URBAN & SUB-URBAN SURGICAL PRACTICE:Coping strategies.

INTRODUCTION:

• In general terms, rural practice can be defined as practice in non-urban areas, where most medical care is provided by a small number of general duty practitioners/family doctors with limited or distant access to specialist resources and high technology health care facilities. 11

• Whereas, urban surgical practices on the other hand, enjoy the benefit of deploying advance surgical equipment, IT support services, better amenities and social infrastructure.

• This is further complemented by steady pool of trained and experience health and technical workers.

INTRODUCTION CONTINUE:

• In Nigeria and in most developed countries of the world, the urban surgical practice would also benefit from major healthcare determinant factors such as health care insurance [HIS] and degree of indusrialisation.

• These city practices however suffers from government over regulation and control, multiple taxation and harassment from overzealous government agencies and officials.

• Other challenges are burden of high overhead, traffic congestion, noise pollution, non-functional/inadequate and ill maintained social amenities and the perennial struggle to compete and remain relevance.

ABSTRACT:

• Urban and sub-urban surgical practices present a totally contrasting practice environment.

• While the challenges in the urban areas borders on the practitioner’s ability to establish a competitive practice that will be able to attract and retains the interest of company/ factory workers, build impressive image presence that will attract and retain the attention of captains of industries, HMO providers and also meet the expectations of the average city dweller and regulatory agencies, the challenges in the sub-urban areas on the other hand, are totally of a different kind.

• Rural areas are by implication areas that are not urban.

• Different countries uses different criteria to define their rural areas, including low population figures in the United States, provincial towns outside the cities in New Zealand.

• There is the presence of Agriculture and the common factor of limited resources and under-service in public amenities. JI Umuna .2

ABSTRACT CONTINUE:

• In Nigeria, “rural “may be classified into two.

• There are towns and villages at the fringes of cities which benefit from public utilities in the near-by cities , and there are the typical Nigerian villages which may be recognized by the following characteristics:

• habitats interspersed with trees and forests, approachable only by foot paths, or at best, untarred or 'were-tarred' roads;

• inhabitants mostly peasant farmers and low grade artisans and other poor income earners;

• disease and poor nutrition; lack of useful government attention with regards to public utilities e.g hospitals, potable water, public electricity supply, and even security of lives and property. JI Umuna. 2

BACKGROUND:

• Rural/Sub-urban surgical practice is the practice of Surgery under conditions of limited resources which brings surgical services to the doorsteps of the rural Populace, majority of whom are poor while urban surgical practice in Nigeria may not necessarily fare better for a totally different reasons.

• Many rural communities in Nigeria may not have the luxury of Electricity power supply, pipe borne water and good network of roads;

• They all remains largely scarce commodity in most Nigerian cities for reasons of neglect, poor maintenance and outright corruption.

BACKGROUND CONTINUE:

• While the peasants in the sub-urban communities will easily appreciate your sincere efforts, an average city dwellers on the other hand, with all his exposure, education and access to internet, would demand, as of right, that you render quality service even though he may not be particularly eager to pay commensurate bill.

• There is also the serious competition to outshine your closest rival in the struggle to corner sizable enrollees from both the NHIS and HMO providers.

AIMS & OBJECTIVES:

• The aim of this paper is to compare surgical practices in both urban and rural areas of Nigeria.

• Highlight the challenges and to ultimately suggest ways of coping and overcoming them.

• Basically, whether one’s practice is based in the city or in the rural area, the challenges may be different but the coping strategies are of universal applicability.

MATERIALS & METHODS:

• A review of personal experiences in urban and sub-urban surgical practice [the author has had 24 & 7years practice in Epe and Ajah respectively, both in Lagos].

• Grey literature(conference papers, technical reports and dissertations), journal articles, abstracts, relevant books and internet articles were reviewed.

• Personal interaction with other practitioners, friends and colleagues in the field was also exploited. JI Umuna. 2

KEY SEARCH WORDS:

• “Challenges of rural surgical Practice”

• “coping with the challenges of rural surgical practice”

• “National health insurance scheme in Nigeria”

• “primary care surgery” Health Care Insurance

• “ surgery for the poor”

• “community based health insurance” and

• ”rural surgery and health infrastructure distribution in Nigeria”.

RESULTS:

• Scope of surgery performed is commonly and usually limited by infrastructure, manpower, practitioners experience and funding.

• Procedures include fields such as Obstetrics and Gynaecology, Urology, Orthopaedics, Ear Nose and throat, Anaesthesia as well as General Surgery.

• A high proportion is contributed by emergencies especially Caesarian Sections, removal of foreign bodies from the ear, nose and throat, initial management of simple fractures, Hip-pinning, appendectomies, relief of intestinal obstruction, supra-pubic-cystostomies, catheterization and management of ruptured ectopic/tubal pregnancies. JI Umuna

RESULT CONTINUE:

• These procedures are carried out by General Duty doctors with only a few surgeons in established self-owned practices. JI Umuna.

• Nigeria has a population of 140milion and annual growth rate of 3.2% - [NPC, 2007].

• “Like many other developing nations, majority of Nigeria’s population [about 70%] lives in rural communities [ Ekong, 2003].

• The Nigerian ministry of health, ironically, spends about 70% of its budget in urban areas where only 30% of the population resides and remaining 30% on the sub-urban areas where the 70% of the population resides.

RESULT CONTINUE:

• More than 90% percent of all deliveries, # cases and gunshot wound invariably end up at the TBAs place.

• Our approach was to have some understanding with them so that when they have difficult cases they can refer to us for a better quality of care.

• We also made it easy for them to use some of our facilities such as X-Ray, laboratory and scanning machine to improve on clinical examinations, diagnosis and by extension management.

RESULT CONTINUE:

• It may be assumed that the health care services in Nigeria is inversely related to the need of the people.[10]

• In Epe, the challenge was and still is how to break the strangle-hold of the alternative practitioners [TBAs] on our clients.

• An average clients will register with us for ANC but end up having their babies at the TBAs place.

• In Ajah, Lagos on the other hand, our major challenge is coping with a bloated and ever rising overhead [major % of recurrent expenditure].

• Creating a niche in a market that is paraded by famous and not so famous multi-specialist hospitals manned by supper specialist managers and experience personnel is more than enough source of anxiety for any new entrants any day.

RESULT CONTINUE:

• To that headache, you can add multiple taxation, overregulation, undue expectation from clients and your employees. Your ability to manage all these, without being overwhelmed, would be a major success factor.

• For the 3rd consecutive year, the Lagos State Government has just concluded the unsolicited comprehensive auditing of First Graceland Hospitals to determine our annual tax liability.[ In saner clime this is suppose to be once in 5 years exercise]

• An average Lekki client would first come for a “general facility inspection” and ask you all manner of questions before making up his/her mind whether to choose your facility or not.

• [This habit was probably introduced first by the HMO providers as a pre-condition to determine the suitability of your facility to be appointed as a health care provider].

• This habits has now become a fad.

• Their question ranges from the mundane to the ludicrous.

RESULT CONTINUE:

• I can recall a pregnant lady, few years’ back, who after “interrogating” my front desk officers, walk into my office and demanded to know whether we had a CTG machine and a Morgue facility.

• What on earth would a pregnant woman do with a morgue? I was so exasperated that I had to ask her “why morgue?” “I don’t know, I just asked” was her simple response.

• When she was ask about what she knew about CTG “she said she only read it on the internet and was hoping that I would explain the meaning to her.

• During the resent Ebola outbreak, we had to acquire infra-red thermometer, hand sanitizer and put on protective gear as mater of necessity, else we stand the chance of losing our patronage.

COPING STRATEGIES:

• 1. TWENTY SURGEONS IN ONE

• "He only is wise who knows that he knows nothing. “Socrates.

• As a doctor in a sub-urban surgical practice, you are unlikely to be a fully qualified specialist surgeon with 5 to 8 years of postgraduate training.

• Instead, you will probably be a ''general duty medical officer” with only a few years of surgical experience.

• But somehow you have to care for the sick in all of the 20 specialist fields, into which surgery has fragmented in recent years.

• The chances of your being able to refer patients to specialists is often constrained by distance, time, availability, finance and willingness or otherwise of the client.

COPING STRATEGIES CONTINUE:

• There may be no maxillofacial surgeon, or hand surgeon within reach, and you may not even have a specialist anaesthetist to work with.

• Even your own teaching hospital may lack the complete range of specialists.

• Nor, despite present training programs, is the situation in many countries likely to improve much in the near future.

• Even your nearest State/ general hospital may not have a single general surgeon. But surgery will be a necessary part of your work.

• This would be in addition to your being a physician and a paediatrician at the same time.

• So you will have to do your best in all these fields simultaneously if you must succeed.

COPING STRATEGIES CONTINUE:

• What we did in First Graceland Hospitals, however, was to collaborate, engage and sometimes invite more experience colleagues and specialists to work with us whenever there is the need.

• At other times, we had formed broad based working partners with other practitioners where we horned each other’s surgical skill.

• Here again, our patients are carefully assessed and selected so that we do not build up damaging negative reputation for our young practice. Primary Surgery. 5

• ARSPON Free Surgical Workshops and the DFM class organized by the Family Medicine Dept, LUTH in collaboration with the National Postgraduate Medical Coillege has become, for us, an oasis in the desert.

2. SURGICAL STAFF ENGAGEMET & MANAGEMENT:

• One will have to maintained lean surgical staff by not replacing lazy, indolent, uncooperative and redundant ones.

• Ensure that only workers that shares your vision are retained.

• In my practice, this is the only way to stay on track and get things moving.

• I particularly discourage a situation where a particular staff stays forever on the same job schedule.

• It encourages fraud, indolence and discourages versatility.

• In this wise, it is preferable to have staff that can perform multiple task rather than to have to engage a staff for every task.

SURGICAL STAFF ENGAGEMET & MANAGEMENT CONTINUE:

• I move my staff around a lot.

• It is for me, a matter of necessity.

• The nurses will be moved between the pharmacy and the nursing departments while the administrative staff are moved through the Front Desk, HMO and the Account departments.

• I tolerate positive and constructive criticism and encourage workers with divergent views so long as they are constructive while the management decision must be held as final.6

3. BASIC FUNCTIONAL SURGICAL INSTRUMENTS:

• When First Graceland hospitals took off in 1992 at a very remote location in Epe, one of our major challenge is retain the services of trained medical staff and procure basic surgical instrument.

• Apart from the fact that qualified Nursing and paramedical staff were scarce, the few available cannot be engaged for the overhead implication on the young facility.

• To solve these twin problems, we resolve to train our own staff and preferred re-usable, simple surgical equipment.

• Even needles and syringes were been sterilized and recycled until the scourge of HIV/AID made that a crime in Lagos State.

• While that may not be advisable today, there are however many other surgical equipment and tools that can be re-used over and over again and they should be preferred over non-reusable ones.

• There is no reason to invest in a Million plus modern theatre bed when with just #20,000 you can fabricate a basic and functional one.

•

BASIC FUNCTIONAL SURGICAL IN STRUMENTS CONTINUE:

• My theatre bed in Epe, till date, cost far less and it has been in use for over 20 years. My circumcision set is 24years old today and it is still as good as new.

• The bottom line is to get the job done. Clients tend be more impressed by successful outcome during surgical procedures than the sophistication of your theatre.

• The average urban clients may however not be swayed by this argument.

• His assumption is always that poorly equipped theatre [and general state of your practice may be a recipe for disaster waiting to happen].

• Again, if one really desires to corner a sizeable enrollee from NHIS, Private HMO providers and the upper and the middle class in the society, an urban surgical practitioner may have to invest more in modern health techs and IT support services.

• Whatever type of instrument you choose however, maintaining and keeping them clean and sterile where possible is key to a successful outcome.1, 2

4. FAMILY MEMBERS INVOLVEMENT:

• In low resource facility, involving one’s spouse would definitely be of tremendous advantage especially in reducing overhead cost and ensuring close supervision.

• But if you are outside and looking inward:

• Do not feel discouraged because there is no proven statistical evidence to suggest that you need to have your spouse work in your rural surgical practice to succeed.

• Although, I might be wrong, but available evidence tend to suggest that the reverse, may in fact, be the case.

• But if your spouse have relevant qualification and share your vision, then her contribution would be invaluable.

5. GROWING YOUR INFLUENCE & CLIENT LIST:

• Activities of non-physicians.

• These fellow Nigerians are inevitably responding to the phenomenon of WHERE THERE IS NO COMPETENT DOCTOR which is a variant of the dictum NATURE ABHORS VACUUM.

• Legislation will not solve the challenge as those who will make and enforce the law patronize them.(Oluyombo Awojobi)

• What we did here is adopting a different positive approach, and that is to collaborate with alternative practitioners and to encourage them to referred cases that they, for obvious reasons, cannot handle to us and in return we assured them we will never take over their clients.

• We also introduce our scanning machine to them, training them to understand how to interpret its results.

• To achieve this we had had to incorporate simple reporting technics and diagrammatic illustrations to our reports and it worked.

•

GROWING YOUR INFLUENCE & CLIENT LIST CONTINUE:

• For upward of 10years we were the only scanning center in Epe.

• When we moved to Ajah in 2007 however, we had to change strategy.

• We set out to increase volume by setting up a strong HMO dept. to liaise with NHIS and Private HMOs providers and also to establish a “Business development Unit” whose responsibility it is to strategize on how to attract corporate clients and small business owners.

• This unit also came up with idea to create a platform to enable the poor have access to quality care.

• We have special clinics for widows, single mothers, children and the Aged.

6. HEALTH CARE INSURANCE:

• Health insurance is insurance against the risk of incurring medical expenses among individuals. According to the Health Insurance Association of America, health insurance is defined as "coverage that provides for the payments of benefits as a result of sickness or injury. This includes insurance for losses from accident, medical expense, disability, or accidental death and dismemberment. 14.

• I am aware that many ARSPON members has been thoroughly schooled in the art of surviving in rural surgical practice, we are really doing a good job of that presently.

• But I don’t think that, at this moment, we are making enough efforts to take advantage of the healthcare insurance scheme. This is one key area that our members must begin to explore, if we do not want our practices to be taking away from us or rendered so unprofitable in a not too distant future.

• Before going into the history of healthcare insurance in Nigeria, it is necessary for me to try to explain why we need to position and prepare ourselves to benefit maximally from this scheme.

•

HEALTH CARE INSURANCE CONTINUE:

• From 2005 till date, the government had done so much to ensure that worker in the formal and informal sector of Nigeria economy [by this, I mean the workers in organized private sector and those in all the 3 tiers of Government] are captured by either NHIS or private HMO scheme.

• It is a matter of regret that many of us ignorantly schemed our practices out of its benefits at the time.

• The second phase [Community health insurance] has just being rolled out.

• This is to cover the informal sector, the self-employed, artisan, market women trade and community associations.

• In a nutshell, the health insurance scheme is designed in such a way that every Nigerian is ultimately captured in this second phase of the scheme.

• This would be good news to many of us in the long run if we take heed now as it has the tendency to increase full utilization of available health infrastructure both public and private

• . But should we ignore this clarion call, it may be a cause for regret for many us later on.

7. EVOLUTION OF NHIS IN NIGERIA:

•The Bill on the introduction of a NHIS was first introduced to parliament in 1962 but this was not approved

•The idea of NHIS re-emerged in the 1980s

•The National Council on Health commissioned a study on NHIS in 1984

•Report of the study was submitted in 1989 and directive was given to the Federal Ministry of Health to start the NHIS in 1992

•The formal launching of the scheme was performed in 1997 by Gen. Sanni Abacha, the then Military head of state.

•An enabling law was promulgated in 1999

•Some pilot schemes were carried out from 1999 to 2004

•The National roll-out of the NHIS scheme kicked off in earnest in May 2005 under the Government of Chief Olusegun Obasanjo.

8. GRACELAND HERNIA FOUNDATION- GHF:

• The foundation was set up in 2010 as an NGO with the onerous task of eradicating hernia in Nigeria.

• It is the lot of the foundation to organize surgical workshops, seminars and outreaches.

• Till date, the foundation has successfully organizes about 6 [ 3 in collaboration with ARSPON] surgical workshops and seminars and 2 successful cervical screening campaign in collaboration with a sister primary health care Centre in Lekki, Lagos.

• So far, over 400 hernia patients has benefited from GHF.

9. PRUDENCE ON LEAN FINANCIAL RESOURCES:

• Be prudent and avoid waste.

• In most private surgical practices, like any other small businesses, there is always serious strain on the liquid capital, this is especially so in sub-urban practices where access to bank’s loan facility is near impossible.

• The solution is to avoid unnecessary expenditure by cutting down on expenses in less vital areas of the practice.

• For instance, if you are buying generator, go for cheaper options.

• Rationalize your personnel so that duties can be combined where necessary.

PRUDENCE ON LEAN FINANCIAL RESOURCES CONYINUE:

• The receptionist can also double as the cashier and the record officer instead of having different officers for each of these duties.

• The practice should be insulated from undue financial pressure from the family else it would collapse far quicker than one can imagined.

• Again, every employee must understand financial prudence, transparency and accountability.

• The system must be leak and fraud prove as much as possible.

• The place of regular and comprehensive auditing cannot therefore be over-emphasized.

10. SIMPLE TECHNICS & TOOLS:

• ”Safety and cost are far more important than cosmetics and comforts. Technique which is safe in average hands, Must have the highest priority for training in any developing country” - V.N. Shrikhande

• WHO has recently made a great advance in the X-ray departments of the world's district hospitals by developing the BRS or Basic Radiological System.

• The BRS machine is made by several manufacturers to WHO's specifications. If you are thinking of buying an X-ray machine, this is the one to get.

SIMPLE TECHNICS & TOOLS CONTINUE:

• If you don't have electricity all day, you can run it on a battery/ INVERTER which you charge when you turn your generator on.

• It is so simple that a radiographic assistant can easily work it, but if you have a radiographer who has been trained to use a more sophisticated machine, he will not like this one because it does not give him enough freedom to adjust the settings.

• With as little as #250,000, one can acquire a simple and new scanning machine made in one of the Far Eastern countries.

• It is no longer tenable to be saddled with an unserviceable fairly used Machine that has no warranty or dependability.

SIMPLE TECHNICS & TOOLS CONTINUE:

• This apart, it is gradually becoming fashionable these days to have the equipment delivered to your facility with a very little deposit while you pay the balance on instalment basis over an agreed period of time.

• Efforts such as these helps to drive patronage as patients tend to get discouraged where a facility is not making obvious efforts to improve.

• Many clients see themselves as un-acknowledged co-owner of your practice and would like to boast and glory in your demonstrable efforts to move up the success ladder.

• They often interpret anything contrary to the foregoing as signs of failure

• Sure enough, we are all aware that failure in any endeavour is always an orphan.

• Keep up to date inventory of your tools and equipment and develop a habit of handing over and taking over as a way of controlling pilfering.

11. TEAM APPROACH:

• Build and encourage team work.

• Gain staff confidence.

• Boost morale by been open, fair, firm, compassionate and to see every worker as key in the actualization of this unique vision.

• Use carrot and stick approach when necessary.

• Be socially responsible and tolerant to criticisms especially when it is constructive.

• Reframe from acting on impulse and let every team member have a sense of belonging.

12. FOCUS ON THE BIG PICTURE:

• When it is obvious that the goals cannot be reached, don't adjust the goals, adjust the action steps. Confucius

• Set your goals and keep to it.

• "You need to have goals to build a strategy and manage a successful business”.

• Your goals need not be just one but they need not be too many either.

• It must be achievable and realistic enough.

• Many surgical practices would have started small never out of desire but out of the constrains of circumstance and that we all can, overtime, crop an enviable practice with impressive financial returns and outstanding cooperate image.

CONCLUSION:

• “Wherever you go, go with all your heart.” –Confucius

• While there are plethora of challenges to the sub-urban based surgical practitioner, his counterpart in the cities may not necessarily fare better.

• While public utilities do not exist in many villages and rural communities in Nigeria, the cities where these facilities supposedly exists experience more darkness than light, all year round.

• While the average rural community lack access roads, public health institutions, schools and IT support services, his counterpart in the cities suffers from pothole ridden roads, traffic congestion, multiple taxation, bloated overhead and cut-throat competition.

CONCLUSION CONTINUE:

• Many new practices like any other business collapse not because of challenges, but because such practices are not founded on renewable values, ethics and strategies.

• By this, you must follow your instinct and draw up simple strategies to help achieve your full potential. Whatever you do, be socially responsible and never take your eyes off the cash flow.

• Tap into your brilliance and leverage on your strength.

• Above all, stay positive and be sure to inspire your team and everyone connected to the big picture.

• Finally, do always remember that the focus should never be on the profit but the cooperate brand.

REFRENCES:

1.Dr Oluyombo Awojobi: “Rising to the Challenge of Rural Surgery in Nigeria” Bulletin of the WHO,Vol 8, no 5. May 2010; 321-400.

2.Dr JI Umuna: Nigerian Journal of Surgery: July 2011. Vol 17. No 1: Pages 25- 28

3.Dr Oluyombo Awojobi: RURAL BASED MEDICAL PRACTICE IN NIGERIA – THE IBARAPA EXPERIENCE: Paper read at THE FIRST NATIONAL CONFERENCE ON HUMAN RESOURCES FOR HEALTH IN NIGERIA, Abuja, October 2011

4.TrendWatch, produced by the American Hospital Association. April 2011, Rural Health in Rural Hands: Strategic Directions for Rural, Remote, Northern and Aboriginal Communities

5.Primary Surgery, Volume 1: Non-Trauma: The surgical care of the poor. Chapter 1&2

6.AOA Aderounmu,SA. Afolyan,TA Nasiru, JA olaore, M Adelasoye; Rotational Rural Surgery for the Poor; TROPICAL DOCTOR, 2008;38,141-144

7.Olugbenga-Belo, OL Abodunrin, AA Adeomi: Global Journal Of Medical Research; Vol.11; Jul, 2011.

8.Dr Paul Jesuyajolu, MISSION TO INDIA: ARSI INTERNATIONAL CONFERENCE, RATLAM. 2012: MEDRACE, Issue no. 4, Dec. 2012.page 11

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10.Rais Akhtar; Health Care Patterns and Planning in Developing Countries. Greenwood Press, 1991. 265 pgs.

REFERENCE CONTINUE:

11. James Rourke: In Search of a definition of “Rural” Canadian Journal of Rural Medicine; Can J Rural Med vol 2 (3):113

12. PETER U. NWANGWU, M.Sc., Pharm.D., Ph.D : HEALTHCARE DELIVERY IN NIGERIA: ONTRIBUTIONS OF NIGERIANS IN DIASPORA: ADDRESS TO THE CONVENTION OF NIGERIAN PROFESSIONALS IN DIASPORA, AT PARIS, FRANCE

13. O. A. Ajala1,, Lekan Sanni, and S. A. Adeyinka: Accessibility to Health Care Facilities: A Panacea for Sustainable Rural Development in Osun State Southwestern, Nigeria J. Hum. Ecol., 18(2): 121-128 (2005)

14. Health Insurance: principles, models and the Nigerian National Health Insurance Scheme

OE Onwujekwe, BS Uzochukwu, OP Ezeoke, NP Uguru. Jon. Coll Of Medicine. Vol. 16, 2011.

15.Health Insurance: WIKIPEDIA

16. Aderounmu A. O: NATIONAL HEALTH INSURANCE SCHEME IN NIGERIA, Director, Health Services, OAU, Ile-Ife.

17.MURAT KASIMOĞLU: SURVIVAL STRATEGIES FOR COMPANIES IN GLOBAL BUSINESS WORLD –

A CASE STUDY