COVID-19 AND STIGMA IN HEALTH FACILITIES AND THE IMPACT OF COVID -19 ON PRIVATE HEALTH FACILITIES IN THE FCT
A LECTURE PRESENTED AT THE VIRTUAL ANNUAL GENERAL AND SCIENTIFIC CONFERENCE OF THE NIGERIAN MEDICAL ASSOCIATION, FCT HELD ON 16TH AUGUST, 2020
DR. ABIMBOLA SILVA MBBS (IB), FWACP
CONSULTANT FAMILY PHYSICIAN
CMD, TAPROBANE MEDICAL CENTER, ABUJA
IPC PILLAR MEMBER, FCT EOC
TREASURER, GUILD OF MEDICAL DIRECTORS, FCT.
PART 1: COVID- 19 AND STIGMA IN HEALTH FACILITIES
Definition of Stigma1
Stigma is a social process characterized by labelling, stereotyping and separation leading to a perception of low status and then discrimination of the stigmatized person or group of persons, all in the context of power.
The end point of Stigma is the negative differential treatment i.e. discrimination. This is described as the unfair and unjust action towards an individual or group based on real or perceived status or attributes, a medical condition (Covid-19) in this case, age, gender, race, sexual identity or socioeconomic status.
Stigma in Health Care Facilities2
This ranges from denial of care, provision of sub-standard care, physical and verbal abuse and more subtle forms like keeping some people waiting longer in the hospital or sending them off to be cared for by younger medical colleagues. It makes it difficult for health care workers to be effective at offering good quality care.
People who are in a vulnerable situation are unable to receive care, treatment or support for their conditions. It worsens the spread of disease in the context of Covid-19. The delay in decision making leads to preventable loss of lives. Complications of diseases that could have been prevented may be worsened due to delays in decision making.
In the long run, with so many preventable deaths and complications, patient’s confidence in the health care system will become eroded.
Causes of Stigma in health care facilities2
- Fear of Infection: If health care workers are afraid of becoming infected with a contagious disease in the hospital, this can predispose to a display of differential treatment towards patients who appear to show symptoms of such an infection. This is primarily a self-preservation reaction which is a common human reaction at its core.
- Lack of awareness: In a situation where the actual status of each patient cannot be easily and quickly confirmed and the contagious disease may be present without clear cut symptoms or quick testing such that diagnosis cannot be readily and quickly made, this predisposes to stigma towards any patient who may be perceived to be a suspect.
- Inability to manage or lack of confidence to manage: When health care workers are unsure of the treatment or the management of an infectious disease or they do not have the confidence to manage the condition either because there is no known cure or standard protocol of treatment of the condition, or they do not have the license or authority to treat such conditions, this also predisposes to stigma or a negative differential treatment.
- Fear of the behaviour of the stigmatized group: When Health care workers are afraid of the possible behaviours of the suspected patient with the contagious infection, they may treat them discriminatorily in a bid to protect themselves from such behaviour e.g. in the case of drug addicts and possible irrational behaviour or in the case of some patients who while attempting to avoid stigmatisation have been known to deny or hide possible symptoms that may make the health care worker suspect Covid-19 infection. This fear of such denial of symptoms by patients may make a HCW stigmatize against possible suspects.
- Fear of mortality: If a disease has a high mortality rate, the fear of such by health care workers is higher especially if it is also highly contagious and difficult to diagnose quickly among patients. This predisposes them to stigmatize or give differential treatment to such patients.
- Institutional policies of care: When the treatment or care of a group of patients is specifically set apart by government policies, this already makes them vulnerable to stigma. This is because once they present to health care workers in a facility where they are ‘officially not meant’ to be treated for that suspected ailment, such health care workers are already biased to not treat them and subconsciously give them negative differential treatment.
Relationship between Stigma and Covid-19 in Health care facilities in Nigeria
In view of the causes of stigma in health care facilities in Nigeria with respect to an infectious disease like Covid -19 which may be spread by asymptomatic patients as well as patients who may deny their symptoms and which cannot be speedily recognized at presentation by a readily available test with results being available within a short time, some differential treatment is required in the process of infection prevention and control.
This is because the basic protocol of ‘universal precautions’ may not completely apply to this disease given the mode of spread, details of which is also evolving daily.
Unfortunately, when the differential treatment relating to infection prevention and control is not properly handled and carefully explained to patients, it may be interpreted as Stigma.
However, when responsible and appropriate infection prevention and control protocols are in place, any further differential treatment towards a suspected case of Covid-19 in health care facilities is Stigma and the discrimination that results must not be acceptable in health care facilities anywhere in the world.
Reduction of Stigma in Health care facilities in the context of Covid-193
- Provision of information & tools for care– In order to avoid stigma or reduce it, adequate Covid-19- appropriate personal protective equipment need to be readily available at all times for all health care workers. Infection prevention and control training of all staff from the medical personnel to the support staff such as records and front desk staff, cleaning staff e.t.c. must be an ongoing practice.
- Skills-building activities– HCW should be given the appropriate skills to be able to treat and care for the stigmatized group. E.g. Availability of a standard protocol of treatment and care of Covid-19 patients nationwide or regionally gives skills to all HCW. If treatment pathway is clear and routinely enforced, it is easier for HCW to accept all patients knowing what care needs to be given at each step and when and how the subsequent management of the patient would be achieved based on standard protocol that every facility adheres to. This is needed because of the novel nature of the disease and as the whole world works together to fight it.
- Participatory learning– Health care workers working with the public in reducing stigma. E.g. adverts and jingles encouraging patients to be truthful. HCWs can help to make videos as they get involved in the process of reducing stigma and making it easy for patients to come to the hospital for care when needed.
- “Contact” with stigmatized group– This involves the inclusion of recovering or recovered Covid-19 patients in the fight against Stigma e.g. getting them to make videos to help everyone develop empathy towards them, to humanize them and break down stereotypes about the disease and its effect generally. Seeing healthy survivors’ helps to negate the stereotype of Covid-19 being a ‘death sentence’.
- Structural” or “policy change” – this can go a long way to reduce stigma and the required changes by the government include but are not limited to the following:
a. Providing reliable redress systems such as functional help desks in all facilities where stigmatized Covid-19 patients can seek redress and expect to be heard and have justice served.
b. Facility restructuring such that testing is readily available with fast turn -around time of the results in as many facilities as possible. This makes it easy to triage in each facility and refer accordingly and appropriately when needed. The element of uncertainty about a patient’s status is removed and those who need Covid-19 specific protocols of care (including isolation) can be set aside from those who do not.
c. Readily available PPEs for all health care workers without discrimination among health care facilities.
d. Adequate assessment, accreditation and support of more hospitals to treat Covid-19 patients so that more facilities can treat and/or admit confidently without fear of repercussion which is a basis for many of the rejections of Covid -19 patients which is then translated into ‘Stigma’.
e. Faster test turn-around time to ensure that the hospitals where patients are ‘temporarily held’ can make decisions regarding their care in a timely manner. Delays in getting the results to the care giver unnecessarily prolongs the need for Covid-19- specific personal protection in health care facilities. These delays translate to higher overheads and higher cost of already overstretched services.
PART 2: IMPACT OF COVID-19 ON PRIVATE HOSPITALS
- Perception of Private hospitals by patients 4
- Impact of Covid -19 on Private hospitals
A. Challenges/ Negative impact
B. Positive impact of Covid 19
- PERCEPTION OF PRIVATE HOSPITALS BY PATIENTS4
*Majority of patients perceive private hospitals to be more dependable than public hospitals.
*Patients tend to trust the employees of private hospitals more than those in the public hospitals.
*Private hospitals tell their patients exactly when services would be rendered, and they keep to it.
*Private hospitals keep their records more accurately
*Private hospital employees are more polite
*Employees in private hospitals are deemed to have adequate specializations
*Private hospitals had their patient’s best interest at heart
*More than 60% of health care is offered by private hospitals.
- IMPACT OF COVID-19 ON PRIVATE HOSPITALS
A. NEGATIVE IMPACT OF COVID -19 ON PRIVATE HOSPITALS
These are from experience of myself & colleagues in private practice so may or may not be fairly generalizable.
- TRIAGE PROBLEMS- Screen- Isolate – and Notify (SIN)
When Covid-19 was still an imported disease, some patients were not completely honest about their travel history, so there was often failure of the “Screening” system which depended only on the self- reported travel history.
When it spread to the Community, patients were not honest about their symptoms and many blatantly would deny having the symptoms. Of note were also those who truly had NO symptoms and yet were able to spread the disease, a fact that became known only months into the pandemic.
This meant ALL patients needed to be treated as though they are Covid-19 positive. This meant Covid- specific PPEs and Covid-specific infection prevention practices including sitting position in waiting areas to guide direction of air flow, frequent surface and door handles cleaning, open ventilation, N95 masks, avoiding dry sweeping, avoid nebulization in enclosed emergency room, maintaining negative air pressure, where possible, all had to become the order of the day.
The most efficient way to appropriately screen for a highly contagious and deadly disease is to have a readily available test with readily available results within hours or minutes, with which the care giver could then easily separate or Isolate the positive cases from the negative ones. This was not available.
The available Covid-19 test was not freely available to any and every one. Certain criteria had to be fulfilled to be able to qualify for a test.
In situations where the criteria could be fulfilled and the tests could be done, it may take days to actually get the test done and many more days for the results to be available to the health care provider.
Although temperature checks were used to assess possible infection, we all know it was not always useful as many other illnesses presented with fever and many Covid-19 patients positive presented with no fever.
Fortunately, on May 3rd, an NCDC document was published to help with the Screening Process.5 This document gave a list of possible symptoms that would point to a Suspected Case. This meant that the criteria for testing was wider and more could be tested.
So Fever and/or cough within previous 2 weeks with ONE of: Shivering, Body pains, Headaches, Sore throat, recent loss of smell, Difficulty in breathing, Diarrhoea/ Abdominal pain, Runny nose/ Catarrh, Fatigue/ Tiredness in the previous 2 weeks.
This was a good development to guide Health Care Workers.
More testing centers were also accredited and set up making testing more accessible.
However, in some instances, test results were delayed from reaching the Health Care Worker or the patients by sometimes up to 10 days or more by which time, sero-conversion would have occurred and patient may not even be infective anymore.
Once able to identify a suspect, they were to be ISOLATED. Isolation meant you admit in a temporary space to offer life-saving care until results are ready. This is because the designated treatment centers would not admit until results are positive. So private hospital staff must wear full PPEs always while attending to them including the cleaners and sanitation workers in the hospital since results were unknown. The cost of care was higher than usual as more consumables were now needed and other patients could not use the same space.
This additional cost of care had to be borne mostly by the hospitals as most patients were not also financially capable to take on the added costs.
Insurance payments/ tariffs did not increase despite the higher costs of rendering the same services to protect patients as well as hospital staff.
C. NOTIFY- Apart from the delay which may occur after a case is confirmed and the authorities are informed, the notification process was somewhat straightforward. However, the fact that only confirmed cases would be evacuated to the isolation centers was a challenge as described since results did not come out in a timely manner in many instances. If the burden of “temporary isolation” was pushed to the government- funded or public hospitals and all patients were readily taken off private hospitals once suspected, no private hospital would hesitate to take on and give first aid to ALL suspects for onward immediate transfer till confirmation and further care as needed.
- Stigmatization of private hospitals– The Government announced that Private Hospitals were not accredited to treat Covid -19 and would be penalized if “caught”.
In a situation where you cannot be certain who has Covid-19 without prompt tests, private hospitals were accused of sending patients away and refusing treatment to patients especially if they had Covid-like symptoms.
Some hospitals who were big enough to provide a Temporary Isolation area for patients awaiting results were labelled “Covid hospitals” when Covid results took 10 days or more to be available and the patient sometimes spent the whole period of Sero-conversion on the private hospital bed.
In some instances, it was because the patient blatantly refused to be referred to be isolated in the government operated isolation centers. Some of these were forcefully evacuated from such hospitals by Government officials with the hospitals then labelled “Covid- hospitals”.
- Exploitation of Private hospitals
In a pandemic where everyone is seeking a way to stay above board some establishments capitalized on this to exploit private hospitals
- Radio and television taxes (among many) as high as half a million naira as well as other multiple taxes became more rampant from government agencies who were also low on cash.
- Consumables suppliers increased prices at will without any way of controlling them.
- There was no relief from landlords for rented hospital buildings even if only as a CSR. In fact, some increased the rates.
- Some private HMO tariffs were cut down despite increasing costs to the hospital of rendering same services.
- Other HMOs introduced new and near unattainable rules and regulations to create more loopholes whereby payments for services rendered would be evaded after services have already been rendered.
- Payments from HMOs on the NHIS platform continued to be delayed. (Many months backlogs despite all the inflation and devaluation of the naira)
- Government Financial aid- Difficult to access
- The CBN 5% loan which was widely publicized was often unattainable to those who needed it.
- While it remains true that many private hospitals needed and still need to employ professionals to keep their books, some of those who already do this, still found the loan difficult to access. So much so that certain banks started working around specific aspects of the loan to make it accessible by going working with Medical Doctors’ Associations, or Medical Directors’ Associations.
- Other challenges
While some public hospitals were given PPEs regularly, private hospitals generally needed to purchase by themselves. After some time, few private hospitals listed on the NHIS scheme were later given some basic consumables on a one time basis.
The cost of these PPEs multiplied exponentially e.g. Surgical facemasks price which pre- Covid era was N2,500 became as expensive as N18,000/pack of 40/50 pieces) at a time.
N95 masks were up to N5- 7k/piece, depending on the quality of the product.
At times there were completely unavailable especially during the lock down
Cash paying clients generally had low spending power because of the depressed economy and the increased cost of care could not always automatically be pushed to ALL the patients even though Covid- specific PPEs are applied to all.
Many old patients of private hospitals now present in very bad state and with no money and private hospitals are expected to offer CSR despite having all odds against them as well.
POSITIVE IMPACT OF COVID -19 ON PRIVATE HOSPITALS
- SHOWCASE OF HIGH-END PROCEDURES
There was an increase in the number of high end- life saving procedures done for cash paying clients who would have travelled to pay the cash abroad but could not travel during the travel restrictions.
There was an opportunity to showcase these available high end services in Nigeria leading to a progressive increase in the confidence of those who thought they had to travel for some of these procedures or tests.
- GOVERNMENT FINANCIAL AID- WHERE THIS WAS ACCESSIBLE
a. For the private hospitals who were able to afford to pay specialists to help them navigate the CBN 5% loan and get it, it will be very useful.
b. Although the 5% interest rate increases to 9% after a year, the fact remains that this is one of the very few unit interest rate loans available for private hospitals to scale their business and offer better services at affordable prices to the public.
- PRIVATE TESTING AND TREATMENT CENTERS
Collaboration has improved to a good degree with the Federal Government and Private hospitals such that:
a. More private testing, isolation and testing centers have now been accredited nationwide.
b. Most of these sites have tests available albeit not free considering the costs of setting up Covid testing labs. But the tests are available, and results Turnaround Time are very short.
c. Any private hospital who shows interest in being accredited can now approach the Accreditation Team set up by the Ministry of Health for this and once all the criteria are fulfilled, they would be accredited.
- INNOVATIVE SAFE REUSABLE PERSONAL PROTECTIVE EQUIPMENTS
a. Innovative production of safe and reusable personal protective equipment mainly overalls and face masks, have surged making it easier to cut the costs of services in some instances and be able to offer some services at the pre-Covid prices.
b. Some private hospitals have invested in such production of safe and reusable PPEs for their domestic hospital use as well as sale to others hence diversifying income streams.
- INNOVATION RELATING TO HEALTH CARE DELIVERY
a. Some major deficiencies in our health care system were exposed by the pandemic. Discussions are ongoing to find solutions. One of such is the discussion relating to Ambulance or Emergency services.
b. This will involve both public and private hospitals and is hoped to improve access to health care in emergencies and guarantee payment for emergency services to some private hospitals who hitherto have offered ‘free emergency services’ to avoid patients dying in their hospitals.
- INNOVATIVE PARTNERSHIPS
a. In a situation where the cost of rendering services far exceeds what clients are ready to pay, smaller private hospitals are in discussions with larger private hospitals for innovative partnerships where certain costs could be shared. E.g. sharing ambulances, sharing laboratory services etc.
b. Also, pooling of funds among hospitals helps them get better rates from suppliers e.g. buying drugs and consumables.
c. This also means quality would be improved together as partners would want to be associated with a similar level of quality always and each can be a ‘control’ to the other.
- Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Soc. 2001;27(1):363–
- United Nations Agency for International Development (UNAIDS). Protocol for identification of discrimination against people living with HIV. Geneva: UNAIDS; 2000.
- Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in health care settings: what works? J Int AIDS Soc. 2009;12(1):15.
- Ross CA, Goldner EM. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. J Psychiatr Ment Health Nurs. 2009;16(6):558–67.
- NCDC Guidelines for Community Case Definition https://covid19.ncdc.gov.ng/media/files/Community_Case_Definition_PDF.pdf