Wednesday, 28 January 2009

Shake Up in Health Ministry

I have never been been convinced that "restructuring" on its own solves any problem in any organisation. But at least the new Minister of Health is not spending as much time as the president spent on his appointment.

After 7 months in quasi limbo....he is changing things around. We are incurable optimists about the future of the Nigerian health sector. No doubt one reason is that you just cannot imagine it could get any worse.

While we wait for a vision statement and a strategy on how to achieve his vision....find below the change in personnel.

The first surprise is Dr Abdulsalami Nasidi, Director of Public Health for just 5 months which he took over from Dr Ngozi Njepuome has been reassigned to the vague "Special Duties Dept", while Dr. Jonathan Y. Jiya mni, erstwhile Director of Family Health now becomes the Director of Public Health.

Other changes - Dr. Mrs. P. Momah replaces him in the Family Health Dept.

Dr. Mrs. Folake Ayo has been moved from the National Blood Transfusion Service to become the Director of Hospital Services

Dr R.E Akerele-Nwaha will head the Food and Drugs Dept

Dr. Mohammed Lecky will continue in his post as the Director and Head of the Health Planning, Research and Statistics Dept.

Public Private Partnership which will be led by Dr. Tolu Fakeye

Tertiary Institutions Commission under Dr. J Adetunji

States Coordination Team made up of Dr. M Anibueze, Dr. W.T. Balami and Dr. Toyin Salawu who will be the Convener of the Team.

There is also a new Task Force on AIDS, Tuberculosis and Malaria, which will similarly operate under the direct supervision of the Minister consisting of the Heads of the departments as previously constituted for the three diseases viz; Dr T. Sofola (Malaria), Dr. B. Coker (HIV/AIDS) and Dr. M. Kabir (Tuberculosis)...

You might wonder why we have gone into the trouble of stating all the names on this blog. The reason - YOU. These appointments are made to serve the best interests of Nigerians. You have a right to know. You should hold them accountable!

Sunday, 25 January 2009

Nigerian imports Lassa to the UK: matters arising

On the 23rd of January, the Health Protection Agency in the UK published a press release about a patient being treated for Lassa fever at the high security infectious diseases unit of the Royal Free Hospital in London.

The patient returned to the UK, from Nigeria, on the 6th January.

There is no doubt that this patient will receive the best treatment available at the Royal Free Hospital, and no doubt too that no effort will be spared in protecting the health of all those that have come in contact with this patient since his return, especially those that have handled his clinical care (Lassa is transmitted via direct contact with body fluids). The HPA in the UK has a large network of approximately 3000 staff based at three major centres (Colindale, Porton and Chilton) and regionally and locally throughout England to do just this. In the USA it would be the responsibility of the Centers for Disease Control (CDC), in Germany it would be the Robert Koch Institute, in France; the Institute de veille sanitare. In South Africa; National Institute for Communicable Disease. So...that is not the subject of this blog!

The truth is that if the HPA was to pursue this in Nigeria, they would have no clue on who to call! The closest they would get is to the Director of Public Health in the Federal Ministry of Health. To his credit the present Director has been advocating for such a centre for some time now. The need for similar institutes across the world has also been recognised with the formation of the International Association of National Public Health Institutes as a catalyst (funded largely by the Bill and Melinda Gates Foundation). In Nigeria, rather than admit we do not have a similar centre, we have registered the Nigerian Institute for Medical Research Yaba
(sorry website is "down" (23/01/09) as our National Public Health Centre. Oh well....

It is not a secret that Lassa is endemic in Nigeria, with occasional reports of outbreaks. The cases we hear about probably represent the tip of the iceberg. Apart from individual research interests, what government body is responsible for the public health investigation of these incidents. I dare say non...

A bit of history
....In 1969 a disease characterized by high fever, muscle aches, mouth ulcers, and bleeding in the skin emerged in a village in northern Nigeria.
Several people died and there was panic in the land. The causative virus was found to be harboured by a rat, Mastomys natalensis. It is spread to humans via the rat's urine in airborne droplets or contaminated food; however, the most feared means of transmission was by medical personnel treating patients in hospitals. This was later named Lassa fever, after the village in Nigeria where it first emerged.

Since then the emergence of HIV, Legionnaire's disease, Ebola haemorrhagic and several others where all warning signs to the world on the continuing threat caused by emerging infections, however it was the emergence of diseases like SARS, Avian Influenza and to an extent Anthrax after 9/11 that reawakened the consciousness of the world to the dangers these pose. Since then, countries have reacted with various levels of intensity to protect their population.

Influenza pandemics have occurred regularly throughout the history of mankind. In the two pandemics in 1957 and 1968, the casualties were in excess of 6 million worldwide. The WHO and the wider scientific community believe that we are as close to the next pandemic as we have been anytime in the past 37 years. The rapid spread of SARS from Asia to Canada, has shown that the ease of international travel and our own tendency to travel to all the nooks and corners of this world, makes Nigeria potentially an extremely fertile ground for the explosion of an infectious disease such as SARS.

The key to not being overwhelmed in the first wave of a global infection is to plan very carefully and thoughtfully while there is still time. European countries have been busy preparing pandemic preparedness plans, partly in response to this threat, by setting up a European Centre for Disease Control in Sweden.. Several African countries including our neighbours Ghana have established Field Epidemiology training programmes. You can find the African Network of Field Epidemiology Training Programmes (AFENET) here.

Yet the silence in Nigeria has been deafening.

The question is: can we afford to ignore this threat. Since we are barely coming to terms with the financial and infrastructural requirements to deal with the HIV/AIDS epidemic, and only just being rescued from the quagmire into which we put the Global Polio Eradication Programme, should the threat of the emergence or re-emergence of an infectious disease be a priority for health care resource allocation?

I dare say that if we ignore the threat, we might yet pay a very high price.

With a population of more than 140 million, Nigeria is Africa's most populous country. With the state of our health care provision at all levels being poor, the consequences would be devastating should such a virus spread here. Our response to the rumoured case of SARS in Nigeria in 2003 is a case in point. Lacking any central mechanism to deal with threats of this nature, the then Minister of Health quickly set up an "Inter-Ministerial Committee on the Prevention of SARS". Rumours made their rounds on the massive procurement of special masks, gloves, protective gowns, infrared digital thermometers, spray machines etc. if these things were indeed procured, where are they now?

When the first cases of Avian Influenza in Africa were identified in Nigeria, the response was similar; the Avian and Pandemic Influenza Rapid Response Team, led by the present Director of Public Health, Dr Abdulsalami Nasidi.

Although actions like quarantine, isolation, port-of-entry screening (in Nigeria - bird incineration, or using mobile police men to shoot them!) are often the most visible tools used in controlling the spread of emerging infectious disease, the most important aspect of these is to plan ahead.

At present, this is saddled on the technocrats in the Ministry of Health. Within the ministry is a Public Health Department that manages a series of vertical disease specific programmes. The only ones that can justifiably claim to be engaged in any visible activities are primarily driven by donor funds. No active coordination between the federal level and the states exists. If tomorrow we had to vaccinate front-line personnel for an emerging epidemic, who would decide what front-line personnel to vaccinate first, and how many. Do we start with doctors, the police, or maybe the army? Who will manage and coordinate the process? A new "Inter-Ministerial Committee"?

In addition to the threat of emerging infectious diseases, outbreaks of cholera, cerebrospinal meningitis, measles, and yellow fever occur regularly in Nigeria. While we might have been socialized to believe that this is a normal part of life, this most definitely should not be the case.

In conclusion, while we invest considerable resources in the apparent modernisation of our teaching hospitals we need to remember the not so glamorous infectious diseases. Surveillance, outbreak investigation and control are public health functions representing the first link in a chain of activities aimed at countering infectious viral and bacterial agents. Prevention often involves simple means to interrupt the transmission process of an infectious agent. For these activities to be successful, we must think of them now, or our predisposition to panic reactions might make the aftermath of the Ikeja ammunition dump explosion seem like child's-play.


Monday, 19 January 2009

Managing Nigeria's Public Health

Maybe because they do not die in aircraft crashes, in gruesome fires following oil spills or in similar tragic circumstances no voice is raised in anguish about the Nigerian children that die from vaccine preventable diseases everyday. When outbreaks are reported in our newspapers on an almost daily basis, nobody links these to the missed opportunities of vaccination.

In a recent conference on health and health care of Nigerians, that held in London on the 22nd of November, 2008, no presentation left a greater impact on me than this slide (above) presented by Dr Abdulsalami Nasidi, the newly appointed Director of Public Health at the Federal Ministry of Health in Nigeria. As reflected in the feedback, he won much respect in his honesty in depicting the sad state of affairs, but less so for the vague assurances about the future.
(this and all other presentations from the conference can be found here)

The graph above shows a truly Nigerian perspective of what happens to a problem when you "invest" resources in it. Every Nigerian will tell you a similar story about what happened to funds dedicated to power generation or to the building of roads.

The graph shows that funds available to immunise Nigerian children has increased exponentially from the late nineties, during exactly the same time period the immunisation rates of Nigerian children reached a low of 20 - 30% from about 80% in 1990.

Our thesis is that as much else in our country, this is simply a failure of leadership. For some insight into how the National Programme of Immunisation was led, please read the book Academics Epidemics and Politics by Idris Mohammed.

But now...the National Programme for Immunisation has now been disbanded, and absorbed into the National Primary Health Care Development Agency. Its roles and functions are now shared with the Department of Public Health of the Federal Ministry of Health with its newly appointed Director; Dr Nasidi. Recently, Dr Nasidi was also recently appointed Chairman, Presidential Task Force on Polio Eradication and Routine Immunisation.

Dr Nasidi talks a good talk, and the report here shows that he is also a man of action...

But now, together with the newly appointed director of the National Primary Health Care Development Agency, he carries a huge responsibility, both for polio and for other vaccine preventable diseases.

He has been placed with a unique opportunity to be the Director of Public Health when Nigeria saw its last case of Polio and got its routine vaccination coverage rates back to the numbers required to stop our children from dying from diseases no one else is dying from.

What a story that would be to tell...

He can make history..he truly can...but will he? Only time will tell...

Friday, 9 January 2009

...referred to India

by ndubuisi edeoga

It started with American companies; the quintessential capitalists outsourcing their call centers to India where call center operators earn a tenth of US salaries. Then it snowballed into every country doing some outsourcing of their own...

This concept cannot be put in a more succinct way than Thomas Friedman did in his book titled “The World Is Flat: A Brief History of the Twenty-first Century(read this book!). Doing business has never been easier with the physical boundaries of countries overwhelmed by the omnipresent Internet, cheaper air travel, faster planes, and even greedier business men.

The first time I heard about medical outsourcing, I was in Georgia in th US for a conference. The hospital had an arrangement with some doctors in Australia called the “night hawk” services group, very aptly named.

How it works - a patient comes to the hospital at night to a radiological examination done e.g. chest x-ray, (CXR), Computed tomography scan, (CT scan) magnetic resonance imaging (MRI). In the past a radiologist on-call had to interprete the results and have it ready for the doctors before the morning rounds or have it ready immediately if it was urgently needed. This radiologist is paid huge sums of money as on-call allowances.

So some smart guy came up with the idea - let us send these tests over the Internet to Australia which was in a different time zone, so while its night in the US, it is bright daylight in Australia. The radiologist in Australia interprets the results the hospital avoids the huge on-call allowances paid to the radiologist in the US. Globalisation!

Some weeks back I got a call from a friend in Nigeria, he was at the Indian embassy in Nigeria to get a medical clearance and travel documents for his mother to go to India for knee replacement surgery. He told me that he had to wait in line because he had about 11 other Nigerians waiting to get cleared to go for different types of medical and surgical treatments too, that’s in one day.

Quick sums 11 X 365 = 4015, add the cost of air travel to India usually for the patient and a companion, add the cost of the surgery and other expenses. That’s what Igbobi hospital is losing every year....but who really cares about that?

It gets even better, when he got to India with his mum he was amazed at the facilities available, he claims the hospital and the theater looked exactly like the ones he saw in the UK and Europe. The surgeon, was trained and worked in the UK for more than 10years, he operates in a hospital just like the one he worked in the UK, read more here

It gets even better still, the cost of the surgery which was very successful was 1/6th of the cost of similar surgery in the USA, I even made him, take a picture of the prosthesis that was used for his mum, packaging and all, and it was the same as the ones used in the USA.

Since health care does not seem to be on the agenda....the Nigerian government can at least provide transport for people in my village to go to Ghana fro their healthcare...

GHANA! the new light of West Africa...

We can be proud of our neighbours

Tuesday, 6 January 2009

A selection of health stories from the Press

...a selection of stories from the press on our health sector as we enter the new year...

Twice in the outgoing year, the President showed his lack of confidence and commitment to Nigeria’s health sector by travelling abroad for medical treatment. In the outgoing year, the former governors, including Lucky Igbinedion of Edo; Orji Kalu (Abia) and Chimaroke Nnamani of Enugu, sought for the release of their international passports to go for medical treatments abroad. Former governors are not alone in the craze for foreign treatment. In January, the Kaduna State Government, out of tax payers’ money, paid for foreign treatments of the Deputy Governor, Mr. Patrick Yakowa; the Secretary to the State Government, Mr. Waje Yayok and the Speaker of the state House of Assembly, Mallam Abdulahi Adamu.

Thisday - Resign, Lagos Tells Striking Doctors
Lagosians may be in for an unhealthy start to the new year as the face-off between the doctors and the state government has taken a new turn, with the Commissioner for Health, Dr Jide Idris, asking doctors planning to embark on strike today to resign their appointments.

Daily Trust - As general hospitals become ‘killing grounds’.
Mr Mike Okon was an expectant father as he sat on the bench outside the labour room of the maternity ward of the Wuse General Hospital, anxiously awaiting the news of his wife’s delivery. She had just been taken into the labour room and laid on the delivery bed by the nurses who attended to her. But barely ten minutes later, noisy arguments from the labour room jarred on his nerves and he went in to take a look when he saw his wife cursing and dragging along her heavy frame towards the exit door. On enquiry, he was simply told by the nurses that since his wife’s baby “is not ready to come out, she should please stand up and give other women the bed.

The Guardian - Nigerian applies for leave to stay in the UK on health grounds because going home "amounts to passing a death sentence"
A Nigerian travelled to the United Kingdom, accompanied by his wife, a few years ago on a business trip. While on this trip, Mr Chukwu , who suffered from hypertension and diabetes, developed a cerebrovascular accident that led to a left-sided hemiplagia with some degree of dysarthria. This means that he developed a stroke that led to the paralysis of the left side of his body with some difficulty in making speech. Following discharge from the hospital, Mr Chukwu continued to receive medical care at a nursing home in London. When this misfortune sets in, he exhausted the money on him, including those remitted to him from Nigeria by family and friends. His wife resulted to doing early morning odd jobs, cleaning and the likes, to raise money so as to make ends meet. One day, at about six in the morning and while at work, Mrs Chukwu was arrested by the police and immigration officials for working illegally in the UK. It was discovered that Mr and Mrs Chukwu came to the UK on a six month visa that had expired. This visa did not permit either Mr or Mrs Chukwu to work in the UK. Mrs Chukwu was subsequently prosecuted and spent 5 months in jail. Not only this, she and her husband also faced deportation back to Nigeria.

BBC - Breathing life into Niger Delta clinics
An ill person paddles a canoe for two days across the world's richest oil fields for access to the most basic healthcare or children walking five to 10 miles in search of medical care only to find a crumbling building and not a doctor in sight.
Lagos State State Governor, Babatunde Raji Fashola, commissioned a ultra-modern (dont we love this word) BT Paediatric/Family Medicine Complex and BT Health and Diagnostic Centre at the Lagos State University Teaching Hospital (LASUTH), Ikeja. These two projects were part of the encompassing four-year infrastructural development plan for the state health sector, in line with government's policy thrust as outlined in its 10-point agenda (as opposesd to the president's 7-point agenda :)).

Saturday, 3 January 2009

How many lives have BUILDINGS saved

(again apolgies for the earlier post for those subscribed by email)

Health in the Nigerian polity is often discussed in terms of "hospitals built", "health centres renovated", "Xmillion drugs purchased" or "health equipment bought or donated".

While all these are important to some building has ever saved a life. is convenient for politicians to brag about these. Find below an advert in newspapers, placed by the Governor of Bayelsa State, and the hopsital his Government his building.

Now..the State Governments are trying to out-bid each other with their "Building projects"

  • Benue okays renovation of 10 hospitals ...In a bid to ensure quality healthcare delivery to the people, the Benue State Executive Council, has approved the commencement of comprehensive renovation of 10 general hospitals. This is planned across the state, just as it also gave approval for the construction of seven new hospitals in various local government councils of the state.

  • Imo State claims to have built the first e- tertiary hospital at Imo State University Teaching Hospital.

  • Lagos completes 100-bed children's hospitals

Nigerian medics in the Diaspora have also joined the race to "BUILD" some stories here:

Foriegn Governments too have joined the frame...

...and you you might even remember our previous post about a fully-equipped hospital that lay unused for two years, and has burned to the ground in Maiduguri as it was awaiting commisioning! The General Hospital in Maiduguri was built in 2006 but the state government refused to open it until the president came to cut the ribbon.

Now...we are not saying that shiny buildings are not nice (at least for the first 6 months after commissioning). We are not saying that we do not like the lush green grass at the National Hospital... It does make a difference.

However, we suggest to our politicans to make 2009 a year to improve the quality of health care provided in our hospitals. Let one Governor tell us that he guarantees that when you drive into the Accident and Emergency Centre in Birnin Kebbi, the capital of Kebbi state...that Doctors will RUN to your attention.

...that if you go into the out-patient department in Ebonyi State University Teaching Hospital in Abakiliki, that doctors will be on their consulting tables by 8 am, and that patients will not have to wait 5 hours to be seen....

...that when a patient goes to Ado Ekiti Teaching Hospital...and is prescribed basic antibiotics....that he/she can get them without going to the market...

Who will take the lead in guaranteeing the quality of healthcare for Nigerians, and not the buildings....and honestly...I dream of attending the nice old colonial buildings at the Federal Medical Centre in Owerri, if I'll be seen quickly and efficiently. I am sure most other Nigerians will share my dreams. Let 2009 be a year of quality, and let us get over the delusions of grander that often cloud our thinking.

Thursday, 1 January 2009

2009...things can only get better

Dear Readers,

Its been a tough year …2008.

We lost our Minister of Health in difficult circumstances….and after 8 long months, we finally have a new one. This left the health sector rudderless and clueless. Our public health indicators got worse with a resurgence of polio, immunisation rates of around 20%, and one of the worst maternal mortality rates in the world. Nigerians lost confidence totally in their health services, led by the President himself. Our representatives in parliament continued bickering over the National Health Bill. All this in a period of oil selling at $150 per barrel…a wasted era.

In the chaos there were a few bright lights. Slowly, state governments are waking up to their responsibilities towards health care. The private sector too is starting to fill the spaces left by the state, with HMOs like Hygeia branching out into the communities. Nigerian health professionals living abroad increased the frequency of so-called “health missions” and converged in London with unprecedented energy to brainstorm on a way forward.

But beyond health….the one event that we have all engaged with to some extent was Barack Obama’s historic win in the US elections. This has made us think about 2 broad issues that affect health just as much; leadership and the engagement.

Lets explore "engagement". The image below is one of Barack Obama’s campaign stops that has stayed on my mind. Never in the history of the US have as many people engaged with politics as in 2008. Students, young people, people that have never voted …ever. Until we take ownership of the problems of the health sector in Nigeria …we will all fall victim. And it really does not matter how much money or influence you have….if you have a heart attack, a car accident or any other of several medical emergencies even in the middle of Nigeria’s capital…the chances are that YOU WILL DIE. Think about that. Unfortunately…it is not a problem we can get Julius Berger to fix…It will need some careful planning, resourcefulness, time, energy and patience. It will need leadership; the leaders in all of us.

This brings me to the second lesson from Barack Obama’s victory; Leadership. The 6th US president, John Adams is quoted as saying
“If your actions inspire
others to dream more, learn more, do more and become more, you are a

In that respect…Obama has already moved the world.

But how does this translate to health in Nigeria. Where are the Obamas' for health? Can Professor Osotimehin inspire Nigerians to take on their roles as leaders in primary health care centres, in our immunisation programmes, in our teaching hospitals?

Can we be inspired to believe again? To insist on quality? To do the bit we can?

Can 2009 turn out to be the year we celebrate a re-birth, a restoration of some pride and confidence in our health care system?

Can we be inspired to remember those we are actually committed to serve ?

This is our prayer and hope for 2009…..we are sure that by reading this blog…it is yours too.

YOU are the reason we bother.

Thank you!