Wednesday, 24 August 2011

An air ambulance to India

A friend of mine travelled from Lagos to New Delhi for a business meeting, and called me shortly after his return. "Chikwe, you will not believe what I experienced on the flight; almost every passenger had a tube of some sort, from catheters to intravenous lines, often accompanied by nurses or/and family, both in business class and economy class, all headed to India for healthcare that they cannot get in Nigeria". He said it felt like being on an air ambulance. A Nigerian newspaper speculated that at  least 3,000 Nigerians travel each month for medical treatment to India, spending close to $200 million (N30 billion) yearly. While it is not clear where these figures come from, another newspaper is explicit in reporting that the Indian High Commission in Nigeria issued 4,000 medical visas to Nigerians seeking medical treatment in Indian hospitals in 2009. This is what has become of our once great country.

What started as a niche endeavour, often for serious conditions such as renal transplants has evolved into big business. As the years have progressed, more and more people are losing confidence in the services offered by our hospitals in Nigeria, and raise funds desperately to go to India for even minor ailments. Indian hospital services have risen to the challenge of the discerning Nigerian, who often come with his payment in cash and have access to a wide range of care, but also ancillary services including airport pickup, accommodation for the family, support with logistics in India and even phone cards to call home. All of this can easily be organised over the internet by companies specialising in "medical tourism". But it does not end there, at the end of treatment, patient "testimonials" are put up on hospital websites as this one. There are even emerging "innovative" health insurance packages offering healthcare in India.

Not satisfied with the Nigerian patients coming to India, they are bringing Indian healthcare to Nigeria. The famous Apollo Hospital group recently announced plans to build a hospital in Nigeria. A modestly named Primus International Super Specialty Hospital has recently started providing health care services from Karu, in Abuja, and it appears that Nigerians have not wasted any time in making it their new favoured destination for health care in Abuja.

So why has the Nigerian healthcare industry not evolved and kept pace with the rest of the world. Like India, we have Nigerian doctors trained and are working in the best healthcare sectors in the world. Across the USA and the UK, Nigerian doctors have reached the very peak of their professions. We have a growing and discerning middle class. We had pioneers in the provision of private health care in groups like Eko Hospitals. We have huge banks with money to spare to finance projects in healthcare. Mckinsey in its important report in 2009 stated that:

The expected improvement in Africa’s macroeconomic climate over the next decade will expand the healthcare gap, as higher incomes will create new demand for quality.
So, while we are happy for the entrance of India into the Nigerian health scene, at least for the sake of those that are not able to travel, we really need to see some of the innovation that has driven the growth of the telecommunications industry, the financial services industry brought to bear in the health sector. The truth is that such innovation will not necessarily come from doctors, infact it is unlikely to!  For growth to happen, we need innovation in financing models, management models as well as the core medical expertise. No country's health sector has grown with a fee-for-service structure as is presently pervasive in Nigeria.

I truly believe that the health sector is the next big thing.....but it will depend not on the money we throw at it, but on our ability to combine our intellectual capital to find a workable solution for Nigerians. Because of the pace of development around the world, this will have to come both from expertise in Nigeria and in the Diaspora.

Nigerians can do this....! If not for our health, for the money. While investing in the Indian economy is great, investing in the Nigerian economy is even greater, and maybe we can save a few lives in the process.

In my life time, I hope we will see people travelling to Nigeria for their health care - as one of my mentors says - we have to set BIG BOLD and AUDACIOUS goals for ourselves - this is one! 

Lets go do....

Thursday, 11 August 2011

Visit to Chris Hani Baragwanath Hospital - the largest hospital in the world

One often needs to look beyond the circumstances at home in Nigeria to understand the scale of our challenge. We have 17 Teaching hospitals, and a Federal Medical Centre in every state without a Teaching Hospital. During a recent visit to my alma mata - the University of Nigeria Teaching Hospital Enugu, I found many of the beds empty. I remember this was the case even when we were in Medical school - especially in our famous 140 bed medical ward. I often wondered why the beds in the premier tertiary care facility in Eastern Nigeria were empty.

As I made my way to "Bara" recently, I wondered if this would be the same. "Bara" (as it is affectionately called in South Africa) is reputed to be the largest hospital in the world, with approximately 3,200 beds. It is at the entrance of Soweto in Johannesburg. It is a teaching hospital for the University of Witwatersrand Medical School. Patients travel there from all over the country and surrounding African nations. The hospital employs almost 5,000 people, including 600 doctors and 2,000 nurses, and has about 10 km of corridors!

Walking around the corridors of the hospital with my South African colleagues on a "Grand Round", it is impossible not to reflect on the health challenges in the South African population. But it is also impossible to miss the pride with which colleagues here have dealt with these challenges - especially that of HIV/AIDS. There are more people living with HIV/AIDS in South Africa than in any other country in the world. This is followed on the African continent by Nigeria. The difference between South Africa and Nigeria is in how they have responded (despite the initial politicization of access to ARVs).

Our grand round was led by Dr Alan Karstaedt, the Director of the hospital's Institute for Infectious Diseases. He has been working at Bara since the first case of AIDS in South Africa was diagnosed in 1987. Despite efforts by the South African government to "down refer" patients to the primary care level, Bara still has over 5000 patients with HIV on its list. After the round we spoke in detail about how practice has changed and how every medical diagnosis has to be reconsidered in the context of a possible underlying HIV infection, especially now patients are living longer with access to ARVs. After eating lunch together at the modest "tea room" on the hospital grounds...I thought of asking Alan why he stays at Bara, but could not bring myself to ask. I guess the answer was obvious....a colleague for whom the profession remains a vocation.

Bara is a magnet for medics from all over the world, drawn to its wards for the invaluable experience it gives them. With an acute shortage of doctors, nurses in South Africa, one day in Bara can be as insightful for young doctors and nurses as one month or more elsewhere in the world. Despite its difficult history during the apartheid years and the challenging present the fact that this hospital works, and is literarily full every day is testament to the resilience of the country.

Public sector hospitals in South Africa get a lot of criticism from its population, as do ours in Nigeria. The anticipation of details of a National Health Insurance Scheme that will guarantee universal coverage for the population is on most people's minds as the government grapples with the complexities of delivering health care to a population that has the largest differences between rich and poor in the world. But this is in effect no different from the challenges Nigeria faces. Ultimately, the planned National Health Insurance in South Africa will succeed or fail on one critical point - people's confidence that they will get appropriate care in a public sector hospital.

Nigeria urgently needs to have an open debate about its public sector hospitals. Eighty percent of all health expenditure at the Federal level is spent on our tertiary care facilities. Yet, while I do not wish for any hospital in Nigeria to become the largest on the continent, but we want our hospitals to work, to serve the people they are there to serve. We want our brightest and best to stay in Nigeria to find their vocation and stick with it. We hope that our hospitals get their groove back, that they become real "centres of excellence" always working in the best interest of the people. I think of Alan's illustrious career and wonder why most of the consultants in my clinical years at the University of Nigeria, Enugu had all either left the country, retired or just given up on the public sector. I think back to the inspiration we all drew from these colleagues and wonder where the colleagues in medical school at the moment are getting theirs from....

We will inevitable reap what we sow....

If you visit Johannesburg, pls do leave your fancy Sandton hotel and visit will be well worth your time!

Saturday, 6 August 2011

The controversial clause in the "new" National Health Bill

The "new" National Health Bill is stuck in the presidency where it has been sent to be signed, as health sector professionals quarrel over a significantly flawed yet, trivial clause in the bill. This does more to illustrate the state of national thinking and dialogue, than anything else in recent national discourse. It is a pity that all the politics in Nigeria is tribal - and this is not just about the ethnic based "tribes" - but is also the tribes of professionals - doctors' vs pharmacists' vs nurses' etc. The tribes of "home grown" vs "diaspora" medical professionals. The tribes of "federal" vs "state", the tribes of "PDP" vs the "rest of the world", "public sector" vs "private sector".....all our politics is tribal! So the debate on the health bill is not about how it will best affect the health of the Nigerian people, no! There is actually no pretence about it - its just about the professional tribes, and how they are positioned to manage 80% of the budgetry resources on health spent on tertiary care at the Federal level in Nigeria. This is currently spent on our 17 teaching hospitals, 3 Orthopaedic Hospitals, 8 Psychiatric hospitals, one National Eye Hospital and 22 Federal Medical Centres around Nigeria. Until now each hospital has had its own management structures, with a super powerful Chief Medical Director.

The bill sets up an innovative structure called the "National Tertiary Hospitals Commission" to better manage this 80% allocated to tertiary care annually. Specifically the Commision is mandated in the new health bill to do the following (amongst others)

  • Establish minimum standards to be attained by the various tertiary health facilities in the nation and also to inspect and accredit such facilities;
  • Advise the Federal Government on the financial needs, both recurrent and capital, of tertiary health services and in particular investigate and study the financial needs for training, research, and services and to ensure that adequate provisions are made for these;
  • Set standards and criteria for allocation of funds from the Federal Government, monitor their utilization, source for grants as laid down by the Commission;
  • Collate, analyse and publish information in relation to tertiary health care services annually;
  • Monitor and evaluate all activities and receive annual reports from the tertiary hospitals, reward performance, apply sanctions and supervise annual peer reviews; 

This is all great stuff, and there is little to argue about, rightly so! Now the crux of the matter holding up the bill, has nothing to do with all this but simply on the Commission's leadership.  The new bill states that the "Executive Chairmanship of the proposed National Tertiary Hospitals Commission must be a; 
"Medical Director of the status of a Professor with a minimum of ten years working experience in a Teaching Hospital" 
This clause that limits the Executive Chairmanship to medical doctors in perpetuity has all the other health professions up in arms. Doctors argue that it is their traditional (read tribal) role to lead a medical team. The other health professions argue that they (their tribe) must also have a go at leading the commission. 

It is our contention at NHW, that this clause in the health bill is flawed, as it does not protect the best interests of Nigerians, and has placed tribal interests as belonging to a profession (a tribe of doctors), reaching an academic height (a tribe of professors) and having worked in teaching hospital (a tribe of public sector workers) - none of which ultimately guarantees a good leader and manager which the National Tertiary Hospitals Commission needs to fulfill its promise to the Nigerian people. 

Mr President - lead. On behalf of the Nigerian people, send the bill back to the Senate and House, let them remove the clause and open up the leadership of the commission to all those able to lead and manage, and let us move on to more important issues. The fundamental questions that we are not answering are -

- how best to organise and manage our health service
- how to fund our health service adequately
- how to balance the often conflicting demands and expectations of patients, staff and taxpayers
- how to ensure finite resources are targeted where they are most needed.

The health of our people should not be subject to tribal politics.

P/s declaration of a potential conflict interest - Chikwe is a medical doctor who believes that doctors should lead in the clinical management of patients!