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By Job Osazuwa and Doris Obinna
Chief medical director (CMD) of Lagos University Teaching Hospital (LUTH), Prof. Chris Bode, has revealed that many patients go to the facility with the intention of accumulating bills that would in the end be written off by the hospital. In this interview, he spoke on the need for Nigerians to change such orientation and stressed that, to render accessible and sustainable quality health care, every patient must pay accordingly.
The professor of surgery also spoke on the pull and push factors responsible for brain drain in Nigeria, the role of National Health Insurance Scheme, public-private partnership, up-to-date facilities and staff motivation in boosting quality health care delivery. As LUTH marks its 60th anniversary, he went down memory lane on the many feats of the teaching hospital and how they can be improved upon. Enjoy:
What has your journey been like with LUTH as it celebrates 60 years?
It has been a hectic but exciting ride. Of my 42 years as a doctor, I have spent 40 years at LUTH. First as a trainee, to specialist and consultant surgeon till I became a professor of surgery. Having spent these years, I have seen when LUTH was very good and also seen the decline. At some point, there was disenchantment among the staff and loss of confidence on the part of the clients. Many things were dysfunctional but we were able to use good leadership quality, team spirit, advocacy and networking to change the narratives. With strong will and the right investment and collaborations, we began to give the hospital a facelift and rebuild the lost confidence.
For instance, when I became the CMD, the operation theatres were locked; they were shut down by our accrediting bodies because our theatres were substandard. And when we began to revive them and moved in, everybody became happy. That opened my eyes that it was not that the workers were not willing to work but it was for the fact that they didn’t have the ambience to bring out their best. Paying someone good salary is not enough but being able to provide an ambience that gives job satisfaction.
To tackle the incessant power outage that LUTH was always criticized for, we embarked on public-private partnership (PPP). And an independent power project was installed in LUTH in 2017 and since then we have uninterrupted power supply here. That alone boosted our productivity. So when we approached the Nigeria Sovereign Investment Authority (NSIA) in 2016 that our cancer machine, the last one in Nigeria, had broken down and for the authority to come to our aid, they agreed because there would be steady power supply. We attracted an initial $12 million worth investment to put in the best cancer centre in West Africa and sub-Saharan Africa. Everybody now wants to build a cancer centre like LUTH, which is good. The place is oversubscribed as we now see over 150 cancer patients a day. Patients come from across the country. Because of the success story, governments now give out money to public hospitals and mandate them to build a cancer centre just like the one in LUTH. Riding on the success of that, a Nigerian donated a building worth N1.5 billion, which will be inaugurated soon. It is a 60-bed cancer ward. There is renewed confidence in the hospital in the areas of our X-ray Department, Labour Ward and we are building a 30-bed intensive care unit that will be the biggest in West Africa, to be launched in the next two months. Block A and B were rebuilt after 58 years. And Lions Club, through District 4018 with its late district governor, built a renal dialysis centre for us costing over N300 million. Somebody donated 15 brand new dialysis machines to the centre. The sewage system, which has been there over 60 years, is being redone completely.
These achievements wouldn’t have happened if not for the cooperation of staff who stopped embarking on strike to display their grievances.
What are the core challenges?
As a CMD, we met so many infrastructural dilapidation, which is not the blame of anybody. The population of Lagos over 20 years ago was two million but we are now talking of over 20 million. As the population exploded, the facilities also needed to be expanded, which we did in our Accident and Emergency building. Our equipment was down too. I saw those challenges as opportunities to solve problems. You need to keep planning consistently towards your vision and you will certainly get it right. I see challenges as opportunities to score vital points. That is my own view to everything in life. Politicians have donated money to us here for one project or the other, but if we didn’t plan ahead we might not have something concrete to execute.
Do you believe that services would have been far better at LUTH if the Federal Government had injected more funds into the health care sector?
In Nigerians, we are fond of bashing the Federal Government for everything. The Federal Government is not going to do anything much more than it is doing. In 1948, the University College Hospital (UCH), Ibadan, Oyo State, was built. It was the best teaching hospital all around. Up till in the 60s or 70s, princes of Saudi Arabia were coming for treatment in Nigeria. Then it was just five federal hospitals, but now we have over 60 federal medical tertiary institutions. Can you compare the quality of a child of a man that has five children will have with a man that has 60 children? Nigeria’s population has exploded.
Primary and secondary health care have failed because they are not funded by local and state governments. Once a governor builds and inaugurates a hospital, he doesn’t bother anymore and the hospital keeps struggling. The implication is that almost all patients now go to tertiary institutions to seek all manner of care. Is it the Federal Government that will fund all the hospitals? There is no free lunch in Freetown. Let’s starting thinking of how to adequately fund the health care sector.
What is the way out?
A good, well-conceptualised and well-run national health insurance scheme will provide the pool of money that will pay doctors and other health workers adequately. It will enable us buy the needed up-to-date equipment and easily replace obsolete ones. It will make investors to have confidence in the system. Let make the market economy drive health care management and operation through a well-organised health insurance scheme.
Imagine 1,000 people paying N1,000 every month for health care, that is N12 million in a year. It is possible the majority of the people contributing the money won’t have any reason to visit the hospital or spend the money for the year, but that money can assist in getting things ready for two or three people who need health care. But the mentality from some abuses in the past that if one doesn’t go to hospital at the end of the year then the money should be returned to the contributor was created when people used to share contributors’ money. That is not how health insurance works; it is a collective pooling of money to provide health care for those who need it. It is dangerous for us not to have functional and universal health insurance.
The National Health Insurance Authority Act of 2021 as signed by President Muhammadu Buhari is a good thing because that is the easy part. And we need to domesticate it and implement it faithfully just the same way we did in the telecommunication industry. Just as people insure their cars, houses and other valuables, Nigerians should insure their health. There is actually an anomaly because people insure cars for as long as six years without an accident in those years, yet they go to hospital now and then without any insurance package.
Let government provide immunisation for children, care for the elderly and other vulnerables in the society. Government should give us policies and guidelines for insurance companies because the money we are making from insurance at the moment cannot even take us home or replace equipment. We need to discuss health care financing holistically for the benefit of the patients and all stakeholders.
How does LUTH respond to situations where patients are unable to pay their bills? Do you detain them?
In the real sense, no hospital detains or ties a rope to a patient over failure to pay bills. But I will always ask, do you go to restaurant and eat without paying? I can sympathise with the way we think that health care should be free because when orthodox medicine was first introduced, government sponsored it. But how many people went to the hospital that time compared to now? We have left that time. There was a time we watched our television stations for free but it is no longer so without subscription. We need to reorientate the mentality of Nigerians that anything good is being paid for by somebody.
Have you ever heard that LUTH turned a patient back because he or she didn’t have money to pay for service? We have a culture in Nigeria that is empathic. We can never turn anybody back. Is it a woman in labour that we will turn back? For example, a woman came in after a complicated cesarean section she had somewhere else. Her kidney failed and we treated her, we treated her baby too. But at the end, her bill was over N4 million and somebody said CMD should waive the bill. If we don’t collect operational cost then how do we run the hospital? I told them, no, that it is not done like that. Then ensued the waiting game. She and the husband went to stay at the ward because there is a popular myth that when you wait in LUTH for a long time, we will tell you to leave. This is what many people do even those who have the money to pay their bills. We asked them to write an undertaking and bring guarantors and go, they didn’t. One evening, the husband gave her some liquid substance to drink and the woman choked and died. The following day, they brought over 150 people to protest that LUTH detained their patient. They destroyed hospital property because they are claiming that health care should be free. The case is in court till date.
We do our best to assist patients. In the last two weeks, we have waived N4 million each for two patients. That is a complete loss on the part of the hospital. You may want to ask, how many of such bills can the hospital waive? There is a lot of distortion of facts about this and it is painful. What I render is qualitative, consistent and accessible services; it is your business to go and look for money to enjoy the service. If these facilities break down tomorrow without maintenance, the same people will go somewhere else and pay for it. The cotton wool and syringes we use are purchased from Mushin market from a revolving fund.
Going forward, LUTH is going electronic. Each patient will have to obtain a chip-embbeded card just like smart card. When you come in, you register and load your money to it from where you will pay every service rendered to you. This will solve the problem because our people won’t be able to access such services if you don’t pay. There have been so much abuses in the past. I already have my own card though it will be done in phases, department by department.
What is your take on brain drain in the health sector?
I am badly affected by it. It is something we almost can’t help for now. We need immediate, intermediate and long-term strategies to combat it. You finish training a doctor, you are giving him or her a golden international passport. Apart from job satisfaction, doctors and other health care workers need certain things to be taken care of in the society. There should be security, quality education, stable electricity supply and other basic good things of life. A country whose land once flowed with milk and honey is now chasing away its professionals. The factors responsible for this brain drain are multifaceted. Is there adequate pay, job satisfaction, safety and prospect? Whereas, the UK, Canada, USA and other developed countries need doctors, nurses, pharmacists and are ready to pay them higher with best equipment to work. These are push and pull factors. Really, nobody wants to leave his fatherland to become a second class citizen somewhere else. But this is where we have found ourselves. We need to invest more in the sector to change the narrative, though a lot already going on. There are many doctors in Lagos and Abuja looking for job, meanwhile, in the rural areas, there is no single doctor. It is paradoxical. If we rebuild the health care sector into a vibrant economy, people will start coming back in the next few years. When I first travelled to the US in 1983 when I had a five-year visa, my N500 then gave me $800. The same N500 cannot buy $1 today.
