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Cash before treatment in Nigerian Hospitals: * doctors, lawyers, other Nigerians react

…blame government for failing to provide effective healthcare system

By Innocent Anaba, AbdulWahab Abdulah and Chioma Obinna

There is a dangerous trend in the healthcare delivery service across the country, which Nigerians have lived with all these years and have expressed disgust over the development.

It is the demand for cash deposits before a patient is treated. Many lives have been lost due to this stringent condition, which unfortunately also applied to public hospitals. The only people who are free in this unfortunate trend are people, whose company pay for their medical treatment.

In this edition, Vanguard Law and Human Rights sought the views of medical practitioners, lawyers and ordinary Nigerians on the issue. While the medical practitioners justified this phenomenon, lawyers and others condemned it, but all those who spoke insisted that government must be held responsible for the trend, for failing to provide an effective healthcare system for the citizenry.


Chief Medical Director, Lagos University Teaching Hospital (LUTH), Prof Akin Osibogun also a Professor of Public Health: “we all know that health goods and services cost money. Rents and salaries must be paid and PHCN does not supply electricity free to any health institution and neither does the Water Corporation waive payment of water rates by hospitals. Equipment and materials must be paid for.

Particularly for private hospitals, if funds are not recovered through patient charges, such hospitals will close down within a short period of time. So, if we are agreed that money must be available to procure all the inputs into the provision of health goods and services, then we must agree that somebody or a group of people or an organization must pick up the bills. All over the world, health bills are settled through a mixture of mechanisms involving the government, communities, families and individuals.

In one model, government can pick up all health bills and in that case citizens will not have to pay for health services at the point of need. In such instances, citizens must have paid their taxes religiously as that is one important source of government revenue. if a high percentage of the citizenry pay their taxes, we can agree that a certain proportion of the accruing funds will be used to finance all health services.

At the other extreme, a model leaves individuals who need health goods and services to directly and fully pay for such services out of their own pockets.

In most countries however, the mode of financing is mixed. In Nigeria, specifically, government finances certain services e.g childhood immunization and other preventive interventions while subsidizing some other services such as hospital care. This mixed model therefore suggests that individuals and families are expected to play some financial role in health care.

In many developed countries, governments and citizens have adopted different forms of health insurance to protect the citizens against catastrophic expenditure for health. In other words, citizens are encouraged to pick up some form of health insurance for which they pay regular premiums and in return for which they are guaranteed access to health care without having to pay at the point of need. Once the hospital gets the patient’s insurance number, it provides treatment and forwards the bill to the insuring agency which will then settle the bill on behalf of the patient.

While it is a general policy of the Federal Government that emergencies must be treated regardless of ability to pay in its own facilities, we must bear in mind that families and individuals have a continuing role to play. Health Insurance appears to be a very useful tool in ensuring individuals and families have access to quality health care. Public hospitals waive payment for cases in emergency in addition to the overall subsidy already provided by government.

The decision to waive payment or not, in private hospitals depends entirely on the private hospitals and their other sources of funding if any. The Government has established the National Health Insurance Scheme (NHIS) and we should all work together to ensure the expansion of its coverage. The press has a unique role in promoting awareness. I should point out that in addition to the NHIS, there are also private Health Insurance Schemes that achieve a similar purpose.

Chief Medical Director, Lags State University Teaching Hospital (LASUTH), Dr Femi Olugbile, said, “someone has to pay for the services whether public or private. There is nothing wrong with that. In the case the patient is close to death or if it is an emergency case, the hospital can wave the deposit or requirements temporarily for that purpose but there is need to recover cost otherwise you can not sustain services. In government establishment, it is not free even in government sponsored programmes.

It is just that government will pay. In private establishment it is required that you have fee -for -service otherwise you can’t sustain the service. It is a basic business arrangement. You need to return cost to sustain service. The only difference in government is that government will pay the fee for the patient. It is not that it is free otherwise that service will be sustained.

In private establishment nobody else is paying on behalf of the patient the patient should pay. But in emergency situation, the private hospital will obviously wave deposit for attention to be given to the patient. But soon afterwards that they started treatment, arrangement should be made to return cost otherwise that service cannot be sustained.
Of course ultimately out of pocket expenditure is not sustainable what we should have is total insurance system but even America has not achieved that totally.

That is what Obama has focused upon. Nigeria has to pay serious attention to the ways of funding health services. We have not done anything yet. It is not an emotional thing. You should not be painting people as shylocks because they are demanding cost for their services. You are just begging the issue.

Chief Medical Director, Federal Neuro Psychiatric Hospital Yaba, said “in emergency situation, deposit will be waved. This has nothing to with the ethics. In a normal situation, the patient pays for deposit. If it is not emergency the patient has to pay. You have to pay at least for consultancy and card.

Bamidele Aturu, a Lagos lawyer, says, “the increasing resort to either rejecting patients in manifest need of care or throwing out those on admission on account of their inability to afford hospital fees is a sad reflection of the pervading crisis of capitalism.

This practice which is now routine in class-divided societies, including even the so-called advanced ones, makes a mockery of whatever is left of the Hippocratic Oath. It would be foolish to blame medical doctors for not respecting their oath.

I believe the blame lies squarely at the doorstep of those who have imposed themselves on society as leaders and who have made profit-seeking the fundamental motive. A doctor who has to pay his own legal, rental and sundry fees in a predatory economic climate cannot but see the Hippocratic Oath as hypocritical.

The point being made here is that it is futile to fulminate against doctors for not exhibiting human kindness to people in dire and desperate need of medical attention simply because they cannot afford it. The solution lies in socializing society in such a way to ensure that basic medical and other needs are provided by the state. This is the only logical solution.

The doctor in my view is no more guilty than the seller of yam who refused to offer her tubers of yam free to a woman dying of starvation-and there are many such people in this country. What of the lawyer who asks a miserable tenant to provide fees ten times the rent in dispute?

Of course, I would be glad if our doctors and our hospitals demonstrate that they have a social conscience and help reduce this frightening practice to the barest minimum. Nevertheless, I would vote for a system change any day and, I should add, anyhow. Until we deal decisively with graft and ostentatious living by vermin who contribute nothing to our economy and bleed the nation only on account that they are politicians for so long would we see doctors shut their gates against indigent fellows.

It is not a matter amenable to legislation or pious declarations about the immorality of shutting out the under-privileged from medical aid. It is a social and revolutionary matter, one which must involve the dismantling of all structures and apparatuses that create the poor in the midst of plenty that is wasted by the lazy and avaricious class in power. Our people must wake up; it is not a bread and butter affair.

Mr Onyema Omenuwa, a Lagos lawyer, said “granted that citizens have right to life, is it the duty of doctors to guarantee it, its government’s duty and the way to ensure this could be to provide free medical care for all and if I am a doctor in private practice, should I be forced to provide free medical care? No, it cant be done because I am in business (practice) to make profit.

So, if you are talking about right to life under the constitution, it is government’s duty to ensure that necessary machineries are in place to guarantee that, of course, you cant be talking about welfare without life. The only way to make a provision of this nature binding on government is to make chapter 2 of the 1999 constitution justiciable.

Part of the Hippocratic Oath reads, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone”, but a person does not become a doctor’s patient until the doctor accepts them. Even where he does and the patient cannot pay eventually and he is thrown out, the doctor’s action will only be against the oath and not against the constitution.

Jude Njoku, a journalist, says “for me, there is no milk of human kindness anymore, because you see somebody at the point of death and that person is asked for a cash deposit before he could be treated. I think the best thing should have been to save life first and after, the hospital will ask for money. If the condition of the person stabilises, then the hospital can ask for deposit or full payment.

Many of the hospitals argue that people run away and don’t pay, but I think saving life is more important than whatever amount of money the hospital want to charge the patient. Some people really go to hospital and when they stabilises, they abscond.

I have heard of it from my doctor friends, but even though it is sad that it is one finger that takes the oil that soil the rest, we should not visit it on every other person that comes to the hospital. A lot of people have died as a result of this cash demand. I think doctors that do this are heartless.

It should not be money all the time. Money is good, but to look for money at the detriment of a human life is certainly wrong. If you visit the hospitals these days, the doctors and nurses are so antagonistic and don’t care again. If you don’t buy the drugs, you maybe left to die and in most cases, if you don’t have money, death becomes inevitable”.

Tony Abaye, a media practitioner, said “I think that it is not morally right to harm a helpless man. By and large due to our very dishonest disposition to issues of money, one could say its okay. But come to think of it, payments are often in arrears for services. That not withstanding, hospitals are in the special services sector.

They render humanitarian service to people. They should try and deemphasize the issue of pay before service. This is also an indictment on the government, who in their lack lustre attitude to provision of basic needs have failed to cater for their citizens. The seven point agenda of our government to me still remain the most shameful display of comprehensive hypocrisy.

Mr Emmanuel Majebi, a Lagos based lawyer, says “it is the general practice of most medical centres that patients are asked to make cash deposits before they are treated. The question that worries the mind of most people is whether this practice is wrong or not.

From the Legal point of view there is nothing in the law that lays down what can be called the rule when it comes to treatment of patients! It is thus left to the individual medical centre to lay down their rules. It is a matter of morality not law whether or not a hospital will ask for cash deposit as a precondition for treatment.

Medical treatment cost a lot of money and someone has to pay for it. Whilst it may be immoral for a hospital to demand for cash before treatment I do not see anything wrong in Law about that! I am however sure from experience that there are many hospitals that will offer you at least first aid or emergency room treatment and later demand for cash when you are diagnosed and declared to need other forms of more expensive treatments like operation, scans or xrays.

The truth of the matter is that all over the world medical treatment is not free. It is either you pay for it or someone else pays on your behalf!! Rather than bother ourselves with why hospitals ask for cash before treatment we should ask ourselves why is it that a country-Nigeria- that has earned Trillions of Dollars from Oil production over the years does not have a Medical care system that takes care of all it’s citizens poor and rich?

In the United Kingdom for example they have the National Health Service(NHS) which is integrated with a well oiled National Health Insurance Scheme. In those kinds of organized set up once a person needs medical care the issue of payment does not arise at all as the medical insurance is there to take care of the medical bills.

Just the other day we needed to do a brain scan for a relative and this cost as much as N80,000. The Government Hospital where we went to, had no facilities to do the scan and we had to go to the private place. You do not expect them to do such an expensive procedure for you without you paying? It is sad that out governments over the years have not put our national wealth where it ought to go and so many innocent persons have died just because they do not have money to pay for the care they need.

In summary I would like to point out that medical treatment is like every other professional service like legal service, mechanic service, tailor’s service e.t.c you cannot walk into a lawyers office and tell him to offer his services without you making any prior financial commitment. It just that in other countries where they have better governments they have gone out of their way to make sure that lack of funds do not stand between their people and medical care.


Comments expressed here do not reflect the opinions of vanguard newspapers or any employee thereof.