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Destination Universal Health Coverage: Can PPPs be the vehicle to get us there?

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PharmAccess Foundation’s journey in PPPs has shown significant promise and evidence of the organisation’s successful partnerships can be seen in the revitalised primary health centres in Lagos and Delta State. Photo source: PharmAccess Foundation

The best stories of growth in Nigeria have been private sector driven – whether it is in telecommunications, financial services or in infrastructure. So, why have we not felt the impact of the private sector in the health sector, especially on the frontlines of primary health care (PHC)?

Almost everyone in Nigeria has directly or indirectly experienced the catastrophic impact of emergency out-of-pocket expenses on healthcare. We can no longer keep on doing the same thing – and hope for different outcomes – it is time to think differently and do things differently. It is time for strategic private sector engagement.

We all agree that the desired destination is Universal Health Coverage (UHC), i.e. ensuring that everyone in Nigeria has access to quality healthcare. As defined by the World Health Organisation (WHO), UHC means that “all people and communities can use the promotive, preventative, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship“.


Image credit: Nigeria Health Watch
Countries that have made significant progress in reaching this goal have health systems that include functioning primary healthcare, with a trained health workforce, access to essential medicines and the requisite technology to perform their roles. Sustained financing is also available to the health system and the entire population irrespective of their economic status has access to quality health services. However, in Nigeria, how do we achieve this goal given our mixed and fragmented health system that encompasses the private and public sector? How do we ensure that no individual or family is impoverished by catastrophic health expenditure?

The current state of the Nigerian health sector
The Nigerian health sector has suffered from chronic underfunding, 72.24% of current health expenditure is out-of-pocket, leaving patients to bear the burden of funding their own healthcare. This has led to sub-optimal healthcare delivery with many of our health indicators below national targets and international standards. Eighteen years after the Abuja Declaration where African Union states pledged to allocate at least 15% of their annual budget to health, Nigeria continues to default. Low budget allocation (and it is reducing rather than increasing) has crippled the Nigerian healthcare system in many ways. We forget that a healthy population is truly the best insurance we can have for our economy to thrive. Several studies have shown that investing in health leads to economic development.

If primary health care provides whole-person care for health needs throughout one’s lifespan, not just for a set of specific diseases, why do we neglect PHCs in Nigeria? Why do we still have wards that have no functional PHCs? Why do Nigerians visit secondary and tertiary health facilities for illnesses that should be treated at the primary level? This is likely because the primary healthcare system has failed them.

The important role of the private sector
There are competing demands on Nigeria’s national budget and health has not been given sufficient priority, leaving it underfunded. In a recent speech by Christine Lagarde, Managing Director of the International Monetary Fund (IMF), she stated that the Nigerian economy will struggle due to low revenue generation, given the country’s tax-to-GDP. This will have implications on the country’s ability to direct sufficient resources at the health sector and there is little hope that more funds will be made available to strengthen our already weak health infrastructure.

The role of the private sector is therefore critical in enabling improved access to health for all. It is clear that our public health system faces limitations, as it is not able to meet the healthcare needs of the population. The private sector, however, has the capacity to provide the technical efficiency required to deliver health services. Engagement of the private sector has, therefore, become critical as with the growing population in Nigeria, the public health sector is overcrowded and slow to innovate. Many initiatives have been tried to bolster the health sector and public-private partnerships (PPPs) in healthcare have emerged as a possible vehicle to enable the advancement towards UHC.

Yet, this is not an easy space. It is littered with failed projects and lost investments. It requires extensive thought leadership – an area that we at Nigeria Health Watch partnered with PharmAccess Foundation to address through a recent health policy dialogue.

PharmAccess Foundation – Systems transformation through PPPs 
The private sector can play an important role in strengthening health systems in Nigeria. Through their expertise and capacity and PharmAccess Foundation has an integrated approach that focuses on the supply side of healthcare delivery, not just the demand side. The health policy dialogue on the 11th April 2019, organised by PharmAccess Foundation and Nigeria Health Watch, titled Disrupting health care – PPPs as a model adoption for health system strengthening in Nigeria” highlighted PharmAccess Foundation’s journey in revitalising primary health care centres in Lagos through PPPs. This is not PharmAccess Foundation’s first foray into PPPs, the organisation had worked with Hygeia Community Health Care and the Kwara State Government on a PPP to develop the Kwara State Community Health Insurance Scheme, with the aim of providing affordable access to quality healthcare through the introduction of subsidised health insurance.

 
“Quality is not a pass or fail process in our own books. It is about improvement”, Ms. Njide Ndili, Country Director, PharmAccess Foundation. Photo source: PharmAccess Foundation
The selection by PharmAccess Foundation of primary health care centres to revitalise first involved a geo-spatial mapping of existing facilities in Lagos. In the process, it became evident that there were many non-functional primary health care centres which still received an allocated budget to run. The PPP model adopted by PharmAccess enabled greater access to finance to enable the revitalisation of primary health centres – the frontline of healthcare access for more Nigerians. Realising that health facilities have struggled to access finance due to the stringent requirements put on them by financial institutions, PharmAccess established the Medical Credit Fund (MCF), which places money within the banks as guarantees, with the purpose of helping private healthcare facilities to access affordable finance and PharmAccess supported with capacity development. The effort as Ms. Njide Ndili, Country Director, PharmAccess Foundation, explained, was to provide loans at single-digit interest rates, compared to financial institutions with interest rates as high as 24%, making repayments easier and anchored on a model of sustainability.

“All health PPP projects must consider dimensions of quality including technical competence, access to services, effectiveness, safety, efficiency and continuity”, Dr. Ibironke Dada, Director of Quality at PharmAccess Foundation. Photo source: PharmAccess Foundation
In providing loans, PharmAccess Foundation also ensured that the healthcare services provided by such facilities met a minimum quality standard. To support the revitalised health facilities, PharmAccess Foundation introduced SafeCare, the only quality accredited standard for resource restricted countries like Nigeria. SafeCare standards were developed with Joint Commission International (JCI) and facilities receive their accreditation from the Council for Health Service Accreditation of Southern Africa (COHSASA). “Quality is not a pass or fail process in our own books. It is about improvement”, Ms. Ndili said while discussing SafeCare. “All health PPP projects must consider dimensions of quality including technical competence, access to services, effectiveness, safety, efficiency and continuity”, Dr. Ibironke Dada, Director of Quality at PharmAccess Foundation pointed out.

“Trust drives financial services. Trust drives lending. Trust is capital for the doctor and equipment supplier”, Mr. Olufisayo Okunsanya
Business Development Director of the Medical Credit Fund. Photo source: PharmAccess Foundation
Challenges funding healthcare in Nigeria
What drives the lending system? Trust. Trust. Trust. Trustworthiness matters in all financial transactions; healthcare transactions are not excluded. At the policy dialogue, Mr. Olufisayo Okunsanya, Business Development Director of the Medical Credit Fund, explained how trust is key between all stakeholders and in its absence, lending does not occur. “Trust drives financial services. Trust drives lending. Trust is capital for the doctor and equipment supplier”, he said. In addition, when looking at the challenges in funding healthcare in Nigeria, the inconvenient truth is that the government cannot fund the infrastructure requirements of the health sector. The bulk of the federal government’s expenditure is spent on recurrent expenditure leaving little for capital expenditure.

“To ensure that adequate domestic resources are allocated to the health sector, dedicated analytic, policy, and advocacy efforts are required”, Dr. Olamide Okulaja, Director of Advocacy and Communications at PharmAccess Foundation. Photo source: PharmAccess Foundation
If Nigeria is to adequately fund its health sector, we need to view healthcare not as an expense, but as a business. According to Dr. Olamide Okulaja, Director of Advocacy and Communications at PharmAccess Foundation, financing is not the only solution to solving Nigeria’s healthcare problems. He said that we would also need to have systems that are in place to absolve financing and continually justify its release. “To ensure that adequate domestic resources are allocated to the health sector, dedicated analytic, policy, and advocacy efforts are required”, Dr. Olamide added. The role of the government in this mix is to ensure that they create the enabling environment for the private sector to support the running of primary health care facilities. They should be regulating and providing governance in healthcare and let the private sector use their expertise and competence to deliver healthcare.

Healthcare needs to be seen as a business and only bankable ideas get funding. With PPPs you cannot do collateral borrowing and so the healthcare provider is borrowing against the future cash flow that will come from the business. This provides reassurance for the financing organisation for the loan will be repaid. We all have an enlightened self-interest, so it is in our best interest to fix healthcare in Nigeria and look for solutions outside of traditional government financing to address the funding challenges in healthcare.

Case study – Toronto Hospital brings healthcare to the Polobubo Community
How do you provide health care for a community left out of the health system for many years? That is the story of Polobubo, in Delta State, one of the most remote hard-to-reach communities in Nigeria. With a population of about 75,000 inhabitants, the community had until recently no access to healthcare due to their extreme isolation and remoteness.  Accessing Polobubo through its closest town Warri, requires a 3hr 45mins boat ride, travelling with a 200-horsepower double engine speed boat, through the Niger Delta creeks, and across the Atlantic Ocean.


“We are breaking boundaries and getting healthcare to areas no one will dare”, Dr. Emeka Eze, Toronto Hospital. Photo source: PharmAccess Foundation
The high maternal and infant death rates would have continued in Polobubo if not for the intervention of the Delta State Health Insurance Scheme delivered through a PPP model consisting of PharmAccess Foundation’s Medical Credit Fund’s Access to Finance framework, the Bank of Industry and Toronto Hospital, in Anambra State. A successful approach, the model had registered 2,639 enrollees who pay an annual premium of N7,000 and attended to 3,990 cases, including caesarean sections, minor surgeries, appendectomies in the Polobobo health facility, within two months of operation. All of these and many more success stories would not have been made possible without a PPP. “We are breaking boundaries and getting healthcare to areas no one will dare”, Dr. Emeka Eze of Toronto Hospital said.
Also Read Health For All: Achieving Universal Healthcare Coverage in Nigeria | Adaku Efuribe

Now what? The Scalability of the PPP model in healthcare
In the 2019 health budget, about ₦50billion has been allocated for capital expenditure. Clearly, this amount is unable to cover the infrastructure gap in the healthcare industry and cater for the health needs of Nigeria’s burgeoning population of almost 200 million people. Can PPPs fill the gap in health funding? The government does not trust the private sector due to fear that they will put profit before performance, however, there appears to be a sea change. For the first time in Nigeria, two state governments are releasing funds to the private sector to revitalise some of their healthcare facilities. This is a testament to the political will in Lagos and Delta State to partner with the private sector.


The PPP model registered 2,639 enrolees who pay an annual premium of N7,000 and attended to 3,990 cases, including caesarean sections, minor surgeries, appendectomies in the Polobobo health facility, within two months of operation. Photo source: PharmAccess Foundation
In 2017, the federal government flagged off its Primary Healthcare Revitalization Programme, announcing its target of revitalising 10,000 PHCs in Nigeria. Recently, the Minister of Health, Prof. Isaac Adewole, however, said that the government has only been able to revitalise 4000 PHCs. Could financing be a major hindrance to achieving the FG’s target? Perhaps this is an opportunity for the private sector? In joining the PPP vehicle, the words of Mr. Olufisayo during the policy dialogue, come to mind “If you want to be a good public-private-partnership candidate, do not come alone. You have a better chance if you collaborate with others. The strength of the pack is the wolf, and the strength of the wolf is the pack”.
 
The first panel at the policy dialogue focused on financing healthcare projects. Photo source: PharmAccess Foundation
The ability to scale up PPPs needs to be driven by government policy, regulation and political will, critical enabling conditions for the successful implementation of PPPs. This was seen with the partnership between the Lagos and Delta State governments and other stakeholders; the public sector commitment was evident. Dr. Olaokun Soyinka mentioned during the policy dialogue that “Government needs to advocate within government”, and so promoting the benefit of PPPs. Evidence of a successful PPP model, as Engr. Chidi Izuwah pointed out, was Garki Hospital, in Abuja, the first ever public-private partnership in the Nigerian health sector.

Under the stewardship of Prof. Chris Bode, the Chief Medical Director at the Lagos University Teaching Hospital, a state of the art Cancer Centre was commissioned in partnership with a consortium that included the Nigeria Sovereign Investment Authority (NSIA) in February 2019.


The second panel at the policy dialogue focused on creating synergy for PPPs to strengthen primary healthcare delivery. Photo source: PharmAccess Foundation
PharmAccess Foundation’s journey in PPPs has shown significant promise and evidence of the organisation’s successful partnerships can be seen in the revitalised primary health centres in Lagos and Delta State. So, opportunities to scale up PPPs this model is encouraging in the absence of more funds being directed at the health sector.  The role of the government is critical and as public funds are increasingly being invested in the private sector, we are slowly pushing ahead in the journey towards Universal Health Coverage.

A detailed report of the policy dialogue will be made available. Please contact [email protected] for further details. If you would like to watch the live coverage of the event and see photo highlights, kindly visit our Facebook page. To view some of the presentations from the event, click here

Health

Providing Affordable Healthcare in Nigeria Should Be Everyone’s Business

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Adaku Efuribe

“It is my greatest desire that we improve the healthcare system in Nigeria and provide affordable healthcare for local communities at the grassroots so that people can have access to the care they need, when they need it, in ways that are user-friendly” –  Adaku Efuribe

The 74th UN General Assembly took place in New York last September; high level meetings were held and Universal Health Coverage (UHC) was a hot topic for the week. As expected, Nigeria had a delegation of Government representatives, NGO’s and individual advocates who are working towards achieving SDG3 and UHC in attendance. So how do we implement new policies and what are the key drivers to providing UHC for all in Nigeria?

As an advocate for UHC/SDGs, I have been lending my voice over the years calling the Nigerian Government to action towards implementing UN SDGs agenda and achieving UHC.I have studied and participated in primary healthcare provision in developed economies and can say for sure healthcare provision is very expensive, but I believe we can up our game towards providing primary health care for everyone at the point of need.

Some developed economies have used the tax system to ensure their national health service does not run out of funds, a percentage of all earnings is taxed and put aside in a ‘pot’ to supplement the health budget. From a lay man’s point of view, just like the banking system, we all bank our money at different times and we withdraw money at different times, so for a contributory  healthcare system, everyone will not fall sick at the same time, some will experience life threatening sickness at some point in their life, some would have long term conditions like CVDs, Diabetes, etc., while others would only go through emergencies or minor ailments/major diseases.

In Nigeria for instance, we have a few HMO schemes covering the organised private and public sector. The ‘common man’ on the street does not have any sort of health insurance whatsoever, which leaves them at the mercy of chance. In an unfortunate event of serious illness like cancer or organ failure, they find themselves in a situation where they cannot pay for medical services hence resorting to luck to stay alive. A lot of unavoidable deaths have occurred due to lack of funds to pay for medical treatment.

The public primary care providers are underfunded and the issue of corruption has eaten deep into the fabric of the healthcare system where funds allocated for medical equipment’s, pharmaceuticals etc. are diverted for personal use.

What plans does the present Government in Nigeria have to provide Universal Health Coverage and in so doing, contribute to the economic growth of the Country?

Sustainability can be defined as meeting the needs of today without compromising the needs of tomorrow.

‘As articulated in SDG 3, health is crucial for sustainable human development, both as an inalienable human right and an essential contributor to the economic growth of society. Health contributes to national development through productive employment, reduced expenditure on illness care and greater social cohesion.

We believe that universal health coverage (UHC), delivered through an adequately-resourced and well-governed health system, will be capable of addressing these and other health challenges. Universal health coverage must ensure equitable access to affordable, accountable, appropriate health services of assured quality to all people.

These must include promotive, preventive, curative, palliative and rehabilitative services. UHC must be supported by policies and services addressing the wider social and environmental determinants of health for individuals and populations’. Sustainable Developments solutions network

Key words for providing health systems that works!

  • Well Governed Systems- Are there systems and policies in place that can be retained and continued
  • Promotive- Do we have health promotion strategies in place to promote good health and wellbeing
  • Preventative- Are we taking preventative measures seriously, screening, vaccination, reducing CVD risk through lifestyle management?
  • Curative- When we fall ill or in times of emergency, do we have access to affordable healthcare, or does sickness lead to poverty?
  • Palliative and rehabilitative services- For terminally ill patients, do we have plans for social prescribing and support? For people engaged in substance misuse, do we have plans for treatment, rehabilitation and integration back into the society

WHO uses 16 essential health services in 4 categories as indicators of the level and equity of coverage in countries: Where does Nigeria rank in the indicators?

Reproductive, maternal, newborn and child health:

  • Family planning
  • Antenatal and delivery care
  • Full child immunization
  • Health-seeking behaviour for pneumonia

Infectious diseases:

  • Tuberculosis treatment
  • HIV antiretroviral treatment
  • Hepatitis treatment
  • Use of insecticide-treated bed nets for malaria prevention
  • Adequate sanitation.

Noncommunicable diseases:

  • Prevention and treatment of raised blood pressure
  • Prevention and treatment of raised blood glucose
  • Cervical cancer screening
  • Tobacco (non-)smoking.

Service capacity and access:

  • Basic hospital access
  • Health worker density
  • Access to essential medicines
  • Health security: compliance with the International Health Regulations.

Also Read: Meet Mariatheresa S. Kadushi, Founder of M-afya, A Mobile App Providing Health Information In Native Languages In Africa

The Nigerian Government can do more to improve health outcomes and tackle poverty, by increasing coverage of health services, and by reducing the impoverishment associated with payment for health services. We can subsidise the payment for health services and provide emergency health care at the point of need by ensuring we are constantly reviewing our health policies and implementing proven international strategies. The Health budget does not in any way reflect the health needs of Nigerians, this needs to be reviewed.

As Individuals, if we take health promotion seriously, and change our lifestyle habits, then we can make changes that would reduce the cost of health as well.

Adaku Efuribe is an SDGs/UHC Advocate & Clinical Pharmacist with expertise in medicines management, integrated healthcare and health promotion.

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GE Healthcare Launches Versana Ultrasound Machines to Drive Access to Affordable and Quality Healthcare in Uganda

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GE Healthcare team displaying the Versana Premier and Versana Essential Ultrasound machines during the Uganda Society for Advancement of Radiology and Imaging Conference (USOFARI).

This innovative system is well suited for general practice clinics, physical check-up centers, community health clinics, and other facilities offering basic medical care

KAMPALA, Uganda, November 11, 2019- GE Healthcare has announced the launch of Versana Premier and Versana Essential for the first time in Uganda. The launch was announced during the Uganda Society for Advancement of Radiology and Imaging Conference (USOFARI).

Versana Premier is a world-class ultrasound designed for peace of mind, easy to use and easy to own. The Versana Premier ultrasound system can help deliver high-quality, personalized care, patient after patient, day after busy day. This innovative system is well suited for general practice clinics, physical check-up centers, community health clinics, and other facilities offering basic medical care. It also comes with local product and clinical training to help healthcare professionals gain comfort and proficiency with the system to enhance patient care.

Versana Essential is a complete ultrasound solution that healthcare professionals can learn to use quickly and productively. It enables confident clinical decision making for quick referrals and immediate clinical correlation to help scan a wide range of patients. The machine is designed with the growing medical center in mind, to provide the clinical capability and support they want without compromising the quality, reliability, and affordability needed.

Both Versana Premier and Versana Essential are part of the Versana ultrasound family, which comprises of solutions that help to empower care without compromise, balancing capability, affordability, and reliability. These innovative systems found within the GE Healthcare Primary Care Ultrasound Segment are well suited for general practice clinics, physical check-up centers, community health clinics, and other facilities offering basic medical care.

“We are excited to participate in this year’s USOFARI conference together with other private and public partners in an effort to continue providing the latest imaging solutions to enhance early detection of diseases and ultimately the most appropriate treatment for patients,” said Andrew Waititu, General Manager, GE Healthcare East Africa. “The launch of Versana Premier and Versana Essential is a testament of our continuous investment in innovations that help to drive access to affordable and quality healthcare for all across Uganda.”

Also Read Meet Mariatheresa S. Kadushi, Founder of M-afya, A Mobile App Providing Health Information In Native Languages In Africa

Universal Health Coverage (UHC) is part of the United Nations sustainable development goals, to ensure that every person, everywhere, should have access to quality healthcare. As part of its vision 2040 and the health sector development plan, Uganda seeks to accelerate movement towards UHC with among others, essential health and related services needed for promotion of a healthy and productive life. 

GE Healthcare

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Understanding Nutrition History For A Healthier Life

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Pounded yam with vegetable soup (Image: Simplinatural)

“We are less healthy today than our ancestors. By disregarding traditions, we’ve predisposed ourselves to genetic damage.” Catherine Shanahan M.D author of Deep Nutrition.

It’s the 21st century and the machines, computers, social media and tech drivers are here. Giant strides in medical science, engineering, technology has made life better and easier for us. We were supposed to be a very healthy and wealthy generation but instead we started to get sicker and unhealthier. Over the last 50 years cardiovascular related health issues is the number one killer of men and women worldwide according to a WHO report.

Our diets changed and so did our bodies and health. We deciphered so many hypotheses of what could be the problem. We thought it was inadequate exercise, so we exercised more but nothing changed. Whenever we thought we knew the answer to what was happening to our health decline, we realised we were right back where we started from. We continued to grapple with modern diseases medical science seems unable to mitigate.

What does history have to do with our health?

The year is 1901 and my maternal Grandmother is preparing dinner of Amala and ewedu soup (Yam flour and a vegetable). She prepares the dinner just before sun down and gives her large family to eat. Three times in a week, she prepares the same type of meal. However, unknown to my grandmother was the fact that the fermentation process during yam flour processing had converted the starch present in the yam into more complex nutrients like minerals and vitamins by the help of a bacteria called lactobacilli.

Fermentation converts starch(sugar) to lactic acid leaving by-products like beneficial minerals, vitamins that the gut uses to produce important neurotransmitters like serotonin. Serotonin is responsible for regulating sleep, appetite, moods and pain inhibition in the brain but its production is influenced by the billions of friendly bacteria like lactobacilli in the gut. She knows nothing about the science behind what she prepares for her family but from observation over time along with thousands of other women, she knows that a good meal of amala was easily digestible, filling and kept everyone happy.

It’s the 21st century and we no longer sprout our grains for their beneficial vitamins and minerals but cart them off for processing and our diet high in refined sugar and processed oils have now started to harm our brain. Our cells are weak from oxidative stress and inflammation but we continue to eat these modern diets.

We see a spike in suicide rates and depression amongst young people all over the world with no end in sight. Maybe this is the right time to begin to study nutrition history. What worked in the past? What did our ancestors eat that made them strong and healthy? More evidence in nutritional psychiatry are starting to show a connection between what we eat and how we feel.

A critical look into traditional African diets show a rich healthy source of nutrition based on what is now known as the four pillars of the human diet according to Catherine Shanahan author of best-selling book, Deep Nutrition. What is fascinating is how African dishes combine every aspect of the four pillars of the human nutrition making it one of the most nutritious and earlier diet in the world.

Fermented food: delicacies like kunu (fermented millet drink) masa (fermented rice fried in oil) beautifully incorporate food techniques like fermentation ensuring adequate gut health and microbial balance in the body.

Organ meat: Organ meat known to contain vital vitamins are extensively used in preparing soups broth popularly known as pepper soup in southern Nigeria. It is also eaten with other delicious dishes.

Meat on the bone: dishes with meat containing bones are known to provide collagen and body building nutrient and a Nigerian dish that incorporates this is miyankuka dish(a favourite) from northern Nigeria.

Sprouted foods: sprouting known to convert carbohydrate in grains to complex nutrients like vitamins and mineral was on e of the ways our ancestors could successfully grind their grains to powdery usable forms. A traditional African dish that incorporate the technique is Eyin drink from the north central part of Nigeria.

Healthy nutritious diet is delicious, natural and better. Our generation advanced in technology, science and knowledge but needs to pay attention to a vital part of history- our nutritional history. History tell us what’s worked in the past and what’s not working now. It’s time we change the trend once again and return to our roots.

Also Read: How Working Mothers Can Find A Life-Career Balance

Author

Deborah Ogwuche is the creative director and founder of Food Channel Africa, a 24-hour television channel dedicated to showcasing African cuisines. She is a published author, a food blogger and a healthy food advocate.

Email: [email protected]

 

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