I read with interest the statement credited to the Lagos State Governor, Babatunde Fashola, whilst launching the Eredo Primary Healthcare Centre Constituency II in Epe division recently. Whilst the efforts of the State government in improving the delivery of healthcare in the state remains commendable, certain comments and spurious impression being created by those in authority need to be challenged.
The governor was quoted at this ceremony to have said: “Very soon, no doctor will attend to you at the General Hospital, except you have a referral from a primary healthcare centre. What you seek in the UK is now here with you. You do not need to travel long distances anymore.” While the first part of this statement remains contentious and shall be dealt with later, the latter part remains manifestly untrue and irksome. To say the least, it was deceitfully grandiose and completely opposite to the reality on the ground. Every Nigerian knows that our healthcare facilities, or systems for that matter, are so chaotically unorganised and completely unproductive. Most health facilities are horribly abandoned with patients and staff left to crude innovations on how to make the best use of such facilities. In a country where over 40% of its healthcare delivery is left in highly unorganised private hands, one wonders how such can equate to the very advanced and efficient system obtainable in most western countries including the United Kingdom.
Our healthcare system essential rests on a quartet of primary healthcare, secondary care, tertiary care and of course, the ubiquitous private healthcare. The core of this system is basically preventative, hence the primary healthcare system where preventative measures can be taken to forestall diseases. It was at the height of this romance with preventive healthcare that the late Professor Olikoye Ransome-Kuti as health minister started the mass training of Community Health Officers (CHOs) who were trained to handle basic ad preventable illnesses. These officers later acquired the pseudonym of Olikoye doctors and have contributed their quota to the progress or mess that is associated with our healthcare system.
Our healthcare system across the many states that constitutes present day Nigeria differs little, resting on the basic principle enumerated above. What has changed is probably the alarming levels of underfunding and massive corruption associated with the system. Our shambolic system sounds very operational, practicable and soundly efficient in theory. The reality, however, is a story of horror, inefficiency, tripling deaths from preventable illnesses and unmitigated disasters. Try as we may, we have simply failed to get it right.
The concept of Comprehensive Health Centres is not new. The notion of 24-hour staffing and operation as being implemented by Lagos State government is commendable. Nevertheless, I dare submit that this innovation (if it may be so called) cannot simply elevate a crumbling system to world standard. The system requires rather radical and innovative approaches to make it work efficiently. Whilst it may be said that Nigeria, being a dysfunctional federation with disparage political goals amply entrusted to malicious and incompetent leaders, the expectations of a functional federal solution to the present menace called healthcare system may be a mirage, yet it is still possible for states to individually and collective carry out emergency operations to abort the rapid decay of the parlous health system and eradicate its untoward effects on the citizenry. It is only then “you do not need to travel long distances anymore” to seek for better healthcare.
What is wrong with our healthcare system?
For a system where funding is abysmally low and government interest is barely existent, and where existent purely for political gains, functionality would be a mere dream. Nigerian governments, over the years, have voted barely single digits of our budgets to health contrary to international recommendations and the requirements of the World Health Organisation (WHO). Our achievement of the Millennium Goals in this regard is highly doubtful. Our Health Centres, which remain the nucleus of our healthcare system are nothing more than empty buildings where all sorts of anti-good health practices are encouraged. They are ill-equipped, if there was ever any equipment there at all. In reality, no government has ever taken them into reckoning in the scheme of things except perhaps the regime of Babatunde Fashola as we are just being informed. They are usually manned by nurses, who over the years, with the absence of continuous professional trainings and developmental courses, become so rusty that at a point, should ideally be stopped from using the prefix “Nurse”. It is that bad, believe me, and I have the experience of over 15 years practice in this shambolic system to say this categorically.
A Comprehensive Health Centre is a step above your ordinary health centre and makes the provision of primary health care a full package. Ideally, such a centre should have the full complement of health professionals including doctors, nurses, and pharmacists and so on. In fact, a Comprehensive Health Centre should be able to undertake some surgical procedures and also have some level of expert staffing. The idea is that the burden on general hospitals (which represent the second-tier of delivery) would be lessened. We should not forget that the focus of a health centre is basically preventive, no matter its degree of expertise or professional staffing. Preventive illnesses should be vigorously tackled at this level and the results should be obvious for all to see. Comprehensive Health Centres cannot and should not be made to replace the functions of General Practitioners (GPs) which forms the thrust of the referral system in the United Kingdom, a system that Governor Fashola robustly referred to. It is not a crime to aim for a world standard provision of healthcare, but this should be based on a structural sound and viable foundation. There can be no shortcut about it.
The story of the General Hospitals and the Teaching Hospitals are in public domains and there is no point wasting space here talking about their legendary abandonment, underfunding, dearth of continuous professional development for staff, shortage of 21st century equipment and so on. In fact, it appears as if talking about any improvement at these levels (and even at the primary healthcare level) is forlorn for as long as we continue to battle with epileptic power supply, lack of clean and sufficient water supply, etc. The main thrust of this write-up, especially in relation to the statements credited to Governor Fashola, is simply that opening of Comprehensive Health Centres alone cannot be the panacea to the years of neglect of our health systems. Comprehensive Health Centres, where truly functional, would ease the burden on General Hospitals but this should not be enforced. These centres are scarce and insufficient. For an ideal model, which is my conviction Governor Fashola truly desires, attention should be urgently given to the powerful fourth force, the private providers.
Apart from perfunctory attention by government centred on registration of private health facilities and the occasional special attention brought about by influx of fake practitioners and charlatans, Nigerian governments have over the years left a powerful force in the overall success of its healthcare delivery largely uncontrolled, unsupervised and unregulated. Our private healthcare system has become a veritable and deep jungle where every Dick and Harry, whether qualified or unqualified can operate. There are masses of private clinics and hospitals littering our landscape, most barely able to fit the description of a health dispensary not to talk of hospitals or clinics.
Government registration of those who even deemed it for to apply for registration is filled with massive corruption. I am repeating this boldly as I have been there before. There are demands for bribes before private facilities are registered and each inspection exercise is a mere exercise in futility as the original registration had been completed the moment money had changed hands. This is usually before the inspecting team left their base. It is best left to imagination the product of such a corrupt-ridden system.
The resultant effect is that unwary citizens are left at the mercies of unscrupulous practitioners who are only intent at making money and not in the least absorbed with service provision. The few genuine practitioners amongst this lot have their job made more difficult as they have to compete with charlatans in the midst of a largely illiterate populace who cannot actively separate the whiff from the shaft. The other spectrum is the influx of newly qualified and largely inexperienced medical graduates into the private health sector. This development is perhaps explained by the alarming lack of appropriate jobs for this cadre of the medical workforce. Alarming in the sense that medicine as a profession, for those who chose to stick with it, is a lifelong commitment of studying and development. Experience based on exposure, guidance, career development and so on, are the hallmarks of a good medical practitioner. However, what is obtainable in Nigeria is the influx of frustrated and often times, ambitious medical graduates into the money mill of private practice. Thus, the country is awashed with loads of mushroom private clinics and hospitals where the doctors have over the years been reduced to healers of only malaria fever and typhoid diseases. Challenge them with something radically different only at the greatest risk to your life and wellbeing.
Private healthcare delivery system in Nigeria is extremely dangerous with only a few exceptions. Those exceptions can only be accessed by the novo rich sadly. Majority of the citizens are saddled with the hugely available and widespread mediocrity. The picture is often of a 3-bedroom flat serving as the base from which professional deterioration and malpractices are manifested. There are various associations for private healthcare providers in Nigeria but none has focussed on improving the quality of facilities and that of practitioners. A situation where I graduated from medical school, completed my internship and national service and only to become a medical director is dangerous and unacceptable. A situation where my next step is to rent a flat, buy a made-in-India foot propelled suction machine, rickety steriliser and sphygmomanometer should not be a license for me to disseminate rubbish to the populace. I become so entrenched with survival and coupled with my alarming degree of inexperience, become so rotting that in a few years’ time, I had simply forgotten the pathogenesis of malaria fever or even the remotest causes and indications of ischaemic heart diseases. How many Nigerian doctors in private practice can successfully carry out basic cardiopulmonary resuscitation, not to talk of advanced resuscitation using a defibrillator? I need to make this clear, how many Nigerian doctors (including those in tertiary practice) can confidently manage a myocardial infarction popularly known as heart attack? Indeed, do we have the resources and manpower to effectively manage cardiovascular diseases in Nigeria? This is the sad state of our healthcare system. And this is the system on which Governor Fashola and others are predicating an efficient and functional healthcare delivery system. There is, indeed, cause for alarm.
It would be foolhardy to lay the whole blame for the rot in the system at the doorstep of Nigerian doctors. In a system where the government has been lackadaisical about the management of health resources and provision of healthcare, no doctor should be blamed. The simple fact is that the onus rests on the Nigerian state to harness its resources and manage same efficiently. The truth is that Nigerian doctors are part and parcel of the health resources available to the Nigerian state. Better managed, Nigerian doctors have demonstrated in other climes and places that they can be efficient, resourceful and productive. It is sad that it takes others to demonstrate the value of our own. The government has a constitutional and moral role in reforming the chaotic and disgraceful private healthcare system in the country. For crying out loud, this is not just a system that caters for few. It represents, once again, about 40% of healthcare provision. Examples abound worldwide as to how this level of healthcare can be reformed. Not only this, the government should focus stringently in reforming post-graduate policy for practicing doctors in Nigeria. For example, there should be certain level of professional accomplishment and attainment before sole ownership of private practices can be allowed. The whole concept of General Practice vis-a-vis private ownership calls for reformation. There is thus an urgent need for government involvement in private practice. The situation that presently obtains in the United Kingdom may be a model to copy, reform and develop. It needs stating here that the suggested reformation and complete overhauling of our healthcare system would be more pragmatically tackled at the federal level but can equally be initiated at state levels where the federal government, with its legendary non-performance, is found wanton. There is simply no excuse for lack of action.
Back to Governor Fashola. Whilst your effort at reforming and establishing Comprehensive Health Centres (CHC) is commendable, the truth is that such an effort is only scratching the surface in the urgent need for the provision of adequate healthcare system in Lagos State. Lagos, by its enviable position in the federation, amply magnifies the intractable problems with our healthcare system and this the government is aware of. Using health centres as the referral basis for specialist attention or treatment at General Hospitals is not workable and fraught with dangers. Even in the United Kingdom, accidents and emergency units (A&Es) make specialist referrals. In fact, some hospital units provide GPs at A&E units to attend to more routine cases and make appropriate referrals. The targeted aim of providing 57 CHC is indeed a milestone but can only succeed with attention to other salient issues highlighted earlier. Still the figure is grossly insufficient bto meet the needs of our teeming population in Lagos to make them the sole sources of referrals to general hospitals for specialist attention. Also, the referral system cannot be hinged only on these CHC while neglecting the private providers, who are often the GPs in our system .Experience in other places has shown that an effective referral system actively hinges on GPs and hence the need for government involvement in their operation and practices.
The GP referral system forms the bedrock of any successful healthcare system. GPs are found in CPC, General Hospitals and even Teaching Hospitals. They are also more abundant amongst private providers, hence the need to take a second look at this category of providers. There is an urgent need to prune the number of such providers. A pruning process that would encourage amalgamation to institute quality and harness resources. There is a need for a more organized government involvement at this level of healthcare provision such that it would constitute almost a sort of bulk provision of desired healthcare with government regularisation aimed at ensuring quality and efficiency. This is probably the only way to encourage genuine and qualified providers and weed out charlatans. This is also the way to structure the process such that practitioners would be enforced to develop themselves and be made more useful to the society. There are indeed exciting potentials in the possibilities of the reformation possible with the additional benefits of job creation and job satisfaction. I do hope that someone somewhere relevant is listening.
Dr Olusegun Fakoya