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Wednesday, 14 June 2017


‘WHOLE SYSTEM CHANGE OF FAILING HEALTH SYSTEMS: ’A Toolbox Based On Experience of a Successful 4-year Pilot of Clinical Governance, Quality and Safety in cross
River State, Nigeria 2004-2008’

From our centre,  we ask, is it ethical for public hospital/clinic owners and managers to issue circulars that compels/directs medical doctors and other health workers not to attend to emergency patients unless they deposit money, even when some of these patients bleed to death in the hospital emergency centre, not on the open roadside, or even pregnant women in labour or children critically ill and convulsing? In many other countries it will be adjudged to amount to corporate / management negligence and manslaughter, at least!.

Such circulars/directives made to ‘increase IGR’ is pitching patients and their families against health workers/professionals on duty. Patients are now taking it out on defenceless health workers – humiliating, abusing, beating up and injuring health workers. Surely something can be done and urgently before any someone is killed!
How can it be that medical doctors and other health workers now receive beatings and injury from their patients and families – a tragic breakdown of the practitioner- patients relationship which for centuries of medical care has remained the anchor, the raison de tre of the care we deliver to the sick on oath? We are reminded every day, ‘------- at least 'Do No Harm”.

How come we read almost on daily basis in Nigeria in 2017 that health workers on duty in accident / emergency departments in hospitals and clinics across our country sit and watch patients bleed to death whilst waiting for their relations to ‘pay deposit’ before they attend to the dying patient? The patient dies, their relatives turn up with borrowed money and so what? The dead cannot be brought back!

Why should the Health Planners , Policy makers, Hospital and Clinic Managers make these rules / give these directives that make our colleagues appear inhumane contrary to our sworn ethics: which policy maker or hospital manager is making doctors and other health workers ignore basic professional ethos, duty of care,  and their ethical obligations to their patients, especially in dire emergency cases?

How is it that the medical doctors and health workers have become so cowed by high authority that they allow themselves to be intimated by the policy makers so that they ignore the basic obligation of Clinical Governance – “protecting patients and supporting the practitioners in tandem’’.  What have the Associations of the professions of medicine and health to say to their members on how to deal with the abhorrent situation?
No country has enough money to pay for all the medical and health needs of its citizens even the oil -soaked countries in the Middle East, but their leaders ensure that the basic needs of every human being is met including accessible , equal and fair health care.

The Western countries and The Global North countries that colonized our country may not be as endowed with natural resources as the Middle Eastern ones but since the second world war ended, they have built and established National Health Systems ‘free at the point of care’. These are the same countries that even grant our health system donor funding! These countries have also established in at least the last 70 years social safety nets for ALL their citizens so that everyone is guaranteed roof over their head, health care and basic education, security and pocket money to buy food. In these countries everyone has a named general practitioner and National Insurance Number.
How do they do it:  money is pooled from those who have work in public or private sector, from businesses and other taxes, and from the pool those who do not have work or are temporarily out of work, the sick and elderly are provided the obligations of the social safety net (social contract from Craddle to Grave). In the UK, Australia, Canada and all over Europe and Japan this is what applies.
The  USA, which Nigeria copies, is different and was the exemption to the social safety net rule ( to some extent)  but that was why Obamacare was created to try and catch up with the other Western countries.
Obamacare humanized the society, brought-in to the system over 20 million Americans who hitherto had no basic access to health care. Notice what happened as President Trump tries to change Obamacare, which he has failed so far. He is failing even though his Republican Party controls the three arms of government ( White House, Congress and Judiciary). The Republican Politicians told him to bring forward what is equal to or better than Obamacare. Yes, American politicians of the same Party as heir President defending the Health Rights of Americans even though they control both Houses of Congress!

Politicians, members of Nigeria’s National Assembly can emulate the actions of their counterparts in the USA and all over the Global North. And sanitise the National Health Insurance Scheme (NHIS) today if they care!
It is all about funding for Health. The Nigerian Medical Association (NMA) for ages but particularly from Dr Osahon Enabulele’s tenure as President fought for the National Health Insurance Scheme (NHIS) to be made to work.  The NHIS is in its 12 year of existence and its sixth Executive Secretary but covers only a miserly 3-5% of the population of 180 million. This is the main catastrophy that befalls funding of health in Nigeria. The NMA also recognized other potent sources to boost the NHIS, namely ‘Special Intervention Health Fund ( akin to TETFUND for Education) from taxation of the profit ( not gross income) of selected companies e.g. tobacco, alcohol manufacturers, oil & Gas and GSM companies. President Gooduck Jonathan promised the Association he would do it, but words did not become action!
 Rather, today, States in Nigeria that are struggling to pay basic salaries and pension are busy competing on which would announce establishment of State Health Insurance schemes  – experience tells us that it cannot work: 38 different (Federal, States & FCT), separate ill-thought out government health insurance schemes scattered across the one country cannot work especially when it is run by Government. Does anybody remember the states announcing ‘free maternal and under 5 child health schemes? How many are actually working today. And that is theoretically easier than covering the whole state.

 In 2005, first we banned collection of deposits from emergency cases before treatment in all state-owned hospitals and clinics under Governor Donald Duke. Then  we commissioned the actuarial studies to set up a Cross River State Insurance Scheme. We had just received the consultants reports and were mauling the costs when thankfully in April 2006, the NHIS under Professor  Eyitayo Lambo as Minister of Health and Dr Mohamed Lecky as Executive Secretary NHIS all the states were invited to the first year anniversary of the NHIS. That was a blessing because Cross River State promptly joined/ bought-into the NHIS and paid its dues which was only a fraction of what the actuarial study told us it would cost. Cross Riverians have the story of the benefits to tell other Nigerians. We also advised Former Governor Isa Yuguda of Bauchi State to join the NHIS in 2007.

It is a no-brainer that a bigger insurance scheme under-written by the Feral government of Nigeria in which 180 million people are pooling premiums must be infinitely better and more affordable and cost effective, run properly without the profit-driven middle man called HMOs, than a tiny motley collection of 37 different state health insurance schemes.  We were told by colleagues in the states that did not want to join the NHIS that it is the lack of confidence of the states in the Federal Government ( Nigeria Factor) that has led to this unworkable situation/model. But it is not too late at all to have a national re-think of the functioning of The NHIS to serve all Nigerians by the states. There cannot be more than three states who mabe can run independent schemes, but even for those three states have huge savings to make by join the NHIS and using their savings for other numerous developmental necessities!.

No country has achieved Universal Health Coverage without first establishing a functional National health insurance scheme that mandatorily involves all its citizens according to levels of contribution and exemptions!.

Therein lies the solution to the ignoble and unethical situation that is rampant in Nigeria’s hospital and clinics today when health workers on duty in an emergency unit in public hospitals sit idly and watch emergency patients bleed or labour to death. LUTH is only in the news because of its location but this tragic practice occurs all over our country. It is a National Shame and a blot on our country!

Who will stop it for the sake of the next patient and family!.

Joseph Ana

Africa Center for Clin Gov Research & Patient Safety
@ HRI West Africa Group - HRI WA
Consultants in Clinical Governance Implementation
Publisher: Health and Medical Journals 
8 Amaku Street Housing Estate, Calabar
Cross River State, Nigeria
Phone No. +234 (0) 8063600642

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