Emeritus Professor

RADIOLOGY AND UNIVERSAL HEALTH COVERAGE

Guest Lecture 52nd. Annual Scientific Conference Of the Association of Radiologists of West Africa

By  NIMI BRIGGS, University of Port Harcourt, Port Harcourt, Nigeria.

26 June 2014 email:nimi@profbriggs.net

Website: nimibriggs.org

OPENING REMARKS

An Association of Radiologists of West Africa, ARAWA, is a unique and laudable society. Unlike the well-known West African Colleges of Surgeons and Physicians which, in a way, are off -springs of government protocols – the Economic Community of West African States (ECOWAS (English), CEDEAO (French) – a regional grouping, now of 15 West African states, founded in 1975), through its specialised agency of the West African Health Community (WAHC), now the West African Health Organisation (WAHO), with principal orientation for the development of human resources for health, ARAWA is a voluntary association of medical specialists with common persuasion. Formed 52 years ago through the visionary actions of Howard Middlemiss and Peter Cockshott, both of blessed memories, for the purposes of sharing knowledge and experience and the advancement of the science and practice of radiology, the organisation has existed despite the linguistic barriers foisted on the sub region by its erstwhile colonial masters. I congratulate you all immensely for keeping ARAWA alive and for ensuring the continuity of its annual scientific conferences. Furthermore, I thank you most sincerely for inviting me to be part of today’s great event and to play such a significant role as that of being the Guest Speaker.

INTRODUCTION

The World Health Organisation (WHO) defines Health, the principal remit of all associations in the global health community, including yours, as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity1. The organisation regards “the enjoyment of the highest attainable standard of health” as a fundamental human right and an important resource needed for daily living. Consequently, without health, individuals will neither be equipped to carry out their daily tasks nor contribute to national development in a satisfactory manner, even with their best intentions. Health thus becomes an essential ingredient for inclusive national growth and as such, ensuring the health of all its citizens stands out as a vital responsibility and ambition of governments of all nations irrespective of their stages of development. Indeed health and mortality indices – life expectancy at birth, under five mortalities, childhood immunization coverage and others – are some of the recognized gold standards for assessing quality of governance.

In this respect, there is an emerging global consensus around Universal Health Coverage (UHC) as the pathway for achieving the concept of health for all. International organisations, a large number of countries and the academic community are promoting it and 90 United Nations member states co-sponsored a resolution in 2012 that endorsed it. At the United Nations Conference on Sustainable Development which was held in June 2012 in Rio, Brazil (Rio+20), The Future We Want – the official outcome of the conference, emphasised the importance of UHC in enhancing health, social cohesion and sustainable human and economic development …as well as improving educational opportunities and reducing impoverishment and inequalities and so, pledged its strong support. Indeed, the world is moving towards UHC and the words of the Director-General of the World Health Organisation (WHO), Dr. Margaret Chan, that UHC is the single most powerful concept that public health has to offer,2 perhaps, constitutes the strongest impetus for this drive. It therefore did not come as a surprise that a few months ago, on March 10, 2014, Nigeria, Africa’s most populous nation, boasting about 50% of the population of the West African sub region, led by the nation’s president, Dr. Goodluck Ebele Jonathan, organised a summit on UHC in which Mr. President depicted UHC as a vehicle for sustainable growth and development. Universal Health Coverage was also at the heart of the recently concluded African Ministers of Health Conference in Luanda, Angola (14-17 April, 2014) which was attended by many from West Africa, including Nigeria’s Minister of Health, Professor Onyebuchi Chukwu. At that meeting, the ministers, among other resolutions, committed their countries towards the attainment of UHC in Africa by 2020. Furthermore, at the 24th edition of the World Economic Forum for Africa (WEFA) which was held in Abuja, the capital city of Nigeria, 7-9 May, 2014, participants from the country highlighted a vision for the health system by 2030 which aims at providing UHC by building on the National Health Bill 2014.

Therefore, it is on the platform of universal coverage that I wish to anchor the material context of today’s Guest Lecture and to explore modern medicine which is the theme of your conference this year and of which radiology is an important component, in the context of UHC. My focus on this area is premised on the fact that UHC within the environment of modern medicine, should not only improve the health of all the people but also fast track development in the West African sub region which has a good number of low income and lower – middle – income countries, well beyond 2015, the target date for the achievement of the Millennium Development Goals (MDGs).

So, in carrying out this assignment, I will examine the advantages of instituting health coverage for all people that does not involve devastating out-of-pocket expenditure and how the challenges facing such an action are being met in some West African countries. Thereafter, I will draw attention to the place of modern medicine, along with radiology, in current health care systems that are expected to serve as vehicles for UHC. Then I will comment briefly on health care beyond 2015 and what the role of ARAWA should be. My conclusion will amplify the thrust of the paper, which, essentially, is an advocacy for a strong support for UHC in each of the component countries of the West African sub region.

UNIVERSAL HEALTH COVERAGE AND ITS POTENTIALS

Universal Health Coverage aims to provide access to basic and functional health services as may be required and in a sustainable manner to all people within a state or nation but without unbearable financial burden on them. It also includes proactive and promotive activities, together with education on lifestyle choices that are designed to enhance healthy living and so reduce the chances of ill health with their cost consequences. It is intended to provide everyone, especially the poor, with the opportunity for a healthy life as a fundamental right as improvements in health contribute directly to human development and economic growth, just as those who are unable to work can get pushed into or descend further into poverty3.

However, due to a number of factors, inequity included, it is estimated that about a billion people worldwide are unable to obtain modern health care and about 100 million people are forced into poverty by out-of-pocket health costs4. This burden disproportionately affects the poor, women, children and other vulnerable groups, marginalizing them further and deepening their poverty. Thus contributing to maternal and child mortality as well as death and disability from communicable and non-communicable diseases. Other than access, shortages in critical resources such as health infrastructure, trained health workers as well as essential medicines and commodities, complement the unfortunate situation.

By aiming to deliver basic health services at affordable costs to all people, UHC can address most cases of preventable deaths and morbidities. The health system reforms that are contingent on UHC strengthen the system, enabling it to deliver services more equitably, efficiently and sustainably, thus reducing out-of-pocket health expenses.

MEETING CHALLENGES

But setting up health systems that meet the goals of UHC is complex and difficult. They involve putting appropriate policies in place that define aims, objectives and priorities; the establishment of management structures for day-to-day operations; harnessing of public and private institutions for their critical imputes; raising funds for the venture through requisite legislation and taxation; and much more. It is for these reasons that approaches differ among nations, based on local peculiarities and a large number of research findings exist on a variety of successful models5, 6. If this is true in the global context, it is more so in the West African subcontinent.

Speaking at the opening of the 15th. ordinary meeting of the Assembly of Ministers of ECOWAS in Liberia on April 11, 2014, Her Excellency, Ellen Johnson Sirleaf, the President of Liberia, informed participants that achieving UHC by ECOWAS countries is a daunting task not only because it takes time and perseverance, it also involves accessibility, affordability and quality of service. According to her, while countries recognize inadequate financing for drugs and facilities, construction and lack of incentives for health workers as stumbling blocks in the path to achieving UHC, ‘the added challenge we need to overcome today is the declining contributions from international partners…this is a reality and it is clear that if our countries are to achieve Universal Health Coverage, we must go to work to build a sustainable health financing that is domestic based”. So how are countries in the sub region grappling with these challenges? A few examples will suffice:

Ghana. The country celebrated the 10th anniversary of its National Health Insurance Scheme (NHIS) in September, 2013. The scheme is mandatory for all residents and is largely funded from general tax revenues and a special tax levied on goods and services. The enrolled beneficiaries are entitled to receive a broad package of services covering 95% of the disease burden. While many challenges remain for achieving the UHC goal, the institutional building blocks are firmly in place to continue to improve and innovate for providing financial risk protection to the Ghanaian people against the impoverishment impact of out-of-pocket health care expenditures. Since its establishment in September 2003 following a series of pilots in different districts, many policy and institutional measures have been launched to support the growth and expansion of coverage from a membership base of 1.3 million in 2005 to 9 million in 2012 (about 35% of the total population).

Mali. On February 9, 2011, the President of Mali and Board of Ministers formally adopted a policy which is to provide a Universal Health Insurance scheme for the establishment of comprehensive health care in the country to which everyone would have access. This was done by merging three existing systems through which health care provision was financed: formal sector coverage, medical assistance for indigenous population and the Community Based Health Insurance Schemes (Mutuelles in French ) – not-for-profit mechanisms of health financing grounded in principles of solidarity among community members and risk sharing. Specifically, the policy is designed to address financial barriers for Malians to access and use priority health services. The expectation is that utilization would soar from its previous low level of about 2% because of high-level government commitment, partner collaboration and consensus among a wide range of stockholders.

Burkina Faso. Since 2009, Burkina Faso has funded some health care systems that have supported maternal and child health services. But measures to expand funding to improve access are now being put in place as UHC is now being planned for 2015. Mutual social benefit, state funding, contributions by stakeholders as well as technical partners constitute the methods of financing that are envisaged.

Nigeria. Nothing points more to the seriousness with which Nigeria is currently pursuing its march towards UHC than the recent presidential summit it held on the matter on March 10, 2014, in its capital city of Abuja, to which reference was made in the earlier section of this paper. At that well attended meeting by experts from health-related fields, the country reaffirmed its resolve to find solutions to its daunting health challenges and promised to invest strategically to improve equitable access to health care at all levels. It committed itself to a 30% health insurance coverage by the end of 2015 and expects, within 5-10 years to have raised sufficient funds to enable it achieve UHC. Such funds, the country expects, would come from making health insurance mandatory for all Nigerians – a policy which would lead to the enhancement of budgetary allocations to the sector as well as harnessing contributions from all income earners in the formal and informal sectors of the nation’s economy. A special fund is to be raised to cover the poor and a standard benefit package of essential health services that would address priority health care needs of all Nigerians will be defined.

Furthermore, as one of the outcomes of the WEFA which the country recently hosted, the nation’s healthcare is set to notice a substantial improvement as was announced by the country’s Health Minister. This, the minister said, will come from a $20m Memorandum of Understanding (MOU) to improve the sector that has been signed between the Federal Government of Nigeria, the United States Agency for International Development (USAID) and General Electrical (GE) Healthcare.

What is clear from these few examples is that there is no universal way of funding health care which is probably the most pressing challenge in establishing UHC. Since 2005 when the WHO called on member states to work towards achieving UHC7, approaches have been different, despite a consensus on desired outcome which are: that the financial burden of health care is shared widely and evenly, that all those who fall ill have coverage in an incremental manner, that available resources are better utilized and that there is a progressive improvement of health outcomes.

At this point, some comment has to be made on the security situation in some West African countries, especially in parts of Nigeria, Mali and Cameroon where extremist forces are engaged in various acts of warfare. Such a disorderly and chaotic situation, if left unchecked, will bring to naught, the lofty plans for UHC as is being envisaged in the sub region.

DOES RADIOLOGY MATTER?

If the goal of UHC is to enable all persons to enjoy the highest attainable standard of health, then modern medicine, which essentially is predicated on evidence-based practice, must be part of it.

Empirical medical care, driven by experience as well as trial and error, gave way in the 19th. century to one based on identification of causative factors of disease or the establishment of concrete evidence of cellular malfunction as the bases for prevention, treatment, patient care, rehabilitation and prognosis. The microscope was discovered and the science of Microbiology developed, making it possible to recognize that microorganisms – minute forms of life – can cause disease. As the disciplines of Haematology and Physiological Chemistry and some others also became well established, derangement in cellular functions and body fluids, including blood and its components also became known as fundamental causes of disease and ill health. Additionally, technology made its welcome incursion into medical science and vastly improved and expanded the portfolio available for diagnosis, care and treatment of patients as well as the rapid acquisition and dissemination of knowledge – medical as well as others. Better accuracy of diagnosis and precision in patient management were thus introduced into medical care and became accepted as best practices as they are further fuelled by research, involving clinical investigations, laboratory work and other forms of study. Furthermore, the frontiers of medical practice were stretched, based, among others, on enhanced dexterity brought about by accuracy and precision. Thus, newer aspects of modern medicine, of which there are many, came into being.

Radiology, the medical specialty that employs various forms of energies for imaging and visualising the interior of the human body and also treatment as in Radiotherapy, made its debut in 1895 with the discovery of X-rays by Wilhelm Roentgen, a German Professor of Physics, while working with a cathode ray tube. From then on, the discipline has expanded and now uses a wide array of imaging technologies, including ultrasonography, computed tomography (CT), magnetic resonance (MRI), radiography, positron emission tomography (PET) and others, to access the human body for the purposes of diagnosis, treatment and prevention of disease. It is now in the forefront of tools and procedures used in providing evidence on which the practice of modern medicine is based. Little wonder your association has described radiology as the “eye of modern medicine” in the theme of this year’s conference. Even at the risk of preaching to the converted, let us, very briefly, examine a few examples of the contribution of radiology to modern medicine that largely support your assertion.

Radiography is an imaging procedure in which electromagnetic radiation – x-rays or gamma rays, other than visible light, is used to view the internal structures of the body. In passing through the body, some of the rays get absorbed by the different objects they encounter, dependent on density and composition. While the rays that pass through are captured behind the object by a detector, usually, a photographic film or a digital instrument, which then superimposes a 2 dimensional representation of all the object’s internal structures. Simple Radiography is frequently used in medical practice to diagnose many common diseases, like those in the chest, abdomen, bone, and foreign objects within the body. Of these, the chest x-ray is the most common medical imaging examination.

Computed Tomography (CT) is also based on the variable absorption of multiple x- rays by different tissues. But here, the process produces a different form of imagining known as cross-sectional imaging or slices of the object the rays have passed through. In contrast to conventional radiography, CT results in a 1000-fold increase in image resolution, and can pinpoint lesions < 2 mm in greatest dimension. Its popularity has therefore grown steadily since its introduction in 1972, especially as it is non-invasive and generates a 3D representation of the objects.

Ultrasonography, also called sonography is the process of imaging deep structures of the body by measuring and recording the reflection of pulsed or continuous high frequency sound waves.

In diagnostic ultrasonography, the ultrasonic waves are produced by electrically stimulating a crystal called a transducer. As the beam strikes an interface or boundary between tissues of varying density, some of the sound waves are reflected back to the transducer as echoes. The echoes are then converted into electrical impulses that are displayed on an oscilloscope, presenting a “picture” of the tissues under examination.

Ultrasonography is commonly utilized in examination of the heart (echocardiography) and in identifying size and structural changes in organs in the abdomino-pelvic cavity such as benign and malignant tumours. The technique is particularly useful in obstetric practice where ionizing radiation is to be avoided whenever possible. It evaluates fetal size, number and maturity as well as fetal and placental positions. It is for this reason that ultrasound machines are regarded as vital equipment in many Labour Wards and Antenatal Clinics.

Magnetic Resonance Imaging (MRI). An MRI is a scanning process that uses magnetism, radio waves, and a computer to produce images of body structures. The resolution of the images so produced is quite detailed and can detect tiny changes of structures within the body. The ability to detect several abnormalities, such as cancers at their early stages, other than is possible through many other imaging procedures, has put magnetic resonance imaging ahead in the battle against many diseases. MRI can also be used to look for a wide range of other conditions, including brain injuries, damage to organs in various cavities as well as injuries in the central nervous system. Because radiation is not used, it is generally believed that patients are not harmed by having an MRI examination.

What comes through from these few examples and many others is that radiology is now one of the leading components of modern medical science to which it contributes strong evidence for the diagnosis of some diseases as well as accurate treatment for others. However, it is true that a good number of these modern imaging procedures cannot be incorporated into the standard benefit package of essential health services as is envisaged for UHC on account of their complexity, cost and sophistication. Many require high voltage uninterrupted power supply which is a luxury many countries in West Africa are currently unable to afford. But a few of these appliances can still be deployed at the entry points for UHC, with good effect. Simple x-ray machines with less demand on electricity can be located in Primary Health Care centres where they can be used to quickly diagnose many common disorders like pneumonias, acute abdomens, fractures, presence of foreign bodies and others. Such prompt diagnosis will save lives, enhance management, improve efficiency, reduce cost and promote patient satisfaction. Furthermore, as a functional referral system is integral to the tenets of UHC, even the sophisticated and expensive radiological procedures should be made available at appropriate secondary and tertiary health institutions where experts should be provided to man them for the benefit of patients.

At this point, attention must be drawn to some abuses of radiological services in modern times especially in Nigeria where these services are used as first line contact with patients when formal histories and clinical examinations have hardly been carried out. X-rays of various kinds, ultrasonography and even MRI are being carried out by persons with little or no knowledge and skills and without proper control on patients who have not been referred with provisional diagnoses for such investigations. They are being done on patients with the flimsiest of complaints – headache, fever, abdominal pain, cough and others. It was therefore not surprising to see that a senior member of ARAWA, Dr. Abiodun Fatade of Crestview Radiology Ltd. Lagos, expressed grave concern about this quackery at an interview he granted “Meet The Guru” – a Dokilink interview series with medical doctors who have distinguished themselves9. I will like to join him in calling on ARAWA to seek for ways of instituting a better control of the radiological practices.

BEYOND 2015

Most of the issues that underpin the eight Millennium Development Goals (MDGs) can be said to be of greater concern to developing countries in Latin America, Asia and Africa. Signed up in September 2000, by world leaders, the MDGs commit them to combat poverty, hunger, deprivation, disease, illiteracy, environmental degradation, and discrimination against women and to use this as a platform to offer everyone a better quality of life. No doubt, over these 14 years, substantial progress has been made on all goals, including the health related ones (4, 5 and 6), if unequally, but there still remains some unfinished business. This notwithstanding, 2015, the target date set by the leaders for the realisation of the goals is round the corner and so, world leaders, civil society and global financial organisations are once again mulling over the next set of development goals to sustain gains by MDGs and uplift humanity to a higher level of growth and advancement . And on this, there is a growing agreement that such goals should include UHC2, 3, 8 which is being considered as the third transition in health (the provision of health care to all persons through financing health care and organising health care systems), following the demographic (hygiene and sanitation) and epidemiological (communicable and non-communicable diseases) transitions of the 18th and 20th centuries, respectively9. The argument is that health, as an important resource for daily living, is a significant way of guaranteeing a life of dignity for all10. Furthermore, health is an avenue for eradication of poverty and inequalities as well as fostering human and economic development and promotion of social cohesion. Thus, health is a sustainable development issue for which it serves both as an indicator and a driver.

Africa, the new frontier, regarded in 2013 as the world’s fastest-growing continent with a GDP growth of 5.6% a year, and one expected to rise by an average of over 6% a year between 2013 and 202311, the continent’s economy is currently on the bounce, especially those of its resource-rich countries. In the same vein, GDP in sub Saharan Africa, including West Africa, is projected to rise from 4.9% in 2013 to about 5.5% this year – an acceleration that reflects improved prospects in a large number of countries in the region.12

Nigeria, Africa’s most populous country (about 170 million) and the home base of ECOWAS, recalculated its nominal Gross Domestic Product (GDP) in early April, 2014, to include current trends and developments across all fields – entertainment, communication, agriculture, education and others, which were not previously captured in the former computational framework – and leapfrogged from $270 billion to $510 billion. The country thus becomes the biggest economy in Africa and 24th largest in the world, a flight from the 37th position and representing 89% increase. Understandably, there has been a flurry of commendation; the nation’s economy receiving a “BB-” Fitch Rating, also in early April 2014, with a stable outlook.

However, others are quick to point out that despite its rebased GDP, poverty with associated inequality and regional disparities is deeply-entrenched with a significant part of Nigeria’s population earning less than $2 a day and that even with the new GDP data, the per capita income in Nigeria only becomes $3 000.This is less than half of South Africa’s per capita income of $6 620. The recalculated GDP in other words does not change Nigeria’s overall status of a lower middle-income country even if its global per capita ranking has just jumped 15 positions…13.

Sadly, this discordant relationship between rising GDP growth and entrenched poverty is not peculiar to Nigeria as it obtains in several other African countries. On the other hand, the role of good health in preventing a drift into and in uplifting people out of poverty, has been sufficiently canvassed in this paper and so, members of ARAWA and others of the medical community in West Africa, should strongly lobby their respective governments for the bigger economic base that many of them have acquired in recent times, to be channeled to improvement in health services and health related facilities and services – portable water, clean environment, decent housing and education. And here, what is needed is the “highest attainable standard of health” for all, which incorporates modern medicine that is based on evidence supplied by radiology and other services. While the commitment to UHC by 2020 by African ministers of health at their recent meeting in Luanda, Angola, including those from West Africa, as a means of providing access to functional quality health services for all their citizens is a welcome development, talk is cheap and the yawning gap that commonly exists between pronouncement and implementation, especially by government functionaries, dictates that such robust lobbies are required if health is to be part of an inclusive and sustainable growth, envisaged beyond 2015.

CONCLUSION

Economic considerations – need to form a large regional trading block – rather than social matters – informed the formation of ECOWAS in 1975. By 1987, the Commission had matured sufficiently to be more inclusive; the organ which eventually became the West African Health Orgainsation (WAHO) was formed as a specialised agency of ECOWAS. The objective is to pursue “the attainment of the highest possible standard and protection of health of the peoples in the sub-region through the harmonisation of the policies of the Member States, pooling of resources, and cooperation with one another and with others for a collective and strategic combat against the health problems of the sub-region.”13

Aside from those whose principal orientation is the development of health manpower for the West African sub region, health related associations with sub continental mandates, are few; ARAWA must be among the very few functional ones. Thus, the association is a huge advantage which should serve as a podium for the propagation of health related matters across its concise and comprehensively delineated area of West Africa, seeing that matters of health are not bound by linguistic differences. So, even outside radiology, your association should take the lead to push for the common good in health matters; after all, you are all at one with all doctors who took the common Physicians’ Oath. Support investment in malaria eradication to defeat our age- long enemy – malaria; support efforts at containing the on-going spread of the ebola virus haemorrhagic disease in the sub region – Guinea, Liberia, Sierra Leone; support the planned formation of an African Centre for Disease Control and others.

As for your pet discipline, radiology, with its eye to see beyond the skin and so provide evidence that forms the basis of disease in the entire human body, its place in modern medicine is prime, supreme and assured. So much so that imaging, the bedrock of the science of radiology, has now been used to establish newer branches of modern medicine – Telemedicine, Interventional Procedures like Interventional Cardiology, Minimal Access Surgery like Laparoscopic Surgery, Robotic Surgery, Laser therapies, Assisted Reproduction and others. Indeed so widespread is imaging technique in modern medicine that some of the procedures are no longer being carried out solely by radiologists – obstetricians do ultrasonography, physicians, echocardiograms. Clearly, future medical specialists would require greater expertise in technology and computing.

The discipline must continue this impressive contribution to modern medicine, serving as its eye. But it must also make efforts at establishing itself at the other end of the health spectrum; nothing provides a better opportunity that a stern advocacy for UHC within an environment of modern medicine, which benefits the poor more than it does the rich.

Port Harcourt, the capital of Rivers State, the Treasure base of Nigeria, is proud to host this year’s ARAWA conference. In doing so, the city wishes to draw attention to its status as the 2014 UNESCO WORLD BOOK CAPITAL whose overall mission is to promote the free exchange of ideas and knowledge through the BOOK, which opens possibilities. If therefore your deliberations at this 52nd Annual conference is envisaged to lead to knowledge propagation from which some books of transnational significance will emerge, then you would have contributed, in no small measure, to the success of PORT HARCOURT, the 2014 UNESCO WORLD BOOK CAPITAL.

I thank you for your time and attention.

ACKNOWLEDGEMENT

I wish to acknowledge Raphael Oruamabo, retired Professor of Paediatrics and Child Health for useful advice on the script and the kind assistance of Professor Iheanacho Akakuru of the Department of Foreign Languages and Literature of the University of Port Harcourt, Nigeria for the abridged French translation of the presentation.

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9 Info@dokilink.com. http://dokilink.com/dr-abiodun-fatade#sthash. VWkabt7x.dpuf. Posted 18 May, 2014

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13. thenationonlineng.net/new/nigerias-big-economy-gigantic-challenges/. Culled from the Sunday Independent of South Africa.

14. Article III, Paragraph I 1987 Protocol of WAHO