‘Nigeria Operating 19th Century Health System’
konknaijagirl | On 09, Mar 2013
Mustapha Danesi, Professor of Neurology, College of Medicine, University of Lagos, spoke on the Nigerian health system and its weaknesses.
The high contribution Nigeria is making to medical tourism in India a developing country like Nigeria – speaks eloquently of the decadence in the healthcare policy, governance and practice in Nigeria. What factors are driving Nigeria’s contribution to global medical tourism at the expense of developing local capacity and knowhow to deliver quality and even affordable healthcare to the teeming Nigerian population?
I would class Nigerian healthcare policy, governance and practice as under-developed rather than decadent. Nigeria’s healthcare policy since 1960 has remained static apart from introduction of Primary Healthcare policy in the 1980s and the Nigerian National Health Insurance policy in 2005. Implementations of both policies have been abysmally poor, and so they have not made any impact.
Nigeria’s health governance since independence remains the same. Government provides “free” or subsidized healthcare in competition with private providers who “charge money” for healthcare. There is no ‘Integrated Healthcare System’ that is all embracing, where government and private providers work in synergy, as is done in many developed and developing countries. Therefore, in Nigeria, over 90% of common folks go to government hospitals for “free or highly subsidized medical care”. However, statistics show that not more than 10% of doctors practicing in Nigeria are employed by government health institutions. Access to the government “free healthcare” is therefore unacceptably cumbersome. Patients may line up in a government hospital from 9.00 am to 4.00 pm before they can see a doctor for diagnosis and treatment. This is because there are many patients and very few doctors: there may be over 120 patients and only 2 or 3 doctors available to see them. In contrast, doctors working at the surrounding private hospitals may be quite idle with very few patients to see.
On our healthcare practice, Nigeria is still in stage one healthcare development with practice characteristics of the 19th or 20th century health system. Stage one healthcare development is characterized by highly fragmented delivery system with physicians, hospitals and other healthcare organizations functioning autonomously. Patients rely on physician training and experience for guidance and physicians rely on their own experience to make best decisions. Patient’s role is passive and they have no control over treatment decisions. Information technology and tools are entirely absent.
Medical practice in many developed and developing countries is now in stage 4 healthcare development which is the health system of the 21st century. In stage 4 healthcare practice, healthcare organizations have the characteristics of high performing organizations and focus on the six aims for improvement: safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. Patients have as much control as they want over treatment decisions and services are coordinated across practices, with generous use of information systems. A lot of hard work will need to be done to move our health care system to stage 4. It will require training and retraining of our medical practitioners, our nurses and other health workers, healthcare administrators and educating the populace. According to criteria of the Institute of Medicine in U.S.A. for Characterising 21st century stage 4 healthcare practice, healthcare should be:
Safe: avoiding injuries to patients from the care that is intended to help them.
Effective: providing services based on scientific knowledge to all who can benefit.
Patient-centred: providing care that is respectful of and responsive to individual preferences, needs, and values.
Timely: reducing waits and undue delays.
Efficient: avoiding waste of supplies, ideas, energy.
Equitable: providing health service that does not vary in quality because of personal characteristics, gender, ethnicity or socioeconomic status.
Our healthcare system should be geared towards meeting the above criteria.
What are the factors driving Nigeria’s contribution to medical tourism in India?
The first factor is patients’ choice. Rightly or wrongly, going to India has become a fad among Nigerians who can afford it. Even those who cannot afford it beg for money. This is the nature of health-seeking behaviour of Nigerians today. All over the world, health-seeking behaviour has not always been rational or based on doctors’ advice. Booter and Bachuk in U.S.A. reported in 1972 that in United States of America, more patients tended to consult lay persons in kin and friendship network than to consult medical persons when about to decide how to seek medical help and that the lay person tended to provide advice based on their specific knowledge or bias. In our studies and that of Igun in Nigeria, most persons sought the type of treatments they need for their illness usually on advice of friends or neighbours. Social network therefore has a powerful influence on health-seeking behaviour and this is what is partly driving the India fad. Many Nigerians believe that India is the place to go for specialist treatment and usually advise their friends or neighbours to do so.
The second is doctors’ factors. Many doctors in Nigeria need re-training to upgrade their practice from stage 1 to the current 21st century stage 4 healthcare system. Many doctors should be taught to know when to refer patients to other experts and where the experts are in Nigeria; some doctors refer directly to India instead of Nigerian experts partly because they do not know them and partly because they are given generous incentives to do so by way of commissions from the Indian hospitals.
On the one hand, there are probably more Nigerian doctors practicing abroad than those working in the country, and we have issues around inadequate knowledge and skill by practicing Nigerian doctors in the country. But on the other hand we have an expert like yourself who is among the world’s best in your specialty. What perspectives do patients need to have regarding this seemingly contradictory state of medical practice in the country with regard to outflow of medical tourists?
It is true that more Nigerian doctors are practicing abroad than those working in Nigeria. If all these Nigerians were to be working in the country, many people from other countries in Africa would have been coming to Nigeria on medical tourism. Many of these Nigerian doctors abroad have world-class knowledge and skills.
The question one will ask is: why so many highly skilled Nigeria experts abroad?
The answer is obvious: practice of medicine is not rewarding in Nigeria. Most doctors employed in Government services are poorly paid. For example, a young consultant, after six years of undergraduate training, 2 years of house job and Youth Corp Service, and six years of post graduate residency training (a total of 14 years), earns less than N300,000.00 (three hundred thousand naira) per month in a government hospital or even less in a private hospital, while his school mate who did other course would have graduated several years back and would be earning, sometimes, well over N1 million naira as a senior manager in a company. On the other hand, Saudi Arabia for instance can employ such a young consultant on a starting salary of sometimes, over N1.5 million per month. In such cases the doctor simply emigrates. Medicine in Nigeria has not yet been developed as a viable business, so there are very few opportunities in private hospitals for young specialists. Despite the above, some of us who had opportunities to practice abroad, left our lucrative jobs and decided to come home as a sacrifice in the interest of the country. Although not many, there are such Nigerians who are world-class medical experts, practicing in the country.
Nigerian patients should know this fact and should seek out these experts. The Nigerian public has the perception that Indian hospitals are more equipped and have more experts. The key to quality medical care is the availability of highly knowledgeable health practitioners and not necessarily sophisticated equipment. It is the availability of the experts that determines success in treatment of complex illness. Where such experts are available in Nigeria, patients do not need to go to India.
Some might think equipment shortage is a big problem here. But in a wider context, are we having enough public and private investments in the Nigerian health sector?
Equipment shortage is not the problem in Nigeria. The weakest link in our medical system is availability of highly skilled experts. Nigerian government should therefore invest in training highly skilled medical experts, and then give the experts the equipment they need and pay them well. At present, Nigerian governments and Nigerian political elites have no respect for skilled Nigerian professionals and little interest in training highly skilled medical experts for Nigerian health system. They undervalue highly educated professionals hence many of them are outside Nigeria. Private providers would have been an alternative but healthcare business in Nigeria is at present not viable in general. We cannot have adequate private investment in Nigerian healthcare until healthcare becomes a viable business. This may happen when we have a viable health insurance system and integrated health care systems where private and government health systems work in synergy. At present, only 3.5% of Nigerians are covered by health insurance.
When doctors employed in government hospitals go on strike, we get the impression of the dominance of the role of government in providing healthcare in the country. In that sense, maybe government should get the blame for the state of healthcare provisioning in the country. But what are Nigerian doctors and their professional bodies doing to lift their profession?
The various Governments (Federal, State and Local) play a dominant role in healthcare provision in Nigeria since they promise to provide free or subsidized healthcare for the ordinary Nigerians who cannot afford private clinics or hospitals and attempt to do so. These Governments are therefore partly to blame for the state of healthcare in the country. It is politically expedient to promise free healthcare during campaign for votes. It is not however, possible, in all honesty, to provide viable “free medical care” from basic government budget.
The near-collapse of our healthcare is as a result of poor financing of the so-called “free healthcare”. The better option is to have a health financing arrangement that takes care of everyone. This can be done with a credible health insurance system where all workers are covered and self-employed or unemployed persons covered by a community health insurance system where people pay premium and government subsidizes the premium of those who are poor and unemployed. The medical profession should fight for this. This will make healthcare, a viable business where both private providers and government institutions work in synergy as partners. At present many State Governors are not interested in the National Health Insurance System and those who entertain the idea of community health insurance want to run it themselves the way they are running their “free healthcare” system.
We are aware that some HMOs who operate in the nascent National Health Insurance Scheme (NHIS) have begun to de-risk by deregistering some registered individual accounts, despite current low coverage of the scheme. One of the bigger HMOs saw high usage by individual subscribers as unprofitable. Do you see any fault line in the implementation of the NHIS?
HMOs drive the Nigerian health insurance system in Nigeria. Insurance is about pooling resources of a large number of people together to give a cover to those of them who might be ill. By actuarial principles, the larger the number in a group, the smaller the viable premium each may pay. An individual who insures for N1, 500 a month may use up over N5, 000 just for one illness. However, for 10,000 people who pay the same premium, the amount will be N15 million. This may suffice to take care of some of them who may fall ill that month. Employers insure their workers and their families as a group and this may constitute a viable insurable number. Self-employed individuals should therefore come together in a community such as “organized health cooperative group” to form a viable insurable group.
As a result of rising economic and social stresses, very likely the cases of neurological diseases might be on the rise in Nigeria. What is the situation and what is the nature of the data you are confronted with as a neurologist practicing in Nigeria?
Non communicable diseases such as hypertension and diabetes are on the rise in Nigeria as a result of changes in eating habits to Western-type diet including fast food, lack of exercise and obesity. Neurological diseases such as stroke may result from hypertension or diabetes mellitus. Unlike psychiatric illness, social stress does not really cause neurological diseases which usually arise from damage to the brain. Stress can however aggravate existing genetically determined conditions such as tension headache, migraine or sleep disorders. Social stress causes all manners of psychosomatic illnesses and many doctors and especially psychiatrists in Nigeria are confronted with these. Neurologists also see these patients as doctors, not necessarily because they are neurologists.
I am aware of your initiative to use technology to leverage access to quality continuing medical education by doctors practicing in Nigeria. Are we getting it right with re-certification of doctors as part of the strategies to improve healthcare delivery in the country?
Continuing professional development and medical education of Nigerian doctors to keep abreast of current development in medical practice are compelling necessities. As I had said, the weakest link in provision of quality healthcare in Nigeria is the knowledge of the practicing doctors and not necessarily availability of sophisticated equipment.The Medical and Dental Council of Nigeria made Continuing Medical Education a requirement for recertification since 2011. It is still too early to evaluate the effect of this since enforcement of the re-certification scheme has only just started. It was implemented for the first time in December 2012. Although all manners of sharp practices accompanied this initial implementation, as time goes on, I believe they will be sorted out.
I am using technology to leverage access to quality continuing medical education. MDCN accredited the e-learning platform of Medical Tutors Limited which is my company. The e-learning platform is potentially capable of providing continuing medical education, online, to a very large number of Nigerian doctors who have access to the internet. Materials there are up to date and prepared by notable experts in their field and there are self-scoring multiple choice questions which participants interact with as feedback to how much has been learnt or absorbed.
Interviewed by Jide Akintunde, Managing Editor, Financial Nigeria magazine, and Director, Nigeria Development and Finance Forum.