Integrative approach towards evidence-based medicines: Policies and practices in Nigeria

April 3rd, 2019

By Dr. Godswill C. Okara

Definitions: – Policy, a course of action adopted by a government or party or person; prudent conduct having or showing insight or good judgement;
Practice, the actual application or use of an idea, belief or method as opposed to theories relating to it.

Traditional Medicine (TM): Traditional medicine has a long history. It is the sum total of the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.

Complementary Medicine (CM): The terms “complementary medicine” or “alternative medicine” refer to a broad set of health care practices that are not part of a country’s own tradition or conventional medicine and are not fully integrated into the dominant healthcare system. They are used interchangeably in countries.
Traditional and complementary medicine (T&CM): T&CM merges the terms TM and CM, encompassing products, practices and practitioners.
The World Health Organisation’s (WHO) constitution charges the Organisation to pursue the universal realization of the right to health: “the attainment by all peoples the highest possible level of health”.

The promotion and protection of good health is essential to human welfare and to sustained economic and social development. People rate health as being one of their most important priorities. As a result, health frequently becomes a political issue as governments try to meet peoples’ health and social expectations.

The WHO in the 1978 Alma-Ata Declaration stated as follows: “reaffirms that health, as a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”

This singular declaration emphasized the WHO’s founding vision of achieving “the attainment by all peoples of the highest possible level of health”, which has been technically referred to as Universal Health Coverage (UHC). It has become the political aspiration and goal of all countries, governments and societies to protect and promote human health and survival as a fundamental right.

The World Health Assembly (WHA) Resolution 58.33 of 2005 says everyone should be able to access health services and not be subject to financial hardship in doing so. WHO’s member States have set for themselves the target of developing their health financing systems, mechanisms and options to ensure that all people can use health services, while being protected against financial hardship associated with paying for them. An effective healthcare delivery system can rightly be described as one that guarantees timely access to appropriate and affordable, high-quality health services to all persons needing them in a well-functioning health financing system.

This highlights the imperative of integrating all types of healthcare systems and practices that have evidence of any benefit to a given population. For example, India is said to have six traditional systems of medicines with official recognition. They include: Ayurveda, Yoga, Naturopathy, Unani medicine, Siddha and Homeopathy, all with institutionalised education system. There are 508 colleges with an annual capacity of 25,586 undergraduate students, 117 of these colleges also admitting 2,493 postgraduate students.

The WHO estimates that a considerable number of people in many countries rely on traditional, complementary and alternative medicine (TCAM) systems to meet their primary healthcare needs, yet there remains a dearth of research evidence on the overall picture of TCAM utilisation in these countries.

Consequently, the WHO has consistently advocated the integration of traditional, complementary and alternative medicine with the orthodox medical system to achieve and sustain access, affordability and high-quality services. This underscores the great importance of the topic of this lecture and discuss.

Policies and Practices in Nigeria

In keeping with these declarations and resolutions of the WHO, Nigeria has made sustained effort to institutionalise policies, measures and legal framework to recognise and enhance the practice of traditional medicine. These measures include the constitution and inauguration of the National Technical Working Group on Traditional Medicine; development of policy documents on traditional medicine, including the National Policy on Traditional Medicine, National Code of Ethics for the Practice of Traditional Medicine, and Minimum Standards for Traditional Medicine Practice in Nigeria; advocacy for traditional medicine at all levels and in relevant fora, such as the National Council on Health in 1997, Consultative Meetings of the Honourable Minister of Health with commissioners of Health and Local Government Chairmen in 1999, and the Presidential Think Tank Forum in 1999.

A bill for the Traditional Medicine Council of Nigeria Act was proposed in 2000. The bill was represented in the current National Assembly for legislation. The Federal Ministry of health recently set up the Traditional Medicine Development Division in the Ministry, with the hope of upgrading it to a full Department of Traditional, Complementary and Alternative Medicine (TCAM), as revealed by the Honourable Minister of State for Health. He added that the Ministerial Committee on Herbal, Complementary and Alternative Medicines had developed curriculum for Training Herbal Medical Practitioners in Medical Schools; introduction of traditional medicine modules into medical and nursing students training curriculum; expansion of pharmacy students training in traditional medicine.

In June 2017, the Centre for Research in Traditional, Complementary and Alternative Medicine was established in the Nigerian Institute of Medical Research, Yaba, Lagos.

The Centre, which aims to support the WHO programme of integrating Traditional medical practice into public healthcare in Nigeria and around the globe, is to among other activities, provide training of orthodox (medical doctors and nurses) and healthcare workers on the role of traditional medicine in health care delivery to the population.

It is instructive therefore that the Universities offering the BMLS education programme in conjunction with the Medical Laboratory Council of Nigeria should proactively think of possible ways to incorporate and impart this essential body of knowledge to medical laboratory scientists.
Evidence-based healthcare practice

Sackett et al (1996) defined Evidence-based Medicine as “the conscientious, judicious, and explicit use of the best evidence in making decisions about the care of individual patients.”

Evidence-based medical Laboratory practice could be defined as “ensuring that the best evidence on testing is made available, and the clinician is assisted in using the best evidence to ensure that the best decisions are made about the care of individual patients to lead to increased probability of improved health outcomes.”
“The revised and improved definition of evidence-based medicine (EBM) is: a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values; or a conscious, specific and reasonable use of modern best evidence in making decisions about treatment of individual patients.” (Eddy 2005)

The appropriate application of Evidence-based Medicine ensures cost-effective and better healthcare. It is used to prevent mistakes in the treatment of patients, and enhances the quality of health service provided to the patient. The integration of clinical expertise, patient values and the best research evidence into the decision-making process for patient care has been referred to as Evidence-Based Practice (EBP). The full integration of these three concepts into clinical decision has been shown to enhance the opportunity for optimal clinical outcomes and quality of life.

The Scientific Revolution in Healthcare Delivery

The tools of science and technology have revolutionized healthcare practice. Medical laboratory science is a profession endowed with the mandate of applying the methods of experimentation, enquiry and observation for diagnostic and therapeutic accuracy by the medical practitioner. The tools of laboratory analysis and the methods of using them reside at the frontiers of knowledge and so they are always changing and moving forward.

Medical laboratory science provides over 70% of the empirical data that constitute the evidence in modern healthcare practice. The medical Laboratory Scientist must therefore subject himself/herself to continual formal and informal professional education and the pursuit of excellence in practice.

As lawyers would say, cases are won or lost in the chambers; similarly, to a great extent, the fight against diseases is won or lost in the medical laboratory. This requires men and women who will always strive to be at the cutting-edge of professional knowledge. Research has shown that knowledge doubles every seven years; it therefore means that in three and half years, one will be 50% outdated if not continuously engaged in study in their discipline and area of practice.

Professional practice is a knowledge-based occupation. To remain relevant as a professional, one needs to imbibe the spirit of new technology and continuous professional education to constantly upgrade the standard of practice. You should read journals and magazines; develop the habit of efficient literature searching, attend workshops and conferences to remain current. The tools of biotechnology and molecular diagnostics have opened new possibilities in disease diagnosis, management and therapy. We should take advantage of these developments to foster the culture of excellence in healthcare practice Nigeria.
Modern Healthcare practice

Modern patient care and healthcare practice have grown beyond the training and competence of any single professional group. It is a teamwork involving many healthcare professions. Working together means acknowledging that all participants bring equally valid knowledge and expertise from their professional and personal experience. Affirmations, acknowledgements and recognition are important in a team. The questions and challenges that arise from the differences in teamwork are vital. A diverse group can arrive at a place no individual and no like-minded group can reach. The era when healthcare practice was a one-man or mono-professional venture is gone and gone forever. Anybody striving to re-enact or sustain prehistoric healthcare practice in Nigeria is not only insulting the sensibilities of other health professions and the Nigerian public, but indeed turning backward the hand of the clock.

This mindset of doing it alone and be-all and end-all in the Nigerian health sector is militating against the benefit and gains of integration, making the cost of health service beyond the reach of a majority of our population.

Professional Partnership in Healthcare Delivery

The UK National Institute for Clinical Excellence advocates for a collaborative model. It acknowledges that no one who works alone can stay at the forefront of knowledge given the speed of organizational, clinical and scientific change. It acknowledges that change is a constant factor in human existence.

“Change is the law of life, those who focus only on the past and the present are certain to miss the future” …. John F. Kennedy.

“The doctor-father, nurse-mother, patient-child and others-servants’ mentality in healthcare delivery has proved a colossal failure. Our hope for total wisdom and protection from father is forlorn, our wish for total comfort and protection from mother unachievable, and the patient has grown up” said R. Smith. “A new three-way partnership should displace this vanishing family mentality” Smith argues.

Healthcare professionals working as a team with others have the skills to unlock important medical information that is pivotal to the diagnosis, treatment and prevention of disease. There is no reason we should not work harmoniously with physicians, pathologists, surgeons, physiotherapists, radiographers, dieticians and nurses in the overall interest of the patient. The relationship and roles should be complementary to each other in an atmosphere of mutual respect and reciprocity.

Let me in concluding speak particularly to the fresh graduates being inducted today.
Dedication to Service and Dignified Comportment

By the MLSCN professional oath and code of conduct:

“I solemnly pledge myself to the service of humanity as a Medical Laboratory Scientist”. Through this pledge you owe the patient, the clinician and the public a great deal of obligation in the hospital community. By its very nature, modern healthcare practice is a team work. It requires team spirit in an atmosphere of mutual respect and reciprocity. When professional elephants fight in the field of healthcare service, innocent patients and society suffer. The increasing tendency to seek medical attention in India, Europe, South Africa and Egypt by Nigerians should arouse our curiosity and concern. Despite our immense human and material endowments in Nigeria, we are yet to get it right in our healthcare system. We need to constantly nurture and cultivate the attitude of inter-professional and inter-personal cooperation and collaboration in healthcare practice in Nigeria.

Honesty, Objectivity, Incorruptibility and Confidentiality.

By its nature, laboratory testing is done behind closed doors, away from the prying eyes of patients, their doctors and relations. Ordinarily, this raises some questions or doubts in the mind of patients and doctors viz: Are the tests being done with sufficient care? Are the people honest enough in reporting what they have discovered? Do they have the required skill and wherewithal to give a reliable and accurate result?

You surely need to cultivate a good dose of these qualities to make a successful medical laboratory Scientist worthy of trust by patients, clinicians and the public.

Let me congratulate you on the choice of this topic for discussion. Let me urge and wish our young graduates a stimulating and fulfilling career in medical laboratory practice.

I urge you to take it very seriously, and ensure that you become a ‘polyvalent’ and ‘multi-competent’ Medical Laboratory Scientist through a commitment to a life-long personal character development, professional education and self-improvement.

Dr. Okara delivered the paper at the induction ceremony of 2017/2018 medical laboratory science graduates, University of Benin, Benn City, recently.

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