Healthcare in Nigeria: A game of Russian roulette

By Soji Apampa

According to Dictionary.com, “to play Russian roulette is to gamble foolishly on a risky or potentially ruinous business. The expression refers to a deadly game in which a participant loads a revolver with one bullet, spins the cylinder, and fires at his own head.” In Nigeria, if you visit private healthcare facilities, you may well be playing Russian roulette with your life and the lives of your loved ones. This statement may not at first ring true for those with the resources or the HMO cover that includes the top private health facilities in Nigeria.

It is sadly true for more than 90 percent of Nigerians who, according to a 2021 National Health Institutes of Nigeria study by H. O. Shobiye et. al., have no health insurance coverage. Is anyone able to tell the difference between a “chemist” and a “pharmacy” in Nigeria? Excluding the top facilities (which, as we have established, most Nigerians cannot access), can anyone tell the difference between a “hospital” and a “clinic” in Nigeria? Are all private hospitals registered and certified to manage all conditions, or are there important differences Nigerians should note?

How do we get better health services for Nigerians? It is tempting to first think of the processes within a proper hospital. Appointment booking, arrival, registration, taking of vital statistics (or triage even), allocation to a doctor, consulting a doctor, tests, interpretation of results, confirmation of intervention, prescriptions, follow-up sessions, and so on. To improve outcomes, one might think of sophisticated timeline optimisations so patients have less wait time, or training of personnel to show more empathy with patients so patients have a better care experience for their hospital visits, or certification of the facility to meet standards set by the Society for Quality in Healthcare in Nigeria (SQHN) announced in April 2024 or by COHSASA (Council for Health Service Accreditation of Southern Africa) that several of our top hospitals have attained to ensure globally acceptable practices can be guaranteed, and so on.

But Nigerians end up in body bags more often simply because they seek care from unapproved private health facilities and from unqualified professionals. For this reason, the Lagos State Health Facility Monitoring and Accreditation Agency (HEFAMAA) has shut down many private healthcare facilities in the state.

Lagos is only one of 36 states in Nigeria, and tales of woe reverberate across the entire country. In 2017, the Ogun State government, for its part, sealed up 168 of such facilities. The question is: how many private health facilities are operating across the country without approval, and how many of those with accreditation have issues with inadequate staff or unqualified personnel interfacing with patients? How many such facilities are offering services they are not equipped or accredited for, and how many private practitioners are offering services they are not trained to provide?

Nigeria’s Minister of State for Health, Dr. Tunji Alausa, was recently reported to have lamented the proliferation of quacks in the health sector, suggesting these untrained people were now complicit in organ harvesting syndicates. In what sounds like a major indictment of the health regulatory framework, the minister was quoted as saying, “We will be pushing for a new regulation to regulate the healthcare sector, as more than 60 percent of the nation’s healthcare is in the hands of the private sector without adequate supervision… You see hospitals, laboratories, and diagnostic centres being run without anybody checking on what they are doing, and these are some of the places where illegal practices like organ harvesting are taking place.”

In Lagos State, HEFAMAA advises residents to desist from patronising uncertified health facilities in the state. But how should residents tell if they are approaching a certified facility? They urge residents to look out for HEFAMAA logos, which should be displayed publicly by certified health facilities. All states could do something similar, and the Federal Ministry of Health could coordinate this to ensure standardisation of the approach, but we all know this is not foolproof. Logos can be faked. How about QR codes and barcodes that can be scanned using the now ubiquitous mobile phone to confirm, from the regulator’s site, details of the facility being utilised?

We need public vigilance and public feedback on what is happening to the healthcare facilities used by many Nigerians to reduce the incidence of needless deaths. Having a feedback system that works only makes sense if we can hold the quacks to account. Some experts say these uncertified facilities are usually set up by at least one trained professional who then hires and trains the quacks to carry out the unlicensed activities. When we catch that trained professional, are we prepared to get him or her struck off the register of professionals for all time?

Logos, QR codes, and so on still only treat the first level of root causes. The deeper root cause is that most Nigerians cannot afford healthcare and, in their desperation, run to whomever looks able to help even when they know the facility is unlikely to be certified (like when they rush to the local “Chemist” for a medical diagnosis and prescriptions) and know the person attending to them is unlikely to have been properly trained. Secondly, there is a paucity of acceptable-quality private healthcare facilities even in high-brow urban centres that talk less of peri-urban and rural locations.

The Minister of State openly admitted that 60 percent of healthcare provision is by the private sector, meaning the government has only 40 percent coverage. What created such a gap? In Cameroon, Togo, Benin, Ghana, Chad, or Niger, is it the case that the private sector dominates health care as it does in Nigeria? And if so, how do they regulate these private facilities to ensure their citizens get acceptable care? Nigerians like to one-up South Africa when they can. What is the situation in urban, peri-urban, or rural South Africa or Kenya?

The problem with Russian roulette is that every time you pull the trigger and escape death, you reduce your chances of survival. The next attempt might just be the one that ends your life. In the same way, some have visited these facilities and gotten away with it in that they did not die and their condition was managed, but the next time or the next person from your family or community using them might just be the unlucky one. “I am my neighbour, and my neighbour is me,” which means I will show concern and do something even if I am not directly affected right now. I am sure each of us knows someone who has been a victim, and even elites are not exempt. They each know of someone who went for a tummy tuck (elective cosmetic surgery) in an unlicensed but very expensive facility and lost their life. It could be someone close to you next time.

As we say, “shine your eye” and let us start an integrity movement on this issue, gather data and evidence, and enlist the help of the Federal Competition and Consumer Protection Commission (FCCPC) in this fight against quacks in Nigeria’s private healthcare sector. “Our Mumu don do!”

Soji Apampa, co-founded The Convention on Business Integrity in 1997. He is an Executive Director for the Convention on Business Integrity and also serves as a Consultant on CBi projects.