Gov’t Needs to be Clinical about Regulatory Approaches

Nov 21 , 2018
By Tigistu Adamu (MD) , Samson Esseye (MD)

Lack of proper medication and diagnosis by doctors has eroded the trust in health care provision, costing the nation human and economic loss, write Tigistu Adamu (MD), independent public health consultant and fellow of College of Surgeons of Eastern, Central & Southern Africa (COSECSA), Samson Esseye (MD), consultant surgeon and fellow of COSECSA, and Alemseged Janka (MD), surgeon in private practice.

As many doctors do, my friends and I often receive calls from family and friends asking for a recommendation on what to do about an illness, a medication, which clinic to visit or doctor to choose. This is true everywhere and in every profession, but it is always sensitive in medicine.

A week ago, a 50-year-old, well-built, workaholic professional and father of three contacted one of my friends for a suggestion on a clinic he could visit for a check-up. He had felt some tightness in the lower chest and a vague pain that traveled to his neck and shoulders, forcing him to remove his tie.

This man was in a meeting out of town for a couple of days when he decided to come back to Addis and see a doctor in one of the private clinics.

The man sounded happy about his care, was told there was nothing serious and had a bunch of tests done to make sure his cholesterol and glucose levels were okay.

The next morning, the man calls my friend excited and happy and tells him about the exchange he had with his doctor. He learned his cholesterol is slightly elevated, nothing to sweat about, and that his glucose levels are normal. The doctor gave him medication for what was diagnosed to be heartburn, a common stomach complaint that gets treated in town routinely.

My friend asked to go over the list of tests and the lab results. After a read-through of the abbreviations and some of the confusing lists on the lab result, my friend, concerned about the symptoms the man reported, told him to see a heart specialist for an urgent second opinion. A chest pain that goes to the neck and shoulders is one of the classic symptoms of heart muscle disease.

The man, confused with my friend’s “fearmongering,” went to see a specialist in a clinic and had two additional laboratory tests done, one of them to measure the levels of troponin in the blood. The most frequent cause for heart muscles to release troponins is when the oxygen coming to the muscles is lowered as a result of reduced blood feeding the area. Again, the reduced blood supply to the heart muscles commonly results from narrowed or blocked blood vessels of the heart. A potential danger sign for heart muscles under attack.

The man’s troponin level was very high indicating a danger to his heart muscles. His doctor also ordered echocardiography - a medical imaging technique that uses sound waves to produce an image of the heart to see how it is functioning. The results showed the man’s left lower heart chamber had wide areas of wall akinesis and the right lower heart chamber was dilated wide to compensate for the reduced function of the left side - both grave signs that are likely to kill the man if not treated urgently. The heart doctor told the man that he needed to be admitted immediately and that the blood vessel was narrowed, causing the wall to dysfunction and had to be corrected urgently.

A week before this incident, the man told my friend about another friend of his who was in a meeting with him two weekends ago and suddenly died the following Monday with no incident or illness. The man was saying how his friend was completely healthy.

The fact of the matter is that heart disease is the leading cause of death globally and the challenge remains that many such events are either ‘silent’ or are not clinically recognised by patients, families and health care providers. But in the case of the man, even after having the symptoms and laboratory results, he was not going to get the care he needed.

Think of all the people you know who have mentioned how their doctor did not reach the right diagnosis or gave them the wrong medication, failed to take their symptoms seriously or was too pressed for time to listen. Think of how that created a huge lack of trust in the health care providers in the country, causing many to travel abroad and spend too much to get proper care. Think of the human and economic losses.

Ensuring that people get high-value care - defined as care that aims to improve health, avoid harms and eliminate wasteful practices - must be at the centre of policy and decision making by those who carry the mantle of leadership.

What is currently happening though is a disproportionate focus on parts of the health system that are not first on the priority list given the current situation in caring for our community. To highlight one example, the Ministry of Health and the federal regulatory bodies have chosen to put in place restrictive and stifling requirements for the establishment of speciality clinics and practices. The regulatory requirements have everything about equipment and concrete, space measurements and staff requirements. Sadly, the requirement does not encourage or mandate accountability for clinical excellence and superior patient care.

As a result, the requirements favour those with money, who tend to be non-clinician business people whose primary measure of success is revenue. The model they promote is collecting fee-for-service regardless of outcome, hiring clinicians in purely transactional manners to deliver on volume rather than quality and accountability. The regulatory obstacles for a competent, compassionate and caring clinician to set up an office consultation where patients will be diagnosed early and linked to the correct management are presently insurmountable.

Healthcare is a business of people’s lives, wellness and death. Its planning and design should have people at the centre. These people come as nurses, doctors, healthcare administrators and patients. The endeavour should be to strive for the best use of scientific evidence to improve the health and well-being of every individual in the country. But neglecting the central actors in favour of out-of-context and imported regulatory practices will do more harm than good for our people.

The 50-year-old man, confused and shocked by what had happened in the span of two short days, upon the recommendation from family members and friends decided to go for a third opinion. After an additional set of tests, he was recommended a non-surgical intervention, which is now one of the most commonly performed medical interventions. He now says he is lost, for the first time feeling powerless. He considered going abroad for treatment, since most of the people he knows recommend that option. But such decisions come at a hefty social and economic price.

Many people like him come to both public and private health facilities to get care, but the path to link these patients and clients with the right clinician, at the right time, is obstructed by the endless bureaucratic regulations and hurdles. This may appear as the fault of one specific group or individual - the health care system, the patient or the clinicians. Such thinking, however, is much farther from the truth. While each actor plays an important role, as the adage goes, "Every system is perfectly designed to get the results it gets.”

The decision makers spearheading the selection of priorities in health need to re-design the system, prioritize what matters and ensure high-value care is provided by well-trained, supported and accountable clinicians. Throwing well-written regulations onto the problem will not save lives - keeping people healthy is the raison d'être for the Health Ministry. Being “clinical” about the regulatory approaches is of prime importance.

PUBLISHED ON Nov 21,2018 [ VOL 19 , NO 969]

By Tigistu Adamu (MD) ( Tigistu Adamu (MD), independent public health consultant and fellow of College of Surgeons of Eastern, Central & Southern Africa (COSECSA). ) , Samson Esseye (MD) ( Samson Esseye (MD), consultant surgeon and fellow of COSECSA, and Alemseged Janka (MD), surgeon in private practice. )

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