The Case of Nigeria: A Health System Not Built To Serve.

Nigeria is the seventh most populous country in the world, but struggles with its healthcare system. For a country that is endowed with several natural resources, Nigeria fails at providing basic affordable quality care to the common Nigerian. According to a World Bank report, Nigeria spends 5.07% of its GDP on healthcare. [1] However, people in life threatening conditions are still being denied treatment at local clinics due to their lack of money. Very little progress has been made despite the fact that the country currently has two federal ministers of health.

The fundamental problem with the Nigerian healthcare system is its inability to serve the people for which it is made to serve. The National Health Insurance Scheme was introduced in Nigeria to make healthcare access more affordable. However, only four percent of Nigerians are registered under the national insurance scheme. [2] Some Nigerians can afford the costs of healthcare straight out from their pockets. So why privatize a system that should be set up to cater for Nigerians who do not have the financial capacity to afford healthcare?

Priority setting in Nigeria is another challenge for the country. The Ministry of Health is taking on projects that are not in the mission and agenda for which it was established. In addition to health, the ministry also focuses on other issues relating to the environment and natural gas, when there already is a Ministry of Environment. There is a huge discrepancy on the progress that the Ministry reports versus the actual state of health in Nigeria.

Even in the private sphere of healthcare, the quality has diminished. Dr. Ado Jimanda Gana Muhammad states that, “Over the years our quality of care has eroded. You can have everything right, but if the quality of care is not there it erodes confidence.” [3] Whether you are in the capital city of Abuja or as far north as Zaria, it is common to see people told to come back days because of a shortage of drugs and healthcare personnel.  The healthcare system in Nigeria is inefficient because of the constraints set up in place to make effective decisions. The Federal Ministry of Health makes all the rules and hospital officials and administrators have little say.

Corruption in the healthcare system of Nigeria is a major hindrance to any intended progress. According to a report from The Center of Global Development, current budgets and fiscal expenditures do not correspond in several states. Furthermore, in Kogi state, forty two percent of healthcare staff are experiencing a six month lag in salary payments. [4] Currently, health workers in Nigeria are on a nationwide strike because of their lack of belief and confidence in the system. Corruption is even prevalent at the ministry of health’s highest office. The current minister, Onyebuchi Chukwu, has been accused of abusing his power as a government official.

The Nigerian healthcare system is failing as a national entity. Several interests are being pursued by several actors. There is no coordination at the federal level and no accountability. In order to move forward, the federal ministry of health needs to regain public trust. Furthermore, the healthcare crisis in Nigeria is an adaptive challenge that can only be solved by regulating distress and keeping the attention focused on key issues.

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[1] World Bank Report. Trading Economics. 2012. http://www.tradingeconomics.com/nigeria/health-expenditure-total-percent-of-gdp-wb-data.html

[2] “NHIS Covers Only 4.3% of Nigerians”. National Mirror. 6 May 2000. http://nationalmirroronline.net/new/nhis-covers-only-4-3-of-nigerians-executive-secretary/

[3] “The Toughest Job In Nigerian Healthcare”. The Guardian.  11 September 2000. http://www.theguardian.com/global-development-professionals-network/2013/sep/11/primary-healthcare-nigeria-gavi-vaccines

[4] “Tackling Healthcare Corruption and Governance Woes in Developing Countries”. Maureen Lewis. Center For Global Development.  May 2006. http://www.cgdev.org/files/7732_file_GovernanceCorruption.pdf

October…It’s all about the “pink ribbon”

 

Breast cancer is the second most common cancer in the world and the most common cancer among women. ¹ It was estimated to account for 1,105,000 cases and 373,000 deaths in women in 2000. ²

Scientists do not know what exactly causes breast cancer, but one thing they do know: there are a lot of risk factors that are linked to this disease. Family history, age, genetic, race, obesity, alcohol, unhealthy diet and many more factors that increase the chance to develop breast cancer. ³

There are some of the risk factors for breast cancer we can’t change, for example we cannot change our family history. But there are simple changes we can make in our lives to help us create a healthy lifestyle and control and prevent this disease. We need to create awareness to the public by campaigns and education and help raise knowledge about ways to prevent the risk.

Raising public awareness about breast cancer is the key and first step to help prevent this disease. With the help of appropriate policies and programs this can be done. World Health Organization (WHO) performs national cancer control programs to promote breast cancer awareness and take action in controlling it. ⁴

In the month of October we are reminded about how many people are fighting breast cancer and struggling to survive. During this month we see pink ribbons everywhere. This is so important that you can see the pink skylines in big cities in the world such as New York City, supporting this cause for raising awareness for breast cancer. The “pink ribbon” is a worldwide symbol for breast cancer. Before anything we need to know where this “pink ribbon” come from.

It all started in the early 1990’s. 68-year-old Charlotte Haley began making peach ribbons. Her daughter, sister and grandmother had breast cancer. She spent time making thousands of ribbons with massages saying how the National Cancer Institute allocates only 5 percent of its budget for breast cancer prevention where she believed it should be more. As her word spread through the public, many organizations asked permission to use this ribbon as a symbol for awareness. Haley thought it was too commercial so she refused to contribute. Therefore they decided to change the color to pink, and use that for raising awareness to the public. ⁵

Companies use this pink symbol to sell products. This strategy has had both positive and negative impacts. On the positive side this has been a way of supporting breast cancer research, which has resulted in a large amount of funds both by non-governmental and federal organizations.  In 2007, the Breast Cancer Research foundation awarded 32 million dollars for cancer research. Tis existence of symbol everywhere also is a reminder to the public especially women to obtain a more responsible perspective and undergo the process of screenings tests and mammograms, which can help prevent and control the disease. ⁵

While there have been positive impacts, we witness some negative outcomes we well.  When we see pink ribbon on all items, it can become less effective. Since the vision no longer catches what it is used to and can cause visual saturation towards it.  Research shows that the proportion of women undergoing screening and mammograms decreased from 69.7% in 2003 to 66.5% in 2005. This decrease is very eye opening and catches our attention of what we could be doing wrong. There are many factors that could contribute to this decline, but this research suggests that it may be the overwhelming pink symbol that has less effect on women these days. ⁵

There are both pros and cons in every action and every campaign. We have to continue to raise awareness and spread the word out the most effective way possible; supporting this cause to help the research move in the best direction. The Breast cancer research is a multi-billion dollar industry that spent 572.5 million dollars on breast cancer research in 2007. Over 30 federal agencies are funding breast cancer research. ⁶

October is the time of the year to think more about our loved ones and the people fighting this battle. Supporting the ones we may not even know, because we are all on the same globe aiming the same target. The beautiful soothing and comforting pink color supports this cause. We hope to see brightness and a comforting light as soothing and comforting as the color pink, in the eyes of those who are fighting cancer.

 

 

This blog post was inspired by:

1. Diet, nutrition and the prevention of cancer, Timothy J Key, Arthur Schatzkin, Walter C Willett, Naomi E Allen, Elizabeth A Spencer and Ruth C Travis

2.International Journal of Cancer. Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000.

3. What are the risk factors of breast cancer? October 2013. www.cancer.org

4. Breast cancer: prevention and control. www.who.int

5. The Power of Pink: Cause-Related Marketing and the Impact on Breast Cancer. Jennifer A. Harvey, MDa, Michal A. Strahilevitz, PhD. 2009.

6. Funding for breast cancer research. www.bcaction.org

 

 

 

Kangaroo vs. Machine

Photograph by Nicole Duplaix, via National Geographic

It’s a thought we’ve all had at one point or another: you’ve just purchased a shiny new electronic device—a computer, say, or a CD player—but your old one still seems to have some useful life in it, even though it’s not working as well as it used to. Surely, you think, a charity will be able to put your hand-me-down device to good use for a few more years. Right?

Probably not. Your aging MacBook, for example, may not be compatible with the PC-based system your favorite charity uses and would require costly investments in software and maintenance in order to make it useful. And, honestly, who listens to CDs any more?

The same goes for medical equipment. A recent article in The Atlantic, “The Inadequacy of Donating Medical Devices to Africa” by Mike Miesen, looks at the practice by some NGOs and aid agencies of donating secondhand devices to healthcare facilities in poor countries….which have a tendency to break down soon after delivery. Even when the donor agency has carefully and thoroughly refurbished the equipment, it still requires expensive parts to operate and specialized expertise to maintain. As a result, many hospitals in developing countries are host to “graveyards” where inoperable donated equipment is stored.

In an ideal world, all hospitals everywhere would be stocked with the best medical devices and the technical capacity to keep them up and running. Until that day comes, however, there may be less high-tech but more effective uses of limited resources that can produce better-quality healthcare. Writing in The New Yorker, physician Atul Gawande recently described his work on the BetterBirth Project, an initiative to test the efficacy of the World Health Organization’s Safe Childbirth Checklist. The checklist identifies 29 steps for birth attendants to follow during a normal delivery, among the simplest of which is binding a newborn baby skin-to-skin with its mother in order to help the infant regulate its body temperature, a practice known as “kangaroo care” (other steps include ensuring that sterile supplies are on hand and administering medications at certain key junctures). Kangaroo care, which is free, rivals the efficacy of all those broken-down incubators littering medical device graveyards; the challenge is in convincing birth attendants to take up the practice. The BetterBirth Project is seeking to increase adoption of the Safe Childbirth Checklist by training “childbirth-improvement workers” to help birth attendants understand why the checklist is essential and practice implementing the steps until they become part of the attendants’ regular routine. It’s a low-tech but highly personalized approach to improving medical care in resource-poor settings.

Gawande argues, “We yearn for frictionless, technological solutions. But people talking to people is still the way that norms and standards change.” Donors of medical equipment expend enormous amounts of time and resources to source, refurbish, and deliver the devices. Would poor countries be better served if those same donor organizations instead focused on raising money to hire and train childbirth-improvement workers, or fighting to ensure the availability of affordable generic drugs? My money’s on low-tech, high touch solutions all the way.

Health: Is it there…,or not?

“It is health that is real wealth and not pieces of gold and silver” Mahatma Gandhi

What is health? It seems like a very simple question, but yet it had us students thinking, talking and arguing about it for a couple of minutes in our global health policy class.

The word “health” means different things to different people, depending on the situation and location. (1) The most famous modern definition of health was created by the World Health Organization (WHO), which states:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”(1)

How do we know if we have this “health”?
Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment.(2) Determinants of health are used to measure health of the people in a population.

According to WHO the determinants of health include: The social and economic environment; the physical environment, and the person’s individual characteristics and behaviors. (2) In other words, Determinants of health are a range of personal, social, economic, and environmental factors that influence health status.( 3)

Health might just be a feeling we feel and we may not be able to describe it, but we need to translate this “feeling” to variables and indicators in order to measure health.

The measurement of health started with Codman’s “end result” idea.(4) Codman’s idea of the End Result developed between 1902-1910.(5)  The “idea” entailed following patients long enough to determine if treatments proved successful and taking comprehensive measures to prevent new failures if outcomes were undesirable.(4) This has been largely neglected in the history of health measurement. After Codman, clinical researchers and surgeons such as Visick, Karnofsky, Katz began to develop scales to measure the outcomes of procedures.(4) In the 1960s, increasing recognition of the importance of assessing a broader array of outcomes were witnessed when measuring the impact of disease.( 4)

The rising expectations of the past 150 years have led to a shift away from viewing health in terms of survival, through a phase of defining it in terms of freedom from disease, thence to an emphasis on the person’s ability to perform his daily activities, and more recently to an emphasis on positive themes of happiness, social and emotional well-being, and quality of life. (6) This shift, which occurred during the 1970s (5), was for a number reasons. First, the narrow definition of health in terms of morbidity and mortality was replaced by a broader definition of health as a “complete state of physical, mental and social well-being and not merely the absence of disease or infirmity”. Second, there was an increased interest in measuring more complex and subjective aspects of outcomes pertaining to the health impact of disease and/or treatment. Third, there was increased demand for clinicians to demonstrate evidence of cost-effectiveness, in which the benefits of a particular health service or intervention are weighed against the costs of that service or intervention. (5)

The ICF (International Classification of Functioning, Disability and Health), which was released by the WHO, has been accepted by 191 countries as the international standard to describe and measure health and disability. While traditional health indicators are based on the mortality rates of populations, the ICF shifts focus to “life”.(2) This can better help researchers measure the health status of an individuals and therefore a population. 

The health of an entire population is determined by aggregating data collected on individuals. The health of an individual is easier to define than the health of a population. For reasons of simplicity and cost, nowadays, most health measures rely on verbal report rather than observation. Subjective health measurements hold several advantages. They extend the information obtainable from morbidity statistics or physical measures by describing the quality rather than merely the quantity of function. They give information about people whether they seek care or not, they can reflect the positive aspects of good health, and they do not require invasive procedures or expensive laboratory analyses. (6)

In past years, individual clinicians, based mainly on their personal experience, developed many widely used scales for health measurements. The process of developing a scale has become a long, complex, and expensive undertaking involving a team of experts, and in most cases, the quality of the resulting method is better. (6)

 

This post was inspired by the following links:

1)   http://www.medicalnewstoday.com/articles/150999.php

2)   http://www.who.int/hia/evidence/doh/en/

3)   http://www.healthypeople.gov/2020/about/DOHAbout.aspx

4)   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140310/

5)   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758958/

6)   http://a4ebm.org/sites/default/files/Measuring%20Health.pdf

Slum Living: Could You Do It?

Above portrays the Hewitt Family. The two images below are both of slums: the left is of present day Africa, the right is of early 20th century NYC.

The Rich Don’t Just Get Richer: They Also Get Older

On average and throughout the world women have longer life expectancies than men and life expectancies for both men and women are continuing to lengthen. That is the good news.  The bad news is that women’s life expectancy is not increasing as quickly as men’s and the gap in life expectancy between women in rich and poor countries is widening.   Due to great improvements in maternal health women are living longer all over the world and older women represent a large portion of the population.  By 2050, it is predicted the women over 50 will represent, almost a fifth, 19% of the global population.[i]   Stevens, Mathers, and Beard (2013) discuss these trends in the WHO September Bulletin in the article “Global mortality trends and patterns in older women.”  The WHO devoted the entire issue to the importance of addressing non-reproductive health issues for women.

What I found very striking about this article is that women over age 50 in developing countries are dying from similar causes of death as women in developed countries, however, in developing countries they are dying sooner.  Stevens, Mathers, and Beard discuss the importance of using and improving health systems to address these needs.  Additionally, health education and preventative care will be important components of success.

Cardiovascular disease and diabetes are causing many of the deaths in women over 50 but in high-income countries these deaths are occurring later in life.  Stevens, Mathers, and Beard question if these earlier deaths are related to increased stress and environmental factors in the low and middle income countries or decreased early detection and care in these countries.1  Most likely a combination of these issues is contributing to the differences in life expectancies.  The WHO has developed a non-communicable disease action plan that would address these inequalities and health concerns for women over 50.  Some particular actions in the plan that would benefit women in all countries are conducting needs assessments, strengthening national programs, and developing national plans and budgets to reduce deaths from noncommunicable diseases.[ii] I also believe an increased use of health advocates or health coaches would greatly benefit women over 50.  The advocates could educate women and monitor exercise and eating patterns that can prevent cardiovascular disease.  The advocates could also monitor early signs and treatments for the diseases. The close follow up could increase accountability of the patients and better their health outcomes.

In developed countries many education and early detection and treatment programs have already lessened the death rates from cardiovascular disease and diabetes among women over 50.[iii]  These countries need to continue to build upon that success and developing countries need to assess their current states and implement these successful strategies that are detailed in the WHO NCD Action Plan to improve the lives of millions of women over 50.

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[i] Stevens, G. A., Mathers, C. D., & Beard, J. R. (2013). Global mortality trends and patterns in older women. WHO Bulletin.http://www.who.int/bulletin/volumes/91/9/12-109710/en/index.html

[ii] WHO Noncommunicable Disease Action Plan for 2013-2020 http://www.who.int/nmh/publications/ncd_action_plan/en/

[iii] Science Daily. (2013). Health of Older Women in Developed Countries Continues to Improve: Gap With Developing Countries Grows. http://www.sciencedaily.com/releases/2013/09/130902102013.htm

Related articles

• Life Expectancy Gap Growing Between Rich/Poor World Women: WHO (nlm.nih.gov)