THE TROUBLE WITH THE NIGERIAN HEALTH SECTOR
For a longtime now I have come across so many articles
and reports in the national dailies and in online social
media
on the rife in the health sector which centers mainly on the
row between doctors and non-doctors working in the
healthcare system. Most of these reports and articles,
mostly lopsided, have one common denominator,
presenting the
Doctor as an enemy of the people and the manner of their
submissions is such as to draw undue sympathy from the
unsuspecting public. But for the neutral members of the
society who have had cause to have sufficient contact with
the hospital environment, I’m not talking of some quasi
journalists, they need not be told, if there are, who the
Angels
and Demons are.
This article is not aimed at indicting or exonerating any of
the two combatant parties as both have had a fair share of
the blame, and honestly, the deplorable state of our
healthcare system is not as a result of the performance of
the
health workers, but it is a component of an overall failed
system called Nigeria which the current government is still
trying to salvage amongst other difficult challenges.
Considering the lines along which the divide has been
made, I
shall delve into an inquest of some of the key issues at
stake, mostly those that affect the general public, and this
I
will do by placing the Nigerian Doctor on one side to be
reviewed alongside a few of the numerous “health
professionals” working in the healthcare system with due
consideration to the most important person in the system,
the Patient. I shall concentrate mostly on the tertiary
healthcare institutions where the bulk of the rivalry is most
felt.
The Patient and the Hospital:
Let us begin from the beginning. A healthy person falls
sick and needs to regain his health and function properly.
He
says to himself, “I don’t feel well enough, I need to see a
Doctor. May be I should go to the hospital tomorrow”. He
sets out of his house with this principal aim. On getting to
the hospital, he first gets to the reception, obtains a card
at the Out Patient Department and then proceeds to see a
Doctor (usually a Medical Officer) who attends to him and
treats him. However,if his condition is one that
necessitates a Specialists attention, he is then Referred to
another
Doctor, the Specialist (Consultant) for further treatment.
On getting to the point of referral, the Record staffs assist
him in opening a folder containing case notes, and in the
process of this, a Doctor (Consultant) is assigned to him.
The entire processes of obtaining a card and folder have
no direct effect on the patient’s condition but helps ensure
proper documentation and recording within the hospital.
He is then directed to the designated Specialist or
Consultant
Clinic where he is received by a Nurse who does further
documentation and records his vital signs which may or
may
not be repeated by the Doctor. Then the patient enters the
clinic to see the Doctor, his primary aim for coming to the
hospital ab initio.
The Patient, the Doctor and Other Health Workers:
The Doctor begins by taking a complete history of the
patient which includes his current complaints, previous
health
challenges, living condition, social habits, family history,
drug history, financial capacity, religious and cultural
beliefs,
and then proceeds to do a complete physical examination
of his entire body system, at the end of which the Doctor
would have verified the patients complaints and identify
any other problems unknown to the patient, before arriving
at
a Provisional Diagnosis. He then counsels the patient,
draws up a treatment plan, which is to be strictly adhered
to
provided the patient is within the hospital environment,
and automatically takes full responsibility for any
problems
encountered along the line. He finally schedules him for a
follow-up visit to ascertain his response to treatment.
This
process of history taking creates a personal relationship
between the Patient and the Doctor and this is where the
confidence of a patient on the Healthcare system of a
Nation is built; the Doctor-Patient Relationship.
The treatment plan of the Patient, drawn by the Doctor,
may or may not include; the investigations (or tests) both
laboratory or radiological to be carried out, the drugs to be
dispensed and the appropriate prescription, the additional
care to be rendered outside the basic nursing care and the
treatment orders to be followed, some of which he does
himself (or via his subordinate Doctors) and others by the
Nurses. There is no stereotyped outline of what must be
done for every patient; investigations to be carried out,
treatment to be administered or drugs to be prescribed lies
solely at the discretion of the Patient and his Doctor.
Apart from the Nurses, all other “Health Professionals”
come into patient care when the Doctor’s plan involves
them.

Clearly, a patient has no business with the Radiographer if
the Doctor’s plan does not involve radiography, neither
does he have any business with the Pharmacist if the
patient does not require any drugs, of course, not every
patients
require drugs. Therefore, it is safe to assert that if Patient
Care is the sole interest of everybody in the Health sector,
then the Doctor takes the Central stage in this service to
Patients and must carry the Nurses along at every point in
time, and together they look out for any other “Health
Professional” that should be roped into patient care. Why
then
should the Doctor take the Central stage? Very simple. He
has been trained thoroughly to do so. Invariably, the
Doctor
is naturally the undisputed leader of the Health team and
only two classes of people can challenge this standing; the
criminal minded ones pursing their selfish interests and
the dim-wits incapable of any logical reasoning.
On the Headship of the Hospital:
Over time, the functional head of the tertiary hospital
setting has been the office of the Chief Medical Director,
CMD,
and part of the Act establishing the hospitals specified that
this position be held by a Medical Doctor. However, there
has recently been a loud cry from other “Health
Professionals” under the auspices of the Joint Health
Workers Union
(JOHESU) for the chance to also partake in the
“enjoyment” of this office, as if to say it is a political
office, a
“National Cake” which should be shared equally to
everyone in the scene, whereas, it is the most sensitive of
all
positions in the hospital setting, one with huge
implications on the health of patients. The Medical
Doctors on the
other hand, insist that the office of the Chief Medical
Director and the headship in general, of the Hospitals is
their
exclusive reserve.
How true is this claim by the Doctors? Again, it is very
simple. Healthcare is all about patient care, and in
rendering
care to the patient who is the main focus of everyone, the
Doctor is the arrow head. He brings together the activities
of all in the health care delivery system to bear fruit in the
health of the patient. He has a broad-based and yet in-
depth medical knowledge that enables him to function as a
leader in patient management and take responsibility for
the outcome. It is then indeed a funny ideology to expect
the Doctor to maintain leadership of Patient Management
and then cede the leadership of the Hospital Management
to a Non-Doctor. Right thinking people would agree that
whoever takes the blame should take the lead.
Leadership is about responsibility, and Doctors embrace
such responsibility mainly as it involves lives which they
have sworn an oath to protect.
Furthermore, JOHESU, a body comprising of other “health
professionals”, support staffs and in fact all in the Hospital
setting except Doctors, claim to be equal and allied to
Medicine. But my question is, how is the clerical staff
allied to
Medicine? How can a support staff head the core members
of the organization? Also, why should a “profession” that
is “allied” to Medicine surmount Medicine?
Can a Non-Lawyer become the Attorney General of the
Federation? Why isn’t the office of the Vice-Chancellor
made
open to every staff in the University system since ASUU
and NASUU both consist of “professionals”? How would
ceding hospital leadership to JOHESU improve the health
indices of our country? These are people that do not deal
directly with patients, people that do not really understand
the agony of patients which Doctors do. The saddest part
is
the extent they can go to press home their irrational
demands. We have a documented occurrence of how they
turned
off power supply to the Intensive Care Unit during a
JOHESU orchestrated strike action in a southeastern
Teaching
Hospital leading to death of patients on life support. This
was an attempt to frustrate the Doctors’ effort to keep
hospital services running while they were “striking”. How
can people who have displayed this level of irresponsibilit
y
be allowed to head the Health sector? Again, God forbid!
It is a common saying that Doctors are “proud”, and I
insist, they have very just reasons to be, and when it
comes to
arrogance, the patients can tell who amongst Doctors and
Nurses are more approachable. Doctors are a selected
class
of elites and comprise the best brains of the society. Yes,
the entry requirements into the profession and the medical
training ensure that only the bests emerge as Doctors. As
such, the government has to understand that any
arrangement that sees a Non-Doctor in a sensitive
position to head Doctors in any Health related issue would
be met
with fierce resistance and the never ending tussle it will
ensue will have detrimental effects on our nation’s
healthcare
delivery. In the interest of peace and decorum, the Federal
Government have to dig in and ensure that the status quo
is been maintained. The ear that will hear needs not be the
size of a raffia palm.

On conferment of Consultancy on other “Health
Professionals”:
A Consultant (Medical) is the title for a senior hospital-
based physician or surgeon who has completed all of his/
her
specialist (Residency) training and has been placed on the
specialist register (Fellow) in their chosen specialty. This
level of Doctor joins the Civil service as a Consultant and
automatically leads a team of Doctors comprising
Residents, Medical Officers and House Officers who train
under him.
Currently, there has been an outcry by JOHESU to also be
awarded Honorary Consultancy based on the fact that
Doctors are been appointed as Consultants, why not they
too. The concession of the government to this particular
demand has led to the entire hospital going berserk in
some centers. This was done against the warning of the
Nigerian Medical Association that the introduction of such
“alien” practices would be detrimental to the lives of
patients and the results are showing.
At the Nnamdi Azikiwe University Teaching Hospitals, it is
been said that a “Consultant Pharmacist” invaded the
wards with his team, cancelling patients prescriptions and
also demanded that a Consultant Cardiologist remove a
key drug in an inpatient prescription, on grounds that the
drug has some known adverse effects. Another report
have it
that in Abuja University Teaching Hospital, the Ante-Natal
Clinic was invaded by Nurses who decided to consult
patients and make prescriptions, of which the Doctors left
the clinic and the Patients were confused. Patients who
sought to see their Doctors were told that there was a
“Consultant Nurse” who does whatever a Consultant does.
Also,
in University College Hospital, Ibadan, stories had it that a
Consultant Plastic Surgeon was barred from reviewing the
surgical wound he created post-operatively because a
“Consultant Nurse” had reviewed the wound earlier and
was
satisfied with her findings.
Let us address one of these occurrences. It is grave
ignorance for a Pharmacist to tamper with a drug
prescription
simply because he has looked through his drug formulary
and have identified a known adverse effect of the drug
when
he/she has no knowledge of the processes involved in the
making of diagnosis and prescriptions. Patient
management
is highly individualized. To make a prescription, the
Doctors put many things into consideration viz; patient’s
history
and examination, financial cost of the drug, benefits
against the risk of using the drug, other drugs to be
administered
etc. Sometimes the side effect of a drug is the desired
effect needed in one patient but would remain a serious
adverse effect in another patient. But no, the Pharmacist
didn’t think in that line before cancelling prescriptions. I
am
not saying every doctor’s prescription is infallible. No.
But if a pharmacist wishes to express concern over a
patient’s
prescription, he should discuss with the Doctor to sort out
their concerns.
This whole consultancy for non-doctors arose as a result
of their quest to have better remuneration. I am not
opposed
to better remuneration for other health workers, but
looking for cheap means to it at the expense of the lives of
patients is grossly unacceptable. Why would you want to
be a Specialist (Consultant) when you have no specialty,
or
you have a specialty in an area whose service is not
needed?
Even if a non-doctor must be a consultant that does not
automatically make him/her a Doctor. We all know how to
become a Doctor and age is no barrier.
If non-doctors must immutably be made consultants, their
duties and jurisdictions must be clearly spelt out and
understood by all involved. A Consultant Nurse should be
confined to Nursing Practice and she will be expected to
enhance it, not to invade Medical Practice. She must
ensure that the management plan of a Doctor is properly
carried
out, even if he is a House Officer. Unfortunately, the idea of
non-doctor consultant emanates from the desire of these
other “health Professionals” for position and better pay
than the desire to meet any specific needs. For instance, a
ward Nurse that does her duties properly becomes a
Consultant, what extra services and improvement does
that bring
to nursing care? The fact that there exist non-doctor
consultants in a few foreign countries does not explain
why the
government should channel huge sums of money into the
payment of honorarium to consultants that add nothing to
the existing system but chaos.
The NMA have identified these unhealthy health policies
and should do all it can to prevent it from killing
Nigerians.
On relativity of Wages:
Another very important object of discord is the demand by
JOHESU for a unified salary scheme for everyone in the
health sector and that will see a close approximation of
the eventual earnings of all in the sector. What else can be
sillier? Need I remind us that in every organization there is
usually an established strata.
Even in heaven, there are Angels and Arch angels, and the
angels are content with their positions and would not want
to usurp the duties of the Arch angels either. People
cannot obtain different qualifications, different expertise,
subserve
different needs and end up earning similar pay. No. That
cannot happen. Why would a non-specialist insist on
being
paid specialists allowance? Why would a Non-doctor
terrorize the government because he wants to be paid like
Doctors? Where in the world is that obtainable? Relativity
is sacrosanct and must be reflected both on the basic
salaries and all allowances.
Granted. Doctors are few. Very very few. The World Health
Organisiation recommends that a Doctor should consult
not more than seven patients in a clinic session and
should pay maximum attention to their needs, but our
environment see us in a situation where a Doctor consults
over 40 patients in one clinic session, yet, he is underpaid
compared to his colleagues even in nearby Ghana. There
are less than 30,000 Doctors currently practicing in
Nigeria
subserving over 170 million Nigerians, and there is a dire
need for more, but that will not push the Medical schools
to
take in everybody and churn out unqualified people as
Doctors, neither will the Nigerian Doctor allow a Non-
Doctor to
tamper with the lives of patients.
Doctors swore an oath to preserve lives and the NMA must
see to it that the lives of Nigerians are safeguarded. If the
Hippocratic Oath is to be taken serious, then the NMA
must win this battle.
More often than not, we are clear on the knowledge that it
is injustice to treat equal people unequally, but it fails to
come to our minds that, it is graver injustice to treat
unequal people equally. This is not pride, it is a statement
of
fact.
Doctors and Non-doctors in the Health sector are not
equal and they cannot be treated as equal. There is a
reason
why some students work harder than others to become
Doctors. Some sat for JAMB several times to achieve that,
although many fail to do so and even some do fail out of
medical school and end up as “other Health
Professionals”.
To eventually anticipate to be rewarded equally with those
who triumphed where you failed is simply madness. The
government must see to it that relativity is maintained. For
if a Nurse or Pharmacist consults patient, not regarding
quality of the consult, earns equally with a Doctor and
even get a chance to head the Doctor, why then would one
need to work harder to become a Doctor when he can
easily become a Pharmacist? Tampering with relativity is
a
conscious attempt at breeding mediocrity, again at the
expense of lives. If the Nurses and Pharmacists accept to
be
paid equally with the Lab “Scientist” and Janitors, it’s
their own cup of tea, but paying Doctors and Non-doctors
equally? God forbid!
On the Physiotherapists’ demand to make first contact
with Patients:
According to Prof. K. E. Obidike, there are three reasons
why patients go to see Doctors.
Firstly, is to ascertain the causes of their complaints and
resolve them.
Secondly, is to identify any other health problems
unknown to the patient, and again, resolve them timely,
And finally, to have a baseline documentation of the
patient as a reference for subsequent health issues.
The second reason especially, answers the question as to
why a Physiotherapist cannot make first contact with
patients. Medicine is holistic, and the initial assessment of
a patient takes the entire body system into account not
just the presenting complaints. Therefore, Physiotherapist
s should remain Physiotherapists and should come into
action when consulted. Simple.
On adoption of Foreign Healthcare Structure:
The fundamental idea behind the establishment of Tertiary
Healthcare centers (Teaching Hospitals) in Nigeria was
primarily for training of Medical Practitioners, Research,
and provision of specialized healthcare at very affordable
rate. It is not a business venture, and if this aims and
objectives are to be met, then the hospital must be made
to
operate under the very Act that established it. Comparing
our Healthcare practices with that of foreign nations
without
a review of the aim and objectives viz-a-viz that of our
country is practically insane. Granted, a few hospitals in
Canada are headed by Non-Doctors, and there are few
Non-Doctor Consultants with well-defined jurisdictions in
a few
foreign countries, but that does not in any way directly
improve their health indices. After all, high quality health
care
is still not affordable for a large proportion of Americans
despite their very potent health insurance system.
Our very first interest should be to assist the government,
which some members of the health sector have chosen to
distract, to ensure there is affordable healthcare services
to all its citizenry, seek ways of improving the training of
the
medical personnel and carry out Research programs that
will elevate the quality of healthcare delivery in our own
nation. Yes. We can go abroad and observe what obtains
from there, but instead of disrupting order in the already
existing system, by trying to blindly implement it over
here, we can see how best to fit a few of them into our
system
and get the best out of it. The Government should
concentrate on policies that will better the lives of the
larger
population of Nigerians, not those that pacify some
disgruntled group of individuals fighting for position and
their own
other personal interests.
There are many other issues that do not only need
Government attention, but also its speedy response.
Some of these areas include:
The appointment of Directors in the hospitals which
distorts the chain of command in the hospitals, induces
anarchy
and expose patients to conflicting treatment and
management directives;
The passage of the National Health Bill, and extension of
Universal Health Coverage to cover 100% Nigerians and
not
30% as currently prescribed by the National Health
Insurance Scheme;
The appointment of the office of the Surgeon General of the
Federation alongside many other pressing needs.
These are health issues of paramount importance and the
Government cannot afford to be lackadaisical about them.
No. Not this time.
My Recommendations:
First of all, JOHESU is an amorphous body comprising of
different entities with varying agitations, concerns,
qualifications, expertise, and eligibility status and should
not be confronted in that front by the government. Our
government has to recognize the various constituents
independently and verify their individual complaints as
some
parts of it have no moral standee to withdraw its services
because of the unmet demands of another.
For instance, The Medical and Health Workers Union
(MHWU) comprising of Clerks, Messengers, Record
Officers,
Admin staffs, Janitors, Engineers, Security etc., an
association of different people with absolutely no training
in any
Health related courses should not dare to aspire for
headship positions in the hospital let alone been
prevented from
doing so. We do not have to give reasons why they should
not.
Therefore, the five different associations and unions under
JOHESU should be made to make their specific
submissions independent of one another for clarity.
Secondly, the Nigerian Labour Congress and Trade Union
Congress should look beyond Unionism and focus on the
ultimate goal of everybody in the health sector which is
adequate Health care for the Nation. They should
relinquish
their parochial stand in the dispute between JOHESU and
NMA, and as well desist from all forms of hooliganism and
attempt to bully the Government and NMA on this matter.
Finally, the Government should resist all attempts to
coerce it into yielding to the demands of one party in the
dispute
when the matter is still in court. There should be absolute
regard for the Rule of Law. And all previous “concessions”
should be stalled, and pending till a decisive ruling by the
court.
We can go on and on to address so many other issues in
the health sector that require attention but I have decided
to
throw light at just some parts of it before the Doctors
under the auspices of the Nigerian Medical Association,
an
association of all certified Medical Doctors practicing in
Nigeria down their tools as proposed come July 1st, 2014.
Before the health of the nation would be thrown into the
hands of Non-Doctors in the Health sector that usually
prefer
the exclusive services of Doctors when they and their
loved ones take ill. Before the general public begin to lash
out
on Doctors and blame them for lives lost as a result of the
forthcoming massive industrial action. The onus lie on the
general public to call out on the Government to resolve
these life threatening issues before the Doctors take to this
hurtful last resort of theirs.
God bless Nigeria.
By,
Basil, C. B. – M.B.B.S (Nigeria),
Department of Clinical Chemistry and Metabolic Medicine,
Benue State University Teaching Hospital

Factual write up, please try and edit it.