Tracking Intervention Coverage for Child Survival

You will find below the word format of a powerpoint presentation of a review article I presented at the department of Family Medicine, Jos University Teaching Hospital, Jos, Nigeria, recently. It borders on the progress the developing world has made so far towards achieving the MDGs. Please read.

• Review article

• 10 researchers from WHO, UNICEF, the World Bank, Johns Hopkins, PMNCH, Universities in Brazil and Pakistan

• Funding for the research provided by these institutions

• Commenced in 2005

Background

• The Millennium Development Goals

• The fourth: achieve 2/3 reduction of under-5 mortality between 1990 and 2015

• Other MDGs relate to Child health: the 5^th calls for reduction of maternal mortality and others eradication of extreme hunger, universal basic education, etc

• Success in one MDG imparts on others

• MDGs adopted worldwide in 2000

Childhood survival strategies: the evolution

• The 2^nd world war and relief provision for children ravaged by war

• Access to health & the Welfare view

• CSDPP: Child Survival Development Protection and Participation policies packaged into GOBIFFF in the 1980s

• The Child Rights Commission (CRC) in the 1990s: health of child a right

• Recently, Integrated Management of Childhood Illnesses (IMCI) and the MDGs

The Essence of tracking

To determine the progress (or otherwise) made so far towards achieving the 4^th MDG especially in resource-constrained countries of the world so as to intervene early for rapid actualization of the 4^th MDG

The Process of Tracking intervention coverage

• In this context, it involves

– Identifying target countries

– Developing profiles for each country

– Identifying essential child survival interventions that are already in place in those countries

– Measuring success of coverage by estimating the annual reduction in under-5 mortality rate

Contd:

– Measuring extent of coverage of essential child survival interventions

– Classifying countries into 3 categories according to progress made towards internationally agreed targets viz: “on track”; “watch and act” and “high alert”

– Feedback

What are the essential Child Survival Interventions?

• There is evidence that a set of about 20 interventions could reduce child mortality by over 60% if made available to all who need them.

• Countries that have good coverage for 6 out of the 20 interventions are rated to be doing well

• The interventions are listed below:

• Note that the figures indicate the median coverage levels (in percentages) of each of the essential interventions in 60 countries with the world highest rates of child mortality; those in parenthesis represent the range

Newborn health

• Skilled attendant at delivery 51(6-97)

• Tetanus protection at birth 59(10-90)

• Postnatal visits within 3/7

• PMTCT 3(0-50)

• Timely initiation of breastfeeding 36(9-72)

Other prevention interventions

• Use of improved sanitation facilities 41(6-80)

• Use of improved drinking water sources 69(13-98)

• Vitamin A supplementation 80(1-98)

• Insecticide-treated bed nets 3(0-44)

Nutrition

• Exclusive breastfeeding at <6mths style="mso-tab-count: 5"> 24(1-84)

• Breastfeeding plus complementary food at 6-9mths of age 66(13-94)

• Continued breastfeeding at 20-23mths of age 54(8-94)

Immunization

• DPT immunization 73(25-98)

• Measles immunization 74(35-99)

• Hib immunization 89(73-98)

Case management

• Care-seeking for pneumonia 47(14-76)

• Antibiotic treatment for pneumonia

• Oral rehydration therapy for diarrhea 38(7-80)

• Antimalarial treatment for fever 45(1-69)

Nigeria and Child Survival Strategies

• Under-5 mortality rate: 230 in 1990

197 in 2004

Estimated annual rate of reduction from 1990-2004: 1.1%

MDG target of under-5 mortality rate by 2015: 77

Average annual rate of reduction needed between 2004 and 2015 to meet target: 8.6%

• Nigeria classified as one of the 60 countries with highest child mortality rates (inclusion criteria: annual child mortality rate >90/1000 live births)

• Out of the 60, Nigeria close to the bottom; those with higher child mortalities than Nigeria are either ravaged by war or natural disasters

• As at 2004, the measles and DPT immunization coverage was less than 50%

• Also, considering each of the other interventions, Nigeria falls below the minimum estimate required to achieve the MDGs by 2015

• Nigeria is not on track to meet the MDGs, going by available data.

Child Survival: state of the world

• Only 7 of the countries with the highest burden of under-5 mortality in 2004 are on track to achieve the MDG-4: Bangladesh, Brazil, Egypt, Mexico, Nepal, Indonesia and the Philippines

• Mortality rates increased between 1990 and 2004 in 14 countries and most of these countries are affected by armed conflicts or and the AIDS pandemic

• Generally, rates of progress in child survival is slow

• Has been directly linked to the low levels of coverage of interventions discussed above

• Though some countries recorded up to 10% increase of access to above interventions within 2 years

• This shows that even the poorest of countries can make when needed resources are made available

Panacea for rapid reduction of Child Mortality

• Strengthen health systems

• Improve management capacities

• Ensure availability, sustainability of commodities needed for the interventions

• Increased, rationalized financial flow

• Human resource development

• Advocacy for political commitment

As regards donor assistance and financial flow

• In a companion article, the following were highlighted:

– The 60 countries with the highest burden of child mortality cannot achieve MDG-4 without external aid

– In 2004, donor assistance for activities related to maternal, newborn and child health was US$1990 million which represents just 2% of total aid disbursements to developing countries

Contd:

• This amounts to US$3.1 per child

• Grossly inadequate

• There is a direct relationship between mortality and Official Development Assistance (ODA) per head

• Recommendation: increase ODA significantly for desired effect

Relevance to Family Medicine

• Family Physician: Frontline doctor

• Tackles undifferentiated illnesses; provides curative, preventive, rehabilitative care from cradle to old age in a coordinated, comprehensive way.

• No one else best suits the position of instituting the childhood survival strategies

• Look through the interventions again

Conclusion

• In 2 years, the Childhood Survival Countdown team will be at work again in Geneva.

• They will come up with newly generated data representing how we have fared.

• Meticulous use of the interventions will produce astounding success and realization of MDG-4

Thanks for listening!

It's been awhile!

I have received a number of mails inquiring about this long silence. I replied some giving the reasons why I have not sent new posts for awhile.
I had to write a number of professional examinations. I dont know wether that reason is good enough but I am pleased to let out that I will be fairly constant in updating this blog, at least as I glean enough time off preparing for my dissertations and other duties assigned me.
I really am glad to be back!

REPORT OF THE WORKSHOP ON PAEDIATRIC ANTIRETROVIRAL THERAPY ORGANISED BY THE INSTITUTE OF HUMAN VIROLOGY NIGERIA FROM THE 24TH-28TH, JULY, 2006

We participated in a workshop recently. The following is the Word format of the Powerpoint report. I experienced difficulty uploading it in powerpoint format.

Facilitators
• Watson Douglas
– Pediatric HIV specialist
IHV-Baltimore; University of Maryland
• Bowman David
– Pediatrician/Clinical Training Director
IHV-Nigeria/Baltimore
• Okechukwu Adaora
– Pediatrician, Gwagalada Specialist Hospital, Abuja
• Nadew Kidest
– IHV-Nigeria
• Adamu Grace
– IHV-Nigeria
• Okundia Patience
– National Hospital Abuja

Institute of Human Virology Nigeria
• Affiliate of Institute of Human Virology, Baltimore
• Dr Dakum, Chief of party
• Professor Blattner, Alashle Abimiku, investigators
• Work closely with Professor Robert Gallo, co-discoverer of HIV
• The ACTION (AIDS Care and Treatment in Nigeria) Project so sets out reduce the incidence HIV/AIDS in Nigeria

Arrival
• Meant to have been on the 23rd
• I arrived on Monday the 24th
• I was on call the previous day
• I met the 2nd session
• Accommodation was splendid
• The food was good
• We had a Pre-test

Thrust of the Workshop
• Focus on Pediatric HIV/AIDS care
• Reduce the incidence of HIV/AIDS by prevention and treatment of pediatric HIV in Nigeria
• Build comprehensive pediatric HIV care for Nigeria
• All that prescribe pediatric ARVs must do it right
• Prevent multi-drug resistance
• Intimate workers in new sites with IHV’s potentials and planned work in Nigeria
• Raise awareness about GON intended harmonization of HIV care in Nigeria
• Build capacity to be able to achieve above



• Workshop overview
• We had a Pre-test
• The burden of pediatric HIV
• Globally (UNAIDS 2005 figures): 2.3million (5.7% of total) children living with HIV
• 700,000 (14% of total) new infections/year
• 1900 infections per day
• Above preventable by good PMTCT
• 570,000 (18% of total) deaths/year
• 1560 deaths/day-mostly preventable by early detection, prophylaxis and treatment
• Most of these in sub-Saharan Africa
• 13million orphans worldwide-90% in Africa
• By 2010, 25million AIDS orphans



• In Nigeria (FMOH 2004 figures): estimated 4.4% National prevalence
• 3.5million Nigerians living with HIV-third highest worldwide next to south Africa and India
• 1.7million women
• 270,000 Nigerian children lives with the virus (14% of total African burden)
• 847,000 Nigerian children orphaned by HIV


• Next, we considered, broadly, steps needed to prevent and treat pediatric HIV starting by reminding ourselves that-HIV can be treated
-HIV can be prevented
-treatment/prevention require dedication, cooperation and a team approach
-resistance is a serious threat
We examined the HIV structure, its pathogenesis, history and manifestations; HAART as criterion for successful viral suppression, mechanism of developing resistance and the draft revised WHO guidelines for initiating ART in children

• Draft revised WHO guidelines for initiating ART in infants and children: clinical criteria

• Stage <18mths>18mths

1 CD4-guided CD4-guided

2 CD4-guided CD4-guided

3 Treat all Treat all,
(consider TB,
LIP, OHL, ITP,
CD4 count)

4 Treat all Treat all

• Draft revised WHO guidelines for initiating ART in children: immunologic criteria

• Marker Age at initiating ART

<12>5yrs

CD% 25% 20% 15% 15%

CD4
count 1500 750 350 200


• We then began to broach the task of building a comprehensive pediatric HIV care in Nigeria
• Systems approach-multiple disciplines
• Standards of care-harmonization of care

PMTCT
• Targets
– Prevent young women from infectn
– Prevent unintended pregnancy in HIV+ women
– Prevent HIV+ women from transmitting to their children
– Provide HIV care, treatment, support to HIV+ women, their infants and their families

UPDATES
• Nobody should prescribe single dose NVP for women in labor (i.e. without protecting the “tail”) for prophylaxis because of risk of resistance in mother
• A single mutation of the HIV leads to resistance to NVP; NVP takes 3-7 days b4 it clears from the bloodstream; mutation/resistance develops in the presence of inadequate drug
• Also, to prevent resistance in infants, protect NVP “tail” by giving AZT + 3TC for 1wk thereafter continuing with AZT for 5wks
• WHO encourages standard practice in all facilities


ARVs FOR PMTCT: INFECTION RATES AT 1MTH
• Effectiveness depend on duration and intensity of ARVs
• No intervention: 20% infected
• Single-dose NVP: 12% infected
• AZT from 28 wks: 7% infected
• 2 drugs: 1-4% infected
• HAART: <1% infected

• There are different scenarios
– Pregnant woman who is HAART eligible
– HIV+ woman on HAART who got pregnant
– HIV+ pregnant woman who is not HAART eligible
– HIV+ positive pregnant woman who is/who is not on HAART but developed TB
– HIV+ woman who will breastfeed after delivery
Different other scenarios beyond the scope of this report
Many health facilities pledged to review their policy on PMTCT

CONCERNS
• Resistance
– NVP
– AZT good drug, needs 5 mutations for resistance to develop
– Mutation to 3TC beneficial overall
– Efavirenz teratogenic in early pregnancy so delay till 3rd trimester
– DDI causes infantile lactic acidosis
– AZT: anemia in newborn
– TDF: ?bone toxicity
– Neurodegenerative mitochondrial brain disease if AZT + 3TC started from 23-32wks gestation and continued in neonates 6wks in the postpartum period

THE DILEMMA OF FEEDING THE HIV-XPOSED INFANT
• We considered this thorny issue
• No easy answers
• Especially its implications for resource-poor settings
• HIV is transmitted to about 15% of exposed infants after 24mts of breastfeeding; exclusive breastfeeding cuts this risk by half; most women do mixed feeding;
• Infant breast milk substitute (BMS) is encouraged but not imposed on the woman
• BMS must satisfy WHO’s AFASS criteria: acceptable, feasible, affordable, sustainable, safe
• Institute appropriate ARV therapy: infant/mother
• Do not allow mixed feeding
• Supplementary feeds: breast with clear fluids-tea, water
• Complementary feeds: breastfeeding + semisolids especially at weaning
• Mixed feeds: any of above 2 + another milk

DIAGNOSIS OF THE HIV EXPOSED INFANT
• Challenging
• Clinical
• Serologic: detects antibody response to infection-rapid tests; have to wait for 18mths for full seroreversion in neonate
• Virologic: Directly detects virus in cell or plasma 2-4wks after infection-viral load testing by DNA PCR; available in some centers
• Immunologic: effect of infection on the immune system-CD4 count or %

Presumptive diagnosis of HIV in infant (WHO 2006 guideline)
• When there is no DNA PCR
• Infant seropositive
and either
pediatric stage 4 disease
or
2 or more of:
-oral thrush
-severe pneumonia
-severe sepsis
Supporting evidence:
-death or advanced HIV in mother
-CD4< 20%

Paediatric stage 1
• Asymptomatic
• Persistent generalized lymphadenopathy
– Lymphadenopathy is a good prognostic sign- probability of death in HIV-infected children with adenopathy is half as much as those without

Paediatric stage 2
• Unexplained persistent hepatosplenomegaly
• Papular pruritic eruptions
• Extensive wart virus infection
• Extensive molluscum contagiosum
• Recurrent oral ulcerations
• Unexplained persistent parotid enlargement
• Lineal gingival erythema (red line along the gum line)
• Herpes zoster
• Recurrent upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis )
• Fungal nail infections

Paediatric stage 3
• Moderate unexplained malnutrition not adequately responding to standard therapy
• Unexplained persistent diarrhoea (14 days or more )
• Unexplained persistent fever (above 37.5 ºC, intermittent or constant, for longer than one month)
• Persistent oral Candida (after first 6 weeks of life)
• Oral hairy leukoplakia
• Acute necrotizing ulcerative gingivitis/periodontitis
• Lymph node TB
• Pulmonary TB
• Severe recurrent bacterial pneumonia
• Symptomatic lymphoid interstitial pneumonitis (LIP)
• Chronic HIV-associated lung disease including bronchiectasis
• Unexplained anaemia (<8.0 g/dl ), neutropenia (<0.5x109/L) or chronic thrombocytopenia (<50 x 109/ L)

Paediatric stage 4
• Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
• Pneumocystis pneumonia
• Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia)
• Chronic herpes simplex infection; (orolabial or cutaneous of more than one month’s duration, or visceral at any site)
• Extrapulmonary TB (except lymph node TB)
• Kaposi sarcoma
• Oesophageal candidiasis (or Candida of trachea, bronchi or lungs)
• Central nervous system toxoplasmosis (after the neonatal period)
• HIV encephalopathy

Paediatric stage 4 (cont.)
• Cytomegalovirus (CMV) infection; retinitis or CMV infection affecting another organ, with onset at age over 1 month
• Extrapulmonary cryptococcosis including meningitis
• Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis, penicilliosis)
• Chronic cryptosporidiosis (with diarrhoea )
• Chronic isosporiasis
• Disseminated non-tuberculous mycobacteria infection
• Acquired HIV-associated rectal fistula
• Cerebral or B cell non-Hodgkin lymphoma
• Progressive multifocal leukoencephalopathy
• HIV-associated cardiomyopathy or nephropathy

Differentiating pulmonary disease in paediatric HIV (2)
• TB
– Common- about half of people with HIV
– Less likely to be cavitary, more likely to be pneumonia or extrapulmonary versus non-HIV
– HIV patients do poorly if not treated
– PPD useful if positive
– Smear culture can be done in children with right sampling technique, but not widely available
• LIP
– Chronic, slowly progressive- often older children
– Cough, wheeze, hypoxia
– Clubbing may be present (TB usually will kill before clubbing develops)


Differentiating pulmonary disease in paediatric HIV (2)
• Pneumocystis pneumonia (PCP)
– Triad of cough, tachypnea, and hypoxemia
– Acute or subacute, not chronic
– CXR may not be impressive early in disease
• Bacterial pneumonia
– Very common
– Acute presentation
– Usually pneumococcal, but can be many others
• Bronchiectasis
– Chronic with multiple episodes of acute worsening
– CXR shows areas of atelectasis, especially right middle lobe

6 year old with severe distal clubbing secondary to chronic pneumonia
Immunization
• All National EPI immunizations should be given
• BCG
-risk of local adenitis or even disseminated disease; treat with antikoch’s
-benefit outweighs risk
DTP, OPV, Hepatitis B, Measles (may withhold measles vaccine if advanced HIV and measles not active in community


• We had a session examining the new revised pediatric HIV staging (we got a manual) and its bearing on prescribing “ideal HAART” (potent, durable, convenient, non-toxic, tolerable and sustainable).
• We defined HAART as a combination of drugs that is potent enough to stop HIV from growing and requires many different mutations to fail (high genetic barrier to resistance) that the patient takes daily, all doses.
• The real HAART is unsparing-must be taken daily, all doses.
• The issue of resistance to ARVs came up again

• We then began to examine each of the antiretroviral drugs on the PEPFAR list one after the other in some detail-their toxicities, interactions, storage, formulations, palatability, potency, immune reconstitution syndromes e.t.c
• We considered the issue of co-infection of HIV with TB and WHO’s recommendation
• We established that repeated adherence counseling by ALL members of the team is the key HAART success
• The most complication of HAART is resistance
• The treatment of resistance is prevention

• We reviewed the need for excellent ongoing management of the child on HAART
• The role of the family-friendly clinic
• The role of home-based care
• The elements of interval visit
• The place of proper documentation
• The place of adherence

• Treatment failure will occur in some
• ARV specialists must know which drugs to switch to-could be lifesaving
• The workshop facilitators took us through the precursors, mechanisms, indicators, perpetuators of treatment failure
• Successful management of treatment failure is enshrined in a sound knowledge of the different ARV regimen (1st-3rd line) after addressing adherence and the issues listed above

• We again went through the rudiments of post-exposure prophylaxis and universal precaution examining updates about special situations such as rape, PEP following casual coitus, occupational exposure, e.t.c

• An M&E staff of IHV-Nigeria took us through the different PMMs (patient monitoring and management systems) in Nigeria
• He outlined the usefulness of the PMMs-research, patient monitoring, feedback, program evaluation, e.t.c
• Intimated us with the plan of the GON to harmonize all HIV work in Nigeria

• Each day, we reviewed ART cases, the types we encounter in our clinics thus consolidating the theoretical knowledge we were gathering.
• We had a session with our constituency-PLWH/PABA who gave us insightful talks on how we can be more useful in ensuring stigma reduction in the hospital and the society at large

• The workshop ended on Friday evening after we were given some resource materials, certificates, contact information of all participants/trainers.
• We left with a resolve to affect lives


Thanks!!!

Differential Access to Antiretroviral Drugs in the Third World: PEPFAR as a Mitigating Agent

The Acquired Immune Deficiency Syndrome (AIDS) caused by HIV is a scourge that is ravaging humanity. A 2005 global epidemic update by UNAIDS puts the total number of people living with HIV at 40.3 million (adults: 38 million; women: 17.5 million; children under 15 years: 2.3 million). The total number of deaths due to AIDS in 2005 was 3.1 million people (children under 15 years: 570,000). There are about 13 million AIDS orphans worldwide-over 90% of these orphans are in Africa. The number of AIDS orphans is projected to reach 25 million in 2010.
Most of the people living with HIV/AIDS live in the developing world.
Access to antiretroviral drugs and HIV care as a whole has been very difficult in the third world. Earlier on, we grappled with the problem of inadequate capacity. There was only a limited understanding about the dynamics of the disease. Many health facilities lacked the capacity to carry out even simple diagnostic procedures such as the rapid antibody tests. And when eventually this capacity was acquired, those who were positive were not able to procure the antiretroviral drugs that were just coming to the third world. The costs were prohibitive. At that time, in Nigeria, for instance, it cost the equivalent of four months salary to procure a month’s worth of antiretroviral drugs. Apart from the fact that many died from AIDS since they could not afford these drugs, it was difficult to carry out quality assurance on these drugs. Those bent on surviving the scourge got involved in some practices such as monotherapy, skipping doses, sharing medications with relatives and so on, laying a good foundation for multidrug resistance.
The third world is a complex place which has defied conventional economic theories. Poverty and disease exist alongside so much wealth. There is a very deep and wide gulf between the rich and the poor. The rich did not have much trouble procuring their antiretroviral drugs. Ofcourse, the rich also acquire HIV!
The WHO has been instrumental in ensuring universal access to antiretroviral drugs. There was the 3 by 5 campaign and recently again, the urgent call to scale up antiretroviral drug access especially to resource-constrained settings. In response, international donors have taken up the challenge almost in a fevered pitch. And in frenzy, many health facilities have opened up their doors, some stopping short of alluring donors.
PEPFAR (President’s Emergency Plan for AIDS Relief), a US government initiative, has served as a mitigating agent for some time in alleviating differential access to antiretroviral drugs in the third world. I am not about to sing the praises of PEPFAR but I simply submit that this program has achieved quite some. PEPFAR serves the center where I work. VCT (voluntary counseling and testing), laboratory investigations, antiretroviral drugs, contact tracing and home-based care, capacity building in terms of health personnel training, facility development and so on are all provided by PEPFAR.
And we have seen results. The patients directly benefit. Their follow-up indices gladden our hearts.
We still have a long way to go. The uptake of antiretroviral drugs in the third world is still unacceptably low considering the burden of the disease.
And it is time governments in the third world (as in Botswana) began to put in place the necessary framework to sustain HIV care when the donors have gone: the donors will not be here forever.

Thank you, Christiane Amanpour

I have just watched Christiane Amanpour’s documentary on AIDS Orphans in Kenya.
The report cannot come at a better time. Though it once again depicts the grim, deathly, hopeless outlook of the African continent, there is a small ray of hope that things can change-this dead horse can live again.
The notion that this kind of report denigrates Africa is utter nonsense. We cannot continue to live in denial. Let all concerned listen to the passionate appeals of Christiane Amanpour, discard the cloak of irresponsibility and act quickly.
See www.cnn.com/eyeonafrica.

Family Medicine in Resource-Poor Settings: The Need for a Paradigm Shift

Family Medicine is that discipline which provides continuing, coordinated, comprehensive healthcare for all patients irrespective of their age, sex, or type of illness. Family Medicine approaches care from a holistic perspective putting into consideration the patient’s family, environment, culture and community and integrating other specialties in a new whole thereby successfully eliminating the reductionist approach to care.
The Family Physician views the family as a unit of care since the concept of family dynamics in health and disease posits that the family influences the causation, perpetuation, therapy, rehabilitation and prevention of disease. Family Medicine takes cognizance of the General Systems Theory which holds that natural entities and phenomena can be organized into specific systems that share common properties. These systems can in turn be allocated into a hierarchy of systems giving rise to the concepts of the suprasystem or biosphere (the community, culture, family) and subsystem (the person/personality, organs, cells, organelles, molecules, atoms and subatomic particles incorporating the genetic makeup). The individual is managed in this context recognizing that an imbalance in either system can lead to ill health.
The well-trained Family Physician has acquired the requisite skills to build on the strength of the family unit since the family is able to harness resources more than the individual in crisis situations.
The Family doctor thus provides primary, family and secondary healthcare, coordinating care when referrals are needed.
I have just described the ideal above. I make bold to say this situation is not what obtains in many resource-limited communities since I am a trainee Family Physician working in such a community. For ages, the West has realized the cost effectiveness and efficiency of using Primary care/Family Physicians in meeting most of the health needs of its citizenry. Current evidence supports this. Though there are instances of inter-specialty wrangling in some Western countries, policymakers/governments still do the right thing by equipping primary care physicians to take care of most ailments in a sustainable way.
Resource-poor countries must quickly shift position and move in this direction even in the face of constraints such as brain drain, poor remuneration of physicians that are still around, prolonged duration of training of Family Physicians, obsolete training facilities, dearth of trainers, inadequate motivation to enter into residency training, excessive workload on those who decide to train, inter-specialty/discipline bickering, among others.
And we must not shift this responsibility to the government alone-all must be involved in creating this system that sustains itself.

Revisiting Nigerian Health Indicators: Lessons Learnt from the Swedish Example

I am in Lagos at the moment. I traveled by road from Jos-a 12-hour journey. It was quite exhausting but it allowed me some time off my daily routine. I am not here entirely on vacation. My place of work cannot afford for me to do that. To the contrary, I am here to attend a workshop on reproductive health organized by the Faculty of Family Medicine of the National Postgraduate Medical College of Nigeria. It has been quite revealing, quite riveting!
We discussed several issues that bordered on the ways and means by which we can reduce maternal mortality and morbidity. Chairmen of Local Government Councils, officials of the Faculty of Family Medicine, among others, were present. Renowned, experienced university professors from Nigeria’s premier university were some of the facilitators. The workshop was participatory in approach. Issues such as the following were appraised:
Community obstetrics-its relevance in reducing maternal mortality in poorly urbanized settings,
Maternal mortality-its cause, effects and needed intervention,
High risk pregnancy
Puerperal sepsis
Breastfeeding
HIV issues in pregnancy
Hypertensive disorders in pregnancy
Contraception
During one of the sessions, one of the facilitators decried the state of medical record keeping in Nigeria as we could not agree on what the maternal mortality in Nigeria is.
The workshop, for me, has re-echoed the intrigue I wrote about in my last post (see below). By the way, I kept on coming back to that post to compare those figures. I am still amazed by the fact that Sweden, with a population of about 9 million people, spends more than 50 times what Nigeria spends on the health of about 130 million people. Perhaps it is more accurate to say that Sweden’s Total Health Expenditure as % of GDP is twice that of Nigeria. Here lies the difference-responsible governance. And the rest of the Swedish data speak for themselves.
Some may consider it cruel to compare Nigeria with Sweden. But there is no wisdom in doing otherwise. I would rather compare myself with those who are better than me. After all, Nigeria’s Fitch Rating is now BB minus, comparable to some countries that are doing well. The fact that Nigeria is rich in resources, the fact that Nigeria has paid off its debts to her creditors, the fact that Nigerians have got the resolve, among other things, is enough impetus. Jeffery Sachs, the acclaimed global economist and advisor to the United Nations’ Secretary-General is strongly of the opinion that resource-challenged countries have the capacity to initiate the process of change successfully even before the often needed support comes from donor countries. While canvassing for prudence and responsible governance by resource-limited communities, he encourages “big” countries to quickly help so as to achieve the MDGs as scheduled.
Developing countries should take a cue from the foregoing.

Nigerian Health Indicators: Intriguing!

I found the following Nigerian health indicators on the WHO’s website recently. I consider these very intriguing, very distressing. Take a look. You may leave a comment-perhaps you have a nostrum for Nigeria’s (and other resource-constrained countries) health problems.

Total population: 131,530,000
GDP per capita (Intl $, 2004): 1,085
Life expectancy at birth m/f (years): 45.0/46.0
Healthy life expectancy at birth m/f (years, 2002): 41.3/41.8
Child mortality m/f (per 1000): 198/195
Adult mortality m/f (per 1000): 513/478
Total health expenditure per capita (Intl $, 2003): 51
Total health expenditure as % of GDP (2003): 5.0
Figures are for 2004 unless indicated. Source: The world health report 2006

Compare these with Swedish statistics:

Total population: 9,041,000
GDP per capita (Intl $, 2004): 30,336
Life expectancy at birth m/f (years): 78.0/83.0
Healthy life expectancy at birth m/f (years, 2002): 71.9/74.8
Child mortality m/f (per 1000): 4/3
Adult mortality m/f (per 1000): 82/51
Total health expenditure per capita (Intl $, 2003): 2,704
Total health expenditure as % of GDP (2003): 9.4
Figures are for 2004 unless indicated. Source: The world health report 2006

What do you think?

As regards Nigerian Health Reforms

The Nigerian Government has finally decided to do something about the crisis in the healthcare system. I am sure they are haunted by the fact that the private sector provides 65.7% of healthcare delivery which in most part is unregulated, inaccessible and not affordable to the predominantly poor Nigerian populace.
Although there were a number of white papers on health policy reforms during the protracted, mediocre military era, there was total disconnect between policy formulation and implementation.
This present regime’s effort at revitalizing the Nigerian health system anchors its foundation on a certain health policy (the National Policy and Strategy to achieve health for all Nigerians) promulgated in 1988. This policy was revised by the present administration in 2004 and forms the platform for collaboration with several agencies for healthcare development, including the WHO.
There has been a number of consultations with several stakeholders with the ultimate aim of implementing the health strategies of the New Partnership for Africa Development (NEPAD), National Economic Empowerment and Development Strategy (NEEDS) and the Millennium Development Goals (MDGs) allowing primary healthcare to remain the fulcrum of sustained, equitable development by encouraging and strengthening Village Health Committees (VHCs) to mobilize community. The following are some of the policy thrusts of the reform agenda:
-National Health System and its Management
-National Healthcare’s Resources Management
-National Health Interventions and Services delivery
-National Health Information Systems
-Partnerships for Health Development
-Health Research and Healthcare Laws.
I do not want to appear pessimistic but there is need for total resolve by all concerned to translate all the above to improved health outcomes for the ordinary Nigerian.
I work as a physician in Nigeria and I experience firsthand the difficulties people face here when trying to obtain quality healthcare or any healthcare at all. Perhaps those experiences are for another post. But it can be very frustrating working in here because of inadequate capacity, among other limitations. You can not help many as you would want to. You cannot even help yourself! We simply toil on.

Technorati Profile

Of Poverty, Millenium Development Goals (MDGs) and Equity

There has been so much talk about the nexus between extreme poverty (as if poverty in 'mild' form is permissible) and health. It is a vicious cycle of poverty birthing ill health and vice-versa. Prior to the report of the WHO's Commission on Coordination of Macroeconomics and Health(CMH), it was popularly believed that wealth was the driver of health. It is now known that the reverse is the case-health drives poverty reduction.
The WHO's Coordination of Macroeconomics and Health Program aims to support countries to achieve the millenium development goals (MDGs) by encouraging National Ministries of Health focus on the poor by identifying cross sectoral strategies and cost effective options that will sustain improved health outcomes;
strengthen commitments to increased financial investment in health; and
minimize non financial constraints to the absorption of greater investments by increasing efficiency and effectiveness.
I am saddened by the fact that we have become so proficent in drafting policies and neologisms-for instance, Health for All by 2000, Vision 2010, (the list is endless)-without realizing these goals. There is no advantage in finger-pointing. These policies can work if all resolve to contribute to development.
Compare the 2 pictures. Both were taken in Nigeria, my country. There is so much disparity in the socioeconomic status of people here. Ofcourse, most live in conditions you find in the second picture. And it is true that Nigeria is rich in mineral resources.
It is not uncommon to find poverty and so much wealth existing side by side. Did you see Oprah's coverage of Katrina and CNN's coverage of living conditions of some in France?
Many do not crave for stupendous wealth: many simply desire basic, equitable means by which they can lead 'normal' lives.

The Whole Systems View

It is absolutely imperative to approach healthcare development from the Whole Systems perspective: it is impossible to achieve sustainable development without this. Health systems do not exist in isolation. All other systems must work harmoniously, in synergy to ultimately improve our existence. We all want the better, brighter life. We cringe from human misery.
And we deserve to live well-in the best of health, in abundance, in a sustainable environment.
A lot of effort, no doubt, is needed to create an equitable society. But it is doable!
This picture of a malnourished child on her mother's lap was taken at the Yiriba Feeding Center in Awasa, 300km south of Addis Ababa,Ethiopia. This Center's initiative may not be considered an epic in the quest to undo humanity's misery but it is a step in the right direction. We stand guilty of negligence if we stand aloof, fold our arms and do nothing.

The Competitive Advantage

It is becoming increasingly obvious that to achieve Sustainable Health Systems (SHS), Business, among others, must take the lead. This applies to both developed and resource-limited communities. Corporate Social Responsibility (CSR) is now birthing Corporate Social Development (CSD). Successful business leaders know that for business to grow, you must have this competitive advantage. It is all about considering the business of health and consequently, the health of business.
The World Business Council for Sustainable Development now has a project that is addressing this issue. Have you read their Executive Brief? Check www.wbcsd.org

Welcome!

This welcome is belated, but it is better late than never.
I am a Change Agent. I want to see sustainable development especially as regards Health Systems in resource-constrained settings. This is my Creed: my chosen path in life. I seek for people with similar vision-those who are entirely sold out. It is a well known fact that you achieve more when there is a cross-fertilization of ideas; when resources are pooled together.
You cannot as yet acquaint yourself entirely with my person in this single post but I reproduce below an essay I submitted when applying for a Master's Program I have just been admitted into. This will give you a glimpse of me.
Please read.


The Master of Strategic Leadership towards Sustainability Program: My Statement of Interest.

I live in a region of the world termed “developing” . This classification appears to be a misnomer . Everywhere I turn I see stagnation , retrogression and at times , outright decay . There are just a few segments of our daily lives that we have noticed the similitude of progress-slow , painful progress .
I have a background in the health industry. Some of our health indices were better during the pre-independence era than what obtains now. We even have done more harm to ourselves than good during our development, so-called. Consider Nigeria, my country. Nigeria is a populous nation of about 150 million people. This country occupies a landmass of about 923,768 sq km. She is blessed with abundant natural resources but sadly ranks as one of the poorest nations of the world. The average Nigerian lives below the poverty line. Corruption, greed, years of military rule, unstable economic polity, lack of political will and poor planning are some of the reasons why Nigeria remains poor. The health sector is not spared. The health indices are poor. A 2003 estimate puts Nigeria's infant mortality rate at 71 per 1000 live births and life expectancy at 51 years. In 1993, there were 5,208 persons per doctor and for many years, less than 3% of the GDP was spent on health care. Infectious diseases remain a major problem and preventive measures are rudimentary, almost non-existent. Public health institutions are mere spectacles of what they should be: most are under-staffed; the out of stock syndrome is rampant; health workers embark on work to rule campaigns incessantly and many health centers are death traps. There is substantial evidence that things were not this way at the beginning. Our development is not sustained. We grapple with mediocre leadership.
This is the state of many countries in the developing world.
I have been accosted by many, even accused, that I hold a somewhat simplistic, parochial view about the solution to the development issues facing resource-constrained settings. I strongly believe that the solution lies in our hands. We have to allow for responsible leadership that will give Sustainability issues priority of place. Otherwise, we will still continue to reel in the quagmire of under-development. This has been the thrust of my pursuits for a long time.
Ideas of a sustained environment first formed in my mind when I volunteered to join a Self-Help group that embarked on tree planting and beautification of my secondary school. I was in secondary school and we had just had a rain storm that pulled down a good number of the trees in my school. A tutor spearheaded this project and I came to learn from him that an imbalance in the milieu of the things on earth often results in chaos and devastation.
While at the university, I joined a socio-philanthropic organization called Les Ami where we imbibed principles of social responsibility and became advocates of sustainable development especially as regards healthcare delivery. Through this organization, we were able to conduct awareness campaigns about our core values at different levels of the university and the host city. We got some of our funding from the WHO and some public-spirited individuals.
I have an undergraduate degree in Medicine and Surgery from Nigeria’s premier university. I am at the moment involved in postgraduate training in Family Medicine at the Evangel Hospital, Jos, Plateau State, Nigeria. Before commencing residency training, I worked with a number of health outfits. Out of these, the public health outfits provided the most satisfaction as they exposed me again to issues of inequity in health distribution, inefficient, inaccessible and dilapidating health systems. I was able to carry out community mobilization and health advocacy which most of the time focused on establishing small but efficient health systems that work for people living in resource-limited communities. Sustaining larger healthcare networks was a challenge.
The Grace and Harold Sewell Foundation recognized these efforts and issued a scholarship to enable me present two papers at the 133rd Annual Meeting of the American Public Health Association last year. The papers bordered on sustainable healthcare development in developing countries. We have authored several other documents for publication/presentation at other fora. Recently, we started addressing the issue of universal access to antiretroviral drugs which is not possible without sustainable supply. If the supply is constant, then, we can scale up all other aspects of HIV care.
I have always nursed the ambition of pursuing a postgraduate degree in public health. While applying to schools around the world, I stumbled on information about the masters program in Strategic Leadership towards Sustainability which began to shed light on a peculiar principle dubbed The Natural Step Framework. I instantly came to terms with the fact that this degree is what I have been looking for to enable me achieve all that I have set to do for my community. For now, I have put on hold the quest to study this broad categorization called public health and pursue initially (if admitted into the program) principles that will empower me to follow my passion-that of ensuring sustainable development especially as regards healthcare delivery.
As at now, I am filled with burning questions which I hope this masters program will enable me to answer. It is common knowledge that health systems do not exist in a vacuum. Disease results as a complex interplay of several factors. And good health is not just the absence of physical ailments-the person is viewed as whole. Thus, the relationship of health systems to other systems is pivotal. Considering the whole systems approach how does health systems relate to other systems? With the well-known demon of brain drain bedeviling developing countries, how do you train and retain manpower for sustainability? What alternatives are available to build human capacity? What is “community”? How do you mobilize community to take responsibility for sustainability? How do you foster social responsibility by the corporate community?
I want to learn from other would-be course participants about how they were able to carry out advocacy campaigns to convince policymakers to ensure that sustainable development is given priority. How do we manage scarce resources to allow for needed growth? How does widespread poverty impart on development? What methods are available to reduce poverty? I can go on.
The developing world is my constituency. My immediate community is my starting point. If I am admitted into this program, I intend to use whatever I learn to ensure sustainable development especially as it relates to sustainable health systems. I will become a better ambassador for this cause.

Ifeolu Joseph Falegan, MD.

The 14th ICASA, Abuja, Nigeria.

I (in traditional African attire) accompanied 2 Consultant Family Physicians (shown in picture) to the 14th ICASA (International Conference on AIDs and STIs in Africa) that held in Abuja, Nigeria. It was a gathering of world-renowned researchers, AIDs experts, Activists, OVCs (orphan and vulnerable children), PLWHA, donor organizations, pharmaceutical companies, government dignitaries from all over the world and other stakeholders in HIV care.
One message resounded (reverberated?) repeatedly: it is high time we stopped the talk and just took action-simply scale up (in a sane way of course!) all aspects of HIV care. Period!
Here, we brainstormed, after one of the sessions.
Check www.icasa2005.org.ng for other details

Middle level capacity building: Ensuring viable alternatives for under-resourced settings-a case in focus

DR. IFEOLU JOSEPH FALEGAN*; ECWA EVANGEL HOSPITAL, JOS, NIGERIA

Background- The developing world faces the daunting task of training and retaining manpower. There is a dearth of healthcare professionals. For instance, the projected immediate need of surgical specialists in Nigeria is 5756 but only 1256 are at post leaving a shortfall of 4500. The West African College of Surgeons is at the forefront of ensuring middle level surgical manpower development in Africa. There exist at the moment several programs in various African countries that seek to achieve this same objective. We consider one such case: the example of Evangel Hospital, Jos, Nigeria.
Method- We examine this hospital, founded in 1959; the different departments; the nationally acclaimed vigorous residency training program in Family Medicine; the dedicated local and foreign experts who facilitate this training and the impact this hospital has had on developing Nigeria’s middle level manpower.
Lessons Learnt- Evangel Hospital complements the effort of the West African College of Surgeons to develop middle level surgical manpower.
Conclusion- To achieve sustainable healthcare development, we must collaborate to discover evidence-based best practices that will ensure viable alternatives and allow for middle level capacity building.
Keywords- Manpower, Under-resourced settings

*Presenter

Submitted for presentation at the 46th Annual Scientific Conference of the West African College of Surgeons.

Nigeria is a populous nation of about 150 million people. This country occupies a landmass of 923,768 sq km. She is blessed with abundant natural resources but sadly ranks as one of the poorest nations of the world. The average Nigerian lives below the poverty line. Corruption, greed, years of military rule, unstable economic polity, lack of political will, poor planning are some of the reasons why Nigeria remains poor.
The health sector is not spared. The health indices are poor. A 2003 estimate puts Nigeria’s infant mortality rate at 71 per 1000 live births and life expectancy at 51 years. In 1993, there were 5,208 persons per doctor and for many years, less than 3% of the GDP was spent on health care. Infectious diseases remain a major problem and preventive measures are rudimentary, almost non-existent. Public health institutions are mere spectacles of what they should be: most are under-staffed; the out of stock syndrome is rampant; health workers embark on work to rule campaigns incessantly and many health centers are death traps.
The need for alternatives, for other viable options to the existing health care framework was borne out of necessity, out of the quest for survival. There was no intention to compete with public health institutions. Faith-based health institutions provided that viable alternative to rescue the masses from the doldrums prevalent in the nation’s healthcare system.
The ECWA (Evangelical Church of West Africa) medical directorate (EMD) has for many years provided quality healthcare to the ordinary Nigerian. It is a beacon of hope to many. It is a well-planned department of ECWA intended to be efficient in healthcare delivery. It adopts a holistic approach to the care of the person. Thus the recruitment process to the leadership of the EMD is a very thorough and competitive one.
The director of the EMD reports to the leadership of ECWA. He has several deputy directors reporting to him. These deputy directors head various health organizations run by the EMD. The EMD anticipated the problems being encountered by the public health institutions and set out to serve as a model that will bring sustainable healthcare development. Several consultations were made. Existing health policies were critically examined. The reasons for successes and or failures of several health programs were debated. A common standpoint was reached. Several departments were set up to meet different needs.
The School of Health Technology was set up to train community health extension workers. 55% of Nigeria’s populace lives in rural areas with significant health needs. Graduates from this school are trained to meet these peculiar needs.
The ECWA Community Health Program is spread through many states of the federation and is made of primary/secondary health centers. This program often traverses very difficult terrain to bring healthcare to the grassroots. It is a ready employer of graduates from the School of Health Technology.
The ECWA Evangel Hospital is a center of excellence for residency training in family medicine. There are several consultants (local and foreign) in different fields of medicine who facilitate this training. This hospital also serves as a referral center for many hospitals (including government teaching hospitals) in northern Nigeria. It is at the moment undergoing transformation to become the Bingham university teaching hospital.
The Vesico-Vagina Fistula (VVF) center is located within the Evangel hospital premises. It is one of its kinds in the country. It was borne out of necessity as many women develop fistulae due to a complex interplay of several factors. According to a retrospective study done on 899 women with obstetric VVFs in this center (check American Journal of Obstetric and Gynecology, 2004, April), the typical VVF patient was small and short; had been married early but was now divorced or separated; was poor, uneducated and from a rural area and had developed her fistula as a primigravida during a labor that lasted at least 2 days and which resulted in a stillborn fetus. This center has significant overseas sponsorship and the latest technology and expertise are employed in the repair of the VVFs of these helpless women.
The Family Health program is sponsored by the Packard foundation. It seeks to provide viable options for the family as a whole. It trains health workers and collaborates with many health institutions especially in northern Nigeria. It aims to reduce maternal morbidity and mortality especially in northern Nigeria. It organizes training workshops for emergency post-abortion care, seminars on family planning, universal precaution, cost-effective ways of managing sexually transmitted infections and so on.
Christoffel Blindenmission (CBM) supports the ECWA Eye hospital, Kano. It is a large eye referral center sited in the second largest city in Nigeria. There are consultant ophthalmologists and others, who help dispense health and train doctors from Nigerian universities undergoing their fellowship training, theater nurses and primary eye care personnel. World-class surgeries are done here. It is a resource center for many eye care projects spread throughout the West African region.
The School of Nursing and Midwifery supplies well-trained and much-needed nurses to the depleted workforce.
The ECWA Hospital, Egbe, also serves as a center of training for family medicine. It has for a long time collaborated with researchers from other Nigerian university to carry out groundbreaking studies. It provides affordable quality healthcare to people in its community.
The EMD has other subsets, which has for a long time been serving the people.
The EMD is involved in several collaborations to achieve its objectives. There is no disconnect with other institutions. It collaborates with the WHO, UNDP, the Packard foundation, EngenderHealth, the Netherlands TB and Leprosy program and so on to bring quality healthcare to Nigerians.
The EMD is not alone in its quest to provide sustainable healthcare development. There are other faith-based initiatives that aim to serve this purpose. This pool of faith-based health organizations provide succor from the turbulence experienced in healthcare delivery in Nigeria.
The lack of space will not allow us the luxury of elucidating the impact the EMD has made on the ordinary Nigerian. The results, however, as overwhelming as they seem, have not made EMD rest on its oars as new opportunities to influence the health polity are continually being sought after.
We present our example. We present this viable option for developing countries.

2-Page Summary for Faith-Based Health Initiatives....

Nigeria is a populous nation of about 150 million people. This country occupies a landmass of 923,768 sq km. She is blessed with abundant natural resources but sadly ranks as one of the poorest nations of the world. The average Nigerian lives below the poverty line. Corruption, greed, years of military rule, unstable economic polity, lack of political will, poor planning are some of the reasons why Nigeria remains poor.
The health sector is not spared. The health indices are poor. A 2003 estimate puts Nigeria’s infant mortality rate at 71 per 1000 live births and life expectancy at 51 years. In 1993, there were 5,208 persons per doctor and for many years, less than 3% of the GDP was spent on health care. Infectious diseases remain a major problem and preventive measures are rudimentary, almost non-existent. Public health institutions are mere spectacles of what they should be: most are under-staffed; the out of stock syndrome is rampant; health workers embark on work to rule campaigns incessantly and many health centers are death traps.
The need for alternatives, for other viable options to the existing health care framework was borne out of necessity, out of the quest for survival. There was no intention to compete with public health institutions. Faith-based health institutions provided that viable alternative to rescue the masses from the doldrums prevalent in the nation’s healthcare system.
The ECWA (Evangelical Church of West Africa) medical directorate (EMD) has for many years provided quality healthcare to the ordinary Nigerian. It is a beacon of hope to many. It is a well-planned department of ECWA intended to be efficient in healthcare delivery. It adopts a holistic approach to the care of the person. Thus the recruitment process to the leadership of the EMD is a very thorough and competitive one.
The director of the EMD reports to the leadership of ECWA. He has several deputy directors reporting to him. These deputy directors head various health organizations run by the EMD. The EMD anticipated the problems being encountered by the public health institutions and set out to serve as a model that will bring sustainable healthcare development. Several consultations were made. Existing health policies were critically examined. The reasons for successes and or failures of several health programs were debated. A common standpoint was reached. Several departments were set up to meet different needs.
The School of Health Technology was set up to train community health extension workers. 55% of Nigeria’s populace lives in rural areas with significant health needs. Graduates from this school are trained to meet these peculiar needs.
The ECWA Community Health Program is spread through many states of the federation and is made of primary/secondary health centers. This program often traverses very difficult terrain to bring healthcare to the grassroots. It is a ready employer of graduates from the School of Health Technology.
The ECWA Evangel Hospital is a center of excellence for residency training in family medicine. There are several consultants (local and foreign) in different fields of medicine who facilitate this training. This hospital also serves as a referral center for many hospitals (including government teaching hospitals) in northern Nigeria. It is at the moment undergoing transformation to become the Bingham university teaching hospital.
The Vesico-Vagina Fistula (VVF) center is located within the Evangel hospital premises. It is one of its kinds in the country. It was borne out of necessity as many women develop fistulae due to a complex interplay of several factors. According to a retrospective study done on 899 women with obstetric VVFs in this center (check American Journal of Obstetric and Gynecology, 2004, April), the typical VVF patient was small and short; had been married early but was now divorced or separated; was poor, uneducated and from a rural area and had developed her fistula as a primigravida during a labor that lasted at least 2 days and which resulted in a stillborn fetus. This center has significant overseas sponsorship and the latest technology and expertise are employed in the repair of the VVFs of these helpless women.
The Family Health program is sponsored by the Packard foundation. It seeks to provide viable options for the family as a whole. It trains health workers and collaborates with many health institutions especially in northern Nigeria. It aims to reduce maternal morbidity and mortality especially in northern Nigeria. It organizes training workshops for emergency post-abortion care, seminars on family planning, universal precaution, cost-effective ways of managing sexually transmitted infections and so on.
Christoffel Blindenmission (CBM) supports the ECWA Eye hospital, Kano. It is a large eye referral center sited in the second largest city in Nigeria. There are consultant ophthalmologists and others, who help dispense health and train doctors from Nigerian universities undergoing their fellowship training, theater nurses and primary eye care personnel. World-class surgeries are done here. It is a resource center for many eye care projects spread throughout the West African region.
The School of Nursing and Midwifery supplies well-trained and much-needed nurses to the depleted workforce.
The ECWA Hospital, Egbe, also serves as a center of training for family medicine. It has for a long time collaborated with researchers from other Nigerian university to carry out groundbreaking studies. It provides affordable quality healthcare to people in its community.
The EMD has other subsets, which has for a long time been serving the people.
The EMD is involved in several collaborations to achieve its objectives. There is no disconnect with other institutions. It collaborates with the WHO, UNDP, the Packard foundation, EngenderHealth, the Netherlands TB and Leprosy program and so on to bring quality healthcare to Nigerians.
The EMD is not alone in its quest to provide sustainable healthcare development. There are other faith-based initiatives that aim to serve this purpose. This pool of faith-based health organizations provide succor from the turbulence experienced in healthcare delivery in Nigeria.
The lack of space will not allow us the luxury of elucidating the impact the EMD has made on the ordinary Nigerian. The results, however, as overwhelming as they seem, have not made EMD rest on its oars as new opportunities to influence the health polity are continually being sought after.
We present our example. We present this viable option for developing countries.