NIGERIAN MEDICAL ASSOCIATION (NMA) National officers committee press release

 

IMPENDING DISASTER AND COLLAPSE OF GOVERNMENT HOSPITALS AND THE PUBLIC HEALTH SECTOR IN NIGERIA: A CALL FOR IMMEDIATE ACTION AGAINST EXISTING AND EMERGING ABSURDITIES IN THE NATION’S HEALTH SECTOR 

For almost two decades now, the nation’s health sector has been unduly traumatized and continually subjected to crippling upheavals by persons who have insisted on redefining the time hallowed and universally accepted meaning of Medicine and the Medical Profession. They have been aided by the acquiescence or collusion of some persons entrusted with power and authority to perform certain roles in the system, to foist a state of frozen conflict on the healthcare delivery system of Nigeria to the detriment of the public. Their main motivation seems to be the misguided belief that decimating the medical profession and “equalizing” medical practitioners with other health workers and professionals, will lead to the fulfilment of their ambitions to also lead the health team. They have used a combination of contrived misapplication of government policy and establishment circulars and misuse of legislations to cause unimaginable divisions, segmentation, acrimony, mischief, indiscipline and other vices in the healthcare system with attendant but avoidable injuries and deaths to unsuspecting and hapless members of the public. 

The Nigerian Medical Association (NMA) is highly appalled by the state of affairs in the healthcare delivery system which has been reinforced by the recent ruling of National Industrial Court. An ill-informed ruling as a result of a poor understanding of the meaning of Medicine, its ramifications and appendages, the role and rights of practitioners of Medicine and their relationship with allied healthcare professionals for the purpose of maintaining members of the public in a state of health. 

Surprisingly, everybody in the health care setting have argued for a direct and unfettered access to the patient, against the standard health system practice, all in the name of autonomy. This has culminated into a voracious appetite for positions, extra roles and responsibilities cursed with a spirit of get-it-at-any cost mentality, industrial acrimony and senseless strikes became the order of the day. For NMA and her members, ethical principles were inadvertently compromised in efforts to attempt to restore normalcy to the system. Those who were in positions to take actions did little to stabilize the system or to halt the decent to anarchy. Decisions and agreements were reached based mainly on emotions, fear, half-truths, disregard for quality and excellence, ignorance and total disregard for international best practices as the authorities became impotent in the face of the looming threats and blackmail by these forces at moments of  decisions, and literarily handed over their mandates to unions and professional associations.  

Frivolous courses and programmes with no relevance to hospital and indeed the health care industry were quickly developed, and accredited by institutions that could have first verified their usefulness to the system. In some others, the duration of training have been elongated as a way of measuring up to medical training with no added value to actual job requirement and the  government compelled to commit scarce resources to funding such. The middle level manpower critical to the needs of a developing and cash strapped country like ours have been virtually eliminated even with all the hues and cries of alleviating the acute shortage of healthcare expertise among our rural poor populations. The financial burden on government became unnecessarily and excessively increased with no added value commensurate with the extra expenditures. Resources that could have been deployed in improving infrastructure/facilities to facilitate further relevant/needed training and provide commodities and consumables to guarantee better healthcare for the citizenry were used to service largely redundant and over bloated bureaucracy without the people seeing commensurate improvement in efficiency and promptness of services rendered.

The legislative process appeared to have been hijacked. Legislations were passed without fully exercising the rigorous legislative scrutiny necessary to ensure that law making remains all about entrenching order, good governance, peace, discipline and standards in the society and not to cause chaos. Arising from the seeming hijack, conflicting laws were passed against expert advice thus creating absurdities, and attempting to reverse nature and its sequence of order and hierarchy. If these absurdities were allowed to stand, it would only create undesirable and unintended disastrous consequences to both individual health seeker and the public. Public interests have been seriously compromised in favour of corruption and ego promotion. Patriotism and conscience to promote decency and preserve the sanctity of a noble profession like medicine have been thrown overboard to deliberately or inadvertently destroy the healthcare system, thus accelerating the descent into anarchy. 

Under our watch judicial pronouncements that rather than annul inordinate desires, moderate insatiable appetites and quench greed and jealousy by seeking out these absurdities further escalated the conflagration in the guise of interpreting the letters of the extant laws and not their spirit. Deep rooted enmity of a lifetime and for future generations has been created among a group of people who work and live together as a team because of these interpretations that pacified only the crying baby without asking for the reason for the lamentation. Chief Medical Directors and Medical Directors (C/MDs) were and are still being compelled to do things that further waste scarce public finances even when they know such actions complicate the system of service delivery and add no value to the system, just to please individuals and groups. Yes, when the fire of the attacks gets too hot on the ministry, it is transferred to the management of the hospitals. Confusion held sway.

Many well-trained and highly-skilled Nigerian doctors and dentists have left the shores of this country over the years because of suffocating, unhealthy, antagonistic, unproductive and acrimonious work environment in the public health sector. Else, how can one explain the situation where a professor of haematology is barred from performing tests and exercise quality assurance programs and activities in the haematology laboratory by a judicial pronouncement. Can a science laboratory technologist bar a professor of chemistry from conducting his researches and overseeing the operations of a chemistry lab? But in medicine, a consultant plastic surgeon was prevented from reviewing the wound of a patient in the ward he operated on earlier because a “consultant” nurse had given order that the wound must not be opened. Can the Nigerian sick people survive under this state of anarchy? Who would be the loser? Our experts who couldn’t stand this seeming primitive jungle-like scramble for relevance and roles are now sojourning in other countries and performing excellently well to the shame and pain of their motherland. Privileged Nigerians and other impoverished citizens sell their life savings and even family landed resources and embark on medical tourism only for them to discover that that famed world class surgeon or other medical experts are Nigerians. Asked why they are not coming back home to save their people, they will respond- the Nigerian factor, the system that has put the world on its end. For how long would this continue?

The NMA is deeply concerned for our dear and beloved country; concerned for the dead and those who die daily from these senseless pursuits for positions, role and equality. We are concerned that unless decisive actions are taken NOW to allow international best practices to take root and prime position in our approach to patient care many more avoidable deaths are in the offing, as a result of the miscarriage of unionism, impunity, ignorance and lawlessness in our health institutions. Who knows who the next victim could be! Confirmed stories of staff removing life-support gadgets, switching off oxygen supply lines, electricity and water during strikes have become common. Rather than charge those concerned for murder what we see is an agreement that “No one should be punished for his/her role in the strike”. Regrettably, while these agreements were being concocted and signed, many families have been forced into untimely mourning and burying of their loved ones who died as a result of such senseless strikes.

Doctors who had chosen to assume the elevated calling of the medical ethics and wished to work during those strikes had been violently prevented and assaulted by detailed thugs-often junior and middle cadre staff, sometimes imported from other establishments for cover. No form of protection is provided. 

It is in the light of the foregoing and others too numerous to mention here that the NMA has decided to step out boldly against all odds and insist that things must be made right, provided they are done in the best interest of patient care and the health system in line with international best practices. What else is worse than the current sorry state of industrial disharmony in the public health sector? We shall seek to enthrone international best practices and ensure the enforcement of the globally acclaimed principles of medical ethics in all its ramifications in all areas of health care service delivery. Avoidable and senseless deaths must cease; sanity must be restored to the health care environment. 

Our motivation stems from the fact that the Nigerian people whom we serve do not have all the facts and would not hesitate to call governments at all levels and their agencies to order. To this end, NMA is constrained to inform the public correctly and make the following clarifications;

1. Medicine and Dentistry are internationally- infact, we are humbled to say that medicine is one of the few noble professions in the world. That they must be practised as in other countries of the world is a fact that should have been taken for granted if not for the distortions of the Nigerian system. In all other countries, other health professions are recognised and designated as professions allied to medicine. This has meanings with implications which include that of a relationship of a tree with its branches and accessory parts. It is not a Nigerian creation. It was not designed to please one group and displease another, but to ensure that quality and safe health care is delivered in the most efficient and cost-effective manner. This relationship is not restricted to medicine and dentistry.

2. At the moment, there about 15 broad Medicine and Dentistry specialties including but are not limited to, Internal Medicine, General Surgery, Paediatrics, Laboratory Medicine (Pathology comprising broadly Anatomic Pathology, Chemical Pathology, Haematology and Blood Transfusion and Medical Microbiology and Parasitology), Obstetrics and Gynaecology, Radiology, Otorhinolaryngology (ENT Surgery), Ophthalmology, Psychiatry, Public Health, Family Medicine, Orthopaedics, Anaesthesia, Radiotherapy and Oncology, General Dentistry, Dental (Maxillofacial) Surgery. In these specialist domains, there are also divisions and subspecialties.

3. These specialised branches of medicine and dentistry are organised into departments for ease of service delivery, administration, control and to facilitate inter-relationships. It is only a specialist doctor in each of these branches that can be the Head of such departments. This is an international dictum. 

4. Members of the allied health professions whose training or areas of practice are allied to any of the medical or dental disciplines are employed into such departments to work with the specialist doctors as members of the team to give quality and safe care to the patients. E.g., Obstetricians work with midwives to give ante-natal care to pregnant women, manage delivery and post-natal care; ophthalmologists work with optometrists and opticians in eye care; Anaesthetists work with Anaesthetic nurses and technicians in critical care medicine especially during surgical procedures; radiologists work with radiographers to support investigations and diagnosis in imaging medicine; radiotherapists and oncologists work together with radiographers and  medical physicists in treating cancer; nuclear medicine physicians work with nuclear physicists also in cancer treatment, etc. 

It is in this line of reason and purposes that Pathologists (laboratory physicians) work together with medical laboratory technologists/scientists to examine patients’ biological samples for purposes of diagnoses-ensuring that the laboratory reports have relevance or proper connection with the patients’ clinical conditions, considering that a request for a pathology test (clinical laboratory test) is a consult to the pathologist. The philosophy of these inter-relationships presupposes that there is a core healer (doctor) who understands the patient’s conditions and a technical collaborator who helps him carry out assigned roles in that particular jurisdiction with the sole purpose of assisting to unravel what is wrong with the patient or treat them successfully.

5. The doctor initiates the process of care and has ultimate responsibility for decision making, type and quality of care (treatment modality) and safety of such care, irrespective of whoever a responsibility has been delegated to or is involved in the process of care. The doctor also bears the liability in cases of default.

6. Facilities and infrastructure provided in any medical or dentistry department are meant to enable and enhance the work of the medical and dental specialists and other allied professions deployed in the department. They do not belong to any particular worker or groups of workers. In Nigeria, allied health professionals lock up equipment, cannibalize them, re-label reagents, and even pull off or plugs off life-support machines with patients connected to them when they embark on strikes under the watch of the authorities in the land. No one is brought to account for this act of wickedness, not even the mildest caution or sanction. 

7. Heads of departments anywhere exercise control and supervisory authority over all sections and persons in their departments either directly or by delegated authority. We are not aware that the structure and composition of departments as well as the line of duty/authority in government establishments are defined by the judiciary in any other part of the world. The organisational structure and responsibilities in the health care system are designed to ensure effectiveness, efficiency and safety of patients, and it is the same all over the world. We cannot afford to do otherwise here in Nigeria.  

8. All health professions in Nigeria are regulated by their respective regulatory agencies, and no one is expected to cross boundaries in any way. Each regulatory agency has certain standards and guidelines prescribed for their members which they are expected to meet or comply with. Sometimes, the regulatory functions of some medical and allied health regulatory agencies appear to overlap. For people in the same line of duty this ought not to cause any problem as the superintending MDA clarifies any areas of conflict, but in Nigeria it has been a source of serious in-fighting, acrimony and unnecessary litigations. Elsewhere, allied health professions have supervisory roles delegated by their parent medical specialty. In recent times in our country, authorities concerned have permitted the establishment of all manners of regulatory agencies even where they are not needed. It has been a bazaar awarded like a gift to pacify sulking and nagging persecutions without recourse to how it would affect service delivery. It is unarguable that whenever there seems to be a conflict of roles in patient care between the doctor and the allied health profession, the overriding preference has been that it is in the overall interest of the patient and the public that the roles be performed by the doctor who by training and responsibility is expected to operate at a higher level of efficiency and quality. To do otherwise will seriously endanger public interest and health. This is how it is done elsewhere.

9. All disciplines and aspects of the medical and dental professions are totally regulated by the Medical and Dental Council of Nigeria. No other regulatory agency can regulate the practice or practice environment of the doctor and dentist wholly or clandestinely through any of the specialties. We will always defend the dignity and tradition of the medical profession according to the dictates of the Hippocratic Oath and the ethics of the professions. It is in the interest of the public that we do so always.

10. Therefore, any regulatory agency whose enabling Act purports to give authority over another profession or practice environment should see it as an absurdity and restrict itself to the members of its profession only. NMA will not tolerate any encroachment in any medical or dental arena as no doctor or dentist will submit his/her practice to any other health professional regulatory body other than the MDCN and the relevant state ministries of health. For emphasis, pathologists must perform their roles in the pathology services laboratories. Pathology and medical laboratory science professions are related but the job descriptions, training and responsibilities differ, just as they are with obstetrician/midwife, ophthalmologist/optometrist, radiologist/radiographer etc.

11. All pathology laboratories existing in the respective pathology departments of our hospitals are established, designed, and mandated to render pathology services to support clinical services and in some cases public health activities, train undergraduate medical students and pathology resident doctors, where applicable and train some other allied health professionals. This is a global situation- a standard Nigeria now wants to alter for reasons that would never guarantee peace, progress and development but satisfy the lustful appetite of a few, and ultimately abolish all forms of medical training and obstruct quality and safe health care. NMA will resist any action in this direction.

12. Doctors and dentists are hereby cautioned against using pathology services laboratory results not reviewed, interpreted and reported by pathologists thus guaranteeing reliability, safety and assuming responsibility for outcome of use. The unquenchable appetite to extort money and exploit suffering Nigerian masses leading to the phenomena of “pseudo-typhoid epidemic, small hepatitis and little malaria syndromes”, the ravaging of the populace by staphylococcus, etc, is one handy example of what running laboratories without pathologists’ looks like- human samples are handled without a recourse to the state of health of the owner. It’s only the pathologists that have the training and mandate to situate and connect the biological samples and the patient. Laboratories that do not have permanent or visiting pathologists are to be avoided as much as possible in the interest of patients and the public as quality and safety can hardly be guaranteed. The same applies to Radiology where there are no Radiologists.

13. NMA hereby informs all Chief Medical Directors and Medical Directors that it is more than ever willing to join hands with them to ensure the enthronement of international best practices, to resist all forms of mediocrity and wastefulness, and will stiffly resist any attempt to impede any category of doctors or specialists from optimally making their expertise available to patients, clinicians and the public or carry out responsibilities to meet the training requirement/curriculum of training colleges for those in training. International best practice shall remain our gold standard. Right to life is a fundamental human right, and giving of quality health care is in line with the fundamental right to life.  

14. We make bold to say that Nigerians deserve nothing less than quality and safe healthcare. We are determined to ensure that within the limits of available resources particularly in this era of heavy economic down turn; 

Enough of Mediocrity, Enough of Ignorance, Enough of Absurdity, Enough of Indiscipline!

15. The road we have decided to thread may appear rough but we are determined to forge along it though with pains. We therefore, call on all relevant government MDAs, the federal as well as state government and legislatures, and the entire Nigerian public to come to the rescue of our nation from the impending doom in the public health sector by taking immediate steps to redress the numerous anomalies and downward slide of the health system into the circus show it seems to have become. This is the time for the National Assembly to hold joint probes into what has shattered the peace of the public health sector. The best time for eminent Nigerians, respected traditional rulers and religious leaders to plead with government to halt the charade and bazaar going on in the healthcare delivery sector was yesterday, today is another good opportunity. We’ll hate to say we warned the nation.

We request that, the Medical and Dental Council of Nigeria should be reconstituted without any further delay so that appropriate regulatory activities can be effectively executed in line with the legal provisions, and malpractices and other breaches of its Codes of Ethics sanctioned accordingly. NMA is a lawful organisation. We will not support even our erring members in the name of camaraderie but must always defend the tradition of medicine handed over to us by our fore-bears right from the time of Hippocrates. There is no going back.

In line with the above, the Federal and State Ministries of Health must now rise and restore normalcy to guarantee quality care and safety; all seeming conflicting and obnoxious laws must be repealed or amended now. No bad law must be allowed to stay. For us as doctors, we have no business with any law or pronouncement that places individual or public interest at risk, for such will run contrary to the principles of medical ethics.

Finally, we believe that the recommendations of the Yayale Ahmed Committee on inter-professional relationships in the public health sector should be implemented forthwith. If the nation assembled a committee of great patriots of noble reputation to travel round the world to understudy and collate first-hand information on how the several professionals in the public health sector relate with each other in the work place and they’ve satisfactorily concluded that assignment, what then is holding the government from implementing the recommendations that would engender greater harmony and efficiency? 

We have spoken as never before, and we hope our nation will listen and act NOW. Let it be known that the private health sector does not experience the negative vibrations of the public sector – there are lessons here to learn. As you read this, please lend your voice against the descent to anarchy and implore the government to be courageous in doing only what is right according to international best practices. 

God bless Nigeria. 

 

SIGNED:

Dr. Kayode OBEMBE                                           Dr. Adewunmi ALAYAKI

 

PRESIDENT                                                         SECRETARY GENERAL