The well publicised effort and current legislative exercise by the National Assembly to enact a bill that will make it compulsory for medical practitioners to treat victims of injuries from gun shots is not necessary. The process is patently a knee jerk response to the latest publicised death from such injuries in the context of a disordered health care delivery conundrum. Knee jerk responses are by their nature signs of some underlying problems. It is the underlying problems that must be addressed.
Technically, such underlying problems lie at the controlling centre of corporate functions. In this case, the controlling centre is the government of which the House of Representatives is a part.
Genesis and sustenance of the problem
There are a number of issues involved in the genesis and the unfortunate sustenance, in the last 12 years of the barbaric notion that doctors required letters from the police before they could attend to their patients. It has always been a fallacy and has been consistently so described in the past 12 years that the nation has been put under such an avoidable, indeed unwarranted claim to law and normalcy.
Firstly, it was the Police that introduced this odious concept in 1997 and did all it could to give it the teeth of correctness. Patients who sustained injuries were being readily treated by doctors in Nigeria before the illegal pronouncement by the Police in 1997. In case the Police was interested in any particular patient who is receiving treatment in a hospital, there are time tested procedures for obtaining the cooperation of the hospital authorities and the attending doctor. The President of the Guild of Medical Directors at the time publicly debunked the queer notion and to be fair, the Police authorities at the time apologised and publicly withdrew the illegal directive. Most unfortunately, a number of doctors in private institutions as well as some police posts still maintain that illegality. Whenever the present writer at different professional forums had the opportunity to address issues on professional ethics, he deliberately included the issue in his presentations. The latest such event was on Wednesday 27 May 2009 at a workshop for female medical practitioners drawn from across the country at the Africa Leadership Forum, Ota.
Existing laws and rules cater for good practice
Secondly there are laws that provide for the nature of practice and responsibilities of doctors in Nigeria. In particular, after 46 years of the use of Westminster laws to regulate medical practice in Nigeria, national statutory provisions emerged after independence with the promulgation of the Medical and Dental Practitioners Act, which became operational from 18 December 1963. That law established the Nigeria Medical Council, the first regulatory body of medicine and dentistry in Nigeria. The political turmoil and the instability of government that characterised Nigeria from 1966 (at the advent of the first military autocracy) had their adverse effects on the development of the regulation of medicine and physicians over the years. The Medical and Dental Council of Nigeria succeeded the Nigeria Medical Council as a consequence of the promulgation of Decree No. 23 of 1988 (now the Medical and Dental Practitioners Act Cap M8, Laws of the Federation of Nigeria, 1990).
Further, since 1963 there have been Codes enacted by the appropriate national authority for the regulation of ethics in the practice of the profession in Nigeria. Every new medical or dental graduate is given a copy of the Code of Medical Ethics at the induction ceremony into the profession. By virtue of the Act,
• every prospective medical practitioner must have been trained in an institution duly accredited for training by the council
• such a duly trained person is put on the Medical Register that is maintained by the council. There are three registers: provisional, full and limited.
• every registered practitioner is subject to the Code of Medical Ethics as promulgated by the Council
• the Council issues rules and instructions from time to time to which every doctor is subject
The Code of Medical Ethics is the instrument for the maintenance of discipline within the profession. These rules cover certain areas of human actions and interactions in respect of:
• Legal requirements for physicians and dentists to practise in Nigeria
• Relationships between registered practitioners and patients.
• Relationships among colleagues.
• Relationships between practitioners and the lay public.
• Relationship between practitioners and para-professional persons.
• Advertisement, media exposure and health information dissemination for education of the public.
That essential role of the regulation of discipline is performed by the Professional Brethren of Good Repute and Excellence. This is a nominal body that legally does not meet but operates in two independent but complimentary bodies
1. The Medical and Dental Practitioners’ Investigating Panel, and
2. The Medical and Dental Practitioners’ Disciplinary Tribunal
Rights of patients
The doctor has a right to decide whom he would attend to professionally, just as the patient has a right to choose his doctor. Indeed, the relationship between a doctor and his patient, once that relationship is established is a contract. It is a contract that respects the constitutional rights of the patient.
The Code of Medical Ethics goes a long way in its Section 28, Professional negligence to protect the rights to treatment of patients who require urgent and immediate attention. It states specifically in a specific list of what, among others constitute professional negligence (a) failure to attend promptly to a patient requiring urgent attention when the practitioner was in a position to do so
The objective to be met by the proposed treat gunshot injured patient bill is already properly provided for in the National Health Bill that has been kept hanging in the House of Representatives.
Clauses 20 to 30 of the National Health Bill 2008 that was recently passed in May 2008 by the Senate but is still awaiting the action of the House of Representatives go a long way to give some details on the rights of the patient.
Specifically and relevant to the issue in discussion, Section 20 of the bill says
PART III - RIGHTS AND DUTIES OF USERS AND HEALTH CARE PERSONNEL
20. (1) A health care provider, health worker or health establishment shall not refuse a person emergency medical treatment for any reason..
(2) Any person who contravenes this section is guilty of an offence and is liable on conviction to a fine of N10,000.00 (ten thousand naira) or to imprisonment for a period not exceeding three months or to both fine and imprisonment.
Obviously for the reason of prompt emergency care to patients including those who sustained injuries from gun shots and for other reasons of equal significance, the House of Representatives needs very urgently to complete its work in respect of the National Health Bill that has been passed by the Senate since May 2008 and indeed has been in the legislative works since 2005, a period of four years.
The second leg of work to be done urgently by the government is to make universal to the 140 million Nigerians ready and coordinated access to healthcare. Presently, only 21 million Nigerians have any form of organised and ready access to healthcare. The national population is 140 million. A massive 119 million Nigerians cannot access health care even in emergency situations. The vast majority of those who die from gun sot injuries without receiving any care come from among the 119 million. It is this category of people that the National Health Insurance Scheme is expected to cater for. Like most Nigerian programmes, the scheme that had been in the works for 47 years and got enacted into the Statutes in 1995 merely catered for 1.8 million persons as at 2008. There is a lot that we can achieve by a judicious implementation of the Health Insurance Scheme. I quote from a recent work that we put out as a publication:
The National Health Insurance Scheme has the capacity and inherent virility and vitality to address the following basic issues in the Nigerian healthcare delivery situation:
Access by all Nigerians to modern healthcare delivery service is imperative and urgent. We are aware of the problems this policy might pose to a government that is implementing a structural reform programme at the behest of the World Bank and International Monetary Fund. It is our belief however that the government can overcome the dilemma by insisting that the NHIS is a part of the poverty alleviation programme it is pursuing. The point really is that it is unacceptable to have in these years of the 21st century even one person who cannot access healthcare services not to mention the 122 million Nigerians that are in that deprived category
Provision of an organised and integrated flow track from primary care level through secondary to tertiary facilities. Care delivery institutions must be appropriately designated for a level of care delivery on the bases of facilities, personnel and relevant functions. The regulators of the Scheme and the various governments will have to dismantle the mixed services that are lumped in the various institutions as of now. Each institution, either publicly or privately operated will provide service and care either at primary or secondary or tertiary level. Aside from easier overall monitoring and administration of the system (yes, we do need a system), practising professionals and the institutions will focus their skills and facilities on a definable spectrum of service provision and care delivery. Peer and regulatory monitoring of service delivery whether at institutional level or at individual or group professional level will be clearer and easier thus enhancing the quality of service delivery throughout the country.
The very unfortunate and anti-professional behaviour of practitioners in the health sector that has been upgraded to corporate levels in forms of quarrels among the professional associations of medicine, pharmacy, laboratory technology and other paraprofessional groups should not have arisen at all. There are laws in the books that very clearly define the different roles of the various professionals in the wide field of health care delivery. The relevant law that regulates each of the professions defines the roles of each profession in the wide terrain of giving care for the sick. The NHIS should be used to regularise professional service delivery in consonance with global tradition and practice through the ages and with the laws in Nigeria. That straight and simple solution to the unwarranted quarrels will willy-nilly lead to a resolution of the associated quarrels over fees.
Certainly, we can and should utilise the NHIS to integrate service delivery to patients and training of healthcare professionals at all levels. To some degree, there will be a coordinated and better integration of training facilities across the country.
The NHIS can be oriented to serve as a spark for the development of local capabilities for healthcare technology take off, local production of equipment and instruments, local capability for the maintenance of materials. This can be done within a programme of inter-sectoral coordination of efforts.
Over time, funding of healthcare delivery services in the country will generate considerable excess pool of funds that can be utilised through well organised system of disbursements both as loans or grants to refurbish, maintain, and expand facilities at institutional levels in addition to sectoral development of facilities in the country.
Other countries in the developed and not so developed world have successfully utilised concepts that are similar to the NHIS to solve the individual and national burdens of health care delivery in their societies. Having gone this far in a period of 46 years of imbibing the concept by starting the scheme, we should put available intellectual, managerial and operational efforts to create a credible system of access to good healthcare services by the underprivileged millions that are victims of the present anarchy in the sector. Indeed, the 16,560 political office holders and few civil servants who access taxpayers funds that should be applied to better use for the good of all will no longer need to travel abroad to sort out their minor and other ailments. To achieve these good objectives, it is wise that for a period of some ten years at the least, membership of the Governing Board of the NHIS should be restricted to serious intentioned professional experts drawn from the health sector and other areas in management, finance, and development economics. Partisan politicians and their cronies should for now stay off to allow a proper building of the operational infrastructures that are badly desired to lift the Nigerian healthcare delivery services to a modern age.
With the NHIS spread across the country as the template on which health care delivery thrives, the following principles and features will be made to operate:
• All basic services will be free to every citizen who must be registered for regular care with the nearest general practice outfit to his residence.
• Health centres to provide basic and preventive care services are run and maintained by Local Councils
• State governments will provide facilities for general hospital care across the local government areas in the state
• Regional governments will provide facilities for secondary care across the region
• Federal authorities will provide tertiary facilities across the entire country
• Private institutions will be available to provide care facilities at any level. However, such facilities will be within the needs as planned by the NHIS. The private institutions will be incorporated into the national plan and system for care delivery in the country.
• An organised referral system will be ascertained such that a patient receives the required care nearest to his home.
• Specific programmes in the areas of prevention of disease, eradication of diseases, environmental enhancement for good living, work ethics and practices in consonance with the promotion of good health and family living, food and water sufficiency for the promotion of the health of the citizen, recreational facilities will be pursued at all levels of government to reduce the magnitude of efforts in curative healthcare from time to time at all levels of government.
There is need for an organised healthcare delivery system
Finally, the governments of Nigeria must accept the sad judgement that there is no credible healthcare delivery system in Nigeria. A situation whereby the sick does not know where to receive appropriate care smacks of an animal kingdom. Every doctor is doing everything and every clinic or hospital is doing everything. That certainly is confusion to the carers and the patients. The National Health Policy recognises three levels of care. It goes further to allot the levels of care to the three strata of government. However, the state and federal governments hide under the cloak of the concurrency of health in the constitution to be involved in investment and management at every level of healthcare delivery. The local governments behave as if primary care delivery is not important to the needs of the population they govern at the so-called grass root level. The care centres are poorly equipped and poorly staffed.
Conclusion
In conclusion, there are two or three things to be done by the government
1. The legislature should as a matter of top priority, pass the National Health Bill into law and let the President assent to it
2. The executive should implement full access to an organised healthcare delivery system by full utilisation of the National Health Insurance Scheme.
3. Discard the treat gunshot injured patient bill. It is a knee jerk response. It is only a sign of illness. Treat the illness.
Dr Abayomi Ferreira
Head, Clinical Services
Med-In Specialist Hospital
Ogudu, Ikeja, Lagos
9 October 2009
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