What is the state of healthcare in Nigeria? We examine this through the eyes of a Nigerian doctor.
I have the need to put down my thoughts and frustrations in writing because people need to be informed about the happenings in our health care sector and circumstances within which the average Nigerian doctor has to work.
These are personal experiences and opinion of the writer. I do not intend to write specifically about any patient in details because I don’t have their permission to do so; patient biodata and location of events would not be disclosed in order to keep them anonymous. Some scenarios may be so familiar and this is due to similarities in patient presentations and similar limitations in different healthcare centers in the country.
I have over 10 years post qualification experience working in both public and private sectors in Nigeria. I have schooled and worked in almost all geopolitical zones in Nigeria, so when I write from my own perspective, it is CERTAINLY NOT a single story.
When I decided to study medicine, it was solely on the premise that it would afford me the opportunity to help people remain healthy and/or get cured of various ailments. During my clinical rotations as a medical student, I got to realize that there is a limit to which doctors can help. Peculiar to our setting however was the shocking revelation that there are further limitations which are solely due to the environment in which we practice.
As students, we were shown some instruments either in pictures or from the hospital store rooms that were not functional. We learned how to improvise a lot of basic things but our teachers would often drum it into our ears that this is not ideal. They would always make reference to the fact that most of us might not all practice in Nigeria or in government-owned hospitals. Some private settings are even more equipped than government-owned hospitals.
Lack of equipment in our Nigerian hospitals
One of the first bitter experiences I had that brought to fore the problem of lack of equipment happened during one of my surgical rotations. I was on call duty and a certain elderly woman was brought in with gunshot injuries sustained during an armed robbery attack while travelling to a nearby state. The chief surgeon came to do an exploratory laparotomy at 1am. Exploratory laparotomy is a type of surgery where the surgeon opens up the abdomen without prior knowledge of abnormalities that may be seen in the abdominal cavity. Hence the surgeon goes in to explore and find what the problem is during the surgery.
She had a bullet in her right kidney and perforated bowels (intestines) from the gun shot. She had to have her left kidney removed (nephrectomy) and 4 points in her intestine had to be cut out and the stumps attached back to the intestine (resection and anastomosis). She had blood transfusion during the surgery because she had lost a lot of blood.
When she awoke from anaesthesia and was taken to the recovery room, it was about 6am. The surgery had lasted about 4 hours. She was eventually transferred to the ward and was stable until about 10 pm when she developed sudden breathlessness. She needed oxygen and was given the one available in the ward but there was not enough in the oxygen plant that night. Her oxygen saturation kept dropping, all oxygen cylinders were empty. She passed on early hours of the morning.
In most hospitals in Nigeria, there is no functional oxygen pipeline system therefore we have to move oxygen cylinders around to wherever a patient is in need of oxygen. There is only one tertiary institution where I have seen a functional oxygen pipeline system. It is very unfortunate that she got the help she needed, developed a complication but couldn’t be helped to the best of our limits because of a dysfunctional system.
While she might have still passed on from pulmonary embolism which was the most likely cause of the breathlessness, we would have known that we did all within human limits to keep her alive if she had gotten the so much needed oxygen.
The out of pocket payments and lack of universal insurance has caused a lot of preventable deaths in the country. Most people do not know when they would fall ill. Most times the financial burden of treating an individual is borne by the sick person and their relations. I’ve often had to witness how much effort is put in to gathering money from different friends, well-wishers and relations. Making of phone calls and sending text messages. The sadness in the face of care givers while awaiting contributions from different quarters in order to be able to get required tests and medications for their loved one is heartbreaking.
A young lady in her early 20’s who had a child 3 months earlier came to the hospital complaining of difficulty breathing, cough and body swelling. Obviously from history and examination her heart had failed from peripartum cardiomyopathy. She needed a gamut of investigations and then medications. we informed her relations but they could not afford most of the tests that were requested. She had an abnormal heart beat rhythm (we can tell from examination).
We knew she might have a blood clot in her heart and we wanted a heart scan (echocardiography) to find out so that we can give medications to dissolve the blood clot and prevent stroke and other complications that may arise. There are times we can foretell the course of a disease and outcome if an urgent intervention is not instituted. We go ahead to find a way to mitigate this by sourcing for donations or waivers on behalf of the patient. On several occasions, I have had to make contributions to raise money for a patient’s investigations and drugs. This case was one of those.
Every doctor in the team contributed money and she got some of the blood tests and heart scan. Alas, our fears were confirmed. She had a huge blood clot in her heart and she needed anticoagulation. Anticoagulants are drugs that help to melt blood clots in the body and keep blood flowing through the body in liquid form. The drug was prescribed but 3 days later there was no money to purchase it. Relations were still trying to gather money.
By the 5th day on admission, she was suddenly unable to move one side of her body and was not fully aware of her environment. What we wanted to prevent had happened! Stroke in a young woman in her 20’s. Then we needed an urgent brain CT scan. They also could not afford this, and it is dangerous to anti-coagulate at that point without a brain CT scan because we do not know the type of stroke she had suffered. Anticoagulating a patient with a hemorrhagic stroke would worsen the bleeding in the brain, Anticoagulating one with a big infarct can cause bleeding in the brain.
This was the dilemma in which we found ourselves. She later deteriorated and became deeply unconscious. We envisaged that she might have had another blood clot in her brain or the brain was swelling up rapidly, so we gave intravenous drugs to help with reducing the swelling while hoping for the best. We couldn’t determine the extent of the insult to the brain, whether a surgical intervention was needed or not because she didn’t have a brain scan. Our hands were tied, so we prayed and hoped for a miracle.
Next, the nurse drew my attention to the darkening of the right hand, there was no palpable pulsation in the wrist and the hand was cold. Another blood clot had blocked the vessels in the hand. We only speculate, we do not have any radiologic or laboratory evidence for this. She passed on in the next day; one of the many preventable deaths.
A 51-year-old man was rushed into the emergency department at about 12 midnight. He had convulsions more than 10 times in the preceding 6 hours. The wife noticed he had become unconscious after the last 3 episodes and raised alarm for neighbours to help her bring him to the hospital. We gave the first line drugs but he was still having convulsions so we prescribed second line injections.
Unfortunately, it was not available in hospital pharmacy and all pharmacies in town were closed at the time. We prescribed the oral anticonvulsant and planned to pass a tube through his nostril to deliver the drug but it was also not available. So we went to the ward in search of patient on admission who had the drug that this man desperately needed. We had to inform the patient that we wanted to borrow part of his drugs and it would be replaced in the morning.
That is the extra mile we go often and we pay back if the patient does not replace the medication or passes on before morning. It is difficult to start telling someone who is recently bereaved to pay for a drug you borrowed, so you just pay back yourself.
We gave the drug and he stopped convulsing for some time but by the next morning, he had started having convulsions again. Administered another drug, still no resolution of the convulsions. We then invited the intensivists to review and transfer to Intensive Care Unit (ICU) because at that point, he needed anaesthetic agents and closer monitoring as it had become refractory.
There was no space in ICU, we had no High Dependency Unit, so we continued to give 2nd line medications. You can’t give 3rd line without close monitoring. This has played out before my eyes many times. We only pray and hope they get better and not suffer complications. Luckily, some patients eventually get well and go home with some temporary memory problems. Others will eventually suffer a sudden cardiac arrest.
The problem of fake drugs in Nigeria
Another huge problem that plagues the healthcare system is the problem of substandard and fake drugs. We have had patients with meningitis on several occasions who were not getting better even with optimal treatment. Going through their treatment sheet, we see that they are actually getting the drug as and when due but clinical condition is still on a downward spiral. Then we request to see the drug being given and realize it is most likely substandard. A particular brand of antibiotic for meningitis is what we recommend because we have used it many times and gotten good results.
A patient relative once came with 10 vials of this antibiotic and I asked how much he bought it and he said it was
N4500 (about 10 dollars). The one that works is N3500 per vial so how can one of this be 450 naira. He insisted he was told it’s the same thing at the pharmacy where he went to buy it and we should administer it to the patient. This was after 4 doses of the branded one.
After explaining and he insisted, we started administering this one and of course the little improvement noted was gone and the patient never fully regained consciousness. When a doctor tells you to buy a particular brand of a medication, it is for your own good.
Your doctor is most likely making that recommendation based on experience and evidences that abound of substandard drugs in circulation. That drug probably had much less than 50% of the dose of active ingredient written on it. Some patients are just suspicious of doctors even when you have their best interest at heart. They think you just want to extort them even though they are not directly paying to you.
Sometimes we prescribe drugs which we know are not readily seen so we tell the patient the drug may be difficult to find. We go ahead to recommend where they are likely to get it but they misinterpret our good intentions. Quite unfortunate.
Another issue is the lackadaisical attitude of the society towards their health. I know that some health professionals don’t do well in adequately educating patients. Even when they do, sometimes the patient refuses to listen because it is generally believed that doctors are a bearers of bad news. Some of these attitudes are due to illiteracy, religion, poverty and ignorance. You can subscribe to medic drive or join the groups on medic drive to get up to date medical information.
Religion and Healthcare in Nigeria
A story comes to mind about a woman I met during an outreach where women had free pap smear done. Her result came out suspicious of early stages of cervical cancer. The team contacted her to return for a repeat test after explaining the implications of the result and reasons she should act immediately. She was over 45 years of age and we had explained to her that the uterus and cervix should be removed at this early stage before it progresses to the late stages. She said it is not her portion, she can never be sick and no doctor will ever touch perform surgery on her.
I understood she was exercising her faith so I let her be after pointing out the consequences of her decision. This kind of attitude is very common among Christians. They quote scriptures, declare that they are healed and tell me what their pastor said as though I am the devil himself. I understand having faith but there is no harm in checking to confirm that you are really healed and then you have evidence of your miraculous healing. I have seen patients that got healed miraculously and confirmed by examination and tests so I do know that miracles are real.
The next time she came to hospital was due to vaginal bleed and she was almost at the last stage. She started chemotherapy and other treatments. I left the town afterwards so I could not follow up on her progress. While I was there, whenever I saw her I couldn’t help but imagine how much better her life would have turned out if she had only repeated the test and had the surgery.
Finance and Healthcare in Nigeria
My heart bleeds when I see patient relations insisting, they want to go home with a very ill person due to financial constraints. We have Social welfare departments who can only offer drugs and pay for tests for the patient. They do not offer food and other means of sustenance to care givers. Some of them want to go home with their sick loved one because they don’t even have money to feed. I would explain that the person is critically ill and may die if they take him/her away. They agree that they understand that.
What level of lack will make a brother and wife agree to take their sick brother and husband home knowing the consequences of such action? Sometimes it’s the shame that come with being at the mercy of people to help feed, the fear of loss of job of the caregiver, the loss of business profits and even capital. It is the children who are starving at home or out of school because the breadwinner is unable to trade/work and earn the daily bread. The pressure from home to bring the sick person home for traditional healing or to church/mosque for prayers.
Refusal of vaccines and the role of suspicious and superstitious beliefs
I see people refuse to vaccinate their children and they die from complications of a vaccine-preventable disease. The vaccines are available free of charge but suspicious and superstitious beliefs make them refuse to take it and/or allow their children receive it. I was in a team treating a man with hepatitis B-related liver cancer whose brother and father died of same condition. At that point, his wife wasn’t aware of her status.
We offered her the test but she declined and her children had never received vaccines. The same disease that killed your father and brother is not plaguing you but you are not concerned enough to ensure it doesn’t kill your children?
Lack of confidence in Nigerian doctors
Sometimes when people complain about the healthcare system, they are not being totally truthful. A middle age man had been complaining of stomach ache and weight loss and treated for ulcer many times. My team saw and advised an endoscopy to look into stomach. He said he had no money for the test. The rich uncle called to ask what was wrong he said he was told it is ulcer. Uncle was concerned cos he was losing weight. He said doctors could not find what was wrong but didn’t mention the tests that were requested to aid arrive at a diagnosis.
His uncle eventually took him to India for treatment, where they paid for all tests and was found to be cancer of the stomach. Then they will begin to praise foreign doctors to high havens for making the diagnosis. Patient with cancer went to India for chemotherapy, returned and was insisting cost of chemotherapy was too high and he is being extorted. He failed to recall that India has laboratories that produce the drug but in Nigeria we have to import and pay duties and businessman must make some profit.
Another had paralysis from lower limb he needed intravenous immunoglobulin or plasmapheresis but neither of the 2 were available so he was referred to a hospital where he could get it but could not go because of costs. Was convinced he would start walking once he left the shores of Nigeria. When he requested for a medical report, we explained to him that his is a gradual healing process as he was out of the acute phase of the disease and these treatments may not make much difference but he insisted and travelled. I saw him during follow up and he was lamenting on how he went and wasted his money and time.
You may be wondering why the writer is still in the country with all these issues. Why not leave like your colleagues? You may ask. Well, It’s not all gloomy. Inasmuch as I’ve had frustrating experiences. There have been good experiences with beautiful outcomes that bring a smile to my face.
It’s not all gloomy
A woman brought her 2-year-old with fever and rashes all over his skin. He was so skinny because he was refusing food and drugs. There were sores in his mouth. The woman wanted to bring the child to the hospital earlier but had to wait for her husband to return from a journey.
We later got to know the father of the child finally accepted to take them to the hospital because of the mother’s cries and pleas. The boy had never been vaccinated and he had measles. The father paid for drugs the 1st day and started requesting discharge. The mother was pleading with him to let them stay as the boy wasn’t better yet.
There was some drama in the ward the day this child was transferred to the ward from emergency unit and the father came to the ward insisting that he be discharged immediately. The mother was begging, doctors and nurses were explaining that we had to transfer to make space for other emergencies. He insisted he didn’t want admission. We even told him money won’t be a problem as there is a dedicated welfare fund for children and philanthropists from time to time made donations for treatment of indigenous children.
He flared up, saying we were implying he is a poor man. He turned to his wife and told her that if she doesn’t follow him with that child immediately, he will never come to the hospital to see them again and she should do whatever she wants. She kept pleading with him till he left the ward, along the corridor she decided to return.
We asked what she wanted to do and she said with tears in her eyes that we should go on with treatment as she didn’t want to lose her son. We had a meeting and agreed on bringing food for the mother, involved the child social welfare department, nutritionist and continued to treat for the next 2 to 3 weeks.
He got better, started gaining weight and was discharged home. True to his word, the father never came to see them till he was discharged. I don’t know if the parents reconciled afterwards but my joy is that the child was saved and we got the chance to educate his mother on need for vaccination to prevent recurrence of such event. I’m so sure she learned her lesson cos she brought her older children for catch up vaccines and promised to vaccinate subsequent children.
A young lady had had fever for months and was losing weight. Had been transfused blood many times due to anaemia. Also had abdominal distension from fluid in her abdomen and lungs. We explained to the parents and husband that we were suspecting an autoimmune condition and she needed some tests which were not available in the locality of practice.
We made enquiries and found that the closest place she could get the test done was about 6 hours away by road. Her parents accepted to do the test because they were glad to know that someone even had an idea of what may be wrong with her. Her blood samples were taken to the laboratory out of town and tests done. Results came out and confirmed she had an autoimmune disease.
She started treatment, got better and went home. She was taking her drugs, coming for her follow up visits and has been stable since diagnosis. The last time I saw her mother she had told me the lady just had a child and was doing well. Happy ending.
We admitted a young man with acute kidney injury who had no source of income. Family managed to pay for a session of Haemodialysis but he needed more sessions to salvage the kidney. The specialist in charge of his case was able to get a waiver for him to get 3 sessions and his kidney function returned to normal after the 3rd session.
Another happy ending because the specialist had to go advocating for the patient. Sometimes going extra mile works and sometimes it backfires when same person you were trying to help backlashes you. However the joy that comes with happy endings is what keeps us going.