From compassion and charity to health economics

We learnt more than clinical medicine at the bedside. We also learnt that poverty and ignorance could make people deadly sick. We learnt that illness could also further slide already poor people into deeper poverty. We learnt that a lot of people were suffering from acute and chronic diseases but could not help themselves. We saw the people could die because they couldn’t afford to pay for healthcare.

During ward rounds in the teaching hospital, we came across children in the Emergency Paediatric Unit with childhood cancers or protein-energy malnutrition, often complicated by infections, anaemia and electrolyte imbalance. They could not afford to pay for treatment. Without being asked, we would contribute money to help the patients pay for treatment. Moved by a deathly pale child with severe anaemia and impending cardiac failure, as a manifestation of severe malaria, we would rush to donate blood to save the child. The children’s resilience and will to live often rewarded such shows of compassion – they often bounced back as if by magic. We were poor medical students. The reality of the training and experience thrust empathy and compassion upon us.

In the Islamic Medical Association (ISMA), we formed a Patient Relief Committee to systematically obtain funds and materials to help patients who needed but could not afford them.

After graduating from medical school, we would, often at odd hours, be called upon to attend to a neighbour with acute severe asthma, a child with febrile convulsions, or a woman with acute exacerbation of peptic ulcer. Without thinking about it, we would spring up to buy aminophylline, hydrocortisone, phenobarbitone, ranitidine, pentazocine, promethazine, needles, and syringes. No one would offer to pay us either for the medications or our time and skill. It would not even cross our mind to ask for payment. The relief of acute pain, suffering or anxiety was enough payment. The vocation was its own reward. We intuitively knew that medicine cannot be wholly commercialized; because then, money would be a barrier.

When I ran a hospital in Jalingo, we admitted a child who had protein-energy malnutrition. The father didn’t show up and the poor unemployed mother couldn’t afford the high calorie, high protein diet we had prescribed. Would we watch the child vanish because of that? We had to give them money to buy what was prescribed. You diagnosed the ailment, made the prescription and donated the treatment.

As doctors undergoing post-graduate training, we would, under the auspices of the Association of Resident Doctors, and as part of our annual health week, organize medical outreaches to deliver medical and surgical services to the indigent for free. Some of us would use our cars to carry disposables, medications and other materials over the terrible roads that led to where these people lived. We would also use the opportunity to conduct health education to empower people to combat disease. I know of many doctors who, after official working hours, go to consult pro bono at faith-based clinics and hospitals.

Many of our colleagues in the United States, United Kingdom and other parts of the world also organize outreaches, in partnership with home-based doctors, bringing along much-desired expertise and resources once in a year to diagnose and treat medical conditions and perform surgical operations as a way of giving back to the community that gave them medical education.

We recognize and are moved by the pervasive inequality in healthcare access and have been trying, since student days, when we didn’t have much, to do something about it.

But, as well-meaning as these charitable gestures are, they are ultimately merely symbolic and cannot adequately address the needs, the gaps. They are good but not visionary. They do not go far enough. And the health of a people is too much of a thing to be left to individual charity. We cannot leave the control of crimes to individual morality or conscience; the government has to enforce laws and uphold justice with all its might. Same with health. The right to health has to has to be systematically provided for. We need is a more systematic and more sustainable effort to provide universal access to healthcare.

To ensure universal access to healthcare is a social enterprise for which, we as doctors, must provide the scientific, professional, but also passionate, leadership. We have to become advocates, even activists, for universal health coverage and persuade the government that it is possible. And more importantly, we have to show the government how it will be done. Where are the health economists among us? Where are the health policy experts? Where the health systems experts?

National Health Insurance Scheme (NHIS) is obviously an attempt to address this issue but, after almost two decades, hasn’t even begun to scratch the surface. Established under Act 35 of 1999 by the Federal Government, with a mandate of providing easy access to healthcare for all Nigerians at an affordable cost through various prepayment systems. After 20 years, it is very limited in both scale and scope. A lot more has to be done, and more quickly. And, is it the even the most sustainable and equitable model for Nigeria? And how do we balance equity and efficiency in our own context? Is a trade-off between the two even necessary?

Beyond access, what of quality of care, patient safety and other clinical governance issues?

First posted on Facebook October 2017

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