Archive for February, 2013

Abraham Lincoln, one of America’s most pragmatic leaders ever, was a huge proponent of conscientious law making and democracy that considered all men equal, and therefore amenable to the same laws and standards. Lincoln’s approach and strive for conscientious law making, are a cornerstone of modern day democracy.

14 years into Nigeria’s democracy, and our conscientious law making continues to come under heavy scrutiny. A nation with an estimated 170 million people, 608 maternal deaths per 100,000 live births, 157 under-five deaths per 1000 live births and unquestionably some of the worst health indices from around the world, still does not have health legislation.

A former Minister of Health, Prof. Adenike Grange said in 2008, “the absence of a National Health Act to back up the National Health Policy has been a fundamental weakness which needs to be tackled frontally. This weakness means that there is no health legislation describing the national health system and defining the roles and responsibilities of the three tiers of government and other stakeholders in the system. This has led to confusion, duplication of functions and sometimes lapses in the performance of essential public health functions.”

The National Health Bill, is Nigeria’s first all encompassing health legislative. According to the World Health Organization (WHO), an explicit health policy can achieve several things: it defines a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people. The National Health Bill fits the bill, on all of these counts.

The National Health Bill started its journey in 2004 at the National Assembly (NASS), scaled through by 2011, following re-reads and re-negotiation of some redundant bureaucratic hurdles within NASS. Finally passed in May 2011, the bill was refused assent by the President, for reasons that were never made public. A 7-year journey had hit a brick wall. During these 7 years of debate of the bill, the Nigerian Medical Association (NMA) estimates 7 million children and 385,000 mothers died in that interim.
After almost 2 years of inactivity, the bill has been returned to and re-opened by NASS, including a public hearing on the bill last week. This may be the beginning of another 7-year trip.

The National Health Bill seeks to define, streamline and provide a framework for standard and regulation of health services in the country. It spells out the rights and duties of healthcare providers, health workers, health agencies and users. It serves as a guide in the development, promotion and formulation of national health strategies amongst others. The National Health Bill promises to provide all Nigerians with a basic minimum package of health services. It pledges to develop a national health policy that includes about 60 billion naira (about US$380 million) devoted to primary health care each year, provision of essential drugs, and comprehensive vaccination programs for pregnant women and children younger than 5 years of age.

When the bill was passed in May 2011, the Lancet, one of the world’s leading medical journals, described the passage of the bill, as momentum that had never been seen before, towards making a real commitment to improving health in this country. The journal went as far as to say that on the evidence of the passage of the bill, that perhaps President Jonathan is more devoted to rectifying the appalling state of health in Nigeria than has been apparent thus far, in his regime. The journal, as far back as May 2011, pushed President Jonathan, saying “if he really is committed to providing equitable and affordable universal health care for all of his people, he should sign the National Health Bill immediately, as there was no better way to say “thank you” to the people for electing him.”

The National Health Bill, together with the amendment of the National Health Insurance Scheme (NHIS) Act, being debated in NASS, can together bring about a healthcare revolution in Nigeria. Primary Health Care will be re-energized, relevant financial commitment from the government will be available, health coverage will be extended to many who today cannot afford care because they have to pay out of pocket, and greater transparency and accountability within the health sector will be assured.

Nigeria needs both of these pieces of legislature to be adopted, signed into law and implemented, to lead our health sector out of the present dire straits that we find ourselves in.

A lot of opposition has arisen to the National Health Bill, especially around certain issues of unchecked authority for the Minister of Health, and issues surrounding embryonic and stem cell research. I personally do not see these issues as being controversial or irrational, as the surrounding debate around them may suggest. I however think that some of those issues merit an independent act that can be openly debated and decided upon as we see fit, without allowing those issues to hamper smooth sailing of the rest of the bill.

The time has come to move forward with the National Health Bill, for keeps. Its promises will not change everything for us, but the bill does allows us to finally hold the government to account for our right to health, including equitable access to care. To aid this process, Nigerians must make major demands, from all of us, who are involved in this bill, in one way or another.

We must demand that everyone debating or contributing to the bill keeps the big picture in mind, and finds the right balance between principle and compromise. Principle without compromise is empty. Compromise without principle is blind. If finding a balance will entail deleting or amending the controversial aspects of the bill or relinquishing them to a different legislative act, then let us do that and show that we place the numerous benefits of the bill high above all other issues that are debatable. There is definitely no debate about the number of lives that will be improved by the safe passage, assent and implementation of the bill.

We must also demand that the bill concludes its journey and be signed into law by the last quarter of 2013. This will among many things, ensure that relevant budget implications of the bill for the coming fiscal year are factored in. Nigerians have waited too long for the conclusion of this bill, for its implementation and above all, for adequate political support towards an improvement of our health and the available healthcare. We must therefore demand that a repeat of the events of 2011, does not play out. NASS must show its commitment to the people, not only by fast and smooth passage of the bill, but by additionally showing the willingness to garner the required two-thirds majority to sign the bill into law, without support or approval of the Federal Executive Council (FEC).

NASS were elected from among us and should stand for us, against all odds, within all the provisions of the constitution. The National Health Bill is back, and we will be looking to them, to do the right thing.

Assent and implementation of that bill must happen on this trip, because our need for it is biggest now, more than ever before!

Weekend Musing: Market Saturation?

It is usually quite annoying to listen to doctors try to get involved in issues other than patient care.

This is a sentiment that many people, doctors included, hold tightly unto, for reasons that remain quite unclear to me. This sentiment definitely raises more questions, than answers.

That said, I would go on to say this for myself. Among doctors, I will probably not rank very highly, based on the amount of clinical knowledge in my head. I generally make up for this with a good work ethic and broader knowledge on a whole lot of other issues, ranging from irrelevant football data and statistics, through health policy and health economics, to more general social issues. I therefore tend to have musings, on a wide range of issues.

Now that we have got that mule out of the way, let us examine the real issue, contained in this article.

Market Saturation.

Market saturation is defined as a point, at which a market is no longer generating new demand for a firm’s products, due to competition, decreased need, obsolescence, or some other factor. It is a situation in which a product has become diffuse or distributed within a market.

A product or service that becomes profitable in the market will almost always invite new players. As a business trend becomes increasingly popular, more and more enterprises tend to join the industry, and soon enough, the market becomes saturated.

As an example, in many households, and depending on the economy, the number of automobiles per family is greater than 1. To the extent that further market growth (i.e. growth of the demand for automobiles) is constrained (the main buyers already own the product). The automobile market is basically saturated. Future sales depend on several factors including the rate of obsolescence (at what age cars are replaced), population growth, and societal changes such as the spread of multi-car families.

It is important to note that market saturation does not mean that every consumer has a product. Instead, the term generally means that a substantial portion of those who are likely to purchase a product have already done so.

Over a decade ago, when mobile phones took over the world, we were presented with a huge emerging market. Soon afterwards, a number of investors wrongly pulled out of mobile phone companies, with the wrong impression that it was a tipping and potentially saturated market. Considering that the man hawking sales in traffic owns a mobile phone or two, those investors could be forgiven for their knee jerk reactions!

Fast-forward to 2013 and mobile phones are still it. With innovation, and emerging technologies, the mobile phone industry continues to successfully navigate a saturated market. The trick however, must lie in the details. And no one is sharing.

Non-governmental Organizations (NGOs) are mostly non-profit organizations, and so many people will be surprised that I will mention NGOs and market saturation in one breath. At this point, I will urge you to remember that I am a doctor. What do I really know right? 😉

Health based NGOs have become a dozen for a dime. Many of which are doing redundant work, and some, no work at all. However, many of these NGOs actually strive day and night, to make a difference to thousands of people out there. And a lot of them are quite successful at it!

Many questions then arise, for many NGOs, who set up to address a need, and also go out to raise funds, in their bid to do “good” work. What are the necessary steps to undertake that will help ensure and sustain the benefit of your work? How do you guarantee effectiveness and efficiency in your area of work, to potential donors?

How do you find your edge in a market that has already reached saturation?

Should these NGOs use diversification strategy? How much innovation can these NGOs really bring into their work, to ensure evolution in a saturated market?

I run two health-based NGOs, and volunteer for a number of others, and my experience tells me that mere suggestions of a diversification strategy and innovation are not enough to convince anyone, or to actually bring about a sustained effort and output, on the part of the NGO.

Motivation and addressing the need of a population are such huge players, in the need for and effective benefit provided by an NGO. Professionalism and accountability help build the brand and image of an NGO, and helps them successfully improve the lives of the communities that they address. However, when all of this is in place, convincing donors and potential partners of the value, that any such organization will add to the community, is a huge challenge.

I am hosting a webinar and a session on the issue of addressing Market Saturation in health and healthcare, in the coming month. However, I figured it would be really great to get a buzz on this issue, and get a few perspectives from a wider online community, even before the sessions start.

My questions to the economists, and to everyone else, who reads this and is kind enough to use the comments’ section are these:

  1. Does market saturation affect a Non-profit?
  2. If yes, how can a non-profit organization, address market saturation?

Use the comments’ section, freely! 🙂

Weekend Musing: Why do countries go to war?

Diplomacy and the politics of wars, is not simple, trifle or an issue that mere words can undermine. This weekend however, it may be necessary to take a look at certain events from a less astute and less rigid perspective, as we explore the real benefit or lack of it, of wars.

This piece is filled with political naïveté. Read with caution, all of you who are politically “aware”!

An inadvertent coup d’état last March, by low-level military officers, created a vacuum in Northern Mali. Gradually, jihadist groups stepped in and seized more and more territory, imposing a harsh form of Islamic law upon hapless Malian citizens. These jihadist cells started to advance their hold unto Mali’s government-held south, and in January this year, France stepped in and began bombing the jihadists, to stop their advance.

This is the popular scripting of the events that have led to “war” and political instability in Mali.

The French, are said not to have invaded Mali, but to have been called upon for assistance, of a military kind, by the Malian government. At the moment, there are approximately 3,000 French forces deployed to Mali and an estimated total African force of 7,700 soldiers. The french intent is supposedly, to pull out soon and allow African governments provide the needed support for Mali to rebuild, restructure and move on.

Some say that there is hope for a “victory” in Mali.

I wonder what exactly qualifies as victory in Mali.

The US foreign policy records estimate that at least 100,000 people have been displaced since the turmoil in Mali. Homes have been lost, along with lives and livelihoods. These displaced people automatically become at risk groups for infectious diseases, malnutrition and hygiene related morbidity and mortality. These displaced people will also migrate to new territories, and such influx of people into a new territory will bring with it increased tension, and possibly another full blown conflict.

To these displaced people, what exactly qualifies as victory?

The 2nd Gulf War
President George W. Bush uttered this famous sixteen words in his 2003 State of the Union address: “The British government has learned that Saddam Hussein recently sought significant quantities of uranium from Africa.” These words, were supposedly based on a British intelligence white paper that contained a number of allegations according to which Iraq also possessed weapons of mass destruction, that were a threat to the free world and to US national security. These words, inadvertently laid the foundation for the 2nd Gulf War.

Without exception, all of the allegations included in this so called white paper, have been supposedly proven to be false.

A former US diplomat, involved in gathering intelligence in the build up to the war, also alleges that the relevant information on how false these claims were, was available to the US government, who still went to war against Iraq.

Recent opinions, are that the US went to war, to liberate Iraq and set the Iraqis free from Saddam Hussein. And also hopefully spark off democratisation across the Arab world. Some would even go as far as to suggest that Oil for Aid, played a key role in precipitating Iraq occupation and the 2nd gulf war.

Was Saddam Hussein a terror? A maniac? A tyrant? Yes.

Did the US or any members of the International community have the right and justification to invade Iraq for the 2nd Gulf War?

Did Iraqi citizens deserve military intervention that cost hundreds of Iraqi lives?

Wars over Water Resources
Speaking to President Ólafur Ragnar Grímsson of Iceland, in 2009, after his visit and address of an assembly of mostly Nordic medical students, it struck me that climate change is an issue that many people take a casual approach to.

Lots of research on Climate Change and its effects on the planet and its inhabitants, have been carried out by various departments of the United Nations and various other institutions (health, industry and environment based institutions). One conclusion that has never been disputed or opposed is the effect of climate change on health. Climate Change is identifiably a threat to global health, with wide range of short and long-term effects on health.

A growing body of scientific evidence strongly suggests that climate change has enormous and diverse effects on human health. Rises in temperatures and resultant heat waves can lead to forest fires, causing droughts and additional deforestation. Glaciers melt away, depleting the world’s sources of fresh water. Sea level rises and extreme weather events such as floods cause water logging and fresh water contamination, which in turn exacerbate diarrhoea diseases. The spatial and temporal distribution of vector-borne diseases like malaria and dengue has been projected to increase due to favourable temperatures, with resulting alterations of communicable disease dynamics.

The poor and the most vulnerable populations are likely to be disproportionately affected, with poorer nations bearing the brunt of the impact due to deficient health systems and resources. The World Health Organisation (WHO) estimates that every year about 150,000 deaths occur worldwide in low-income countries owing primarily to the adverse effects of climate change, primarily crop failure and malnutrition, floods, diarrhoea diseases and malaria.

President Grímsson’s take, was that Climate change is a global issue and its adverse impact can affect the entire world. He worried that some day, the world could go to war over scarce fresh water resources, a plight with huge implications!

Climate change harms the health of a population. Wars also harm the health of a population. And climate change depletes fresh water resources.

What happens when our water resources are so depleted, that countries go to war over water resources?

In the post world war 1 era, would anyone have ever thought that countries will go to war over oil resources, whether as a direct or indirect factor? And now?

The Downsides
Countries go to war for a number of different reasons, some reasons more selfish than others. However, every war has certain underlying features in common:
– Women and children will die
– People will be displaced and be forced to migrate
– Lives and livelihoods will be shattered, never to be the same
– The people do not come out as winners from a war. Not usually!

Former US Ambassador Joseph Wilson, once maintained that a diplomatic approach, with a credible threat of military intervention, must be extensively explored before any country sends its men and women to death over any cause.

What he however didn’t mention, is that 4 out of 5 wars (by my count), do not achieve the so-called political stability and liberation of citizens that are promised. These wars mostly paper over the cracks and allow the unrest continue to fester. Wars are more often than not, lose-lose situations!

Nigeria fought a civil war, along ethnic divides, many years ago. The war has long been over, but the ethnic divides are even more pronounced today, than is imaginable. The war kept Nigeria as one country, but has left such gaping ethnic distrust and disharmony, that continues to be manifest, ever so shamelessly among many of today’s generation.

Could the Nigerian civil war have been avoided? What lessons did we learn from that war, and how have they impacted governance and citizenry in Nigeria today?

Too many questions. Not enough answers.

Enough of the political naïveté now. It is overoptimistic to want a world without wars, yes. But a world with more altruistic approaches, especially when the health of a populace are considered?

It beats me that we can’t seem to have that, either!

People-centered and integrated health services are critical for reaching universal health coverage.

People-centered care is care that is focused and organized around the health needs and expectations of people and communities, rather than on diseases. Whereas patient-centered care is commonly understood as focusing on the individual seeking care (the patient), people-centered care encompasses these clinical encounters and also includes attention to the health of people in their communities and their crucial role in shaping health policy and health services. People-centered care as a principle is driven by efficiency in the use of health resources, towards priority issues, and with sustainable interventions.

Evolution towards People-centered care is touted as the only way to guarantee a healthier future for today’s young people and the coming generations.

The auspices of People-centered care continue to be extensively discussed, but is definitely not the focus of this article. The issue on hand is an examination of our health expenditure and a critical look at the issue of wasting health resources. This article was mostly inspired by a recent run of events, that included the purchase of 34 ambulances by the Oyo state government and the budgeting of N5 billion by the FCT mostly for the rehabilitation of commercial sex workers.

Some schools of thought across the country advocate that any health expense by the government should be applauded and rubber-stamped. This may stem from a culture of government not for the masses, or from the really low bars that have been set for our leaders, for what qualifies as people policy. It may also stem from a lack of understanding of some principles of health economics and public health. This writer’s thoughts and conclusions are a bit different. They may qualify as optimistic and far-fetched to some, but a look at the good health achievements in Ethiopia, India, Brazil and Cuba, at relatively low costs, provides hope, as to what is possible and achievable.

Extensive research and documentation show that in the post-World War I era, the basic view of success shifted, and success became more a function of public image. This shift was one that public servants noted very quickly. This is increasingly manifest by health policy approaches filled with social image consciousness, techniques and quick fixes, with social Band-Aids that address acute problems (and sometimes even appear to solve them temporarily), but leeave the underlying chronic problems untouched to fester and resurface time and again.

We will all agree that there is great health import to the purchase of ambulances by the state government, and or the allocation of funds to rehabilitate commercial sex workers. The merits of ease of access to health services, through speedy ambulance conveyance, increase in voluntary testing and counseling for HIV associated with rehabilitation of sex workers and the general support to curbing the spread of sexually transmitted infections, can not be over stated.

The issues that then come up can be summed up under 3 headings: Priority; Long-term solutions; Inefficient use of limited resources.

Health-care systems hemorrhage money. A recent study by the PricewaterhouseCoopers’ Health Research Institute estimated that more than half of the US$ 2 trillion-plus that the US spends on health each year is wasted; a Thomson-Reuters study reported a lower but still substantial figure of US$ 600–850 billion per year. The European Health care Fraud and Corruption Network says that of the annual global health expenditure of about US$ 5.3 trillion, a little less than 6%, or about US$ 300 billion, is lost to mistakes or corruption alone.

While some countries lose more than others, most, if not all, fail to fully exploit the resources available, whether through poorly executed procurement, irrational medicine use, misallocated and mismanaged human and technical resources or fragmented financing and administration. But there is nothing inevitable about this and there are many shades of inefficiency. Some countries obtain higher levels of coverage and better health outcomes for their money than others, and the gap between what countries achieve and what they could potentially achieve with the same resources is sometimes enormous.

While raising more money for health is crucial for lower-income countries striving to move closer to universal coverage, it is just as important to get the most out of the resources available. Finding the most efficient ways to meet the multiple challenges health systems face is also an issue for those countries that might be struggling to sustain high levels of coverage in the face of constantly increasing costs and growing demand.

There are many opportunities for efficiency gains. This does not mean simply cutting costs. Efficiency is a measure of the quality and/or quantity of output (i.e. health outcomes or services) for a given level of input (i.e. cost). So efficiency gains could help to contain costs – an important objective in many countries – by reducing the costs of service delivery. However, no one wants to contain costs by reducing health outcomes, so seeking efficiency gains should also be seen as a means of extending coverage for the same cost.

As richly pointed out in the 2010 World Health Report, no country, no matter how rich, has been able to ensure that everyone has immediate access to every technology and intervention that may improve their health or prolong their lives.

This is even more so, in a country like Nigeria, with less than 6% of total national expenditure for the 2013 fiscal year, allocated to health. The health system of such a country must then be built on prioritization, sustainability and efficiency.

If the FCT ministry, wants to commit N5 billion to curtailing STIs and providing social reform for commercial sex workers, would it be more prudent to spend the same allocation and Provide skills acquisition programs for young people (N1 billion), focus on job creation (N3 billion) and use its extensive network of NGOs and the support of the international community to provide sex education, screenings and free condoms to young people across the FCT (N1 billion)?

There is no perfection or analysis justifying the proposed numbers above. The emphasis is on the broader scope of interventions, affecting more young people across the capital and also looking to provide long term benefits all round. This is of course, just the opinion of this writer.

If the government of Oyo state wants to make healthcare more accessible to its citizens, would it have been more prudent to prioritize the improvement of state health facilities and provision of social health insurance to students, children under 5 and pregnant women across the state? Again, just the opinion of this writer.

It is not to say that some of the proposed alternative expenses are not in play. They may be and the pioneers within the ranks of government do not just feel like sharing these aspects of their work with the masses.

If however, the elements of government have done the needed research and have found that the areas they have chosen to invest in, merit the commitment of our meager health resources, and have found that their approaches mirror best practices, the masses will appreciate that they share the evidence with us all. Through such transparency, the masses will be educated and will be carried along by their government. This is the expected framework of democratic policy making, in all its tenets.

The Federal Government of Nigeria, through the Federal Ministry of Health continues to reiterate its recognition of the fact that, to improve the health and wellbeing of Nigerians, there needs to be a scale-up with strengthening of the health system including additional financing for health and with building and strengthening of the Primary Health Care System in line with the principles outlined in the Ouagadougou and Abuja declarations. As clearly captured in the Nigerian National Strategic Health Development Plan 2010 – 2015, quick fixes and band-aids, will not achieve the required scale up.

The 2013 health budget is riddled with only 20% capital expenditures, numerous duplications and inconsistencies, inadequate investment towards universal health coverage and an inclination towards catering for the upper class and the civil servants, more than the masses. When put together with some of these so-called health investments and projects, it makes a mockery of some of the well-meaning efforts to improve health and healthcare across this country.

Our generation, as young people, need to see beyond the quick fixes and demand political effort with a backbone of efficiency, priority and sustainability. We must stop pretending like or acknowledging that any bone thrown to us, is a good bone!


Posted: February 3, 2013 in Uncategorized

Last week the media was agog with a news report titled “Saraki commends Jonathan’s intervention in Zamfara village”. When I read this title on twitter, I quickly clicked on the link with excitement to read the details. I thought the reason for the commendation could be that the problem of lead poisoning which has reportedly claimed the lives of more than 400 children in Zamfara State has probably become a thing of the past. I was completely wrong. The Chairman of the Senate Committee on Environment, Dr Abubakar Bukola Saraki was commending Mr. President for his “approval to release promised funds for the remediation of Bagega Community in Zamfara State”. My excitement immediately turned to strong feeling of disappointment. I feel you may want to know why, please read on.
In March 2010, an unprecedented epidemic of lead poisoning was discovered in Zamfara State. This was a consequence of the…

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