by Ibrahim Toli
The health system is an important component of community development as it strives to maintain holistic well being of the various demographic units of a society. The sector has many players each contributing in an immeasurable quota towards attainment of one single ultimate goal of individual and or communal highest level of health. To achieve that, the industry is divided in to 3 interrelated hierarchical health care delivery platforms, albeit with increasing service delivery complexity and competence. Thus, we have primary, secondary and tertiary health institutions exemplified by primary health centers (PHCs), General Hospitals and Federal Medical centers (FMCs)/Federal Specialized Centers/Teaching Hospitals (THs) which are funded by and are the responsibilities of Local Government Areas, States and the Federal Government respectively.
They differ in their “jurisdictional” powers in rendering health services to various clients, however unlike the courts there is no strict barrier in attending to or disqualifying medical emergencies or even cold cases. What is clear among them is the understanding of limitation to service delivery based on expertise and equipments and therefore the need for referral to the ultimate last bus stop as soon as practically possible in the case of emergencies and subsequently without delay for cold cases in order to keep complications and disease progression at bay. Their mode of professional communication is through laid down guidelines for referral systems to the next hierarchy. Therefore, PHCs refer to GHs and the latter to Tertiary Centres as the case may be through vertical referral in that order and not the other way round. There is also room for one way diagonal (from PHCs to tertiary centres) or both way horizontal (from GHs to GHs or from tertiary centre to tertiary centre) referrals based on availability of expertise and or equipments.
Each of the first two groups has limited disease conditions it can competently cared for, for example the PHCs see minor uncomplicated medical cases that do not require hospital admission or advance intervention; at best such cases require only observation for few hours. Any changes in hitherto uncomplicated case or advance case ab initio, will necessitate a referral. They are specifically design to cater for community basic health needs like personal hygiene, environmental hygiene, immunisation, etc. The tertiary hospitals are the highest level of health care delivery in most countries providing specialist proficiency for complicated and or advanced medical conditions. Core functions of tertiary health institution are research, teaching and patient care. Various players, professionals and non-professionals, contribute to this feat and include, but not limited to Doctors, pharmacists, nurses, laboratory scientists, physiotherapists, dietitians, technicians, psychologists, administrative staffs, account staffs, community health workers, porters, hospital attendants etc.
There has been protracted industrial dispute between the Doctors on one hand and a gang up of all the remaining health workers on the other hand, which will continue to be unless a genuine categorization and proper job description are done. This row is more intense and noticeable in the public tertiary institutions where the struggle for peck of office and titles have pitched the Joint Health Sector Union (JOHESU) against the Nigerian Medical Association (NMA); and if not quickly addressed with a proper job evaluation and using the acceptable best practices; will continue to undermine the service delivery of the health sector.
In order to comprehend this vicissitude that has taken its toll on our health system, let us attempt to analyse the pathways to qualification for the major players in the health sector and see whether there is an attempt to re-write the history and standards of best medical practice in Nigeria using Ahmadu Bello University Zaria (ABU) as a template. Medicine is considered glamorous by any growing intelligent baby (and his/her parents) and not surprisingly, the Faculty of Medicine of ABU receives 5,000-10,000 annual applications to the department of human medicine alone against available 100-120 slots!
First, to be a doctor in Nigeria, one must spend at least 6 calendar years (not 6 academic years of 3½ months/semester) in the undergraduate medical school. During this harrowing period, the medical student must take and pass courses in basic medical sciences such as Anatomy, Physiology, Community Medicine, Biochemistry and Pharmacology. These students struggle to learn within 3 years what a bachelor degree student in these basic medical sciences will acquire in 8 academic semesters. To make matters worse, the medical students minimum pass mark is 50% as opposed to the 40% for a bachelor’s degree student.
The general consensus is that a doctor should improve the patients’ health beyond 50%, and hence a medical doctor cannot pass any course without scoring at least 50%. Also, as opposed to the bachelor’s degree programme where each semester is discrete and exams covering each semester are held, the situation is different in the medical school. The need for the utility of both current and past knowledge in medical decisions makes medical examinations integrated to draw on the knowledge gained from work done over the whole year and not just over a semester.
Therefore, the only difference between a graduate of Human Anatomy, Physiology or Biochemistry and a medical student after the preclinical studies is the dissertation. Medical students do not write a dissertation at this level but only in the final year of graduation. Little wonder that though the medical schools attract the best brains (local champions) from the secondary schools with many of the applicants having glorious grades in both WAEC and JAMB exams, very few survive the brutality of medical school and many are forced out the system.
The next 3 years constitute the clinical phase, which is even more rigorous because it exposes the medical student to various aspects of medicine. The students are taught both didactic lectures and bedside medicine; they also participate in tutorials and presentations. The scope covers all aspects of medicine such as: internal medicine, surgery, paediatrics, obstetrics and gynaecology, public health, pharmacology, ophthalmology, orthopaedics, anaesthesiology, psychiatry etc.
During this period, the medical students also participate in ward rounds, call-duties and attend to emergencies with senior colleagues. The aim of MBBS degree is therefore, to train a high quality Doctor that can recognise a disease process, categorise it and start appropriate management and if necessary, depending on the limitations, refer to the appropriate specialist for continuation of management. It is instructive to note that the Nigerian MBBS is equivalent to the United States MD, which is generally regarded as a postgraduate degree.
Department of Internal Medicine,
Ahmadu Bello University Teaching Hospital Zaria, Kaduna State, Nigeria.