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From Kenny Ashaka & Abdullahi Hassan, Kaduna
Former Secretary of the Nigeria Medical Association, NMA, Prof. Lawal Khalid says cancer patients need not panic over their health status as the Federal Government would soon install Linear Accelerators in seven hospitals spread across the six geopolitical zones.
In this interview in his office in Zaria, Prof. Khalid who is also the Chief Medical Director (CMD) of the Ahmadu Bello University Teaching Hospital(ABUTH), said the “sophisticated” Linear Accelerators would be made available on a Public Private Partnership, PPP, bases and that the chosen hospitals as the third parties are expected to provide the bunker where the machine will be installed. He spoke on the problems with the health sector and
ABUTH status as one of the Centers of Excellence for cancer treatment,
among other issues.
As a one-time Secretary of the Nigeria Medical Association, we’ll like
to have your thoughts on the health sector of the country.
I must say that the health sector in Nigeria today is undergoing or is passing through a lot of challenges in terms of trying to make it work and to work well for our people. As you know the Federal Ministry of Health is saddled with the responsibility of ensuring that health care
is provided for the citizens of Nigeria and anybody who is in Nigeria indeed. Unfortunately, the health sector has been bedeviled by lots of challenges, the challenges that one would hope that in the nearest future government would be able to address them.
What are these challenges?
From my own understanding the challenges are many; but the most important one which I think is militating against having a good health care delivery in Nigeria is industrial unrest in the health sector.
Industrial unrest coupled with industrial disharmony because even among the ealth professionals now you have inter and intra professional rivalry which is going to the zenith of whatever scale you are thinking about. Now, industrial unrest has so much made it impossible for us to plan adequately in the health sector because if
you want to deliver a good health care system you must be able to plan very well. If you don’t plan then you are planning to fail. You won’t go anywhere. So it has been impossible for a long time to even plan for a year in the health sector because part of your plan is that you must give a provision that the crisis might erupt and you may have people not working in their different places of work. Therefore, things may go back to square zero again. So industrial unrest is a big problem and it rallies around issues of remuneration, one professional group feeling that they should be adequately compensated, remunerated or they should be equated with another group and so on. And it has been difficult. Government in its own wisdom has introduced some measures to address this issue. For example relativity has been
introduced but people are still questioning it. Relativity simply means let different professionals be paid according to what they put in so that all cannot be paid the same thing. There must be that disparity. But that has not addressed the problem. As I speak to you now doctors are having problems with other none doctors in the
hospital. I am sure that you are aware that the medical laboratory scientists, the pharmacists, the nurses and other allied health professionals have come together as one body and their agenda is always one: how do you address this issue and make sure that doctors don’t take all the cake in the federal ministry to their detriment. So that has been one. Then the issue of disharmony is not something that has to do with remuneration but the actual work itself. The hospital system which is the unit where health care is provided is supposed to work in such a manner that they work as a team. There is no one professional that can do it alone. Every other profession must come and work together for the benefit of the patient. Now, this struggle for superiority, this struggle for independence has further brought us
backwards. It has not promoted the kind of progress that we are supposed to have in the health sector. And I will give you an example, the medical laboratory scientist will want to live alone and offer medical laboratory services without other laboratory physicians working together. That is what they say and that is what they are
pursuing and in Nigeria, anything goes. So they have been able to go to court and court, the Industrial Court, in its wisdom has given judgement in one case that has to do with the University of Jos Teaching Hospital asking that they should be given a separate department as if medicine is practiced in unitary system. Medicine is
a combination of effort that is put by everyone starting from the labourer, the man that issues card, the Doctor that sees the patients, the nurses that assist, the pharmacists, the laboratory scientists,
everybody, including the security man is important as far as health care is concerned. So once you miss that point then we are lost. And like I said and I will continue to repeat that point that no health
professional can do it alone. It is one sector of the economy where you need support, cooperation with all coming together, having one common objective and that is the care of patients. These are the daily things we face. Of course, I am not unmindful of the fact that some other people have started by saying that funding is the greatest challenge.
Would it not be right to say that government is complicit in this area
of intra professional rivalry, talking in terms of budget?
Budget alone cannot solve every problem because in Nigeria today when you budget for something at the end of the day you don’t get everything. You may have it on paper but at the end of the day all the
money may never be released. I can tell you, for example in 2015, the capital allocation for capital projects in this hospital was just N38 million and this is a premier hospital; you can see how large and extensive this hospital is and yet we got N38 million. There are some hospitals that got zero allocation in 2015. We are hoping that things will get better.
Is N38 million inadequate?
I don’t know what word to use, but N38 million for a big hospital like our own is grossly inadequate. That is what I would say. What I would rather want the budget to look like? You know again the budgetary system is not an open ended system that we are operating. At the beginning of every budget year you will be asked to come up with whatever capital project you will like to do; but somewhere along the
way the government will now give you an envelope. So you will have to compress, prioritize whatever project you want to do to fit into the amount of money that is given to you. Definitely, some projects will suffer and some priorities will have to be set aside because you won’t be able to get money to execute those projects.
What did you propose as the budget for this hospital that you ended up
getting N38 million in 2015?
No, it’s not N38 million that I proposed. I am just saying that it is N38 million that was eventually given. Certainly, every year we make proposals; there are many projects and sometimes we will make wishful lists for these projects, but based on economic reality of this country that may not be possible. So at the end of the day you are asked to fit into an envelope. Sometimes in the envelope, a hospital like our own may just be N200 million and you are asked to fit into that. Even at that amount that you are asked to fit into, the issue of the release of that money is another thing altogether. And that was
why I said the actual amount that was released was only N38 million. And N38 million will not take you anywhere as far as a big hospital like ABU Teaching Hospital is concerned. When we talk about budget again it is not only for capital projects. It is another problem even for recurrent expenditure. When I started as the CMD of this hospital, what we receive as overhead allocation every month is about N17, N18 million. But now as I speak to you as big and extensive as this hospital is what we are getting is about N5.3 to N6.3 million in a month. Now it is important to mention this because the overhead allocation is supposed to cater for the things we do every day in our hospital, utilities- light, power, generators, diesel, engine oil,
travels, repairs, fixing things in the hospital are all done within that sub-head of N5.3 million or at most N6.3 million. If you now calculate the amount of diesel you require to sustain the hospital you
find out that the minimum requirement is one truck of 3,000 litres and now it costs more than N7 million. Here you are, the maximum amount you receive for the month is N6.3 million. You cannot buy diesel alone. Electricity company is now privatized. They bring in all kinds of bills which we have complained to government. The bill we receive in this hospital touches the sky. For the month of May our bill was N11 million and you are supposed to pay. There was a time we had some interruptions but not for up to two weeks. They are charging us commercial rates and we are essential service providers. We cannot afford to overcharge our patients just because we want to have money to pay. If we charge more, healthcare will now become inaccessible and
unaffordable and that would jeopardize the already worsened health indices in this country. So we are mindful about our role as essential service provider. If we were getting the N17 million or so we were getting before there would have been no problems like the ones we are encountering now. That is why a casual visitor to the hospital will find one or two things wrong. But all the blame goes to management and management is not by words of mouth. You must be given all the tools
that are necessary to effect repairs. If these things are not provided, definitely things would suffer. This is the story all over our tertiary hospitals today. It is not only ABU Teaching Hospital.
Would what you have just said now be the answer to leaking roofs, lack
of maintenance of equipment and other inadequacies of this hospital?
Well it will not be the complete answer to be fair to the system. Yes, it is true there are leaking roofs here and there, but I think it is good you have the history of a place before you run into that conclusion. This hospital project started in 1975. Nobody moved in here until 2005. So when you have a building that has been lying there for a very long time there is wear and tear even if it is a building.
By the time we moved in it was already an old structure. The pipes are old and rusty. The roofs have been under the sun for a long time, no maintenance and so when the problem starts coming, they come in a big way. Therefore, you have to start battling them. You will not be able
to fix all of them because of the limitations of finance. However, there is now a Maintenance Committee on ground going round the wards to see things. For us the patients ward is the most important. We have been able to do appreciable work. Now, you mentioned Radiology. That
is one department we are very proud of. It’s the place where you have the most sophisticated, expensive equipment in this hospital. I tell people that I am not a politician and that the greatest thing that has
ever happened to our federal tertiary health institution was the intervention by Obasanjo government in tertiary health care delivery in the provision of modern equipment for diagnosis and treatment
across our hospitals.
So our Radiology Department benefitted from that and, in fact, ABU Teaching Hospital was number one. The first commissioning was done here in 2005 for the equipment that we have in Radiology. As a student I can tell you I have never seen some of the equipments before but because of the intervention by that regime we had the equipments and other ones for the screening of women with cancer of the breast installed. The problem now is that of maintenance
and sustainability. They are capital intensive to maintain. So these machines have been there for up to 10 years. Most of the machines in developed countries are not kept for too long. After five years they are removed and other ones brought. But we cannot do that here. So a lot of the money we are generating from the machines is ploughed back into maintaining the machines. So we are faced with old equipments that are becoming obsolete now. What we require is a new set so that
we can provide the services required of us. Let me exemplify here. The scan that was installed in 2005 was a four-slice one that does not have the same capacity with modern scan. The scan text photographs and then slices it to tiny minute precision to enable the Radiologists to easily interpret and diagnose it. In many places we have 32, 64, 128 and 160 slice. But here we are battling with a four slice scan. So you know that definitely that machine is old and outdated. The cost of repairing and maintaining it will be very high. Of course, you know it’s difficult to get the spare parts. Sometimes we do not even have a scan service for two days or so. Unless we are able to get a new one we may not be able to carry out our duties as expected. A new scan now will cost about N250 million. So unless there is an intervention to do something similar to what Obasanjo did it may be a mirage. It requires real intervention to get things working.
In your opinion is this why Nigerians are jetting abroad for medical treatment?
I may not be able to speak for everybody but from the little I know
from interactions with patients I think there are many reasons why
some people will want to go out. It is easy to hide under the guise of
unavailable facilities in this country, but I don’t think that is
completely true. We have a lot of accessible, available equipments
that are very much affordable to many Nigerians; but people simply
prefer to leave Nigeria and go outside for reasons that are best known
to them. I have just given you an example of the Scan machine. This
machine is available in many hospitals in the country. Some private
hospitals even have them. But Nigerians would want to go to Egypt,
Dubai and some other places. So there may be something we in the
medical profession don’t know that is making people to go abroad. I
may not know all the reasons, but what some have said is that our
hospitals are tertiary hospitals, we don’t have modern equipment.
Today, there is no light, tomorrow no water and so on. But the truth
of the matter is that we are still able to perform under the
circumstances. And it will be wrong to generalize. Some are doing
better than the others and health workers are doing a lot despite the
harsh weather we find ourselves. It is easy to just use one word that
the hospitals are reduced to consulting clinics. Unless we develop
this attitude of making use of what is available in this country,
forgetting what is happening in other parts of the world, this
syndrome of people leaving this country for other places will
continue.
Government also has a fair share of the blame. For instance funding is
a problem; maintaining existing equipment is another…
I just want to buttress the point I am making. Attitude is the most
important determinant reason as to whether you will go outside this
country or you will stay. Funding may be a problem militating against
performance. But we also have big private hospitals where they have
virtually everything. In fact, they bring expatriates to come and man
those hospitals and provide services. Yet our people will not go
there. So, it’s not just one reason. I think it is something that
investigative journalism would help to unravel.
Talking about cancer, ABUTH was tagged along with four
other hospitals in Nigeria as centers of excellence. But whereas
others are treating patients, ABUTH would rather refer cases to
the other three hospitals. Why is ABUTH not acting
like others?
ABUTH is designated as center of excellence for cancer
treatment. With that we are supposed to have all the equipments that
are required for the diagnosis and treatment of cancer. Unfortunately,
that is not the case. I will say we are designated center of
excellence but there was nothing to match that status. For example the
key thing that is required for the treatment of cancer is the
Radiotherapy machine, a machine that emits radiation to treat and kill
cancer cells. With all this noise about ABU being center of excellence
what we have is a Cobolt 60 Machine. That is the machine we are using.
But the more modern machine for the treatment of cancer is a Linear
Accelerator. So you see the paradox. If we are designated a center of
excellence for cancer treatment, then all the things that are required
for the treatment of cancer should be made available to ABU Teaching
Hospital. Here we are we just have a Cobolt 60 machine. That is what
we are using as a source for external beam and Radiotherapy. That’s
all we have. Some other hospitals that came after us have Linear
Accelerators. National Hospital has Linear Accelerator. LUTH has.
Sokoto here also has a Linear Accelerator which was provided under the
Vermin Project. It’s a later project. But ABU Teaching Hospital does
not have. The implication is that you may not be able to treat cancer
adequately the way it should. I have just given you an example of
Cobolt 60 Machine. There are other things that are required for the
treatment of cancer because you have different types of cancers,
different locations and the machine that is used for them is
different. For example there is Brakitherapy machine. We have that
one. It helps to deliver radiation to people who are afflicted by
cancer inside cavities. For example in women they have cervical
cancer. This is very common among women, the mouth of the womb is the
cervic. That is why you have cervical cancer. We have also Auto
Voltage Machine for the delivery of radiation to superficial cancer,
but that machine has never worked and yet we are designated as center
of excellence for Radio Onchology. We are supposed to have a
simulator. But we have never had that simulator. You mean whether we
have made a case for them? I can tell you we have made cases and cases
time without number. That is the problem on the ground. The thing is
that where is money? For you to have a Linear Accelerator now, you
will need about N500 million. This will not come from budget. You
require some kind of divine intervention. I have given you this
picture so you can understand why ABU Teaching Hospital cannot do what
others are doing in terms of cancer treatment. Even the Linear
Accelerator is not the solution, although now there are better Linear
Accelerators that are able to withstand energy changes and so on. Also
some of the problems that are attributed to all those versions are no
longer applicable to the ones available now. But people still come
from Abuja to ABU Teaching Hospital. In the last couple of weeks, the
Linear Accelerator in Abuja did not function and people were forced to
come here. So while we are complaining, sometimes that is the only
equipment that salvages cancer patients in this country and beyond.
But the good news is that the Honourable Minister of Health, Prof.
Isaac Adewole has taken it seriously that this cannot continue and
there is now an aggressive approach towards making it possible for us
to have centers in this country that can adequately diagnose and treat
cancers adequately and then treatment effectively. Therefore, seven
hospitals have been identified, virtually one in every geopolitical
zone. In North West, ABU Teaching Hospital is one of them. The
government is going to partner with the manufacturing company of these
sophisticated Linear Accelerators to make them available on a PPP
bases, government and the company will partner and that we as the
third parties are expected to provide the bunker where the machine
will be installed. So it is in the 2017 budget. Government has put in
about N11.7 billion for this project and I think it is going to be
wonderful. It is going to be a major intervention that will bring
relief and succor to many of our patients that are afflicted with
cancer in Nigeria.
