Monday, 30 May 2011

Four Ministers in four years: can our Ministry of Health find the leadership it so desperately needs?

This article first appeared in the new country edition of AFRICA HEALTH

In the last four years of the Yar’Adua/Jonathan presidency, Nigeria had four Ministers of Health. 

It all started with Professor Adenike Grange, who had an impeccable reputation as a paediatrician and academic. Nigerians had a lot of hope in her leadership. But, her service hardly got off the ground when she lost the office following corruption allegations and an EFCC investigation. Then came Mr Hassan Lawal, who combined this portfolio with the Ministry of Labour for a few months. Mr Lawal too is currently facing corruption charges for dealings when he was subsequently given the lucrative Ministry of Works to manage. After Mr Lawal’s short tenure came the well publicised battle between Professor Akunyili and Professor Osotimehim following a cabinet reshuffle, with the later winning and becoming the Minister of Health. He had great plans for the Ministry, transversing the country to get support for his National Strategic Plan for Health, using the approach he used when he was director of the National Agency for the Control of AIDS. But he had hardly settled down to implement the plans when President Yar’Adua passed away and he lost his position to the intrigues of his positioning during the 3 months of uncertainty relating to the former president’s health. On the emergence of Goodluck Ebele Jonathan as president, he sought out a new leader and found Professor Christian Onyebuchi Chukwu in the quiet confines of Ebonyi State University Abakiliki, from where he was offered the Ministry of Health to lead. Most of the barely one year he has had in office has been spent navigating industrial disharmony with strikes across the country. The four Ministers in four years have been an unmitigated disaster for the Nigerian health sector, not necessarily for a lack of capacity but for a lack of time to deliver on their goals.  The losers in all this have been the Nigerian people.  The health sector has not benefitted from the sustained leadership necessary to make real progress on people’s lives.

But, why does leadership matter? The problems facing our health sector in Nigeria are often over-simplified as relating to the lack of funding, appropriate technology and human resources. These are all true, but do we really think that given the resources, equipment and personnel our hospitals will be buzzing with activity and our immunisation programmes would work? I don’t think so! I would suggest that the single biggest challenge in all our health institutions from the Ministry of Health to our health institutions in Nigeria is one of leadership. Now more than ever, we need leaders who will develop innovative policies and programs, and assure that systems are maintained and improved, within whatever resources they have available.

The ambitious agenda for the rapid development of Nigeria by 2020 in line with the Federal Government’s Vision 20 2020 programme would require transformation in the way public services are delivered. The population must feel that they own the public services and they are getting a service that is appropriate and efficient.  Yet this transformation has to be done within the limited resources available due to the economic realities of our time. All the investments in the infrastructural development of the health sector undertaken by current and previous governments may go to waste if there is not an accompanying change in attitudes of those that deliver public services to the people; public servants. This is most urgent in the health sector.

There is political capital to be gained in transforming the Nigerian health sector, but this transformation is a little more complex than bringing Julius Berger to build great infrastructure. The health sector is complex and requires competence, passion, and resolve. As the president deliberates on his new team of Ministers, we urge him to pay particular attention to the next Minister of Health. Once he has chosen his Minister, he must assure him of the time to deliver on his programmes and empower him with the space to do so.

We must not underestimate the challenges faced by the Nigerian health sector. The Nigerian health sector has to respond to outbreaks of old diseases like cholera and measles as well as the increasing burden of chronic illnesses, increasing patients’ expectations regarding the quality of health care they receive, escalating labour union demands and resource constraints. This makes leadership all the more critical. We cannot afford to get it wrong this time. We eagerly await the appointment of a new Minister of Health (or the reappointment of the present one) who will take the Nigerian Ministry of Health to the next level; a minister that will be able to empower his staff to deliver and communicate to the people his vision for our future.

Leadership matters to the health sector now more than ever before. It matters at the ministerial level but it also matters at all levels in the Ministry of Health, its parastatals and tertiary hospitals. Business-as-usual is not good enough any longer. 

We must put our best foot forward!

Monday, 16 May 2011

"Being the change" – Nigerian specialists providing world class endoscopy in Nigeria

We will be bringing you a series of articles intermittently over the next few months on Nigerians who have decided to challenge conventional wisdom, and deliver world class health services in Nigeria. This will not be about fancy buildings or hotel service; it will be about delivering quality health and healthcare. 

We had heard that a few colleagues with complimentary skills had recently started a clinic in Lagos. We also heard that they had a gruelling schedule, literally flying to Nigeria from London, for 4 - 5 days every 3 weeks! So it was time to visit these colleagues to see what they were doing in Lagos. After driving around Lagos for a bit, we found the clinic nestled in a quiet street in Ikoyi . There I met Austin Obichere, one of the partners in D&TEC (Diagnostic and Therapeutic Endoscopy Centre) . He showed me around the practice, and shared the partner's vision.
Before getting to that, let us deal with the definition of endoscopy -
Endoscopy is the examination of the body's interior through an instrument inserted into a natural opening or an incision. Endoscopes include the upper gastrointestinal endoscope (for the esophagus, stomach, and duodenum), the colonoscope (for the colon), and the bronchoscope (for the bronchial tubes). Attachments to the endoscopes can take tissue samples, excise polyps and small tumours, and remove foreign objects.
The challenge with endoscopy is that you are completely at the mercy of the surgeon, classic information asymmetry. He alone understands what he sees when the scope is inserted into an opening in your body. They analyse what they see with trained eyes, and make a judgement whether what they see is normal and abnormal. If it is deemed abnormal, they then decide whether it is abnormal enough to proceed with a course of action, take a sample or decide to wait and see! Big decision for patients! I sat through a consultation with one of Austin's patients. He gently obtained the consent of the patient for me to be present during the consultation, explaining that I was a colleague. He proceeded to explain the details of the procedure he was about to perform. He then explained the potential risks and benefits of the procedure, always stopping to re-assure the patient, and carefully taking into consideration any possible concerns she might have had about the procedure. Apart from the technical expertise delivered by the clinic, attention to bedside manners was central to the healthcare delivery, and this stood out during the consultation. In the same way that the "Customer is King" in a retail environment, the "Patient is King" in a healthcare setting, and health practitioners have a duty to ensure the patient gets empathy, as well as satisfactory clinical care from their doctor.

Clean and appropriate infrastructure
The three colleagues managing this Practice are surgeons who have practiced for several years in the UK, and in addition to general surgery have acquired rare expertise in using complex flexible tubes (called endoscopes) to look into the feeding pathway, the airways, the urinary and reproductive pathways of the human body in order to make a diagnosis, and where possible solve a health problem without the need for more invasive surgery! I asked Austin why they were putting themselves through this arduous regime of flights, and absences from their families. He spent the next hour filling me in on the disastrous stories of mis-diagnosis that had come his way, and stories of surgeries that had gone awry. At some point he said - he could no longer justify the cosy life of clinical practice in the West. At the same time, he felt that the circumstances in Nigeria were not ready to fulfil his other professional needs in this niche area. So he had to find a way to contribute to Nigeria without cutting his ties to his professional circles. It all came together when he linked up with two other colleagues; Abuchi Okaro and Ayo Oshowo, and they realised  that in addition to having similar expertise, they also had a shared vision for Nigeria, and the rest fell into place quite quickly.

Was starting off difficult? Absolutely he answered, but hugely rewarding. There are several recognised 'pre-cancerous' conditions that if detected early and treated can alter the natural history of the disease, literally giving people a new lease of life. One can have a significant impact on people's lives by getting this right. But on the other hand, start up costs for this specialist area were quite high, and there is a need to maintain extremely high standards of sterilisation for equipment that penetrate the human body in such depth.

But in addition to seeing patients referred to them, what else were they were doing to inform people and colleagues on the need and benefits of the rare clinical service they provide? Are they training other colleagues? Are they actually contributing beyond their own practice? Austin said that this was one of their key objectives and primary drivers. To achieve this, they were running a "masterclass" for medical colleagues in Lagos in the first instance. Reading through the Nigerian Guardian, I saw a report of the first of such courses, and knew that Austin had kept his word!  They are also planning a series of health awareness campaigns to inform and enlighten the community on the risks of cancers of the gastrointestinal tract, and what can be done to detect and prevent them….a tube in time literally saves lives!

Austin, Abuci and Ayo During a recent course organised for doctors in Lagos (courtesy of Nigerin Guardian)

Why is this story so important for us? 10 years ago we published a paper in the Lancet that showed that 50% of all the members of 3 sets in our medical school (Univesity of Nigeria) had left Nigeria. We are sure this may be more in the region of 70% at present. While many in our parent’s generation returned to Nigeria, many Nigerian doctors have found this difficult to accomplish. There are a myriad of reasons for this, none of which are easily surmountable! For several reasons, the old model of coming back to set up a solo clinic or working at your local teaching hospital is unlikely to be attractive. We have to learn to be innovative about our return home. Our governments also needs to think innovatively on how to attract some of its most valuable resources home. A solitary "Diaspora Desk" at the Ministry of Health, or signing MOUs with various groups is just not enough. Abuchi, Austin and Ayo have provided a small glimpse of what is possible. But it can be scaled, and it can be made easier.

It is simply amazing that probably the best endoscopy unit in Nigeria is not in any of the acclaimed centres of excellence that our Federal Government and its Vamed contractors has spent millions of dollars in the last 12 years refurbishing and equipping but in a small corner in Lagos managed by 3 Nigerians with little more than their skills, guts and perseverance.

Read some press articles here and here.

The winners can only be the Nigerian people!

Monday, 9 May 2011

The Midwives Service Scheme - an emerging success story

Yesterday was Mothering Sunday (8th May) in some countries among Christian communities (would it not be great if a common date was agreed across all countries) we thought we should bring you the story of a scheme that is bringing hope to our mothers across Nigeria; the Midwives Service Scheme (MSS), managed by the National Primary Health care Development Agency.

Maternal mortality has continued to be one of our most serious challenges in Nigeria. Despite several efforts (policies, initiatives and instruments etc...) we have not been able to make much progress with this most basic indicator of health and development. In the North East zone the maternal mortality ratio according to the most recent Demographic and Health Survey is as high as 1,500/100,000 live births; meaning literally that just over one in a hundred mothers lose their lives during childbiirth. An extremely distressing statistic.....

To respond to this, the Midwives Service Scheme was established in 2009. It recruited midwives from across the country, some unemployed, others previously retired but still able. The aim at the onset was to provide an emergency stop gap to the human resource shortage of skilled attendance at the level of Primary Health Care in Nigeria by mobilizing and deploying these midwives to health facilities in rural communities. It will not solve all the problems but it is a a start!

The scheme uses a cluster model or hub and spoke arrangement in which 4 Primary Health Centre (PHC) facilities are clustered around a General Hospital. A total of 1,250 health facilities in the 36 states / FCT,  were selected based on agreed eligibility criteria comprising of 1,000 PHC facilities and 250 designated referral General Hospitals making 250 clusters. Each midwife is trained in skilled birth techniques, and is equipped with a ‘mama kit’—a series of tools such as a stethoscope, razor blade, essential medicines, weighing scales, blood pressure indicator and mobile registration system. The midwives also perform child immunizations for facility-based births and family planning services. The major objectives of the scheme are...
  • To increase the proportion of pregnant women receiving antenatal care from 38% to 80% by  December 2015
  • To reduce Maternal, Newborn and Child Mortality by 60% in the MSS target area by 2015.
When I visited the project consultant Dr Ugo Okoli, one cannot help but be inspired by the work they were doing. She spoke with passion about the midwives they had recruited to the scheme who were working across the country, often far from home. She referred to how they were appreciated by the communities they were serving. Dr Okoli also spoke about the programme at the 2nd Nigeria: Partnership for Health Conference in London, last year.

Another innovative approach to the project is its use of mobile phones to collect and send data from the Primary Health Care facilities to a central location for analysis. Entries are collated on the phone and transmitted via 3-page SMS units to the central remote server for processing. Reports are presented in charts  for analysis. This data is then monitored centrally and the managers of the scheme are able to respond to the data in real time.

Other partners in the health sector are now falling over themselves to support this programme, and rightly so! The Federal ministry of Women Affairs launched an ambulance scheme and this has been affiliated to the centers involved in the MSS scheme, while WHO and UNICEF are supporting the capacity building of midwives. PATHFINDER international has provided anti-shock garments for the 37 Midwifery schools in the country.

The scheme is already making a significant difference to the lives of our mothers. The major challenge the programme faces is making an impact in the North East zone. But with energy and drive the programme has shown, maybe we can turn this around.

So the question on all your minds will probably be if we can bring this system to work, why is the rest of the primary health care sector in the rest of the country in such a state. Why is data collection from the health sector such a challenge. These are valid questions for which the NPHCDA will do well to provide the lessons learnt. They promise that they will be documenting progress over the next few months, and hopefully we can build on this as an example that we can deliver an innovative programme when we focus on it.

Watch a video of the scheme HERE.

Wednesday, 4 May 2011

Reaction to "The Edge of Joy" - MUST READ!

The night we posted the last blog I got an email from a good friend in Lagos. I have not been able to get this out of my mind. I therefore asked him if I could share it with you. Sometimes when we write and advocate for a better deal for health and healthcare in our country it might sound a bit abstract. It is hard to imagine that we are talking about life itself, our existence, our humanity. Read this post and reflect on it...and note that this is not happening in some obscure corner of our country to some poor citizen.   This is happening to one of us - just like you, living in Lagos, middle class, happy and full of energy about the future....Read his email, unedited...


I have extracted a quote from your recent NHW blog as a real life testimony of some of the salient issues you raised...
"Imagine a woman in labour; and her husband does manage to get her to a hospital. it is 8pm. He has to find blood…., the town is dark as there is no electricity….the private laboratories are all closed"
That was exactly the situation when a couple of months ago when my younger cousin was going to become a first-time father.

A young, upwardly mobile banker, he had payed a high premium to register his wife for antenatal care in a highbrow Victoria Island private hospital. He was therefore shocked when he got his wife who was in labour to the hospital and some nonchalant nurses ordered him to go and get blood!

Never lacking in humor, and despite his anger, he asked what they took him for: A cultist or occultist wondering how on earth they expected him to intuitively know where to get blood from that night! As the go-to-person for my family and friends in difficult medical situations (a.k.a. "where there is no doctor"!), I was called upon to advice on the nearest possible blood banks.

Given that he had tried Island Hospital unsuccessfully, I suggested Military Hospital Ikoyi where he managed to get 2 bags which were then taken to St Nicholas Hospital for testing.

In parallel, I was working my contacts and my friend who is an obstetrician was able to get us some supply at the Lagoon Hospital. First she expressed surprise that a patient's relation will be sent to go and look for blood at night when giving blood is not standard practice in child birth.

Finally at about midnight, the result of the blood test at St Nicholas indicated one of the two bags tested positive for HIV! My young cousin was in shivers, his mind was imagining all sorts of scenarios that could have happened if his wife had been transfused with the contaminated blood.

Eventually the wife had an uneventful delivery but the drama was not over.

The next morning he was handed his baby's placenta to dispose of!

That's the situation of our healthcare delivery system in 2011!!!

My brother ......where do we start?