PATIENT SAFETY IN AFRICA: THE OBVIOUS CONCERNS

Across the world, healthcare leaders and stakeholders have launched a number of initiatives to improve patient safety and eliminate preventable harm within healthcare facilities. A number of goals have been set and several sustainable actionable plans have been designed. The initiatives, plans and goals are impressive, and we are hoping they can transcend to healthcare systems across Africa and particularly in Nigeria where I am domiciled.

Healthcare facilities were not originally designed to harm patients. They should be a place where patients receive care and empathy to heal the body, mind and soul. In the words of Florence Nightingale, “the very first requirement of a hospital is that it should do the sick no harm.” This is a clear mandate to both the stakeholders who sit on boards and to the caregivers who care for patients. We are all collectively responsible for ensuring that patients return home to their loved ones unharmed.

This mandate can become reality only when leadership commits to patient safety and positive patient outcomes – and this is where we largely get it wrong in Africa as a government and as a people. From my experience, a culture of safety is the bedrock for eliminating preventable harm in hospitals.

One of the concerns is that our hospitals do not give due consideration to the safety and health of caregivers. This box has long been left unchecked and this shortcoming correlates to negative impacts on the safety of patients. For example, most hospitals do not have procedures that consider the vaccination profile of healthcare employees. Some healthcare workers have existing health concerns when they are employed, which leads to infecting the patients they manage. Compulsory vaccination of the employees should start at recruitment. This would give staff some relief knowing he or she is covered against certain preventable infections.

We have to address the healthcare work schedule in Nigeria. Most healthcare systems have two shifts of 10–12 hours each. This leads to exhausted workers and tired workers make mistakes. These schedules are set for a couple of reasons: either the hospital does not want to pay more in wages to have the appropriate number of healthcare workers or there is a shortage of healthcare workers.

The lack of a safety culture is also responsible for certain situations in which there are no documented work procedures or processes to ensure patient or staff safety. In most cases, we see different processes being used by different healthcare workers in same facility, this is both frightening and intolerable; and leads to poor patient outcomes.

We also have a high rate of surgery site infections and injuries. Most are never reported or documented so we can learn from them, and they are never disclosed to the patients or their families. This immense absence of honesty of care goes against the principles of CANDOR. Patients that get infections experience longer hospital stays and they are still made to pay for the extended admission for a problem that was caused by the healthcare system. This happens daily in healthcare facilities here.

There is a shortage of healthcare professionals in Africa and most countries in Sub Sahara Africa have few qualified doctors or nurses. Some hospitals are even forced to train young secondary school teachers as nurses. This has given rise to a high number of quacks who are not registered with professional councils and are never guided by any code of practice.

The latest data from the World Health Organization reveals that Nigeria’s Physician-to-Patient ratio is 4 doctors to 10,000 patients. Compare that to countries like Qatar, which has 77 physicians to 10,000 population. According to the 2014 WHO report, Nigeria has only 150,000 registered nurses for a population of 160 million, a ratio of 1 nurse to 1,006 people. The WHO standard is 22 nurses to 10,000 population. In Nigeria, we train and graduate healthcare professionals, but they do not stay to practice due to our poor healthcare infrastructures and discouraging remuneration.

Poor healthcare funding is another key issue. Nigeria’s annual healthcare budget is less than 4 percent of the National Budget, public hospitals are not funded even for the right drugs or diagnostic equipment, let alone investment in training and integrating patient safety into behaviors and systems. This leads to a poor infection management system and poor levels of disinfection and sterilization. Personal protective equipment needed by healthcare workers are insufficient, we lack hand sanitizers, and most times there is no running water for caregivers to wash their hands after handling patients. I have witnessed a nurse, during delivery with a failed suction machine, use her mouth to suck the baby, that was all she could do, these are some of the lines of risks to both patients and even the care giver.

A number of hospitals are even allowed to operate without regulatory registration. In these facilities, patients are harmed daily basis without any reporting. This is where the government has absolute responsibility. Patient safety has to be at the front line of healthcare discussions and our national agenda.

We need to look at things differently. First, we need to look at the healthcare system as a workplace before seeing it as a place in which we seek care. Then let’s consider safe processes as part of the infrastructure of healthcare facilities, the spaces have to be designed to reduce patient harm. We need to review the increasing number of hours in healthcare shifts, accidents will surely happen through overwork and overdraw of healthcare workers. We need to start creating a culture of incident reporting and give assurances that we will not be blamed. Then we can use the incident as a learning moment.

Most importantly, we need to improve our healthcare infrastructure and increase our healthcare budget. Without these two factors, patient safety and good treatment outcomes will only be a dream. In the WHO Abuja Declaration (2000), it was agreed that healthcare funding should be increased to at least 15 percent of the National Budget. Most countries across Africa, including Nigeria, have yet to acknowledge or meet this agreement.

We need to start the dialogue from here. 

WORKPLACE MENTAL HEALTH IN AFRICA: THE CURRENT STATE AND NEGOTIATION FOR IMPROVEMENT

Workplace mental health is a growing concern in Africa with daily increasing burden as a result of the fast mutation in work pace, work processes and changes in employment patterns. This is expected to go even worse as we all gradually slide into the new global concept known as the “Future of Work” which will be characterised by very high technology, high use and dependency on machines and robots who will fiercely compete for work with their human counterparts. This will further change the entire landscape of workplace mental health with an increased burden of disease traceable to excess work demand, burnout, longer hours of work, workers overdraw, the fear of loss of job, lone worker syndrome which will further dismantle the existing human interactions and socialization between and amongst workers in workplaces.

There is an urgent need to change the notion of seeing an employee solely as a tool for the profitability of the employer who makes little or no provision for the maintenance of the employee’s health and wellbeing. This is very crucial because these same employers have dates when their machines are due for servicing and they never fall short of those dates but they never in same way have a scheduled dates within their calendars for employees’ health and wellness assessment. 

Concerns as highlighted above are underpinned with the absence or poor legislation on mental health at work in Africa. Owing to the fact that even mental health was not amongst the illness classified by ILO in the list of Occupational diseases, most countries in Africa still lag behind in trying to have mental health concerns captured and rightly provided for in workplace safety and health legislation. There exist a number of countries now that have National Mental Health Act or Policies but these are domiciled with the Ministry of Health while most OSH Departments or Agencies are under Ministry of Labour and Employment. In a number of those mental health policies, it is assumed there was never a broad consultations that included the Ministry of Labour and Employment and other Workplace safety and health stakeholders in arriving at those polices hence these actors do not see themselves as co-owners of such policies. Absence of these policies has made it difficult in holding employers accountable for violation of national workplace mental health provisions, we must first have a document of reference before holding employers accountable.

We need a strong political will for review and updating of existing National legislation. A number of countries across Africa govern their workplaces with highly obsolete OSH legislation that have no bearing with the new workplace and work-life-balance realities, no element of mental health and employees’ wellbeing provisions. The urgent need for an early review of these documents is so crucial, at OSHAfrica we are doing something about this. Even where these documents or legislation exist, they are not promoted or sold to employers of labour, instead they are stacked in a certain office where they are made unreachable to those who need to interpret and domesticate them into their corporate OSH policies.

Advocacy and education and the right definition of what workplace mental health is all about will be a quick fix to the current level of information deficit along the lines of mental health and wellbeing at work. The mentality and understanding of mental health generally has to scale up if we must change the current perception of mental health in Africa. There are currently little or no definite programs that are directed at mental health at work and psychosocial hazards that are imminent in our current workplaces.

In having an honest conversation and drawing programs on mental health at work, it will be wrong to isolate business leaders, Human Resources Managers, employers of labour and others who are daily actors in the implementation of these policies and programs. This is the current situations across many countries in Africa, there is an urgent need to shift from the idea of developing a policy for them and embrace the friendly participatory approach of developing a policy with them. Let them own it.

Mental Health Treatment and Rehabilitation.

Stigma: When we talk of mental health stigmatization, we must first also look at the current location and design of mental health facilities. This is the root of the stigma.

In many facilities, mental health units are located in some isolated and lonely wing of the hospital almost far off other adjoining facility. This makes it so obvious to identify any patient walking towards that direction for care as patient having a mental illness. This on its own, turn people away from accessing care.

We have specialised facilities called Psychiatrist Hospital, owing to the poor level of information on mental health in our locality, no one wants to wake up, get dressed and walk into a psychiatric hospital. He is careful and ashamed of who may have seen him walk in, he ends up not accessing the service and his condition is left untreated. So we need to look at the location and design.

Shortage of mental health experts: The region needs more mental health experts. Virtually every country in Africa needs more hands to support the system in managing mental health. Kenya with almost 50 million population has only 80 Psychiatrists and 30 clinical psychologists, Nigeria has 130 Psychiatrists as documented in many studies but lately Association of Nigeria Psychiatrists through their website reported are now 250 Psychiatrists for 200 million population. This shortage of mental health experts is common. Ethiopia with a population of 61 million people has only 10 Psychiatrists, the shortage led to an estimated 85% of emotionally disturbed people seeking help from traditionally healers, this is according to a publication by Prof Oye Gurege etal.

Training of healthcare workers on mental health: When you are presented with co-morbidity of physical illness and mental illness, only the physical illness are mostly taken care of in the hospitals at the expense of mental health or other emotional disorders. The patients are allowed to leave with a mental health condition that was not even diagnosed let alone being treated.

Funding is a critical issue. At the Abuja declaration 2001, leaders of all countries in Africa met and pledged to increase the healthcare budget to 15%. Only 1 country has met this target, 26 countries have increased theirs, 11 countries have reduced theirs and there were no significant trend in the other 9 countries.

In most countries in Africa, only an average of 1% or less of their healthcare budget is allocated to mental health when compared with 6 – 12% allocation in Europe and North America. This poor funding does not allow growth and improvement in management of mental illnesses in the region.

Insufficient mental health facilities: There are no enough mental health departments or facilities, even when they exist, they are mostly in the cities. How do we cater for people who live in rural communities knowing that mental illness does not discriminate or have location biases? This has led to wide spread of traditional practice including spiritual healers in mental health who end up complicating the presenting conditions with physical tortures and leaving their victims in chains.

OSHAfrica and AU-DA partnership project

We are currently reviewing the Occupational Safety and Health legislation across the 54 African countries, we are looking for the similarities and peculiarities in content and also making provisions for areas that were hitherto not covered or were not adequately covered inn existing legislation. Upon completion of these reviews, we will come up with a harmonised document called “The African Occupational Safety and Health Act” which will be presented for further review by the African Union leadership for adoption and possible sign off for use across all 54 countries in Africa.

One of the key things we have in mind while on this project is to make clear and robust provisions for:

·       Mental Health at Work

·       The Informal Sector

In this partnership, we are also looking at how we can run Train-The-Trainer program on mental health at work across all the 5 sub regions in Africa.

Another discussion we had along this line is designing a Mental Health at Work Training for Business Leaders, this is currently in the mandate of the Scientific Committee in charge of OSH Education and Competency Improvement.

Ehi Iden

ehi@ohsm.com.ng

OSHAFRICA CONFERENCE 2019: THE SUCCESS NO ONE SAW COMING

The OSHAfrica 2019 Conference has come and gone but the pleasant memories it left everyone with is so difficult to let go of.

The choice for South Africa being a host Country started from a very quiet nomination made by Debbie Myer when we requested for nomination submissions, this stood alongside countries such as Sudan, Zimbabwe and Tunisia which were also put up for hosting nominations. South Africa emerging as the host was a blessing to OSHAfrica because most speakers and delegates were all interested in coming to South Af

rica. The moment the nomination sailed through; the conference planning began with Dr. Thuthula Balfour showing the very positive leadership in putting the conference planning committee together which she co-Chaired with Dr Claire Deacon.

The day one of the conference was amazing, I walked into the hall that was already packed full of people with so much expectations and this was to my utmost amazement. It was fun to see a very energetic dance troop whose performance passed a very clear message on workplace health and safety.

We had very sound keynote addresses from several stakeholder groups which was followed by interesting and very stimulating plenary papers and other very technical papers running across all parallel sessions simultaneously. We were all amazed to the depth of knowledge in the keynote paper presented by Hon. Richard Musukwa, the Zambian Minister for Mines. This was so rich on thoughts and a true representation of the current health and safety situation not just in Mining but across workplaces in Africa. These all put together set a tone for a very successful conference.

One of the key highlights of the OSHAfrica 2019 conference were most importantly the turn out, the number of speakers and non-speakers that flew into Johannesburg just to be a part of this conference, that was a key highlight that will be difficult to remove from the conference success. We had a young lady who flew in all the way from Canada, others from Thailand, The United States of America, Russia, UK, Turkey, Ukraine, Australia and several other countries. We had of course a whole community of Germans where a number of them were coming to Africa for the first time and also Africans from all over the sub-regions represented in this conference.

It was indeed a very successful conference with over 1,200 delegates from 31 countries, 54 international speakers and 40 South African speakers. We had two serving Minsters, the presence of both ILO, WHO and the African Union representation for a three-day conference, I think that was another highlight that was mind-blowing and too quick to forget. Everything was really on-point from planning to implementation.

If you recall, one of the primary focus of OSHAfrica is to bring African Occupational Safety and Health professionals together for collaborative work and sharing of data. That was further strengthened at the course of this conference where most of the delegates across Africa were meeting themselves for the first time and sharing such networking and bonding opportunities, I think that was really good. We saw both African professionals and professionals outside Africa sharing stages together or Charing sessions together, this was further strengthening the OSHAfrica dream. We had a dedicated training class within the conference that was focused on teaching delegates how to write abstracts and research papers, this strongly reinforces the overarching aim of OSHAfrica.

Owing to the fact that it was our maiden conference, the problem of being able to get professionals across the continent and the world at large to gather in Johannesburg was envisaged. But we needed to put forward the right attitude that people could trust, we started our engagement along these lines and many of our members who had existing contacts to great professionals all volunteered their time and resources in contacting these great minds and bringing them all in to Africa. The African Union Development Agency contributed immensely in funding some of the speakers from the continent.

The Occupational Safety and Health professionals across Africa and the rest of the world (we also have members who are non-Africans), should carefully align properly with the OSHAfrican plan for the next three years. A report of the conference was presented Dr Zweli Mkhize, Minister of Health of South Africa and the recommendations in the report will be implemented going forward.  We have a number of projects already put together by the three scientific committees and these are all geared towards improvement in the capacity and capabilities of the African OSH practitioners and translating these gains indirectly into OSH improvement in workplaces across Africa.

The OSHAfrica 2019 conference has set a very high tone which I think we will all follow as a trend. You saw the pitch put together by our colleagues from Kenya towards the hosting of the OSHAfrica 2022 conference. OSHAfrica is full of ideas and the years after will always be better and more innovative than the years before.

Within this conference also, we also had a very successful General Assembly which had been designed to hold within the conference every three years. At the General Assembly, our existing interim board got dissolved to make room for democratically elected Board. This exercise was very peaceful as we now have a new Board of Trustees supported by members to lead OSHAfrica for the next three years. We currently have over 500 members from over 37 African countries and we have new members signing in daily.

Reported By:

Ehi Iden

President, OSHAfrica

ehi@ohsm.com.ng