How soaring cost of medical examination, diagnosis impair medicare
• HIV Test No Longer Free
• Inter Laboratory Variation Of Test Results Worrisome
• To Achieve Universal Health Coverage, All Lab Tests Must Be Covered By NHIS- AMLSN
From an initial visit to a hospital, to the conclusion of treatment, patients are often subjected to a series of laboratory tests, which may be routine or specialised, depending on the investigation.
These tests are needful in order to confirm accurate diagnosis and treatment.
“Sometimes when the diagnosis is not very clear, then you have to order so many tests, though this is not ideal,” said a consultant neurologist at Marina General Hospital Lagos Island, Dr. Olubunmi Omojowolo.
Unfortunately, the burden of paying for too many expensive laboratory tests is often overwhelming for many patients, who have to pay out-of-pocket.
In line with the universal health coverage, the World Health Organisation (WHO), has mandated that medical laboratory services should be of the highest quality, available, accessible and affordable to patients.
Based on this, the Nigerian government included laboratory services in the nation’s healthcare system, (ranging from primary to tertiary levels) with the aim of making these services affordable and easily accessible to everyone.
However, investigations reveal that laboratory services uptake at most government hospitals are replete with limitations, just as the charges are skyrocketing.
In fact, some patients interviewed not only expressed dissatisfaction with the high cost of the specialised tests, but also complained bitterly about mix up of results, delay in getting test results out, unavailability of some tests due to non-functional machines, as well as, general poor quality of service.
Susan Ubon, for instance, recalled what she went through after developing severe pains in her pelvic, and was referred to Lagos University Teaching Hospital (LUTH).
“At LUTH, I was asked to carry out a laboratory tests, which I did at the hospital’s laboratory. When the doctor saw the result, he said it did not match with my prognosis. He referred me to a private lab, which came out with a different result, which tallied with my case. It was discovered later that my laboratory test result at LUTH was misplaced.”
According to experts, misplaced results are often not common, but can happen mistakenly while specimens are being collated by the health worker. Over 100 specimen are collated daily in some cases.
The lack of availability of these tests on a 24-hour basis in most government hospitals, is another challenge that patients’ relatives have to contend with.
According to Mrs. Samuel Ego, whose 70-year-old father was attended to at the Lagos State University Teaching Hospital (LASUTH), “one evening the doctor prescribed tests including ECG, urine and blood. But the tests could not be done that evening because the clinic was closed and some of the machines like the ECG was situated in the clinic, which closes by 4pm. Because of this, we could not carry out the tests that evening.”
“Ideally, all these tests should be available 24 hours if the hospital and laboratory are properly run, but because of logistics, you find out that this is not the case. For instance, ECG is sited at the clinic, which closes after office hours, but this should have been at the medical emergency, which runs 24 hours. Before now, full blood count was only available during office hour, but now it is available 24 hours,” said associate professor and Consultant Haematologost at LASUTH, Dr. Akinsegun Akinbami.
He continued: “After close of work, we have one or two persons on call, so even if the machine and reagents are available, the tests may not be done due to few expert personnel on ground. But there are some tests that are not urgent, such as ESR. I believe there is need for all the medical emergency staff to be trained on the use of devices such as ECG. Tests like x-ray should be available 24 hours.”
On why there is delay in getting
laboratory tests results sometimes, Akinbami said this is due to logistics.
“In haematology, they will wait to gather all the tests together because they cannot be putting the machine on and off frequently as this may damage it. Anytime they put the machine on, they need to clean it with a reagent, which is expensive. So, they operatives usually wait till about midday before having it on, and they would let it run till about 3 or 4 pm because they receive as many as 600 to 1,000 test requests daily.
“For collection of results, maximum time is 24 hours because some tests need to be done the same day in order to get appropriate results. If it is urgent, the doctor would reflect so on the test request sheet.”
In the area of cost, some tests are cheaper at government hospital/laboratories, compared to private labs. That notwithstanding, the cost is still unaffordable to the average Nigeria.
For instance, CT Scan at government hospitals costs around N34, 000 while it goes for about N40, 000 in private facilities.
When 10-year-old Andy Eket, who had a growth on his head arrived the General Hospital, Lagos Island, with his parents, the neurologist prescribed several tests that must be carried out before treatment proper could commence.
“The tests, which were so many, included MRI, ECG Scan, blood tests, and others that I can’t remember, but their cost was put at about N180, 000,” Ann Eket, Andy’s mother lamented.
Because the Ekets could not afford the cost, they opted to visit a traditional healer, who applied some ointment that forced to growth to give way. But Andy may not be so lucky if the growth had been malignant.
As the cost of some tests continue to escalate, some that were hitherto free of charge, including HIV tests, are no longer free.
Concerning this, Akinbami said: “Initiatially everything was free until donors started withdrawing their services. But now, consultation is free, medication is free, but the lab test is not completely free. The full blood count, urea critenun, liver tests, hepatitis, are not free. Patients pay up to N4, 000 when they want to enroll, but we sometimes give waiver to patients who cannot pay. Every six months, they repeat their CD4 count and viral load for N2, 000.
“For HIV positive persons, undergoing lab tests before treatment is mandatory, so we can determine the kind of treatment suitable for them. Some patients may have a condition that makes the drug unsuitable for them, which is why tests are necessary,” he explained
Delay in getting test results out is also a major setback to some patients that are in critical conditions. Matters are made worse when the crowd at government laboratories surge in such a way that this class of patients have to wait for hours on end to be attended to.
This was the kind of situation Abel Johnson, 60, found himself after developing a partial stroke on his left side. Johnson, a diabetic was rushed by his people to LASUTH where some tests were prescribed.
“The crowd that I met there was too much. I was also told that the hospital’s x-ray machine was faulty, so I had to go to a private lab- BT Health Diagnostic Lab, located inside LASUTH. All the tests that I carried out there amounted to about N80, 000. I did CT Scan for my brain at N40, 000, abdominal and pelvic scan at N5, 000, HB12 test at N5, 000, full blood count, liver tests, Urea and others that pushed the amount to about N80, 000,” he said.
Kingsley Israel, a retiree, also experienced similar situation not long ago after he started feeling strange in one part of his body. “I started having this numb feeling in my left leg and left hand. It got so bad that my leg felt very heavy to lift, and my left hand too lifeless that sometimes, things dropped from it. As I continued feeling as if blood was not flowing in that part of my body, I became very scared, and had to rush to Gbagada General Hospital. The doctor asked me to do ECG test, CT Scan and x-ray. At the lab, there was so much crowd, that one of the nurses advised me to go to a private laboratory, stressing that if I decided to carry out the test there, it would definitely take a while.”
According to him, he had to cough out as much as N8, 000 for the ECG test at the private hospital, instead of N2, 000, which is charged at the general hospital.
For the chest x-ray he was told it was N2, 500, which was about the same amount at the general hospital, “but the CT Scan was N40, 000. I couldn’t afford that so I had to stay back home for months until I could gather the money,” he said.
Apart from during industrial actions by health workers, when laboratory services are suspended, some government-owned hospitals offer only few laboratory tests.
For instance, a patient who was diagnosed with breast cancer at a government hospital, said she was referred to a private laboratory for a mammogram test because the mammogram machine at the hospital was broken down.
Explaining why some medical tests are unavailable at government hospitals, Dr. Akinbami said; “It is possible to do all tests in government hospitals, but most of the time, reagents are not available, or the machines are broken down. Also, there are specialised tests that may not even be available in the country such as some DNA tests, which are still a novelty here. But the daily routine tests are available at government hospitals. This is why patients are referred to private laboratories for some of these tests.”
President, Association of Medical Laboratory Scientists of Nigeria (AMLSN), Toyosi Raheem, explained that just as the government is incapable of making available all drugs needed in hospitals, it is in the same manner that it is incapable of making provision for all the laboratory tests.
“In the same manner, it is not all ailments that can be managed or treated at a particular hospital owing to lack of equipment or reagents needed to run specific tests. Lack of requisite professionals with required skills and knowledge for running some specialised tests is also one of the reasons that these things happen. That is why referrals or laboratory networking is encouraged so that any test(s) not offered in a particular laboratory can be referred to another nearby or distant laboratory, where it is available,” he said.
On the appalling delays in getting test results in government hospitals, he said: “There may be several reasons for that. Test results can be delayed if there is poor
logistic management in the facility, a development that may lead to reagents getting out of stock without prior provision for replacement. Delay can also be due to lack of provision of back up, for every equipment used for each of the test menu. Quality management in laboratories requires that every equipment used in the laboratory should have a back up such that if an equipment breaks down suddenly, one can switch over to the back up without affecting the turnaround time for the test.
“Attitude to work may also be one of the reasons for delays in issuance of test results. A de-motivated worker, whether in public or private sector would be discouraged and may see no reason to work with the required passion and commitment These are some of the reasons for delayed laboratory results in public or private laboratories.”
Still on the delay in issuance of results, he said, some specialised tests are not run on daily basis. “This is because they may be batched depending on the number that can be run in a batch. The reasons could be due to economic reasons. It would be economically unwise to open a kit for only one test when such a kit cannot be reused after a particular number of days of opening it. So, the laboratory may decide to wait until there is a reasonable number of samples before opening such kits.
“Another reason could be that the laboratory does not have an expert as permanent staff in the facility, and so rely on visiting medical laboratory scientists. In that situation, tests will be carried out only on the days that such experts are on duty.
However, quality management system frowns at delayed results. In fact, any laboratory that cannot provide 80 per cent of its test results within their turnaround time is regarded as performing below standard.”
He stressed the need for every standard medical laboratory to be manned by “licensed and qualified medical laboratory scientists. They should also have clients’ handbook or policy on turn around time (TAT) for all the test menu run in a particular laboratory.”
On why the cost of the specialised tests are expensive he said most of the equipment and reagents used for laboratory tests are imported, so lab tests are affected by exchange rates such that high exchange rate for dollar and other foreign currencies, will cause the cost of laboratory tests to go up.”
He regretted that not all laboratory tests are covered under the NHIS. “Very common tests are covered but special tests such as tumour markers, hormonal assays, infertility tests, blood transfusion services etc are not covered by the NHIS. In fact, if Universal Health Coverage is to be achieved, all laboratory tests should be covered under NHIS and there should be no exclusion.”
Commenting on conflicting test results, Toyosi said: “Inter laboratory variation of test results is at a worrisome level in Nigeria. This is traceable to a number of factors, such as use of substandard reagents and equipment by some laboratories; use of unqualified personnel; use of obsolete equipment and techniques; erratic power failures; lack of training and re-training for licensed medical laboratory scientists, technicians and assistants, among others. That is why laboratory inspection to monitor compliance to standards is very important.
“Recently, the Federal Government supported MLSCN to assess all in-vitro diagnostic reagent and equipment. This should be fully supported by all Nigerians because it will eliminate or reduce drastically, inter laboratory variation of test results,” he noted.
In order to improve the standards of medical lab practice in the country, Toyosi said laboratories must be registered with MLSCN, which is the recognised agency of Federal Ministry of Health, and is empowered to function under Act M25 LFN 2004 (also known as Act 11, 2003).
Sadly, “Those who are supposed to encourage and cooperate with MLSCN are not doing so because they are also benefiting from quackery in medical laboratories. So, only few who are sure of themselves register their laboratories with MLSCN. It is difficult to get up to 500 private and public medical laboratories that are registerable by MLSCN. Only about three or so laboratories are accredited.”