Tuesday, 26 October 2010

Nigeria: Partnership for Health - a conference on health in Nigeria.

by Ike Anya (This post was first published on BMJ blogs)
A major milestone passed in October this year, when Nigerians marked 50 years of independence. While our government celebrated, most Nigerians reflected on why the country had not fulfilled the great hopes engendered by the handover ceremonies in Lagos fifty years ago.
 From a turbulent past marked by a sudden end to colonialism, a civil war, a series of coups and periods of military rule, Nigeria today is experiencing a sustained period of relative stability, peace, and civilian government. Some of these changes are reflected in the steady economic growth, large reduction in external debt, and structural reforms of the financial and telecommunications sectors that are hallmarks of the last decade. 
These changes have resulted in massive increased access to mobile phones and improved banking services, but the impact on the lives of ordinary Nigerians has been minimal.
From a health perspective, there are still many challenges. The health systems are weak, immunisation coverage is poor, and prospects of achieving the millennium development goals are remote.
Perhaps because of our large population, Nigerians can be found all over the world. Meeting Nigerians working in public health at international conferences and meetings was the stimulus for founding the Nigerian public health network a few years ago.
The network now consists of over two hundred members working all over the world, including in Nigeria; and in our electronic conversations, it emerged that there were a large number of initiatives aiming to improve health in Nigeria, a broad range of expertise and skills, and a keen interest in engaging in the onerous task of improving health in Nigeria. Out of this network has emerged the Public Health Foundation of Nigeria, a new foundation with 3 main goals:
  • to improve the health of the Nigerian people. With this mission, it aims
  • to influence public policy formulation for health, and
  • to increase capacity in the Nigerian public health system and advocate for the health of the Nigerian people.
Why has health slipped down the order of priorities in Nigeria? Is this a sustainable state of affairs for the country with the largest population on the African continent, the 8th largest crude oil producer in the world? 
Most importantly; what can we do about it?
It is obvious that there are many groups and individuals in Nigeria and abroad (the so-called diaspora) doing their bit to support the health sector in Nigeria. Several missions, projects and programmes are initiated every year. Yet, often the initiatives appear disjointed, uncoordinated and unsustainable.
Lessons learned are often not shared, leading to duplication and an inefficient use of resources. Many professionals abroad are keen to learn how best to contribute towards improving health in Nigeria.

To address this, we felt that this was an auspicious time to bring together different groups and individuals to learn from each other, build partnerships, and pull together from the same end of the rope.  
Towards this end, the foundation has convened a conference, the second in the series: Nigeria: Partnership for Health which will hold at the Royal College of Obstetrics and Gynaecology on 6 November 2010.

Maybe, we can spark the drive to awaken the sleeping giant. Perhaps we can learn from the recent progress in working in collaboration to radically reduce the number of polio cases diagnosed in Nigeria. Perhaps we can learn how multi-disciplinary teams are necessary to improve on our health sector ranking as the 187th out of 191 by WHO. Perhaps this conference can encourage us to seek resources from within us and beyond, to work together not in opposition, foster collaboration, and suggest a credible, pragmatic way forward. Perhaps we can achieve a re-energised Nigerian health workforce in the diaspora together with our friends and partners inside and outside Nigeria ready to re-engage with the country.
Join us on this journey by taking one of the few places left on the conference.

Tuesday, 19 October 2010

Polio in Nigeria - An emerging success story

Vaccinations are celebrated as one of the miracles of modern medicine. In the past 50 years, it has saved more lives worldwide than any other medical product or procedure.The development of the polio vaccines led to the first modern mass vaccination campaigns. The global effort to eradicate polio began in 1988, and as of 2010, polio remained endemic in only four countries, including Nigeria. The country’s polio eradication program suffered a major setback in 2003 when rumors swept across northern Nigeria that immunization activities were part of an effort to sterilize the population.

So when one of the most obvious "magic bullets" of all our public health interventions failed, as it did in Nigeria - almost crippling the polio eradication programme - public health professionals were at their wits end as to how to respond. What to do? Public health problems like this are complex and require innovative solutions.

Slowly and steadily, colleagues ploughed their way back from the brink. While Nigeria remains one of four remaining polio-endemic countries, reporting the highest number of polio cases anywhere in the world  in 2008 (798), in 2009, this number was down to 388. From January through to 12 October 2010 only eight cases had been reported, representing an all-time low, and a reduction of over 98 percent.

How has this been achieved? 

Well there are a few innovative approaches used in Nigeria that you will probably not find their way into many public health textbooks!

Firstly, there was an increased involvement of traditional, religious and political leaders in promoting vaccinations and encouraging acceptance within our communities, helping to turn the tide. This was not some token involvement, but a real integration into the response. From planning, to implementation through to evaluation cycles. While this engagement of traditional rulers occurred all over Northern Nigeria, extra mention is deserving of the of the Sultan of Sokoto. When the articulate Sultan engaged with the programme and joined hands with the community, people again recognized the problem as their own and engaged in its solution. The video below from the Wall Street Journal shows an articulate Sultan engaging with Bill Gates in Nigeria.

But it was not just the Sultan. Across northern Nigeria, traditional rulers were mobilised at all levels. They joined the state governments and international agencies in the micro planning and decision making. The leaders adopted the program as their own, and vigorously promoted it in their communities. A media campaign was undertaken to help ensure that messages of support from the Sultan were widely disseminated. Something truly amazing was taking place here. A complex problem was being solved by the ingenuity and engagement of the local leaders.

While the progress made remains fragile and tenuous - there are already lessons to be learnt from this. If we really commit to solving a problem, engaging all the necessary stakeholders - solutions to what may seem like complex problems can be found - found in Nigeria!

To find out more about this emerging story, be sure to attend Nigeria: Partnership for Health where the Executive Director of the National Primary Health Care Development Agency; Dr Muhammad Pate will be speaking. Register here.

Saturday, 9 October 2010

Twitter and Nigeria Health Watch

Long before we started blogging, we would copy and paste the few stories on health from the Nigerian press on emails, and send these round. When we started blogging, we would intermittently dedicate one blog to news articles. We knew this was inefficient, but we were trying to find a balance between informed commentary on the health scene in Nigeria, and simply giving people information on stories regarding health. But then a neat small piece of technology came along and solved our dilemma - Twitter!

Using Twitter we could share in real time the health stories related to Nigeria and you could read them just by folllowing us on TwitterBut it gets better - you can search retrospectively for health related stories out of Nigeria using the hash tag #nigeriahealth. For those of you that read the blog directly on the website - you will find the twitter feed on the right side of the blog. 

If you have not been paying attention to twitter - you should! Recently, the news of the explosions in Abuja first came through via Twitter, from eyewitnesses using their mobile phones. Conventional media relied on citizens tweeting. Within minutes some the victims of the bomb blast were “seen” first on Twitter. NTA (which was running life commentary on the 50th jubilee activities from Eagle square) lost its mojo with Nigerians because for the first time in a long time, people realised the power on in their hands, on their mobile phones,camera phones and the internet.

But why does all this matter?

We believe that it matters because social media not only brings awareness to important issues affecting society (in our case health care) but will hopefully also incite action around them. Action by people, professionals and government. We believe that as we build a critical mass of self-selected people interested in health issues in Nigeria, we will eventually be able to mobilise ourselves and draw attention to specific issues in our health sector, rallying around the positives and protesting the negatives. While we acknowledge that the awareness that we seek to create is on its own not sufficient for activism, it is a necessary one.

Online communities, like the one we seek to create around health issues in Nigeria will introduce new (or old) issues into our collective consciousness and create empathy for the situations that might be on face value irrelevant to us. Ultimately we should then be able to make the connections between a Ministry's allocation of its resources and deaths from cholera in Zamfara or during childbirth in Akwa Ibom.

In the digital age that we live in, access to information will remove some of the boundaries artificially created by our governments to deprive us of access to the information which we need to inspire action. Maybe the dream of a Twitter powered grass-root movement for health and health care in Nigeria might seem a bit too much to achieve at the moment ...but hey ...why not? Quoting Evgeny Morozov, a well known internet scholar and blogger (watch his TEDtalk) - "Access to information is the first tile in the domino effect of awareness, empathy and action".

The power of Twitter is to inform, inspire and to incite...incite positive action by society. Ours is an experiment to see if it works. It will depend on you!

Take the first step and "Follow" us @ http://twitter.com/nighealthwatch

But when you put yourself in the public space ...one must be confident in not just the content but also on one's motives, and it is only because we are confident in both that we were not deterred when the following popped up in our email box saying the "Nigerian Police Force is now following your tweets on Twitter"

Friday, 1 October 2010

Cry my beloved Nigeria

I cannot forget reading the epic "Cry the beloved country" in my early teens, and the impact it had on my life. This novel by Alan Paton is the deeply moving story of characters in apartheid South Africa, set against the background of a land and a people ravaged by racial injustice, of unfulfilled dreams, broken promises and humanity's inhumanity. For some reason, I have woken up this morning, the date marking 50 years of Nigeria's independence thinking about this book. Of injustice, (not just racist but by a political ruling class), of unfulfilled dreams, broken promises and our inhumanity - of my beloved country - Nigeria. Yet, mixed up in this are stories of love and hope, courage and endurance of the Nigerian people. How can one feel so despondent about a country yet feel so much love for its people. Probably the same way Alan Paton felt about his country at the time he wrote Cry the beloved country.

Today, the 1st of October 2010, the only thing there is to celebrate really is the love, hope, courage and endurance of the Nigerian people, despite 50 years of rape of our natural resources by an unperturbed ruling class. It seems that they cannot have enough, and the draw to power for them is so irresistible that they keep coming back for more. No sector has suffered more than the health sector....

We can celebrate some relative successes in sectors driven by the free market such as the growth in the financial sector, telecommunications, Nollywood and the rest of the entertainment industry. We have even  recently seen improvements in the aviation sector however, the health sector  has remained in the dark ages. But what does this mean for you and I ? The lucky few in a population of over150 million people who are in a position to have access to electricity, a computer, and time to read this blog ?.
It means that anytime one is in Nigeria, and we have a real medical emergency, a heart attack, a motor accident, a serious asthmatic attack, difficulties in child birth, a gun shot wound... the chances are - we are going to die
I do not want go on about measles, cholera, lead poisoning, diseases that most people in other countries only read about in medical history books....

Ah...I hear you shout! It is not that bad!

Now this is what really worries me. How come we are no longer willing to stand for hours in a bank, no longer willing to wait for months for a land line, no longer willing to drive on bad roads? We shout about the air crashes, lack of electricity....why do we then seem to accept that it is normal for our children to die from diseases no one else is dying from anymore? Why do we accept that we can go to a hospital, and no one seems to care, why do we accept that there is still no integrated ambulance service anywhere in Nigeria. I will proffer a reason for this situation, as was similarly described by Donald Rumsfeld so eloquently as "unknown unknowns". We cannot demand what we do not know exists. Most Nigerians have never known how a functional health care system looks like, and therefore there is no political imperative to demand better.

So after 50 years all I can really do is cry for my beloved country....

But you are right. Crying is not enough. What can we do?

I will proffer 3 broad directions of travel. For government, for professionals and for us ...the people.

Firstly, our governments at the federal and state levels must invest more resources; financial, human and infrastructural investment in health. The graph on the right shows the allocation to the health sector last year. This was just 4%. This is an indication of what our government is willing to allocate from its pool of resources to health. These are the choices they make on our behalf. So when next we are building a 4-lane  highway, buying 3 new presidential jets or spending 6 Billion Naira on celebrating a birthday - we have to ask our politicians - at what cost? How many women need to die in child birth to finance this highway. How many? But its not just financial resources. It is also about professionals and infrastructure, but maybe most importantly its about management and leadership. The picture below is of the beautiful edifice costing millions of dollars, built by Delta State - the Delta State University Teaching Hospital in Abraka. What do you think is missing from this picture? You are right ...people!

Now to the professionals. How often have you heard the Nigerian Medical Association stand up to proffer solutions in public or respond to any national issue. They appear dis-empowered and emasculated. The only time their voices are heard is when there is a strike over doctor's pay. This has not always been the case. I remember the "good old days" when colleagues like Dr Beko Ransome Kuti led the struggle not just for salaries but for social justice.  On all critical national matters, the silence of medical colleagues has been deafening. The "professionals" have gone silent. The professionals that have had the opportunity of public service - Dr Peter Odili, Dr Chimaroke Nnamani etc have joined the looting of the people. So how then do we restore some credibility in the eyes of the people. Our professional bodies must wake up to the challenge of leadership.

Finally, for the people...Wake up guys! Wake up! Your doctor is not GOD!

The reverence with which doctors are treated in Nigeria has led to a horrible conspiracy of silence. Nobody holds anyone accountable for anything. No it is not normal that your child should be dying of measles, or that your wife should be dying in childbirth. No..it is not right that the doctor does not tell you what the diagnosis is, nor the name of the medicines you are being prescribed. No it is not okay that the doctor does not explain the side effects or the possible complications of surgery. Wake up people. It is your life! Don't throw it away!
No...No....No...Your doctor is not GOD!

Finally while I spend today reflecting on the last 50 years, I am quietly optimistic about the future.

There is a growing critical mass of Nigerians determined to put to bed the last 50 years in Nigeria. Every day I meet inspirational people doing amazing things....not with support from the government, but in spite of the lack of support from the the government. They are finding solutions by whatever means. In the cities, in the villages, in the diaspora. They are not seeking publicity. They cannot wait for government. They are the "Cheetah generation" described so eloquently by George Ayiteh in his TEDTalk. Therein lies my hope for the next  50years....the hope for my children ...and I hope...yours.  

Nurses in a primary health care centre 
Picture credit  Femi Sunmonu

A nurse seeing a patient in a primary health care centre 
Picture credit  Femi Sunmonu
A doctor seeing patients in a primary health care centre
Picture credit  Femi Sunmonu