A tangled web: the complicated ethics of medical referrals from Nigeria to India

This thought-provoking piece was contributed by Ifeanyi Nsofor who has just joined the NHW team. Pls share it with every one you know….its worth thinking about before you need to think about it.  Please share your perspective on the comments section or by tweeting us @nighealthwatch 

Our beautiful daughter was born in August 2009 and weighed 3.4kg. No abnormalities were discovered at birth. However, at 4 weeks of age, we noticed bluish discoloration of her inner lips, sweating while breastfeeding, poor feeding, weight loss and failure to thrive. After a series of investigations which included echocardiography, it seemed certain that she had been born with congenital heart defects (“holes in the heart”). However, we received conflicting diagnoses from a tertiary medical centre and a private diagnostic centre both in Abuja. To say we were worried would be the understatement of the century!! Subsequently, the Paediatric Cardiologist at the government tertiary medical centre in Abuja referred our daughter to MIOT hospital, Chennai, India. At MIOT, the definitive diagnosis was different from both diagnoses we received in Nigeria. The Indian Paediatric Cardiac Surgeon successfully performed an Arterial Switch Operation which closed the defects. Our daughter is now fine and her energy sometimes makes me wonder if perhaps she was given two hearts in India.

Red Fort, Delhi, India. Photograph: Ifeanyi Nsofor

I am sharing my family’s medical challenge to demonstrate our experience of Nigeria’s fast growing medical tourism to India industry. Over the last few years, medical facilities in India have become increasingly aggressive in marketing their services to clients across the globe. The dearth of standard healthcare facilities/services, the poor governance of clinical practice and the lack of confidence of the people in the care available in Nigeria makes it a ready market for Indian hospital groups. The Indian economy benefits not just from the cost of the healthcare provided but also the ancillary services of accommodation and welfare of accompanying relatives. The Nigerian Medical Association estimates that over 5000 Nigerians travel to India and other countries monthly for medical treatment leading to capital flight of $500 million annually. It’s anyone’s guess the impact an annual investment of $500 million would have on Nigeria’s healthcare industry. To put it in perspective, that sum was approximately a third of Nigeria’s entire federal health budget for 2013.

The aggression in marketing medical tourism to India, targeting Nigerian doctors has more recently taken on a worrying dimension. While in the past, many Indian healthcare facilities had focused on advertising discreetly to Nigerian doctors and directly to Nigerian patients in the newspapers, a more ethically dubious model is emerging. It is time to question the ethics and economics of this type of marketing and its impact on the Nigerian healthcare industry. For example, an Indian medical group openly operates an incentive-based patient referral program. This program promises earnings of “$1000 by simply referring patients” and “10% referral fee when patient’s trip to India is finalized”. It implies that for a patient whose medical procedure costs $10,000, the referring Doctor will receive a “commission” of $2,000 just for the referral, creating a perverse incentive. That is a huge amount in a country where Doctors’ salaries are abysmally low. With this kind of incentive, what is to stop unethical doctors from referring their patients to India even when such an action is unnecessary or sometimes potentially harmful?

There have also been anecdotal reports of Indian hospitals coming to Nigeria directly to solicit for patients through their own clinics and facilities set up largely for that sole purpose.

Kanchi Kamakoti Medical Trust Natraj Hospital, Coimbatore, Tamil Nadu, India. Photograph: Ifeanyi Nsofor

Economically, for patients and their families, paying for treatment in India does not come cheap. Nine of every 10 Nigerians survive on less than US$2 a day, it is not surprising that most people have to seek significant cash donations and loans in order to pay for medical treatment in India. Even, as a doctor myself; my wife and I still had to take loans amounting to thousands of dollars from both of our employers to pay for our daughter’s surgery.

In my case, and for several other Nigerians that have successfully raised the funds for medical treatment in India, this has been life-saving.

However there are several questions that arise; is it ethical for Indian hospital groups to market health services this way through Nigerian doctors? Is it legal for Nigerian doctors to accept financial incentives for referral without declaring this to their patients? Is it fair that Nigerian Doctors/hospital groups are not allowed to advertise their services locally while their counterparts from India brazenly do so? These questions are for Nigerian health regulatory agencies to provide answers to. Nigeria’s health industry should be properly regulated and hapless patients adequately protected. The Minister of Health, Professor Onyebuchi Chukwu has advocated for the Medical and Dental Council of Nigeria (MDCN) to allow medical practitioners to advertise their services. He was of the opinion that the prohibition of advertisement by the MDCN is responsible for the increase in medical tourism in the country.

However, the biggest question is why the Nigerian healthcare sector is not responding rapidly enough to the huge demand for high quality, well managed, ethical and financially sustainable medical services.

For a long tim
e, governments at all levels in Nigeria have failed to implement policies to drive the improvement of health services. Despite the often acclaimed projects to equip hospitals, very little has changed and there is little confidence in health care services offered in Nigeria. Even in the private sector, the story is not much different. It is time for some game changing investments in the Nigerian health industry. Investors can take a cue from Africa’s richest man, Aliko Dangote, who is investing in the construction of a 1000-bed ultra-modern hospital in Kano State. He should be encouraged to make the proposed hospital a centre of excellence focusing on few specialties. Kano could as well become a medical tourism destination; patients from other parts of Nigeria, the West African sub-region and Africa as a whole should benefit from the hospital if it is well organised and equipped. In starting off, he must learn from previous attempts to set up ultra-modern hospitals in Nigeria and understand why they failed

While the equipment and clinical expertise may appear like a tough problem to solve, they are actually the relatively easy ones. Until we find a financial model that works for the poor and the middle class, one not based on a fee-for-service model, it is unlikely that any investment in the health sector will be sustainable. Strengthening primary care and efforts at prevention will also be essential.

Nigeria is now the largest economy and has the largest population in Africa. These positives should translate into better healthcare for all Nigerians. We really have no business travelling thousands of miles to India for healthcare. For us at Nigeria Health Watch – We will celebrate when Nigeria becomes a health tourism destination. Until then….there’s work to be done!


Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

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