Dr Othman Kyari, an Associate Professor of Obstetrics and Gynaecology, is Chief Medical Director of the University of Maiduguri Teaching Hospital (UMTH). In this interview with Daily Trust's Regional Editor (North East), Abdullahi Bego, he speaks about the recent federal government intervention to modernize teaching hospitals in the country, including the UMTH through a programme called the FG-VAMED project, and the challenges that the initiative poses to the administration of tertiary health institutions in the country. Dr. Kyari tried to address the concern as to whether the federal government intervention would lead to a lower or higher medical cost for ordinary Nigerians. The CMD also spoke about the emerging partnership between the UMTH and Aminu Kano Teaching Hospital (AKTH), Kano in the area of kidney treatment, where he observes that the prospect for the beginning of kidney transplant at the UMTH using 'local resources and partnerships' is bright, among other is sues. Excerpts:

You have been Chief Medical Director (CMD) of the UMTH for nearly three years now and this is the first time you are granting a major interview to a newspaper. Tell us how daunting the challenges have been for you running the hospital so far.

Well, although there have been many challenges and hurdles, I must say so far so good. Let me say on the outset that first of all, there must be peace before there is progress. This hospital has enjoyed industrial harmony since I assumed its leadership. Our activities were not marred by strikes even in those days when there were nationwide strikes affecting all the other federal health institutions over shortfall in salaries or non-payment of arrears. For this we are grateful to all our staff and unions in the hospital. Second, you probably are aware that the UMTH is one of eight teaching hospitals earmarked for upgrading and rehabilitation under the federal government-VAMED Engineering Project, which is currently ongoing. Third, in the areas of patient care, teaching and research, we have recorded a tremendous increase in our patient log.

Some three or so years ago, if you may recall, there was a total shut down of all health institutions from the primary to tertiary levels in Borno State, except the UMTH and the Federal Neuropsychiatric Hospital in Maiduguri. At the time, we had had to respond to the growing need for our services from the community. We were able to absorb that large workload of patients that besieged our health facility, and if you happened to be around the hospital at the time, you would have noticed that our accident and emergency and outpatients departments were so full that we were forced to admit patients on benches and trolleys because there was nowhere we could turn them to go to. Since then, it became something of an eye-opener to many people in the community to be coming to the teaching hospital; all the suspicions about the hospital evaporating. From then on, we were constantly inundated and overwhelmed by both in-patients and outpatients who come from far and near.

The UMTH is a tertiary federal medical institution. It seems you have taken over the work of primary and secondary health centers, which probably may have been partly responsible for the poor services being provided at those levels

Well, it is true that a teaching hospital should ordinarily have nothing to do with a majority of cases that turn up to it, and this is something that the general public should know. In actual fact, we are supposed to see only those critical and difficult cases, and this statistically probably constitute only about 15 percent of the disease burden in our community. By and large a substantial majority (of the disease burden) should have been attended to at the primary and secondary health care levels. Those two levels of health care delivery belong to the local government and the state government respectively.

However, for some reasons, patients are probably u nable to get adequate attention in those two tiers of health service delivery, and so they turn to the teaching hospital. In a way, we are also burdened by this increasing number of patients who should have been at the primary and secondary health care centers; it takes away attention in focusing on the very critical patients who should be here on referral from other institutions, for whom also the very specialized care is available.

For instance, let me say that a normal delivery (of babies) shouldn't take place in teaching hospital. The antenatal care and delivery should be conducted at the primary health care level. Where the midwives and traditional birth attendants are not able to cope, the case is referred early enough to the secondary health care level. In most cases, 96 percent of cases should be taken care of at that level. Only maybe one or two percent should end up in teaching hospitals. But now if you go to our obstetric department, you realise that may be 60 of the cases were normal deliveries, and this hamstrings the specialists and therefore the few (patients) that would require specialist attention and time from nurses and doctors, end up being diverted by the normal patients.

Let's talk about the FG-VAMED intervention. You said it was designed to upgrade eight teaching hospitals in the country. Tell us, the constituents of this intervention and how the UMTH is benefiting from it.

Let me first of all thank the federal government and indeed Mr. President for this project, which by any standard is gigantic. It's the first time actually in the history of this country that so much has been invested in one fell swoop to resuscitate our tertiary healthcare centers. In the first phase, the FG-VAMED Project involved eight teaching hospitals - Ahmadu Bello University Teaching Hospital, Zaria, University College Hospital, Ibadan, University of Port Harcourt Teaching Hospital, University Teaching Hospital, Enugu, Lagos University Teaching Hospital, Ilorin University Teaching Hospital, Jos University Teaching Hospital and the UMTH. These are the eight teaching hospitals earmarked under the rehabilitation and re-modernisation programme.

The project itself is a state-of-the-art turnkey project. Before its commencement, there was a committee set up under Emeritus Professor Akinkugbe. The committee did the preliminary work by taking inventory of equipment available in all teaching hospitals and tried to standardize these equipment. By standardizing, it means you will find different equipment even within the same teaching hospital from, say, a hundred different manufacturers. When it comes to maintaining them, the hospital has to look to one hundred maintenance vendors to be able to look after these equipment.

However, assuming that these equipment are only from three or four manufacturers, it would be much easier to train our people under those three or four vendors as well as get the maintenance service easily fr om the two or three manufacturers, than when it has to come from about a hundred. After completing the assignment and submitting the document to the federal ministry of health and indeed to Mr. President, this phased rehabilitation of the teaching hospitals was begun. The project is worth one hundred million euros. It went through the usual due process. The Akinkugbe committee was also saddled with the responsibility of identifying the equipment needs of each teaching hospital and identifying the sources of procurement of these equipments and making recommendations to government. All teaching hospitals made their submissions based on their needs. At the UMTH here, we requested for inputs from all the clinical departments.

Since the fund is limited and we cannot get everything new we need, we asked the departments to re-prioritize those equipment that are essential after submitting their requests in the first place and they did that, and so we compiled our needs and took our requests to the Presidential Project Implementation Committee (PPIC). Although all the equipment to be provided to all the benefiting hospitals are from different manufacturers, they are all under the VAMED Engineering Company which was given the responsibility to source the equipment in the quantity and quality that is required and contracted out, and also to make the pre-installation environment conducive for the installation.

The beauty of it is that the project is a turnkey; it involves training of local specialists and staff, as well as a five-year maintenance agreement. The maintenance agreement is such that the VAMED technicians are actually on site for all those five years on a 24-hour call. In UMTH here, they have already built their own quarters within our premises where they would take residence for the next five years. Also, the PPIC wanted to have five-star teaching hospitals, where no patient would go out of the catchment area of each teaching hospital to seek for medical attention elsewhere. So, the modernisation programme in each beneficiary hospital was not restricted to one single department; it spread across all clinical areas and specialties so that the desired five-star status is attained. In this hospital, every department is touched. But the areas we have benefited most are the radiology department, laboratory department, the pharmacy department, and theatre/intensive care unit.

Our biomedical engineering school was also upgraded so that we can train middle and lower cadre technicians not only for our institution but also for the entire catchment area. In the radiology department specifically, we have almost had to change all the equipment in the department from the static x-ray machine to the acquisition of new state-of-the art equipment such as the Magnetic Resonance Machine (MRI) which for now is only available throughout the country at the National Hospital, Abuja, a fluoroscopy machine, a mammography machine, automat ic film developer, etc.

Indeed, we had almost total replacement in the radiology department. What we have now is compatible to what you will find in any hospital in the western world.

This sounds great indeed that the federal government spent one hundred million euros to modernize our hospitals with new machines, but will that make medical service cheaper for patients coming to the UMTH, for instance, or is it going to be only for those who can afford?

The installation and maintenance of the equipment cost a lot of money as you are aware. Yes, we are living in probably one of the poorest parts of the world, but these things have to look after themselves. We have also been directed by government that we must generate enough revenue for these equipment to ultimately maintain themselves. In doing so, each hospital would be judged by how best it has put the equipment to use, and how much it has generated etc. But we are also very mindful of the current socio-economic reality for the citizenry in our catchment area.

Therefore, even with these new equipment, we are going to be very mindful of how to make things easy for our patients. There may even be situations where we can provide services with these machines free of charge if a given patient is in dire need of the service, and we have conferment that they are unable to pay for the service.

The UMTH has a kidney center commissioned by President Obasanjo sometime in 2000.  We learnt that the VAMED intervention has also affected the kidney center. Given that lack of resources and equipment had torpedoed the hospital's quest to begin kidney transplant in the past, are we now to expect the start the start of transplant with the machines you got?

Before I talk about our aspiration to begin kidney transplant, let me go back a little to speak about the kidney center itself. It was established through an endowment in 1992 during the tenure of one of my predecessors, Professor Idriss Mohammed. The project to ok off with the commencement of the building and the procurement of some dialysis machines. Unfortunately, the endowment was not able to complete the project and equip it. Subsequently, through the defunct Petroleum (Special) Trust Fund (PTF), it was completed and equipped. The project was then commissioned by Mr. President in 2000. Since, we have been dialyzing patients. We have built a large crop of renal failure patients who are dependent on dialysis. You know the ultimate treatment for most of these patients is transplant. Every institution that runs this kind of dialysis service should, in its long term objective, be aiming for a transplant surgery.

The kidney center in this hospital is the only purpose-built kidney center in the country. It has got a laboratory of its own, it has got two operating theatres, it has two wards - male and female - it has 12 dialysis rooms, it has two water treatment plants which is essential for dialysis, it runs on its own power generatio n system; we have two standard generators not connected to the national grid; it has 200KVA UPS that keeps the center running in time of power interruption. We have been very successful in the dialysis area. Indeed, we have trained our people and even nurses from other parts of the country and the private sector in renal dialysis. Our next plan is the transplant. You have to remember that it's a very capital intensive venture.

But we have deficiencies in three areas; one is in manpower development. You need nephrologists, transplant surgeons, technicians and lab scientists who are able to do what we call tissue-typing. We also need drug analysts who would be able to assess drugs. All these are things that at the beginning we do not have. We did train some doctors and nurses in Germany but it was a very limited exposure. So, this is an area that we feel we need to team up (with others) to be able to address successfully. There are institutions in this country that have been a ble to undertake renal transplant successfully. But because this is a programme that requires strategic long term planning, all of them have faced some difficulties, and as I am talking today, none of them is undertaking transplant.

One of those institutions is University of Ife teaching hospital and the other one is Aminu Kano Teaching Hospital (AKTH). In the case of AKTH, they have been able to undertake transplant and we have been sending patients. I have personally participated in observing some of their transplant. However, they were able to do it through the goodwill of some of their hospital, which is a team that comes from the United Kingdom through a philanthropist in Kano, who arranged for them to come and with the assistance of doctors in the hospital they were able to undertake about 12 to 15 transplants, two of whom were my own patients from Maiduguri here. However, they discontinued because some of the investigations still have to be done outside the country, e ven for those patients who have had transplant successfully conducted on them. So, they took a second look on the programme. We are now in touch with them. They have gone ahead of us in the manpower area.

Of course, we have nephrologists in this hospital, we have surgeons who have interest in renal surgery, and we also have very competent lab scientists. If we team up with AKTH with the standard they have attained - and this is the way I feel we can move forward in this country because no single hospital can beat its chest to say it can do transplant alone - I am sure we can achieve our objective. In fact, a team of surgeons and specialists from the AKTH have visited us, inspected our facilities and interacted with our doctors. We are looking forward to sending our team to Kano so that they can gain this valuable experience. The second vital area - talking about our deficiencies - is the issue of infrastructure.

Although the kidney center was completed, there are some vital aspects necessary for kidney transplant which were not. One of these is the theatre. Although we have two operating theatres, one for the donor and another for the patient, it's just the operating theatre rooms but they were not equipped. Fortunately, through the VAMED project, the theatres have now been fully equipped with operating tables, operating lamps, anesthetic machines and all the machines that are needed in an operating theatre. The other vital area is the area of laboratory support. The transplant patients would be dependent on some drugs for the transplant to be successful. Therefore, we need support in drug (unclear) so that we know exactly what amount of drug is in the patient blood level and how to adjust and control it. We did not have this but through the VAMED project, we have been able to acquire drug analyzer, which we have established in the pharmacy department. So, with these, our focus now is how to team up with our sister teaching hospital in Kano and possibly even Ife to be able to develop our indigenous manpower. By the time that we open our doors and say we have commenced kidney transplant, it will be a programme that will be there forever rather than as a stop gap measure.

So, are we going to see transplant services being offered by the UMTH anytime soon?

That is the dream of my predecessors and it remains my dream too. We have come a long way; we are now talking of transplant. Four years ago, even dialysis was a big issue here we do not want a half-hearted approach to starting transplant. We want a comprehensive solution so that by the time that the project starts there is no going back. And I believe that the future of renal transplant in the country is going to be very bright.

There are concerns that patients in hospitals sometimes get exposed to unsafe or sub-standard drugs even with all the efforts that the National Agency for Food and Drug Administration and Control (NAFDAC) is making to rid the country of fake and sub-standard drugs. As a teaching hospital, this must be an area that should occupy your attention, and not only for the safety of your patients. Can you tell us what mechanisms are there in place to ensure that drugs administered on patients in this hospital are very safe?

Our need to have a quality control laboratory has been on the drawing board for a long time. If you go to the pharmacy department, you will see a quality control lab area which was built some 12 or 14 years back. Even at that time, the need for quality control was realized, even though we have not been able to procure the necessary equipment to run a quality control laboratory. The VAMED project once again brought a lifeline, and this hospital was able to get all the equipment needed to run a quality control lab. The quality control lab has many functions. For instance, the kidney center cannot be run without drugs. There are some drugs that you cannot give to a patient without monitoring the patient closely. When I say monitoring, I mean you have to monitor the level of drugs in the patient's blood. Before you give drug to the patient, the doctor may also need to know what level of that drug needs to be given to that particular patient. You can only do this when you have the equipment that can precisely tell you what level of drug is in the patient's system. Also, the quality control laboratory helps to assess poison and chemicals. Equally important, as a teaching hospital, we purchase drugs.

NAFDAC is the organization that identifies whether a drug is safe and even if it is safe, whether the active ingredients are in the right quantity and composition in the drug. These are things that we are also able to do for the drugs we buy through our quality control laboratory. We hope that in the coming period, we shall be able to produce our basic syrups and elixirs and limited tablets using our compounding equipment and our quality control lab, although at the end of the day we still need NAFDAC to overlook these things.

In our drawing board, we also have a plan to establish an intravenous transfusion plant, just like we have set up an oxygen plant using a public-private sector partnership. Actually, no hospital can do without the intravenous fluids, but this is one commodity that we have difficulty in obtaining.

The problem of HIV/AIDS is said to be on the rise in Borno State and other catchment areas of the UMTH. We know that the UMTH is one of the centers designated by the federal government for the control of this dreaded disease through the supply of free anti-retroviral drugs. What is your assessment of the problem and the efforts so far made in tackling it?

The immunology department of the UMTH has been treating HIV patients for a long time. We are in collaboration with a number of international agencies. For instance, the three of them that have given as a lot of support and with whom we have contractual agreement are the PEFPAR - i.e. the (US) Presidential Emergency Plan for Aids Relief in Africa, the Aids Prevention Initiative in Nigeria (APIN) and Global Fund for AIDS. Very recently too, as you pointed out, Mr. President has decided that all the tertiary health institutions where this treatment is carried should provide free treatment to AIDS patients. The government has made good its promise in the supply of anti-retroviral drugs. Now, all patients that need treatment are always being attended to free of charge.