Mike Ogirima, a Professor of Orthopaedic and Trauma Surgery, is the President of the Nigerian Medical Association, NMA, and President of Nigerian Orthopaedic Association. In an exclusive interview with Ayodamola Owoseye and Nike Adebowale, he speaks on quackery, doctor’s exodus from Nigeria, medical tourism and other issues affecting the profession in Nigeria.
PT – We have been trying to get the statistics of doctors working in the country. That has been quite difficult. Who is responsible for keeping such records and how does the NMA know its members?
Ogirima: The practitioners in the country are registered with the Medical and Dental Council of Nigeria, the body that is in charge of regulating the practice of medicine in Nigeria. In our own association, we are trying to complement their efforts by introducing doctor stamp, which will be mandatory on all medical documents that will be used by any physician in this country. With that, our doctors will take their stamps to be able to capture the statistics. Also we have an application, NMA App that will be available both on android and ios. As from April, every doctor is supposed to subscribe to that and statistics will be made available at the finger tip from NMA office.
PT- What would you like to achieve with the use of this stamp and how will it help in curbing quackery?
Ogirima– It is an anti-quackery measure. We discovered that medical reports are written from so many people, who disguise themselves as doctors. A case in question is a report written by a would be NYSC Corp member to camps, saying that a woman will have a man’s disease. Definitely, that cannot be from a medical doctor. But such a report, if a doctor’s stamp is on it, the stamp has the file number of that doctor, the name of that doctor, the institution and the year he graduated from medical school. So, it is there to checkmate a lot of quackery. And also, each medical institution, particularly private institutions should have a logo of such stamp by their sample so that you will know that yes, this is a qualified doctor. From 31st march, 2018, any doctor without the stamp will be treated as a quack. All doctors therefore have until the 31st of March to get their stamps because any letter emanating from a doctor without that stamp, is quackery.
PT- The law amending the National Health Act and prohibiting public servants from going abroad for medical tourism has passed its second reading. What is your opinion on this?
Ogirima– As long as a public worker is not using the public money for expenses outside the country, he/she has the right to seek qualitative health care outside the country. For us to have such a blanket law, it is not fair to every Nigerian who has the reason to seek for medical tourism. That law, if passed should be backed up by our infrastructure working optimally. They should be able to compete with such facilities outside the country that our people are running to. The irony is that all the facilities people run to abroad are privately owned. You don’t hear our patient going to general hospital Chicago or general hospital, London for treatment. The NMA is advocating that our private entrepreneurs should be encouraged to own and manage a government institution that has been badly managed. When good equipment are put under the private entrepreneur, then you can manage everything. So a public private partnership should be pursued. The government should first manage the infrastructure deficit on ground before passing a law preventing public workers from seeking medical attention abroad.
PT- With the government trying to reduce the pocket spending of Nigerians, don’t you think bringing the public private partnership into the health care system will increase more pocket spending?
Ogirima– Public Private Partnership (PPP) do not go in isolation. Let me draw our memory back to pre GSM era in our country. I bought my line for 20,000 in 2001 but today, the same line is offered free of charge. With PPP, there will be an initial stress but if it is wisely implemented, the cost of care will drastically reduce and there will be a lot of massive competition just like we have with GSM. That cost will also be buffered by government making Social Health insurance scheme, like the National Health Insurance Scheme, mandatory for all Nigerians.
With resident based study, only 10 per cent of a community will need health service at any point in time. So if everybody is pulling money in a central form that is going to be used for healthcare, only 10 per cent will access that money at any point in time. So we will still have a lot of funds to develop the infrastructure, build up more hospitals, and equip those hospitals to international standard. So health insurance scheme is the key. All these medical tourism outside the country, if you don’t subscribe to NHS in Britain, you can’t access their services.
Presently, health insurance is only 3 per cent coverage and it is only federal government staff. Few states are trying to come up with their own version but we want all the states to come up, federal government should also bring a template for non-formal sectors, the farmers in the village, the petty traders. This group of non-formal sector have a traditional system of contributing their produce without quarrel. Out of this you can say, one percent of what each person will take as contribution should be set aside for the health insurance scheme.
PT- Most tertiary health institutions in the country have become a shadow of themselves, most of them lack equipment and functional machines. How have doctors been able to work around this and how is it affecting specialization?
Ogirima– We have about 42 tertiary health institutions in the country, Federal Medical Centres, Specialist Centres and Teaching Hospitals. Some of the first generation hospitals like UCH, LASUTH are pulling their weight. And then because of negligence over the years, we have some of them dilapidated. Poor funding- The average budgetary provision for healthcare in Nigeria is between 3 to 6 percent as against minimum of 15 percent as agreed in the 2001 Abuja summit. Even the hospitals that are functioning are only managing the little funds they have.
Government in its own wisdom went ahead to withdraw some utility services like laundry, water, light, security. So each hospital is forced to source for them. This is affecting the provision of health services, training and also affecting the general well-being of Nigerians. Some of these hospitals have little options available to treat the populace.
There was an attempt by the past administration, that is 1999 to 2007 to rehabilitate eight of them but after four years, all the facilities were grounded due to (lack) of maintenance of infrastructure. That maintenance culture is not there. Garki hospital in Abuja is 100 percent PPP, and if you look at Garki hospital today and compare it to about 10 years ago, you will know that a lot of significant improvement has been achieved. Though you may say their service is expensive compared to a general hospital but the people who have the money to patronize medical tourism have the money to patronize these services. On the long run, we are still hammering on developing the PPP arrangement to rescue the health system.
PT- What is the reason for wrong diagnosis in Nigeria and what can be done to change this?
Ogirima– There are various regulatory bodies. The one for doctors is the MDCN, for the pharmacist is Pharmaceutical Council of Nigeria, the lab scientist and nurses also have theirs. A doctor is trained to listen, examine and subject that patient to specified test(s). In Nigeria, a lot of people want to take a short cut. When someone is having head ache, the first place they go to is the chemist, which means such a person has jumped the normal procedure, which is to first see a doctor.
The first thing the chemist should ask is where is your prescription from the doctor? The problem in this country is that, everyone wants to do everyone’s work. There should be inter professional collaboration in the health system. Misdiagnosis occurs because a lot of patients wants to short cut the referral system and they meet quacks in the field.
If Nigerians learn how to follow the steps, by first consulting a doctor who will then refer you to a lab and back to the doctor for prescription. If you jump any of these steps, you will end up with misdiagnosis and the regulatory bodies are empowered to minimize misdiagnosis. Another reason for misdiagnosis is because people are rushing for the money. The value of our system has changed from following the ethics to pursuing money. I tell doctors that practising this profession entails a divine call. If you don’t have the call to practice this (and it is) because of the monetary gain, that is where we have a lot of quacks.
PT- We have been having complaints about doctors carrying out operations on people, and just stitching them back, telling them they are treating them for an ailment. What is your association doing about that and how can this be curtailed?
Ogirima– As a doctor, you are trained to make a diagnosis. There are certain diagnosis that cannot be made just by seeing or examining the patient or even testing the patient. There are very few surgeries to explore. You open the patient and once you see the diagnosis, a trained surgeon will know when to proceed. If you can’t do anything to add value to the surgery, then take a piece of the tissue or organ you think it’s diseased and come out. Surgeons are trained to make appropriate decision. But the one you are talking of is, somebody, without making a good diagnosis, not prepared nor trained. That is quackery of the highest order.
That is professional misconduct and (the) regulatory body should discipline such an individual. Any member of our association caught doing more harm than good will be disciplined. A doctor must know his/her limit and stop there. Doctors that are not trained to carry out sophisticated surgeries are doing it, forgetting that every surgery carries its own risk. In Nigeria, every male staff is a doctor, even lab scientist, pharmacists are called doctor. And it is a country where great importance is attached to title so everyone wants to be called a doctor.
PT- Nigerians have experienced outbreaks of some diseases in recent times, leading to the death of some medical workers. What can you say they are not doing right, knowing full well that some of these diseases have been with us for years?
Ogirima– The whole system is in shambles and that is what we are not doing well. We have the epidemiology of all the diseases, yet we can’t prevent them. When last has government taken health education to schools, particularly on personal hygiene? When last did we have public officers going round, making sure our environment and dustbins are clean?
The ministry has an epidemiology unit that is supposed to know the statistic of disease and day in day out, we still have epidemics. So preventives measures are not there. When you come to the hospital, ideally if you enter the emergency room. The doctor has a gadget on, before you touch any patient you must be gloved, you must wear your gown, face mask but all this will add to the cost of services. The only place you can get this services now, is in private hospitals and few selected government hospitals.
I don’t advice my colleagues to touch patient with their bare hands. Every patient should be treated as a source of epidemic, so the doctors must use their gloves. If protecting personal equipment are not there then whose responsibility is it to provide such thing? There is what we call certificate of standard in the national health act, who is enforcing that? Do we have monitoring team of the federal ministry of health going round to ensure that this things are available?
PT- There are recurrent cases of medical negligence in the country. How is NMA working to curtail this?
Ogirima– Day in day out, we organise retreat to remind ourselves of the call as doctors. Attitude is one of our greatest problem in the health sector. The health practitioners are no more empathic, handle patients as your family. Negligence comes in when ethics are not being followed. The cases of negligence are serious and as an association, we don’t encourage such act. The council has an investigating panel that investigate doctors and if such person is found guilty, he will be subjected to a tribunal in the council.
PT: Dr Bawa Garba was delisted from medical practice recently. In your own opinion, do you think she was rightly delisted? What does this imply to the practice?
Ogirima: If her chief was brought into the picture, this would not have happened to her. In the practice, if you are not clear about certain things, ask your senior. It is very unfortunate that it happened to her. The lesson there is always ask your superior whatever you do not understand.
PT: Bringing it home, where most consultants don’t go to the hospital in a week because they have clinical days, do we say we have been giving too much to our residents, among others?
Ogirima: Before you appoint someone a consultant, he or she must have that cognitive and professional academic experience. The status of the consultant means that the consultant should have the power finale of the office. Most of our consultants in the public sector don’t even have a good office. I am not trying to defend anybody but that is the truth. For you to accept the role of consultant, you have accepted that you are going to guide whoever is working with you, give them proper advice teach them and transfer your knowledge to them.
Of course, a consultant should have at least one senior registrar, two junior registrar, one or two house officers. The junior registrar after seeing a patient, should call him the senior registrar who is about to be a consultant. If the senior registrar cannot solve the problem, then you call your consultant. If you are on call as a consultant, you must be at alert, whether you are living within the hospital or outside the hospital. The perfect system is that system where there is constant communication between the consultant and the residents on ground. The manager of a health institution must make sure that, if a consultant is on call he should provide an environment where a consultant can be reached within the shortest possible time. As a surgeon, you are available 24 hours when you are on call.
By the ratio of doctors to Nigeria’s population, we are far far below. World Health Organization (WHO) says one doctor to every 600 people but in Nigeria, we have one doctor to 2,000 people, so the work load on the doctors in Nigeria is very high. So if a doctor or consultant sits in the clinic and consults from morning till evening, there should be another doctor taking over but we don’t have this in the system. There is no reason why a consultant should be absent, except he or she is authorised by the institution to be absent.
PT: We have been trying to get factors responsible for the mass exodus of doctors and we got different reasons. How can we effectively keep our doctors in the country?
Ogirima: I have had one or two reasons to call state governments to employ a group of doctors. After two years of serving the country, doctors are jobless. In a country where we don’t have enough doctors, we can’t even employ the ones we trained. The government must increase the capacity of our health institutions, even if it means building more hospitals. There are several abandoned projects in the country but the health sector shouldn’t fall under such category. Government should build more hospitals, employ more hands because doctors are dying due to fatigue. Firms from other countries are coming into Nigeria to recruit our doctors. If my country can’t employ me for two years and I see someone that wants to employ me outside the country, I will go for it. Doctors are not asking to be the highest paid in the country despite the hard process of training. The World Health Statistics shows that doctors training is the hardest of all professions in the world. Doctors should be motivated because it is divine to study medicine.
If you pay a visit to those states that are encouraging their doctors to move, you will see the difference. Osun is in a bad state. In Kogi State, for the past 5 weeks, the government is not talking to the doctors on strike. Yet, we don’t have enough but how are you retaining the ones you have? So, doctors are moving from one state to a greener pasture state. If Zamfara is encouraging doctors from Kogi then let it be. At least, they are still working in Nigeria better than the ones emigrating. I urge more states to motivate civil servants in their states. Abroad, the equipment is there, the motivation is there for doctors to work well.
PT: Over 400 foreign trained medical students recently failed the assessment test. What is the cause of this mass failure? And how can it be addressed?
Ogirima: Globally, if you train in a country that doesn’t have reciprocal agreement with the other country, you cannot really move your service. I am trained in Nigeria and I want to go to England to practice, I must sit for an Exam which is equivalent to MDCN licensing exam. Until I pass the exam, I can’t practice in that country and same goes with America, South African and even Ghana.
Every April and November, we have licensing exams conducted by external examiners selected from Nigeria medical schools, professors. They set the questions they give to their final year medical student in Nigeria and give them to the foreign trained medical students. The pass rate we are having in Nigeria is about 35 per cent, Ghana is 11 per cent and Kenya has 15 per cent, so Nigeria pass rate is till the highest.
Our investigation is that the country where these children went to train have two parallel system. They train for export and train for their country. Turkey and Ukraine are examples of such country. We found out that most of this children that are failing went to medical schools outside the country, not United States, not Philippines and they gave them some packaging and sent them back to their country. They were not well trained as to merit that certificate.
My advice for government is to organise one year pre sitting for licensing exams, for those deficiencies. Once they can do that, the pass rate may increase. If our children trained here are passing the exams and if they say they were exposed outside the country better than our Nigerian candidate, then they should be able to pass the exams.
The solution is allowing MDCN free hand to supervise this examination. I will advise that MDCN should stop posting students to any hospital. Let them find out where they can attach themselves before they sit for the licensing exams. The children trained in Nigeria excel everywhere in the world, so let them all stay here and get well trained.
PT: You said your tenure will be expiring by April, so how can you grade your tenure and what are your achievements so far?
Ogirima: My tenure that started 29th, April 2016 will be coming to an end by April. From that date, we have instilled discipline in the profession. We have harmonised so many challenges, we have tried to unite the different affiliates and we have extended that by uniting the different professionals in the health sector.
During my tenure, I have not declared any national strike. I believe in dialogue, diplomatic, proactive and bridging any dichotomy. I approach the necessary authority once I hear of any crisis coming up and plan on how to resolve it. We have brought in so many innovations and legacies. The doctor’s stamp is innovative and we have re-branded NMA.
We have re-branded the Nigeria physician, we go about with our white shirt and green tie. We have amended our constitution and we have expanded our NEC meeting to bring in officers who have ruled the organisation. They bring in their years of experience and we have had a lot of harmonious relationship with different authorities. And I hope when I leave in April, this legacy will be maintained. I want the incoming executives to move this association higher. I want this association to be more concerned with improving the outcome of our patient care.