How To Resuscitate A Failing Health System: The 12-Pillar Clinical Governance Programme

The 12-Pillar Clinical Governance Programme is promoted by HRI Global for the whole health sector and system transformation.

HRI Global has maintained its founding mission and vision since it was first launched as the Nigerian Medical Forum UK and Ireland (The NMF) in London in 1991, to support efforts to strengthen the health sector and system of Nigeria. Since 1991, when the organization collected donations of medical journals, periodicals, and books and freighted the items to medical libraries across Nigeria, and then launched the BMJ Nigeria local edition and BMJ West Africa local edition, it has conducted workshops for doctors and other health practitioners in Nigeria and Ghana, on how to write, read and publish research.  In 2002, it launched the first Health Information Resource Centre (HIRC) in Calabar, Nigeria.

As consultants to the Cross River State Government, it worked with the State Ministry of Health to prepare the first State Health Plan and carried out the most comprehensive situation analysis (SA) of the State health sector and system, ever. The SA showed why decades of efforts to achieve quality health care delivery continued to fail, in the state and Nigeria generally. 

The state of the health sector of the three million population people of Cross River state was shocking and these were the challenges:

  • • No strategic health vision, mission, and plan backed by law, anchored on a health in all policies policy (HiAPP)
  • • No formalized funding-mix.
  • • Child mortality was 20% and maternal mortality was 1%.
  • • Childhood immunisation rates were under 20%.
  • • There were only 72 doctors (clinical and non-clinical duties) for the 3.1 million population.
  • • Corruption was common/ extorting patients.
  • • Power cuts are ubiquitous/ unreliable.
  • • Potable water is scarce/ lacking.
  • • Waste and sanitation management is appalling.
  • • Bad attitude of health workers to patients was rampant
  • • Lack of consideration of the socio-economic determinants of health.
  • • Out of stock drugs was the standard.
  • • And everything was a struggle.

On the recommendation of HRI Global (then known as HRI West Africa), the State Ministry of Health produced and piloted the 12-Pillar Clinical Governance Programme (12-PCGP), as the home-grown solution to the gaps highlighted by the SA(Situation Analysis), and for transforming the whole health sector and system in Cross River State.


The following expected and desired positive results were achieved within three years of the integration of the 12-Pillar Clinical Governance Programme:

  • • Increase in the number of health workers especially doctors and other skilled professionals, including attracting able retirees to come back to service.
  • • Training the workforce on the right attitude to patients, updating knowledge and skills regulary.
  • • Adoption of making evidence-informed health policy backed by Law, anchored on a health in all policies policy (HiAPP).
  • • Implementation of a sustainable funding-mix, including a mandatory health insurance scheme.
  • • Renovation of the physical infrastructure.
  • • Installation of appropriate equipment; installation of 24/7 potable water and electricity; ensuring security and clean hospital environment.
  • • Creation of a 24/7 Emergency Ambulance and paramedic service, including giving access to Traditional Birth Attendants and Civil Society Organisations.
  • • Creation of a new Department of Clinical Governance, servicom and e-Health, with line budget in the Ministry of Health, for future  sustainability;
  • • Adoption of a multi-sectoral Integration of all Programmes, thereby abolishing parallel or ‘stand-alone’ projects favoured by donor partners.
  • • Establishment of Minimal Access Treatment at the state owned General Hospital, Calabar, with full Endoscopic procedures in 2006.
  • • Adequate Welfare for staff including a ’rewards for good performance’ scheme, and ‘Putting Patients First, Always’ and sanctions for repeated bad practice/behaviour).
  • • Targeted Public Private Partnership (e.g. ‘drug revolving fund’, catering, sanitation, mortuary); enhanced Security initiative: for patients, staff equipment and buildings ( for the whole facility, men and machines).
  • • An evidence-driven, empathy-driven administration of the Health sector and system; and significantly, increased the combined domestic and partner funds for health (from about N438 Million annual budget in 2003/4 to about N5.8 Billion for the 2007/8 budget for CRSMOH).
  • • Increased patient attendance, patient satisfaction and adherence and compliance to medical advise and treatment.
  • • Increased Ante Natal Care attendance and childbirth by skilled health workers in formal primary health care workers and hospitals.
  • • Achieved Public Health Legislations e.g. compulsory seatbelts in cars and helmets by motorcyclist Law which led to reduced mortality from Road Traffic Accidents.
  • • Increased Routine Immunisation Coverage from less than 20% to 84% over three years; eliminated wild polio virus over three years, and reduced HIV seroprevalence rate from 12% to 6.1% in three years.

These results have been replicated during scale-up in other States and in Private hospitals, including winning national and international awards for excellence; quality accreditation and recognition for hospitals, primary health care teams, and the ministry headquarters. 

The 12-Pillar Clinical Governance programme continues to deliver the whole health sector and system transformation wherever it is implemented in Nigeria, and we believe it should do the same in similar Lower and Middle-Income Countries (LMIC). 

The programmes holistic approach also has transferable messages for the high income countries of Europe and America, because it enables the achievement of the universal health mission of ‘Protecting patients, supporting practitioners in tandem’. It is operated on the basis that  ‘no matter how beautiful the hospital buildings, or how sophisticated the equipment, the critical factor to ensure prevention and reduction of morbidity and mortality in health care delivery is the knowledge, skills and attitude to patients by health workers’ (1), and that quality care is neither a given nor an accident, it requires a contextual intervention like the 12-Pillar Clinical Governance programme to deliver it.

If you are interested in finding out more or how HRI Global can support you in implementing the 12-Pillar Clinical Governance Programme, email

For more information on HRI Global visit:

Joseph Ana

Joseph Ana was the Honorable Commissioner for Health, Cross River State, Nigeria 2004-8, and led the introduction of clinical governance to Nigeria. He is Secretary General/Trustee of the NMF and was Managing Editor of BMJ West Africa from 1995-2018. He is the Lead Senior Fellow, at the Centre for Clinical Governance Research and Patient Safety @ HRI Global.


1 Ana, JNE. ’Whole system change of failing health systems’ (experience of the 4-year pilot of Clinical Governance, Quality & Safety in Cross River State, Nigeria. 2009. ISBN: 978-978-49487-0-8. pp185



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