Dr. Oluronbi Odunubi, whose tenure as the Medical Director, National Orthopaedic Hospital, Igbobi, ends next week, spoke with journalists on the journey so far as head of the institution, why Nigerians should access orthopaedic hospitals rather than traditional bone setters, and what government should do for better running of the hospital. He also spoke on other sundry issues.Â Martins IfijehÂ brings excerpts
In few days time your tenure will end as CMD, what were the challenges you met on ground and how did you manage them?
The challenges we had were related to patient care, infrastructural problem and mainly finance for maintenance of services and completing ongoing projects.
On patient care, we were operating basically as a hospital without sub specialisations. But we had to now focus on development of sub specialties so that we can raise the level of practice in orthopaedics and trauma care in order to really serve as a referral centre.
Though there was an ongoing discussion on these sub units before we came on board, but they have now been actualised. Consultants are now divided into sub specialty units. For orthopaedic, five sub specialties were identified and consultants had to get trained in those specialties. Some trained themselves while others were sponsored by the hospital. Now we have sub specialties like arthroscopy and sports medicine, arthroplasty, spine surgery, special trauma units, and paediatric orthopaedics. Of course the bones and reconstructive department still exist.
The other thing we tried to do is to minimise the waiting period for patients. We had to introduce afternoon clinic, instead of just morning clinic for everybody. We also used to attend to all new cases in the emergency service point, but now, we have built a separate Out-Patient Department (OPD) for patients that are not really on emergencies but are new patients. They are seen in that OPD and the emergency cases are seen in the emergency units. So the doctorâ€™s attention is not divided between seeing patients that are not emergencies and the ones that are emergencies.
The hospital is very old and it was established in 1945. So there were a lot of wooden buildings that outlived their usefulness. We were able to convert some of them to more solid structures. For example, the former Prosthetics and Esthetics department is now the NHIS clinic. We had the old Physiotherapy department which was expanded and reconstructed.
We realised Drug Revolving Fund (DRF) we met was very functional. Those who were managing it before had done a good job. It is also making money for us. So since the scheme emphasises that whatever is made from that, apart from the percentage that goes to government, should be used to develop hospital services, we used the money to put up a building for them, and also furnish a quality control laboratory, so they are equipped to test for fake drugs and ensure the supply of drugs. The future expansion in that building makes provision for manufacture of some of the basic drugs. The infrastructure is available now, so itâ€™s just for money to be available to fund that aspect of the building.
What other challenges have you successfully managed?
Although finance has been the main challenge due to budgeting constraint, there are three sources of government support. There is the capital, which should be for the four ongoing projects we met on ground. The administrative block, the theatre complex, a new general patient clinic and a new accident and emergency. All these projects were started between 2010 and 2011, some with a completion period of two or three years, but they are still not completed till date except the administrative building, of which we are still owing the contractor N20m, because he used his money to complete it.
So the budgetary provision for their completion was not available. Before we took over, for instance, capital vote used to be between N340m and above N400m, but in the last few years we rarely get N100m . Yet the projects are just there. The contractors have not been encouraged to come back to sight. They only get paid based on evaluation that is done and money available.
Last year also, we had the budget of N127m for capital, at the end of the year only N82m was released. And the evaluations that were available were over N100m.
The same thing also happened to overhead. When we came in, we were still getting about N7m to N8m per head, but now we are getting only N3m. And not all the months are paid. Last year, we got overhead for only eight months. The PHCN bill per month alone is between N6m and N8m depending on how much supply of light we get during the month. And we buy diesel of between N12m to N14m monthly. So you can see that on energy alone, we spend up to N18m, not to talk of generator repair, and all other repair of infrastructure in the hospital. That is a big constraint. Considering that budgeting provision has come down. The alternative would have been to increase patients fee but they will run away as they canâ€™t afford it.
We have a lot of patients that are brought here as trauma victims. The government policy is that you must treat them first, then give bill after. Many times they donâ€™t pay, and there is nothing we can do. Sometimes, we even have to beg some to leave the hospital after they get well so that other patients can have space. These are the challenges of being a trauma centre. Military, Police, FRSC just bring these victims and leave. Itâ€™s left for us to look for their relations, feed them, and so on.
So what is the solution to that?
The main solution to that is for the larger percentage of people to be on health insurance, such that there will no longer be out-of-pocket services. Nobody prepares for accident or save money for it. The only way is to be on health insurance, and the scheme should be allowed to run properly. Right now health management organisations are owing so many hospitals, and there are many arguments about bills even when one follows the NHIS billing. Assuming a patientâ€™s bill is N20,000, HMOs will still cut it without any rational basis. They will still argue with hospitals and cut it to say about N8,000. How do you keep services going that way?
Some private hospitals are closing down because they canâ€™t cope, especially on secondary and tertiary care. The scheme needs to be run properly.
Why the sudden decrease in funding to the hospital?
Itâ€™s not only us. All hospitals are affected. I think itâ€™s the financial situation in the country. The only funding that has been sustained is the third subvention. You know that tends to increase every year because people are being promoted, while annual increments apply. When the government looks at what they are spending in the hospital, they just add all these together. In their books they may say it has increased but you will see that only about six per cent go into service. About 94 per cent go into salaries.
Why the general belief that orthopaedic hospitals are always quick at amputating limbs?
No orthopaedic surgeon really wants to cut a limb. If we must amputate a limb, it has to depend on the severity of the injury. A limb survives based on blood supply. If by the time a patient comes to the hospital and that part of the body has not received blood supply for a long time it may die off, and if you keep it, that dead part will affect the living parts and such patients will die from infection, so the dead part has to be removed. And that is based on the severity of the injury, or late presentation.
Some people have cancers of the limbs and they donâ€™t come to the hospital on time. If they come on time, that area can be surgically excised and replaced. But when it has spread and has destroyed other tissues, there is nothing one can do.
Another thing is, a lot of limbs that have been amputated are as a result of complications from traditional bone setters. A fractured limb normally has the tendency to heal itself (not all cases though) even if you donâ€™t do anything, because what heals the bone is already in the blood. If you put Paris of Plaster (POP) in the limb, you are only using it to set the bone in position. If a patient eats good food and he is well nourished, the blood will heal the bone, not the POP or surgery. These things are only used to set the bone for proper positioning while healing.
The traditional bone setters also apply splint, but in the process of doing that, they make the splint so tight that it cuts off blood supply to the limb, and the limbs go dead. When such cases are brought to the hospital for savage we then decide either to amputate it or not. That dead limb will ultimately kill the patient because itâ€™s a source of infection. So we are to decide whether to retain the limb and the patient dies or remove it and the patient lives.We have had patients that, despite the obvious dead situation in their limbs, they tell us not to amputate them. And you will be seeing those patients dying.
Have you made efforts to educate traditional bone setters on the apparent danger?
We have been trying to educate them on the danger. In this hospital, we have had seminars and workshops, and we have noticed some remarkable decrease in the incidence of cases coming from them.
Unfortunately, those who often have these problems are children. A child whose limb is under a tight splint wonâ€™t be able to talk. So such a child would be told to bear the pain until the leg goes very bad. If itâ€™s an adult, he or she can remove it and them come to the hospital. For those whose limbs were cut, when they go back to their communities, all they say is their limbs have been cut in Igbobi. They wonâ€™t say they went to the traditional healers. So the antecedent activities will not be related.
Why do people believe more in the traditional system than orthopaedic hospitals?
There is no scientific basis for that. Like I said, a broken bone can heal itself. You have seen dogs hit by cars, and they limp for some weeks, after which they are okay. Nobody has treated them. If traditional bone setters are treating minor fractures, they may claim success, even though the fracture naturally heals itself. So they will do well in simple fractures. But the problem is some donâ€™t know the limitations of their expertise.
Some fractures overlaps each other, and over time they will be healed. And then you will see such a person limping because the traditional setter could not align it appropriately in the right position before the healing took place. But that is unacceptable in the hospital. If someone has a broken bone, we first aim to align it before healing. In some traditional methods, assuming the bone is broken and rotated, that is how they will put the splint. When the person is okay, you will see the personâ€™s limb has rotated.
Donâ€™t you think one of the reasons for the preference is because their services are cheaper?Â
By the time you add up what their patients pay, it may eventually be more. For instance, if you come to Igbobi for a particular treatment, we may say it will cost you N100,000. But take same to traditional setters, and they will tell you to bring N10,000. Then the next week you will bring a ram, then another thing. So by the time you add everything you may have paid the same N100,000.
Your hospital is a training centre. How has it faired so far in that regard?
In the last five years, the School of Prosthetics and Orthotics, which is the only school in West Africa for training technicians fabricating artificial limbs, and support for limbs, was established in 2010. The school was running a national diploma programme, so we succeeded in getting an accredited HND programme for it. So they have graduated two sets already. And we also got the School of Cast Technology accredited. There is also a School of Post Basic Nursing in Orthopaedics, and Post Basic Nursing in Accident and Emergency. These programmes are running. Even recently, the West African College of Nursing recognised the school as the best post basic nursing college in Nigeria.
Then there is the residency programme for doctors who are specialised in orthopaedics, bones and plastic programmes. That is also ongoing and we have full accreditation. Our resident doctors do very well in the postgraduate programme.
Popular assumption is that government hospital workers are nonchalant and uncaring to patients. Do you have that challenge here?
No. We donâ€™t have that challenge. We have training sessions to enlighten staff on attitude to patients. Skill and knowledge is not all one need in a hospital. There are patients that go to hospitals just because of the right attitude.
What is the next level for NOHIL?
The hospital should keep increasing the skills of all workers, not just doctors alone, because that is the mistake most hospitals make. They concentrate only on doctors. We have to increase skill of administrative staff, nurses, therapists, and others.
We should keep developing on the sub specialisations we have. There are so many orthopaedic centres in Lagos, from LUTH, Ebutte Meta, etc. Lagos has about six general hospitals with orthopaedic units.
Unlike before in the 80s when I first came here, simple fractures in Lagos were referred to Igbobi, but we no longer get such cases.
Lagos State has an advantage because they have the LASEMA bus. When accidents happen, itâ€™s their buses that get to the scenes, and they take the patients to their hospitals. Then when the cases are severe, they bring them to us. So what that invariably means is that our team must continue to improve themselves so they can continue to tackle difficult cases.
The hospital needs to keep encouraging Public Private Partnership. Government has demonstrated it cannot do it alone. It has admitted that as well. So the future must involve the private sector. Here we already have a PPP in place. For instance, the MRI and CT Scan are tools crucial for orthopaedic care. We donâ€™t have them in this hospital in this modern era, so we had to send patients to diagnostic centres for test. But now we have gone into partnership with a private company. They have put up the building here and we are just waiting for the machines to arrive. Itâ€™s a win-win situation for government, patients and the private company.
Government needs to also address issues of recurrent strikes. That has reduced growth of many hospitals. Once strike comes, patients leave the hospital and lose confidence in the system. Sometimes before you get the number of patients back after strike is called off, it takes six months.