Patients suffer from Nigeria’s faulty hospital referrals

April 26, 2022 Mary

The lack of organisation and synergy in the referral system operated at different levels of healthcare facilities in Nigeria is taking a toll on patients as emergency care is often delayed, BusinessDay findings have shown.

Many patients get referred from primary or secondary hospitals to tertiary and federal specialist hospitals without prior briefing on the nature of their cases, the resource capacity of the receiver to manage them at the time of referral or current competence level.

BusinessDay, during visits to some government-run tertiary hospitals, found that patients were left stranded for hours as the demand placed on the facilities far exceeds their capacity, especially in bed spaces. It was learnt that some patients gave up because they could not get emergency medical care.

While a few hospitals do due diligence before sending patients down in ambulances to referral hospitals, many let patients with acute illness flock to those facilities without any assurance of being admitted.

Some patients are forced to do self-referral to a higher level facility that is perceived to be better resourced in equipment, skills and drugs to manage their condition.

In one of the visits, BusinessDay observed a middle-aged woman in excruciating labour pains who was rushed into the maternity ward of Gbagada General Hospital, asking to be delivered.

But she and her husband presented their case without any letter. It took persistent questioning from the lead nurse on shift that evening for them to disclose that they had been to a lower private hospital where it was said that she could not deliver the baby without a caesarian session.

They spent about an hour rerouting her through the accident and emergency (A&E) department and then transferring her to the maternity ward.

But some patients are not that lucky. An average of 65 patients or more present cases daily at the A&E department of the Lagos University Teaching Hospital but just about 35-bed spaces are available and an average of 20 are admitted, an official told BusinessDay.

At the 280-bedded Federal Medical Centre, Ebute Metta, about 5,000 new patients register monthly and about 30,000 patients are seen monthly.

Adedamola Dada, chief medical director of the centre, said only five percent of those cases should be managed by the hospital as 70 to 80 percent could be resolved by primary healthcare centres and 15 percent by general hospitals.

For the hospital, a strong referral system would improve its performance in core areas including training and research, Dada said, adding that robust attention could then go to those in need of complex cardiac surgery, major abdominal surgery, cancer care, and congenital deformities, among others.

He said: “The tertiary hospitals are for training, research and guidance of other levels. But what you find in our country which is one of the major problems is that the referral system linkage does not work.

One of the consequences is that general and teaching hospitals are overwhelmed, and the primary healthcare facilities are virtually empty.

“And because of that, they don’t have the time to actually concentrate on their primary responsibilities including treating complex diseases, training new doctors and doing research. We must have a strong referral system. That is one of the major components of that system.”

An analysis by Asia Pacific Observatory on Health Systems and Policies in 2019, citing a study, said patients bypassed primary health care facilities in favour of seeking care directly from facilities providing secondary or higher levels of care in many low- and middle-income countries.

One of the results is that many patients attending higher-level facilities miss initial assessment or treatment due from primary care facilities. It also reduces the quality of care in those facilities, resulting in under-treatment of emergencies and complications.

Many cases indicate that the majority of patients at the secondary level are non-referred. Between 7.7 percent and 37.6 percent of sampled outpatients at referral facilities reported being referred in Nigeria, compared to 9.9 percent in Ethiopia and 20 percent in Kenya.

The analysis shows that the referral function results from the interaction and functioning of different elements of the health system which the organisation of services, and the capacity and quality of care provided.

According to Ebun Bamgboye, clinical director at St Nicholas Hospital, regulatory bodies such as the Health Facility Monitoring and Accreditation Agency should establish standards that ensure referrals for specific conditions are restricted to institutions that have the capacity and competence.

“Not all hospitals have competencies that will necessitate referrals for specific issues. What we do is that we expect to have received information on anyone who is going to be referred to us and we only accept if we feel we have the competence to deal with that issue,” he said.

Muhammad Ali Pate, professor of public health leadership at Harvard T. H Chan School of Public Health, said hospitals should be better supported with resources to invest in health systems, physical infrastructure, technology and platforms that could allow seamless interface between care providers.

“That will go a long way in enhancing the experience of patients when they walk through the healthcare system with whatever conditions they have. When you don’t spend enough on health, and everybody spends only by himself or herself, you will get the result we are getting right now,” he said.