President Nigeria Medical Association Professor Mike Ogirima
Mike Ogirima, a professor of Orthopaedic
and Trauma Surgery, is the President of the Nigerian Medical
Association, NMA, and President of Nigeria Orthopaedic Association. He
spoke in an exclusive interview with Ayodamola Owoseye and Nike
Adebowale and Idris Ibrahim on critical issues in Nigeria’s
health sector and doctors’ perspective of the way forward.
PT -What has been your achievements since you got into office since 2016
Ogirima – Precisely, we
came in on 28 April 2016, following a very sad moment where we lost six
of our colleagues with the driver. We had to set up an endowment fund to
disburse funds for their families, including that of the driver.
We came with an agenda to correct
disharmony within the various groups of doctors and between doctors and
other professionals in the sector. As we are talking now, there is a lot
of trust that has been gained by our junior colleagues versus the
senior ones, between doctors in private business and the ones in
government hospitals. There is trust that has been built between the
doctors who are undergoing specialist training and their consultants.
Everybody thinks we are one family now.
And we are trying to discourage
government from individual negotiations for remuneration and welfare
packages. We have succeeded in making the government negotiate with us
as a group of health professionals within the health ministry. The
doctors, the nurses, the medical lab scientists are carried along when
it comes to issue of negotiations for welfare.
On contributions to various policies, we
have advocated that the National Health Act be fully implemented. Of
course you are aware that there was a peaceful walkout organised by the
NMA in the Federal Capital Territory and all the 36 states of the
country.
As I am talking now, certain provisions
of the Act are being implemented. For example, committees on various
aspects of the Act are being set up by the (health) minister. The
minister is everyday shouting about universal health coverage which
entails that about 10,000 primary healthcare centres will be
rehabilitated and made functional. They have started that with
Kunchingoro Primary Healthcare Centre as a model for all the health
centres.
The National Health Act says certain
provision from the Consolidated Revenue of the federation should be set
aside as Basic Health Provision Fund and stated specifically not less
than one per cent of the fund. That is the grey area and we are hopeful
that in the 2017 budget, if it is finally approved as a law, that
provision should be captured. Even if the President has not mentioned
it, we are very sure that as we partner with the National Assembly
committees on Health, at the end of the day that Basic Health Provision
Fund will be set aside as an additional source of fund to the health
sector.
That fund, if made available right from
2014, would have gone a long way to tackle a lot of issues, particularly
the issues of primary healthcare, because the fund provides about 50
per cent or 45 per cent of that fund to the National Health Insurance
Scheme.
For that of the NHIS, it is supposed to
be ploughed into vulnerable population of the country. That is the very
elderly, the infants and the road traffic injuries as emergencies to our
health facilities across the country.
The minister has made a lot of
pronouncements on accepting emergencies in our hospitals, particularly
public hospitals within the first 24 hours before you start asking for
police report and the public hospitals are keying into that.
The immunisation processes are still
ongoing, but what we are asking for is that we should include more
programmes. Like immunisation against viruses that cause cancer in
women, particularly the immunisation against human papilloma virus
(HPV), Hepatitis B. It shouldn’t just be ad-hoc arrangements. It should
be for adults and children, it should be part of the routine
immunisation package, just like the other killer diseases of childhood
are being immunised against.
PT – What is NMA doing about
doctors’ welfare and hazard of the job as regards deaths due to Lassa
fever and other infectious diseases?
Ogirima – On the public
health side, of course Lassa fever is a disease that is perpetuated by
rats. We are in the first burner of improved environmental sanitation.
But when infection sets in, because the health workers is the first to
be infected because of exposure, we have alerted everybody to take
seriously the clinical universal precautions against infections. That
entails washing of hands, disinfect your environment, don’t leave food
and left over open, these are basic things we have been campaigning with
relevant ministries of health.
For health workers generally, we have
asked them to be on alert. They should report cases that they are
suspicious about and be aggressive about confirming those cases. And
while they are doing their job, there are personal protective effect
that must be available and that we don’t joke about it.
For those who have been affected, there
are structures set aside by the government to address their treatment.
Of course, the mortality rate from the disease is quite high, about 45
per cent. Because of that, we are in the front burner of making sure
that Lassa fever epidemic is not seen again in our country.
PT- A major problem facing the
medical sector in Nigeria is brain drain where most of the doctors after
completion of study leave the country for greener pastures abroad. What
is NMA doing to curtail this, as most hospitals complain of shortage of
medical personnel?
Ogirima – The number one
reason why doctors and other health workers run away from the country
is the working environment. When you are trained as a specialist in your
field and you are left empty handed, there will be frustration. No
equipment to work with. There are lots of doctors now roaming the street
and there is general embargo on employment of health workers. This is a
country that cannot boast of enough number of health workers to manage
our system.
For example, the doctors on register in
Nigeria are about 35,000. That is doctors registered under the Medical
and Dental Council of Nigeria. In total it is 87,000, but practically
maybe out of this figure, 5,000 are in the UK, another 10,000 in Saudi
Arabia or United States. Then in the Far East, we see Nigerian doctors.
We don’t have enough doctors to patients
ratio. It is not enough, yet the ones we are training are not being
employed as at when due.
Even when they are employed, they don’t have up to date facilities to work. We all know the situation of our public hospitals.
These are the salient reasons why you have doctors looking for greener pastures.
Apart from that, though the government
tried to favour doctors’ entry into the salary scheme. In those days, a
graduate will enter at Grade Level 8, while a doctor will enter at grade
level 10 or 12, because there was no 11. In as much as there is a
structure like that on ground, it is not enough package to turn back the
tide of brain drain.
The only thing one as an association can
do is to plead with the government to rehabilitate our hospitals. Make
the working environment of a doctor conducive. If you enter any doctor’s
office in any of these hospitals, you will be shocked by what you see.
You will enter some public hospitals
where you don’t even have wash hand basin. It could be as bad as that,
where a doctor has to share toilet facilities with so many other people,
they have to leave the office for conveniences. That’s how the working
environment is.
In places where you have cases of
surgery, there is a waiting time. You have to wait until it gets to your
turn. You pray it’s not an ailment that will kill the person, but that
is the reality on ground.
Government should try and train more,
make sure our training institutions are up to date in terms of
facilities to train. Make sure the ones you train are engaged and
reabsorbed back into the system.
Yes, some fraction will still find a way
of looking for greener pastures but if you keep on training, going by
global standard I think the brain drain will be there but we will have
enough to take care of the population.
PT – Some colleges abroad do not recognise medical certificates of some institutions in the country.
Ogirima – What I mean by
government improving the training facilities, that does not mean the
ones available now are not training to international standard. Just last
year, two of my students got placements in UK and they are doing very
well once exposed to a better working environment.
Yes, some countries have that aversion to
Nigerians, but other countries still find our products very useful to
them, especially UK and US. If any other country refuses the products
then they have other reasons, not because of incompetence of our
products.
PT- On cases of medical
negligence of patients especially after surgery, how can clients seek
redresses and what disciplinary action does the association take on such
culprits?
Ogirima – Every hospital has or should have internal disciplinary measures to tackle issues that boil down to the care of the patients.
Negligence is one and as an association,
we have a regulatory body, the Medical and Dental Council of Nigeria,
MDCN. The law setting up that council in Nigeria allows administration
to change the composition of that council at any time. Presently, when
this administration came into power, that is President Muhammadu
Buhari’s administration, there was a general pronouncements that all
boards and general parastatals should be dissolved quickly. All the
regulatory bodies, not only the one regulating the practice of medicine,
all those regulatory bodies in the health sector were dissolved.
MDCN is just like Nigerian Judiciary
Council, NJC, for lawyers, or COREN for engineers or NUC for
universities. So why MDCN remains moribund for more than 20 months now
we don’t know. But that is the organ and council that we liaise with in
disciplinary cases such as misconducts and cases of negligence.
In fact, there is a tribunal of that
council that has same status as the high court. In fact, there are cases
now that are pending because that council has not been constituted.
The MDCN is the organ, and at the state
levels there is a committee of the MDCN which is chaired by the Director
of Medical Service from each state in connection with NMA. They are
supposed to monitor the activities of every doctor and to report same.
Apart from that, the National Health Act
provides that there is a certificate of standard for the health
institutions. Before you get a certificate of standard in any health
facility, you must be able to examine the qualifications of staff
working there.
All these things are put in place to make
sure the standard of practice is maintained. The law enforcement
agencies are also there. If you have a case of negligence, they can
actually come in to establish and institute legal procedure on the
culprits. Under an oath, the patient’s lawyer can ask for the case file
on behalf of the patient.
PT – What is the NMA doing on the issue of quackery How many have been arrested and what has been done with them?
Ogirima – NMA is not a
law enforcement agency but just a professional body that advocates and
would cry foul if we find quacks. Quacks are those who are not trained
to take care of sick persons, the only person trained to take care of a
sick man is the doctor. Every other person in the hospital are allied to
the practice of medicine.
So in a situation where I term Nigeria as
a confused state, where anybody can set up anything, it is not only in
medicine where we have quacks. Engineering, pharmacy, among other
professions too suffer from quacks. In a situation where a secondary
school certificate holder can open a chemist in this country, with no
knowledge of medicine and people will patronise the shop as long as
there are drugs there. There is quackery everywhere.
But as an association, anytime we have a
case, we report to the law enforcement agents. And we also advise the
law enforcement agents that when they catch a quack, they should not
label that quack a doctor until they have gone to MDCN to establish
whether that person has a licence from MDCN.
We have numbers, I know my file number
with MDCN. That is why NMA has a strategic plan which is going to bring a
lot of innovations to checkmate a lot of excesses. Every doctor will
have his own stamp just like the engineer. One of those things that we
are dealing with in our National Youth Service Corps camps is that a lot
of corps members brought medical reports and my committee has found out
that more than 90 percent of those reports were not written by doctors.
Somebody can just go into the hospital,
get a letter head and print something. One of the reports labelled a
female patient with prostate cancer! Women don’t have prostate in the
first instance.
We are doing a lot, in as much that there
is internal discipline among ourselves, we are going to go out fully. I
am sure that in the last three months you heard that NMA came heavily
on some members. As long as you register with MDCN as a doctor in this
country, you are automatically a member of NMA and if you are not
obeying our constitution, we will discipline you.
So we will start with house cleaning,
then we will extend it outside. Slowly we will get there, quacks will be
identified and prosecuted.
PT- Still on quacks, it is a common menace especially in the rural areas where there are shortage of doctors.
Ogirima – We have been
advocating that as government is reactivating the primary healthcare
centres, every ward is supposed to have a primary healthcare centre, we
are saying a doctor should be employed at that primary healthcare
centre.
They should not just leave it to the
Kuti’s doctors, (there was a programme during the late Olikoye Ransom
Kuti, Minister of Health) who brought in community health workers (CHW).
The government should not leave the health of our people 100 per cent
to the hand of these cadre of health professionals.
Let them be supervised by a qualified doctor who will diagnosis and treat the patients.
Those set of professionals work with
guidelines, but a doctor listens, examines and infers and lays out the
laboratory test the patient is meant to do.
We have public health physicians, that is doctors who specialise in public health.
They can be there but what it takes is
that there must be incentives to keep them there. Those doctors in the
rural areas should be able to send their children to good schools. They
should be in connection with the world. The world is a global village so
they must have all those things that will link them to the world.
If you have all those things and a doctor
still refuses, then something is wrong. Maybe in the first instance he
wasn’t called to be a doctor.
We all started practicing from the
village, and that is the essence of NYSC. From there you can go for
specialisation or start working with the government and pursue a career.
With incentives, my members are ready to work in the primary healthcare
centres.
PT- It has been noted that consultants refer patients from government hospitals to their own private hospitals.
Ogirima – It is an abuse
of the system. The MDCN allows a consultant to own a clinic. What we
mean by clinic is a small place where you can see a patient and
recommend treatment plan.
MDCN code of ethics states that if you
are working in a public hospital, you cannot manage in-patients in your
facility. So you cannot run a hospital.
But the mentality of Nigerians, the
people are not knowledgeable to know the difference between a clinic and
a hospital. I will support a situation where the government will come
out clearly and make directive that those employed under the public
hospitals (government services) are not allowed to have a clinic. Then
we will work by the rules to curtail excesses.
But I know that there is a law in this
country that any civil servant cannot practice outside the working hours
except if you have a farm. How many people are obeying that law? You
have surveyors, pharmacists, lawyers in the government that have
external practices. The government should come out clearly to bring out a
law that will ban extra-curricular practice or private practice in all
the professions.
PT – Why is there an embargo on
employment when the number of doctors in the country is a far cry to
what is needed, especially in terms of doctors patients ratio? Ogun
State for example lamented having only 150 doctors in the public
hospitals.
PT – Ask the government. I am not the
government, NMA is not the government. But we have also observed and we
have been shouting. In my state, I met a doctor in my village of about
200,000 people and he is alone in that general hospital.
I asked him how he has time for his
family and when is his weekend, he said he has no weekend. So it’s not
only in Ogun State, it is all over the country. The worst hit is the
northern part of the country.
There are so many general hospitals
without doctors. That is the point we are making; that how can we be in
the midst of plenty and we are suffering? There are doctors looking for
jobs. Maybe it is the recession. I pray this recession will end fast so
that the government should employ more doctors, more nurses, because you
go to the hospital in a 40 bedded ward, only one nurse is on duty for
shift.
Our doctors are dying, health workers are
dying because of fatigue. They are collapsing. The last time we had two
episodes in Zaria, a nurse collapsed, a doctor collapsed, they died
because of the pressure of work.
So we are using this opportunity to call
on government that they must employ health workers to fill up the
existing vacancies. A lot of vacancies exist in the hospitals.
PT- Resident doctors have always
gone on and off strikes. What is your opinion on this? And what is the
association doing about cases of doctors who have passed their primary
and have no placement for residency programme until it lapses?
Ogirima – Agreements
were reached between the government and the residents, between the
government and professional bodies. In 2014, doctors went on strike for
52 days. The reasons they went on strike then are the same reasons they
still go on strike. The last time they went on warning strike and they
are back to their duty post. What is happening in their January salary
is that there is a shortfall of about 30 to 50 per cent. We are asking
the government again, why? And I am seizing this opportunity to ask the
government, particularly the Minister of Finance to release that
shortfall within one week. Other hospital workers have collected their
salary full, 100 per cent. But only doctors, resident doctors
particularly have been subjected to only 50 per cent or 70 per cent of
their salary.
Is it a punishment because they went on
warning strike? I am being forced to believe it is a deliberate attempt.
Those are the reasons why a doctor would abandon his patients. If a
doctor is hungry and nobody to feed the doctor. I am sure if a doctor
and any other professional go to the market to buy any item, for the
fact that you introduce yourself as a doctor they will give those
products at a very high price.’
In those days, the populace fight for the
doctors’ right and that is why we are telling everybody the reasons
now. What crime have they committed? They have done their job 100 per
cent but they were not paid 100 per cent.
But if they abscond from duty, there will
be no work, no pay in the same system. That is injustice. So while I
will appeal to my colleagues not to go on strike, they should tell the
public the reasons why they go on strike and let the public judge and be
the advocate of their plight.
I as an individual, I don’t like going on
strike and at my stage, I will never encourage strike from any health
worker. With the National Health Act, it is illegal for any health
worker to go on strike. As a consultant, I can never go on strike
because the law states that as a consultant before you go on strike,
look for another consultant to handover the patients to and it is not
possible.
For those who can’t get in for residency,
it is still the embargo. The residency programme is a temporary stage
in the doctor’s career. As you finish, another set of residents are
employed. But here we have an embargo. In fact, in most teaching
hospitals now, the top cadre of residents of residency programme is
congested. People who are already waiting to exit, they don’t have the
junior residents as back up to replace the ones that are been trained.
I think it is the embargo or recession,
but we are begging the government to please make sure that the
specialist cadre in the health sector is not depleted. They must sustain
the residency training programme because if you don’t have primaries
you cannot be engaged in the residency programme. A lot of doctors are
having primaries, yet they are looking for placement.
PT – As an orthopaedic surgeon,
you deal with images most of the time. But looking at Nigeria where we
have few hospitals with imaging equipment and the private ones either
expensive for patients or not functional, how have you been coping?
Ogirima – As an
orthopaedic surgeon, I started without a tray and I wasn’t frustrated
because that was my call. I have a passion for orthopaedics. But I had
POP (Plaster of Paris) to apply. So we started from non-operative
treatment and gradually with my personal efforts I got a tray and I was
using it. (Surgeons tray contains all the gadgets they use for surgery).
The medical imaging is a dynamic and
revolving field. Whatever x-ray you use today, in the next two years it
is obsolete. You need to keep updating. Yes, a lot of private hospitals
are giving the government competition now in that respect. If you look
around, private hospitals are coming up, doctors are forming
partnership, group practice.
Why are the government hospitals not
measuring up with these gadgets? The reason is simple. Governments talk
about subsidy in medical care, government will buy an X-ray equipment
of, let’s say $100,000, the same X-ray equipment will be bought by a
private hospital for $900,000. But the private hospital will have a
pricing system that will make the private hospital factor in the price
of changing the machine in some few years and also make profit. There is
usually sustainable costing of service in the private hospitals.
This is quite the opposite in government
hospitals where tests are usually subsidised and done at cheaper rate.
They tend to overwork the machine and when it breaks down, they will be
going to the Ministry of Health or Ministry of Finance to ask for money
to repair or buy a new machine. That is a bad system.
Another reason why people would go abroad
for medical care is because you have a building called teaching
hospital with non- functional machines because they have broken down and
they keep telling people to come back in weeks.
If government has instituted maintenance
culture according to our services, that would not be happening. So that
you will have a plan maintaining the machine, have enough money to buy a
backup. Most MRI (Magnetic Resonance Image) machines we have are just
single unit in all teaching hospitals. If they break down, it takes
another one year to start budgeting and get a spare part. This is not
how to run the medical business.
Yes, some have subsidiary, but is the
government providing the deficit in the charge to the operating hospital
to maintain the machine? Yet hospital management cannot exceed certain
limit in the costing of services to maintain the hospital.
PT – Can you say how much Nigeria has lost to medical tourism?
Ogirima – There is no
study that will harness all the losses we are having for medical tourism
abroad. But there was an estimate about three years ago, on a
conservative estimate, Nigeria spends about $2 billion looking for
health care outside the country.
India takes about 80 per cent of that
fund. That is a conservative estimate. The good thing about the economic
recession is that there is no money again for those patronising the
hospitals outside so they are forced to look inward and patronise the
good hospitals around us.
Until there is a study, I challenge our
colleagues in the public health department to come up with a study and
assess how much Nigerians spend to treat themselves outside the country
so that it will be a national figure.
PT – What is your view on the 2017 proposed health budget?
Ogirima – I am not
comfortable with that figure. The money budgeted is a far cry from the15
per cent agreed for health sector by African countries. I don’t think
it will solve a lot of problems, but I am hoping and trusting that the
National Assembly will pass a budget that will provide extra funds for
the health sector, maybe through the operationalisation of that National
Health Act.
At least one per cent of the Consolidated
Revenue should be set aside for the health sector. If they do that,
there will be more funds in the health sector.
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