of adopting any of these concepts has a far reaching implication to getting health available to the people. The delivery of health care is seriously affected by the differences in the health definitions. The simplest definition of health equated with the absence of disease would result to the promotion of health as an effort to remove disease and lower the numbers of person who suffer from these diseases. Involvement of optimal functions in the definition of health would be reflected in defining the promotion of health as a process by which the capacity of a citizen to cope optimally as an individual is enhanced and strengthened. These two approaches would employ the improved treatment of disease and the removal of risk factors that contributes to disease such as sedentary lifestyles, engaging in drugs (smoking and alcohol) bad eating habit and inco-operation. The last part of the definition does not stop at efforts to remove the disease and lower risk factors through job creations. It requires the involvement of the citizens and communities being educated and exposed to place health values high in their priorities from the implementer to the consumer of health.

An ideal healthcare system is the one with good structures, good equipments, qualified and dedicated staff for taking care of the health care needs of the people, both the rich and the poor. An ideal healthcare system places the health of the citizens first and makes provision for efficient and prompt healthcare services to the general public. Such ideal healthcare system places structures that ensures that even the unemployed and the underprivileged have access to quality healthcare at all times. People want healthcare systems where they can get timely access to high quality, affordable care and one that also promotes innovation of new tests and treatments.

Health insurance scheme (HIS) is one of such structures that make for easy access to healthcare services by all citizens. Through such schemes, government shares in economic burden of rendering efficient healthcare services to the people. The citizens on the other side cooperate with the government for optimal services. An ideal healthcare system can only thrive in a system where corruption and other vices of governance do not exist. Tupocracy, which ensures that the right people are placed in positions of government, is needed for the existence of an ideal healthcare system in any country. The people in head positions in different sectors of healthcare systems should lead by examples by shunning corruption and greed as demanded by Tupocracy. Proper handling of funds by the people in authority will ensure the thriving of an ideal healthcare system.

Ideal healthcare in any society requires that healthcare facilities are extended to people living in remote areas. That is to say that in all levels of government, starting from the Federal down to the Local government levels, efficient healthcare facilities are provided for the people. Such facilities should be adequately staffed and equipped to be able to meet the challenging healthcare needs of the people. People should be able to obtain prompt and premium healthcare services at all times. To ensure the sustenance of such an ideal healthcare system, people in positions of authority within the healthcare system should lead by example by showing commitment to duty and shunning all forms of corrupt and greedy practices as demanded by Tupocracy.
3. The global burden of disease on the poor
In a study carried out by Gwatkin et all ., 1999, it was discovered that 59% of death and disability occur among the world poorest and 20% was caused by communicable diseases. Although the study used a crude estimate, it presented a good picture of changes in attributable mortality among the world poor than the global average in current use. The poor, otherwise known as the underprivileged of the society, are the subset of individuals in any society who are not economically buoyant or privilege to live a standard/moderately comfortable life in the society. Such people often suffer a great burden from diseases, especially in a society that does not share in the disease burden of the citizens.

Poverty has been implicated as meaningful cause of morbidity and mortality among the poor and low income earners across the globe. A large proportion of illnesses in low-income countries are entirely avoidable or treatable with existing medicines or interventions. Some of the disease in low-income countries finds its roots in the consequences of poverty, such as poor nutrition, indoor air pollution and lack of access to proper sanitation and health education. The World Health Organization estimates that diseases associated with poverty account for 45 percent of the diseases in the poorest countries3. However, nearly all of these deaths are either treatable with existing medicines or preventable in the first place.

For instance, diarrhea, caused by poor sanitary condition of a place is linked sometimes to poverty and is easily treatable through oral rehydration therapy. However, diarrhea diseases still claim 1.8 million lives each year. Similarly, respiratory infections caused sometimes by burning biomass fuels in poorly ventilated areas also place a considerable health burden on poor people. According to WHO, exposure to biomass smoke increases the risk of Acute Lower Respiratory Tract Infections (ALRI) in childhood, particularly pneumonia. Globally, ALRI represent the single most important cause of death in children under 5 years and account for at least two million deaths annually in this age group 4. Again malnutrition particularly affects people in poor countries. As a result of vitamin A deficiency, for example, 500,000 children become blind each year 5, despite the fact that such outcomes can be avoided by cheap, easy-to-administer food supplements.

4. The problems and challenges of healthcare delivery in Nigeria
There is a toxic mix of problems including inaccessibility of quality healthcare, poor hygiene, corruption, malnutrition, poor health infrastructures, fake drugs, insufficient investments and lack of sufficient health personnel. The major public health challenges Nigeria faces are; infectious diseases, especially control of vector -causing diseases, maternal and infant mortality, poor sanitation and hygiene 6. Healthcare delivery in Nigeria is experiencing a progressive deterioration due largely to weak political wills on the parts of successive government to effectively solve a number of problems that have accumulated in the sector over the years. More than half of the population live on less than one dollar a day, making Nigeria one of the poorest populations in the world today 7. As at February 2018 Nigeria was ranked 187 out of 191 countries in the world in accessing the level of compliance with universal health coverage. The government provision for health is insignificant. The out of pockets payment for medical bills cause household to incur catastrophic bills. Private health bills as a percentage of the total health is over 85%. The implication of this is that the government expenditure for the citizens is less than 15% across the family budgets 2. Every living being would love good health and good health care delivery. A tupocratic leader would love to have access to good health care within his or her environment. As a result, he makes effort to see that the hospitals around him are well equipped with modern heath facilities. As a tupocrat, he shows example to his subject by not seeking medical services outside his country or state, thereby reducing foreign medical trip by both the leader and the led. This would automatically lead to a concerted efforts by the topocrats in providing the necessary equipments, facilities and enabling environment for sound and efficient health care practice.
Health workforce is seriously depleting due to brain drain of the health professionals to foreign countries especially Europe and America. Common healthcare professional survey shows a serious brain drain in the Nigeria health sector which is increasing at an alarming rate. There is a rising trend of immigration of the healthcare professionals: physicians, radiographers, pharmacists, nurses, laboratory scientists, physiotherapists etc. There is also the problem of skewed distribution with few available professionals mostly concentrated in the cities where most of the large health facilities like general hospitals and teaching hospitals are located. Some of the healthcare challenges in Nigeria include:

(a) Importation of fake and non-functioning hospital equipment— it is not uncommon news to hear that equipments used in some hospitals in Nigeria are fake and non-functioning. This scenario usually poses a big clog in the wheel of medical practice in Nigeria. Fake and non-functioning hospital equipments jeopardize a patient’s health condition and can even cause death. Procurement of fake and non-functioning hospital equipments is possible in a corrupt society where selfish ends are placed over the lives of the patients. In the contrary, when leadership is by example as is obtainable in tupocracy, people in the management positions within the health sector consider the supremacy of human life over personal aggrandizement. Hence, they procure standard equipments that will give best services to the patients as if they procure the equipments for themselves.

(b) Fake drugs— fake drugs and poor-quality medicines used in the treatment of chronic and infectious diseases, causes disease progression, drug resistance, and death. Reliable, good-quality medicine supply is essential for health, but it is often missing in countries with weak regulatory systems. Some of the most compelling stories of pharmaceutical fraud are those of frank poisoning. Between November 2008 and February 2009, 84 Nigerian children died from acute kidney failure brought on by the industrial solvent diethylene glycol in teething syrup 8, 9. The contaminated product, My Pikin, was registered with the Nigerian regulatory authority and made in Lagos, the national manufacturing hub8. Inspectors traced the problem back to deliberate fraud by a chemical dealer in Lagos, eventually leading to 12 prosecutions.


One of the causes of fake drug provision in the hospitals is greed and lack of regard to the sanctity of human life. Tupocracy is one form of governance that abhors the deliberate provision of fake drugs to the hospitals. In this form of governance, therefore they will not like to be treated with fake drugs. A Tupocratic leader and his people resort to the same hospitals his environment for their medical needs, and would not want to be treated with fake drugs. For this reasons he forbids and abhor the production, importation and supply of fake drugs.

(c) Corruption— is a form of dishonesty or criminal offense undertaken by a person or organization entrusted with a position of authority, to acquire illicit benefit or abuse power for one's private gain 10. Corruption also is an effort to secure wealth or power through illegal means for private gains at public expense. Corruption may include many activities including bribery and embezzlement. This evil practice has eaten deep into the fabrics of many countries, especially developing countries like Nigeria. No meaningful development takes place in a society where bribery and corruption is rooted. In such setting people embezzle funds that are meant for the development of infrastructures for the general welfare of the society.

The offshoots of corruption can be clearly felt in healthcare sector where greed and ineptitude by the government and heads of health facilities lead to wanton loss of lives. In such settings, substandard drugs and hospital /health equipments are procured for healthcare services. This kind of evil does not thrive in a system where tupocratic leadership is practiced. In tupocratic government, both the leader and the subjects make use of the same health facilities, unlike what is obtainable in corrupt government where the leaders travel abroad for their healthcare needs only to restrict the poor masses to the underequipped healthcare facilities.

(d) Poor health infrastructure— quality healthcare infrastructure is pivotal to quality healthcare service/ delivery in any society. Both government and non-governmental bodies have failed to make such provision for the masses. In Nigeria, and most other developing nations, government has in the past introduced numerous developments and programmes to improve health care, for all users 11.

Despite a number of commendable goals having been set by government for improved quality of service delivery in healthcare settings, recent reports by media and communities revealed that services in public health institutions were nonetheless failing to meet basic standards of care and patient expectations 12. This has caused the public to lose trust in the healthcare system. Experts have blamed bad government for this ugly incidence13, and we therefore enthroned tupocracy as the answer for the provision of standard health infrastructure in any society.

(e) Inaccessibility of quality health care— in Nigeria and beyond, a significant number of people do not have access to quality healthcare, disregarding the saying that “a healthy nation is a wealthy nation”. The people most affected are the ones living in the rural areas who are often neglected in this regard. Equally affected are those who are financially underprivileged. There is need to galvanise the efforts of relevant stakeholders including the patient in charting a new agenda for health care improvement in Nigeria. The government should make adequate and equal provision of quality healthcare facilities to the public in every part of the society. The public should recognize the presence of such provision and avail themselves of such opportunity for a healthy living. The final end would be a healthy society which is veritable with strong workforce in the development of the society. Tupocratic leadership is the type of governance fully disposed for ensuring adequate accessibility to quality healthcare by the public in any society.

(f) Poor annual budget by the government for the health sector— no meaningful development takes place where there is poor funding of developmental projects. Government should place priority to the healthcare needs of the people by making adequate annual budget for the healthcare delivery system. Findings showed that Nigeria’s healthcare system has not been receiving adequate annual budget for efficient running of her healthcare delivery to the public. This backdrop has been linked to widespread corruption and misappropriation of funds by the government leaders and heads of the healthcare delivery systems. All hands must be on desk in other to correct this anomaly in our nation. This can only take place if tupocracy is embraced, and the leaders see themselves as stakeholders to the nation’s healthcare delivery system. In this scenario, everyone both the big and small depend on our healthcare system and not the people at the top resorting to the healthcare systems of other developed nations.


(g) Frequent industrial actions by healthcare personnel due to poor numerations— frequent industrial actions by the Nigeria’s healthcare personnels has been pointed as the clog in the wheel of development of our healthcare system. Whenever health workers embark on industrial actions a lot of lives are lost, and the country also loses huge economic gains. The government and the healthcare workers should have premium regard for human lives and hence always embrace dialogue and other legal means in resolving their differences instead of embarking on industrial actions.
There is no gainsaying the fact that government sometimes fail to take adequate care of the welfare needs of healthcare workers. A nation with sound leadership model, like tupocratic leadership, would not experience breakdown in her healthcare system. Because everyone (both the leader and the lead) is a stakeholder in the nature of the healthcare delivery, no party would like to allow the system to collapse. Tupocratic government, therefore, is underscored as a vital tool for the smooth running of the healthcare delivery of the nation.

(h) Appointment of people with poor leadership skills as heads of healthcare facilities— effective leadership is a vital component of healthcare systems and has an extensive range of functions in improving organizational effectiveness and efficiency. People in the helms of affairs in different units of the healthcare system should acquire excellent leadership skills in other to manage personnel and non-human resources under their care for optimum healthcare delivery. Studies have shown that most of the problems of healthcare systems are due to leadership and communication problems14.
Poor leadership could increase cost of health services, reduce efficiency and effectiveness, and cause dissatisfaction among staff, ultimately resulting in lower patient satisfaction and societal health level. On the other hand, good leadership skills among the heads of a health institution fosters an organizational structure that is committed to quality health delivery, reducing conflicts, improving efficiency and productivity of teams, enhancing staff’s satisfaction, advancing hospital performance, and finally, meeting personal and organizational goals15.

5. Solving the problems of healthcare sector through tupocracy/tupocratic leadership
Tupocratic leadership is the best form of leadership that should be able to meet the increasing demands of our healthcare systems. Because the leaders take responsibility of the outcomes of their leadership in tupocratic form of governance, they would strive at all times to put in their best and eschew corruption and other practices capable of jeopardizing their leadership. Tupocracy will ensure cordial relationship between the heads of the healthcare systems and their staff. Research has shown that when personnel in any establishment are sufficiently motivated, there is often a maximum output delivery in such an establishment.

When tupocracy is adopted, cases of fake and non-functional hospital equipments are controlled because the leaders know that they also depend on the available healthcare system for their healthcare needs. As such, they would not engage in practices capable of putting their health and that of the common man in danger. They would always procure standard drugs and equipments for the healthcare systems. Tupocratic leadership when adopted will minimize cases of fund embezzlement, corruption and misappropriation of funds in the healthcare systems. The leaders being stakeholders in the system will always make sure that funds are generated and properly managed for the best interest of the healthcare delivery system.

Incessant industrial actions by the healthcare workers in our country and beyond have been blamed partly on the adoption of poor leadership model. In an efficient leadership model like tupocracy, the leaders place the welfare needs of the health workers very high and in return, the workers put in their best in their services. When the welfare of the workers are taken care of, industrial actions are prevented leading to improved patient satisfaction and general output. There is no gainsaying the fact that tupocratic leadership is the type of leader urgently needed in our country Nigeria, which is experiencing collapse in virtually every facet including the healthcare system.




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