Medical Negligence In Nigeria [Part 3]: In Search Of Solutions

This is the last in our three-part series on medical negligence in Nigeria. Part one, “When Hospitals Kill,” explores the reasons for the prevalence of medical negligence. Part two, “The Slow Road to Justice,” focuses on the challenges of reporting and prosecuting medical negligence. Now in this piece, we look at solutions for preventing medical negligence in the first place and reducing the number of Nigerians dying from the very medical system whose function it is to save lives.

When it comes to Nigeria’s epidemic of medical negligence, medical doctor Biodun Ogungbo has this to say: “We are in a cesspool; everybody is swimming in that cesspool. Deaths are happening. Yet, we do the same things.”

There have been repeated calls for improvements to the health care sector, including better funding and upgraded facilities. These issues have even been the focus of labor actions; last year, two medical organisations – the Nigerian Medical Association (NMA) and the Joint Health Service Union (JOHESU) – went on strike for a total of six months, crippling hospitals.

The signing of the National Health Act (NHA) into law in December 2014 drew even more attention to the health care sector, yet since the bill’s passage, not much has changed. Our government hospitals remain largely the same: under-equipped, under-staffed and crying for help. In addition, many private hospitals need to be regulated, and some to be shuttered altogether.

As we strive to extricate ourselves from the cesspool of medical negligence, it is important to remember that everyone has a role to play, including the government, hospitals, medical doctors, lawyers, medical organisations and patients themselves.

The Role of Government

The government at all levels is responsible for the delivery of quality healthcare: the federal government for tertiary healthcare, state government for secondary healthcare, and local government for public health centres. Many people believe that because the government both champions and enforces health policies, the responsibility for ensuring quality care falls on the government first and foremost. But what exactly does the government need to do?

Medical doctor Douglas Okor has put much thought into the issues he would like to see addressed by the Nigerian government in order to reduce medical negligence: “First, there should be a quality health care workforce with global standards of knowledge, competence and skill. Second, these hospitals should have the right leadership and management. This includes political leadership (through the Minister of Health) and administrative leadership at all health care facility levels. Third, the hospitals should be equipped with the right health care infrastructure and technology in place. Fourth, there should be robust regulatory and accountability mechanisms/institutions in place.”

These solutions sound ideal, but what happens when funding is scarce? This question is central to Nigeria’s ailing health system. The recently passed National Health Act established the Basic Health Care Provision Fund, to be funded by the Federal Government Annual Grant at not less than 1 percent of its Consolidated Revenue Fund, international donors and any other sources combined.

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But in these days when the federal purse is said to be empty and when state governments cannot afford to pay their civil servants, the fate of hospitals is unclear. It remains to be seen where the funds – 50 percent of which are to be used for providing basic minimum health care services to citizens – will come from, as well as how state governments will finance their state-owned general hospitals. It is critical that the government find more practical financing options for the health sector.

Procedural improvements are needed as well. The NHA’s requirement regarding making reports for issues within the health sector remains unfixed. And while the NHA places the responsibility for instituting mechanisms for reporting medical negligence under the purview of the minister, commissioner or any other appropriate authority, Ogungbo advises a more practical approach.

“I went to a hospital in Bangkok, and they had on their notice board something called “Medication Errors,” which means all the staff – especially the nursing staff – are sensitized that they are monitoring errors: injection errors, whatever errors that had been made. So each month, they are looking to see what has happened wherever. Each month, this board keeps record.”

Ogungbo says this is different from the “morbidity and mortality” reporting practiced in Nigerian health facilities, in which only deaths and their causes are listed. It should not end here, he says. “The thing is that nobody actually says, ‘This must never happen again and these are the things that we will need to put in place.’”

What exists in most government-owned hospitals is Servicom, which for users who do not speak English it is just a notice board with letters in front of an office (the Servicom notices are usually written in English). And many private organisations still do not have reporting mechanisms, even though it is important for complaints to be acknowledged.

But besides simply receiving complaints, the government needs to enforce policies to ensure that errors and complaints are actively investigated. If, for instance, deaths tend to occur in a particular bed in a particular hospital, one should be asking: Why that bed? Why that ward? Or as another example, if more premature babies die at night, we should be asking: Why at night? It may be because there is no electricity to power the incubators. It may be because there are less hospital staff on duty at night. Saving lives may ultimately have to do with paying attention to the small details.

To make Okor’s dream list a reality, all branches of government – legislative, executive and judicial – need to work at all levels, and they must work with hospitals. The legislature passed the NHA, and the executive branch signed it into law; now the judiciary can also take steps to speed up action when it comes to the prosecution of medical negligence. Currently, prosecution is often impeded by loopholes in Nigerian law such as the Public Officers’ Protection Act, the Pre-Action Notice and the exceedingly long duration times of the cases themselves.

These hurdles discourage reporting and delay prosecution, thus perpetuating the causes surrounding medical negligence. If patients or their families do not report cases or file cases in court, then there are no sanctions, and sanctions are effective deterrents, according to Ogungbo. “If you are punished once, twice, all these kind of things will stop, but because there is no punishment, it will continue to happen.”

If the government takes a strong leadership position by ensuring that the National Health Act becomes a reality, many of Nigeria’s health problems will be reduced. Perhaps with the Basic Health Care Provision Fund, even local health care centres will have access to state-of-the art equipment, and Nigerians will no longer have to travel to India for kidney transplants. Perhaps health care will be more affordable, and Nigerians will no longer have to create “GoFundMe” pages for heart surgeries. And perhaps the standards of health care delivery will improve as defaulters are punished, resulting in better-equipped hospitals, less pressure on staff and more effective medical practitioners.

However, the government is only one piece of the puzzle, and medical practitioners must also play a large part in reducing medical negligence.

The Role of Medical Practitioners

Medical practitioners are at the centre of medical negligence cases. Most work with limited resources and are under intense pressure as they attend to more patients than they can deal with. Many take cases beyond their specialization. And some are neither careful nor attentive enough. For things to change, business cannot continue as usual. Medical practitioners need to have the requisite knowledge, competence, infrastructure and skills in line with global best practices.

One place to start is with simple things – note taking, for instance. Both medical practitioners and lawyers say that it is important for doctors to take notes, yet this is not the case with some Nigerian consultants whereby only junior doctors take notes. Ogungbo says that notes may be the only evidence that will save a doctor in the case of a medical negligence allegation.

“The times when I have been saved in the UK, the UK lawyers will say, ‘Please give us your notes.’ They will go through everything with a fine-tooth comb, so the only thing that will save you is that you’ve written it there.” He says that in most cases, the notes include the chosen medical treatment, the reason for that choice of treatment, and an indication that the patient understood the procedure. “But if you haven’t written it down, it is taken as if you did not tell the patient. You can’t come back and say that I told the patient this,” says Ogungbo.

Inevitably, complications can occur. One of a doctor’s duties is to explain the risks of a chosen medical procedure, including the possible complications that may arise. At the same time, a doctor is also expected to reduce the risk of complications. Ogungbo says, “I say to the person, there is risk of death, paralysis, bleeding, infection, but my job is to prevent such. It is not that they don’t exist; I am not God. My job is to minimize the risk of complications and to manage the complications if they occur.”

The Role of Professional Bodies

There are many professional bodies in the Nigerian Health Sector – the Nigerian Medical Association (NMA), the Nigerian Medical and Dental Council (MDCN), and the Joint Health Service Union (JOHESU), just to name a few. Many advocate ways, beyond strike actions, that these groups can show leadership when it comes to ensuring best practices among their members.

Douglas Okor recommends that professional organisations work not only with their members, but with the Nigerian citizenry as well. “Be proactive, take the lead in strategies to improve the consciousness of Nigerians regarding medical negligence and associated issues,” he says.

These organisations should be involved in processes to improve policies, and they should be part of the review and amendment of legislation and laws, especially those laws that are obsolete. They should also be involved in implementing strategies aimed at reducing medical negligence. For instance, they should be at the forefront of ensuring that the Nigerian Health Act becomes a reality.

Another way to reduce medical negligence may be in making available to the public an online database of medical practitioners in Nigeria. This service is available in the UK on the General Medical Council Website, and the American Medical Association has a “Doctor Locator” app on their website. With a similar database, Nigerians would be able to view the qualifications of the medical doctor sitting right in front of them – or check to see if the person is a registered medical doctor at all. Patients might also be able to find out whether the doctor has been involved in any previous cases of medical negligence.

The Nigerian Medical Association (NMA), which is a body comprising all registered medical doctors in Nigeria, has strategic roles to play in order to ensure that its members abide by best practices. According to Ogungbo, “The NMA should focus on making the medical profession as strong as it can be, as good as it can be and within us sanitise our own profession. It is the MDCN that can punish, but if within the association we know that somebody has done wrong and everybody says this is actually wrong, a lot more doctors will sit up, as they will not want to be made scapegoats.” Ogungbo says the NMA can champion these issues by writing about them in regular newsletters sent to their members.

And the MDCN, even in punishing medical negligence cases, must be more independent in its investigation, says Ogungbo. “There is no serious critical evaluation of the investigation which will openly say, ‘Medical Director, come and talk to us.’ Then the resident doctor says, ‘Okay, I ordered for this drug and it did not come on time (or whatever) and this is why this thing happened.’ After the investigations are carried out by the MDCN, the decisions of such proceedings should be made available to the public through various channels. This would help patients make better health decisions when they choose to approach certain health facilities.”

The MDCN also needs to make the steps for reporting medical negligence more readily available to the public. Currently the petition form is tucked away on their website.

Other organisations can help as well. Non-Governmental Organisations can call the attention of the masses to these issues through public forums, radio shows and other media. They can also petition that the loopholes of the law be reviewed, and they can pressure the government to ensure that the NHA is transformed from a piece of paper into a reality. Technology enthusiasts could develop online platforms for reporting medical negligence, and these platforms could also give medical doctors a chance to reply. This could be a way of not only informing the masses about the issues surrounding medical negligence, but of encouraging medical practitioners to be more careful with their work.

The Role of Patients

Douglas Okor, who has years of work experience in the United Kingdom, believes that there is a huge difference between the average Nigerian patient and the average British patient. He explains, “UK patients are better informed and less superstitious. They have a much better health-seeking behavior.” Okor says that this greatly affects how they perceive medical professionals.

Biodun Ogungbo says that it is important for the Nigerian patient to know that “the doctor does not know everything. Ogungbo says a better informed patient complements the doctor’s work, as the patient is the only one who knows exactly how he or she feels.

It is also extremely important for patients to ask questions about their health if they are unsure of anything. Doctors are required to reveal information; the National Health Act states that “every health care provider shall give a user relevant information pertaining to his state of health and necessary treatment,” especially when it is in the best interest of the patient. The patient can ask about treatment options and the risks associated with them. The patient also has a right to refuse the treatment options.

Ogungbo says that patients sometimes contribute to negligence by hiding vital information from their doctors, such as being HIV positive, taking certain drugs, or their family health history. He says, “No, I don’t know best. If you don’t give us the pieces of the puzzle, we can’t piece it together to see the whole picture.” The simple way to end this problem is simply to come out with all the information.

Ruth, whose story we profiled in part two of this series, “The Slow Road to Justice,” is still coming to terms with her fears about raising a daughter struggling with epilepsy. Today, she says that she is learning to prevent medical negligence in her own way: she always seeks a second opinion. “Whenever a doctor tells me anything now, I ask what another medical specialist thinks,” she says, adding that seeking a second opinion could also involve consulting the Internet to learn more about the kinds of drugs that her daughter is being given.

Tips for Patients

• When you have a health issue, see the medical doctor as soon as you can (not as a last resort after you have already been to the herbalist, the pastor and the chemist).
• Do not withhold information from your medical doctor – he needs all of the information in order to help with your treatment.
• When in doubt, request a second opinion.
• Be sure to ask questions if you have any concerns about the chosen treatment plan.

Tips for Medical Practitioners

• Take good notes. Record the patient’s information and medical condition, your selected medical treatment and the reasons for your choice. Record whether the patient understood the process and agreed to it. These notes are documents; they may save you one day.
• Seek a second opinion if you need to, and encourage the patient to seek one if they want to. Again, record everything.
• Do not take on more than what you are trained to do. If any issues arise, they will be easier to deal with if they fall within your scope of expertise.
• Detect, advise and act upon any abnormal results.
• Play it safe – always consider the possibility of a serious diagnosis.
• Some patients just want an apology, which can go a long way. So, apologise (and correct the mistake, if possible).
• Respond to complaints extremely carefully, especially in writing.
• Consult your medical insurance company – they are the experts.

Now, over to you: how confident are you that Nigeria’s medical negligence issues will be resolved in the forseeable future?

In case you missed part 1 & 2, read them here: Part 1: Medical Negligence in Nigeria: When Hospitals Kill  and Part 2: The Slow Road to Justice.