THE HIDDEN EPIDEMIC: Let’s rise above the growing CANCER challenges
Cancer is fast becoming a major killer in Nigeria. Hardly any day passes without either the diagnosis of new cases of cancer, its complication or its related deaths in Nigeria. Today, a number of high class Nigerians are either dying or suffering severely from cancer in Nigeria and around the world. In the past, I lost loved ones to this monster – when people hardly ever spoke about it. First was my elder sister. Then, my younger brother. Both died from primary liver cell carcinoma (PLCC). And this occurred just a few years apart. When the scan revealed the diagnosis in Port Harcourt, I was a medical student. I completely understood the prognosis. I also knew that, with our level of poverty, we could not prolong their lives. We did all we could to make their last days on earth peaceful – but it was still very painful.
Just last year, I lost a very close colleague from the same cancer. For him, he had resources that allowed him to travel to the United States for liver resections a number of times. But despite the surgeries in world renowned centers, chemotherapy (and I think radiotherapy), he still succumbed to the disease leaving behind a young wife and two wonderful sons. I am not sure there is any family in Nigeria where someone has not suffered from this monster. The bad news is that, despite this large unrecognized epidemic, the world is not doing enough about discovering the cause and treatment of the disease.
Like most health issues in Nigeria, the true burden of cancer in Nigeria is not known because of poor statistics and under reporting of cases. However, the World Health Organization (WHO) estimates that over 100,000 Nigerians are diagnosed with cancer annually (that is about 300 cases per day! Or 12 cases every hour!!). Out of this number, 4 out of 5 (or approximately 80,000 people) die from the disease. Despite this level of morbidity and mortality, cancer has not been given its rightful place in health politics in Nigeria, and thus has practically remained an unrecognized issue (URI). Breast, cervix and prostate gland cancers are said to be the most common forms of cancer in Nigeria. But with the rising prevalence of PLCC, one is unsure if this will not with time take over from the rest of the cancers as the commonest form in Nigeria.
However, although most cancers cannot be cured, majority can be prevented. This is why Nigeria must join the rest of the world to fight this epidemic. February 4th every year is World Cancer Day (WCD). It’s a day the world set aside to create awareness on cancer. It serves as a platform for stakeholders and the general public to awaken to ways of preventing, early detecting, treating and managing cancer.
This year, the theme is “We can. I can”, and seeks to explore avenues through which everyone collaboratively and individually can work towards a sustainable reduction of the burden of cancer. Everyone must own the fight against cancer, if we are to succeed against it.
The alarming indices are particularly disturbing as preventive measures and early detection and treatment can go a long way to prevent untimely death. According to the WHO, one- third of all cancers can be prevented; another one- third can be successfully cured with timely diagnosis; whilst palliative care can improve the quality of life of the last third. There is therefore the need to strengthen infrastructure, improve public awareness about preventive measures and early diagnosis as well as increase availability and accessibility of treatment through establishment of more treatment centers.
In order to achieve this, there is the need for increased government expenditure and commitment in this area. The current allocation to health amounts to only 3.65 % of the 2016 budget. This falls short of the 5.78 % allocated in 2015 and a clear departure from the agreed 15 % of national budget to be allocated for health made in 2001 in the meeting of African head of states and government which Nigeria hosted in Abuja. With the aforementioned shortfalls, universal health coverage cannot be achieved, which would improve availability of affordable and efficient health services, including cancer care. At present the Nigerian Health care system is not ready for the rising cancer cases and also ill equipped to handle the complexities in managing cancer.
Therefore, there is certainly a need for a paradigm shift towards pragmatic approaches to averting the impending catastrophe. This gives more credence to the theme of this year’s World cancer day “We can. I can”.
It’s time we unite, using our circle of influence to inspire government to make policies that will ensure the availability of adequate recourses and infrastructure that will help reduce premature deaths from cancer. The needed policy changes can be achieved through effective advocacy at all levels of government. These policy changes will engender greater commitment from government and the private sector. In addition to waiting for needed policy changes, the slogan “We can. I can” brings home the point that we as individuals and communities can also play a role in fighting cancer.
We all can reduce individual risk of developing cancer by adopting strategic lifestyle changes. Smoking, alcohol consumption, poor diet, abuse of drugs, and sedentary lifestyle are risk factors for cancers which can be avoided. Arming individuals and communities with apt knowledge of the links between lifestyle and cancer can help people make healthy choices and understand that the premature deaths from cancer can be averted by making right choices.
In addition, we can avail ourselves of available screening tests to facilitate early detection, as cancer is more amenable to treatment if diagnosed in the early stages. Many of the common cancers like cancer of the breast, cervix and prostrate have screening tests which aid their early detection. Employers in the formal sector, educational institutions and NGOs working in this space can encourage increased uptake of cancer screening by individuals and communities by advancing knowledge and awareness in those under their sphere of influence, as well as paying for these screening processes.
We can all help to defuse myths and stigma surrounding some cancer cases by arming ourselves and those in our sphere of influence with the right information. This in turn will create acceptance, adequate recovery path and the love required in recuperating and surviving cancer. The wide gap in awareness of cancer in rural communities due to paucity of information and high illiteracy level also needs to be addressed. Until cancer awareness is stepped down to the grassroots and actions are taken to prevent and treat the disease, millions of people in developing countries like Nigeria will continue to die unnecessarily over the coming years. We must act now because the threat posed by cancer epidemic is massive and set to destabilize the socio- economic development of unprepared Nations.
Finally, achieving the required objectives begins with our personal resolve and together we shall rise above the challenges by making healthy life choices. Understanding that early detection save lives is key to this campaign but we must first challenge perception and dispel myth. Efforts should be made to improve asses to affordable orthodox care for the public. It is vital at this time to improve asses to care by making the case for investing in cancer control and building quality cancer workforce. Together we can work to increase impact and create a healthy environment if individually we say “I can and collectively agree we can”.
Dr. Obinna Oleribe, Grace Iyalla, Muna Ekweghariri and Dr. Oluwakemi Akagwu
Excellence and Friends Management Care Centre (EFMC)
Season Greetings from EFMC
As the year draws to a close, EFMC sincerely appreciate all those who made the year a worthwhile one for her. We cannot, but remember and celebrate God for life, health, provision, protection, and guidance all through 2015. In Nigeria, we are especially grateful to our funders, US CDC Nigeria, Institute of Human Virology Nigeria (IHVN), Federal Ministry of Health (FMOH), National Agency for the Control of AIDS (NACA), IntraHealth CapacityPlus Nigeria, eHealth Africa, UN Foundation, Health Strategy and Delivery Foundation (HSDF), and Clinton Health Access Initiative (CHAI) for believing in us and working with us to make a little difference in the health outcome of Nigerians. Together we have added value to Nigeria and Nigerian and we are proud of you, glad to have worked with you, and appreciative of all your helps and supports all through the year. We also thank and appreciate all CBOs, healthcare workers, over 75 supported Service Delivery Points (SDPs), suppliers and government officials who worked with us and provided vital mentorship and quality improvement guidance.
We also thank our clients, communities and friends who in their own way made this year very eventful. We wish you a very Merry Christmas, and a blessed and prosperous 2016 filled with laughter, love, and amazing blessings.
Courtesy: Communication Team
WORLD AIDS DAY CELEBRATION: THE RACE TO ZERO
The World AIDS Day is a time to reflect on colleagues, friends and family members lost to the epidemic, raise awareness about HIV/ AIDS and the global burden of the virus, as well as recommit our efforts to address this global pandemic. This year’s World AIDS Day Campaign led by World AIDS Campaign Organization, still keeps the theme of the last four years which is “Getting to zero”. Zero New infections, Zero Discrimination and Zero AIDS-related deaths.
There are approximately 36.9 million people infected with the HIV virus globally, with 2 million new infections and 1.2 million AIDS related deaths occurring in 2014.Sub Saharan Africa continues to bear the biggest burden of this epidemic, with 25.8 million people living with HIV in the region and 70% of the 2 million new infections occurring there as well. Sub Saharan Africa also accounted for 790,000 (65%) of AIDS related deaths in 2014.
Despite these statistics, the world has come a long way in the fight against HIV. Cuba made history this year by becoming the first country officially declared to have eliminated Mother to Child Transmission of HIV. Globally, new HIV infections in children have decreased by 58% since 2000 and by 48% in 21 high priority Sub Saharan African countries. Statistics from UNAIDS indicate that 15.8 million people had been placed on ARVs as of June 2015, of which 10.7 million are in Sub Saharan Africa. AIDS related deaths have also dropped by 42% from a value of 2 million in 2005.With regards to investments, the world appears to be within reach of achieving the investment target in the 2011 Political declaration of HIV/AIDS, which called on the global community to mobilize between 22 billion USD and 24 billion USD in low-and middle-income countries for the HIV response by 2015. As at the end of 2014, 20.2 billion USD had been invested in the HIV response in low-and middle-income countries.
However, though a lot of progress has been made, and records of exceeding the HIV related targets of Millennium Development Goal (MDG) 6, HIV continues to highlight existing inequalities in the world. Curbing the HIV epidemic is an unfinished agenda and the significant gaps and shortcomings of the response in the past must be identified and rectified. There is an urgent need to accelerate the AIDS response in low- and middle-income countries. With the right strategies and investments in place, 28 million new infections could be averted, and 21 million AIDS-related deaths prevented between 2015 and 2030, saving 24 billion USD annually in additional HIV treatment cost.
“Getting to Zero”and ending the AIDS epidemic within the next 15 years may seem to be an ambitious and impossible feat, but so did placing 15.8 million people on ARVs appear 15 years ago. Getting to zero will require that opportunities and knowledge of what works are maximized to full potential. Adoption of the UNAIDS Fast-Track approach will also be key in getting to zero. The fast track approach is focused on 90% of all people living with HIV knowing their HIV status, 90% of people who know their HIV-positive status having access to treatment, 90% of people on treatment having suppressed viral loads, reducing new HIV infections by 75% and achieving zero discrimination by the year 2020 This will require donors, governments, communities, NGOs, health institutions and other stakeholders to re-strategize and commit to working together to make sure resources and efforts are effectively allocated and used.
It is time for all hands to be on deck, as the next five years would be critical if the world would see the fast track targets achieved by 2020 and an end to the HIV epidemic by 2030. Therefore, don’t cast your minds alone on the progress made, but also the unmet need that still exists in the world. That is why EFMC will be joining the world by providing the best possible prevention and care services and walking the talk of getting to zero.
Making Universal Health Coverage (UHC) through Health Insurance Scheme (HIS) work in Nigeria: The 5-Steps Approach
Dr. Obinna Oleribe
The world has just signed the Sustainable Development Goals (SDG) to replace the current Millennium Development Goals (MDG) which has been achieved by some countries across the world. However, the absence of data in Nigeria makes a real assessment of progress made very difficult. We are sure of the following: Nigerian children are still dying from preventable diseases and infections. Women are still dying from pregnancies and deliveries. Poverty is still mitigating the fulfillment of destinies and lives of over 75% of Nigerians. And millions of Nigerian children are still outside the four walls of any formal institutions. Can these change in the SDG period? For this to happen, the “weak or useless health system” in Nigeria must be strengthened, there must be laws that support UHC, and the recently approved National Health Acts must be implemented. Policies to implement the SDGs must be designed, developed and implements; and a unified national health care system that removes the dichotomy between federal, state and local health systems. These were some of the views of patriotic Nigerians in a recent Christian Aid gathering in Abuja, Nigeria.
I attended this very informative program organized by Christian Aid International during which their findings from an Assessment of the Primary health Care Centers in selected States of Nigeria and a review of community-based health insurance schemes: lessons from Nigeria and Ghana were presented. The findings from both the PHC assessment and HIS insurance were both revealing – although they were not a surprise to me and several others in the hall. Participants were tired of hearing a lot of talks and asked for actions – walking the talk. Can we make HIS work? In the assessment, deficiency in human resource was a major challenge mitigating PHC effectiveness in all states; poor infrastructure was a major issue in three of the five surveyed states; services were available, but the quality was questionable; and stock-outs of consumables were common occurrences across most states. Although the researchers disclosed that these findings may not be representative of all the states, one is not amazed at their findings. A walk into most PHCs in Nigeria will reveal a worse scenario as even when the buildings are refurbished, the workers are not.
But how can we make HIS work in Nigeria? Let me start by saying that I do not believe in free healthcare for every person as this is not sustainable. Neither do I believe that healthcare should be managed only from premiums paid by enrollees. The government needs to play a very significant role in this process. The government needs to provide quality care, but the people need to use these services in a very effective and efficient manner. The Ghana experience is very informative. We cannot afford to make the same mistakes they made! People have asked that health insurance be made compulsory. This is good, but is it the first step? People complained of poor enrollment by communities and workers into the scheme. Has anybody tried to find out the cause of this?
Just imagine a community where all citizens are willing to pay their premiums to partake of the benefits of health insurance scheme. I mean, a community with a 100% willingness to pay (WTP). Imagine that HIS was offered to them and because of their 100% WTP, they all paid. Now, the HIS system is functional, and everyone is enrolled. Now fast-track a month later when a learned citizen from the community became sick of malaria and needed to access care. He believed that because he was covered in the HIS, he would receive care and treatment without any immediate financial burdens since he has paid his premium. He visits the nearest PHC, sees the doctor/health worker within an acceptable period. Upon review by the doctor/health worker, he was asked to visit the laboratory for some laboratory investigations. At the Laboratory, he was told that only one of the three investigations could be done in the current laboratory. He was, however, advised to visit a nearby laboratory facility owned by a member of the laboratory team to do the remaining laboratory investigations. When he arrived at the laboratory (thinking that he will receive the needed investigations), he was given a cost implication that he was not prepared for. He reminded them that he had already paid the bills through his insurance scheme but was refused these relevant laboratory investigations. Since he was not prepared for this, he left the laboratory and returned to his doctor/health worker to inform them of his experience. The health worker had no meaningful answer for him.
Not doing the needed investigations was a minus for him, and he was disappointed. Next, he visited the pharmacy to collect his medications only to be given two of the five prescription drugs (Paracetamol and multivitamins), but was told that the antimalarial and antibiotics were not in stock and could be purchased across the road. This again, involved out of pocket expenditures that he did not plan for, nor was prepared for. This made him leave the center in a very bad mood with a resolve to work against the HIS. He was also ready not only to fight the scheme, but also to make sure that nobody from his community ever pays another premium for the HIS. To him, the scheme is a scam and made up of a bunch of thieves! Are you, therefore, surprised that people do not have confidence in the process? Are you surprised that there are few enrollees despite governmental support and funding for some schemes?
This is the reality in Nigeria and most West African countries. How, therefore, can we make this HIS work in Nigeria? I propose a simple 5-Step approach for Nigeria. This is not a panacea for all health issues in Nigeria, but will serve as a catalyst for better health outcomes in Nigeria resulting from improved enrollment and use of the scheme. Although we are currently at less than two percent coverage in Nigeria, I believe that HIS can work in Nigeria and that Nigeria can achieve more than 90% enrollment rate. But, to make HIS work in Nigeria, people should be incentivized to enroll based on some factors relevant to health. Allow me to suggest the following simple five (5) steps:
Step 1: Institutionalization of good Quality of Care (IQC):
The country has tried to make health insurance compulsory for some sectors of the economy. But this is not the right approach as we are putting the cart before the horse. The country MUST first establish and institutionalize comprehensive quality health care services at all levels of the system. The PHC under one roof concept is great – but must go beyond governance to real service delivery. There is the need for a significant investment in health care services in Nigeria resulting in the provision of quality and comprehensive health care services. Healthcare infrastructures (including building, equipment, communication, and accommodation for healthcare workers), human resources for health (quality and quantity) should be upgraded, services provided must cover most common health needs with a functional referral system for secondary and tertiary care), laboratory and pharmaceutical services, as well as home-based care. The quality of care must be in place before HIS can be stimulated. The government can do this through a public-private partnership. Also, as significant proportion of Nigerians access health care from private practitioners the government must institute a minimum standard for both public and private health care facilities in Nigeria. This will, among several other benefits, re-ignite confidence in the health system and motivate people to use the health facilities.
Step 2: Proper Documentation and Communication (PDC): One of the key challenges of the current system is poor documentation. This has resulted in the inability of the regulatory body to state exactly the number of people enrolled into the scheme, double registration, and even ghost memberships. The government working seamlessly with relevant stakeholders must develop and implement a functional Electronic Medical Record (EMR) for proper tracking of patients and their families. Poor documentation results in a very ineffective and inefficient system as there is poor identification of registered individuals, transfer of cards in-between persons, and even sales of pharmaceuticals by enrollees. Also, poor documentation encourages the abuse of the system by providers, HMOs, and several other stakeholders. A robust Information Management System (IMS) must be in place to ensure proper documentation and communication between key stakeholders. Enrollees’ details should be captured biometrically. This will prevent duplications and multiple registrations. To sustain people’s confidence in the scheme, there should be proper management of information and confidentiality must be maintained at all levels. This may require the development and approval of a data management policy that prevents abuse of this information including sales of patients’ information to data hawkers.
Step 3: Policy Framework (PF): There are existing policy frameworks in Nigeria, but these should be revisited to ensure that Universal Health Coverage (UHC) is a critical component, and that quality based comprehensive health care services in a strong health system is proposed. The proposed policy frameworks must also define the roles of all stakeholders with proper delineation of functions. These roles should have identifiable key performance indicators that should be assessed periodically to evaluate the health of the scheme. The policy should also define the measures which will be taken against those who abuse the process/scheme at all levels of its implementation.
Step 4: Same Package Scheme (SPS): The current system where different people have access to different packages based on how much they are willing to pay should stop. Every Nigerian has the right to good health and thus should have access to the highest level of health care – once they are enrolled in the system. With an identifiable and authenticated HIS number, every Nigerian should be free to go to any facility and receive care. The concept of enrolling into any hospital should stop. Also, the use of HMOs should be reviewed and streamlined as multiple middlemen increase administrative cost for the process. Having the same package for all will engender equity and fairness. I believe that one's willingness to pay their premiums should be seen as enough evidence of their responsibility and thus, grant them access to the highest quality of care. And as I said earlier, the government should support health care services through taxations and other funding streams. It is the belief that individuals will get the best of care that will incentivize people to register, pay their premiums and encourage others to enlist.
Step 5: Price discrimination (PD): The HIS should use price discrimination to ensure UHC for all. Individuals who refuse to buy into the scheme should be made to pay twice to thrice the cost of health services needed as against the cost for the fully insured. Also, services should be provided first to those in the scheme before those outside the scheme. This will serve as a deterrent to not enrolling into the scheme and thus, help make everyone enroll into the scheme. To ensure that people understand this possibility, proper social marketing should be put in place to popularize the scheme and educate the people on the need to be enrolled into the scheme. It is a fallacy to believe that once there is a service that people will buy into it.
As already pointed out, there is the need for full political involvement and buy-in. However, beyond political commitment, there is the need for all stakeholders’ buy-in and commitment. The health managers and workers must decide to make the health system work. Strikes will kill the program as the health systems cannot deliver quality and timely care. The clients must be willing to pay their premiums as failure may deny them access when needed and to the level needed. The regulatory bodies should be fully committed to ensure that the rights and privileges of both providers and users are protected at all levels and by all participants in the process. I, therefore, believe that all stakeholders have vital roles to play and must be fully involved in this process. Finally, community participation is key to the success of this process as the use of community structures will allow for a sustainable process within the community.
To ensure continuous improvement in the scheme, periodic monitoring and evaluation of the process must be in place. Knowing where we are today, where we have moved to in six months and where we are by 12 months allows for proper analysis of the progress of the program. Findings may also help midcourse correction if there are challenges that hinder the actualization of the set goals and objectives. Finally, the scheme can only succeed if there is openness in the entire process. People must believe in the process, see their funds work for them and be able to trust and have confidence in the people who are implementing the entire process. Honesty, transparency and best practices in the financial management of the scheme are critical to the success of the entire project.
Dr. Obinna Excellence Oleribe
Chief Executive Officer
Excellence & Friends Management Care Centre (EFMC)
No 8 Excellence & Friends Street, Dutse