George Egbuchulam: why we must act now!

I write with tears in my eyes. I’m heartbroken, I weep for the future of my country if people like George Chimezirim Egbuchulam should be dying from curable medical conditions. I’m terribly disturbed because I’ve continued to see this kind of deaths since my days in medical school. While some may see it as an act of God, it is perhaps more traumatic for those of us who due to our professional training, know it ought not to happen. The question then is, why can’t we stop it?

A lot of times, determinants of health and outcomes of health conditions are not within the control of the medical personnel. The behavior of the people and the actions and/or inactions of the leadership of any society largely determine the state of health and life expectancy. In the case of George, the later is to blame.

Late George Egbuchulam

Over the last months, George, his family, friends and well-wishers, medical personnel at the University College Hospital (UCH), Ibadan and even folks like me that haven’t met him fought through prayers, fundraising, professional input, blogging, etc to save his life. How I wish death had spared George for the sake of the loved ones and what he stands to contribute to societal development, but it didn’t. What do we do now? The usual stuff: shed tears, blame health workers or UCH, observe one minute silence, fill condolence registers, do candle light procession, post nice words about George on our facebook and twitter timelines; and move on? No, George deserves better that. Nigerian youths deserve better! We must not allow this to repeat itself, but how do we stop it? Let me give a brief background about the medical condition that killed our beloved friend, George.

Chronic Renal Failure (CRF) is an abnormal condition when the kidney is no longer able to perform its functions optimally and it is usually caused by chronic kidney diseases (CKD).  Common causes of CKD in Nigeria include chronic glomerulonephritis, hypertension, diabetes, sickle cell, urinary tract obstruction, etc.  The functions of a normal kidney includes blood formation, maintaining calcium balance to make bones strong, removal of harmful metabolic waste products (like urea and creatinine), control of blood pressure, maintenance of potassium balance which enhances the activities of the heart and also regulates the pH of the blood. When the kidney fails, there will be low blood count (anemia), weak bones, accumulation of toxic substances in the body, high blood pressure, heart failure and increased acidity of the blood. All these do not occur at the same time but anyone that occurs progressively gets worse as the illness progresses with time. The goal of haemodialysis is to remove excess fluid and toxic metabolic products from the body. It is not and can never be as effective as the kidney will do it naturally. It has its own side effects too. It’s only a temporary measure and transplant ought to be done as quickly as possible. 
   

A cross-section of the human kidney

 

In the case of George, a scanned UCH radiological investigation request paper I found in google images suggests he had chronic glomerulonephritis (CGN). The functional unit of the kidney is the nephron. The part of the nephron responsible for filtration of harmful waste substances is the glomerulus.  CGN is the inflammation (swelling) of the glomerulus and it has various types; needless to bore you with their names. It appears to me that he was in Stage 3 renal failure around July 2012. There are some types of CGN that 80 to 90% of patients may progress to Stage 4 (end-stage) renal failure within 10 days to few weeks. If transplant is not done early enough, the body progressively gets weaker even with ongoing dialysis. It may get to a level that it may not be strong enough to even withstand and survive the transplant. This is the problem most people with this condition face in Nigeria.

Our health system unfortunately is in a condition where about 70% of expenditure is out-of-pocket in a society where about two-third live in poverty and half of the youths are unemployed. The disease does not understand that the money is not there, it continues to get worse if unattended to. Many countries including Rwanda have social health insurance covering this type of condition. If Nigeria had such, perhaps George might have had his transplant as early as July, and wouldn’t have had to be on dialysis until September when good-spirited Nigerians were able to raise adequate funds for the procedure. Perhaps we wouldn’t have lost him. Yes, he would have lived. I’m very upset, same way I was when I lost a 17year old patient who was the only child of her widowed mother; same way I was when a youth corps member with similar condition had to leave our care in hospital for prayers because of lack of funds only to return later in a worse condition and eventually died. Some got sponsorship from their state governments and went to India for transplant, but couldn't return alive; the funding came late. Too many cases!  I can still see their faces, they all shared their dreams and life ambitions with me but they are gone with those lofty dreams. I wept the days I lost them, it could have been me, and it could have been anyone else.

More so, one thing I’ve learnt from many change-makers is that they’re usually inspired by an unpleasant occurrence. I heard many of such accounts while watching the presentation of CNN Heroes recently. The Tunisian revolution was reportedly instigated by an unemployed youth who committed suicide.  My health advocacy activities since my undergraduate days at the University of Ibadan (UI) were also inspired by some ugly personal experiences and furthered strengthened by my professional experiences too.  We need a stronger health system in Nigeria to provide good quality, affordable and equitable health care. When I read Fisayo Soyombo’s piece on George in July, I decided to do an article on this blog to support the fundraising effort and draw attention to what people with such conditions go through. Like Fisayo, George would have been a very close friend if I had met him in person. They both share admirable and enviable qualities. Beyond that, my colleagues and I in HAPPYNigeria launched a #SaveAll campaign to demand that government begin a functional social health insurance scheme. We started an online petition and expected that thousands of Nigerian youth will rush to sign it, so far, less than 200 have signed it.

For the sake of George, we must insist that government takes the needful measures to make our health system stronger and also begin a universal health insurance for all Nigerians irrespective of socioeconomic status. We should do it with same vigour and enthusiasm demonstrated during the #SaveGeorge campaign. I have started it in HAPPYNigeria, feel free to join the #SaveAll campaign by signing the petition here. A youth ambassador like Nze Sylva Ifedigbo wrote about it here. You can do same – update your facebook wall, tweet, blog, and sing about it, use your respective organizations, organize peaceful rallies; send SMS, call or mail your legislators and governors; just do whatever you can.  

George had a very bright future. I and many others started just like him in UI with active participation in campus journalism and other extracurricular activities. Our development as a nation will reman stunted if we continue to lose people like George in similar circumstances. No one knows who would be next. For the love of George, for the love of us and for the love of Nigeria, let the youths take action to persuade the government to make Nigeria healthier. By so doing, George will be remembered for not only doing well in life but also that his death brought about lasting change that saved many lives. Let’s #SaveAll, Act Now!

May the soul of George Chimezirim Egbuchulam rest in the bosom of the lord, and may God strengthen his family to bear his painful demise, amen.

Follow me on twitter - @donlaz4u

 

Managing Health Projects in Nigeria: My PATHS2 Experience

This piece was published on PATHS2 page in August 2012. Enjoy.

 

I’m a graduate student of the University Of Kentucky College Of Public Health in United States. I’m studying for a Certificate in Global Health and Masters in Public Health with concentration in Health Services Management. I did my summer internship at Partnership for Transforming Health Systems phase 2 (PATHS2) country office in Abuja, Nigeria.

Prior to the commencement of my graduate studies, I had a one year experience working on implementation of the Health System Strengthening project of Global Fund with focus on HIV/AIDS, Sexual & Reproductive Health, Tuberculosis (HAST) and Malaria.

I wanted a different experience during my practicum and PATHS2 provided that. Being aware that PATHS2 project being implemented by a consortium of 5 different organizations led by Abt Associates; my interest was in learning how they all work together to manage the project successfully. The experience was awesome, I must confess.

My Supervisors - Dr Amina Aminu and Dr Sam Usman

I worked directly with the Service Delivery Team at a very important period of the project when PATHS2 was preparing for annual review as well as development and costing of the Year 4 Work Plan of the project. I participated and prepared the report on a technical meeting to review the service delivery component of the project.

The 2-day meeting improved my understanding of project management and report writing skills. Although the project has same output/outcome indicators and targets, I was excited to learn how the implementation strategies varied from state to state (factoring in the people’s culture, religious belief, and some other peculiar circumstances etc) to bring about lots of success stories already recorded. The supportive supervision from Bethesda headquarters office of Abt Associates and the cooperation/ team spirit demonstrated by all the partners including DFID were amazing.

In my Health Economics class, I learnt about the management of scarce resources to get optimal value in service delivery and I learnt how PATHS2 uses the principles to get maximal value for money. I observed a technical meeting on the financing of the project, value for money for activities already executed was demonstrated and costing of the work plan for the subsequent year done. I may not be able to aptly express the impact of that meeting on me, but I have no doubt that the experience has enhanced my management skills.

PATHS2 focuses on strengthening health systems and improving the maternal, child and new born health services to reduce Nigeria’s unenviable high maternal and infant mortality rate. With the support of PATHS2, the free MNCH programme of Jigawa state government is being implemented in a cost-effective manner with satisfactory outcome.

The emergency transport scheme has brought about lots of success stories in Kano; ongoing partnership with private sector in Lagos is expanding the availability of good quality services and the support to DRF system in Enugu has solved problem of stock-outs in supported cluster facilities. Apart from advocating for the sustenance of the gains of the project, PATHS2 is also making deliberate and targeted efforts to persuade government to replicate her model in the non-cluster facilities. I consider that awesomely good.

PATHS2 has very dedicated and lovely staff; I enjoyed my time with the organization and cherish the experience and new skills I acquired. My supervisors - Dr Amina Aminu and Dr Sam Usman were awesome. My only regret is not having more time to work on the project as I have to return to Kentucky to complete my studies. I will miss the jokes of Dr Mike Egboh, the National Program Manager.

 

PATHS2 Country office Service Delivery Team

 

 

Will Nigeria’s ‘Saving-One-Million-Lives’ Initiative save a thousand?

As a growing child in my hometown, Okposi (Ebonyi State), news of a new born child in our neighborhood was always a pleasant one. My peers and I always looked forward to visiting those homes to rub a local liquid powder-mix called nzu and watch our mothers sing and dance. Our joy came from the fact that there was an additional person who would queue behind us to pick whenever gifts are shared by seniority; the new born was also a potential playmate. Okorie (not real name) was only 2years old and had many episodes of febrile convulsion. Usually while we play, we would see the mom rushing him to the clinic after applying some local herbs and palm oil, the siblings wailed while we watched with fear and apprehension. We had lost a couple of our playmates with similar condition in the past. We didn’t lose Okorie but he grew up with a very low intelligence quotient (IQ). No doubt, those convulsions caused significant brain damage.

In another development, one of our neighbors, a widow had only one daughter – Chi Chi. She got married to one spare parts dealer who used to buy biscuit for us. We loved her because she also used to shower us with gifts. We were patiently waiting for her arrival from a missionary hospital where she had gone to deliver her first baby. They came back with the baby, and everyone’s face was gloomy and eyes were red and tearful.  Chi-Chi reportedly died after child delivery. Her mother almost became psychotic.

Since then, I grew up with lots of questions on my mind. Why was Okorie’s fever always leading to seizures? What may have caused Chi-Chi who was hale and hearty to die after delivery? Could such occurrence be stopped? If yes, how? I found answers many years later during my medical training. Those childhood experiences and my desire to be part of the solution to the disaster of high maternal and child mortality in our clime influenced my decision to build a career in public health.

President Jonathan, health ministers and legislators during the launch

President Goodluck Jonathan launched an initiative to Save-one-million-lives by 2015 in Abuja a few days ago. It is a comprehensive program to scale up access to essential primary health services and commodities for Nigeria’s women and children. Nigeria accounts for about 10 per cent of the global maternal mortality and has one of the highest infant and Under-5 mortality rates in the world. This initiative builds on a growing international momentum behind maternal and child survival.

I consider this initiative laudable. Any program that can save one woman or child from dying should be applauded and supported. Perhaps if this was started much earlier, Nigeria would not have lost Mrs Ngozi Nwozor-Agbo (initiator of the Campus Life page of The Nation newspaper) to child birth 4 months ago. She was one of the most intelligent and inspiring women I’ve ever met. But am I excited about this initiative? The answer is no. But I have cautious optimism.

Nigerian health professionals are among the best one can find anywhere in the world. We have always come up with laudable health initiatives many of which have been used as a template for health programs in other countries. But the biggest problem has always been in implementation. It is depressing to know that the primary motivation for a majority of the people who would implement this initiative would be how much money they would make rather than the number of lives saved. Endemic systemic corruption in the system has led to stunted growth of our health system despite billions of naira spent annually. This is what makes me worried. My expectations have been dashed on several occasions.

I have browsed the website of the Federal Ministry of Health to find details of this initiative but it appears the last update of the site was more than a month ago. By launching this initiative, I believe government has demonstrated the political will to improve the maternal and child health situation. The Midwives Service scheme, I hope, will provide human resources for the severely under-served communities but would that be enough?  Will the government strengthen the logistics management information system to ensure those essential commodities reach the intended beneficiaries and not end up in the homes of some unscrupulous officials? Will the monitoring & evaluation system be strengthened to effectively monitor the impact being made? With this top-down approach, are the local government councils who directly oversee the primary health centers effectively engaged in this scheme? Will this initiative not end up becoming Saving-one-million-naira for the officials involved?

Will this Saving-one-million-lives initiative save up to a thousand lives by 2015? Only time will tell.

May God continue to bless Nigeria. 

Sustainable Health Improvement: Is #Save'X' the way to go?

The recent upsurge in #Save'X' or #Save'Y' appeals on social media should be of great concern to any well meaning Nigerian. I was excited that Sylva Ifedigbo’s column of September 9, 2012 in Daily Times Nigeria dwelt on this subject. I wasted no time in reading the piece; had wanted to know if it addressed some concerns raised by other folks. Sylva and I have made donations towards some of these campaigns but there are concerns on whether it's really the way to go. This piece is a response to the opinion shared by my good friend, Sylva Ifedigbo and published in same newspaper on September 16, 2012. 

In my understanding, Mr Ifedigbo agreed that it is fine to provide funding assistance to people with ill-health but expressed fears that such appeals on social media could give limitless opportunities for manipulation by some bad eggs among us. He absolved government of blame but rather lampooned non-governmental organizations (NGOs) whom he also accused of applying donor funds for personal uses. He felt the solution was the development and promotion of ‘sincere’ health advocacy and philanthropy.

There is no doubt that there are some compatriots who have made it a duty to manipulate excellent initiatives for personal gains.  Mass appeal for funding support for people with health challenges did not begin with social media; I can remember the ‘Save Steve Kadiri’ appeal on African Independent television in late 90s. People also do same with scary pictures on the streets and parks. Like Ifedigbo rightly noted, the success of #SaveOke campaign on social media must have triggered the upsurge in such appeals. The credibility of the appeals was brought into question when someone was found to have included his personal account number alongside with those of the beneficiary. But apart from the proclivity to being abused, donor fatigue makes the #SaveSomebody appeals unsustainable.

Although Mr Ifedigbo made a correct diagnosis of the problem, I think the scathing remarks and blanket indictment of NGOs is ill-informed, undeserved and most unfair. NGOs like other institutions in Nigeria are not free from corruption, but that does not make them culpable for the inability of many Nigerians to afford health care. Donor agencies have targets for NGOs which they work assiduously to meet. Most donor funds support provision of free HIV/AIDS, TB, Malaria, maternal and child health services in designated facilities across the country. On the other hand, the #SaveSomebody appeals are required for the management of non-communicable diseases. I’m not aware of any donor fund meant for free treatment of cancer, chronic kidney diseases, diabetes and hypertension in Nigeria. As a health professional that have worked with both government and non-governmental institutions, I can confidently say that successive governments in Nigeria have not demonstrated satisfactory political will to addressing the nation’s health challenges.

Succinctly, the problem highlighted by this article borders on health care financing. Though it isn’t peculiar to Nigeria but is our government doing enough to solve it, the answer is NO. The report of National Health Accounts (2008) found that 69 per cent of our national health expenditure is out-of-pocket. The National Bureau of statistics report also showed that more than two-third of Nigerians live below poverty line. The official national unemployment rate (which I feel is underestimated) is about 24%. Yet, there is no functional health insurance programme for the unemployed, the poor or even children neither does the existing health insurance program cover catastrophic health expenditure as required by organ transplant and other major surgeries.

A recent study, CarapinhaJL, et al. Health insurance systems in five Sub-Saharan African countries:Medicine benefits and data for decision making. Health Policy (2010), noted that households use savings, sell assets, procure loans or borrow from family and friends to cope with high out-of-pocket payments.  Out- of-pocket payments lead to impoverishment when payment is required to access health care services and when households do not have the ability to pay.

Undoubtedly, well implemented social health insurance policies prevent impoverishment from catastrophic health events. Well-designed medicine benefit packages are therefore urgently needed to protect households from economic burden and facilitate affordable, equitable access to quality use of essential medicines.

I’ve discussed this topic with lots of Nigerian youths in the last couple of weeks and all agreed that we need a sustainable solution. In my opinion, a sustainable solution for this problem will be for government to go beyond the formal sector and implement the other five social health insurance programmes (urban self-employed, rural community, children under-five, permanently disabled & prison inmates) contained in the NHIS Act and also create insurance policy to cover catastrophic health events, the unemployed and the poor.

Additionally, the National Health Bill should also be re-presented to the national assembly for legislative action without further delay. Government cannot do it alone but she must take the lead. It is then that trusts/foundations by the billionaires, celebrities, religious/corporate organizations would become more useful and less prone to abuse. It would be awesomely good if all Nigerian youths and promoters of #SaveSomebody appeals join efforts and demand that government makes this happen. 

God bless Nigeria.

  

George and the fate of Nigerians with Chronic Kidney Failure

I was enjoying a long vacation in Lagos, Nigeria during my secondary/high school days in late 90’s when I watched the announcement on African Independent Television (AIT) calling on viewers to donate towards the “Save Steve Kadiri” Appeal Fund. Steve Kadiri was an ace broadcaster with Ray Power 100.5FM in Lagos. He was diagnosed with Chronic Kidney Failure and was undergoing hemodialysis while preparation for kidney transplant was ongoing. Prior to that time, I knew nothing about kidney disease. I imagined how serious the illness was to require kidney transplant that was to cost about five million naira (N5m) then. Steve’s colleagues in the media continued the announcement for months until he eventually had the transplant in 2001. When I heard that Steve had a successful transplant, I was excited that the moneys donated by good spirited Nigerians were not in vain. Although the transplanted kidney eventually developed another problem that claimed Steve’s life in 2009, the earlier intervention and love showered on him extended his life by at least ten years. 

I began to understand the plight of people with kidney failure during my clinical posting in Nephrology Unit of the University College Hospital, Ibadan while I was a medical student. Then, I observed that chronic kidney disease was debilitating and adversely alters the body systemic functions; I noted that the cost of hemodialysis was unaffordable and unsustainable for a middle-income earner/family and also that most of our patients were usually moved from the ward to the morgue. 

Three years later while working as a House Physician in Nigeria’s capital – Abuja, I also worked in the Nephrology unit for three months. During this time, I co-managed patients with a variety of kidney diseases and also monitored some of them during hemodialysis.  None of the aforementioned observations I made while in medical school had changed. Rather, I noticed that we had a lot of teenagers and young adults being admitted for chronic kidney failure. It also came to my consciousness that a significant portion of our patients were people of low or middle socioeconomic class. The experience was frustrating because the fate of majority of people with such diagnosis in Nigeria is usually heartbreaking.

What are the causes of kidney failure? Why would a young man have chronic renal failure? Why can’t dialysis cure kidney failure? Why is renal transplant the definitive treatment? Why is the treatment so expensive? Why is there a possibility of recurrence even after transplant? What is the government doing to raise awareness on prevention of kidney diseases? Does Nigerian government support the treatment of people with chronic kidney diseases? If “No”,  then why not?

The questions above could be one of those boggling the minds of many compatriots. I do not intend to provide the answers in this piece. Then why I’m I writing this article? 

 George Chimezirim Egbuchulam is another  compatriot diagnosed recently to have chronic renal failure. As I write, he is still undergoing conservative management and would benefit from renal replacement therapy (kidney transplant) if more good spirited people show him the kind of love that Steve Kadiri got. George is a very intelligent young man and has been full of life, doing great things and serves as a model to his younger colleagues. I’ve not met him in person but I’m not ignorant of his activities and positive impact he has been making as an undergraduate and now a graduate student of the University of Ibadan, my alma mater. It was not surprising that thousands of Nigerian youths have embarked on intense online advocacy to raise the eight million naira (N8m) for George’s renal transplant and associated postoperative expenditures. Already, over N2million has been reportedly raised but I do know the ongoing dialysis would continue to depreciate available resources.

But why should people with such conditions be allowed to bear the burden alone? The government of United States, as rich as the country is, takes over the treatment of people with chronic kidney disease under the Medicare insurance program. Would it be out of place if government of Nigeria designates a portion of our collective wealth to assist George and other people in his situation? Thankfully, Delta State government responded to the #SaveOke twitter campaign and supported his surgery for a chronic leg ulcer (most likely due to diabetes) in India; Oke is a young man in his 20’s. Must the government always wait such advocacy to respond? What about the likes of many patients I managed with similar conditions that lost their lives? Has life become that cheap?

While I use this medium to call on well-meaning Nigerians to come to the aid of George Chimezirim Egbuchulam, I strongly recommend that the federal/state governments create a fund to finance the treatment of people diagnosed with chronic renal failure and other chronic disorders that are very expensive to treat. Preventive measures should also be taken to reduce the incidence of renal pathologic conditions in the country. It’s traumatizing to imagine that George’s may have further complications should the surgery be delayed, God forbid!

Please let’s save George, kindly send your donations to any of his accounts:

GTBank – 0117968706; Fidelity Bank – 3020722444; Unity Bank - 0018310939

May God bless everyone who has made contributions towards the efforts to save George’s life very abundantly. 


Addendum:

I'm excited to disclose that over N5million has been reportedly raised for George, a kidney donor has been identified and the surgery would be done in the near future. 
I think it would be great if we channel similar energy used to canvass for the fund raising to carry out a strong advocacy for government to take over treatment of people diagnosed with chronic renal failure. This can be done through the platform of Health Advocacy & Promotion Partnership by Youths in Nigeria. (HAPPYNigeria). You may wish to follow @HAPPYNigeria on twitter.

My Vote for 'ObamaCare'

The Supreme Court of the United States recently upheld the Affordable Care Act (2010) referred to as 'ObamaCare' in unofficial quarters. I wish to share a policy analysis/position paper I presented in February 2012 at the University of Kentucky Graduate School. Kindly read and share your thoughts. 

Affordable Care Act good for American People

The United States has the highest expenditure on health among all countries of the world and this progressively increases every year. However, the country ranks 31^st on life expectancy and fares relatively worse on many health indices than many other developed nations. The cost  of healthcare in the U.S. has been increasing progressively, while family income and employment numbers have fallen or been stagnant.  In addition, health disparities appear to be widening along socioeconomic lines. According to a report by US Census Bureau, the number of uninsured Americans has been increasing over the last thirteen years and has worsened during  the recent economic recession. 
The report stated that the number of American people without insurance coverage in 2010 was September 2010 was made up mainly of young adults aged 19 to 25, and low income families with an annual household income of less than $25,000. Much of the declines in the rates of insured Americans can be attributed to the loss of employer-provided coverage, which fell amid sustained unemployment and as employers continued to cut back on benefits. The percentage of people who had health insurance through their employers fell to 55.3% in 2010 from 56.1% the year before, continuing a long downward trend (compared to 64.1% in 2000). Apart from other contributory environmental factors, the relative poor health indices were attributable to the situation as analyzed above. There was therefore a compelling need to address the situation and that, in my thinking, was what the Patient's Protection and Affordable Care Act 2010 intends to do. 

President Obama giving assent to ACA

 Health Reform Policy
Before the passage of the Patient Protection & Affordable Care Act (ACA) in March 2010, a couple of futile attempts were made in the past to reform the American health sector through legislative policies; the last being President Clinton's proposed reform which failed to scale through in the Congress. Here are the implications of this policy on various age groups, when fully implemented. 

• Retirees on Medicare: Expansion of primary care by increasing Medicare payments to doctors in Family Medicine; Reduction in the cost of pharmaceutical medications; Encourages development of protective services for the elderly. 
• Young Adults: Can be kept on family insurance plans till age of 26; Can qualify for Medicaid if annual income is $14,444 or less
• Middle Class: More affordable and fairer insurance markets; Improved access to essential medical services in family medicine, pediatrics care and community medicine. 
• High Socioeconomic Class: Increased taxation for families making more than $250,000 per year. 

This policy when  fully implemented will guarantee near universal health care insurance for all American people. 

 The Case against the Policy

Final judicial pronouncement is being awaited on this policy following a suit by 26 states opposed to it seeking its nullification on the following grounds:

-          That it violates the right of an individual to choose whether to have health insurance or not.

-          That it violated the 10^th Amendment to the United States Constitution

-          That the requirement for state-level health insurance exchanges and expansion of Medicaid is an encroachment on the sovereignty of the states

In addition to the above legal challenge, a section of people believe the policy would increase the country’s deficit and harm  the economy.

My Position

From the public health perspective, I support this policy based on the fact that it will promote near universal health insurance for all American people. It will reduce health disparities and improve quality of healthcare received by people of different socioeconomic status. Given that the burden of ill health falls predominantly on those with low socioeconomic status who can often not afford care, making health care more affordable could improve the health indices of the U.S. in the near future. In addition, increasing access to  family medicine, pediatrics and screening services would lead to early detection and treatment of many non-communicable diseases and improve outcomes.
Without prejudice to the pending decision of the Supreme Court on this matter, I do not agree that ACA violates the rights of individuals; rather, I feel it guarantees the rights of individuals to affordable and proper health care which could mean right to life. 

Conclusion
While supporters and opponents of ACA may have legitimate arguments, the fact that the United States of America lags behind most other industrialized nations in health status and access to affordable healthcare insurance by citizens is indisputable. ACA has had an almost immediate positive impact on healthcare in US, by mechanisms such as providing tax credits for small businesses offering insurance to their employees as well as improve coverage for seniors. My final submission is that ACA has become, and hopefully will continue to be a positive force for improving the health of American people, and should remain in existence. 

Who Would Rescue Nigeria's Health System?

"Failure can be divided into those who thought and never did and into those who did and never thought" - W.A. Nance

The lingering crisis in the health sector of Lagos State which led to the dismissal of 788 medical doctors and the commencement of nationwide strike by other health workers have once again provoked discussions on the state of the Nigerian health system.

Three years ago during the Muslims' Ramadan fasting period, Mrs Aisha (not real name), a 38 year old pregnant mother of 6 children accompanied by her husband and a couple of relatives walked into the doctors' consulting room in the labour ward of the University of Abuja Teaching Hospital. Incidentally, I was the one on duty. History was taken and physical examination done, except for her age and grand multiparity, no other risk factor for a possible negative outcome was identified. The period of cyesis was largely uneventful. She was admitted in first stage of labour, closely monitored till she delivered safely. Third stage of labour was actively managed and the husband and relatives were predictably jubilant with the news of the arrival of the seventh baby. Little did anyone know what was to come. Mrs Aisha was still bleeding 15 minutes post delivery. Initial steps of management of the post partum haemorrhage were implemented to no avail. The initial challenge was getting the relatives to donate fresh blood which was preferred in this condition, they declined citing Ramadan fasting. While effort to persuade them was ongoing, 3 units of stored whole blood gotten from the Blood Bank (in the absence of other substitutes) were transfused, but patient was still bleeding profusely. She was later taken to the theater, hysterectomy done and moved to the intensive care unit with continuous blood transfusion. However, the bleeding continued, seven units of blood transfused at this time, no more blood at the bank and few minutes later we lost the patient I and other senior colleagues and nurses had battled to save for over 4 hours. Mrs Aisha would probably not have died if there were other blood products at the blood bank to serve as substitutes.

More so, I was working as a House Surgeon at Ebonyi Teaching Hospital a year earlier when I admitted one Mr Festus (not real name) who was victim of a fatal road traffic accident along Lokoja-Abuja road. He was transferred (not with an ambulance) without referral letter from a local private hospital in Kogi State where he was resuscitated after the accident happened within 24 hours of injury. He had spinal injury with paralysis of both legs, floating left knee (caused by fracture of the left femoral, tibia and fibular bones). He was severely anemic with a packed cell volume of 16% but no ongoing overt or covert blood loss. He was scheduled for urgent blood transfusion and being worked up for an emergency surgery (to fix the fractured leg bones). First challenge - no blood available for transfusion. All the blood bags in the blood bank were donated for other patients and no assurance from Mr Festus' relatives that they would donate blood for replacement. We continued with other treatments and investigations hoping to persuade his relatives some of whom came with bible and praying fervently outside the ward to donate blood for the use of their loved one. A couple of days later, the patient requested for discharge. Reason? "I want to go home, my private doctor would come and treat me there" he averred. When orthopaedic patients make such requests,  can you guess where they usually go to? Traditional Bone Setters! The health care team counselled him on the consequences of his intended action but all those efforts ended in futility. He left the hospital against medical advice. A month later, he came back with a putrid leg with a terribly offensive pungent odour. The entire limb has gone gangrenous and the only viable option was dis-articulation of the leg at the hip level.

But is the health system all about health care providers and their patients? No. A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health. Health is defined as a state of physical, mental, social and psychological well being and not just the absence of disease or infirmity. The World Health Organization has identifies six building blocks for a health system which should be strong for an equitable and efficient health service delivery to be achieved. They include - health workforce, health service delivery, health information systems, access to essential drugs, health systems financing and leadership & governance. From the two experiences I shared above, that we have a frail health system is incontrovertibly factual. They exposed the weakness in the health service delivery block in two different circumstances. In both cases, no blood products for use in emergency situations even when the health workforce was there. In the later case, the patient took a step which is very common in our clime. One can also infer that such may be a consequence of dearth of funding and weak leadership. They're all linked in one way or the other. If you want to learn more about the building blocks, kindly click here. It would therefore be a sheer demonstration of stack ignorance for anyone to expect the system to function optimally with an unhappy health workforce, assuming other blocks are strong.

Furthermore, I did not realize that my assessment of the weakness of our health system during my clinical experience was a gross underestimation of the reality until I worked on the Global Fund Health System Strengthening (HSS) Project. I was a member of the Federal Government Site Assessment and Selection Team to Edo and Ebonyi States. I also supervised the project implementation in 13 other states including Sokoto and Lagos. Primary Health Care (PHC) system in our country is still very weak, to say the least. Although federal government may have been voting lot's of money to improve the situation, it's not immune from the endemic corruption in the system. The LGAs and most state governments are doing little to nothing to improve the PHC system. For instance, the Ward Minimum Healthcare Package requires a PHC to have a minimum of 6 skilled manpower (Nurse/Midwife, Community Health Officers/Extension Workers), none of the states I supervised met this criteria.  What we saw was a situation where the only health facility in a community without an access road will have two JCHEWS and two unskilled assistants commonly referred to as "auxiliary nurses" No state met the minimum requirement for the PHCs in any of the building blocks of health system. This accounts for why health workers and facilities in functional secondary and tertiary health facilities are being over-stretched.

Compounding the situation is the unending and in fact, deteriorating inter-professional wranglings within the health workforce. The latest casualty of this unnecessary rivalry is the demise of the National Health Bill passed during the last days of the 6th National Assembly. The health workers themselves gave the government an excuse not to sign the bill that would have ensured a percentage of national revenue automatically goes to strengthening of the PHCs. Funding of PHCs would have tremendously improved and other blocks strengthened. My consiracy theory is that government employers surreptitiously promote this rivalry to further polarise the system and abdicate their responsibilities (divide and rule strategy). One could go on and on to analyze this problem, it's a legion.

Ideas on the solution to the problem are not lacking. There are lot's of good documents and policies but no political will to implement them. The question now is who will save the situation? Why is it that our politicians don't like to invest so much in the health sector? Should we wait until we have politicians that won't play to the gallery and tackle the problems head on? If yes, for how long shall we wait? At what cost? (Cost includes preventable loss of lives). From experience, our politicians do not honour agreement with workers until they go on strike, an action that further disrupts and weakens the system. In some cases, they use intimidation or like Governor Fashola just did, employ draconian and Machiavellian tactics. Is it the health workers that fight themselves over which profession should head hospitals that would save the situation? What about the infrastructure and logistics supply chain? In my opinion, the most important thing that is needed to rescue our health system is a strong and sincere political will by the government. It's not as if government does not understand what needs to be done, the truth is that it's financial intensive and the effect may possibly not be obvious to the common man on the street on a short term. The citizens have significant role to play in this regard, get educated on what we want our health system to be like and mount a sustained pressure on the leaders to get it done. An average politician wants to implement populist projects, and our health system would most likely get better attention when the Nigerian people consider it as such. Enough of the blame game! Enough of the politics! It's time for more purposeful action. Let's go, we can't wait!

please your thoughts are welcome!

NHIS Policy: Time for Universal Coverage?

Nigeria is one of the most populous countries in the world. By October 31, 2011, the United Nations estimated the population to be about 167 million. Located in the West African tropical region, the country also has a high burden of disease and inequity. According to the Ministry of Health, about 60% of health expenditure is out of pocket, health expenditures in 1999 were about 4% of the national budget. In order to provide equitable access to healthcare delivery in Nigeria, the Federal Government of Nigeria introduced a National Health Insurance Scheme.


The National Health Challenge

The health indices of Nigeria have been unenviable. According to the 1999 National Demographic Health Survey, the infant mortality rate was 75 per 1000; childhood vaccination was 17%; only 42% of births were attended to by skilled health workers¹. A 1999 Multi Indicator Cluster Survey by the Federal Office of Statistics estimated a maternal mortality ratio (MMR) of 704 deaths per 100,000 live births for a period of six to twelve years preceding the survey. 
According to UNAIDS/WHO Epidemiological Fact Sheet 2004, the 1999 HIV prevalence in Nigeria was 5.4; about 3.1 million new infections occured that year and 16,188 AIDS cases were reported. Nigeria also has one of the highest malaria and tuberculosis burden in the world. Average life expectancy was 47 years for males and 49 for females. The Nigerian health system ranked 187th out of 191countries in WHO global health rankings released in 2000. 


The National Health Insurance Scheme (NHIS) Policy
This policy was enacted by Act 35 of 1999. It is officially organized into six Social Health Insurance Programs (SHIPs): formal sector, urban self-employed, rural community, children under-five, permanently disabled persons and prison inmates. Of the six programs, the formal sector SHIP is the only one that is currently operational, and is available to both public and private organizations of ten (10) or more employees.
Under the Formal Sector SHIP, organizations register with the NHIS and are required to affiliate themselves with a particular health management organization (HMO). Each employee then registers oneself, plus up to 4 dependents, with a particular primary care provider. Contributions towards the insurance program are earnings-based and equal to 15% of a member's salary. Of the contributions paid, two-third (10%) is covered by the employer and one-third (5%) is paid by the employee. The HMO pays the primary healthcare provider (HCP) directly for services rendered, according to capitation, fee-for-service, per diem or case payment system. Under the capitation system, providers are paid a monthly fee in advance, of approximately $5 per month, per beneficiary. Secondary and tertiary HCPs are paid on a fee-for-service basis. Only those pharmaceuticals on the NHIS formulary is developed based on the national essential drugs list, and generics are strongly favored for inclusion on the list where available. Although this policy was enacted in 1999, its implementation did not start until 2005.  


My Position
I agree with the overall objective of this policy which is to ensure universal access to good healthcare services, limit the rise in healthcare costs, facilitate equitable distribution of healthcare costs among different income groups, and to reduce the financial burden of paying substantial medical bills out of pocket. A policy like this is important for a country high levels of poverty and unemployment. The 2010 Nigerian Poverty Profile Report  stated that 61% of Nigerians live below the poverty line, a 5% increase from 1999 when the health insurance policy was enacted. The policy covers primary care and treatment of endemic diseases which will help to reduce disease burden. 


However, the policy as presently enacted will do little to significantly improve the health indices of Nigeria. It does not provide timeline for starting the implementation of insurance programs for the informal sector. So far, only the Formal Sector SHIP is being implemented and there is no insurance for the unemployed, retirees, children, and the entire low income segment of the society. A lacuna in the policy has made states reluctant to join the scheme, so far; only two of the 36 states have enrolled their employees into the scheme. 


More so, more than half of Nigerians are either traditionalists or Muslims and both allow marriage to multiple wives with many children. Therefore, the proviso allowing only 4 dependents on the scheme has excluded many other possible beneficiaries. In a recent interview, a regional coordinator of the scheme disclosed that only 4.5million Nigerians are accessing their healthcare through the scheme. This is only 2.7%% of the total population. 


Conclusion
A universal health insurance for the Nigerian people would be a laudable idea. The NHIS policy presently benefits the employed and influential segement of the population leaving out the poor and vulnerable group. I recommend an urgent review of the policy to fill the gaps and implementation of the other SHIPs. The time to act is now. 


References

1.    National Demographic Health Survey 1999

2.    UNAIDS Facts sheet - http://data.unaids.org/Publications/Fact-Sheets01/nigeria_en.pdf

3.     Federal Office of Statistics (FOS), United Nations Children Fund (UNICEF). Multiple Indicator Cluster Survey 1999.  Lagos, Nigeria: FOS and UNICEF, 2000.

4.    WHO Statistics 2011 - http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf

5.    NHIS website –  http://www.nhis.gov.ng/

6.    Nigerian Poverty Profile Report 2010

7.    Newspaper Report on NHIS implementation - http://www.vanguardngr.com/2010/10/nigerias-health-system-ranks-197-of-whos-200-nations-nhis/

Nigeria's National Health Bill: A Call for an Immediate Assent

In Year 2000, Nigeria ranked 187^th out of 191 countries in the ranking of health systems by the World Health Organization. Although the Nigerian people needed no ranking to know that the health system was in a marasmic-kwashiokor state, the WHO report served as an awakening call to the political class to take actions expeditiously to reverse the deplorable situation. Reports of various technical committees set up by the Federal Ministry of Health culminated in the submission of a HealthCare Reform policy in the form of National Health Bill to the National Assembly in 2004.

It appeared as if the bill made the federal legislators narcoleptic as it took seven years of advocacy and protests before it was finally passed in May 2011.

A protest that preceded the passage of the National Health Bill in 2011

The provisions of the bill include but not limited to;

• Free medical care for children under 5 years old, pregnant women, the elderly (above 65yrs) and physically challenged people. 
• A minimum of 2 per cent of consolidated fund of the federation for primary health care.
• A guaranteed basic minimum health package for all Nigerians
• Unconditional acceptance and treatment of patients with emergency health conditions by public and private health facilities.
• Absolute confidentiality of medical records
• Ensures good quality of healthcare services through the issuance of Certificates of Standard to all health facilities.

The full document can be downloaded here: http://www.herfon.org/docs/Harmonised-NATIONAL-HEALTH-BILL-2011%20doc.pdf

Within the seven years the bill stayed in the National Assembly, it was estimated that Nigeria lost 7 million children and 3.8 million mothers. A few months before the passage of the bill, President Goodluck Ebele Jonathan reportedly made commitment to the UN Secretary General that he would sign the bill as soon as it was passed. While Nigerians were in ecstasy about the passage of the bill despite the delay, one had expected an immediate presidential assent. Unfortunately, that is yet to come almost one year after.

President Jonathan with UN Secretary-General, Ban Ki Moon. 

While I must acknowledge that there may have been significant improvement in the Nigerian health care system in terms of infrastructure and human capacity development over the last 12 years, same cannot be said of the health of the Nigerian people. Nigeria has consistently maintained an unenviable position in the bottom quarter in all global development and health indices. Some of these include;

•         156^th out of 187 countries in UNDP ranking of global Human Development Index 2011
•          41^st out of 53 African countries in 2011 Governance Rankings by Mo Ibrahim Foundation
•          104^th out of 110 countries in Prosperity Index by Legatum Institute, a London based public policy organization (our health system ranked 106^th).

According to the National Bureau of Statistics (NBS), almost three-quarter of Nigerians (72%) lived below poverty line in 2011, an increase from the previous years even as the global poverty level has remained on the decline. Following the subsidy removal policy that led to a 50% increase in pump price of premium motor spirit (PMS) without a concomitant rise in income, more Nigerians are bound to fall below the national poverty line. The lingering insecurity problem in some parts of the country has also grounded the economy of the affected states and brought untold hardship to the people. Experts have predicted that Nigeria may have more poor people than China by 2015 if the current trend continues. Victims of the Boko Haram terrorism are either losing breadwinners/ life investments and/or getting permanent disabilities. This suggests that much more Nigerians would not be able to afford quality health care thereby worsening the morbidity and mortality from prevalent preventable and curable diseases.

Below are our tragic and deteriorating health indices:

• 1 million children die every year => 2740 per day or 114 per hour; the highest in the world
• 52,900 women die from pregnancy related causes every year => 145/day or 44 per hour; the 2nd highest in the world. In other words, 1 in every 13 Nigerian women die from pregnancy and child birth.
• 292,000 neonates (babies below 28 days old) die every year => 800 per day or 33 per hour - the 2nd highest in the world. 
• Average Life Expectancy of 50years, among the lowest in the world.

Although some professional bodies reportedly complained about some provisions of the bill; this is not unexpected in a democracy and as such cannot reasonably explain the delayed assent. No responsible government would be leading a country with the above health indices and delay action in reversing the situation. I humbly call on our dear President Jonathan to kindly sign the National Health Bill without further delay. I also implore all well meaning Nigerians and lovers of the Nigerian people to join this call for presidential assent to the bill. 

God bless you! God bless Nigeria!!

References

•      WHO Health Ranking 2000 - http://thepatientfactor.com/canadian-health-care-information/world-health-organizations-ranking-of-the-worlds-health-systems/
•          Legatum Institute Prosperity Indx - http://www.prosperity.com/country.aspx?id=NG
•          UNDP Human Development Index - http://hdr.undp.org/en/media/HDR_2011_EN_Tables.pdf
•      WHO World Health Statistics -  http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf