Emergency Healthcare in Nigeria- creating a workable system out of chaos.
By Femi Olugbile
Last week, the Healthcare Federation of Nigeria held a one-day conference in Lagos. Part of the theme was ‘Optimising Emergency Care Delivery’.
The Healthcare Federation of Nigeria is a coalition of private sector stakeholders dedicated to improving the Nigerian health sector.
‘Emergency’ in the context of health describes any situation that represents an imminent danger to life. Although people often think about such dramatic challenges as road traffic accidents or gunshot injuries, ‘emergencies’ occur across a wide spectrum of health conditions. They may be ‘medical’ or ‘surgical’ and may pertain to any part of the body. They may occur anywhere, and at any time. The ‘victim’ may be male or female, adult, or child.
A lot of lives are lost every day all over the world, due to ‘Emergencies’. Unfortunately, Nigeria is one of the worst places in the world for anyone to have a life-threatening emergency, whether it is a road traffic accident on the Kaduna-Zaria road or a ruptured aneurysm in the head at home in Enugu.
That fact is a call to good, rational thinking, not a charge to precipitate and ineffectual action.
In the past, there has been a tendency to look at issues in a superficial way, leading to knee-jerk policy making. For example, a law was enacted some time ago, making it illegal, on the pain of imprisonment, for any doctor to refuse to treat a patient with gunshot injury. It is true that many victims of gunshot injury die needlessly because it takes too long before they finally get to a place where the skills and equipment are available to save their lives. It is also true that many facilities that could intervene refuse to do so because they are afraid of ‘police wahala’. But the legal prescription is patently unworkable. Statistically, most healthcare facilities in Nigeria are roadside clinics and small, one-doctor general practices which have neither the skills nor the equipment to deal with gunshot injury. Everywhere in the world, Emergency care is stratified and regionalised, and it is considered a dangerous overreach for anyone to function beyond their competence. On the other hand, if the responsibility placed on the first medical stop is limited to first aid – in the form of a cursory assessment to staunch immediate threat to life, such as open bleeding, perhaps the setting up of an intravenous line, and then the facilitation of safe medical transportation to the nearest designated emergency facility, such a protocol would probably be enforceable, and could be the beginning of the building of a truly workable system.
Of course, ‘safe medical transport’, which may range from a ‘mobile intensive care unit’ (MICU) to a simple van with a trolley and a nurse or paramedic, must be available, and accessible. And someone, somewhere would have to pay for it.
There are two key aspects to Emergency care – the prehospital care and the in-hospital services.
A deliberate effort to build effective Emergency care in Nigeria, to the best of this writer’s knowledge, started with LASEMS (Lagos State Emergency Medical Services) at its base facilities in Lagos and Ikeja. A demarcated pre-hospital ambulance service (LASAMBUS) was introduced in 2001 and pushed with massive public advocacy by then Governor Bola Ahmed Tinubu, under the charge of ‘Dr-123’ Leke Pitan. Edo State has lately followed suit with a dashboard and an ambulance call system, and there are efforts afoot in other places to replicate the model.
There is a massive system overstretch, and a crippling failure to integrate resources from public and private sectors. Pre-hospital care in a resource-challenged environment is not solely a ‘government’ responsibility, but an ‘everybody’ challenge. While the few ageing LASAMBUS ambulances have their work cut out ferrying accident victims from highways in Lagos, hundreds of ambulances lie idle and unmanned in public and private hospitals. Effective communication, and a simple functional protocol coordinating and standardising human and material deployment, irrespective of ‘ownership’, would see the beginning of effective integrated pre-hospital services. The only question would be – who pays for the service?
The National Health Act 2014, surprisingly, has an answer. It created a ‘Basic Healthcare Provision Fund’ (BHCPF), allocating 1% of federal consolidated revenue funds annually, plus additional funds from elsewhere, for health insurance to the vulnerable, and strengthening of primary health care. 5% of this fund is dedicated for ‘Emergency Medical Treatment’ (EMT).
As is usual in Nigeria, the problem is how to design a system customised to real needs on the ground, and achieve maximum impact and efficiency, instead of spawning some new bureaucracy to ‘follow the money’.
Funds have been released annually for BHCPF since 2019. In 2023, the inflow into the account was 25.8 billion naira, meaning that money for ‘Emergency Medical Treatment’ – both Prehospital Care and in-hospital care, was more than one billion naira. Small, but a beginning. Each state, too, could add a similar percentage of its revenue to beef up the fund in its locality.
The ideal beginning is to maximally utilise, upscale and coordinate existing human and material resources in public and private hands, instead of, for instance, buying new, expensive ‘federal’ MICUs.
One of the panellists at the HFN parley was a winsome lady – one of only five certified Emergency Medicine specialists practising in Nigeria. She runs a private facility in Gbagada, in the heart of a dense population that includes ‘danfo’ drivers and thousands of commuters. Accident victims are brought in daily in droves. There are other emergencies, such as children with asthmatic attacks. Some of the patients pay part of their bills after the emergency has been sorted out. Many cannot or would not. In a month she is compelled to write off up to 7 million naira in unpaid bills.
She knows it is unsustainable, but what can she do, she asks, rhetorically?
It is a good question to ask of Nigeria. The right answers will, hopefully, lead the way into a brighter healthcare future.
