Thursday, 29 May 2008
Today is the 29th of May.
In Nigeria it is called "Democracy Day" and celebrated by 140 million Nigerians staying at home.
While June 12 is still fondly remembered and celebrated by most Nigerians as the day we conducted our most successful election to date...we are all forced to celebrate the 29th of May, the day the military finally handed over the reigns of governance in Nigeria to Olusegun Obasanjo. Today is exactly one year he handed over to Umaru Yar'Adua, our incumbent President.
We should all be celebrating...
...but sadly there is nothing much to celebrate. Our country is in perpetual darkness, our roads are worse than ever and security of lives and property has never been worse...all in an era of crude-at-$130-per-barrel
...there is nothing to celebrate... more so in the health sector...therefore this short blog will carry a special appeal.
Dear Mr President give us a Minister of Health that we deserve!
You know from your own experiences how important health is....often not valued by many until it is lost.
Sir, please give us a leader with vision, integrity, competence, drive and purpose....with clear developmental objectives for the health sector.
We inherited a health care system from the British after our independence and have adapted this piece-meal over the years. The British National Health Service (NHS), on which ours was modelled, has undergone great change over the years. Profound thinking and strategising by policy makers precede each change to the system. Elections are won and lost on health issues and Margaret Thatcher’s failed market reforms in the NHS were one of the most significant factors that brought down her Government. While we are not attempting to compare these two countries, this government owes it to the people to have clear-cut health related goals on where it wants to take us to in terms of health care.
Jeffrey Sachs, world renowned economist and Special Adviser to the General Secretary of the United Nations in his report commissioned by the World Health Organization a few years ago made the landmark link between macro economics and health, when he and his colleagues showed that paying attention to population health was not merely of altruistic value but also in the interest of national and global economic development. The bottom line of the Commission’s report is that it makes economic sense to invest in health.
The Federal Ministry of Health will need to provide strategic, progressive leadership.
- A leadership that is willing to discard failed and tired structures, systems and indeed individuals. A leadership that is willing and able to maximize and harness all the resources that come the country’s way through this ministry; one that can manage and direct these in a planned and structured way with the best interest of all Nigerians as its ultimate goal. A leadership that is willing to set targets for itself, is ready to communicate these targets to the general public and willing to be held to account on its own targets.
Sir, please give us a Minister of Health. One with vision, integrity, competence, drive and purpose...
Tuesday, 27 May 2008
Gushing with excitement I called one of my colleagues at one of our tertiary hospitals to learn more about this bill from the horse’s mouth……. “I really do not know much about this thing” ...was his response.
That took the air out of my sail. I was already dreaming about calling all my relatives in Nigeria and letting them know about this great step forward for our health system and how they can be a part of it, buying into, contributing, just to be part of it.
Can someone tell me how this bill came to life when the major stakeholders “do not know much about this thing”...
What was it we said about collective ownership and collective effort...how do we "sell" this bill to our beloved patients if we “do not know much about this thing”
The Bill is supposed regulate, develop and manage our national health system amongst other lofty goals. What is the role of the Nigerian Medical Association (I just paid up my dues up till 2011)? What is the role of our hardworking doctors, nurses, physiotherapists, and other medical personnel? What are the roles of other leaders in the health arena. What is the role of the Ministry of Health? The House Committee on health? The commisioners of health in our states....
To ensure a better deal for our patients, that this bill is properly implemented, we all have a role. Health leaders, the NMA and all other health/medical professional associations and every one involved in the health care sector in Nigeria will have to step up to the plate if there is any benefit to be derived from the health bill…and NOW!
We will all have to pull together!
Why are we not all celebrating this bill? Can it be because very few people know about its contents? Very few know about the implications for thier health and health care? Very few know how it will affect thier lives...Very few..even among those that absolutely should know!
If our patients are going to gain from this bill, then we should quit viewing it as just a government thing, we should claim ownership and make sure we get the required purchase from all our long suffering patients.
We are not there yet, but we are on our way, I can see more hurdles on the way, but together we can make this work.
Else...all it will be is a piece of paper...The National Health Bill of 2008!
Sunday, 18 May 2008
We have blogged severally about how this bill has been stalled and its effect on the delivery of health and health care in Nigeria.
Problems of our health care "system"....
Primary Health Care ...the entry point into health services and most crucial for population health is in the hands off the weakest level of governance in Nigeria - The Local Governments. ...So it did not really matter how many clinics the National Primary Health Care Development Agency built...once they were handed over to the Local Governments....well they remained empty buildings.So what does the new bill do?
There is no legistlation describing the national health "system", and defining the roles and responsibilities of the three tiers of government, and other stakeholders in the system.
Each Federal Medical Centre/Teaching Hospital is its own fiefdom...with huge budgets...and little management structures.
The private sector...is out of all formal loops....
- Regulation, development and management of the national health system with primary health care as the entry point.
- A National Tertiary Hospitals Commission with the responsibility of advising the President through the office of the Minister of Health on issues concerning teaching hospitals in the country.
- A Primary Healthcare Development Fund that will apparently provide basic health care to as many as possible through the National Health Insurance Scheme. The fund is to be administered by the National Primary Health Care Development Agency (NPHCDA).
We do not have a Minister of Health....so not sure who will lead...
The Chairman of the Committee on Health is on the run....so not sure who will monitor...
And with the history, the National Primary Health Care Development Agency (NPHCDA) in implementing anything (they are responsible for immunising our children (not)) ...not sure who will implement...
But we remain hopeful....thats one thing we have a lot of in Nigeria.
Monday, 12 May 2008
Letter to the Inspector-General of the Nigerian Police Force, Sir (Dr.) Mike Mbama Okiro CFR, NPM, mni, following the death of CP Haz Iwendi
It is with a heavy heart, but total submission to the Almighty that we write to express our heartfelt sympathy over the sudden death of the Comissioner of Police for Kaduna State, Haz Iwendi. The papers variously report that he died following a massive heart attack or a stroke depending on which newspaper one reads....but we know he collapsed and and was rushed to the Ahmadu Bello Teaching Hospital (ABUTH), Shika, Zaria.
Dear IG, like you, we all have fond memories of Haz Iwendi as he tried doing the impossible in improving the image of the Nigerian Police Force in his role as public relations officer. The biggest paradox of his era was that your former colleague and boss, then Inspector General, Tafa Balogun was himself tried and jailed for six months for allegedly stealing millions of dollars in state funds. Try improving that image!
Dear IG, we thank you for rushing to the scene as a true officer would. Your pain was obvious. You are quoted to have initially made this statement as reported in The Guardian which no doubt showed your confidence about the way we do things in our great country:
Dear IG, you see...with matters regarding health...all those things we hold dear in our country are often worthless. Yes...there are things even money and contacts cannot get you...even in Nigeria! However Sir, what really caught our attention was your follow-up statement as reported by Thisday Newspapers on the 7th of May.
"...Henceforth, ACPs, Deputy Commissioners (DCs) Commissioners of Police (CPs), Assistant Inspectors- General (AIGs) and Deputy Inspectors- General (DIGs) must go for annual medical check up abroad, to certify their health status."
Dear IG, while we are not in doubt of the love you have for your colleagues and your concern for their welfare (especially those from the ACP rank)...we are worried about your indictment of our local health care services. What of our national pride: The National Hospital in Abuja? What of our finest private facilities; the Lagoon Hospital or Eko Hospital? Are none of them good enough for our esteemed Commisioners? Sir, when next you meet the new Minister of Health (who will no doubt come to you to provide protection for his family against the spate of kidnappings)...please whisper your anxiety into his ears.
Dear IG, what if something is found during these "annual medical checks"? Do we continue the management of your esteemed colleagues abroad? No doubt, this is a small price to pay with our tax-payers money for the health of those protecting our lives and property. The great job they have been doing is reported daily in our papers as exemplified here, here and here. They surely deserve the best...and of course abroad only!
Dear IG, if I may ask… what happens to the rank and file? Will it be possible for them to at least attend our General Hospitals if the Nigerian Police cannot afford the small cost of taking all 300,000 of them to Wiesbaden, Germany for annual health checks. I remember Corporal Yusuf, one of my patients during my housemanship. He was in the most feared MOPOL team. I remember him lying helplessely on our ward in the Abia State University Teaching Hospital….waiting for his family to be contacted in Kwara to come to his aid. He was shot by armed robbers in the line of duty. Sir, I cannot forget Yusuf….we lost him on a Sunday, with one colleague by his side. He was not visited by the ACPs, Deputy Commissioners (DCs) Commissioners of Police (CPs), Assistant Inspectors- General (AIGs) and Deputy Inspectors- General (DIGs). His colleagues collected money to send him home....Yusuf RIP!
Dear IG, I once visited one of your Police Clinics. I saw your men and their families waiting. I spoke to my colleague who looked helpless. He told me that medicines are supplied once a month and usually finished a week after, so in the 3 weeks interim period….patients are on their own. Sir you would not want to see the list of these medicines or the state of the clinic. But after giving Haz the burial he deserves, please make out time to pay a surprise visit to some of your own clinics.
Dear IG, I will not take any more of your time…as your work is cut out for you. But as you have seen with Haz’s death…good health is central to the work we all do. Please do not leave this matter to others. Take it up with Mr. President. His own health issues will afford you a sympathetic ear.
Dear IG, finally let me leave you with one thought. As you tour the country ensuring that we are all safe…if you had a heart attack today (yes Sir…it can happen to any of us)…what do you think will be your fate?
Take good care Sir…and check that BP! (you can do it at home too :)
Thursday, 8 May 2008
That's how long it has been estimated that it takes to develop a new habit. Some will argue that it depend on how complex the habit pattern is…agreed. No matter how long it takes, the important thing is that we can change our habits if we work hard and long at it. Are we determined to make changes in the way we live? Are we determined to use what we have learned to improve the lives of our loved ones? Are we going to be better doctors, health practitioners, nurses? Are we going to wait for the health ministries, politicians and their ilk's to bring the necessary changes that we need ..NO!
Nigeria doctors and health professional work under very difficult conditions, sometimes I wonder how people working in health care provision manage to make it through the day, no salaries, poor when they exist, inadequate continuing medical education when they exist, high patient load…which always exists. Despite all these hurdles we still need to continue changing out habits and indirectly changing the habits of our patients.
We will determine to make out more time to counsel our patients about the need to change their eating, exercise, and daily living habits. Studies have shown that patient compliance increase when health related advise comes from their physicians. We need to ask our patients to exercise more days in week, we need to talk to our patients about the need to be the vanguards of their health. Ask your patients to recite their blood pressure reading at every visit, ask your patients to tell you about their weight changes at every visit, ask about detailed smoking and drinking habits.
When you call your relatives in the village ask them if they know their blood pressure readings, if they answer no tell them to get it checked and get back to you. My uncle was telling me about his wonderful doctor and his blood pressure pills. He said that his doctor said his blood pressure was okay. True; reading for that office visit was 120/74mm of mercury. He continued so he now takes his medication "whenever he has a headache or feels somehow". It took me some minutes of detailed talk to convince him that he should really be taking those medications daily. Of course when you ask him about compliance, yes he takes his medicine regularly, and believe me he is not lying either.
Due to economic situation in most families mother have to be away from their children longer than they would have loved, this has affected breastfeeding rates. Are we communicating the results of new studies showing that breastfeeding is still the best gift mother can give to their babies?. Are we encouraging largely ignored habits like effective hand washing, by explaining the link to diarrheal diseases?
It is important to share whatever knowledge that you have. As you give your relatives the western union, money gram codes, ask them their blood pressure readings, blood sugar reading, and weights in exchange. Let's really see how long it takes to changes our habits.
Friday, 2 May 2008
The 25th of April just gone was the World Malaria day.
Round the world there was the usual awareness raising campaigns, and even some innovative new ones....as I joined thousands of others in blacking out our images on Facebook.
But I spent most of that day reflecting on my time on a paediatric ward, 12 years ago at the Abia State University Teaching Hospital in Aba, Abia State in South-Eastern Nigeria. These experiences I am sure are shared by any physician that has worked in paediatric ward in Nigeria...
In all these 12 years ...the memories have lingered of children...mostly below 5 years brought into the paediatric emergency unit with a history of fever for well over a week, almost paper white with anaemia, in the arms of some desperately poor mother at a loss as to what to do. The medical history is classic....with the onset of fever, she attends different alternative sources of health care ....often a Patent Medicine Dealer, who "mixes" a concoction of medicines. This mixture probably contains some paracetamol (which initially relieves the fever) and some antimalarials (but not in the appropriate dose). The lethal consequence is that there is some temporary relief but the parasites rebuild very quickly and destroys red blood cells...leading to acute anaemia. The heart responds to the stimulus of insufficient haemoglobin (the carrier-cells for oxygen) by pumping more rapidly...and this precipitates the features of heart failure. This is usually the point where the mother gets scared and comes to the hospital...Many times...it was too late
The race would start at this point.
With a haemoglobin level of less than 5, weak, tired,...the one measure that will save that life and buy some time for the antimalarials: blood transfusion. The poor parent who has just paid for "card", paid a deposit for admission, bought gloves for the clinicians...is now told that he/she has to go to the blood bank and get blood (obviously it has to be paid for). I remember vividly their looks of distress as they often explained that they will now have to run into town to look for any relatives that can lend them some money (this was before the mobile phone phenomenon in Nigeria).
I remember our "Blood Bank"!. The old, squeaky fridges... in a room with 2 wooden tables and chairs. I think of the rarity of our electricity supply. The epileptic existence of "HIV Kits". The hungry-looking regular blood "donors" milling around outside waiting to be paid to make their 3rd blood donation of the week!
Sometimes the father came back on time, sourced the blood, and with appropriate anti-malarials...the child would improve radically, often within a few hours. The parents will thank us profusely and go home to face their huge dept burden....They were the lucky ones. These days I hear a National Blood Bank service has been launched and the need for blood has also declined with the recent advances in antimalarial chemotherapy especially intravenous artesunate.
Many would not make it...many! Either too late, too poor or a combination. I remember their faces...of the children...and of the mothers...but especially of the fathers. Men would not normally be emotionally explicit in our culture...so it shook me to my foundations seeing these men break down and weep....weep at loss of their children and at weep at failing in their role to protect and nurture them to adulthood.
In the early days of housemanship, one was very emotional too....and ran around to help every parent, often contributing financially. But sadly...and almost inevitably the trauma was "normalised". The cries from the paediatric wards became a routine. Counselling the parents with "Ndo..., Ji si Ike, ..."...became more rhetoric than real....and as usual we took solace in the phrase "O ka Chukwu choro ya" (it was destined to happen)
The frustration of realising that there is so little one can do at the point of the paediatric emergency department was overwhelming. If a parent does not have the knowledge and tools to prevent malaria, if he cannot afford the treatment, if the medicines are fake, if the blood bank has no blood, if the doctors are on strike...what real chance does that child have? What can the father or mother do? Can you imagine the feeling?
12 years ago....I was a fresh houseofficer, full of energy and enthusiasm for the profession...and proud to be called "Doc!". The paediatric ward brought me face-to-face with the limitations of my recently acquired title. Despite all the children with malaria that died on the wards where I worked...I never quite came to understanding the pain until the past 3 years that I have spent trying to raise my own son...(things not taught in medical school).
On the 25th of April and since....I cannot help but think how we have all failed so many children. We assume that Malaria is a simple illness...and it is indeed. But only simple in the context of a well educated, resourced and organised society, which sadly we are not.
3000 children die from malaria every day world wide and a good many of them are inevitably Nigerian. Do not think of this World Malaria Day in the context of these figures...think of it in the context of your own child, brother, nephew or niece.
Next time you are going home to the village, maybe rather than buying clothes for your relatives or "dashing" them cash...load your boot with bed nets. Teach them how to use it. Yes, it is difficult in the heat (thanks to our ever epileptic power supply) and sometimes cumbersome. But compare that to the alternatives...
But maybe most importantly...join hands in holding our Ministers, and Commisoners of Health accountable.
Ask NOT how many MRI machines VAMED has installed in the Hospital, but how many deaths from malaria they prevented. Let us hold those responsible for "health" accountable in "health terms".
Picture courtesy of www.doctorswithoutborders.org