Critical Surgeries: Long queues of patients, shortage of consultants portend ill for public hospitals

• Long queues of patients, shortage of consultants portend ill for public hospitals
•Experts recommend improving working conditions, increase retirement age, engage active but retired staff on contract

Mrs. Agnes Okonkwo is 56-year old. She was scheduled for elective surgery to address a gynaecological condition. Fourteen months after, Okonkwo is yet to be operated on. Okonkwo was asked to deposit N500, 000 at a private hospital before she could qualify for the surgical procedure. Owing to financial constraint, she opted for a cheaper option (N150, 000) at the ‘biggest’ public tertiary hospital in Lagos. And she waited on queue for 14 months.

Four-year old Musa Ibrahim was diagnosed of hydrocele in a private hospital. The doctors asked the parents to deposit N300, 000 before Ibrahim could be admitted for a specialised/elective surgery to correct the situation. The parents, because they could not afford it, swiftly moved Ibrahim to Lagos University Teaching Hospital (LUTH) Idi Araba, where he was operated after three months, at the cost of N55, 000.

Hydrocele is common in newborns and usually disappears without treatment within the first year. Older men can develop hydroceles, sometimes due to inflammation or injury. Hydroceles are usually painless, but may become large and inconveniencing. An ultrasound may be required to diagnose the condition.

Treatment usually involves watchful waiting. In rare circumstances, surgery is required. Okonkwo and Ibrahim represent over six million Nigerians that are delayed for between three months to two years to access medical care, especially surgery for critical conditions.

An elective surgical operation provides time for the attending health team (surgeon, anesthesiologist, nursing, laboratory, and operating room staff) to perform the necessary clinical and laboratory workup before an appropriate date and time are set for the procedure.

Studies have shown that the emotional and psychological effects following admission for elective surgery can be accentuated by delay of performance of the intended surgical intervention.

Researches have shown that in developing countries such as Nigeria, the delay in the performance of these elective procedures is largely due to bottlenecks in the existing health systems. These include lack of adequate infrastructure, like operating theater space, admission beds, diagnostic equipment, and intensive care units. Shortage of a dedicated, well-trained, and motivated human resource (technical and support) cadre is another cause for these delays. Additionally, inconsistent supply of recurrent utilities like blood shortage, medication and theater supplies hinders timely performance of elective surgical procedures.

Other studies have shown that delayed elective surgery may lead to increased morbidity and mortality, but it may also result in high hospital costs given the prolonged hospital stay.

Experts speak
A clinician, consultant pharmacist and a fellow of the West African Postgraduate College of Pharmacists, Dr. Joseph Madu, told The Guardian that delays in executing surgical operations on patients could be due to a number of factors, including shortage of qualified personnel. Madu said due to the menace of brain drain, there is shortage of qualified surgeons. He said this shortage would definitely lead to work overload and demands on the few surgeons who are still in the country.

The clinical pharmacist said this shortage of manpower is not just about surgeons but also about other relevant clinicians such as pharmacists and nurses whose work also affect the execution of surgery on patients directly or indirectly.

Madu, also, said due to the worsening economic situation in the country, patients might not be able to pay for the bills that accompany surgical operations these days in good time.

“Similarly, many surgical operations on patients may be cancelled or delayed due to inadequate pharmaceutical products, devices and consumables and surgical equipment/materials as well as suitable environment for the surgical process,” he said.

TO a former executive of Nigerian Medical Association (NMA) and a consultant endocrinologist with interest in epidemiology and endocrine disorders at Aminu Kano Teaching Hospital Kano, Dr. Ramalan Mansur Aliyu, delay in surgery is largely related to shortage of manpower, especially the specialists (surgeons and anaesthetists). Aliyu said those left in the country are overworked. He said the problem can be addressed by improving the working conditions of those around, increase retirement age, engage some active but retired staff on contract, and increase remuneration to discourage brain drain.

FORMER Commissioner for Health in Ondo State, Dr. Dayo Adeyanju, told The Guardian: “The delay in surgeries is a reality in our tertiary institutions. This is due basically to a shortage of personnel, particularly specialists who have gone for greener pasture. The recent brain drain in the health sector is unprecedented. The economic downturn in the country, irregular and poor remuneration of workers generally, inflation and insecurity are factors responsible for this.

Post COVID-19 across the globe because of strain in the health workforce; the global recruitment of foreign nationals with even incentives of postgraduate studies and work permit has made the offer tempting.

Adeyanju said the government could address this by improving the welfare package of the health workers. “The working environment of the institution is also very poor. There will be a need to provide modern working tools, provide infrastructure that will accommodate the health workers with lounges, conference rooms, comfortable call room etc. There is need for thorough supervision of the institution for discipline and reward of excellence. There is need to also fund the institution to be able to regularly pay their workers promptly and meet other maintenance need,” he said.

Adeyanju said the Federal Government fully supports training of resident doctors and they will need to continue to do this to produce more specialists as replacement for the ones that have left the system.

“What is more is to ensure they sign bond but with enabling environment to perform when they complete their programme,” he said.
PROFESSOR of microbiology and immunology at the Department of Medical Microbiology and Immunology, Nile University of Nigeria, Abuja, Boaz Adegboro, told The Guardian: “Delays in surgery is a sign of an imperfect system. In Nigeria, surgical access is delayed by an inadequate surgical workforce, which is made worse by the wave of brain drain that has become so bad for our health sector, lack of infrastructure and decreased care-seeking by patients. Delays in treatment can result from delayed presentation at the hospital, delays in transfer within the hospital. Delay in surgical access leads to loss of lives, increased complications of a health condition and patients’ dissatisfaction.

“Surgery is a complex procedure that involves patients, their relatives, surgeons, anesthetists, nurses, and technicians for the complete care of the patient. Surgical practice in Nigeria is hampered by a myriad of factors such as lack of infrastructure in our hospitals, poor public utilities such as potable water, access roads, and electricity. Lack of universal health coverage, as health insurance covers only just a handful of the Nigerian population. The rest of the population funds their health-care out of pocket.

“Also, the majority of the patients in Nigeria as in other developing countries are of low socioeconomic status and oftentimes, cannot afford the cost of healthcare. In addition, the literacy level is low among the Nigerian population. All these contribute in many ways to the delay of delivery of surgical care.”

Adegboro said causes of delay in surgery could be broadly categorised into: patient-related factors such as lack of funds, failure to procure materials for surgery, refusal of consent, and inability to provide blood for surgery.

He said surgeon-related factors include failure to obtain consent before a patient gets to the theater, late arrival of surgeon, and failure to identify or control comorbidities.

The immunologist said hospital or health system-related factors include lack of drapes, gowns, and boots; nonfunctional equipment; lack of theater space; and unavailability of light, oxygen, and water.

He said anaesthetist-related factors include difficult intubation, difficult induction of spinal or epidural anaesthesia, and unavailability of anaesthetists. “Nurse-related factors include failure to prepare the instruments for surgery,” he said.

Adegboro said majority of the patient-related cancellations are as a result of financial challenges faced by the patient. This, he said, is particularly important in Nigeria where poverty is endemic and majority of the populace fund their health care out-of-pocket. He, therefore, said the implementation of universal health coverage with adequate funding of health care would certainly help reduce the cancellation rate in Nigeria.

“The National Health Insurance Scheme of Nigeria currently covers only federal civil servants that constitute a small percentage of the populace. The scheme needs to be expanded to include state and local government workers. Special funds can be set up for the treatment of indigent or poor patients,” Adegboro said.

The immunologist said another factor related to this is failure of patients to turn up on the day of an elective surgery for no apparent reason. He said it would be safe to also assume that the reasons for this could be financial challenges, inadequate communication, decision by patients to seek alternative care such as unorthodox or alternative Medicare due to fear of surgery. Adegboro, however, said adequate reassurance and communication with the patient could prevent such situations.

He said surgeon-related factor is the second most common reason for delay in surgical access. “This is usually due to poor patient preparation with patients having abnormal laboratory results that were detected after admission. Reviewing the laboratory results closely before booking patients for surgery can prevent this factor. Another solution is having a pre-anaesthetic clinic for evaluation by the anaesthetist. Pre-operative ward round specifically done a day before surgery to check for fitness of the patients and their readiness with funds, adequate investigation results, as well as other necessary resources remain a good practice,” he said.

“Having a dedicated theatre manager who supervises the stores and collaborates with various units to monitor the supplies and equipment will go a long way in preventing this problem. Power outage is a major factor in interrupting surgery in Nigeria. Setting up a dedicated electricity supply to tertiary health institution will help to reduce logistic problems of unsterilised drapes or instruments, shortage of water supply and lighting for operations. That will in turn reduce surgery cancellation rate in our setting. Government on its part needs to tackle infrastructural decay, which hinders efficient services and productivity with appropriate budgeting,” he said.

Moving forward
Dr Madu said the situation could be addressed if the government can put measures in place to curb brain drain of health care professionals. He explained: “For instance, the president of the Pharmaceutical Society of Nigeria, Prof. Cyril Odianose Usifoh, recently announced that over 5,000 pharmacists have left the country in the last five years. That is just within the pharmacy profession.

“The result will be highly alarming if the statistics of surgeons and other clinical professionals such as nurses, dentists and optometrists is also stated.

Therefore, making the environment conducive for these professionals to stay and work in the country will be highly desirable.”

ON the long delays in surgery, the causes and what can be done to address it, National President, Nigerian Association of Resident Doctors (NARD), and Senior Registrar, Department of Orthopaedics and Trauma Surgery, Federal Medical Centre (FMC) Umuahia, Abia State, Dr. Emeka Innocent Orji, told The Guardian: “This is what we have been saying since we came on board, it did not event start with us. The previous administration tried to draw the attention of government and the general public to the calamity that has befallen the health sector in Nigeria.

“So, when we came on board, we continued from where they stopped, doing a lot of advocacy visit to both executive arm of government and the National Assembly because the truth is that we do not have enough man power in our hospitals and by that I mean clinical staffs; doctors and nurses. People are leaving this country, medical personnel are leaving this country in droves and if government does not do the right thing to mitigate against these, we are nearing a total collapse of the health sector in Nigeria.”

A study by the Nigerian Association of Resident Doctors (NARD) has shown that up to 2,000 doctors have left Nigeria in two years, 800 of them in the last eight months and about 100 doctors leave per month for greener pastures.

Orji told The Guardian: “We did studies amongst our members to find out why they are leaving even though we have always known this but when you are engaging the government without facts and figures, they may not understand the gravity of what you are talking about. So, this study showed that in the last two years, up to 2,000 doctors have left this country and at least in the last eight months from January to August, about 800 doctors have left this year and when you do the mathematics, it is about 100 doctors per month.”

Orji said the statistic is worsening; the same study went ahead to show that amongst the doctors around, about 4,000 of them have indicated interest to leave the country in search of greener pastures.

The NARD President said they have also discovered from the study that the major cause of this emigration is poor remuneration, poor welfare packages and these constitutes about 80 per cent of the reason people are leaving in search of greener pastures.

“The economy is bad for everybody yes, but the truth is that these doctors are putting in their bests and even putting their lives on the line; exposed to several diseases and many of them have died from the diseases they contracted in the course of duty and their families have been abandoned. So, these are some of the things that push people out,” he said.

Orji further explained: “Also, the issue of insecurity and of course poor job satisfaction. We do not have enough equipment in the hospitals to work with. You see a patient that you can help but because of the dearth of infrastructure and medical equipment, you are not able to help them and these leads to depression for some people. So, they see a place where they can get all these and you do not expect them to go?

He said the World Health Organisation (WHO) recommended doctor to patient ratio of one doctor to 600 patients but the Nigerian case is nearing one doctor to 10, 000. “So, when you have such a situation, there is bound to be delays in surgeries. There will be delay too in attending to patients; people come to clinics and spend hours there and some end up not seeing doctor because you cannot divide yourself into two. Most of our clinics in the hospitals, the doctors run it till night, and that is why they are breaking down. Even the fact that we have fewer doctors now who have been over-burdened by work load with the attendant burnout effect, that is also a reason those left behind are planning to,” Orji said.

Orji said the solution to these is for government to quickly intervene.
“We know that some government officials are meeting to bring up ideas on how to mitigate these. We believe that if they implement that, they are going to cause more problems. We know what is happening as an association and we want to be part of the solution. Any effort by government to resolve this, we want to appeal and draw attention to the fact that they need to involve us in the solution, so that they do not make mistakes and worsen the problem. Let us discuss and find a way to stop or possibly reverse this brain drain that is threatening the heath sector in Nigeria,” he said.

Studies
A study titled “Delayed elective surgery in a major teaching hospital in Uganda” and International Journal of Clinical Transfusion Medicine concluded: “Additionally, delayed elective surgery negatively impacts the patient, the hospital, and the community at large. Therefore, we advise that all concerned stakeholders should advocate spending resources on a detailed study of the socioeconomic implications of delayed surgery and come up with timely and acceptable remedial strategies.”

A Nigerian study published in Journal of Medicine in the Tropics and titled “Cancellations of elective surgical procedures performed at a Teaching Hospital in North-West Nigeria” found that cancellation of surgery creates untold hardship for patients who plan their working and family lives around the proposed operation date. The effect cannot be over emphasised, as subsequent operation schedule usually require changes so as to accommodate the postponed cases, thus inadvertently affecting others.

The researchers from the Bayero University/Aminu Kano Teaching Hospital, Kano, noted: “A cancellation rate of 48.5 per cent recorded in this study is higher than 3.6 per cent-23.15 per cent reported from other studies. Since Nigeria is a developing nation, and Kano as one of the states with poor health indices in the country, it is not surprising to find a cancellation rate as high as our finding. Similarly, this difference may be accounted for by the differences in sample size, sampling technique, duration, and type of the study.

“Majority of the population 30 (30.9 per cent) were within the age range of 25-36 years. This differs from the study in Ilorin, which revealed zero-nine years age group as having 70 per cent of the total cases cancelled. This difference might have been from the difference in sample sizes and type of study.”

This study further reaffirms the seemingly different cancellation rates for various surgical units. Of the total number of patients whose operations were cancelled, Obstetrics and Gynaecology unit had the highest number of 27 (27.8 per cent), followed by urology with 14 (14.4 per cent). Orthopaedics and neurosurgery have the least contributions to the total cancellation with five (5.2 per cent) each.

This is far different with the study in Ilorin, Kwara State, in which orthopaedics have the highest rate followed by general surgery, and the least being cardiothoracic surgery. Oguntola et al. in Osogbo, Osun State, also revealed orthopaedics, neurosurgery and Ear Nose and Throat (ENT) having higher percentages.

“The difference arises mainly from the fact that Obstetrics and Gynaecology has the highest number of patients in our hospital, hence the higher rate. Orthopedics may have a low cancellation rate in our setting for the reason that our people most times seek the care of traditional bonesetters. Another reason may be due to the fact that our orthopedic unit sprouts from the major unit in the National Orthopaedic Hospital Dala, Kano; so most patients are seen there. Our centre relied on visiting neurosurgeons during the study period, which may explain the reason for the differences from Oguntola et al.’s study,” it said.

Reasons for cancellation are diverse. More than half of cancellations found in this study are patient related arising from patient absconding from surgery for personal reasons not communicated to the surgeons, and lack of funds to pay for the surgery and it is similar to the study in Australia by Haana et al., in Ilorin by Kolawole and Bolaji, and in the Britain by Sanjay et al., in which patient-related factors constituted 65 per cent, 52.21 per cent, and 51 per cent, respectively.

“Our finding is, however, higher than 19 per cent reported by Kumar and Gandhi, from Delhi 46.4 per cent Oguntola et al. in Osogbo and the 25.3 per cent patient-related causes reported by Ezike et al. in Enugu. This difference may be explained by the poor health and possibly economic indices of our region. Financial constraints, a major reason for cancellation in our study is a big problem and may remain with us until the Nigerian economy improves and the people become better financially empowered or the national health insurance scheme becomes fully operational,” the researchers noted.