Tuesday, 17 January 2012

To protest, or not to protest - a doctor's dilemma

The protests on the withdrawal of petrol subsidies in Nigeria has provided doctors with an ethical dilemma. Do they join the protests on the petrol subsidy removal and "close shop", or stay in their clinics and hospitals since the service they provide is  an essential one? In many cases, this is a rhetorical question as even when healthcare professionals intend to get to work – this is not an easy feat – especially in areas where the protests have been most intensive, as has been the case in Lagos, Kano, and Kaduna. Unless ofcourse one lived within the hospital premises. 

Photo credit: Jide Odukoya
The Nigerian press reported that both the Lagos University Teaching Hospital (LUTH) and Eko Hospital, Lagos, two of the largest providers of healthcare in Lagos have been rendering only skeletal services since the beginning of the protests. Suleja General Hospital, Niger State discharged all the patients on admission at the hospital as they  claimed that hospital workers had deserted their duty posts to participate in the protests. In Lagos, hundreds of doctors were said to be ‘on ground’ at the epicentre of the demonstrations at the Gani Fawehinmi Memorial Park in Ojota to provide immediate medical attention to protesters who sustained injuries during the protests. 

The professional associations have also been at a loss regarding how to respond, trying hard to stay on the side of the people. First, the Nigerian Medical Association threatened to ask its members to withdraw its services. The President of the NMA released a statement saying 
“The NMA will not hesitate to completely close down all health facilities in the country if government allows the NLC/TUC civil society strike/protest extend to Friday, January 13, 2012”. 
After an uproar by members of the public, it rescinded its own decision. The Association of General and Private Medical Practitioners of Nigeria (AGPMPN) called on the Federal Government to put palliative measures in place and urged negotiations to reduce the price of petrol, while the Ekiti State chapter of the Nigerian Medical Association on Friday opened a free medical camp, where protesters against fuel subsidy removal could receive treatment for free. So it continued.....and my personal view is that medical doctors should not leave their clinical practice to join the protests. We can show our solidarity by not charging the patients that come to us during the protests or even by working longer hours but not by abdicating our duty of care to patients. The patient with her pregnancy, acute abdomen, stroke or cardiac arrest will come, despite the protests, so we really have no choice but to work and care for our patients. Of course, when off-duty we can do what we choose to.....what do you think?  What would you expect your doctor to do?

Photo credit Jide Odukoya
Ultimately, these protests are about much more that petrol. They are also about a failure of trust in government. The Nigerian government expects citizens to tighten their belts while they go on living in ostentatious luxury. But lately, with more access to information on how our government’s spending borders on the obscene, Nigerians are using this access to information to increasingly look to hold our government to account. This is aptly illustrated by this tweet: 
@aizukanne - Are u aware the VP's medicine cabinet @ N314m is almost as much and the National hospitals total overhead @ N350m
Find the budget for the Federal Ministry of Health hereIn addition to the lack of trust in our government, Nigerians have also had enough of a government that often just refuses to lead. As with the controversial Petroleum Industry Bill, the Health Bill just lies around – everyone in government ignores it. So, for most Nigerians, these protests are also about a lack of transparency, good governance and a wasteful use of our financial resources (not forgetting human resources), and unless the government uses this opportunity to restructure its relationship with its citizens, it is unlikely that Nigeria will know peace for a while to come.

Something has changed in Nigeria and things will never be the same again. Those that want to - let them listen. 

Saturday, 7 January 2012

My New Year's wish - an efficient, proactive and responsive Blood Service for Nigeria

Over the Christmas period, our country Nigeria was again in the news for the wrong reasons. On Christmas day, we made headline news on all the major international news channels as a bomb exploded in a church on the outskirts of Abuja. Again there were calls in the press for Nigerians to run out and donate blood, focusing the country again on the paucity of our emergency preparedness. Every woman that has given birth in Nigeria will tell you about the high drama that surrounds securing emergency blood should it be needed. We run around for blood as if it is rocket science to organise a blood service- it is not.

So, we have done a bit of thinking into what it will take to run an efficient, proactive and responsive blood transfusion service in Nigeria. Firstly - lets look at how blood transfusion happens in Nigeria - Almost all of it is based on family or replacement and paid donations. For instance - when  a woman is about to give birth, or a patient is about to go for surgery - they are asked to provide a number of units of blood. This is either donated by a family member or if unavailable, by a paid "donor". This method increases the risk of infections including HIV (even when tested), Hepatitis B, Hepatitis C etc.

Culled from the National Blood Transfusion Service Website
So basically there is an entire industry of illegal and lucrative blood banks that rely on "blood touts" for the supply of blood sold to needy patients. It is  an incredible hassle getting blood, the chances are it might cause more harm than good. In recognition of this problem the National Blood Transfusion Services was set up and a National Blood Transfusion Policy adopted. But with its 15 centres across the entire country, there is very little it can do - and just like all our public sector services - it barely functions. To find out how a national blood service can work - I recently visited the South African National Blood Service headquarters in Johannesburg.

My first surprise was entirely organisational. While it is called the South African National Blood Service (SANBS) - it is actually not part of government and run as an autonomous not-for-profit organisation. It receives absolutely no allocated funds from government. However - the Department of Health of the Government of South Africa is its biggest client, taking up 55% of its services. Government hospitals buys blood from SANBS for its patients. SANBS ensures that all the required blood is delivered safely and, on time, and to to There is a negotiated price for a pint of blood, SANBS only gets paid when the blood required is delivered and runs its services completely based on fee-for-service income, in addition to some donations.

My second surprise - all its operations - all its 900,000 pints of blood required annually across the entire country are sourced entirely through voluntary blood donations. In addition to a strong regular donor base, it has an extremely active "marketing" team - using telerecruiting, university campaigns and increasingly social media tools such as twitter, Facebook to recruit donors. This is supported by a significant electronic database of all previous donors, enabling active management, follow up etc.

My third surprise - the risk of transmitting HIV through blood transmission in South Africa has been eliminated. This is because South Africa introduced NAT testing (a testing method that detects HIV almost immediately after infection). Since the introduction of NAT testing there has not been a single documented transfusion associated transmission of HIV. In Nigeria, blood  is screened for HIV using only antibody tests. This does not detect HIV during the "window period" meaning that some blood units will continue to pass through screening undetected.

But, by far my biggest surprise was the steely determination of staff working at the blood unit to keep the blood supplies flowing. With this ticker on their website indication stock levels across the service they not only motivate themselves, but also alert the country to the needs of patients. Apart from the competence and determination of the staff - what else made this system work I asked ?. Three things - I was told.
1. three well equipped and managed  laboratories
2. an integrated IT system
3. a tightly managed transport and logistics operations.

On driving away from SANBS ...the penny drops. With a subvention driven blood service, managed by our Ministry of Health, it will never be able to meet the needs of the Nigerian people. The South Africans have managed to innovatively integrate incentives to drive a successful model - if they do not source the donors in order to supply the hospitals - they do not get paid! There are no such incentives for my colleagues at the Nigerian Blood Transfusion Service.

I hear many of you saying - but this is South Africa - Nigeria is way behind in terms of infrastructural and societal development. Well, that may well be the case, but it did not stop MTN from leap frogging its South African operations. Nigerian banks are right on the heels of the South Africans. So what is it that is driving exponential growth in these sectors that is absent in the health sector.

The answer is simple - a tax funded system of delivering services - almost entirely subsidised by government is unworkable in Nigeria. It is the same reason reason NITEL, NEPA, Nigerian Airways, our refineries etc all failed. Yes, we cannot completely privatise all our public services but we must innovate around them, seeking ways of introducing incentives to ensure delivery. This requires innovation - innovation is absent from the Nigerian public sector.

Consider that government organisations still carry files around manually from desk to desk as was the case in the 60s !!