Monday, 30 June 2008

The House that Jack built !

by ndubuisi edeoga

While we all wait patiently for the new Nigerian Health minister, and we form our opinions about his/her job requirements, lets take stock of the various duties that we owe to ourselves, our patients, our families, our relatives, and our friends. Lets see ways that we can make the job of the in coming minister easier.

By adequately equipping ourselves and adequately informing our patients using the various easily and often times free channels,we would all be in a better position to offer well balanced criticisms, advice and suggestions,that would help in resolving the "difficult" problem of governance in Nigeria, especially in the health sector.

I have had the opportunity to see the practice of medicine in a developing country and in the developed countries, and I have come to the conclusion (rather subjective) that even though the building and all its contents, MRI, CT scans, Linear accelerators, etc etc make for better medical practice the physicians and other health professionals that work inside these buildings make the difference.

To put this in perspective "how many times have anyone reading this blog gotten an MRI in the past 2 years,I can see only one or two hand raised" . Now how many people on this forum have gone to a clinic without any major equipment used, I can see many more hands.

My point exactly, let all physicians and health care professional reading this blog, make use of the free sites available on the web and get more continuing medical education (CME), let your patients know about sites that they can get more information about preventive health, staying healthy and when they are sick to learn more about their sicknesses. such sites as WebMd , medscape, and pri-med. Make use of the free sites such as google Health, Microsoft Healthvault, and so many others available on the web and for a one pass summary of all the good sites go to noedb These sites can assist you in organizing your patient information , so that we can have a ready source of birth rates, death rates, number of pneumonia and Hib's in your clinic in one week, one month , and in the year, and so many other rates that people keep asking for on the various groups that I belong to, and I guess they never seem to get what they need.

Knowledge they say is power ( and that was before the web 2.0 came into the game, imagine what we can do with knowledge and the power of the web), if we adequately inform ourselves, our patients, friends, and relatives, we would all be in a better position to demand our "birth-rights" or "health-rights" from the new health minister and our political leaders.

Saturday, 28 June 2008

On the regulation of Nigerian health professionals

An anonymous commentator on the last post mentioned that the next Minister must put in place a regulatory body to which health professionals are accountable, to deal with cases of negligence and breaches of professional ethics. The commentator mentioned the General Medical council in the UK as a possible model.

The truth is that these bodies already exist in Nigeria. The Medical and Dental Council of Nigeria is supposed to fulfil that role for doctors and the Nursing and Midwifery Council of Nigeria is supposed to do the same for nurses and midwives.

However, the question of how effective these organizations are is a valid one. Strengthening the capacity of these regulatory bodies should be an important aspect of improving healthcare in Nigeria, yet there is little evidence that they are being provided with the tools, resources and capacity that they need.

With a large proportion of Nigerians receiving healthcare from private providers, the need to strengthen the regulatory bodies is very important.

An interesting seminar on the topic was held by the African Leadership Forum nearly fifteen years ago, whether anything has changed since then is open to debate.

On a lighter note, it was interesting to read the following extract from the Standards for Nigerian nurses " (Nurses must.. Always appear Neat and decently dressed, without using bogus/dangling earrings, long and big wigs (all hair do must not extend below the neck level), high heeled shoes, long painted nails and bogus make up while on duty and in uniform. "

Sunday, 22 June 2008

Minister of Health for Nigeria: A Job Description

....if I was looking...this is what I would be looking for:

With the Ministry of Finance and the Attorney Generals Office, the Ministry of Health belongs to a small group of ministries that are unique in the specificity of its functions. Health and health services involves complexities that are extremely difficult to understand in detail by people outside the health professions.

The next minister should come from one of the health professions.

Many in the health profession spend their careers managing individual patients. Few have had any managerial experience beyond their clinical teams. Few receive any management training. They are rarely trained to think strategically, to plan, set objectives, execute projects, monitor milestones, manage budgets, and manage people. Nigerians could not identify with any objectives of the MOH in the past years because none has been communicated to them. Our tertiary hospitals are all managed as single entities by clinicians with no managerial experience either, no surprise none of them attracts the confidence of Nigerians. A vast number of health parastatals are fiefdoms of incompetence that have hardly affected the lives of Nigerians apart from maybe NAFDAC.

The next minister should have proven managerial experience or/and training and be able to see the link between health and development.

Most health professionals spend their careers thinking about the health of individual patients. Since most of them come from teaching hospital settings, they tend to think of health as the health care of those that make it to teaching hospitals. This is the thinking behind the investment of billions of dollars in procuring extremely expensive equipment for teaching hospitals, which on rare occasions that they do work, cannot be afforded by most; a completely flawed investment. How many lives has the £10M MRI saved?

The next minister should have experience or/and training in thinking about health in population terms. I.e. what will be the most efficient way to invest the resources available for health to benefit the most people?

The Ministry of Health is probably the best placed ministry to attract funds well in excess of its federal allocation from partner agencies and bodies. With Nigeria's 140 million people, there will not be any significant impact on global health programmes without Nigeria's engagement. The world needs us, but we have to always remember that it is in our peoples' best interest to attract resources for health and health care to Nigeria.

The next minister needs to be competent, confident, articulate, result oriented and able to deal with international partners.

Finally...the Minister of Health can be the most thankless position. Health indicators do not change over night in best of times. Many of the things that affect health are outside the remit of the Ministry of Health. Healthy people do not make the news! There are a lot of temptations to cut corners, to seek quick solutions, to compromise. Any compromise will lead to people dieing.

Integrity is the single most important quality absolutely required of the next Minister of Health.

Tuesday, 17 June 2008

Behold our finest public hospital

We have previously written a blog titled: National Hospital Abuja: Unrealised Expectations. Pls read it to put the rest of the blog in perspective.

Our interest was aroused by several reports in the press this week....with titles similar to this:

Nigeria: National Hospital Rejects Health Ministry

Now read the comments of the Chief Medical Director, a former personal physician to President Obasanjo, Dr. Olusegun Ajuwon OON. To get to know him better read a recent interview…aptly titled "I Owe My Success to God".

The news paper reports state...

....The Chief Medical Director (CMD) of the National Hospital, Abuja, Dr. Segun Ajuwon has protested moves by the National Assembly to transfer the supervision of the hospital from the Presidency to the Federal Ministry of Health.

....Dr. Ajuwon decried the state of the 53 hospitals currently under the ministry, saying the National Hospital would not like to join them.

...Dr. Ajuwon said the hospital has the best cancer treatment centre in the country, adding that "the equipment has been down for two years now and it requires N45 million for repairs. The new one costs about $1.9 million USD which is about N200 million."

...In the last 9 years, we have had four boards; it makes nonsense of effective planning", he stated.

...Dr. Ajuwon also told senators that the hospital's MRI, which is first of its kind in the country, has also broken down. He estimated its repair cost at N70 million.

...Chairman of the Senate Committee, Senator Smart Adeyemi (PDP, Kogi West) said they were at the hospital to ascertain state of facilities as, "We are particularly concerned that 48 years after independence we still refer ailments of important personalities abroad."

...Senator Smart Adeyemi, Chairman of the Senate committee who led the team, said they were impressed with standards of the National Hospital.

Honestly...I have never come across such a self indictment of mismanagement in the public domain. It really is a shame that the National Hospital, that should serve as the primary tertiary care facility in the hospital cannot be managed to succeed both as a 1st class medical facility and a successfull finacially self sufficient entity.

My thesis...Our biggest problem in health and health care in Nigeria is not a deficiency of doctors, hospitals or clinical expertise....but simply a lack of strategic leadership ...especially in the public sector.


Lagos State...really leading the way

Much has been written about the new Government of Lagos State under its unlikely Governor Babtunde Raji Fashola. Much has been said about the intriguing circumstances that threw up this non-politician to governance...and how this act of fate seems to be transforming Lagos State. But the health sector, its never really been on any one's agenda...

At best, we hear about hospitals being built, BIG hospitals! The bigger the better! It has been difficult to make the argument to people that a BIG hospital does not improve any one's health! Health care is about identifying the health problems of a population, designing an integrated health care service (primary, secondary and tertiary) to provide these services, and managing it accordingly. Having a BIG building does nothing of the above!

When I read the first stories about 5 new 100 bed hospitals being built in Lagos state, it did not attract any attention until I read that further that these were specifically Maternal and Child Health complexes. All were being built in the grounds of already existing hospitals. I read the infant mortality rates and maternal mortality rates being quoted. I read that the hospitals are being built as part of an integrated four-year infrastructure development plan for health care.

It was obvious that someone was thinking in Lagos State!

Then came the next surprise; the press was reporting that the Lagos State government has shut down 184 private hospitals, clinics and laboratories for failing to meet basic standards of hygiene and staff training! Hygiene? In Lagos State?
A government official was quoted to say ; "Corruption, mismanagement and poor leadership are the main problems of the health system in Nigeria,"... "These have been recognized by the Lagos State government which is... tackling these issues through a reform process of which regulating the private sector is a key initiative." Regulating the private sector?

someone really is thinking in Lagos State!

Then came a story that really blew my mind: The Lagos State Government was threatening to sack its health sector workers for ....wait for this...public criticism of the attitudes of some health workers in the state hospitals and other health facilities. The State Commissioner for Health made this threat while on an impromptu monitoring visit to some general hospitals in the State.

someone is thinking in Lagos State!

Lets hop
e it spreads to other states :)

Want to know the public hospitals in Lagos State, there opening times, here

Lagos University Teaching Hospital?... click here

A listing of private hospitals? here

Kudos to the Government of Lagos State, we hope that slowly but steadily health will return to the agenda of Governance in the country!


DFID launches PATHS II in Nigeria

The UK Department for International Development has just launched the second phase of the Partnerships for Transforming Health Systems in Nigeria. The project has been running for the last six years and has been credited with supporting some of the achievements of NAFDAC, the drug control agency and supporting the introduction of better health information management systems in Kaduna State.

The project is based in five states- Enugu, Ekiti, Jigawa, Kaduna, Kano and some support at Federal level

Unfortunately, the communications haven't been that great- a website has only just been set up and is still under construction

The first phase, PATHS I delivered by a consortium led by HLSP ended in 2007. The second phase has just been launched under new leadership

Hopefully, the new website will help in keeping people abreast of the programme and what it seeks to achieve, and help Nigerians hold their governments and donors to account...

Friday, 13 June 2008

Who will cast the first stone?

by ndubuisi edeoga
It seems everywhere I look its always bad news coming from Nigeria, bad news about Nigeria and an even worse future for Nigeria. Lets leave out our president, for he can go to Germany, lets leave out our Police chiefs for they plan to abroad to get good health care, lets try to forget about our health minister in whom we had so much hope, lets no think about the Niger delta issue, lets not think about the Hib's, pneumoccocal, measles polio, HIV, in fact lets not think about anything but about ourselves.

How can we acting individually and in concert achieve enduring change. Lets start from me, I jumped on a scale recently and got my weight , quickly moved to Google and used their quick BMI calculator and arrived at some not too surprising quantity. I jumped on the treadmill and have since become inseparable from that beast.Well how easy it is for us to counsel our patients, friends, and relatives about the dangers of obesity and forget about ourselves, the shield of self indestructibility. Is it time we remove the log from our eyes before we look for specks in our patients, rulers or policy makers eyes.

How many of us in private practice lead by examples. I was speaking with two of my colleagues in Kaduna, Nigeria. Both doing very well by all standards, sizable patient load, nice steady income, comfortable lifestyles that I envy my "diaspora" existences and all its glory. Do you know they both use their extra fast computers/laptops in their offices for checking emails...and.....

Now how can we blame our country, our failed rulers, policy makers for having no records or data when we need them. Who do we blame for failing our patients, remember you took that Hippocratic oath all by yourself. Do you know if my two friends used their computer power to keep effective medical records of all their patients, we would know how many cases of malaria they have each week, we would know how many kids actually get Hibs, pneumoccocal , measles, and these other dangerous diseases. Then we can reasonably extrapolate, then we can have more accurate measures of progress or non progress. Then we can measure progress.

We can all make a change in our lives and in the lives of people that depend on us...only if we take the first step. Change always has the snowball effect, I bet you if those doctors let their patients know that they keep their records on the computer( novelty effect..eehen "he even keeps our records on his computer"), who knows it might even attract more patients, more bottom line, and eventually more doctors would copy them...How else can we achieve social change except by doing?

Wednesday, 11 June 2008

Nigeria still on our minds: even in Iceland

I hear you asking "Iceland?…Yes!

The same thought crossed my mind when I saw that this year’s International Symposium on Pneumococci and Pneumococccal Diseases was holding in Reykjavik. It was definitely not top of my list of “must-visit” destinations…and I must confess that their national hobby; whale watching, will not exactly send my adrenaline pumping…but anyways...we deh for Iceland!
I hoped I would at least be too far from Nigeria to encounter any further frustration at our collective abdication of the health of our people.

Wetin concern us and pneumococcal disease you might ask. Well look at this graph.

Yes, HIV, TB and malaria get all the attention these days…and yes kids are dieing from those too. But not just these!

Serious pneumococcal diseases caused by Streptococcus pneumoniae – primarily pneumonia and meningitis – are the #1 vaccine-preventable cause of death in children under 5. A new conjugate vaccine recently became available and has been introduced in most western countries. In 2007, WHO issued a recommendation for the introduction of pneumococal vaccines into immunization programs in developing countries that will potentially save millions of lives. Good news!

So…1st day of conference…Nigeria is on the agenda:

Kathy O’Brein – of Johns Hopkins -"More children die from pneumococcal disease in India and Nigeria than any other country in the world"

"The 2 countries with significant U5 populations ...where it is most difficult to get any data from are Indonesia and Nigeria"

No...this is not what I hoped to hear!

As usual I meet several Nigerians working all over the world. We share our frustrating experiences of engaging with Nigeria. A colleague tells of his recent experience during an advocacy meeting with our most senior colleagues in Abuja working at the National Primary Health Care Development Agency (Into which the National Programme for Immunisation was subsumed). Stories of incompetence too alarming to be reported in detail.

Historically 15-20 years would pass before new vaccines reached children in developing countries. A new organisation: PneumoADIP, part of the GAVI alliance is working to develop effective public-private partnerships in order to accelerate the introduction of pneumococcal vaccines into developing coutries routine vaccination programmes, potentially saving millions of lives. Good news for Nigeria?

In late March 2007, GAVI issued a brief letter to all 72 eligible countries asking if they would be interested in introducing the new pneumococcal conjugate vaccine. 31 countries indicated an interest in introducing pneumococcal vaccines by 2010. The most responses came from Africa, the region of the world with the highest incidence of pneumococcal disease….and NO! Nigeria was not one of them. We do not care for our children enough....sadly.

The other disease discussed at the conference was Hib. Haemophilus influenzae type b (Hib) is a bacterium which causes serious disease often life-threatening, illnesses in young children. Hib can cause meningitis and severe pneumonia, leading to an estimated 3 million cases of serious illness and 400,000 deaths each year in children under 5 years of age. On average, 20% of children in developing countries with Hib meningitis will die. Hib bacteria normally establish themselves in the nose or upper throat. It is spread through sneezing, coughing, or speaking closely with an infected person.

Fortunately, Hib is now preventable. There is a highly safe and effective vaccine routinely used in the industrialized world for over 15 years. More than 100 countries now routinely use Hib vaccines in childhood immunization programmes and have documented virtual elimination of disease. This month, Uganda announced that it has nearly eliminated deadly Hib meningitis in young children. This comes just five years after that vaccine was first introduced into the country's immunization programme. As a result, Uganda prevented an estimated 28,000 cases of pneumonia and meningitis and 5000 deaths, each year. Precious Ugandan children. Nigeria is one of the few countries that has not made any move to introduce this vaccine despite the support available from GAVI.
We do not care for our children enough....sadly.

Well ….we cannot all blame "some one else". There were at least 6 Nigerians at the conference....and as usual we moaned..and moaned. The lone soldier that actually came from Nigeria was Dr Falade from the University College Ibadan. Ibadan, Nigeria. The rest of us are in the so called “Diaspora”. Dr Falade has been the leading the research and advocacy for pneumococcal disease in Nigeria. he recently wrote an emotional Op-ed published in many Nigerian newspapers titled Vaccine Proves Successful in Eliminating Deadly Disease in Uganda: A Wake up Call to Nigeria.”

Also at the conference was a revered senior colleague, Dr Richard Adegbola by any estimate, one of the foremost scientists in this area. He works out of the Medical Research Council in The Gambia. Read a recent interview. How our country can ignore this man beats me. Yet...where is there for him to come back to? We marveled at the huge team from the Kenyan Medical Research Institute (KEMRI)…and the work they presented….researching, engaging and thinking about Kenyan children.

Again I came across another reason to be saddened at the sacking of Prof Grange, our erstwhile Minister of Health. A pediatrician and president of paediatric association wrote an Op-ed in Washington post asking the same questions I am….why are we doing so little to save her children from diseases no one else is dying from? Still…it is not clear why so little has changed with our National Primary Health Care Development Agency during her short tenure. Time, maybe will tell.

Meanwhile...our children continue to die sef ...I tire

Back to my conference...back to Iceland.

But ....Nigeria remains...always on our minds...

Wednesday, 4 June 2008

Masters in Public Health

by chikwe ihekweazu

Have you noticed how many Nigerians are doing MPHs these days?

I teach a specific module at a few MPH classes in Universities in the UK and have noticed and increasing number of colleagues from Nigeria. Always proud of the few that have chosen this career path, we have often stayed in touch and exchanged thoughts on how some of our skills can be transferred to improving the health of Nigerians. These informal links led to some of us coming together and forming the Nigerian Public Health Network in order to achieve synergy between our professional careers in public health and our personal interests in Nigeria.

However nothing quite prepared me for the lecture of 2 weeks ago at the MPH class of a major UK University.
70% of the class of the students were Nigerians. 70%!
...OK this a coincidence? I don't think so

In all 4 Universities I have thought in this year on the MPH course...there have been a large number of Nigerians, many medics but also many colleagues from other health backgrounds...

Wow....I thought. Is the tide really turning in Nigeria. All these young enthusiastic Nigerians, paying through their teeth, eager to confront health problems from a population perspective. Are we really on the way to confronting our health problems: to raising our scandalous maternal mortality rates, to finally organising primary health care, to vaccinating our children, to developing functional health policies and implementing them? Finally...are we going to get the strategic thinking so desperately missing from our health sector?

Some is this surge will be linked to decreasing opportunities to pursue medical specialist training in the UK but definitely not all of it ...

Many too will be driven by the flawed perception of bumper salaries awaiting them in international organisations...

Whatever the path to public health is all good. Most of us...including yours sincerely...had no inkling of the relevance of public health while in medical school. I so much wanted to be like the huge cardio-thoracic surgeon that walked our corridors with such a swagger, or the elegant physician who always came impeccably dressed with his bow-tie and pockerchief.

As a medical student, I hated, hated biostatistics....especially the way it was taught at the University of Nigeria! Those Friday afternoon lectures..teaching how to manually calculate chi-square tests! Or the boring lectures about sanitation.

But...that was before my eyes were opened to the huge potential of the study of public health "
the science and the art of preventing disease, prolonging life, and promoting physical and mental health and efficiency through organized community efforts"...

...and the huge, untapped potential use to a country like ours..Nigeria

Therefore, I am happy to welcome all the new entrants into our chosen career...and hope that together we can make a difference!

Monday, 2 June 2008

Read the new National Health Bill

Quoting Prof Grange, our last Minsiter of Health:

"....the absence of a National Health Act to back up the National Health Policy has been a fundamental weakness which needed to be tackled frontally. This weakness means that there is no health legislation describing the national health system and defining the roles and responsibilities of the three tiers of government and other stakeholders in the system. This has led to confusion, duplication of functions and sometimes lapses in the performance of essential public health functions"

Thanks to Felix Obi, a strong supporter of this blog....we can now make available to you the new National Health Bill as passed by the Nigerian Senate.

The BILL is for your HEALTH. READ IT HERE!

Have a say, pass it round,....don't leave it politicians...

ps...the bill will still be heard by the House of Representatives before it is sent to the president. It only becomes law when it passes these 2 stages.