Monday, 31 January 2011

Crisis in the health sector - but who cares?

We have spent the last few months in the Nigerian press quarrelling about "zoning". Almost no airtime is given to the issues that challenge our country. The political landscape appears to be an issues free zone. Even at the best of times, health hardly makes it on the political agenda. I have often wondered what it will take for people to demand better health care the way they demand for roads and electricity (not that it has made much of a difference yet). What will it take? We have some of the highest health indices in the world, our politicians keep running to foreign hospitals, yet nothing changes. Health is just not on the agenda. 

As you might know, in parallel to this blog we "tweet" health stories out of Nigeria via our Twitter page @nighealthwatch. Last year doctors in Lagos State were on strike for three and half months’old strike. For three and half months all public health facilities managed by the Lagos State government were closed to patients...3 and half months!

Since January we have seen stories of strikes from all over the country. So we can conclude that in terms of the distribution of strikes in our country "zoning" is truly dead. Maybe this is the reason it is not on the political agenda. If people are treated equally badly, our politicians are unable to make political capital out of this.

If you have missed the articles please read them and hold your politicians, government and doctors to account. If you don't....people will die. Most importantly at the moment ...go out and register to vote!

Osun State....
Abia State...
Nasarawa State...
Oyo State...
Cross River...
Enugu State...
Kano State...

Thursday, 20 January 2011

Good report - BUT how do we move from reports to impact

Every year our Federal Ministry of Health, and the multitude of development partners at its service produce hundreds of reports about their plans and activity. Most of these reports are hidden away on dusty shelves, deep inside websites that no one goes to. Many of the reports are poor and will not stand the scrutiny of enlightened peer review. Some are sprinkled with pictures of newly repainted primary health care centres as evidence of improved health care services. Once in a while a good report is produced that actually addresses some of the major challenges of our time.

It is no longer a secret that Nigeria is at significant risk of not meeting the the Millennium Development Goals 4 and 5.

MDG 4: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate. 

MDG 5: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

Did you know that every day in Nigeria, about 700 babies die (around 30 every hour). This is the highest number of newborn deaths in Africa, and the second highest in the world. 

A new report - Newborn Health represents a major milestone to plan for Nigeria’s 241,000 newborns who die from preventable and treatable causes every year. Published under the  auspices of the Federal Ministry of Health, and developed by Save the Children in collaboration with major stakeholders, the stated goal of the report is  to accelerate action by dutybearers to save the lives of Nigeria’s newborns.

One obvious innovation in this particular report, are written commitments from the development partners, our Federal Ministry of Health, professional bodies and even representatives of the people.

Filled with well analysed and presented data on the Nigerian health sector as it relates to maternal and child care, the report is an excellent summary of where we are and how we can make progress. It ends with a call for action around 5 well articulated recommendations. For me personally, the most striking fact in the opening sections of the report was that "key interventions to save newborn lives are mostly possible through the existing health system and will prevent the deaths of mothers and older children ...but coverage remains poor" ....Below is some of the data. Data that should absolutely shock our leaders and drive them to action. But unfortunately neither our leaders, most of health professionals or the public at large have quite come to terms with the enormity of challenges that face us in the health sector.
  • Exclusive breastfeeding of infants less than six months - 13%
  • Had at least 1 Antenatal visit in pregnancy - 58%
  • Has received 1 Measles vaccination -  41%
  • 12 states where less than 20% of women give birth with a skilled attendant present
  • Coverage is especially low for modern contraception use (10%) 
But this really is not what this blog is all about. We found this report in an obscure newsletter that summarises new publications of relevance in global health. I spent the last few days contacting my colleagues across the country, paediatricians, gynaecologists, nurses...not a single one of them had heard or even seen this report. I have sent it round to all of them...but just to the small group in my network. 

With the money spent on this report, why was there so little obvious effort in launching it, in making it public, in sharing it with people that need to know. Where was the related advocacy campaign around the report? Where was the effort to inform mothers on the findings so that they would hold our leaders to account. Who is measuring the impact of this report? Impact...impact? What was the impact? What is the impact? 

While we are pleased with the emergence of this important document, we ask that all the major partners in our health sector think about the ethical imperatives of spending significant resources on reports, and the opportunity cost of not spending them on health interventions. If we have to write these reports, then we have to plan and fund a communications plan around it. We see from the website of our Federal Ministry of Health that there are plans for a "Data Inventory and Documentation Initiative (DIDI)" This might solve the problem, but we have learnt the hard way in our country not to believe the big long acronyms, and wait to see the final product.  

One approach to solving this would be an undertaking by our Federal Ministry of Health, and our development partners to publish the detailed costs of any report published. Only by knowing what the report has cost to produce can we estimate how may children lives might have been saved not by the inactivity of those that can act, but their activities in the wrong endeavours. 

Having said that - this is a very good report - especially the state specific summaries at the end. 

Not to miss a story on health in Nigeria - follow us on Twitter. 

Friday, 14 January 2011

A short letter to our presidential candidates

Dear Presidential Candidates,

While you argue about the most banal issues such as zoning arrangements, single or double terms, north and south etc and all the other issues that do not matter to the average Nigerian, and indeed simply insult our intelligence we want to offer you some publicly available data on health that might help you decide on what you really should be thinking about at this time.

You will need to understand what is happening to the health of the people you seek to serve. Dear Sirs, you will need to learn from the mistakes of our former presidents who appropriated all the funds in the health sector to white elephant projects - like that awarded to VAMED by our beloved ex president; Chief Olusegun Obasanjo. Our former president awarded on our behalf, to a single firm; VAMED, a N9.5 billion ($65 million) contract to supply medical equipment to twelve medical centres in the country. Yet, he had barely left office when our subsequent President had a "catarrh", and was promptly ferried abroad, to Germany again at the expense of the same Nigerians that had paid VAMED! Despite the investments, none none of us Nigerians can point to any of those facilities as a beacon of hope for health care in our country.

So we suggest you let us know your plans to address some of these most basic indices of our development as they relate to the health sector. If you find these difficult to understand please seek out the competence to assist you. They are not insurmountable.

What are you going to do to give Nigerians a chance at a fulfilled life. We currently have a life expectancy at birth of 47 years. Many of us Nigerians might not still be alive between the time this blog is published and the April elections.

What are you going to do about the sad fact that 75 out of every 1000 live deliveries die before they are one. These are not abstract numbers, but the children of  families that you expect to turn out in April to vote for you.

What of our mothers? 500 of our mothers still die in every 100,000 deliveries. In their grief, will they come to vote?

We could go on and on, but it is just too painful. All the official data from the National Demography and Health Survey of 2008 is available for you.

Click here for a report. Read it! Please

And if you thought there was no money for the health sector, think again! You might not have noticed that N131 billion was budgeted for the sector in 2010. But Sirs, to make things easier for you, we have found the data for you from the budget office of our Federal Ministry of Finance for expenditure on health by the Federal Government alone. Again, we implore you to study this. 

See below a simplified table detailing health expenditure between 2008 and 2010. 

Our great country spent only 3.2%  of its national budget on health at the federal level in 2010. Of this, 83% was spent on paying salaries! There is no better indicator of our priorities lie!

Dear Sirs and Madams, our beloved late president said he wanted to make our country one of the 20 largest economies in the world by the year 2020. We are not sure if you buy into his Vision 2020 as it was fondly referred to, or if you want to create your own vision, but we dare to suggest that none of this will be possible if you do not pay more strategic attention to the health sector.

We hope you do start listening to the people. Its not about your ambition, your zone, your right, or even your good luck. Its about our lives. Listen to us. 

May the debates begin!

Not to miss a story on the Nigerian sector - follow us on Twitter!

Tuesday, 4 January 2011

River Blindness: an emerging success story and the Nigerian lady that drove it...

Those that went to medical school in the University of Nigeria in 90s will remember an articulate, passionate and scholarly teacher we had in first year. Her course "Parasitology" was the first brand new, medical topic we would be exposed to. In retrospect we were incredibly lucky to have Dr Uche Amazigo as our teacher. This year, Dr Amazigo retires after steering for five years a programme widely acknowledged as a success story within the international health community - the African Programme for Onchocerciasis Control (APOC).

When my friend Paul Ejime sent me this story from a recent meeting in Abuja, I thought that it would good to start the year with this immensely positive story to remind ourselves of calibre of people we have in senior management positions in the health sector around the world....

River Blindness: Taking control success to focal elimination

By Paul Ejime*

The international health community – health ministers, donors, non-governmental development partners, UN agencies, health experts and the media – converged recently at the Transcorp Hilton, Abuja, the Nigerian capital, united in one purpose - how to rid Africa of the River blindness scourge.

River blindness, a vicious parasitic worm disease transmitted by the bite of black flies causes intense itching, skin disfiguration, vision loss, and blindness. The adverse impact of the disease on Africa, which bears the greatest burden of Neglected Tropical Diseases (NTDs) include reduced agricultural productivity, recycling of poverty and an impediment to development. The urgency in tackling river blindness and other NTDs cannot be over-emphasized with just five years to 2015, the date set by world leaders for the attainment of the Millennium Development Goals (MDGs) including halving extreme poverty worldwide.

In spite of the lingering effects of the global economic crisis, international donors gathered in Abuja did not disappoint. They committed US$31 million to support WHO/APOC’s efforts to control and embark upon focal elimination of river blindness from Africa.  APOC partners are determined to significantly shrink the regional map of river blindness by 2015. Among the new commitments was a first-ever individual donation of US$1 million announced by a Nigerian philanthropist and survivor of river blindness General T.Y. Danjuma.

General Danjuma, a special guest at the meeting and grand patron of local NGDO MITOSATH, which supports Nigerian government in the fight against river blindness and other NTDs, recounted his experience as a young military officer, who battled and survived river blindness.

“I have had a personal experience with this disease and live with relatives and friends who are victims,” he said, and urged the Nigerian government to also contribute more toward eliminating the disease.  More than 120 million people worldwide are at risk of River blindness with about 90 percent or more than 102 million of the at-risk population in Africa. Nigeria accounts for an estimated 30 million of the population at risk scattered in 31 of the country’s 36 states and in the Federal Capital Territory.

In an apparent response to General Danjuma’s plea, Prof Chukwu reiterated Nigeria’s commitment to step up support and contributions toward the elimination of the disease in line with the theme of the Abuja meeting: “Join forces to make River Blindness history.”

The success of the efforts to eliminate of river blindness from Africa is based largely on APOC’s cost-effective and innovative Community-Directed Treatment with Ivermectin (CDTI) strategy. This strategy also known as the Community-Directed Intervention (CDI) is a bottom-up approach to public health care delivery whereby communities play a leading role in the management of their own health.

As the longest running public-private partnership for public health in Africa, some of the major achievements of the WHO Onchocerciasis control programme in the past 15 years include (86% reduction in severe itching, 33% reduction in prevalence of the disease, prevention of more than 500,000 cases of blindness and an estimated Economic Rate of Return of 17% on invested funds).  The programme has also created a network of close to one million trained community-directed drug distributors majority of whom supporting the Ministries of Health in the delivery of other health interventions.

Despite these achievements, more work is required to expand the programme’s reach, conduct needed research and to secure additional funding to facilitate transfer of ownership to countries and to carry control activities through until elimination of the disease as a public health and socio-economic problem in Africa.

There is good news from recent studies showing that for the first time in Africa there is possibility of eliminating transmission of the disease in some foci (in Guinea-Bissau, Mali, Senegal and Kaduna, Nigeria), using existing tools - the CDI. In response to intensified advocacy by WHO/APOC and partners, 34 African universities, medical and nursing schools have undertaken to incorporate the CDI strategy in their curricula.  No doubt this will lead to an exponential increase in the number of health professionals with requisite expertise in CDI and the engagement of communities in public health delivery with trickle down effects for health system and Primary Health Care strengthening, and contributing to the attainment of health-related MDGs by countries.

“We have reached the stage that Africa can get rid of river blindness, and the APOC partnership, with the support pledged by donors and governments in Abuja can make this happen,” said Dr Uche Amazigo, WHO/APOC Director.

It was also a home-coming of sort for the programme’s first female director, Dr Amazigo, who is retiring early next year after steering for five years a programme widely acknowledged as a success story within the international health community. Dr Amazigo was commended for her outstanding dedication, commitment, strong leadership and effective public health management. The JAF16 meeting in Abuja was a crowning of an illustrious career for the Nigerian scientist, former senior lecturer and parasitologist with specialization in tropical diseases and reproductive health. Her research in 1990 formed the basis for the establishment of APOC with headquarters in Burkina Faso, a former epicentre of river blindness in West Africa.  

Many speakers paid glowing tributes to Dr Amazigo as an advocate for the poor and their needs.  At a dinner given in her honour, WHO/APOC donors and partners under the aegis of the Committee of Sponsoring Agencies presented the out-going director with a special bronze statue of African women gathered under a tree, apparently discussing solutions to their myriad problems.

*Ejime is a Communication/Media Consultant to the WHO African Programme for River
  Blindness Control

Saturday, 1 January 2011

Will 2011 see an awakening in our Ministry of Health

2010 has been a difficult year for keeping tabs on our Federal Ministry of Health. We have our 3rd Minister of Health in 4 years, and there is little to celebrate about. At Nigeria Health Watch (NHW), we were excited when a sister blog of the Association of Nigerian Physicians in the Americas posted a blog titled "Health Minister Gives Progress Report on the First Six Months". We read this in anticipation of a revelation that we might have missed!

But alas, this is what was reported.

...The Minister reported his biggest achievement in the Ministry of Heath to be a "new sense of urgency and responsiveness in the Ministry"

...he also told them  that "President Jonathan has been singularly focused on health policy and has invested enormous political capital to pass the Health Bill that will facilitate the development of a functional health system for the country".

Well ...not a lot to celebrate then fellow Nigerians. On the reported responsiveness of the FMOH - we will let you be the judge of that, and on the passing of the Health Bill.... we have waited for this for 6 years that we shall celebrate no more until it is signed and delivered. It is now 2011.....6 years after this bill was introduced.... 6 years!

 ...When pushed specifically on what had been actually been achieved in the first 6 months - Our Minister said "payment of the new wage structure for health workers and the arrears thereof". 

....When pushed further - our Minster referred to his “Action Push Agenda for Health”, a plan for the period from April 2010 to May 2011. During this period, his top priorities will be on "governance and stewardship", team work and industrial harmony, keeping on track the realisation of the MDGs especially the Health MDGs, disease prevention, surveillance and control, provision of affordable but world-class healthcare services at our public and private tertiary health institutions, and the establishment of a reliable referral system.

What can we say? Lots of grandiose promises and big words. What we fail to see in any of these are clear deliverable milestones that will affect the lives of ordinary Nigerians! What we seek are not big terms like "governance and stewardship" but simple things - that we can understand and hold our government to account for...or can you advise us on what to measure if "governance and stewardship" was achieved?

What Nigerians seek are simple measurable indicators for their health sector.

- If I go to a primary health care centre in Ogwashi Ukwu will my wife be seen by a nurse and have a safe delivery?

- If I give birth to my son in Jalingo General Hospital, will he receive life saving vaccinations?

- If my bus has an accident in Birnin Kebbi, will the General Hospital have blood?

- If the brand new MRI scanner in the University of Maiduguri Teaching Hospital finds a fracture at S1 - 2, will there be a surgeon to carry out decompression surgery if required, will there be oxygen for the anaesthesia, will their be electricity?

- If my president has a cold - does the tax I pay have to pay for medical care in Germany or Saudi Arabia?

All simple things really...

But sadly, health is really not on anyone's agenda. Not on the government's not on any of the opposition party's, and not on the people's...sadly.

Lately one reads statements and headlines from our Ministry of Health in our Nigeria, and we often ask ourselves ....should we really clap my hands and celebrate these as worthy of a news headline? Have we really degenerated to the level where the most basic actions taken by people in positions of responsibility are made into headline news.  As doctors, should our patients clap for us when we examine them, should students clap for their teachers when they teach? should passengers clap for their driver when he drives? should it make headline news when a parent provides for his children? I guess your answer to all this will be NO! Then please people, can you tell me why the following stories should be headline news in Nigeria:

Daily Trust: Jos Victims - Minister Promises Free Treatment, Rehabilitation

FMOH website - Nigeria restates commitment to the Global Fund

Prof Chukwu calls for commitment to the sub-regional plan of epidemics prevention and control

Channels - Health Minister tasks States, Local Govts on Public Health Advocacy

Vanguard - No woman should die giving birth, says Chukwu

FG pledges to sustain polio eradication drive

......its all the Minister "calls for", "advocates",  "pledges", "restates", "tasks".....

Not a single headline stating what the Minister has actually DONE! 

Our health sector has remained an embarrassment for the country, and misery for its people. We have lost almost all confidence that we all shrug our shoulders, and look the other way. We expect little and demand little.

So colleagues in our Ministry of Health, let 2011 be a transformational year. You have a real opportunity to transform the lives of Nigerians. The lives of many Nigerians will depend on what you do in the next 5 months. Make it count! Lets get to work....