Awojobi clinic Eruwa: running a successful rural hospital in Nigeria.

INTRODUCTION

As a student who wants to see medical practice to advance in Nigeria, visiting Awojobi Clinic Eruwa (ACE) was one of the best things the Ibarapa offered me. The zeal to stay back home and practice a kind of medicine that is driven by indigenous technology and available manpower was born through that visit. This is particularly important in an era like ours when there is a mass exodus of doctors to greener pastures across the globe, especially to the United States, United Kingdom, and the United Arab Emirates.

This encounter with the clinic was in April of 2019, during my community medicine posting ( the Ibarapa posting). Before then, I believed that Nigerians were only good at theorizing and very poor at applying sciences taught in schools. This may qualify as a fallacy of generalization. But, I have seen so many chemists, engineers, physicists, etc. who practice no science. Visiting Awojobi clinic dealt with this fallacy. I saw for the very first time, a place where indigenous technology reigned and I was impressed.

Because the visit was very short, about an hour, I decided to come back another time for adequate exposure to the wonderful innovations at ACE and to also understudy the systems that run such a place.

In this paper, I will be highlighting some of the observations I made at ACE, hoping that other ACEs will be born through some of my findings.

Before I delve into the story properly, permit me to introduce Dr. Awojobi, the man after whom the clinic was named.

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Late Dr. Oluyombo Adetilewa Awojobi was born to the family of late Omooba Daniel Adekoya Awojobi of Itun Elepe, Ikorodu, Lagos state and late madam Comfort Bamidele Awojobi. He was the 8th of 9 of the family. His early childhood and education were in Lagos before he move to Ibadan for his tertiary education in the University of Ibadan where he studied medicine. He graduated in 1975 with a distinction in surgery. After the National youth service in Benue state, he went back to UCH and commenced postgraduate training in surgery in 1977. His connection to Eruwa happened in April 1980, when he was posted to the Ibarapa District Hospital for a one-month internship after graduating from medical school. The Ibarapa program was designed by the University of Ibadan to help rural areas by providing them with basic health care services using recently qualified medical doctors.

After graduating from medical school, he returned to Eruwa to work as a surgeon in a government hospital. He was a consultant surgeon at the District hospital Eruwa for 3 years. Due to bureaucracy, in 1986, he left the hospital to establish his own private practice. He set up the hospital with his savings and an interest-free loan from Pa. Obisesan. The rest is history.

In 2000, the late prof. Olikoye Ransome Kuti, the then minister of health of the Federal Republic of Nigeria paid a visit to Awojobi Clinic Eruwa. He had this to say  highly privileged to visit this hospital, an example of commitment, concern for fellow beings, innovation, and imagination I like the way he fabricates everything and saves everything. I have visited an exemplary phenomenon and am honored to be here. Can this be replicated? It must take a particular kind of person!!

Dr. Awojobi derives his inspiration from the writing of Niccolo Machiavellian Italian philosopher which he quoted “ There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.

ACE as a model

It is very important for doctors, especially rural doctors, to understand that for one to run an efficient yet affordable hospital innovation and invention can not be neglected. Late Dr. Awojobi understood this hence his numerous inventions. This is time for doctors, Nigerian doctors, to look inward and ask what do we have? and what can we do with what we have? The situation of power supply in Nigeria does not look like one that will improve soon, which means that a rural doctor must always look for alternatives. Awojobi realized this very early in his practice and sought ways to reduce his dependence on the national grid. He, in fact, went ahead to develop nonelectronic versions of equipment he needed for the smooth running of his clinic. Have you heard of the manual suction machine or the manual hematocrit centrifuge? These are some of the technologies he embraced at ACE.

In instances where manual equipment was seemingly impossible to invent, he went for alternative sources of power. For example, his distillation machine was powered by a native firehouse fueled by a corn cob.

He fabricated his own ambulances by a union between a motorcycle and a chart. When water was as scarce as gold, he resorted to self-made dams for water supply. ACE is a vivid example of using what is available to one’s advantage.

ACE runs a research base clinic. Late Dr. Awojobi was a renowned scholar with a keen eye for details. He was given to research even as he took the path of private practice. His numerous publications bear a record to this. He was not satisfied with the level of information at his disposal. He was a voracious reader. If we must move our healthcare system to the next level, research must be at the front burner of such a system. The doctor must keep himself updated with the latest information on the treatment and management of diseases. The onus lies on him to also find ways of domesticating new ideas in the world of medicine. There is little a doctor can achieve if he refuses to grow in knowledge.

ACE is well known for its advances in areas such as the management of chronic ulcers. Most of the chronic ulcers cases management at ACE, come for far and near after such a case has been labeled hopeless. Herniorrhaphy and snake bites are other areas this clinic has to show great dexterity in. These did not just happen, a man decide to learn, unlearn, and sometimes relearn new areas of managing conditions that are common among his patients. ACE does not play with patients’ records. They understand that the faintest pen is still that the sharpest memory. Patient records are filed systematically to allow for easy access. From the wealth of information in these files, and ACE has been able to fine-tune management of common diseases. These management approaches are often compared and scrutinized with findings else and are almost always made available in publications.

Unlike many other private hospitals, ACE incorporated an informal residency program for doctors who desire to pursue careers in surgery, obstetrics, and gynecology and those who wish to set up their own private practices. What other better can ACE be replicated if not through training such as this? The idea was to train residents that will go on to reproduce what they have learned across the country. It runs for 12 months, within which the doctor is expected to have seen and managed a certain number of surgical cases. Late Dr. Awojobi in emphasizing the importance of training said the logjam of retaining medical officers in rural Nigeria could be solved formally using established governmental institutions and informally through private sector initiatives. First, rural health institutions should be made functional using the appropriate technology (as we have developed ourselves in our clinic). Rotations through rural health institutions should be made compulsory during postgraduate training as it is with undergraduate training but the trainers should also be residents in the institution. “ He was really decades ahead of his generation.

Training junior staff is another way ACE has contributed to the labor market. Junior staff is employed on a contract of 3 years. The staff is trained to function in a particular unit of the hospital. Some even go as far as becoming retained as nurses after they have exhausted their 3-year contract. It is assumed that during this training, the staff, who are mostly young adults, especially secondary school leavers, would have decided on the path he/she wants to take in life. This invariably keeps these young people busy so that devil does not make workshops of them. I learned this program is very flexible that it allows participants enough time to pursue other ventures. I remember a young man that I met during my elective. He had just written the university of Ibadan post UTME before I resumed. In one of our numerous chat, I got to know that he run q shift at ACE. He was permanently on the night shift with two weeks on and the alternate off. He resumes at 6 pm and closes at 8 am.

Right from inception, ACE made patient care its priority. This made ACE to move from a profit-driven venture to a service-driven one. This does not mean that ACE is a nonprofit organization. Rather, ACE through its innovative approach to healthcare services has been able to lean back a bit in other to accommodate the less privileged in society. They understand that patients fail to present to the hospital as a result of the high cost of these services. It is a fact that health care is very expensive especially when the caregivers refuse to look inward for alternative technologies. The care patients receive at ACE is very impressive. The hospital is arranged in such a way that the bureaucracy patients meet in big hospitals are eliminated. From the consulting room, a patient moves to the dispensary then to the laboratory or and the radiology department. This free-flowing sequence has really helped in reducing unnecessary time-wasting.

Patient care was taken to another level when the management decided to allow patient relations to come into the theater to both provide the needed emotional support and observe what was being done for their wards. Late prof. Olikoye Ransome Kuti was impressed by this practice that he said” I like the way he admits relations to the theater to watch operations on their sick relatives.

On referral, compared to what is obtained in some private hospitals, ACE has a very good referral system. They understand that time is of the essence in matters of health. They run a principle of evaluating, stabilizing, and referring. It is commendable that ACEs staff benefit from informal health insurance that allows free treatments for ailing staff. This is a very important incentive and a source of the mural.

We live in a time that with so much emphasis on the RRRs, recycle, reuse, and reduce, but ACE saw a future. Most things at ACE are reusable. From hand gloves to sutures, the watchword is recycled. Jack Haggarty has this to ACE “ Even his anticipation of the environmental movement of reducing/ reuse and recycle was decades ahead of the movement. “ When water supply was an issue all across Nigeria, ACE made its own Dams. The clinic through their dams was able to run well. I have talked so much about how ACE has thrived using indigenous technology but let me mention that the hospital also uses inverters a form of renewable energy to power some of their appliances.

This write-up will not be complete if I do not talk about the flow of money. I was privileged to check the surgery list of the hospital. I was shocked to see that they averaged 60-70 surgeries in a month. I later learnt that there has even been a significant drop from what the number from late Dr. Awojobis days. The number then was around 150-160 surgeries per month.

The irony I noticed was that 60-70 percent of this number were from the urban centers. Most come from Lagos, Ibadan, Abeokuta and as far away as Delta.

This number is a product of the effective and affordable care they receive at ACE. Surgeries are at very reduced prices compared to what is obtainable elsewhere. The story of one Mrs. A. A comes to mind when talking about how affordable healthcare services are at ACE. She came from Lagos for hip bone replacement surgery. When I probed, it was confirmed that such surgery would have cost her at least 5 times more at the university college hospital and even more in any private hospital in Lagos. As at the time of writing this, the woman was getting ready for physiotherapy. Hopefully, in another 3 months, she should be ambulating.

Challenges

It is not all rosy at ACE. There are some areas where I would love some modifications in.

There are a few uncompleted projects at ACE, one of which is the Olajide Ajayi Cancer center Eruwa. Construction at the center has progressed rather slowly since the demise of Dr. Awojobi. This was a center he hoped would tackle the appalling stories of broken-down radiotherapy machines at government facilities. He was moved by the pains and suffering cancer patients battle with while looking for radiotherapy. He had hope to complete the project soon using funds generated by the clinic and donations from well-meaning people. It is a pity that such a noble project has been left to linger on for this long.

The first cesarean delivery I witnessed at ACE was indicated due to prolonged labor. The patient was an unbooked primigravida. She was rushed to ACE after spontaneous vaginal delivery could not be achieved at the source of referral. She was quickly taken to the theater and in no time, the newborn was out with meconium stains. There was no spontaneous cry from the child and after suctioning of the airway alongside tactile stimulation the APGAR score remained 4 at 1 minute. More vigorous tactile stimulation and suctioning were done but the baby’s APGAR score remained 4 at 5 minutes.

Could this be several birth asphyxia? I wondered. Then I noticed that plans for intubation and proper oxygen delivery were not in place. We, sadly, lost the baby. Also, I noticed that the hospital does not have means of checking and monitoring serum bilirubin of neonates with jaundice. This is a dangerous situation and should be looked into. Knowing the neurological problems that may arise from poorly managed jaundice and birth asphyxia, I will like to see the management doing something urgently to address these issues. A more equipped resuscitator is needed in the hospital. The nurses that attend to newborns should also be taught how to identify and manage birth asphyxia.

Junior staff at ACE, as I pointed out early, are predominantly young people. Their passion and commitment to their jobs can not be doubted but they are crude and needs a bit of polishing. Issues bordering on patient privacy should be taught routinely. This will help keep these staff updated on how to handle patients’ privacy. The side talks and gaggles around patients can be annoying and should be stopped.

Staff safety should be discussed at this point. I noticed with great pain how to care freely some junior staff handle blood and sharps. It was even scarier to know that most junior staff have not been vaccinated against the hepatitis B virus. This is almost like playing with fire. The management of ACE has to look into this and act appropriately.

Late Dr. Awojobi introduced the informal residency program to help produce other rural hospitals that will function the same way as ACE. He dream was not only to make great surgeons like himself but beyond that, to create a ripple effect across the nation by exporting through these trained residents the system he has created at ACE. It is quite sad that many doctors enroll for the residency program just to nurture their surgical skills without bothering to understudy the system they met.

Surgical skills can be gotten in quite a lot of hospitals but the system that runs ACE is unique in that it is only seen at ACE. The founder’s love for indigenous technology should be emulated.

The management of ACE should look for ways to incorporate events that will help residents imbibe all that Awojobi stood for, that was he dream. If this is neglected, we will end up with a system configured against the less privileged in society.

To the government

A lot has been said about an individual who against all odds built a system that survived the harsh economic climate created by the government of Nigeria. One would expect our government to look ACE and learn. A former minister of health asked can this be replicated? I expect the government to answer that. He, Dr. Awojobi, has set up a system, that stops our Government from duplicating it across the nation.

There are men of like minds waiting for a simple push from outside “the government “ to act. Our government should awaken to its responsibilities.

Dr. Awojobi maintained a very wonderful relationship with surgeons in India. There must be a reason for that. We share a lot of similarities with India and so should learn from it. We cannot afford to keep looking at Countries that are very much different from us. We should and must follow Late Dr. Awojobi to India.

Government should as a matter of urgency engage Innovative firms like ACE in a public-private partnership. It is a shame that a project like the Olajide Ajayi Cancer center Eruwa is being left unattended to by the government. If projects like such cannot attract interest from the government what will?

CONCLUSION

ACE has shown that where there is a will there is a way. Can health care services be affordable in Nigeria? The answer to this lies in a critical examination and evaluation of the systems in place at ACE. The role of indigenous technology and innovation cannot be over-emphasized. So dear doctor, look inward, think global but act locally.

The government has as got to wake up to its responsibilities. Places like ACE should not be allowed to die. Policies and programs that will bring the best out of such places should be encouraged.