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, 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.