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

Improve Health, Save the Future

In a recent college assignment, I was required to to provide 5 minutes of opening and orienting comments to a distinguished group of public policy makers in the U.S. representing local, state, regional and national levels of government.  Everyone at this meeting was very concerned about the future of health (not health care) in the United States. They are serious about finally doing something before it is too late and are less concerned about the cost of doing something now than the huge costs of doing nothing or the costs of just bumbling along the way we have been doing for far too long. Below was my presentation, kindly read and share your thoughts;

Saving our future

A presentation to public policy professionals in all tiers of governance in United States of America

Distinguished ladies and gentlemen,

I’m delighted to share my thoughts with you - the policy makers from all levels of governance on how we can save the future of health in our beloved country, United States of America. I believe no other time could have been more appropriate to put this issue on the front burner than now. 

United States of America is the world’s largest economy and undoubtedly one of the richest countries across the globe.¹ We also spend more money than any other country on health (care), as confirmed by recent World Health Organization and the Organization for Economic cooperation and Development reports on global health expenditure. But why has our country remained unhealthy? Why should we spend most on health and rank 4^th in Human Development Index² and 30^th among nations with highest life expectancy?³ Why are thousands of American people still dying from avoidable health-related events? The future of our health is on the edge of precipice and there is no gainsaying the fact that an expedient action is required. 

It is obvious from the foregoing that our approach to improving health has been defective. We have been spending billions of dollars on treating diseases instead of preventing them. What can be done in this circumstance? The top killer diseases in United States: coronary heart disease, lung cancer, stroke and obesity share common behavioral etiologic risk factors – tobacco smoking, lack of physical activities and unhealthy feeding habits.⁴ According to the National Health Interview Survey 2009, 21 per cent of adults smoke tobacco while 33 per cent do not engage in physical exercise. Smoking kills almost half-a-million Americans annually.⁵

Creating a healthier future for the American people requires a holistic approach, and the role of public policy makers in this regard is crucial. Governance & Leadership is the building block of health that controls the others. Effective local boards of health and public health agencies would enhance the quality, continuity and assurance of public health in the United States. It’s time to act! A healthy environment must be created in United States through healthy policies.  Policies that would build community coalitions to address tobacco use and create programs that would transform knowledge, attitude and practices by changing the way tobacco is sold, promoted and used. Smoke free work place policy would not only make smokers smoke less but make non-smokers exposed to less side stream smoke and reduce their likelihood to become smokers. Effective antismoking policy would not only save the potential smokers but also the 50,000 people that die annually from side stream smoke.⁵

More so, Public Policy is a component of the 5"P" startegies that would create and enhance the use of other 4"P"s - preparation, promotion, programs and physical projects.⁶   These strategies represent a comprehensive approach to increasing physical activity in a community. Synergistic efforts across all levels of governance in the various counties and states should make or review their policies as indicates; ensuring that public policies do the followings: establish a close and consistent link between land use and transportation plans and priorities, approve local ordinances that are consistent with land use and transportation plans and that promote active living; update road policies, standards, parking requirements and fees to improve connectivity, safety, street design and incentives for transit and active transportation; Update zoning ordinances, building codes, and approval processes to encourage compact community design and a tighter mixture of activities which make it possible to work, play, shop and go to school within walking and bicycling distance of people's homes.⁷

Furthermore, the policy should improve funding for pedestrian and cycling-oriented capital improvements and public transit as well as adopt a pedestrian charter to ensure that walking becomes an increasingly safe, comfortable and convenient mode of travel. Public policies should enhance accessibility to healthy foods, discourage media advertisement of unhealthy feeding habits and create a healthy social environment for healthy lifestyle. The media has to be regulated to reduce scenes in movies that promote unhealthy behaviors.

Nevertheless, creating a healthy environment through healthy public policies has huge political and economic implications. You must be prepared to resist tempting influence and cope with stiff resistance from the tobacco, food/beverage companies, other industries whose economic interests may be adversely affected and possibly from the people. Achieving behavioral change is a Herculean task but it’s not impossible. There are several evidences in the country where these policies have been very successful.


In conclusion, a healthy physical and social environment must be created to ensure a healthy future for the American people and no time is better to start than now. God bless you. God bless the United States of America. 


References 
1. IMF 2011 Top 20 World’s Richest Economies by GDP nominal; http://www.youtube.com/watch?v=d2MSskRjbXs
2. UNDP Human development Reports 2011; http://hdr.undp.org/en/statistics/
3. http://www.worldlifeexpectancy.com/country-health-profile/united-states
4. National Health Interview Survey 2010, by CDC - http://www.cdc.gov/nchs/fastats/hinsure.htm
5. Tom Farley & Deborah A. Cohen. Prescription for a Healthy Nation. 282: 131-143
6. http://www.activelivingbydesign.org/our-approach/5p-strategies-tactics
7. http://www.activelivingbydesign.org/our-approach/strategies-tactics/4p-policy/tactics

Bad Apple and TB Prevention

Tuberculosis (TB) is a chronic infectious disease of Public Health importance caused by bacteria known as Mycobacterium tuberculosis and affects people in most countries of the world. Almost every organ of the body can be affected but Pulmonary Tuberculosis (PTB) accounts for more than 80% involvement. The commonest symptom of PTB is persistent cough lasting two weeks or more, usually accompanied with one or more of weight loss, malaise, drenching night sweat, loss of appetite, low grade fever, chest pain, dyspnea or hemoptysis.

TB is highly preventable and curable. However, patients are placed on medication for as long as 6-8 months (depending on the drug regimen) and poor compliance results in multiple (MDR) or extreme drug resistance (XDR) TB both of which have very poor prognosis.

Global Situation of Tuberculosis

In 2010, there were 8.8 million incident cases of TB, equivalent to 128 cases per 100 000 population and 1.45 million TB-related deaths globally. About 13% of cases occur among people living with HIV (PLHIV) while 290 000 cases of MDR-TB are estimated to exist.  Most of the estimated number of cases in 2010 occurred in Asia (59%) and Africa (26%); smaller proportions of cases occurred in the Eastern Mediterranean Region (7%), the European Region (5%) and the Region of the Americas (3%). India and China accounted for 40% of the world’s notified cases. 92% of the global TB cases are found in 97 countries most of which are developing countries. 22 countries with 80% of global TB cases were classified as high-TB burden countries (HBC) and have been given priority attention since 2000. In 2009, there were an estimated 9.7 million children who were orphans as a result of parental deaths caused by TB. The disease is also more common among men than women, and affects mostly adults in the economically productive age groups; around two-thirds of cases are estimated to occur among people aged 15–59 years. Treatment success rate among new cases of smear positive pulmonary TB was 87% in 2009.²  

In Nigeria, TB, Malaria and HIV/AIDS are major causes of mortality across all age groups. TB interests me because it’s not just a global disease of public health importance but my country, Nigeria ranks 5^th among the high-TB burden disease countries.²The prevalence of TB is estimated at 199 cases per 100 000, far above the global prevalence.² A Study by GI Pennap et al demonstrated statistically significant relationship between low socioeconomic status and high TB burden in Nasarawa State, Northern Nigeria.³ Lower literacy, higher unemployment, higher poverty index are associated with higher TB incidence. The Fulani (tribe) nomads and communities also drink unpasteurized milk from their cattle accounting for relative high cases of abdominal TB (extra-pulmonary TB).³   The distribution of TB follows similar pattern as HIV/AIDS. In 2006, 30 in every 100 persons living with HIV/AIDS had TB. 4

This poses a monumental task in achieving the Millennium Development Goals (MDGs) of halting and then reversing new TB infections by 2015 relative to 1990 levels.

Etiology of Tuberculosis

Mycobacerium tuberculosis is transmitted from a person with TB disease to another person through inhalation of droplets when such person coughs spits or sneezes. In general, a relatively small proportion of people infected with Mycobacterium tuberculosis will go on to develop TB disease. The risk of exposure depends on presence of a person with untreated PTB or poor ventilation or overcrowded areas; risk of developing TB is much higher among immune-deficient individuals such as People Living with HIV/IDS, systemic illness like diabetes mellitus, patients on cancer chemotherapy, prolonged use of steroids, chronic alcoholism and malnutrition.

As an endemic population, many Nigerians have dormant TB infection which could easily be reactivated. Unhealthy behaviors linked to the high TB burden in Nigeria include but not limited to failure or refusal to immunize children, consumption of unpasteurized milk, indiscriminate abuse of cheap local but unrefined alcoholic drinks, declining of HIV screening by high risk groups, harmful cultural practices like female genital cutting and building of homes without adequate ventilation. The strong presence of some religious faith which campaigns against use of contraceptive devices including condoms and relative weak health system are also contributory.⁵

TB Prevention: 'Bad Apple' vs 'Curve Shifters'

Huge financial resources are being committed annually by TB endemic countries and the global community in diagnosis and treatment of TB disease. Ironically, most of the highly endemic countries are among the world’s poorest countries. Among 97 countries for which trends can be assessed since 2006, funding is expected to reach US$ 4.4 billion in 2012, an increase from  US$3.5 billion in 2006.² All these money are being spent on diagnosis and treatment of cases which is the main focus of the World Health Organization (WHO) Stop TB Strategy. This is a ‘Bad Apple’ approach as such huge amount of money is being utilized to control TB among a population at the tail of the Geoffrey Rose Curve. 

The Rose Curve is a graphical representation of a group or population distribution of a health behavior of interest. It is a quadratic curve with the level of health-related behavior on the horizontal axis and the percentage population with that behavior on the vertical axis. It depicts that a small percentage of the population are at both extremes of a health-related behavior while most people are near the average point. This curve can be plotted for various health-related behaviors such as salt consumption, drinking habit, sexual behavior, exercising, personal hygiene, smoking habit, vaccination against infectious diseases, etc. According to Tom Farley & Deborah Cohen - two public health experts, disease control strategies using diagnosis and treatment have over the years proven not very effective as they target the small high risk population while more deaths are recorded among the majority apparently not-at-risk population. Individual health-related behaviors may fall on any side of the curve while that of the group is represented by the entire curve.¹ The “curve shifters” refer to four key features that affect the environment and influence the daily behavior and norms of a population and can be used to achieve a healthy behavioral change in a whole population. 

WHO admitted in her 2011 report that MDG target for TB cannot be attained in 2015 especially in the African Region. Rather than spending so much on a less successful curative approach, I strongly feel a better result would be achieved should Nigeria and other countries with similar health system create a better environment and promote healthy behavioral pattern using the Farley & Cohen "curve shifters" as described below;  

Accessibility: The Nigerian government has a policy of free vaccination of all children less than 5 years against preventable endemic diseases including TB.  However, the vaccines are only free in government-owned health facilities. The rural population most of who live below one dollar per day cannot afford to pay for vaccination. Accessibility to BCG vaccine can be increased if the government builds more health centers and/or partner(s) with the private local health centers closer to underserved population to provide free vaccination services. Malnutrition is one of the commonest causes of Under-5 mortality in Nigeria and a significant portion die from TB infection. Many rural dwellers are subsistence farmers but their farm produce perish due to lack of proper preservation. Food can be made more available and accessible if modern preservation methods are provided. Pasteurized milk should be subsidized and accessibility increased by states of the Fulani tribes.   Free condoms should be made more accessible by installing Condom dispensers in clinics, tertiary institutions and public places like hotels, supermarkets and motor parks. This would reduce risk directly of HIV and opportunistic TB infection indirectly.

On the other hand, accessibility to alcohol and tobacco use should be restricted.

Physical Structures: A Study to determine the factors responsible for the high incidence of TB among children who received BCG vaccination in Okposi, South East Nigeria, found that the vaccines lost potency because the cold chain was not maintained by the local health facility.⁶ As a country with irregular supply of electricity, solar powered refrigerators should be provided to all health facilities while government intensifies efforts to stabilize power supply by building more power stations. Some people complain they don’t enjoy sex with the use of condoms. Making condoms thinner and more sensitive can increase its utilization.  Building of physical infrastructure like good roads, potable water supply and electricity in most communities would accelerate development, promote economic activities and reduce unemployment and poverty. More housing should be provided to prevent overcrowding in highly populated cities.

Social Structure: With increased accessibility to BCG vaccine, a law or policy that would make refusal or failure to vaccinate children a punishable offense and can be helpful. Promotion of community participation in health promotion by strengthening the link between the local community associations to the public health institutions through relevant policies can improve compliance with existing policies that promote healthy behavioral change.

Imposition of heavy tax on the cheap local alcoholic spirits which are mostly abused will reduce its consumption. Indoor, outdoor or workplace smoking bans can be implemented by states and local health authorities. Policies that provide minimum acceptable house standard allowing proper ventilation in buildings should be enacted and enforced especially in the rural areas.

Media: A major challenge in acceptance of immunization was a misinformation that led to the rejection of vaccines by some families. Community and religious leaders and their followers can be more educated through a combination of direct engagement and use of local ‘town-criers’, print and electronic media to promote vaccination and other healthy behaviors in the community. Pornography in prints and electronic media should be reduced to the barest minimum to check indiscriminate sex and HIV transmission. 

In conclusion, the WHO Stop TB Strategy would record more success if Nigeria and other high-TB countries if more money is voted into providing physical and social environments that would improve the socio-economic status and consequently promote healthy behavior of the people using the "curve shifters" as discussed above. Efforts on treatment of diagnosed cases and prevention of HIV  and other chronic diseases should be sustained as they are not mutually exclusive. 

References

11. Tom Farley and Deborah A. Cohen, Prescription for a Healthy Nation. Beacon Press, Boston, MA. ©2005

22. World Health Organization; WHO Report 2011, Global Tuberculosis Control

33. G. I. Pennap, S. Makpa & S. Ogbu – Prevalence of HIV/AIDS among Tuberculosis Patients in a rural community in Northern Nigeria. Trakia Journal of Sciences, Vol. 9, No2, pp 40-44, 2011, Copyright © 2011 Trakia University

44. Nigerian Federal Ministry of Health, National TB & Leprosy Control Program; 2006 National TB Sentinel Survey

55. Family Health International; Community TB Care in Nigeria: a project review, ©2009 fhi

66. Ndukwe, S.O, et al; Factors responsible for the Incidence of TB among Children who received BCG Vaccination in Okposi, South East Nigeria; National Postgraduate Medical Journal (Public Health Edition) 2004