The Legal Rights and Challenges of COVID-19 Patients Accessing Private Healthcare in Nigeria

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It is no news that the first case of the COVID-19 outbreak in Nigeria was confirmed by the Nigeria Centre for Disease Control (NCDC) on February 27, 2020, at the Lagos State Teaching Hospital. 4 The case involved an Italian citizen who returned to work in Nigeria from his home country through the Murtala Muhammed International Airport in Lagos State. Upon this discovery, NCDC, the Federal Agency with the mandate to protect Nigerians from the Impact of communicable disease, swung into action and started contact tracing of persons likely to have had contact with the carrier. In confirming the index case in the country, NCDC, in a notice issued on Friday, February 28, 2020, assured Nigerians of their preparedness to tackle and curtail the pandemic. 5 Unfortunately, despite these assurances, the cases had increased tremendously from a single imported case to multiple imported cases arising from community transmission in several parts of the country. The inability to curtail the COVID-19 virus is attributed to a failure to initiate active measures to curb the spread of the virus. 6 Given the threat of the spread of the COVID-19 virus, the Nigerian government placed a ban on international flights, especially from highly affected countries. Furthermore, Nigeria also initiated a lockdown procedure, particularly in Lagos State, Ogun State, and Abuja. Despite these measures taken to curtail the COVID-19 virus, there is still widespread transmission of the virus among Nigerian citizens, and this has further overwhelmed the Nigerian public health care provider. 7 However, like in other pandemics, the COVID-19 pandemic has provided yet another challenge for the public health care system in providing the required care for the surge of infected patients. This problem is further compounded by the dearth of medical personnel in the country and the shortage of hospital resources such as bed spaces, ventilators, and isolation centers. 8 It must be noted that Nigeria, like many other countries, practices a heterogeneous health care system, whereby both the public and private health care providers are permitted to operate freely within the ambit of the medical codes and guidelines. In this regard, the inadequacies of public health care services necessitate the 3 Darlingtina Esiaka and others, 'Perceived Risk of COVID-19 Diagnosis and Stigma among Nigerians', Scientific African, 18 (2022) need for private sector participation in pandemic health care delivery. 9 However, despite the glaring necessity for their involvement and their supplementary role in health care delivery in the country, the participation of the private hospitals in caring for COVID-19 patients has been subjected to some legal and regulatory restraints initiated by the government. 10 Nigeria is known for having several noble policies, yet only little is done to truly put them into practice. There is no disputing that Nigeria prefers to tackle problems with a firebrigade mentality. This stance was confirmed and demonstrated by the onset of the COVID-19 pandemic, a pandemic that affected the entire world. Certainly, the COVID-19 epidemic came as a surprise to the entire world. 11 All societies and nations were affected both economically and agriculturally by the lockdowns. Although commendable, the emergency measures taken by the Nigerian government to limit the damage are insufficient. Concerning the above, it suffices to opine that where the public healthcare system or facilities are said to be inadequate, is it right or justifiable to limit the patient of COVID-19's access to a private healthcare center. 12 Furthermore, isn't it every Nigerian's right to choose the type of healthcare system he or she will visit with their health problem (such as the COVID-19)? In this regard, it is apt to state that the continuing legal restriction on the private healthcare provider from providing and caring for COVID-19 patients will, to an extent, infringe on the rights of citizens of Nigeria and overwhelm the public healthcare facilities. 13 Hence, this study tends to adopt a hybrid method of research in examining legal constraints and ethical issues concerning the care of COVID-19 patients by private healthcare. 14 Furthermore, the study will also examine the right of a COVID-19 patient to access better or private healthcare facilities for better and proper medical treatment. The study will further recommend possible ways to resolve the legal constraints placed on private healthcare providers in caring for COVID-19 patients.

Research Method
The global devastation caused by the current COVID-19 pandemic, the study investigates some of the legal and ethical issues surrounding the care of COVID-19 9 Oluwasinaayomi Faith Kasim and others, 'Household Waste Generation, Change in Waste Composition and the Exposure to COVID-19 in Guyana and Nigeria', Scientific African, 14 (2021) ISSN 2722-4708 Vol. 10, No. 2, December 2022 Paul Atagamen Aidonojie et.al (The Legal Rights and Challenges…) patients in Nigeria's private health care provider. 15 In this regard, the researchers employ a hybrid research method that involves both doctrinal and empirical research methods. The doctrinal research method enables the researchers to critically examine and analyze relevant laws and literature related to the care of COVID-19 patients in Nigeria. The examination of the laws as they concern the care of COVID-19 patients will enable the researchers to spot some pertinent legal and ethical issues as they affect the private hospital care of COVID-19 patients. 16 However, suffice it to state that the researchers also used the empirical method to gather and collate extensive data with online (Google Forms, given the current social distance of COVID-19 pandemic policy) questionnaire surveys. 17 The researchers use a descriptive and analytical approach to statistically, numerically, and mathematically analyze the data obtained via the online survey questionnaire. The researchers' use of an empirical research method is aimed at ascertaining how sufficient the facilities are for the care of COVID-19 patients in Nigeria, given the legal limitation on a private health care provider's ability to care for COVID-19 patients in Nigeria. 18 Furthermore, it will also enable the researcher to arrive at a better solution in determining which private health care provider would be best suited to embark on the care of COVID-19 patients in Nigeria. 19

Regulation and Ethical Issues Concerning Private Healthcare Providers Caring
Several medical bodies regulate the affairs of private health care providers in Nigeria. One such body is the National Council on Health (NCE), which is the highest policy-making body in Nigeria on matters relating to health. It consists of the Minister for Health as Chairman, Commissioners for Health, and the Permanent Secretary of the Federal Ministry of Health in Nigeria. 20 He is also the secretary of the council. The primary function of the NCE is to coordinate health services rendered by the federal ministry with those rendered by the state, local governments, wards, private health care providers, etc. Part of its responsibility is to facilitate and effectively promote the provision of health services.  ISSN 2722-4708 Vol. 10, No. 2, December 2022 Paul Atagamen Aidonojie et.al (The Legal Rights and Challenges…) The NCE also has the responsibility to manage, prevent, and control communicable and noncommunicable diseases. Another body with a supervisory role is the State Ministries of Health, and they are responsible for licensing and monitoring private health care facilities to ensure they comply with the standard. It is worthy of note that professional associations like the Nigeria Medical Association are voluntary bodies of medical practitioners with no formal role in regulating the medical profession; at best, they are pressure groups set up for the welfare of their members. 22 However, it must be noted that the National Health Act was enacted to ensure effective regulation, management, and development of Nigeria's national health system. The Act set standards and measures for rendering health services (public and private) in the country. According to the provisions of the Act, the National Health System is made up of both public and private health care service providers. The public and private health care providers are responsible for health care delivery in Nigeria. 23 However, under this arrangement, the Federal Ministry of Health is empowered to ensure national health policy development, coordinate health and medical service delivery during a national crisis, and issue guidelines for its implementation. To this end, the NCDC, through its guidelines, restricted the treatment and monitoring of COVID-19 patients to government-owned or public hospitals. In contrast, the private hospitals were initially directed not to admit nor care for COVID-19 patients but to isolate the patients who are confirmed carriers pending the arrival of the accredited public health workers. 24 The Association of General and Private Medical Practitioners of Nigeria (AGPMPN), the umbrella body or organization for all private health care providers, has condemned the government directive, viewed it as an infraction on their rights under the NHA, and requested that the government allow it to care for the COVID-19 patients. 25 According to them, the private practitioners are not less qualified than their counterparts in the public sector; moreover, they are of the opinion that since the public and private health care service providers are recognized under the NHA, the barrier created by the Minister of Health is not necessary. 26 Another potent argument against the government directive is that private hospitals are usually the first point of contact with all kinds of patients. Furthermore, it was also argued that it is not unusual to see ill people going to their doctor for a check-up in private health care services. Although the government repeatedly informed the public that those with the symptom should call the health line, many prefer to visit private doctors for treatment. 27 Given the shortage of bed spaces in Nigeria's public hospitals at this critical time, suffice it to say that there is a need for the participation of more health practitioners during this national crisis. In this regard, the call by the private practitioners for the management of the COVID-19 patient appears rational. 28 Many, especially the NMA, had vehemently opposed the idea of integrating private practitioners, principally because of the concern that the private hospitals lacked the capacity for proper surveillance and infection control. It is also commonly believed that private practitioners may have difficulty adhering to certain ethical codes in the process of managing their patients. 29 Moreover, there are also the ethical issues of commercializing the entire process or the possibility of violating the reporting codes of the treatment procedures, which could create gaps in information sharing between the private practitioners and the regulators. For instance, the family of a rich patient who may not want to make public the family member's status because of the stigma that it may bring may induce the private health care establishment to falsify or manipulate the records. Accordingly, the NMA may account for the missing links to community transmission in the country. These constitute the major reason for distrust between the public and private actors and have limited the participation of the private sectors at this crucial moment of national crisis. 30

The Right of the COVID-19 Patient
The Nigeria National Health Act is legislation that provides for the protection of the rights of patients as well as medical personnel. The Act emphasized the responsibility of the health establishment to ensure that the appropriate conditions for the service to be rendered are based on the status of the patient. 31 This, of course, is subject to the overriding guidelines determined by the Minister, Commissioner, or any other appropriate authority as stipulated by Section 21 of the National Health Act. To that extent, a private hospital must abide by the government's health policy and measures to curb the transmission of the COVID-19 pandemic. 32 It suffices to state that the principal objective of health care providers is to promote the patient's health. In addition, rule 19 of the Medical and Dental Practitioner Rules states that health care practitioners are responsible for promoting not only individual health but also community health. It suffices to state that there is a need to permit private health practitioners to care for COVID-19 patients. 33 Furthermore, it must be noted that it is a patient's right to be adequately cared for by a health care practitioner. As a result, any patient who visits a health establishment for the purpose of 28 ISSN 2722-4708 Vol. 10, No. 2, December 2022 Paul Atagamen Aidonojie et.al (The Legal Rights and Challenges…) receiving health services is unaware of their health status as a carrier of the COVID-19 virus, and the health establishment is aware that it is unable to provide the necessary treatment or care; thus, the prevailing restriction. By Section 17 of the National Health Act, it is required that a health care provider refer such a patient to the appropriate health care provider for the necessary care and treatment. 34 The failure of private health establishments to ensure proper care for COVID-19 patients is a clear violation of the rights of the patient protected by Section 18 of the National Health Act and Section 34 of the Nigerian Constitution, which protects its citizens from degrading, torturous, and inhuman treatment. 35 The code provides that in dealing with a hazardous or contagious ailment, the practitioner should not discriminate in handling and treating such patients and must maintain appropriate confidentiality. It is further provided that practitioners should ensure that they are not used as agents by employers or others to deny infected patients their jobs where there is no clinical indication for removing such employees from their jobs. 36

Legal Impediments for a Private Health Care Provider Caring for a COVID-19 Patient
In some third-world countries, there exists a two-tier health care delivery system that includes a public and private health service. Like other jurisdictions where the private sector plays a complimentary role to the public service provider, the Nigeria case is not different due to its heterogeneous health care delivery system. Although the private sector seems to be a dominant source of health care providers, however, a private health system in Nigeria has not been fully integrated into the national pandemic response due to some legal and regulatory restraint by the regulators of the health sector. 37 This is concerning the fact that in the wake of the COVID 19 Pandemic in Nigeria, the Nigerian government, according to its power under Sections 2, 3, and 4 of the Quarantine Act, made the COVID-19 Regulation 2020. The Nigerian government's efforts to contain the COVID-19 pandemic included, among other things, limiting or prohibiting movement in most Nigerian states. 38 The regulation also required that cases of COVID-19 be reported to any branch of the National Center for Disease Control. In this regard, private health care providers are expected to report to the NCDC branch nearest to them when it is suspected that any of their patients are suffering from the COVID-19 virus. This, to an extent, serves as a legal impediment and creates conundrums that amputate a private health care provider's ability to care for a COVID-19 patient. 39 34 Basiem Al-Shattarat and Yusuff Jelili Amuda, 'Comparative Report of Compliance to Precautionary Measures against COVID-19 in Nigeria and Jordan ', Heliyon, 7.8 (2021) ISSN 2722-4708 Vol. 10, No. 2, December 2022 Paul Atagamen Aidonojie et.al (The Legal Rights and Challenges…) The paragraph 27 of the Coronal Virus Disease (COVID-19) Health Protection Regulation provides that where an individual is confirmed to be infected with COVID-19, the affected person cannot refuse to be isolated in a designated government-owned isolation center for management and disease control. However, an examination of paragraph 30 of the COVID-19 Regulation (the provision of paragraph 30 of the 2021 COVID-19 Regulation is similar to the provision of section 13(2) of the Infectious Disease Act) seems to portray the fact that an individual infected with COVID-19 could make a private arrangement to be isolated. The purport of paragraph 30 of the 2021 COVID-19 regulation provides. 40 the paragraph 30 of the 2021 COVID-19 Regulation specifies some modalities that allow for the care of COVID-19 patients by a private health care provider. However, a careful examination of the provision of paragraph 30 reveals that the modalities to be observed in privately caring for a COVID-19 patient are in reference to a private arrangement made by a person who is infected with COVID-19. 41 Furthermore, a plain and ordinary interpretation of the COVID-19 regulation for 2021 and 2020 reveals that it did not expressly mention private health care providers (private hospitals) as one of the medical bodies responsible for caring for COVID-19 patients. In this regard, there are no provisions, guidelines, or modalities in the COVID-19 Regulations that permit a private health care provider to care for a COVID-19 patient. 42 However, it must be noted that Section 20 of the National Health Act provides that in times of emergency, a private health care provider is not expected to refuse to care for a patient, especially where emergency medical treatment is required. In this regard, a private health care provider may find a defense under this provision to give the necessary attention to the patient. 43 This to be available to a private health care provider, Section 4(6) of the Infectious Disease Control Act provides that they must show that the said patient was actually in need of urgent medical treatment, although his status as a carrier of an infectious disease was unknown to him when rendering medical care. 44 The data presented indicate that most of the respondents who responded to the questionnaire reside or live in various states of the Federal Republic of Nigeria. In this regard, justify the scope and focus of the study, which is meant to examine the legal challenges and ethical issues concerning the care of COVID-19 patients by private healthcare providers in Nigeria. 45 However, given the fact that the majority of the individuals are yet to accept the truth of the existence of BESTUUR ISSN 2722-4708 Vol. 10, No. 2, December 2022 Paul Atagamen Aidonojie et.al (The Legal Rights and Challenges…) COVID-19, research question two was aimed at ascertaining whether the respondents are aware of reported cases of COVID-19 in Nigeria. In this regard, Figure 2 and Table 2 further reveal that 83% of the respondents, which represent most of the respondents, agreed that they are aware of the reported cases of  The reported cases of COVID-19 in Nigeria, several laws and policies were enacted to curtail the COVID-19 disease in Nigeria. In this regard, only a Nigerian governmentestablished medical team and isolation center were required to manage a COVID-19 patient. In this regard, research question three was aimed at ascertaining if the isolation center and medical facilities were sufficient enough to care for COVID-19 patients. A majority of 67.1% (210 respondents), as represented in Figure 3 and Table 3, responded "No." The respondents' responses, as depicted in Figure 3 and Table 3, are not contradictory to what is obtainable concerning the care of COVID-19 patients in Nigeria. This is concerning given that the Nigerian COVID-19 regulations stipulate that Nigerian citizens should endeavor to keep social distance and ensure precautionary health safety by not contacting COVID-19 as there are inadequate medical facilities to care for COVID-19 patients. 47 The respondents further identify some of the medical facilities that are inadequate for the care of COVID-19 patients in the government's isolation center. 83.5%, 78.1%, and 81.4% identify insufficient and conducive isolation centers for COVID-19 patients, inadequate bed space for COVID-19 patients, and a lack of oxygen facilities, respectively, as medical facilities that were not adequately provided for in the care of COVID-19 patients in Nigeria. Furthermore, 59.9% and 34.3% identify COVID-19 medical drugs for patient treatment, respectively, and food supplements to boost COVID-19 patient immune system are insufficient for COVID-19 patient care. 48 The inadequate medical facilities and isolation center identified in date of respondents, as represented, agreed that the Nigerian government's prohibition on private healthcare providers caring for COVID-19 patients is legally unfair. This is a result of the inadequate medical facilities and isolation provided by the government. In this regard, 76.8% (241 respondents), as presented in Figure 6 and Table 6, further agreed that private healthcare providers should be legally licensed to cater for COVID-19 patients with certain requirements. This is concerning because the respondents are very much aware that most private healthcare providers in Nigeria also have trained medical personnel who could run a functional isolation center to care for COVID-19 patients, reducing the responsibility placed on the government to curtail the COVID-19 infection. 49 The given of numerous medical facilities and trained medical personnel available at a private healthcare provider, most politicians and elites in Nigeria who have contracted COVID-19 prefer to 46  BESTUUR ISSN 2722-4708 Vol. 10, No. 2, December 2022 Paul Atagamen Aidonojie et.al (The Legal Rights and Challenges…) access private healthcare providers rather than isolation centers. However, it represents some of the possible requirements a private hospital must fulfill before they can be licensed to care for a COVID-19 patient. In this regard, 79.3% and 73.3% of the respondents agreed that private medical practitioners must seek to collaborate with the government medical team in the care of COVID-19 patients and must sign an undertaking to keep to medical ethics and standards in caring for  Furthermore, 76.1% and 67.3% also agreed that private healthcare providers must possess the requisite medical facilities to care for COVID-19 patients and their medical personnel must be trained and possess the requisite medical skill for handling COVID-19 patients. From the above findings, it suffices to state that curtailing an infectious (such as COVID-19) disease in Nigeria cannot be solved by the government alone. In this regard, the Nigerian government must relax laws limiting competent private healthcare providers from curtailing infectious diseases such as COVID-19.

Conclusion
Based on the explanation above, it can be concluded that outbreak of the COVID-19 pandemic has thrown the global environment into a health crisis and catastrophe. However, the study also observed that the first index case of COVID-19 in Nigeria was recorded on February 27, 2020, at the Lagos State Teaching Hospital. In this regard, the Nigerian government, in its effort to curtail the COVID-19 pandemic, initiated a total lockdown in most of the states in Nigeria. Furthermore, there was a suspension of business and passenger aircraft, both commercial and private. Despite these measures, one of the challenges that has undermined the control and prevention of COVID-19 in Nigeria has been the issue of poor compliance by Nigerian citizens. In further response to the pandemic, the Nigerian government, pursuant to its enabling power in Sections 2, 3, and 4 of the Quarantine Act [1], made the COVID-19 Regulation in 2020 and 2021. These regulations and legal frameworks concerning infectious diseases such as COVID-19 tend to limit the participation of private health care providers in caring for COVID-19 patients. The study also discovered that, despite the measures taken to combat the COVID-19 virus, the virus remains widespread among Nigerians, further taxing the Nigerian public healthcare system.