Tag: Nigeria

Meningitis Outbreak In Nigeria

Statistics: The outbreak began in March 2016, approximately 15 States have been affected, almost 2000 Suspected Cases. Approximately 300 deaths so far. The states with the largest number of cases include: Kebbi, Katsina, Niger, Sokoto, Zamfara State.

Who Is In Charge of Managing The Outbreak? 

  • Nigeria’s Centre for Disease Control  is leading outbreak control in coordination with the World Health Organization (WHO), UNICEF, US Centers for Disease Control (CDC), Medecins Sans Frontieres, and Ehealth Africa
  • NPHCDA is leading vaccination in Zamfara state, similar efforts are being coordinated in other affected states
  • WHO is working to ensure the availability of vaccines.

What Are The Risk Factors?

  • Outbreak tends to occur in dry season because of low humidity and dusty conditions
  • The northern part of Nigeria seems to have a higher perdisposition because of their environment
  • Overcrowding and poor sanitation can contribute to outbreaks
  • Living in Dormitories, military bases, child facilities
  • Lack of Vaccination
  • Compromised immune system
  • Pregnancy increases risk of Listeria meningitis.

What Is Meningitis? 

  • It is an Infection of the brain and spinal cord. Organisms can enter the blood stream and travel to the brain and spinal cord, or invade the meninges directly through an ear or sinus infection, skull fracture, or after surgeries in the brain or spinal area
  • Can be caused by bacteria, virus, or fungus
  • Bacterial meningitis most common in teenagers and young adults, it is very severe and can lead to death
  • Viral meningitis are most common in children <5 years, but often mild, can clear on its own
  • Fungal meningitis is rare, usually chronic, it is not contagious, and may be seen in people with immunodeficiency such as AIDS.

Bacterial Meningitis

  • Could be caused by multiple organisms including Streptococus Pneumonia, Haemophilus Influenzae, Listeria Monocytogenes, and most commonly Neisseria Meningitidis (N. meningitidis).
  • Nigeria’s current outbreak is of N. meningitidis (C serogroup), affects mostly teenagers and young adults.
  • Bacterial Meningitis is highly contagious, can lead to death with 24 to 48 hours if untreated.

How Bacterial Meningitis Spreads

  • It spreads through the respiratory system via droplets. Exposure to kissing, coughs, sneezes, shared cutlery, or sharing items that were in contact with an affected person’s saliva such as toothbrush, cigarettes etc.
  • Can contact meningitis by staying in an enclosed environment or room with an affected person.
  • Spreads very quickly in a crowded environment.

Symptoms Of Meningitis

  • Severe Headache that’s different from your usual
  • Difficulty concentrating or Confusion
  • Sudden high fever
  • Stiff neck
  • Sensitivity to light
  • Sleepiness or difficulty waking up
  • seizures
  • Poor appetite
  • Skin rash
  • Muscle and joint aches

Symptoms Of Meningitis In Infants

  • High fever
  • Irritability or Constant Crying
  • Poor feeding
  • Excessive sleepiness
  • Inactivity or sluggishness
  • Stiff neck or body
  • A bulge in the soft spot on the baby’s head

What To Do If You Suspect Meningitis

  • Prompt response and treatment can save lives and prevent complications
  • Avoid exposing others, wear mask and isolate yourself if possible
  • Go to the nearest hospital immediately
  • Tell the Doctor all your symptoms

Evaluation And Management Of Bacterial Meningitis

  • Bacterial meningitis is a medical emergency. Treatment must be initiated immediately to reduce the risk of death
  • Evaluate Patient for:
    • Recent exposure to persons with meningitis
    • Otorrhea (leaking ears) or rhinorrhea (runny nose)
    • Recent travel to areas with endemic meningitis
    • Recent or remote head injury
    • Recent infection (especially ear infection)
    • Immunocompromised conditions
    • Intravenous drug use
  • Obtain blood cultures and Cerobrospinal (CSF) fluid through lumbar puncture if no contraindications
  • Initiate empiric intravenous antibiotics immediately, can use third-generation cephalosporin like cefotaxime (2grams every 4 to 6 hours) and ceftriaxone (2grams every 12 hours), or fourth-generation cephalosporin such as cefepime (2 grams every 8 hours). These drugs can consistently penetrate the cerebrospinal fluid to kill the causative organism
  • Chloramphenicol is preferred for N. meningitides during epidemics. Ceftriaxone can be used as an alternative if Chloramphenicol is not available or contraindicated. The World Health Organization recommends the use of chloramphenicol as the empiric antibiotic of choice in treatment of patients with N. Meningitidis in Sub-Saharan Africa. 1 or 2 injections of the long-acting formula is acceptable.
  • Add vancomycin (15 to 20 mg/kg every 8 to 12 hours) for empiric gram positive coverage until culture results indicate the absence of other infections
  • Can use dexamethasone as an adjunct to decrease brain inflammation, risk of hearing loss, and other complications
  • Antibiotic dosing should be adjusted for patients with poor renal function.

Complications Of Meningitis

  • Complications usually occurs if a person is left untreated for a long time, and includes:
  • Brain damage
  • Hearing loss
  • Seizures
  • Gait problems
  • Shock
  • Death
  • Memory problems and learning disabilities

Prevention of Meningitis

  • Vaccination of high risk populations is the best option for prevention
  • Vaccination against meningitis should be provided as part of the routine childhood vaccination
    • Haemophilus Influenzae type B (Hib) vaccine prevents infections that cause meningitis and pneumonia
    • MMR (measles-mumps-rubella) vaccine prevents meningitis caused by measles and mumps
    • Pneumococcal vaccines also prevent bacterial meningitis especially in those older than 65, immunodeficient persons, or those with some chronic diseases
    • Varicella (chickenpox) vaccine and shingles vaccine prevent viral meningitis
  • Vaccination with the Haemophilus Influenzae type B (Hib) is recommended for boarding school students or new college students
  • Avoid traveling to areas with meningitis outbreaks or epidemics

Written by Dr. Idongesit Udoh

 

References
BellaNaija (March 30, 2017). Meningtis: 1966 suspected cases reported in five states. Article obtained from http://www.bellanaija.com.
Mayo Clinic Staff. Meningitis symptoms and causes. Article obtained from http://www.mayoclinic.org/diseases-conditions/meningitis
Stephanie Busari (March 31, 2017). Meningitis outbreak in Nigeria kills nearly 300. Article obtained from http://www.cnn.com.
Tunkel, A. R., Calderwood, S. B., Thorner, A. R. (2017). Initial therapy and prognosis of bacterial meningitis in adults. Article obtained from http://www.uptodate.com
Waure, C. D., Miglietta, A., Nedovic, D., Mereu, G., & Ricciardu, W. (2016). Reduction in Neisseria meningitides infection in Italy after meningococcal C. conjugate vaccine introduction: a time trend analysis of 1994-2012 series. Human Vaccines & Immunotherapeutics, 12(2), 467-473.
World Health Organization (March 13, 2015). Meningococcal disease – Nigeria. Article obtained from http://www.who.inte/csr.

 

Spotlight on End-Stage Renal Disease and Therapeutic Options in Nigeria

End-Stage Renal Disease (ESRD) is a state where most of the kidney function is lost, and the individual is incapable of clearing waste products from the body, thereby leading to metabolic derangement and electrolyte imbalances. The progression from CKD to ESRD is often silent and most individuals are not aware that their renal function is deteriorating until they become symptomatic, and are diagnosed with ESRD. For most individuals in Nigeria, a diagnosis of ESRD is a death sentence because of limited availability of therapeutic options, and the exorbitant cost of that which is available. Available therapeutic options for management of ESRD includes kidney transplant, as well as peritoneal and hemodialysis. These three modalities for managing ESRD have been available in Africa and Nigeria for many years, but access to these services remains very limited because of lack of public awareness, cost, and inadequate personnel and providers in this field. Each form of renal replacement therapy (RRT) is addressed below:

  • Kidney Transplant: kidney transplant has been available in Nigeria for about 13 years now, but the public is largely unaware of the availability of this service in Nigeria. Many people still have negative attitudes about organ donation, therefore limiting the availability of organs for transplant candidates. Due to the lack of a formal organ donation registry, transplant candidates are dependent on the willingness of family members or friends to donate. In addition, there are very few specialist and centers capable of providing transplant services in Nigeria, so most people travel to foreign countries to obtain transplant service (Bello & Raji, 2016). For patients who are fortunate to obtain a matching organ and receive transplant, their lives are a lot more complex than the obvious, as these patients need maintenance on immunosuppressive medications to prevent organ rejection.
  • Peritoneal Dialysis: Peritoneal dialysis is a process whereby a dialysis fluid is infused into the peritoneum through a catheter, and the membrane acts as a filter to cleans the blood of waste products. Peritoneal dialysis is the most feasible and cheapest form of dialysis in the world. It is the cheapest because it can be taught to patients and their family members so that they can carry out dialysis treatment by themselves. The major risk factor with this form of dialysis is infection acquired in the process of infusing or exchanging the dialysis fluid, and poor sanitation in managing the equipment. However, this form of dialysis is very costly in Nigeria because the resources such as peritoneal dialysis catheters and dialysis fluid are in limited supply. The dialysis fluid in particular is imported, increasing the daily cost of management for patients that are dependent on peritoneal dialysis (Arogundade & Barsoum, 2008).

  • Hemodialysis: This is the most well-known form of dialysis, and can be used long-term for management of patients with ESRD or until the patient receives a kidney transplant. Hemodialysis involves filtration of the patient’s blood through a dialysis machine to cleans it of toxic waste and correct electrolyte imbalances that are often present in this patient population. Under normal circumstances, hemodialysis should occur approximately 3 times per week for optimum management of ESRD. However, Nigerians with ESRD who seek treatment with hemodialysis face several challenges including limited availability of dialysis facilities and experts, high cost of treatment which is often paid out-of-pocket directly by patients for each treatment obtained, and a high risk of exposure to blood borne infections if dialysis equipment are not properly sterilized. Therefore, most patients who require long-term dialysis do not receive optimum management because of the challenges listed above, and < 5% of patients are able to continue treatment after 3 months (Arogundade & Barsoum, 2008).

Addressing the Challenges of the ESRD Population in Nigeria

The challenges experienced by individuals with ESRD in Nigeria include high cost of treatment, limited availability of dialysis facilities, lack of a Renal Registry and logistics to promote organ donation, and risk of exposure to infections. Contributions by all stakeholders including the government, ministry of health, public health officials, healthcare providers, and non-profit organizations can help alleviate some of these challenges and provide improved care to this very vulnerable population.

  • Cost of Treatment: The cost of treatment is directly linked to the limited availability of facilities that are capable of providing dialysis services, and the cost of importing dialysis fluid and other supplies. Most patients in need of hemodialysis get inadequate dialysis, and the survival rate is approximately 20-70%, with most of those who survive experiencing very poor health due to malnutrition and infections (Barsoum, Khalil, & Arogundade, 2015). Therefore, the government and healthcare providers must collaborate to work on solutions by increasing funding for training of nephrologist and other specialist in the field, including dialysis nurses and technicians. The government can also give incentives to manufactures and experts that can promote the production of dialysis supplies particularly dialysis fluid in Nigeria, as this will decrease the long-term cost of management for this patient population, and promote regular dialysis which is necessary for well-being. The government must also provide a form of subsidized insurance coverage to help alleviate the financial burden on affected patients.
  • Availability of Dialysis Facilities: the number of facilities capable of providing dialysis and related services are very few, with most of these concentrated in large cities like Lagos. This places a significant burden on patients from rural areas and other states to travel far in order to have access to dialysis. For most of these people, the cost of traveling and lodging in a distant city in order to receive dialysis can influence their willingness to continue with treatment and the frequency in which they follow-up with regular dialysis. Therefore, future plans to improve access to renal replacement therapy should include government supported expansion of dialysis services including building new and fully staffed dialysis centers in each state in order to improve accessibility.
  • Renal Registry and Organ Donation: As of today, there is no formal renal registry or organ donation registry in Nigeria and most of Africa. The African Association of Nephrology (AFRAN) and African Pediatric Nephology Association (AFPNA) have an ongoing discussion about establishing a registry for kidney disease in Africa (Davids et al., 2016). A renal registry is fundamental because it would help healthcare providers and government officials ascertain the number of people affected by ESRD, and provide necessary data for research on exposures, comorbid conditions, morbidity, and mortality etc. Such data is essential to developing public health education and promoting awareness on kidney disease, developing interventions for the ESRD population, and preparing budgetary allocation for healthcare management of this group. In addition, a renal registry will increase awareness and improve logistics for kidney transplantation. Kidney transplantation is the only curative way of managing ESRD.  A national registry will be beneficial in that individuals can sign up as donors, and patients could be cross-matched for donated organs and do not have to depend solely on the altruism of family members. The logistics associated with maintaining an organ donation registry is significant, but should become one of the goals for developing the healthcare system in order to meet the needs of the Nigerian people.
  • Infection Control: Infection control is one of, if not the most important concern for patients with ESRD who undergo dialysis. For patients with peritoneal dialysis, there is a risk of introducing bacteria and other pathogens while infusing or exchanging the dialysis fluid. These patients and their caregivers must be thoroughly educated on self-management, proper sanitation, and infection control when carrying out these procedures. For those on hemodialysis, the risk of exposure to blood borne pathogens like HIV, Hepatitis B and C, and several other infections is a huge concern. Therefore, the onus lies on healthcare providers and administrators of dialysis centers to ensure that appropriate sterilization procedures and standardized infection control measures are carried out and maintained in each dialysis facility to avoid exposing patients to life threatening infections.

Written by Dr. Idongesit Udoh

References
Arogundade, F. A., & Barsoum, R. S. (2008). CKD prevention in sub-Saharan Africa: a call for governmental, nongovernmental, and community support. American Journal of Kidney Diseases, 51(3), 515-523.
Barsoum, R. S., Khalil, S. S., & Arogundade F. A. (2015).  Fifty years of dialysis in Africa: challenges and progress. American Journal of Kidney Diseases 65(3), 502-512.
Bello, B. T., & Raji, Y. R. (2016). Knowledge, attitudes and beliefs of first-degree relatives of patients with chronic kidney disease toward kidney donation in Nigeria. Saudi Journal of Kidney Diseases and Transplantation, 27(1), 118-124.
Bello, B. T., & Raji, Y. R. (2016). Knowledge, attitudes and beliefs of first-degree relatives of patients with chronic kidney disease toward kidney donation in Nigeria. Saudi Journal of Kidney Diseases and Transplantation, 27(1), 118-124.
Davids, M. R., Eastwood, J. B., Selwood, N. H., Arogundade, A., Ashuntang, G., Gharbi, M. B., … Adu, D. (2016). A renal registry for Africa: first steps. Clinical Kidney Journal, 9(1), 162-167.

Kidney Disease in Nigeria

Kidney diseases are caused by many factors including injury from exposure to toxins, body fluid depletion due to blood loss or dehydration, sepsis, certain cancers, uncontrolled hypertension and diabetes etc. When these causes of dysfunction are not controlled or reversed, the person losses some of his or her kidney function permanently and can be categorized as having Chronic Kidney Disease (CKD). When most kidney function is lost, and the person cannot adequately clear toxins and waste in the body, the person is said to be in end-stage renal disease (ESRD), and at this point will require mechanical help (dialysis) to clear these toxins.

For persons with CKD who end up with ESRD in Nigeria, the process of health maintenance in this state could be very challenging as the healthcare system is ill-equipped to manage the demand for regular and adequate dialysis, and the cost could be prohibitive. Therefore, the Nigerian government in concert with healthcare leaders in the country must begin to evaluate the process of identifying at-risk and affected persons, and establish methods to ensure early intervention, and improve access to quality healthcare for this population

Identifying Risk Factors and Screening

There are several factors that predispose individuals to the development of kidney disease in Nigeria, and they include:

  1. Volume Depletion: this is seen in cases of severe bleeding or when a person is dehydrated due to inadequate fluid intake or from losses such as prolonged diarrhea, vomiting, etc. The affected individual may be noted to be pale from blood loss, or with sunken eyes, dry mouth, low urine output etc. The goal here is to address the cause i.e control the bleeding, transfuse blood if necessary (requires hospitalization), and hydrate those with significant volume depletion (Olowu, 2015). This is the essence of the oral hydration therapy that is often taught to mothers, so that when their children have gastrointestinal illness that cause vomiting and diarrhea, they can hydrate them to prevent complications.
  2. Glomerular Injury: glomerular injury is caused by insult to the kidneys due to exposure to toxins or infections. In children, it is often caused by streptococcal infection of the throat or skin, which triggers an immune reaction that results in the proliferation and destruction of the glomerular tissue and surrounding structures of the kidney. This process is known as Post-Streptococcal Glomerulonephritis and is the number 1 cause of kidney disease in Nigerian children. Some children with strep infection may not develop kidney disease. But for those who proceed to have this complication, it is important to identify the signs and symptoms, which includes low urine output, blood in urine, swelling of legs and body, and encourage them to seek healthcare immediately. Upon arrival to the hospital, several test should be carried out, and the most obvious result that will support this diagnosis is the presence of protein in urine (Ugwu, 2015).
  3. Hypotension (Low Blood Pressure): hypotension can be caused by several factors including volume depletion which was discussed earlier, and sepsis which is one of the leading causes of death (Olowu, 2015). A person is said to have sepsis when the person begins to show signs of systemic response to an infection, and this will be noted with an increased heart rate, fever, low blood pressure, low urine output etc. When sepsis is not addressed immediately with resuscitation and antibiotics, it could lead to permanent damage of end organs including the kidneys and possibly death.
  4. Chronic Uncontrolled Diabetes and Hypertension: these are the two most common causes of CKD in Nigeria. Uncontrolled diabetes is a state in which a person experiences very high blood sugar levels without adequate management with insulin or other anti-diabetic medications. Over 7% or approximately 20.8 million Nigerians are living with diabetes, and the disease burden is so significant because the cost of treatment and self-monitoring cannot be afforded by many, thereby predisposing this high-risk group to periods of significant hyperglycemia (high blood sugar) (Okoronkwo, Ekpemiro, Okwor, Okpala, & Adeyemo, 2015). Diabetes causes CKD because high blood glucose causes increased filtration through the kidneys. Over-time, the kidney tissues become damaged due to overload, resulting in increased passage of protein through the kidneys as it filters the blood, further damaging the kidneys. The end-result of this whole process is irreversible damage to the kidneys and loss of function (Adebamawo et al., 2016).                             Uncontrolled Hypertension on the other hand causes CKD through multiple mechanisms that promote sodium and fluid retention in the body, and neuro-hormonal responses that cause the blood vessels of the kidneys to constrict in an attempt to regulate the blood pressure. Over-time, these processes cause progressive damage to the kidneys and loss in function if not addressed (Collister, Ferguson, Komenda, & Tangri, 2016).                                   These two conditions require long-term and consistent monitoring and management, and present a tremendous demand on the resources of the affected individual and the healthcare system. As part of an effort to address kidney disease in Nigeria, screening for, and improving the management of hypertension and diabetes should be target goals for the Federal Government, Ministry of Health, and healthcare professionals at all levels. We also need more health promotion activities to raise awareness of these risk factors, the importance of screening, treatment, and monitoring, as well as life-style alterations such as diet and exercise that can help modify the disease process and improve outcomes.

Written by Dr. Idongesit Udoh

References
Adebamowo, S. N., Adeyemo, A. A., Tekola-Ayele, F., Doumatey, A. P., Bentley, A. R., Chen, G., … Rotimi, C. N. (2016). Impact of type 2 diabetes on impaired kidney function in sub-Saharan African populations. Frontiers in Endocrinology, 7(50). doi: 10.3389/fendo.20016.00050.
Collister, D., Ferguson, T., Komenda, P., & Tangri, N. (2016). The patterns, risk factors, and prediction of progression in chronic kidney disease; a narrative review. Seminars in Nephrology, 36(4), 273-282.
Okoronkwo, I. L., Ekpemiro, J. N., Okwor, E. U., Okpala, P. U., & Adeyemo, F. O. (2015). Economic burden and catastrophic cost among people living with type2 diabetes mellitus attending a tertiary health institution in south=east zone, Nigeria. BioMed Central Research Notes, 8(527). doi:10.1186/s13104-015-1489-x.
Olowu, W. A. (2015). Acute kidney injury in children in Nigeria. Clinical Nephrology, 83(suppl 1), S70-S74.
Ugwu, G. M. (2015). Acute glomerulonephritis in children of the Niger Delta region of Nigeria. Saudi Journal of Kidney Diseases and Transplantation, 26(5), 1064-1069.

 

Healthcare Personnel Shortage and Solutions Continued (The Concept of Mobile Clinics, Improved Collaboration and Referral Process)

Mobile Clinics

Mobile Clinics are used in many parts of the world to deliver healthcare services to members of the population that may not have immediate access to healthcare. These are specially designed buses that are fully equipped with basic healthcare supplies, and staffed with healthcare professionals, who travel from one remote community to another and deliver care to those in need. Mobile clinics can be utilized to deliver diverse services to a target population.  However, several factors need to be in place for a mobile clinic program to be successful, and these factors are listed below.

  • Need doctors and nurses who can function in this role
  • Requires government partnership and funding, because the patient population may lack the ability to pay for care delivered
  • Can be funded by non-profit organizations and philanthropist, and this method of funding should be encouraged
  • Recruitment of volunteer healthcare professionals is necessary to boost the workforce of a mobile clinic program, and decrease the cost of staffing.

Mobile clinics can be utilized for basic primary care; treatments and disease screening, immunization programs, and health campaigns. See diagram below:

picture2

The Collaboration and Referral Processes

Collaboration between healthcare providers is necessary for seamless healthcare delivery and improvement of patient outcomes. For example, if a patient with a severe cardiovascular problem goes to see a general medicine doctor who knows that the patient requires management by a cardiologist, the patient should immediately be referred to the specialist, and the generalist should carry out that consultation process to ensure that the patient is in good hands. This is sometimes lacking in Nigeria, with many providers delivering care beyond their expertise, and without seeking input from experts in particular fields of medicine, who could have influenced the quality of care rendered to the patient. In addition, patients are often left to find the experts they need to seek, and this happens after they have spent a lot of money obtaining care at a local hospital or clinic that could not address their medical problems.

To improve collaboration and referral, the following factors must be addressed:

  • Doctors need to collaborate with other healthcare providers in the community
  • Inter-institutional networking is essential to effective healthcare delivery because it allows for timely referral of patients from one institution to another based on their healthcare needs.
  • The referral process should be transparent, timely, and altruistic, with the sole purpose of ensuring that the patient is sent to a place that can treat the disease process effectively. Profits should never be the driving force for a referral.
  • The referral process should be well coordinated with detailed and necessary patient information communicated to the receiving doctor. Transportation should be facilitated to the receiving institution. See diagram below.
  • We need to develop an inventory that list the names, contact information, and sub-specialties  for all healthcare providers within each state. This can be made available to providers and patients, making the navigation process easier when seeking consultation for complex health conditions.

picture4

 Written by Dr. Idongesit Udoh
Reference
Lehmann, U., Dieleman, M., & Martineau, T. (2008). Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Services Research, 8(19). DOI 10.1186/1472-6963-8-19.

Healthcare Personnel Shortage and Solutions

The availability of healthcare personnel is absolutely necessary to effective and timely delivery of healthcare services to those in need. However, several healthcare institutions in Nigeria are still severely understaffed, resulting in long waiting time and further deterioration of the patient’s clinical status prior to intervention.

Addressing Personnel shortage

  • Personnel shortages are most evident in remote and rural areas
  • We need to device an incentive based system such as paying additional allowances to encourage retention of local healthcare providers, particularly doctors who tend to migrate to cities to work
  • Promote education and training of members of a target community to allow them to become associate members of the healthcare team and work within their level of training (can measure vital signs, mobilize patients, and other technical work) to alleviate the work burden on available nurses.
  • Continue to promote education for would-be healthcare providers in the field of Medicine, Nursing, Nutrition, Therapy, etc.

Clinical Franchising for Nurses can help alleviate shortage of healthcare providers in remote areas

  • Clinical franchising involves nurses having the opportunity to provide basic care and meet the healthcare demands of members of the community who do not require hospitalization, and may live far from the hospital.
  • They can provide disease monitoring for patients with chronic diseases such as hypertension and diabetes, who may be on maintenance medications, but do not have the supplies to monitor themselves and their responses to medications
  • They can also help provide rehabilitation of patients post-discharge, as there are no formal rehabilitation centers or  rehabilitation services for patients in the community. Many patients who have had significant and prolonged illnesses or stroke may be severely debilitated, but with rehabilitation, they may be able to regain some function and be capable of performing their activities of daily living even though some deficits may linger.
  • Clinical franchising requires transparency between the franchising nurse and the local hospital or clinic to allow for a seamless referral when necessary. The hospital must be supportive and understand that this helps to meet the healthcare needs of the community.
  • It can be developed further and become a form of advanced  certification for nurses and midwives, with a corresponding certificate upon completion of training.

Clinical Franchising can serve as a benchmark for the development of a formal community nursing service in Nigeria, and should involve the following process:

  • Identify the right personnel (needs nursing experience)
  • Register and train them, provide certification post training
  • Assign them to follow-up on patients living in their communities who require extra care
  • Provide supplies such as blood glucose/pressure monitoring devices etc.
  • Device a means of compensation for work done in the community
  • Each nurse should have a doctor to report complex cases to, and refer when necessary
  • Establish a referral and transfer system for patients that need to be hospitalized

The diagram below demonstrates the many roles that can be played by nurses in the community.

picture1

Written by Dr. Idongesit udoh
Reference
Krubiner, C. B., Salmon, M., Synowiec, C., & Lagomarsino, G. (2015). Investing in nursing and enterprise: empowering women and strengthening health systems in low- and middle-income countries. Nursing Outlook, 1-7. DOI: http://dx.doi.org/10.1016/j.outlook.2015.10.007.
Nganga, N., & Byrne, M. W. (2015). Professional practice models for nurses in low-income countries: an integrative review. BMC Nursing, 14(44). DOI: 10.1186/s12912-0095-5.

Healthcare Funding in Nigeria

The Federal Ministry of Health created a policy in 2006, with the purpose of improving access, equity, and effectiveness of healthcare delivery to Nigerian citizens. With this vision, there was a mandate for the government to contribute 15% of the budget to healthcare in accordance with the 2000 declaration to expand healthcare coverage to most citizens (Uzochukwu et al., 2015). Federal, state, local governments, as well as healthcare officials must collaborate and continue to work towards the actualization of this goal. This will increase access to screening and preventative care, antenatal, intrapartum, and postpartum management, as well as disease management and monitoring for those with chronic conditions. It remains unclear what percentage of healthcare cost will be subsidized, but any form of subsidized healthcare will make a significant impact in improving healthcare access and outcomes in Nigeria.

For now, the focus of healthcare funding by federal, state, and local healthcare officials should be on providing basic healthcare to the most vulnerable population:

  • Free and timely immunization for children
  • Free prenatal care
  • Public health initiatives to educate the population about screening and management of certain disease processes, and promote the well-being of the population at large
  • Leaders of healthcare institutions (hospital or clinic) must ensure availability of basic supplies such as gloves, needles/syringes, power etc.
  • There is need for increased oversight to ensure that healthcare institutions maintain accountability to patient safety by providing basic supplies.
  • Nigerian government must look to create a form of insurance to subsidize the cost of care for patients with extensive medical needs such as those with renal failure who require renal replacement therapy like dialysis or transplant
  • Increased healthcare funding is necessary to build infrastructure and improve standards in the nation’s hospitals. This will improve the quality of care provided to patients, and curb medical tourism to foreign nations.
 Written by Dr. Idongesit Udoh
Reference
Uzochukwu, Ughasoro, Etiaba, E., Okwuosa, C., Envuladu, E., & Onwujekwe, O. E. (2015). Health care financing in Nigeria: implications for achieving universal health coverage. Nigerian Journal of Clinical Practice, 18(4), 437-444.

Addressing the Challenges (Tertiary Level Education)

University education is the goal for most of Nigeria’s youth. It is the level of education necessary for professional preparation and employment, and students strive very hard to attain this standard. However, a good percentage of Nigerian students become victims of failures in the system, which includes poor preparation and poor administration of university admission exams conducted by the Joint Admissions and Matriculation Board (JAMB), limited university seats with only 1 in 3 students receiving admission, poor funding and maintenance of academic infrastructures, and lack of opportunities for research and innovation.

Most universities require a cut-off JAMB result of 180-200 out of 400, with universities and programs in high demand requiring higher scores to qualify for admission. Many students fall short of this target, and are often relegated to multiple exam attempts, remedial programs, or courses that they do not have interest in studying, just for an opportunity to obtain a university education. In addition, many qualified applicants do not receive admission to universities because of admission malpractice, which strongly influences admission opportunities.

Attempts to expand access to tertiary education through creation of new institutions or expansion of older institutions has depleted instructional quality because funding and training of educational staff has not correlated with the demand. Institutional halls are overcrowded with high student to professor ratios that make interactive learning difficult to implement. Approximately 40% of university positions and 60% of polytechnic positions are vacant, creating a significant vacuum in higher institutions, and limiting the effectiveness of available professors.

The lack of admission opportunities and the overall poor quality of higher education in public universities in Nigeria has increased the percentage of Nigerians attending private universities within the country, and more so those who travel to other African countries like Ghana, Kenya, and South Africa, as well as the UK, USA, Canada, and Malaysia to obtain tertiary education. The focus on attaining international education has overshadowed the prioritization of maintenance and improvement of Nigeria’s academic institutions, and we have forgotten that if the decay is not arrested, it will continue to get worst.

Universities provide the highest level of education from undergraduate to post-graduate studies, and several factors need to be addressed to ensure that students are provided with quality education that prepares them for their chosen professions, and inspires their understanding of civic responsibilities and role in developing the society. Listed below are key targets necessary for improvement in the administration and quality of tertiary institutions in Nigeria:

  1. Rehabilitate existing structures, and build new ones to accommodate the growing demand for university education. For public universities, this responsibility primarily falls on the federal government and university administrators. In addition, each university should set up an alumni foundation to appeal to past alumni and other philanthropist for donations to support ongoing projects and development of the institution. Such foundations must maintain transparency and accountability to its donors by updating, and showcasing the projects that have been funded. This is necessary for continued support, as donors who do not see result will cease to donate.
  2. Recruit professors and supporting staff, and provide opportunities for continuing education to help them stay abreast of current research and findings in their subject areas. Professors are expected to attain a level of education that qualifies them as experts in their chosen fields. Therefore, administrators have a responsibility to promote and sponsor continued education and attainment of doctorate degrees by their professors. Continued education and certifications will help professors stay sharp and updated, and this will be reflected in the quality of education provided to students. Recruitment should also extend to various professionals in different fields who might have interest in sharing their knowledge, but are not necessarily desiring permanent positions. This group can be classified as guest lecturers who are scheduled to come in and share their knowledge and expertise with the students without significant compensation. There are many professionals in healthcare, science, arts, and business, who can inspire students through their service as guest lecturers. Guest lecturers provide a bridge between the classroom and the professional world and make a significant difference in the overall experience of students.
  3. Professors and university staff MUST BE PAID for their work. University students are paying tuition annually, as there are no free universities in Nigeria. Therefore, it is very sickening to see the amount of time they loose from strikes because professors are not paid. Lack of payment promotes corruption in the fabric of the school of system, as these professors begin to device means to compensate themselves for their work. Some have manufactured ‘handouts’ for sale to students, some collect bribes in exchange for a pass grade, and may go as far as punishing students who do not want to participate in this behavior. This is deplorable, unprofessional, and a direct result of neglect on the part of government and university administrators to meet the financial needs of the staff. As mentioned earlier, 40% of university positions and 60% of polytechnic positions are vacant,  and this is a result of poor representation of the teaching profession because of the way the educational system has been administrated. There are so many unemployed graduates, and there are so many vacant teaching positions. Yet most of them will not seek out teaching jobs because of a sense that the job cannot meet their financial needs.
  4. The curriculum should be upgraded to reflect current needs of the society at large, and the expectations of the job market. Many graduates are ill prepared for the profession in which they seek. This has resulted in a high rate of unemployment, because potential employers feel that they are not qualified and require too much on-the-job training. Many corporate institutions hire international experts to manage multiple aspects of their businesses and operate the machines used in production. These are positions that could have gone to Nigerians if the educational system prepared students for such roles. Approximately 60% of recent university graduates are unemployed, this is significant and unfortunate. Universities need to update their curriculum to include internship opportunities for their students especially in courses such as healthcare, law, engineering, and business. Internship opportunities help bridge the gap between the classroom and professional world, and provide opportunities for students to build their experiences, resumes, and establish relationships with potential employers. Universities should form liaisons with established alumnus who are willing to take on interns. Students can rotate during holidays if the location of the internship opportunity is too far from the school campus.
  5. Upgrade and ensure the availability of necessary amenities including lecture halls and materials, libraries, research laboratories, and computers etc. These amenities are essential for effective delivery of educational content. The maintenance and provision of some of these amenities can be funded directly by the federal government, the institution, or from donations by philanthropist. It is often noted that some schools establish libraries or labs, but do not fund, update, and maximize its use, thereby allowing these costly endeavors to become obsolete. The concept that “a stitch in time saves nine” should become the motto that drives maintenance of institutional amenities. Once infrastructures are allowed to decay, it cost so much more to rehabilitate or build new ones, compared to the cost of fixing small parts immediately when it breaks down. So this outlook should be adopted for the long-term benefit of saving money while ensuring the availability of educational amenities at higher institutions.
  6. Work-Study programs are necessary to help build supporting staff for the effective administration of university processes. Work-Study programs provide opportunities for students to earn stipends, while helping meet the needs of the institution. In most universities in the developed world, students can apply and work in various capacities throughout the school campus. There are some great campus positions that can be occupied by qualified students, including tutoring and mentoring, leadership and project management, library upkeep, sales persons at school shops etc. These offices require management by a qualified, paid administrator, but students can serve as assistants and help stabilize the workforce. Compensation for students may come in the form of bi-weekly or monthly stipends, or percentage reductions in the cost of their tuition. Each institution can choose the method that is most convenient for them. The overall purpose of these programs will be to ensure that the institutional workforce is adequate, while minimizing the budgetary cost of hiring additional staff.
  7. Each university should have a program that sponsors and promotes individual research and innovation by their students. There are so many talented youths in Nigeria, but very few have the platform to develop and showcase their talents. Universities can establish such platforms, and work in partnership with the government and philanthropic organizations to help students  publicize their research discoveries, innovations, and other productions. if well promoted, some of these innovations can lead to major opportunities for the students and provide spotlight and more patronage for the institution.
  8. Tuition at public universities should be maintained at a reasonable rate to ensure that most students can afford tertiary education. The school can also provide partial or full scholarships for exceptional students from funds donated by philanthropists. Overall, the experiences and quality of education provided by an institution will determine the success of its graduating students, the popularity of the school, as well as the number of alumni who are willing to contribute to continued growth and maintenance of the institution.
 Written by Dr. Idongesit Udoh
Reference
Clark, N. & Ausukuya, C.  (2013). Education in Nigeria. Information obtained from wenr.wes.org>Africa.

 

Addressing the Challenges (Secondary Level Education)

The challenges of secondary level education are much more complex than that of primary schools. This level of education consists of 6 years of learning (3 in junior secondary and 3 in senior secondary schools). This is where students begin to identify interest areas, and the direction for higher education studies. Majority of schools begin to streamline students into areas of interest such as science, arts, and economics once they begin senior secondary school (http://www.ibe.unesco.org/).

At the end of secondary school, students take the Senior Secondary Certificate Examination (SSCE), which are either administered by the West African Examination Council (WAEC) or the National Examination Council (NECO). An average grade of C6 or better is necessary for consideration for admissions to public universities in Nigeria (Clark & Ausukuya, 2013). However, a good percentage of students are unable to meet this target for core courses such as mathematics, English, and particularly sciences, resulting in delays in admission to higher institutions.

To address these concerns, it is necessary to identify the problem areas and holes within the academic curriculum that limits students’ comprehension of certain courses. Starting off with notable failure in sciences, lack of sufficient infrastructure for laboratories and inadequate training of teachers have been identified as primary causes. Science cannot be effectively taught in abstract form. Students need to feel, experiment, and engage in bringing what they learn to life. I remember attending Federal Government College Odogbolu from JS1-3, and being taught computer science without actually touching the computer. One day the teacher took us to the computer lab and all 100 or more of us who were in that class gathered around him as he showed us each part of the one computer that was in the office. Of course majority of students could not see due to the crowd, and just stood there until the session was over.

How can students learn computer science without well-equipped computer laboratories for practice? How can they learn sciences such as chemistry and biology without a science lab for experiments that can clarify some of the theoretical information provided by the teachers? How can they begin to use their imagination and develop interest in research if what they are learning in the classroom has not been applied practically to improve their understanding of the process? This issue is primarily caused by limited funding, and it is exacerbated in public secondary schools, which are funded by the state government.

Some private secondary schools are well equipped, but most public schools are lacking, despite the fact that students still pay fees to obtain their education. Therefore, as part of the movement to improve education in Nigeria, this sector of education must be addressed with the understanding that adequate academic preparation at this level, ensures more success in WAEC/NECO, and in higher institutions. There are several factors that need to be addressed, and these are listed below:

  1. Secondary school teachers need adequate training in their designated courses, and should be sponsored for teacher training programs, conferences, and other professional development opportunities. Private schools have the responsibility to provide this for their teachers, but public schools need government funding to implement it.
  2. There is need for rehabilitation of existing structures, and development of new structures to accommodate the increasing number of secondary school students in Nigeria. Overcrowding of classrooms limit the effectiveness of teachers, as students may not be able to ask questions as they need to, and there is less engagement.
  3. Laboratories are a must. They are absolutely necessary to effective science education, and should never be optional. Even if the lab is small, students can be divided into small groups, with each group taking turns to learn and work in there, and the complexity of the practicals should correlate with their educational level. The lab teacher must be well trained and certified in maintenance and handling of the laboratory.
  4. The Ministry of Education should look to unify the examination board. Instead of WAEC or NECO, there should be one examination board. This will allow for standardization of the SSCE, and upgrading of the question bank to reflect what is currently taught in schools. In addition, the school curriculum should correlate with the expectations of the SSCE. Schools should provide practice sessions to prepare their students for these exams, in order to reduce the failure rate.
  5. Textbooks are essential to students’ understanding of the subject and should be integral to what is taught in the classroom. Some schools, especially private schools tend to make students purchase several textbooks for each course-work, but the semester can come to an end with a good number of these textbooks never being used in the classroom. This is a big waste of money for parents, and it prevents students from understanding the value of actually studying the information available in textbooks. Therefore, I propose that each school should choose one or two comprehensive textbook for each course, and actively teach from it to allow students the opportunity to comprehend the subject beyond the limited information that might be provided by the teacher. For students in public schools who may not have the funds to purchase some textbooks, it is the responsibility of the school to provide a library, where all the textbooks recommended for the academic year are made available. These students can take turns to read or do their homework with the textbooks, and return it to the library. Students who have completed the academic year can be encouraged to donate their old textbooks to the school library for a small stipend. This can reduce the cost of funding the library, and help increase the availability of textbooks for the upcoming school year.
  6. Teachers must be adequately paid. Teachers who are compensated for their work tend to have more commitment towards their work, which trickles down to how students are taught. As stated earlier, public secondary schools are funded by state governments, and salary for teachers should be exclusively set aside each budgetary year without fail. Our government officials cannot be living in opulence, while teachers go to work with empty stomachs without assurance of how they will meet their families’ needs.

We really have to reorganize our priorities as a nation, because where we invest our resources is where we will see results.

 Written by Dr. Idongesit Udoh
References
Clark, N. & Ausukuya, C. (2013). Education in Nigeria. Information obtained from wenr.wes.org>Africa.
United Nations Educational, Scientific and Cultural Organization (UNESCO). World Data on Education 2010/2011. Information obtained from http://www.ibe.unesco.org/).

Addressing the Challenges (Primary Level Education)

Primary level education is a universal right that every child deserves. This level of education focuses on children ages 6-11, and seeks to develop their basic capacity to function in the society with the ability to read, write, count, and communicate effectively. Primary education consists of basic courses including English, Mathematics, Science, Social Studies, Arts, and Civic education (http://www.ibe.unesco.org/).The purpose is to help children develop their minds, ability to think and ask questions, and interest in learning. Primary level education should be funded nationally in order to ensure that every child has an opportunity to read and write regardless of their parents’ socioeconomic status.

Some parents can afford private primary education for their children. However, for those children who will have to depend on free public schools, the government must fund these schools and ensure that the curriculum provided is standard, meets the child’s educational needs, and maintain a conducive learning environment. All public primary schools should have basic amenities including classrooms, chairs, tables, and resources for teachers to use and teach. These items are fundamental to a meaningful learning environment, and should be upgraded and maintained from time to time to prevent decay.

To improve training of teachers and curriculum upgrade, the government (state/local) should fund at least one annual teachers’ free training program for public school teachers. The program should be hosted by experts, with a focus on improving teaching methods and effectiveness, upgrading the curriculum, and maximizing children’s potential. This program should also offer certificates of completion that validates those who participate. Private primary schools should be able to sponsor their teachers to attend training programs. However, for poorer private schools that may not be able to fund the program for their teachers, the government should subsidize a portion of the training cost, in order to maximize participation.

Written by Dr. Idongesit Udoh

Arise Nigeria, Arise !!!

There comes a time in human existence when a group of people have to choose a path. Either stay the course and continue on the path of struggle, mediocrity, and further destruction, or take a stand and fight to redeem the nation and leave an inheritance for future generations. Nigeria is at that crossroad, where we risk losing the value of the democracy we obtained in 1960 if we continue to stand and watch as the nation is being stripped of its identity, and the future more uncertain.

The question we all have to ask ourselves is this; how did we get here? We got here because of negligence on the path of leadership and citizens to look out for the well-being of all, rather than a select few. We got here because we failed to adopt a culture of maintenance and diligence towards the preservation of our national treasures. We got here because despite the blessings we have in natural resources, we failed to seek understanding on how to manage our resources and maximize our revenues. We are here because at so many instances we lacked vision, direction, and passion for our people and nation.

Chief Seattle once said “man did not weave the web of life; he is merely a strand in it. Whatever he does to that web, he does to himself.” What are we doing to our web of life as Nigerian citizens? Are we destroying it? How are we contributing to the challenges we face as a nation? Are we willing to become a part of the solution? What is the limit of our compassion? Are we able to see those who are suffering because of the failed systems in the country? Can we see that the young are most affected, and their futures more bleak? How about the poor children in the villages who do not have enough to eat on a daily basis, and may not have an opportunity to obtain an education? Are they not deserving of a brighter future? Think of our broken down educational system, particularly institutions of higher learning. What will it look like in the future if not fixed today? We can also speak of millions of youths who have completed higher education but remain unemployed. How will they grow and contribute to society, if they have no platform to build their skills and display their talents?

Chief Seattle went on to say “take only memories, leave nothing but footprints.” This statement speaks to the fact that what we do today determines the Nigeria that our children and grandchildren will inherit. Are we creating footprints? Will our footprints lead to a destination that is greater than where we started in 1960? We have to understand that many of the great policies and social institutions we admire in foreign countries were envisioned and implemented by leaders who saw opposition and challenges, but pushed through to establish something that made their nations better for the citizens. Most of these leaders did not see the full manifestation of their vision while in office, but they left traceable footprints that enabled incoming leaders to continue to improve on what was started, allowing the changes or projects to stand the test of time.

The president just launched a “change begins with me campaign.” It does not matter what our political affiliations are, this campaign should speak to the core of all Nigerians. What part are we going to play in our communities and our nation in order to establish the changes we want to see? Look around you. Do you see schools in your community with broken amenities that can benefit from your donation? Have you gone to your local healthcare facility recently? What is lacking that you have the power to provide or help improve? Can our elected leaders begin to value the lives and experiences of those who voted them into office? Will our leaders ensure that our resources are not diverted, misused or wasted? Can we seek to maintain transparency and accountability to our nation and the future of our children? Will our business men and women commit to provide quality and efficient services while maintaining honesty throughout?

As a doctor, are you ready to deliver ethical care within the limits of your expertise and provide timely referral and transfers for complex cases that need a higher level of care? As a senior nurse with years of experience, are you willing to mentor your colleagues and bring structure to the way nursing care is delivered at your facility? Will our teachers rise up to inspire and mentor students, teach them to value integrity and respect the rights of their fellow man? Can our students commit to careful use and maintenance of the structures in our schools? As a person with great wealth, can you go back to your Alma Mata, and pay some of the salaries of a group of teachers and professors who may not have been compensated for their work for several months?

Let us start today, stand for the truth, stand for one another, stand for our children and their children. Let us stand for the identity and future of our nation. We all have our roles to play in this movement. We can do so in our communities or advocate in the corridors of power. We have a shared responsibility to take back the values of our nation, and rebuild our Jerusalem. Our contributions to bring the changes we want to see may be small or big, but we must not underestimate the impact we will create, as we all drop a piece of goodwill in our web of life, and watch as our web becomes stronger and redefines the color of our tomorrow.

written by Dr. Idongesit Udoh