When Healthcare Is Not Healthy

Imagine being chased by a pissed-off grizzly bear and you run into a small cabin and shut the doors. You see a cute polar bear chilling in the cabin, and you feel all is well, but as exhaustion sends you sleeping, the polar bear pounces on you and tears you apart with the agility of a hunter; nothing else seeming amiss except for your warm blood splattered across its cute face. Now, that’s a really horrible nightmare to preface this article.

As at the time of writing this article, there are two Twitter hashtags (#justiceforpeju, #justiceforomolara) that capture an aspect of the dysfunction in the Nigerian Healthcare System. While Peju sought medical care for a fibroid condition, Lara went in for ulcer; both ordinarily not life-threatening conditions, yet instead of the succour they hoped for, their lives were taken away. Before these two ladies caught the public’s attention, there have been several reported cases of medical negligence, including surgeries where foreign items were “forgotten” in a patient’s body; but as is common in Nigeria, people are killed, buried, and life goes on.

This issue of medical negligence struck a nerve because I almost lost my wife last year in a federal tertiary health institution during childbirth. At the end of the day, everything ended well, and we went home with our baby, thanking God, but I look back and wonder what would have happened if she had died. It is more likely that nothing would have happened. The doctors and nurses would have just moved on without any lessons learned, nor any person sanctioned. But then, I recognise that the issues are systemic and not just about the health workers.

For a start, whereas Section 13 of the National Health Act 2014 mandates that no entity is allowed to establish or operate a health facility without possession of a “Certificate of Standards”, there is still no national-level mechanism (in 2021!) for regulating health facilities. Only Lagos State has an agency, Health Facility Monitoring and Accreditation Agency (HEFAMAA), which is responsible for screening health facilities. While we may question HEFAMAA’s effectiveness in Lagos, it is incredulous that no other State Government has so far seen a need to regulate hospitals. Maybe it is because the “big men” can fly themselves and their families for treatment outside Nigeria, sometimes at the public’s expense, even though this is in violation of Section 46 of the NHA 2014.

Since there is no real regulation, most hospitals in Nigeria, whether in the public or private sector, are poorly equipped. Many issues with misdiagnosis could be attributed to “guesswork” due to unavailability of the right equipment, or faulty output from archaic equipment, or the use of substandard reagents for laboratory tests. These are issues that would have been reduced to an extent if the right regulatory environment were in place.

Secondly, contrary to what a famous doctor once claimed, Nigeria has a meagre number of doctors and nurses to serve Africa’s most populous country. With a population of around 200 million people, Nigeria has about 1 doctor and 5 nurses/midwives for every 3,000 persons (2019 WHO Data). Comparing Nigeria with the developed world could make one cry, so let us compare ourselves with China. For its 1.4 billion people, it has about 6 doctors and 7 nurses/midwives for every 3,000 persons. To worsen matters, all the medical schools in Nigeria, combined, can barely produce 4,000 doctors annually, which means we are a long way from having enough doctors. The implication of having few health workers is that those available are overworked, stressed out; therefore, prone to making mistakes.

As if this were not enough, health workers (like most Nigerians) are underpaid. Hence, we have many doctors working in more than one hospital to make ends meet, and maybe save enough to write the required exams to earn a better living abroad. As Jesus alludes in the Bible, one cannot truly serve two masters with full devotion to both. A doctor who is looking forward to a second shift in another hospital may have issues with concentration when attending to patients. While it is true that even abroad, we have some doctors working in more than one hospital, the conditions of service are definitely not the same!

There is also the issue of a culture that refutes continuous improvement. If cases of medical negligence in the past were taken a bit more seriously and properly investigated, we might have learned a thing or two to improve hospital processes. We have a society where autopsies are seen as strange, or as a pathway to witch-hunting health workers. My dad recently died in a state-owned tertiary health institution, and when we enquired about an autopsy to be sure of the cause of death, the response was that we would have to “write through your lawyer”. I wondered why we needed to go through the legalese route when the hospital itself ought to be interested in ascertaining that a person truly died as a result of what the doctor assumes, and if not, improve its operations to prevent a similar death.

Where do we go from here? We need a lot of money to overhaul healthcare delivery in Nigeria. In 2019, I was involved in a consulting project that evaluated the Nigerian Health System and developed policy options for the Federal Government, and it was alarming to see how much was required to change things. Sadly, Nigeria does not currently have the money required to provide sufficient state-of-the-art healthcare facilities and pay health workers enough to keep them in Nigeria, but there are some low-hanging fruits that ought to have been plucked aeons ago. Things as affordable as setting up a system for certifying health facilities, investigating deaths and near misses, addressing the bureaucratic roadblocks that make public hospitals unattractive to many health workers, and requiring health facilities to have Standard Operating Procedures that are enforced and routinely reviewed, will go a long way to improve healthcare delivery. That is, until we have enough money to get the air force to bomb our public hospitals and construct modern facilities that would heal the sick, not kill the sick.

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