In the past month or so, several articles have appeared in the Nigerian press criticizing some aspect or other of the practice of Nigerian doctors. It started (I think) with Bolaji Abdullahi’s “Thank God I Am Not a Doctor” in THISDAY, which unleashed a flood of responses. More recently, Rotimi Oyekanmi in a passionate article decried the perceived role of doctors in the care and subsequent demise of his friend and colleague. Even more touching is the letter from a Mr Sule in The Guardian recently, outlining the circumstances of his wife and baby’s deaths in a hospital in Kaduna.
Reading these articles as I sympathized with the families of the bereaved, I was also conscious of the fact that often, bereaved families feel not enough has been done to save their relation. This is a natural human response and most health workers learn in the course of their careers to accept this with equanimity. I am also conscious of the fact of the very difficult circumstances under which doctors and other health workers in Nigeria work. I am pleased that these articles are being written and that hopefully a debate is being opened which for a long time has been avoided or ignored. There is a need for the Nigerian populace to ask certain pertinent questions – What type of health service do we want? How do we intend to achieve it? Nigerian doctors need to ask – What is our role in the context of the wider population? What do we intend to achieve? What is our motivation? What is behind the recent media onslaught? What can we do to restore our image and credibility? How can we best serve our patients? How can we act more effectively as advocates for the health services? The media have a key role to play in raising awareness of these issues and also must re examine their own roles in this context.
Oyekanmi in his article for instance refers to the fact that many beds in the hospital ward lacked bed sheets and that there were only a few nurses to take care of a large ward and no doctor available on the ward. This merely underlines the paucity of resources that is the lot of the Nigerian health sector today. While I accept that mismanagement of resources is also a common phenomenon I would argue that within the context of Nigeria, that is hardly surprising. I would further argue that accepting that corruption and mismanagement runs through all sectors of Nigerian society, the resources allocated to health fall short of what is needed to produce desired results. The continued brain drain of health professionals to other countries is part of the problem .Too often attempts at analyzing the brain drain have focused solely on remuneration.
Having worked in various health services in Nigeria, I am familiar with some of the problems that result in the sorts of complaints in these articles. In the first instance strengthening primary care and prevention efforts is key as this will actually reduce the demand on secondary and tertiary care. I am aware that several primary health care centers were planned by the present government, but am unsure if they were completed to schedule and if they are producing the desired impact.
Secondly, improving the working conditions of health workers is important and by this I do not mean the ubiquitous salary increases alone. Paying doctors and nurses a million naira a month without providing them the infrastructure they need to work effectively will yield no results. That is not to say that adequate remuneration is not an important factor in motivating health workers. Nor has the present or indeed previous governments done enough strategic planning in this area. In this regard, I had firsthand experience of the attitude of some key government officials during the 2001 resident doctors’ strike. There were proposals from the NMA and the NARD to put in place a mechanism that would have guaranteed regular, seamless review and adjustments of doctors’ salaries and allowances and foreclosed the issue of strikes in the health sector but these were rejected in the most cavalier way. Little wonder two years later, there is still talk of strikes in the health sector.
The other role that needs to be strengthened is the role of the wider public. Patients have a right to care and must demand this right. The media and organizations like the Centre for the Right to Health have key roles in sensitizing the public to this. Such a movement can result in positive changes for the health system as a whole. Lawyers as well have a role to play in this, in ensuring that patients who suffer from a doctor’s negligence gain redress. In doing this, traditional perceptions of justice and letting sleeping dogs lie may need to be challenged. Medicine like any other profession has its bad eggs and it augurs well for society to admit to this and have channels of redress open for victims. But it is not only in fighting negligence and demanding care that the wider public and the media have a role to play. They also need to demand of the government adequate funding for health services. The importance of electing public officials with a clearly defined health agenda is key in this regard. Indeed to paraphrase a well-worn cliché, a society gets the health services it deserves, or as the Pidgin saying goes “Good soup na money kill am”. The quality of health reporting in Nigerian newspapers for instance leaves a lot to be desired. One would expect that a reporter on the health beat should have an adequate grasp of the issues and terminology of medicine and health. However, one daily sees examples of misspelled words, wrong conclusions drawn, faulty statistics proffered and a general desire for sensationalism in the Nigerian health press. Can an inarticulate and uninformed press is an effective watchdog for the medical profession and the public? Organizations like Journalists Against AIDS have blazed the trail in organizing media workshops and training materials on HIV/AIDS but a lot more needs to be done in a wider health context.
Nigerian medical doctors must also be more introspective and seek new ways of dealing with the challenges they face in a changing world. A growing number of articulate patients, a widening of information sources and changes in the traditional perception of doctors and the medical profession all mean that new ways of working must be explored. In this regard, it is heartening to note the Medical and Dental Council’s introduction of Continuing Medical Education where doctors will statutorily be required to undergo revalidation from time to time to ensure the quality of their practice.
Yet more needs to be done. The current system of postgraduate medical education needs to be re-examined. A system that regularly records 20 per cent pass or less must have something fundamentally wrong with it. Either the wrong people are being admitted into the programme (unlikely- as these are very competitive schemes) or the training prepares them inadequately for the examinations, in which case, the structure and content of training needs to be overhauled. In like manner, clinical governance and audit are concepts that need to be introduced more widely into the Nigerian health care delivery system. This, in simple terms involve looking at the quality of a doctor’s work, not necessarily in a judgmental manner but in order to help them improve the quality of their service. So a doctor in effect could ask himself – How many patients have I treated in the last six months? What was the outcome of the treatment? Do my standards compare with those of my other colleagues in the same environment? How can I make my service better? This will go a long way in improving the quality of service. Of course, there are constraints. The average Nigerian doctor and indeed health worker is overworked and introducing audit may appear to increase the workload. However, in the long run, this is a concept that is likely to prove beneficial to doctors, the government and the wider public.
Nigerian medical doctors and health workers also need to rethink the concept of their traditional roles and determine effective working systems and patterns that put patients and their interests at the heart of the system. The continual squabbling over assignation of roles has not been to the benefit of patients. Mutual respect and recognition of complementarity is essential to building better and more effective working partnerships.
There is also a need for better regulation of the private medical sector. A friend recently carrying out a research project in private hospitals in a South Eastern state was shocked to discover that the state Ministry of Health could not furnish him with an up-to-date list of private clinics in the area. How then can standards be checked and maintained? The Guild of Medical Directors and the Nigerian Medical Association have an important role to play in this regard as self-policing agents. The message is if you do not police yourself adequately, others will do it for you, to your detriment. The unchecked proliferation of private hospitals may ultimately be doing more harm than good to the population. A situation where virtually anyone can open a “specialist hospital” is fraught with dangers.
In the final analysis, the ailments of Nigeria’s health system are by and large reflections of the ailments of the wider polity. The bottom line in all this is a reconfiguration of leadership, followership and the wider Nigerian society. Yet within this disordered setting, certain challenges present themselves, which can be turned into opportunities.
In writing this article, I am conscious that not a few feathers will be ruffled. I expect that eyebrows will be raised at me, a Nigerian doctor working abroad daring to prescribe solutions for the health system I have abandoned. To such critics I say that it is precisely because of that distance that I can dare to write this article and explore new and possibly subversive concepts in the search for positive change. I hope that it contributes to the debate and furthermore opens up concrete channels of improving the health of Nigeria’s teeming population.