The exodus of Nigerian doctors abroad has led to acute shortage of medical professionals required to tackle numerous health conditions facing Nigerians. Based on this, the ordeal patients experience while seeking care in the country is unprecedented, reports APPOLONIA ADEYEMI
At the University of Port Harcourt Teaching Hospital (UPTH), the story of a pregnant woman captures what majority of consumers of health care services, especially in public health facilities, experience on a daily basis in the country.
Shifting her bulk, wearily, Madam Onyinye Ogu leaves her home at 5.30a.m., and arrives the hospital at 6.30a.m. anxious to be among the first 30 on the queue. The effort notwithstanding, she sometimes waits till 3p.m. to see a doctor. Although this occurred in Port Harcourt, a high-brow city attracting many oil industry and financial institution workers, the ordeal of patients in Lagos, Ibadan, Lokoja, Makurdi, Kaduna, Kano, Borno and Gombe, is not different.
Arriving the Lagos State University Teaching Hospital (LASUTH) in Lagos as early as 6a.m. is very common among patients seeking doctors’ attention for medical care in that tertiary health facility. Having lost confidence in several primary health centres (PHCs) close to their homes, many patients bypass one PHC or the other, travelling from as far as Sango-Ota in Ogun State, Badagry, Aja, Lekki, Okokomaiko, all in Lagos State and other environs to get to LASUTH, but arriving that hospital before 7a.m. does not guarantee being seen by medical doctors on duty early. It is therefore normal for patients who have arrived at the hospital at 7a.m. to still be on the long queue to see the doctor at 3.30p.m.
When the New Telegraph interacted with patients during a recent visit to LASUTH, some who volunteered to speak, expressed frustration for spending almost the whole day in their efforts to seek needed treatment for various ailments.
One of the patients, Tope Ajala, said it was easier for a camel to pass through the eye of a needle than for a patient, whether on a casual or routine appointment, to walk into LASUTH, see the doctor promptly and depart. On the average, it could take six hours for an out-patient to wait in LASUTH before getting into the doctor’s consulting room. Before then, such patients would have been on the queue for hours, waiting for his or her turn to be seen by the doctors.
Another patient, who gave his name as Adunola, said based on an excruciating headache she had suffered for one week, relations and neighbours advised that she should seek care in LASUTH. However, after the initial registration at the Out-Patient Department, record staff referred her to the waiting area behind the Family Clinic. “That was where the waiting game started,” she said.
“I sat down with hundreds of other patients who were equally waiting for their turn to see the doctor. After sometime, a nurse would emerge from the doctors’ consulting rooms to call out the patients that it was their turn to move into doctors’ consulting rooms.
“Although, the nurse calling out names would have been out more than 10 times, surprisingly, my name has not been called,’’ she lamented.
“Becoming very impatient, I checked the time and only then did I realise that I had been sitting down, waiting for my turn to be called into the consulting room for over six hours, having arrived the hospital at 7a.m.
“My initial reaction was that most probably, my case note may have been misplaced.
“I approached one of the nurses to find out if my file had been mistakenly skipped. ‘Madam, go and sit down in the waiting area. When it’s your turn, I will call you in,’ the nurse shouted at me, rudely. With that cold reaction, I had no choice than to return to the waiting area, but I became very frustrated,” she added.
Adunola said she was eventually called into the consulting room at 3p.m. and by 3.30p.m., a doctor attended to her, prescribed some medications and directed that some medical tests be conducted, the results of which should be presented at future appointment within two weeks. Based on that bitter experience, Aduonla said, “I couldn’t be persuaded to keep that follow up appointment.”
These experiences may seem far-fetched, but a visit to any secondary and tertiary care hospital would reveal that the highlighted experiences are true-life accounts of the ordeal many Nigerians accessing health care face.
An example was the experience of an 80-year-old grandmother who resides in Lagos. After suffering severe stomach discomfort and passing watery, liquid stools for three days in her Ijesha home; she was rushed on emergency to LASUTH, but the facility staff couldn’t take her in based on a strike that had been declared over the non-employment of resident doctors.
Based on their advice to seek care at the Lagos University Teaching Hospital (LUTH) at Idi-Araba, Lagos, she was promptly taken to LUTH where her son was bluntly told that there was no bed space to admit her in. The fear of losing his mother to the ailment prompted her son to seek help from the top echelon of LUTH management, some of whom intervened and ensured a bed space was made available for the patient. The grandmother was lucky to have been treated and discharged after two weeks. While this grandmother was lucky to have been saved, another male patient who had slipped into coma at a private facility from where he was referred to LUTH about six months ago missed out on being treated and died, sadly.
Immediately on arriving LUTH in a taxi, there was no bed space to take him in; hence the patient who was unconscious remained in the cab for over six hours without any hope of getting a bed space for admission. Pressure from the taxi driver, who insisted that the patient be taken off the taxi prompted the relation to request that they (the patient and his relation) be driven back home. The patient passed on subsequently.
Another case that needs to be highlighted is that of the father of a Lagos-based journalist, Pa Ejiogu, who experienced a relapse from a surgical operation he did two years ago. Although he was rushed on emergency to the Federal Medical Centre (FMC) in Owerri sometime in September, the ‘no bed space’ drama played up again. With the intervention of some top officials from the Federal Ministry of Health (FMOH), who put telephone calls through to some top management staff of the FMC, Ejiogu, who was already being driven back home, was recalled to the facility where a bed space was created for him.
The experiences of Nigerians seeking medical care as demonstrated above have not only been frustrating, many Nigerians have lost confidence in the nation’s health care system. While some have resorted to seeking care from traditional medicine practitioners and quarks whose unwholesome businesses thrive against this background, out of the sheer frustrations from seeking medical care in the system, a few have ditched hospital care completely and chose to resort to self-medication as a way out. It has got to that stage where when some become ill they don’t want to hear about seeking care in hospitals. What many do is simply walk into some patent medicine stores where attendants without pharmaceutical training hand out medications to sick persons. Experience has also shown that even those persistently getting prescriptions from pharmacies are doing so as a stop gap, considering the huge burden of seeking care in the country.
Some of the patients, who spoke with the New Telegraph, said that it was not unusual to receive up to four-month appointments for treatments involving surgery from doctors at LASUTH, Ikeja. Some of them said it was almost impossible to obtain a short-term appointment to see a doctor at the hospital.
However, there is no doubt that these issues have contributed significantly to the high morbidity and mortality as well as the poor health indices being recorded in the country. Consequently, the questions being persistently asked are why is accessing care without excessive stress and discomfort from Nigerian hospitals not possible? From the situation that is playing out daily in many public and private hospitals, could there be a reversal of this trend?
Providing some of the background to the current situation, the National President of the Nigerian Medical Association (NMA), Dr. Francis Faduyile, described the overcrowding of patients in tertiary hospitals across the nation as a fall out of medical doctors almost deserting primary health centres (PHCs).
Out of the 80,000 Nigerian medical doctors registered by the Medical Dental and Medical Council of Nigeria (MDCN, 40,000 doctors only practice in Nigeria, taking care of 200 million people.)
Bemoaning the exodus of Nigerian doctors seeking greener pastures in developed countries, Faduyile, at the opening of NMA’s annual general conference/delegates meeting on May 3, 2019, held in Abakaliki, estimated that “over 2,000 doctors migrate from Nigeria annually”.
The Minister of Health, Prof. Isaac Adewole, who was represented at the event by the Chief Medical Director (CMD) of the Alex Ekwueme Federal Teaching Hospital, Abakaliki, Dr. Emeka Ogah, said that the Federal Government was striving to halt the doctors’ exodus.
He said: “We are not happy with the latest incidents of doctors seeking greener pastures outside the country and we will continue improving the welfare of the health workforce.’
“The Federal Executive Council (FEC) has supported our efforts to centralise internship posting and this will be unveiled within a year.”
Speaking further on the trend at another occasion, Faduyile, noted that the country was highest in the number of preventable deaths due to inadequate and poor healthcare services arising from shortage of medical personnel.
According to him, the foreign countries where doctors are relocating have more doctors than Nigeria.
He added: “Any well-meaning Nigerian should therefore be bothered because Nigeria has a low patient-to-doctor ratio and for us to get our acts right, we actually need more doctors. Although the World Health Organisation (WHO) stated that for optimal healthcare to be achieved, countries need doctor/patient ratio of one to 600, we have 0.2 per 1,000. You can see the disparity. What we have is not enough.
“In the United States (U.S.) or United Kingdom (UK) where our doctors are also going, they have an average of 2.8 doctors per 1,000 people.
“In U.S., that is about 14 times the number that they have in UK, whereas WHO states that we need an average of one doctor to 500 or 600 people. Nigeria, currently with our 40,000 to 200 million, has about one doctor to 5,000 people. In some parts of the country, it can be 10,000 people to one doctor and what that means is that for every 1,000 people, we are short of about 10 doctors and it is unfortunate.
“Nigeria has one of the highest perinatal mortality rates, maternal mortality rates and infant mortality rates. Our average lifespan is very low and these are results of poor health management of our people.”
Faduyile stressed the need for the Federal Government to honour the Abuja declaration by raising the bar on health budget from below six per cent to 15 per cent that was agreed by all African Heads of States in 2001.
“Sincerely, we have been advocating for government to put in place things that will retain doctors in this country. They are just shying away from doing that. We have advocated for them to honour the agreement they willingly entered into when, in 2001 at Abuja, all the African Heads of States came and had an agreement that 15 per cent of the budget should be devoted to health every year.”
According to Faduyile, to bridge the gap, the health sector needs a lot from government because government needs to improve primary health care (PHC) facilities.
“At the rural areas it is the PHCs that will take care of that and what we need is for government to strengthen the PHCs and in strengthening the PHCs we need the states and the Federal Government to work in tandem,” he added.
For example, Faduyile noted that most states were not paying medical staff good remuneration compared to the salary package from the federal facilities and “what happens is that if you take five doctors or medical personnel in a state employment, within five years, all of them would have resigned and taken new employments at federal health facilities”.
He said: “The retention of doctors at those PHCs is very poor. We have some states that are owing their medical staff upward of four to five months’ salaries and there is no way they can expect those staff to remain there.
“So, we have to do a lot at those PHCs. This is why the nation’s indicators of health are abysmally poor. It is at that places that we have high maternal mortality rates; it is at those places that we have high perinatal mortality rates; and it is in those places that we have high deaths as a result of illnesses such as diarrhoea, vomiting, malaria; and it is at those PHCs, too that we can take a lot of preventive management to guide against all these diseases.’’
However, retaining doctors at the primary level of care will also involve the upward review of doctors’ salaries. Usually, after graduation in Nigeria, the doctor, who is called a house officer or intern, earns between N150,000 and N200,000. This could be more or less depending on the hospital. Doctors working in Federal Government hospitals typically earn more than their counterparts in the state hospitals.
Usually after the doctor’s tenure as a house officer, the next step is the one year mandatory National Youth Service. In this case, the salary often drops below the earning as a house officer. Some doctors earn as low as N50,000 while others may have to work for free while relying solely on their National Youth Service Corps (NYSC) allowance.
Often times, the best option for the NYSC doctor is to work in any of the major private hospitals in the country. In this case the doctor could earn as close to his salary during his/her horsemanship year. Personalised medicine
Once a doctor is done with NYSC, the next step is to identify a specialisation where he/she intends to do residency. However, it’s not compulsory for the doctor to go on to specialise. There are other career paths for doctors, but the typical path is the residency programme.
Prior to applying for a residency position, it is expected that the doctor pass his/her primaries exam.
Once this hurdle is cleared, the next step is getting placement in any of the government or specialist hospitals that provide residency programmes.
However, getting admitted into a residency programme has become really tough these days due to the increased number of doctors in the country.
This probably explains why many doctors are going out of the country. On the other hand, a doctor can choose to work in a private hospital where he will be paid between N120,000 and N250,000, depending on the hospital.
A residency position offers much better because you earn more as you climb up the professional ladder. Usually, junior resident doctors earn between N190,000 and N220,000. As stated earlier, Federal Government hospitals often pay more than their counterparts.
Consultants in Federal Government hospitals are paid an estimated salary of N800,000 monthly while their state counterparts are paid around N700,000.
Overall, based on the Consolidated Medical Salary Scale (CONMESS), those employed by the Federal Government-owned health facilities, earn between N195,000 and N220,000 excluding tax and other deductions. However, state hospitals may pay as low as N150,000 but the highest paying states may offer up to N240,000 as monthly salary.
Apart from their basic salaries, doctors have access to other allowances and bonuses, which have been highlighted to include specialist allowance, call duty allowance, non-clinical duty allowance and clinical duty allowance.
Others are teaching allowance, hazard allowance and rural posting allowance.
Often, many of these allowances are not paid, hence doctors have learned how to manoeuvre and progress in the area of sourcing finance through multiple job earnings, consultancy services in both public and private hospitals.
Overall, the salaries of Nigerian doctors are not anywhere close to what is obtained in countries in developed countries of the United States (US) and United Kingdom (UK).
Reacting to the situation, the Chairman, Medical Guild, Dr. Babajide Saheed, said it was pathetic that people were going through this lot to access healthcare in the country in pains and in depression.
He said: “It is unacceptable, uncalled for and unjustifiable for the populace because people voted for those in government in order to provide accessible, affordable, equitable and qualitative health care delivery for the populace.
“Unfortunately, they are getting this health delivery through stress, frustration. Some even die in the process.’’
The Medical Guild is the association of medical doctors employed under the Lagos State government.
Giving the background to this trend, Saheed, who is a consultant orthopaedic, said the first cause of this was the shortage of manpower in the health sector.
He said: “If a doctor who is supposed to see three patients, sees six or 10 patients, there will be effect on the person that is accessing healthcare.
“Similarly, if there are 10 patients to be surgically operated and there are two doctors only to carry out the operation, that will also increase the duration of the operating time for those patients because the manpower is not there.
“Thirdly, the needed equipment and infrastructure are not there.’’
According Saheed, if there is not enough theatre and doctors have to share theatre and instead of carrying out operations two to three times weekly it is done once because that is the only allocation that is the patient can get, it increases the waiting hour for patients.
“For instance, if there are two to three doctors that are supposed to see 150 patients, it increases waiting time for the patients because the doctors are not machines. Besides, access to care will be difficult; some patients can arrive the hospital at 9a.m. and before they can see a doctor, it will be up to 3p.m.,” he added.
Based on this, the chairman of Medical Guild said there must be employment of more doctors; there should be incentives; there should be infrastructural development while budgetary allocations to health should be increased to from 5.6 to 15 per cent.
In April 2001, African Union countries met and pledged to set a target of allocating at least 15 per cent of their annual budget to improve the health and education.
Sadly, he noted that the government abandoned this laudable plan, resulting in these crises.
Saheed reasoned that if people had access to quality health care and education, “all these problems will reduce”.’
He listed the way out to include the employment of more health workers, increment of incentives for health workers, improved remuneration, improved welfare package which must include the provision of improved house rent and car loans for health workers.
Similarly, Saheed called for the provision of improved infrastructural facilities: more hospitals and health centres should be built and the tools that the health workers would use to provide the needed services should equally be provided.
On how to address the recurrent problem of lack of bed space facing clients, especially critically-ill patients, Saheed said the problem would not change if the number of health facilities were not increased.
He added: “We can’t have adequate bed space because there is limit to the number of beds in LASUTH. Whereas, he noted that the number of people in Lagos, which is up to 20 million presently, increases by the day.
“If the population is increasing and there is no increase in infrastructure and the health providers, the population will suffer. Until they bring healthcare to limelight and make it a priority before we can move forward.’’
Giving his perspective of the current situation facing patients, a family physician, Dr. Oluwajimi Sodipo, said the challenge had to do with a mismatch in the number of people trying to access care, “which is growing at an astronomical rate and the number of people providing the care”.
However, across all levels of clients accessing care either to address chronic medical conditions or for preventive strategy, “there is a great reduction in the number of health care practitioners and when you juxtapose this with the number of population seeking care, what you get is a mismatch.
“The World Health Organisation (WHO) recommends that one doctor should be in place to cater for 600 people, not to see 600 sick people. But for every 600 people, there should be one doctor,’’ he said.
Sodipo reasoned that out of the 600 people, some might never go to the hospital; some might go for check-up while some would go to hospital because they had acute problem.
“The situation we have in Nigeria is one doctor catering for upward of 3,000 to 4,000 of the population and because of that it has affected how people access care.
“Across all the cadre of clients seeking care, there is a shortage of care providers, resulting in increase in the waiting time for patients making it difficult for them to access care in the hospital.
“This gets worse when patients with special needs. For example, some patients want to access care provided by specialist doctors. In the whole of Nigeria, we have just about 50 neurosurgeons. In some states, many patients can’t even access such care because in some zones, there is only one such specialist doctor.
“We have a problem of increasing population and a decrease in the number of people that can provide that care; again, that is why the government has come up with some strategies: task shifting and trying to promote more of preventive health care so that we don’t have people that are critically ill.
“When people live preventive lifestyles, take certain precautions, they don’t fall ill and the likelihood of them accessing care reduces,” he said.
Sodipo also called for the institution of health insurance by state governments while expanding access for the coverage of more Nigerians into the National Health Insurance Scheme (NHIS).
He added that health insurance would pave the way for generating more funding for treatment. Most importantly, halting doctors’ brain drain would help to stem the tide of long-waiting hours in health facilities as well as in reducing the burden and frustration patients face while seeking health care.
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