29 January 2013

Nigeria: A Troubled Bill

The National Health Bill seems headed for a fresh round of controversy over the contents of its 64 sections, after prolife and private medical practice groups raised objections to at least 11 sections.

The NHB 2012 has passed a first and second reading recently at the House of Representatives and Senate, but is yet to pass into legislation more than 10 years since it was proposed.

Dr Philip Njemanze, said passing the bill as it is was inimical to the overall development of the health sector.

He chairs the Association of General and Private Medical Practitioners of Nigeria (AGPMPN) in Imo, where he also heads the Catholic Medical Association of Nigeria and is international chairperson of Global Prolife Alliance (GPA).

"Our conclusion is that this Bill will destroy medical practice in Nigeria and cause deaths of millions on innocent Nigerians," Njemanze said in an email to news organizations this week. He suggested the present bill was "a thousand times more threatening" to the health system and national security than the failed 2008 version.

In a phone interview, Njemanze told Daily Trust: "If this bill is passed the way it is written now, we will have nothing less than 10 million Nigerian women dying as a result of this bill."

Body trouble

The claim comes from consideration of the sixth part of the NHB, which controls how human blood, blood products, tissue and gametes are used--in everything from removal and transplant of body parts to cloning for purpose of treatment or reproduction.

It also indicates a concern, according to the prolife groups like GPA, about foreign influence in favour of biotechnology conglomerates to obtain materials for embryonic stem cell research industry in Europe and America.

Njemanze called it the best attempt to use Nigerians as "guinea pigs" for the Western stem cell industry and as "body spare parts for the rich of the Western world."

Njemanze suggested nine sections--51 to 58--be deleted completely because "they do not have any relevance" to the country's health system. Second paragraph of Section 51, for instance, forbids import or export human zygotes or embryos without the prior written approval of the Minister on the recommendation of National Ethics Research Committee.

Said Njemanze: "What this means is that the minister can permit the export and import of Nigerians. Who is minister or president to permit the trafficking of Nigerians? How can it be that it is a law?"

Removing tissues for transplant is done by registered medical practitioner or dentist, according to section 55 of the bill, using criteria in facilities to be approved by the National Tertiary Health Commission.

Njemanze faulted the section for being vague. "The aim for the vagueness in Section 55 is to hand over the accreditation of these so-called transplantation facilities to a face-less so-called National Tertiary Hospital Commission which has no instrumentality to monitor and certify any facility, since to this day there are no functional Transplantation Centers of repute in Nigeria. The foreign organ invaders will use this shoddy Commission to claim legality to sell and buy organs of Nigerians," he noted.

He argues that section 52, which prohibits tissue removal in hospital without authorization or not done by an authorized medical practitioner, overly empowers doctors to remove and transplant organs.

Organ donations are already commonplace, "but there is no regulation covering them in this country," said Dr Kenneth Iregbu, who heads the Association of Pathologists of Nigeria. "And we are saying that is not good enough."

He told Daily Trust: "There are laid down guidelines governing organ donation. Surprisingly the people who are supposed to speak out if there is any problem in the proposal are the ones killing it, and those who know little or nothing about organ donation are the one making noise. That is why I feel very concerned."

Doctor who, what?

The inclusion of traditional and alternative healthcare providers as well as ward and village health committees in national health system in part 1 is grounds for concern.

Njemanze called their inclusion "inappropriate" because the individuals are not defined enough to warrant the consideration of non-professionals competent as decision makers in health.

Striking out ward and village health committees smacks of "misinformation and ignorance," according to Dr Osahon Enabulele, president of Nigerian Medical Association. "For you to drive a health system anywhere in the world, you have to commit yourself to community ownership," he said.

Problems in the health system come from lack of community ownership of projects, programmes or policies, and ward health committees held determine the needs of their communities, explained Dr Enabulele.

"It has always been a top-bottom approach. It is supposed to be a bottom-top approach. That is what the National Health Bill seeks to achieve--that before I sit a project in a rural community, the people in that community must first meet to determine their own needs and expectations and then build it into the package that is going to be engineered by the government.

"The bill is saying never again should we have a situation where somebody out of his own caprices gets into a community to sink boreholes, as if that is what the community wants."

Private healthcare providers are also included but the absence of Association of General and Private Medical Practitioners of Nigeria and private healthcare from referral system is another worry which association said "violates the principle of free choice for the patient except amended."

The association wants an extra section 12 inserted to establish a special National Private Health Care Development Fund and financed along the same lines as the National Primary Health Care Development Fund.

Campaign for more recognition of the private healthcare in referral system strikes resonance in some quarters. "A good chunk of Nigerians go to the private sector to receive their healthcare services, especially in places where there is no public health facility," argued Fadekemi Akinfaderin-Agarua, executive director of Abuja-based group, Education as a Vaccine. "In this we see a comprehensive package and not a service focused exclusively on the public sector."


Section 20 has also been faulted for not specifying mandating free emergency treatment in public and private facilities without providing a means to payment for the care or defining what qualifies as emergency.

Section 21 does not have a conscience protection clause for health workers who might refuse to perform particular procedures imposed by their bosses on the basis of their conscience, said Njemanze.

He added section 31 empowering a research committee to determine the extent of health research be deleted, insisting an ethics board should be concerned with ethical use of human and animal subjects. "It is not in public interest to have a committee tell the researchers what to research on," he argued.

Human resources

Sections empowering the minister to decide on health manpower and create new medical or health specialties or personnel have also come under criticism. So too have clauses that prescribe strategies to recruit and retain personnel anywhere domestically and from outside Nigeria.

The argument, according to Njemanze, is that the bill empowers the minister to replace any personnel at any tertiary health facility if a labour dispute is not resolved in 14 days, as required in section 46. "The Bill here offers indication that the agenda here is to fill the tertiary institutions with foreign doctors, nurses and pharmacists who will receive donor funding in USD (US dollars) for their remunerations in order to carry our procedures which Nigerians would hesitate to do," he said.

Power play

The bill does not show any mechanism of improving the health system in any shape or form. With this bill, the entire health system of Nigeria will be "taken over by foreigners," he said, are sponsoring laws that will make it easier for them to collect organs and embryos.

Njemanze cited the visit of British Prime Minister David Cameroon and UK businessmen days before the bill was to be signed previously and the offer of finance in support of the bill as evidence of foreign involvement.

"The reason for the foreign influence is this: the West is depending on getting 100 million eggs they need for perfecting cloning. You cannot take one egg from Britain, America or any western country, but you can take a hundred million eggs from 10 million Nigerian women who will die in three to four years' time because of the consequences of ovarian hyperstimulation."

"As I speak, they are distributing leaflets in higher institutions to get the girls to donate their eggs for a paltry sum of N25,000," he added, citing Federal University of Technology, Owerri, though the claim has not been independently confirmed.

Between the health ministry and lawmakers pushing the NHB, claims of foreign involvement in the bill gets little traction, if any. Representative Ndudi Elumelu, who chairs the health committee in the House could not be reached for comments.

Akinfaderin-Agarua thinks the bill is skewed toward the public sector and medical doctors in how tertiary hospitals should run, but she doesn't buy the foreign-influence angle. There might be funding restrictions, but "the government has the opportunity to say no" to foreign influence or pressure regarding its health. "Nigeria does have the resources to do what it needs to do and invest adequately in the health sector."

What the country needs is to ensure the young, vulnerable and marginalized sections of society are adequately captured in the bill, she explained. "I feel that a lot of the debate around the bill right now is just political and one particular interest group pushing their issues over another.

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