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Mr. Bello, a man in his fifties, was wheeled into the emergency room on account of a dissecting aortic aneurysm (in simple words, internal bleeding from the largest artery in the human body, the aorta). His condition was unstable and he needed an urgent surgery to do a repair of the bleeding aorta. He also would need the placement of a graft. This was a life-saving surgery. If delayed, he would most likely slowly bleed to death. Even if the surgery was done there was still a chance he could die but then he would have a pretty chance to live. It was no doubt an emergency. All was set for the surgery except for one fine important detail. Mr. Bello’s relatives needed to procure the graft to be used from the surgeon-to-be. The surgeon had taken the pain to get his own stock of these often life-saving grafts as they were not readily available in Nigeria.
The
graft cost some hundreds of thousands naira and Bello’s family could not afford
it. But since they had been counseled on his grave condition, they begged the
surgeon to use the graft ‘on credit’ with the promise to pay later. The surgeon
calmly told them it was either full payment for the graft beforehand or
nothing. The relatives begged more and later came up with some money but it was
still short of the set cost for the graft.
They
begged some more. The surgeon was insistent. The patient kept bleeding and the
relatives sourced for funds but kept coming short of the set goal. About two
days of being in the emergency room, Bello was certified dead.
Shagamu, Ogun state, Nigeria. 2011.
Tunde
had just been involved in a bike accident and was rushed into a private hospital.
He was badly injured. The doctor on call reviewed him and made an assessment of
a splenic rupture (the spleen is a large organ in the body that often contains
much blood. A rupture of the spleen might mean death). He also had other
injuries. He needed urgent surgery. The friends and relatives with him had no
money on them but begged the doctors to carry out the operation with the promise
to clear the bills by the following day. The doctors had compassion on Tunde.
He was going to die unless he was operated. Against the hospital policy they
rushed in to operate without the surgery being paid for. Hours after, he was in
the recovery room. He would live.
The
following day, the doctors refused to offer further treatment unless the
relatives and friends paid a substantial amount of the amount spent so far on
Tunde’s treatment. The relatives were vexed especially at what they felt was
the high bill presented to them. They were no longer interested in having him
treated in the hospital. They wanted to carry their friend elsewhere. The
doctors refused. These were relatives and friends with a firm resolve. They
called in hoodlums from the street to forcefully carry away their brother. The
doctors resisted and ended up being mobbed sustaining minor bruises. The patient
was taken away successfully and the matter became a police case.
There are many similar examples. Now I must
answer the question a friend posed to me last week; should Nigerian hospitals
insist on payment before delivering emergency health services?
Why Is
This An Issue?
The media is full of reports of doctors who
were presented with the opportunities to save lives but refused to simply
because the patient could not at that emergency moment afford the cost of care.
May be he had much money elsewhere or maybe he had extremely wealthy relatives
who would foot any bill to save him; the doctors at that moment could not be
certain. One perspective put in simple terms would be that the doctors watched
a human die, without intervening. Doctors have always been declared guilty in
the court of public opinion though without a fair hearing.
I believe in the sanctity of human life and
it is one of the tenets of the physicians’ oaths. A part of the Hippocratic Oath
all medical doctors are made to swear to reads “I will do my best to help
anyone in medical need, in emergencies…” Can we say many Nigerian doctors give
their ‘best’ in this context? If they do not give their best as often subtly or
clearly made known in the media, then we must ask why. Why would people who are
expected to be full of empathy and compassion allow a fellow human to die
simply because he doesn’t have enough money to pay for an emergency treatment?
Is There
Any Law That Makes Emergency Health Care Delivery Compulsory Without Payment?
I checked up the Nigerian constitution and
found nothing of such. I asked the lawyers around me, they all asked to get
back to me. They are yet to. I made calls to few health administrators I know,
none of them knew of such law or act. I asked Google and still came up short.
So I can safely conclude that there is no such health law or act in Nigeria.
Thus, if a patient is rushed into a hospital and the hospital refuses to accept
responsibility of care due to lack of finance from the patient they would not
be liable, legally speaking. But the medical profession is not traditionally built
around legality rather it is built on compassion.
Thus a number of hospitals especially
government-owned ones have a 24-hour policy where all care is given to a newly
admitted patient into the hospital irrespective of whether or not payment for
such health care has been made. This is the morality of the medical practice.
So imagine the situation where a patient who needs urgent attention is wheeled
into the emergency room and no one asks for payment, everyone just goes about
caring for this patient. Swiftly, the laboratory does all the investigations,
the pharmacy supplies all needed drugs, the doctors do all they should –
emergency care delivered as it should. Sadly, over the last few years, more and
more of these few hospitals have cancelled this policy or modified it limiting
its coverage to a large extent. Why?
The
Truth Many Shy Away From
Why have majority of private hospitals not
adopted this 24-hour policy? Why have many government hospitals located in
resource-limited areas, like in most rural areas, not adopted this policy? And
don’t tell me about free health declared by many state governments; it is more
of lip service. A quick glance at the services included in such ‘free’ health makes
one laugh. And why are many of these large government-owned tertiary hospitals
now doing away with the 24-hour rule?
The answer is simple; ‘money’ or in finer
terms, ‘health care financing’. It takes money to pay the salary of medical staff,
to procure medications, to keep a laboratory functional, and to keep a hospital
in business. Also remember that at the end of all these, profit must be made. This
is a dilemma in the face of compassion and morality.
Imagine a world where all health care
workers would go to the market and buy things with discounts because they are
involved in saving lives; a world in which children of health workers would attend
good schools and pay less tuition because their parents are involved in saving
lives; a world in which mechanics would repair health practitioners’ cars at lower
cost too – what a wonderful world that would be! In such world, physicians
would save lives without worrying about accounts that need to balance up at
month end; their staff would not threaten industrial strike actions when
salaries are delayed because they do not need money; all would be well and
health services can be delivered in emergencies without worrying if the patient
would be able to pay later.
So Are
Doctors Justified?
Unfortunately the utopia imagined above is
yet to be so doctors must use their discretion. I tell you what some hospitals
do; they evaluate the cost of health care needed to save a live and if it is
not one they can afford to write off, they don’t accept responsibility of care.
From experience people have learnt that patients don’t usually pay up promptly.
I have seen some extremes. I have seen patients live in hospitals for several
months (although they were restored to health) until they could clear their
hospital bills. I once met a lady who had the C of O of her land withheld by a
doctor when she could not offset the bill of health care given her by a
hospital.
Some of these are shocking and I think some
hospitals take things to the extreme. Yet the situation must be resolved, there
must be a solution. I understand the pain of relatives, friends and loved ones
when a patient dies simply because a hospital refused to offer him treatment
because there was no money available at that moment. And I hear you say, yes!
After all, no one plans for emergencies. But to that I query back, really?
Way
Forward?
What system can we put in place such that
in emergency situations, a hospital (any hospital) will be willing to offer
emergency care for any one in Nigeria without concerns about financial
reimbursement for the cost of health services offered? As at now only one
option seems most viable; health insurance, which is the concept of having
everyone pay for health care even when healthy, in preparation for someday in
the future or present when health care is needed even if it be in emergencies.
Then, when anyone arrives in the emergency room, all he needs to do is provide
his health insurance identity and he is taken care of immediately. His/her
health insurance manager will deal with the hospital on settling of the health
bills once notified by the caring hospital.
This is not a new concept in Nigeria but
the coverage is still low. Other possible solutions exist but this for me is
the most viable on a long-term basis.
A lot has been mentioned and you might not
exactly agree with all I have said. However if I am pressed to give an answer
to that question; should Nigerian hospitals insist on payment before offering
emergency life services? My answer would be ‘it depends’. But some day in the
future, that question will not be relevant when health insurance covers every
one
What do you think?
NB:
Health insurance in Nigeria is still relatively evolving with many limitations.
I am aware of ongoing reforms by the NHIS. This is a topic for another day.
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