‘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
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
Cross River State, Nigeria
Phone No. +234 (0) 8063600642
Joseph Ana has a cumulative continuous practice experience of over 40-years in
Nigeria, United Kingdom and Ghana as a Primary Health Care Physician, Public
Health Expert, General and Urological Surgeon, Health Policy Expert and
Implementer, Medical Educator and Trainer..
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