The lingering crisis in the health sector of Lagos State which led to the dismissal of 788 medical doctors and the commencement of nationwide strike by other health workers have once again provoked discussions on the state of the Nigerian health system.
Three years ago during the Muslims' Ramadan fasting period, Mrs Aisha (not real name), a 38 year old pregnant mother of 6 children accompanied by her husband and a couple of relatives walked into the doctors' consulting room in the labour ward of the University of Abuja Teaching Hospital. Incidentally, I was the one on duty. History was taken and physical examination done, except for her age and grand multiparity, no other risk factor for a possible negative outcome was identified. The period of cyesis was largely uneventful. She was admitted in first stage of labour, closely monitored till she delivered safely. Third stage of labour was actively managed and the husband and relatives were predictably jubilant with the news of the arrival of the seventh baby. Little did anyone know what was to come. Mrs Aisha was still bleeding 15 minutes post delivery. Initial steps of management of the post partum haemorrhage were implemented to no avail. The initial challenge was getting the relatives to donate fresh blood which was preferred in this condition, they declined citing Ramadan fasting. While effort to persuade them was ongoing, 3 units of stored whole blood gotten from the Blood Bank (in the absence of other substitutes) were transfused, but patient was still bleeding profusely. She was later taken to the theater, hysterectomy done and moved to the intensive care unit with continuous blood transfusion. However, the bleeding continued, seven units of blood transfused at this time, no more blood at the bank and few minutes later we lost the patient I and other senior colleagues and nurses had battled to save for over 4 hours. Mrs Aisha would probably not have died if there were other blood products at the blood bank to serve as substitutes.
More so, I was working as a House Surgeon at Ebonyi Teaching Hospital a year earlier when I admitted one Mr Festus (not real name) who was victim of a fatal road traffic accident along Lokoja-Abuja road. He was transferred (not with an ambulance) without referral letter from a local private hospital in Kogi State where he was resuscitated after the accident happened within 24 hours of injury. He had spinal injury with paralysis of both legs, floating left knee (caused by fracture of the left femoral, tibia and fibular bones). He was severely anemic with a packed cell volume of 16% but no ongoing overt or covert blood loss. He was scheduled for urgent blood transfusion and being worked up for an emergency surgery (to fix the fractured leg bones). First challenge - no blood available for transfusion. All the blood bags in the blood bank were donated for other patients and no assurance from Mr Festus' relatives that they would donate blood for replacement. We continued with other treatments and investigations hoping to persuade his relatives some of whom came with bible and praying fervently outside the ward to donate blood for the use of their loved one. A couple of days later, the patient requested for discharge. Reason? "I want to go home, my private doctor would come and treat me there" he averred. When orthopaedic patients make such requests, can you guess where they usually go to? Traditional Bone Setters! The health care team counselled him on the consequences of his intended action but all those efforts ended in futility. He left the hospital against medical advice. A month later, he came back with a putrid leg with a terribly offensive pungent odour. The entire limb has gone gangrenous and the only viable option was dis-articulation of the leg at the hip level.
Furthermore, I did not realize that my assessment of the weakness of our health system during my clinical experience was a gross underestimation of the reality until I worked on the Global Fund Health System Strengthening (HSS) Project. I was a member of the Federal Government Site Assessment and Selection Team to Edo and Ebonyi States. I also supervised the project implementation in 13 other states including Sokoto and Lagos. Primary Health Care (PHC) system in our country is still very weak, to say the least. Although federal government may have been voting lot's of money to improve the situation, it's not immune from the endemic corruption in the system. The LGAs and most state governments are doing little to nothing to improve the PHC system. For instance, the Ward Minimum Healthcare Package requires a PHC to have a minimum of 6 skilled manpower (Nurse/Midwife, Community Health Officers/Extension Workers), none of the states I supervised met this criteria. What we saw was a situation where the only health facility in a community without an access road will have two JCHEWS and two unskilled assistants commonly referred to as "auxiliary nurses" No state met the minimum requirement for the PHCs in any of the building blocks of health system. This accounts for why health workers and facilities in functional secondary and tertiary health facilities are being over-stretched.
Compounding the situation is the unending and in fact, deteriorating inter-professional wranglings within the health workforce. The latest casualty of this unnecessary rivalry is the demise of the National Health Bill passed during the last days of the 6th National Assembly. The health workers themselves gave the government an excuse not to sign the bill that would have ensured a percentage of national revenue automatically goes to strengthening of the PHCs. Funding of PHCs would have tremendously improved and other blocks strengthened. My consiracy theory is that government employers surreptitiously promote this rivalry to further polarise the system and abdicate their responsibilities (divide and rule strategy). One could go on and on to analyze this problem, it's a legion.
Ideas on the solution to the problem are not lacking. There are lot's of good documents and policies but no political will to implement them. The question now is who will save the situation? Why is it that our politicians don't like to invest so much in the health sector? Should we wait until we have politicians that won't play to the gallery and tackle the problems head on? If yes, for how long shall we wait? At what cost? (Cost includes preventable loss of lives). From experience, our politicians do not honour agreement with workers until they go on strike, an action that further disrupts and weakens the system. In some cases, they use intimidation or like Governor Fashola just did, employ draconian and Machiavellian tactics. Is it the health workers that fight themselves over which profession should head hospitals that would save the situation? What about the infrastructure and logistics supply chain? In my opinion, the most important thing that is needed to rescue our health system is a strong and sincere political will by the government. It's not as if government does not understand what needs to be done, the truth is that it's financial intensive and the effect may possibly not be obvious to the common man on the street on a short term. The citizens have significant role to play in this regard, get educated on what we want our health system to be like and mount a sustained pressure on the leaders to get it done. An average politician wants to implement populist projects, and our health system would most likely get better attention when the Nigerian people consider it as such. Enough of the blame game! Enough of the politics! It's time for more purposeful action. Let's go, we can't wait!
please your thoughts are welcome!
