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
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
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
“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
“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
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
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
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
The first panel at the policy dialogue focused on financing healthcare projects. Photo source: PharmAccess Foundation
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
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
Dream Becoming A Reality
The residents of Kyukuni Village, Voo Kyamatu Ward, Kitui County had challenges in accessing water before the intervention of the Amref Health Africa Kitui WASH Project. Residents would trek for over 15km in search of water, a situation that not only affected the time women spent doing other economic activities, but also affected school enrolment and attendance among school going children.
According to the Project Officer George Wambua, there were shallow aquifers which were an alternative source of water, but the residents believed that water from this source would only be enough for household use and nothing else. This was a long standing belief that they held, and changing it was an uphill task.
During a baseline survey that was carried out in 1998, water was ranked first on the priority list of needs among communities. For the residents of Kyukuni Village, water was a priority but they did not realize how it could help to change their economic status. “Changing their mind-set to make them see how water could improve their lives economically was a challenging task. However, with continued follow-ups and interactions with the community, we were able to change the community’s way of doing things,”said Mr Wambua.
In trying to make a case for using water to improve the community’s economic status, the project started by developing a small farm around the Miembeni giant well situated in Zombe/ Mwitika Ward. The well serves a group of 12 families who decided to change their traditional way of doing things. They decided to extend water use from domestic to other economic activities including horticulture farming and poultry keeping.
According to Mr Mutua, one of the beneficiaries of the project, a number of giant wells were commissioned along the Thua River through the support of Amref, but only a few of the groups seriously engaged in intensive farming.
“You would find a group of 15 households doing small scale farming that was not enough to support the whole group, but yet the well had sufficient recharge of about 10m3.
This means they only utilised 30% of the water in the well leaving 70% not utilised”, said Mr Mutua. He added that when his group realized that they were sleeping on gold about two years ago, they started serious farming activities around their water points. The group now owns a two-acre piece of land that can be utilized freely by the group.
Kitui East has been hard hit by the regular occurrence of drought due to erratic rainfall. For the last 10 years, the rainfall pattern has been unpredictable. The rainfall onset has been delayed every year, and when it has rained, rainfall has also not been adequate. The only remaining option is to use water from the well to grow crops that can feed their families and have some left overs to sell for economic sustainability. This is what Mr Mutua the chairperson, encouraged his group to do.
“We started our farming in a small way by cultivating very basic crops just enough to feed our families. Little did we know it was our turning point as a group,” said Mr Mutua.
Mr Mutua added that they upgraded their activities by growing cash crops like tomatoes, onions, water melons and carrots. The first group was successful and made good profit. On sharing the profit among the 15 households’ after all necessary deductions, each was able to get Kshs 5,000. This enabled members have cash to do other things like paying school fees and other bills. The community members had longed for.
“God is great, our dream has come true,” said one of the group members.
Additional activities carried out using water from the well include poultry farming. This is another project that has had multiple benefits to the family. The groups now have eggs that they use to feed their children, thus preventing diseases associated with poor feeding. They also sell the birds to make good money for the household use.
The project though funding from Amref Italy has built 50 giant wells to support 20,500 people with agricultural activities and 218,940 people with access to safe water and sanitation. The project is committed to make safe and affordable drinking water, hygiene and sanitation a reality for the people of Kitui County.
This CSIR Female Researcher Is One Of Few Stem Cell Reprogramming Experts In South Africa
Dimakatso Gumede, CSIR Researcher.
Only a handful of people in South Africa have mastered Stem Cell reprogramming and Dimakatso Gumede (34) is one of them. As the CSIR’s candidate researcher of the Bioengineering and Integrated Genomics Research Group, she works on creating disease models of the innate immune system to study unique African gene variants that lead to elite controllers that naturally control viral load levels without antiretroviral therapy.
By using induced pluripotent stem cell technology, the CSIR research group also creates“mini liver”models in order to determine the adverse drug affects in the South African population.
“The African population is known for its genetic variation, which often affects the way in which an individual responds to particular medication. For example, while an aspirin may work effectively for 70% of the population, it is possible that the remaining 30% may experience adverse effects. Therefore, as part of CSIR’s Bioengineering and Integrated Genomics group, we are looking to create effective and personalised medication for those who do not respond positively to the drugs that have been distributed for the general population,” says Gumede.
Gumede, who is a PhD scholar of the University of Cape Town (UCT), recently submitted her doctoral thesis. She studied the role of a gene mutation that causes skin and lung fibrosis, using a scientific method called induced pluri-potent stem cells. This approach produces any cell type in the body, such as skin or lung cells, which, in this case, provides insight into how an inherited dermatological condition is associated with lung fibrosis – a condition caused by uncontrolled scar formation that affects the organ and air sacks.
However, this was not Gumede’s original project. Initially, her PhD project was on cardio genetics, and she was working with the late Prof. Bongani Mayosi and Dr. Gasnat Shabooden at the UCT Hatter Institute for Cardiovascular Research in Africa.
“While I was busy with my initial research project, the late Prof. Mayosi suggested that I shift the focus of my project to the study of a rare genetic condition that is associated with lung, skin and muscle fibrosis. I was excited because not only was it a ground-breaking research project that would serve as a massive breakthrough for the South African medical science sector, but it would also provide me with the opportunity to apply my cell biology expertise,” says Gumede.
With the assistance of Prof. Susan Kidson and Dr Robea Ballo, Gumede focused mainly on the cell biology of the rare skin condition in question. She learnt a great deal about reprogramming skin cells into pluripotent cells to understand what causes this gene mutation, how this rare skin condition develops at cellular level and how or why it affects organs such as the lungs and muscles and prevents them from functioning properly.
“I discovered that the gene mutation that causes this condition accelerates cell division, which contributes to fibrosis in the affected individuals and is also associated with cancer progression,” says Gumede.
Further, according to Gumede’s Principal Investigator at the CSIR – Dr Janine Scholefield, her ability to not only master but, explain highly technical and advanced science in isiZulu and Sesotho is what makes her so highly prized at the CSIR.
“She has mastered the craft of communicating her work fluently in isiZulu, Sesotho and English which is so important. With science and technology shaping our lives daily, it ought to be accessible to all, especially young people wanting to pursue a career in science. Having a young black woman who is at the top of her game and is able to make the work we do relatable is what will continue to inspire young girls entering the science field. It also makes her even more invaluable to the CSIR and the scientific community at large” added Dr Scholefield.
With the skills that she has gained, she aims to use her PhD to further establish the stem cell platform for precision medicine, drug screening and, possibly, commercialisation in the CSIR. She also intends to use the stem cell and genome engineering platforms to find new approaches to eliminate HIV reservoirs in infected persons and, hopefully, also contribute in finding key therapeutic strategies that resolve excessive scar formation in heart and lung conditions, which are a great burden of disease worldwide.
The African Union Appoints Amref Health Africa Global CEO to Board of Africa Centre’s for Disease Control and Prevention (Africa CDC)
NAIROBI, 8 August 2019: Amref Health Africa Global CEO and Co-Chair of UHC 2030 steering committee, Dr Githinji Gitahi has been appointed as a member of the Governing Board of the Africa Centre’s for Disease Control and prevention (Africa CDC).
Dr Gitahi will join the Governing Board of the Africa CDC pursuant to article 10 of the statute of the Africa CDC. Dr Gitahi was appointed by the Commissioner for Social Affairs, Her Excellency Mrs. Aminra Elfadil of the African Union Commission.
The Africa CDC supports all African countries to improve surveillance, emergency response, and prevention of infectious diseases. This includes addressing outbreaks, man-made and natural disasters and public health events of regional and international concern. It further seeks to build the capacity to reduce disease burden on the continent.
“I would like to extend my gratitude to the African Union and specifically to H.E Mrs Elfadil for this appointment. I am honoured to be nominated to this position that is geared towards strengthening and transforming the health in Africa. I look forward to sharing my expertise and skills as we work towards achieving Universal Health Coverage and achieving health security in Africa,” said Dr Gitahi.
The Africa CDC is also a specialized technical institution of the African Union that serves as a platform for Member States to share knowledge, exchange lessons learnt and build capacity.
This appointment comes after his nomination as the co-chair of the UHC2030 Steering Committee in December 2017. UHC2030 is a World Bank and World Health Organization (WHO) forum for achievement of universal health coverage (UHC) by 2030 and has membership across countries, private sector and civil society organisations.
About Amref Health Africa
Amref Health Africa, headquartered in Kenya, is the largest Africa based international non-governmental organisation (NGO) currently running programs in over 35 countries in Africa with lessons learnt over 60 years of engagement with governments, communities and partners to increase sustainable health access in Africa. Amref Health Africa also incorporates programme development, fundraising, partnership, advocacy, monitoring and evaluation, and has offices in Europe and North America as well as subsidiaries; Amref Flying Doctors, Amref Enterprises and the Amref International University.
Credit: Amref Health Africa
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