The Cost of Getting Sick

Seventy percent of Nigerians pay for healthcare out of pocket, and about one in ten has insurance. Jii and Dr Nana, the Health anchor, sit with what that means on the day you get sick: why the biggest hospital in Ibadan became a byword for dying, whether a doctor must treat you if you cannot pay, what actually happens on the ward when the money runs out (consultants passing a hat for a patient, payment plans signed on discharge, referrals to somewhere cheaper), and why the chemist is most people’s first hospital.

The panel’s answers run through it: twelve of fourteen have watched someone borrow to get well, families treat the most critical case first and the children before the parents, and on a five-point scale of how prepared they are for a sudden bill, the average is 1.8. Also: Alabukun, the N33,000 corps member, transport that costs more than the treatment, and the snake-bite example that explains how a hospital can have the cure and still not have it. Not medical advice, a conversation about the system we live in.

The dataset is on inskriba.com. How We Live is an Inskriba production.

Jii: Welcome, welcome, welcome back again to Inskriba Conversations. We have Dr Nana here. How are you doing, Dr Nana?

Nana: Hello, I'm doing okay, and thank you for having me.

Jii: How is life? How is taking care of patients, healthcare?

Nana: We've been surviving. I think that's the best way I can frame it right now. We've been surviving.

Jii: Good. I want to ask you a question as a healthcare professional before we go into today's topic. Do you take herbs?

Nana: Honestly, I cannot remember the last time I did. As a child I had no choice. But ever since I had autonomy, I've refused them at every chance I can get.

Jii: Why?

Nana: To be fair, I don't like the way a lot of them taste. But if we want to talk about herbal concoctions, we should say that medicinal herbs do exist. At the end of the day, a lot of medications are still derived from natural sources. Then there's the whole thing where people are just combining a lot of different things together, and those can be very harmful for you. So I prefer not to take what I don't know is going to do to my body.

Jii: As supplements?

Nana: Some are herbal-derived, yes, but they tend to put what it's made of on the container, so you can always check. At the end of the day they are extracted from plants.

Jii: Growing up, I think we were subjected to herbs. Some people had this routine every Sunday morning or Saturday morning.

Nana: Especially after you've eaten a really good meal.

Jii: One of the things I want to do a deep dive into is the difference between what healthcare professionals, doctors, nurses, pharmacists, the people who actually make the drugs, think about herbs, because there's this whole wave now against anything from the West. "These people are trying to kill us, these people are trying to colonise."

Nana: The whole big pharma discourse.

Jii: Exactly. There's this conspiracy that cancer should have been solved, that someone was trying to solve it and they were killed. I don't want to get into it. But it's interesting to hear what healthcare professionals think about herbs and concoctions. Anyway, our topic for today is something close. One of the reasons people choose to take herbs is the cost of getting sick, right?

Before I jump into it: like we always do, we had a number of respondents answer our questionnaire, and we'll go through that. But first, there was a time in Nigeria, and I grew up in Ibadan, where if someone was sick and you heard they were going to UCH, the biggest hospital in Ibadan, the family would try everything to avoid it. The whole idea was, if anybody goes to UCH, that person is not coming back.

Nana: I knew what you were going to say.

Jii: And when you look into it, one of the major factors is money. Most hospitals say you need to pay this to get this service. Most Nigerian families can't. And the cost is that their family members, their kids, get worse. So I want to ask you, as a healthcare professional: are there laws, policies, that mandate you to provide healthcare regardless of whether people can pay? Or do they need to pay first? Because there was a time when the first thing you had to do was go and register, bring your card, and the queue was so long. Is there anything that mandates that, especially in Nigeria?

Nana: It's fine, it's a fair question. So the way the system works here: we don't have a free healthcare system. In countries where there is one, everything is basically paid for, so things like registration before being attended to don't become an issue, because it can happen immediately.

There are situations in which patients will be attended to as quickly as possible, emergency situations, where life is at stake. Most people are going to try their best in that situation to assist the patient. But the broader issue people see is that when they're asked to pay upfront for registration, it looks like, this person needs medical care, don't you have empathy? The thing is, if you do that for multiple patients, eventually the hospital runs out of the resources needed to treat patients. This is mostly private institutions, but even in government institutions you still have to register, because there has to be a way to put something back into the system, almost like a revolving fund, so that you can continue providing services.

And at the end of the day, healthcare workers are not the lawmakers. We're the face of it, but we're not the ones creating the policies. We're not the ones dictating how places should be run. We just happen to be the people that people see. In big institutions the first person you see isn't even likely to be a doctor or a nurse; it's a receptionist, admin staff. And you do have to register, because we have to have a log of whatever treatment is given. Records are very important in the treatment of the patient, and from a legal standpoint as well.

So, to answer your question about laws mandating us to treat people regardless: I would have to get back to you on that, because frankly I'm not very familiar with the law there. But we do swear an oath at induction, and one of its major principles is to do no harm. So at the end of the day, that's the principle. You have to do your best to do no harm to the person in front of you.

Jii: It absolutely makes sense. One of the reasons we're having this conversation is to talk about these intricate pockets where people might miss things. Most of the hospitals the general public can go to are government-owned, and policies guide them. A lone doctor or nurse can say "this is the moral thing to do," but you are guided by the laws, the policies, the confines of where you practise.

The numbers say more than 70 percent of Nigerians pay for healthcare out of their pockets, which means getting sick means you have to pay right now. Let's not even look at insurance yet: how many people have it, how much it covers. The question I'll ask is: when a patient cannot pay, what happens? And I'm not asking what happens in your hospital. This is you talking, from your own experience, not on behalf of anybody.

Nana: My experience so far. I've been able to work in a few different places, and a lot of things happen. For one thing, we're all Nigerians, and despite our many shortcomings, as a people sometimes we're nice. You see posts online crowdfunding for health, a call for blood donation for somebody who urgently needs it, and those messages go round quickly and people respond. I bring that up because similar things happen within the hospital too.

Shortly after I graduated, when I was a house officer in a government facility, it was usually difficult to start getting treatment without any payment at all. But the issues really come when you're already on admission and then you can't pay. That's where a lot of the crowdfunding comes in. I still remember being on rounds, and there was a patient who had had surgery and couldn't afford a lot of things essential to his healing. He was at risk of infection, his wound could break down, he needed good food and antibiotics. And right there on the ward round the consultant said, all of us, bring your money. And we all brought our money for the patient. This happens way more frequently than you would think.

Then there are times when that's no longer sustainable, and the patient may have to be referred to a place where they'd be able to afford care. There are also situations where a down payment was made and the treatment extended longer than anticipated because complications happened. In places I've worked, you sign an undertaking, a payment plan put in place after discharge so the person can eventually make up what they owe.

And there are places, more commonly government facilities, where the patient is more involved in actually buying the medication. A relative has to make payments before the medications are released. So if no payment is made, it almost looks like the patient is not getting treated because there's no money. That's where it gets tricky, because like I said, we're not the ones who come up with these policies. And that's where the crowdfunding comes up again. Even as a healthcare practitioner, it's not nice to see somebody you've been taking care of start to deteriorate because they cannot afford it. You've put in a lot of work to help this person live better; you don't want that to go down the drain. So you start: how can we do this? Can we find a place where this person will at least be able to afford the care? You have to find a way to get patients the care they need.

Jii: Thank you. Because of the way Nigeria is, there are so many informal ways people get by that we overlook. This is the first time I'm hearing of it, but I imagine it happens often, and it's part of the informal ways Nigerians survive the cost of healthcare.

Let me go into the questionnaire. One question was: on the cost of getting sick, when the formal system fails people, how do they get by? Most people said self-medication. Self-medication is a whole other podcast on its own. You decide, I think this is what's wrong with me, typhoid fever, and you go to the chemist and get something to treat that. Is it a case of Nigerians having been sick so often that they can almost accurately tell what is wrong with them? What do you think of self-medication and self-diagnosis, especially as it relates to the cost of getting sick?

Nana: I'll start with an example. When you have a headache, nobody needs to tell you before you take paracetamol or ibuprofen. And if you've taken that for two days and it's not helping, you know this is something more serious and you should probably do something else. As a human being, when something is wrong, you tend not to just sit down. You try to find a way to solve it.

It's usually okay to take an antacid when you have acid reflux, or painkillers when you have pain somewhere. These are over-the-counter medications for a reason: they help with the little day-to-day issues that don't require medical attention. The issue comes when you notice symptoms persisting for too long, or giving you more cause for concern. That's when people usually share their issues with someone else, their parents, and everybody wants to offer a solution, because we've all had one experience or the other.

I generally think that when symptoms give you concern, it's better to be checked by a healthcare professional than to keep going to different places and using home remedies. Some people delay and delay, because they find something that puts the symptoms at bay, and they're like, I'm fine. But at some point they're no longer fine, and by the time they get to a professional, whatever is wrong has gotten really bad and is very difficult to contain. That is where the whole "if you're going to UCH, you're dying" came from. People are presenting very late. That's actually where the issue comes from.

So I would always advise: if you have concerning symptoms, and you've tried what you know and it's not working, don't wait too long. Just go. Self-medication for certain things is okay, a little headache, a sore throat. But it should be limited to those. And this is a PSA: self-medication with antibiotics is a bad thing. Antibiotics are a different class of drugs; they should be used with direction, not based on what someone with no training thinks. Analgesics, things for a cold, those are symptoms a lot of people can manage on their own.

Jii: I recently learned that even with ibuprofen, brands like Advil, you should manage how you take them, especially when the pain lasts over a few days.

Nana: Exactly. The problem is we don't read. The packaging always says, if your symptoms persist, please see a healthcare professional. If you've tried it and it's not taking care of your issue after a few days, you really should see a professional to be on the safe side.

Jii: Do you know Alabukun?

Nana: Yes I do. It's a combination of medications. Let me Google it.

Jii: Alabukun powder is a long-standing over-the-counter analgesic powder used to relieve mild to moderate pain. Growing up, anything that was wrong with you, the use was so varied. Back pain, any kind of pain, use Alabukun. I even know people who used it to stay awake.

Nana: It contains caffeine, so yes.

Jii: There was a time there was news that people were using Alabukun with soft drinks and it could lead to death. It was created in 1918 by a Nigerian pharmacist and entrepreneur, Jacob Odulate, in Abeokuta. A lot of inventions happened in Abeokuta; there's a whole colonial story to that. And it has remained a trusted household staple across West Africa for a century. I wonder if there's been any research into what it does long term.

Nana: Long-term effects. Yes.

Jii: And what are analgesics?

Nana: Painkillers. It's the broad umbrella term for painkillers.

Jii: So ibuprofen, aspirin, naproxen. Shout out to you guys for all these names.

Nana: Why we went to school.

Jii: There's a joke that that's why your handwriting is like that.

Nana: My writing is fine.

Jii: The next question on the questionnaire was: who do you turn to when things go wrong, and what would make you stop turning to them? Almost everyone said my mum, my parents, my family. I can bet 80 percent said family. Someone said, my mum is an attorney but she's our family doctor too; she would refer me to a hospital when it's beyond her. My mum was the one that said, what's wrong, use this, go and buy that. She still does it with you, even as a doctor?

Nana: My mum still does that with me. Yes.

Jii: Someone said, I turn to myself. Someone said, I depend on my family and won't stop turning to them.

Nana: Which is understandable. That's a strong source of support for most people. You turn to the people you trust first, before anybody.

Jii: That trust factor. If we go back to the trust Nigerians have for institutions in their country, it's very low. So they turn to people they trust: their family. I want to go to insurance. It's mandatory in Nigeria?

Nana: It's not mandatory. There was a new law recently, but how many people are actually aware of these things?

Jii: It's one in ten. One in ten Nigerians has insurance, so nine out of ten don't. We asked, on the cost of getting sick, how close is this to your own life? Meaning if you get sick now, how close are you to not being able to pay? Most people were around three, some at four; the average was 3.07. In the hospital, do you ask about insurance? How are you going to pay for this? And does that affect how services are administered?

Nana: These days a lot of people working in corporate spaces have insurance, because their companies cover it. And these health insurance companies, the HMOs, tend to be the ones who route their customers to certain hospitals. It's good for a lot of the basic things; consultations tend to be covered. But there are situations that health insurance cannot pay for and the person has to pay out of pocket, and sometimes there's back and forth, which can be stressful. There's generally a limit to what a plan covers. You find all this out when you fill out your forms, and even if it's a company plan you can check what your plan covers. When your plan doesn't cover it, you pay out of pocket.

Jii: Most people don't know about insurance, don't understand it, can't afford it from their monthly pay. So most people don't want to get sick, because of the cost.

Nana: Honestly, that's valid.

Jii: Which brings us to the next question: tell us about a time illness became a money problem for you or someone close to you. Someone said, I've never experienced it. Someone said, scrambling started immediately. One person gave details: "Illness became a money problem for me during my NYSC service year. My monthly allowance was 33,000 naira, which was barely enough to survive on, and the change of weather really affected me; I just kept falling ill. There was a health insurance scheme in the programme, but the closest hospital to the local government I was posted to was really far, and going there is no guarantee you'll be attended to, because of the number of people at the general hospital. So I had to rely on my parents, and other times my friends, to send me money to get drugs from the pharmacy."

Transport, I'll come back to. There's a reason there's so much crowdfunding for health in Nigeria: there's no money to pay for healthcare, and our policymakers are not doing much. I do know charity organisations, NGOs, are doing a lot. I see it on your page, free blood pressure checks, a dialysis drive.

Nana: Yes, it was a dialysis drive, free for a day.

Jii: Our leaders, from federal to local government, aren't doing it, and it's funny that during election periods they find one corper doctor, set up a tent, start checking people's blood pressure, slap their name on it and say vote for us. Another response: "There was a time my mum suddenly fell sick with a chronic ulcer. We took her to a hospital close by, but she wasn't getting better and we had already spent a lot. The hospital recommended another hospital that was quite expensive, and we knew we wouldn't be able to afford the bill. She had to travel to her brother's place, a barrister in Abuja, and he paid for her treatment until she recovered." The same pattern: family trying to raise funds from trusted people. Nigerians don't trust the government, and if there is anything from the government they don't know how to use it, because it feels non-existent.

Let's go into transport. People in rural areas getting to adequate healthcare facilities is a real problem.

Nana: It's a big problem, on so many fronts. Sometimes they may even be able to afford the healthcare, because some government-owned facilities are, let me not say cheap, cheap is relative, but you're not paying so much compared to other places. But everybody's financial status is different. For some people, the money they have is either going to get them treatment or transport them to the place. By the time they've transported themselves there, they can't afford treatment. Transport is literally that expensive. And if it's a child that's sick and both mum and dad want to follow, that's three people's transport. People have to make difficult decisions. Or if they get there and get care, they're forfeiting food for everybody in the house. It's usually an either-or situation. It would be really nice if we had functional, affordable transport systems that worked on time and order.

When you read that story, I could picture it. It's already far, so you're exhausted by the time you get there. There's a long line, because a lot of people use this service because it's more affordable. This person is already feeling sick, taking a long journey that stresses them more, then a long line, and if they didn't get there early enough, there's a chance they won't be attended to, because these places have closing hours too. All of that stress, as opposed to better transport, or more facilities closer to where people are. A functional transport system would help not just healthcare but every aspect of our lives.

Jii: I went to primary school in Nigeria, and in social studies, when we talked about what a new area needs to be considered functioning, there were dispensaries, primary healthcare, the first small facility you go to before being referred to a bigger, more specialised hospital.

Nana: Primary healthcare centres.

Jii: We hear a lot of budget talk, and I know some states are investing heavily, but the transport. How many times have I seen someone being taken to hospital, not even in an ambulance, that's a whole other conversation, but in a private car, and you can see the car bouncing because of the potholes. All these things connect.

I'll stop reading there; anybody who wants to read what people said can check it on Inskriba. The next question: to handle a serious health cost, which of these have you seen happen? A lot of borrowing. A lot of selling something. A lot of fundraisers. Insurance, funny enough. And a few people, not many, said going without treatment. Which leads to: when there's not enough money for everyone's health in a family, how do families decide who gets treated? Someone said: "Most times, children are prioritised over the adults and treated first; they're weaker and are believed to be the future of the family. In some cases of chronic illness I've seen the father given priority, so he can get better and keep the family running."

There are so many choices to make because of the way we live, especially with communicable illnesses. One person gets it and it spreads. Growing up with my cousins, one person gets sick and we just know that in the following weeks everybody will. We were all drinking from the same source, the same mosquito, the same school. Who do you choose first? Have you had a situation where half a household needs treatment and someone says, this person first?

Nana: That feels like a familiar scenario. There are cases where a mum brings four kids, everybody is coughing, and she herself is not looking so good, but she doesn't complain. She just says, this is wrong with this one, this is wrong with that one. And you say, madam, you don't look too good yourself. Don't worry, I'll sort myself later, just take care of them. That happens. In that case we can't do much, but you can give a little advice, because people are going through a lot. Sometimes you just have to remind people that they have to take care of themselves too, and that they are deserving of treatment.

There are cases where people hear how expensive their treatment is and say, I'm going to be too much of a burden on my family, I want to be discharged. And to be fair, you have a right to leave a hospital against medical advice. We can't force you to get treatment. All we can do is explain why you need it. It's ultimately your decision, with certain exceptions.

Jii: What are the exceptions?

Nana: I'd rather not go into those now. I mean a person of sound mind: I can't force you. I can tell you what's wrong and what will happen if you don't get treatment, but if you decide not to, there's nothing I can do but let you go. That's leaving against medical advice. It happens; it's something we're all familiar with.

Jii: Does it happen a lot?

Nana: It happens. Sometimes it comes down to finances, and that's sad. And sometimes it's not finances, it's ignorance. Someone came with a complaint and now they feel better, but just because you feel better doesn't mean your treatment is complete. They say, you're just keeping me here to take my money. You counsel as much as you can and explain the situation. Some people agree; some don't, and they go. You can't stop a person who wants to leave. You can only explain the risks, and if they still choose to go, what else can you do? You can't kidnap them. That's someone of sound mind. It's different if a person has mental health issues, which is a whole other thing.

As for prioritising who gets treated, that's not our call; it's usually theirs. But if you notice a caregiver looking unwell, it's best to bring it up, to remind them that they need care too. If the caregiver is sick, it's horrible for the entire family. A lot of parents will say, don't worry, I'll sort myself out, because of the kids. A lot of parents prioritise the kids.

Jii: And people prioritise the father so he can go back to making money. Whoever the breadwinner is cannot afford to get sick. It goes to places: the person keeps pushing even when their body says no. That's part of the cost. Or they don't trust that if they leave work for a health reason, they'll still have that employment. Some jobs will say, unless you're dying. And I'm not saying this as a term of endearment, "we're a resilient people." I'm saying it as a trauma response. Nigerians have a very high threshold of pain.

Nana: Of tolerating nonsense.

Jii: One of the last questions: how prepared are you, if a sudden illness came with a big cost? One being not prepared, five being very prepared. Most people said one, or two. The average was 1.75. Only three respondents said they are reasonably prepared. I also asked about health insurance. Some said they have it; some don't; some have had it at certain points. Someone said, "I only had health insurance in my service year, and the illness was not severe." Someone said, "I got health insurance from a scholarship. No, it didn't help. The process was tiring and my parents paid the bill themselves."

Nana: Sometimes it's there, but the process of accessing it is so gruelling that you say, I don't have the energy for this. I wish the process could be made easier. It depends where you are. A lot of corporate spaces have made it easier, since they're getting insurance for all their employees. These days it's a bit easier, with email and apps: you don't have to physically go somewhere, the hospital can quickly message your insurance company to know whether what you want to do is covered, and even before you go to a hospital you can find out from your insurer whether the place is covered. Five years ago it was more complicated. That's HMOs. And for NYSC, corpers are generally covered. I believe everybody gets coverage during service.

Jii: That's good to know. Most people don't even know what documents to bring, how to make claims. But it's good that HMOs are automating, with apps where you put in your claims. And hospitals are linked to the providers, who tell you where you're covered.

We asked: have you seen someone choose a cheaper option, or no treatment, because of cost? Everybody said yes. "Yes, a cheaper option, with consequences." "The sickness came back." In some cases it cost the person's life.

To wrap up: do you believe good health in Nigeria comes mostly down to money? The average was 3.71 out of 5. Mostly yes. It's sad, because it's a fundamental need, and a right. If you're a citizen of your country, your government should be able to provide at least the basic healthcare need for a citizen. But people don't even know where to go. That's a whole other conversation.

I wanted to talk about the cost for you, the caregivers. It can't be easy, in a career where you chose to take care of people, when certain things, money, priorities, trade-offs, limit that. What does that do to you?

Nana: It can get very frustrating, honestly. People try their best, but at some point the honest truth is your best is not even good enough, and it gets depressing sometimes. Which is why, if we notice that finances are going to be an issue, we try our best to find an alternative that will still do good and not bankrupt the patient. Because imagine going so far, you're at eighty percent, and now you're stuck there because of finances or ignorance. It's not a nice feeling.

So in situations like that, you try to find a cheaper but still effective alternative for the patient. Each patient's care is tailored to whatever is wrong with them at the moment. I practise in Lagos, and there are places where resources are really scarce; Lagos is not necessarily one of them. So a lot of the time it's more that if a person cannot afford the care they need, you're stuck on their treatment and don't know how to go forward, rather than choosing between two people for one limited resource.

The initial question was whether money plays a role in good health. Sadly, money is a very big factor in securing good health, or in restoring your health after it has fallen. Sometimes, despite the money people have, it doesn't help and they pass away. But money definitely helps. There are people with chronic illnesses who need a lot of support, a lot of carers. It's very difficult to be a caregiver, I mean at home, taking care of somebody. Caregiver burnout is a real thing. People with money are able to employ people for that role, and it helps them and their loved ones.

I'll give an example. A person has a snake bite. You need anti-venom. A lot of hospitals do not carry anti-venom in their stock, because it's expensive and snake bites are not something you see all the time. It also has to be stored in certain conditions, and with all our electricity issues, you have to make sure you're getting the effect you want. So a lot of places instead have access to suppliers. The moment you place an order, the supplier sends it down. It's not a case of, it's in the hospital and we can't give it to you. It's, this is what you need and this is how you can get it. The people who need it pay the suppliers, the suppliers release it, and we use it to treat the patient. That's how that scenario works. Money definitely helps.

Jii: That's what I was trying to explain earlier, and you explained it better. It's better to say stock. With your example, if there are two people with snake bites, it's the person who can pay who gets it.

Nana: Sadly, yes. That is sad.

Jii: And disclaimer again: this is not health advice. This is us talking about the systems we live in as Nigerians. If there's one piece of advice from everything we've talked about, what would it be? Again, not advice you should take. Just talking.

Nana: What I'm going to say is what people already know. Life just gets a bit much sometimes. Eat as well as you can, drink a lot of water, and exercise. Sincerely. When you have a healthy baseline, you become more aware of your body, so when something is wrong you notice in time. It's good to take care of yourself so that when something is up, you notice it and you can raise an alarm early enough for the problem to be taken care of.

Jii: That snake-bite example is so good.

Nana: I remember there was a story on social media about it at some point.

Jii: That one wasn't even because there was no money. The issue was they just didn't have it in the facility. Go there, go there, go there.

Nana: In the facility. It's really sad. In situations like that, government hospitals tend to have access to the vendors for these things. You're very likely to get a plug for something like anti-venom.

Jii: Especially for a country like Nigeria, that's where policymakers come in, the quality of your leaders. Where certain things are almost cultural, we know this happens, we know we have swamps, we know we have mosquitoes. Certain things should be available, in certain places, at certain times, constantly. But let me leave it there. Thank you again for coming on. We've spent about an hour. Thank you for explaining, and thank you for helping me. Anything you want to say?

Nana: At the end of the day, I think we're all here to learn. I really hope I can be of some benefit by being on here. And of course, the disclaimer: I'm not above correction. So that's that.

Jii: Thank you again. Listen to Inskriba Conversations anywhere you listen to podcasts. This is the Health sector with Dr Nana. See you next time. Peace out.

Nana: Alright, bye bye.