Auscultate by International Federation of Medical Students' Associations

health crisis in AFRICA DECEMBER 2012

THE OFFICIAL IFMSA PUBLICATION FOR THE AFRICAN REGION

IFMSA

The mission of IFMSA

was founded in May 1951 and is run by medical students, for medical students, on a non-profit basis. IFMSA is officially recognised as a nongovernmental organisation within the United Nationsâ&#x20AC;&#x2122;system and has official relations with the World Health Organisation. It is the international forum for medical students,and one of the largest student organisations in the world.

is to offer future physicians a comprehensive introduction to global health issues. Through our programs and opportunities, we develop culturally sensitive students of medicine, intent on influencing the

transnational

inequalities that shape the health of our planet.

imprint editor in chief Tade Soji content editors Animasahun Victor, Nigeria Biniam Melese, Ethiopia layout/design Akinwunmi Temidayo, Nigeria proof-readers Ajayi Tunde, Nigeria Helena Chapman, Dominican Republic

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auscultate THE OFFICIAL IFMSA PUBLICATION FOR THE AFRICAN REGION

Dear Reader, This edition of Auscultate beams its light on the health crises in Africa.

Tade SOJI

EDITOR-IN-CHIEF

Africa is faced with its peculiar health challenges and so requires pragmatic solutions. Our authors have painstakingly written on some of these challenges and crises, proffering practical solutions . This edition also featured the culture of West Africa. As you read through this noble magazine conscientiously to digest its contents, many facts that are often overlooked would be clearer and new information would be exposed. This edition is hoped to launch this region into new heights and spur creative writing amongst its members. I thank the regional co-ordinator and the entire happen.

Regards Tade Soji Editor-in-Chief (da.pub.africa@gmail.com)

From the RC

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Dear IFMSA Africa,

This year we are honoured to mark the 8th African Regional Meeting, in Arusha, Tanzania. At the foot of the highest peak in Africa we will be discussing the challenges we face as a region here in Africa in delivering health. What role do we as future doctors have in solving the health workforce crisis here in Africa? Today there are more Malawian Doctors in the English city of Manchester than there are in the entire country of Malawi. Is it acceptable that our region which has 24% of the world's disease burden has only 3% of it health workforce? No! We will seek to scout out what it is we must do to tackle this inequality Waruguru Wanjau individually? What sacrifices will we as individuals and as future Regional coordinator 2012-2013 Africa physicians have to make? Why is that many of us seek to work overseas? And what we will be demanding that governments do to take action? What is it that is needed to be done to strengthen our health infrastructure? Why is it that mothers, children, the old and the young and the poorest in society continue to die due to the lack of basic infrastructure? What can we do to draw attention to this and provide solution? What innovative, tailor-made solutions can we as a region come up with? We will seek to answer all of these questions as well as how we, as medical students should be engaging with health policy on a national and regional level. We will aim to put forward our own vision and commitments for health in Africa as a medical student declaration written and signed. Karibu Tanzania Waruguru Wanjau Regional coordinator 2012-2013

TABLE. of. 6 CONTENTS 7

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TABLE.of. CONTENTS

THE OFFICIAL IFMSA PUBLICATION FOR THE AFRICAN REGION

REGIONALteam

health crisis in AFRICA; HUMAN RESOURCES? YES,

BUT HEALTH FACILITIES KNOCKS HARDLY

photostory .SCOPH 12

Involvement of Burundian youth in the fight against diabetes: ROLE OF THE MEDICAL STUDENT'S ASSOCIATION OF BURUNDI (ABEM)

No Mothers… No Country

Dynamic PEACE

The African Culture -

WEST AFRICAN REGI N

Girl Marriage 20 Early & Vesicovaginal Fistula

REGIONAL team FLORENCE MWITWA (5th year) Catholic University of Health & Allied Sciences (CUHAS-Bugando), Mwanza, Tanzania. -President of the Organizing Committee, Africa Regional Meeting 2012 - Co-Development Assistant for African National Member Organizations (NMOs) 2012/2013 to IFMSA

ANTOINE HABIYAMBERE SCORE-RA, IFMSA-Africa (5th Year) University of Rwanda, Rwanda Hobbies: Listening to slow music, promenade, visiting new places, meeting friends, watching documentary, movies and Basketball.

ERICA TWUM-BARIMAH (5th year) Kwame Nkrumah University of Science & Technology. NMO, Ghana & LEO for the LC Kumasi. SCOPE-RA, IFMSA-Africa ra.scope.africa@gmail.com erykah909@yahoo.com Skype: dr_kukus Twitter: @ericatwumb Facebook: Erica Twum-Barimah Hobbies: Reading, dancing and swimming

TADE ADESOJI Olabisi Onabanjo University, Ogun State, Nigeria Development Asst Publications ‘12/’13 Editor-in-Chief, AUSCULTATE ‘12/’13 da.pub.africa@gmail.com, sojitade@gmail.com Twitter: @eltadoo Facebook: soji tade Phone: +2348063226417 Hobbies: Listening to music, visiting new places & driving.

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WARUGURU WANJAU (Final year) University of Nairobi, Kenya Regional Co-odinator Africa, IFMSA rcafrica@ifmsa.org

ECHE UGOCHUKWU C. Abia State University Teaching Hospital, Aba, Nigeria. SCORA- RA, IFMSA-Africa ra.scora.africa@gmail.com (official) jurntexo@yahoo.com(personal) Twitter: @echeugo Phone Number : +2348034296331 Hobbies : Surfing the net, hanging out with positive-minded people, driving.

HALE TEKA TSEGHAY Ayder University Hospital, Mekelle, Ethiopia SCOME-RA, IFMSA-Africa haleteka@gmail.com Tweeter: tweeter.com/halelujahdotcom Phone: +251910505649 Hobbies: Reading, walking and watching movies

YELSHADAY TEKLU (Intern) Addis Ababa University, Ethiopia SCOPH-RA, IFMSA-Africa yelshaday@gmail.com Facebook: www.facebook.com/yelshaday Twitter: www.twitter.com/yelshman Skype: yelshaday.teklu Hobbies: Listening to Music, taking a walk during sunset, Connecting with people & taking interest in what people do. MOHAMED KAMAL EL-BASHIR University of Khartoum, Sudan VPE- Regional Assistant, IFMSA-Africa 2012-2013 medsin_vpe@yahoo.com, dr.m.kamal@hotmail.com Facebook: http://facebook.com/mohd476

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BUT HEALTH FACILITIES KNOCKS HARDLY MOSSES SIMON TAMSA-CATHOLIC UNIVERSITY OF HEALTH AND ALLIED SCIENCE-CUHAS BUGANDO, TANZANIA

(WHO) estimates that over 1.7 billion people (nearly one-third of the world's population) have inadequate or no access to these essential medicines. Moreover, another study recently found that 10 million children a year die from preventable This show one of the district hospitals in Mwanza, diseases and conditions, with Tanzania having beds with no even matrix. what about dispensaries or health centers! almost all these deaths occurring 3 in poor nations. Another study While it may be 'in vogue' to found that prompt diagnosis and attack the pharmaceutical treatment of health problems in industry, TRIPS and the WTO Africa and Southeast Asia alone more generally,such attacks are could save approximately 4 usually naive, narrow-minded million lives each year. In and apart from adding little addition, resistance to existing substance to the debate, they treatments due to drug abuse divert precious time and plays a significant role in resources away from efforts that increasing the severity of the really count toward alleviating public health crises in many the suffering caused by the nations.4 The consequences of overwhelming health crisis. this vicious cycle between poverty and illness are clear.5 This article describes health crisis in Africa with emphasis on the Health-related issues of precipitating factors. These developing countries, and more factors are divided into three particularly the issue of categories which are accessibility to essential accessibility, availability and medicines, have garnered much affordability of health facilities. worldwide attention in recent It also offers some suggestive years. 6 Unfortunately, public debate on the issue is most often Hundreds of thousands more limited to blaming the people die each year from other, pharmaceutical industry and lesser known, diseases which patent regulations under the predominantly affect developing World Trade Organization (WTO) countries.2 and its Agreement on TradeIndications show that while most Related Aspects of Intellectual illnesses, especially infectious Property Rights (TRIPS), 7 for the diseases, are preventable or lack of accessibility and These are poor, unsterile strings waiting to tie the treatable with existing medicines, affordability of much needed umbilical cord of a new born baby since there is no umbilical cord clamp special for that case. the World Health Organization drugs in developing countries. INTRODUCTION About 85% of Africans opined that poor health facility is a strong indicator for health crisis in Africa. The global health crisis has many parts of Africa as its main domain: Over 14 million people are killed by infectious diseases each year (90% of which are in the developing world); over 40 million people globally are infected with HIV/AIDS (90% of which are in the developing world) and this disease kills over three million people annually; over 500 million people are infected with malaria each year and the disease kills upwards of two million people annually; over eight million people develop active tuberculosis (TB) each year and the disease kills over two million people annually (95% of those afflicted and 99% of deaths resulting from TB are found in the developing world).1

measures, which when implemented well, can overhaul the health sector in these developing countries. ACCESSIBILITY AND AVAILABILITY These constitute a large chunk of the problems faced by many people in Africa as far as health services are concerned. Statistics show that the large number of deaths (about 75% of deaths) in both children and adults is due to lack of appropriate facilities for their treatment. A typical example of appalling cases of shortage of health 8 physical infrastructures can be seen in Tanzania. A single dispensary is expected to cater for more than 10,000 population, a single health centre is expected to cater for more than 50,000 population and other few

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for a Tanzanian man to see their THE OFFICIAL IFMSA PUBLICATION FOR THE AFRICAN REGION th 40 birthday. Furthermore, there is serious shortage of pharmaceutical shops especially in rural areas. Large populations of rural African societies fail to get the prescribed drugs and eventually get conquered by their illness till they 9 succumb to death. For example; statistics show that in South Africa, a great number of people Dying is an easy task once you lack an appropriate help. Mrs. Manyungi, alive at hospital in rural areas suffering from in acute condition as seen, only a wheel chair took tuberculosis and other infectious her while the nurse says â&#x20AC;&#x153;no drip, no Oxygen ventilator, no doctor just a bed to restâ&#x20AC;? diseases die as result of failure to access the required dose. In one the opportunity of enjoying Tanzania, the high death rate of quality treatment.1 children from malaria, The dearth of adequate supply of malnutrition and diarrhea is due some vaccines has been to lack of required treatment at implicated in many childhood the right time. The World Health deaths. For example, there is no Organisation (WHO) data show pneumococcal vaccine in Africa that more than 10 million and the health crisis resulting children die each year due to from this is alarming. It is even preventable diseases and related more disheartening that even the 10 condition but in South Africa, available vaccines do not extend to reach every need in remote areas.

health crisis in AFRICA; HUMAN RESOURCES? YES,

AFFORDABILTY Health care, even if available in developing countries is BUT HEALTH FACILITIES KNOCKS HARDLY unaffordable. The fact that regional and referral hospitals more than 70,000 children die developing countries are not able which cater for a large population due to preventable diseases each to afford existing treatment more than their capacities were year. options is typified by their expected to provide adequate The canker of poverty ravaging compliance to the recent 11 services . This led to an increase may African countries and the advances of anti-retroviral (ARV) in the mortality rates in these relative high price of medical drugs in the treatment of areas. In Tanzania, it was equipment have resulted in the HIV/AIDS. While there is still no observed that 1 child in 9 children shortage of basic medical cure for the disease, it has been th do not live to see their 5 birthday. equipment. Hence, health effectively controlled in the Also, there is probability of 44% workers are unable to provide developed world, largely due to optimal care for the patients and the availability of modern ARV Poor, unventilated, tired building called dispensary this has contributed immensely to 12 in Misungwi district, Tanzania supposed to provide drugs. Studies have shown that good health services to more than 10,000 the increasing mortality rates. For the mortality rate in the United as ministry of health guide. example many health centers States has declined by over 75% have a huge shortage of gloves, over three years through the use oxygen ventilators, surgical 13 of ARV drug cocktails. However, blades, patients' beds, X-ray patients in developing countries machines, surgical masks, can neither afford the wide range microscopes, culture media, of drugs available on the rapid test equipment and so on, developed country market, nor which when available can afford do they have the facilities or the

means to effectively administer the few drugs that they have access to. For these reasons, the epidemic remains uncontrolled in the developing world and subSaharan Africa alone must contend with over 25 million people infected with HIV/AIDS (which account for more than 70% of all HIV/AIDS cases globally). Other drugs for noncommunicable diseases such as heart diseases, cancers and diabetes are also least affordable although these diseases have a steep slope on death now days. The intervention of private health sectors to alleviate the health crisis in Africa has been sabotaged by the fact that majority cannot afford their services. For example in Tanzania more than 85% of populations are not capable to get services in private health service providers.

seen in the health sector if African countries establish pharmaceutical industries and they provide enabling environment for these industries to thrive. This would reduce the cost of importation of drugs and ultimately reduce the prices of these drugs in the local consumer markets. African countries have to invest more in medical research, diagnosis and vaccine development. This will reduce the burden of deaths through vaccine-preventable diseases in developing countries. For example pneumonia in children which is still killing African children because there has not been use of the pneumococcal vaccine. The government, private sectors, donors, pharmaceutical industries and all stakeholders in every developing nation should

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4 . http://www.who.int/whr/2002/e n/whr02_en.pdf. 5. Ruth Mayne, The Global Campaign on Patents and Access to Medicines: An Oxfam Perspective, in Global Intellectual Property Rights: Knowledge, Access and Development 244-58 (Peter Drahos & Ruth Mayne eds., 2002). 6. WHO, The World Medicines Situation 61-74 (1999) 7. Final Act Embodying the Results of the Uruguay Round of Multilateral Trade Negotiations, Apr. 15, 1994, Legal Instruments-Results of the Uruguay Round vol. 1 (1994), 33 I.L.M. 1125 (1994) [hereinafter Uruguay Round] (establishing the WTO in the last round of GATT and also creating treaties covering various trade topics); Agreement on TradeRelated Aspects of Intellectual Property Rights, Apr. 15 1994. 8. The case for Tanzanian healthcare and the Touch Foundation 2010 9. Darren Taylor, Inside South Africa's Rural Healthcare Crisis, SUGGESTED SOLUTIONS work out a health policy that April 30, 2012 Every government can lower would provide accessible and 1 0 . w w w . h e a l t h the cost of pharmaceutical drugs affordable health services to the e.org.za/news/article.php?uid..., and equipment by lowering majority. Public health crisis in South Africa tariffs, levies, duties and other is more just TB and HIV, taxes placed on these items. This REFERENCES: 16.10.2007 would reduce the prices of these 1. Medicines sans Frontieres 11. The case for Tanzanian drugs and make it more [Doctors without Borders] (MSF), healthcare and the Touch affordable to its population. Millions Have a Drug Problem: Foundation Improving the distribution of They Can't Get Any 6-7 (2004), 12. International Intellectual health products and services, and a v a i l a b l e a t Property Institute (IIPI), Patent maintaining the quality of the http://www.accessmedProtection and Access to HIV/AIDS pharmaceutical supply through msf.org/documents Pharmaceuticals in Sub-Saharan reliable testing facilities are key 2. See MSF 2004; supra note 1, at Africa 52 (2000), available at issues which governments must 7. See generally Philip Stevens, http://www.wipo.int/aboutaddress in the fight to improve the Diseases of Poverty and the 10/90 ip/en/studies/pdf/iipi_hiv.pdf. lives of many in the developing Gap (2004). 13. Primo Braga & Carlos Correa, world. So, the government's 3. Robert E. Black et al., Where Intellectual Property Rights, the annual budget must provide and Why are 10 Million Children WTO and Developing Countries: enough money for health sector. Dying Every Year? 361 The Lancet The TRIPS Agreement and Policy Much improvement can be 2226 (2003) Options (2000).

health crisis in AFRICA; HUMAN RESOURCES? YES,

BUT HEALTH FACILITIES KNOCKS HARDLY

ANIMASAHUN VICTOR (5th year) Olabisi Onabanjo University, Ogun State, Nigeria. Following the global eradication of smallpox in 1980, the world became optimistic that polio In the African Region, could also become a disease of st transmission of indigenous polio the past. The 41 World Health Assembly adopted a resolution persists only in Nigeria, while Angola, Chad, and the for the worldwide eradication of It marked the Democratic Republic of the polio in 1988. Congo have been designated as launch of the Global Polio Eradication Initiative (GPEI), “re-established transmission by national countries”. Economic modelling spearheaded governments, World Health has found that the eradication of polio in the next five years would Organisation (WHO), Rotary International, the U.S. Centers for save at least US$ 40–50 billion, Disease Control and Prevention mostly in low-income countries.1 (CDC), UNICEF, and supported by key partners, including the Bill Classified as an enterovirus, polio and Melinda Gates Foundation. is a highly infectious agent that mainly affects children under five years of age. This infectious Overall, since the GPEI was pathogen has a faecal-oral mode launched, the number of cases of transmission, which replicates has fallen by over 99%. A few in the intestines and invades the years ago, the polio-endemic nervous system, causing total countries were called the PAIN countries, including Pakistan, paralysis in a matter of hours. Initial symptoms are fever, Afghanistan, India and Nigeria. fatigue, headache, vomiting, Now, in 2012, only three countries in the world remain neck stiffness and pain in the polio-endemic: Nigeria, Pakistan extremities. and Afghanistan. One in 200 infections leads to irreversible paralysis, usually of the lower extremities. Among those individuals paralysed, 5% to 10% die when the breathing muscles become immobilized.1 Although this disease has no cure, it is a vaccine preventable disease.

The eradication of polio in India reveals that the implemented public health strategies for polio eradication are feasible. However, failure to implement strategic approaches can lead to continual or endemic transmission of the virus. If polio

transmission in Nigeria, Pakistan and Afghanistan does not cease, the world may see up to 200 000 new cases every year, within the next ten years.1 According to the most recent WHO weekly report on polio, Nigeria accounts for 104 of the 193 cases so far recorded worldwide this year. 2 The general population is aware that polio is a large health burden in Nigeria and that the next challenge is its elimination. The literacy level of the beneficiary communities has affected their acceptance of the vaccination schemes. Some common beliefs by community members about the oral polio vaccine include reduced fertility of other complications to women's reproductive health and design of an extermination plan from the Western hemisphere. Another challenge is the coincidental insurgence of insecurity in areas of high prevalence of polio, which has prevented vaccination teams from reaching those marginalized communities. 3 Since polio reduces the health status and quality of life, individuals infected with the polio virus have limited employment options and often result to

working on the street as beggars. With the absence of proper rehabilitation institutions that encourage self-reliance, teach skills acquisition and offer effective physiotherapy, the nation is deprived of potential promising human resources. Hence, an individual's quality of life is distorted, and the nation's economic stance is hampered. The Nigerian government should do more toward polio eradication, especially seeing that India was successful in disease eradication after their financial investment and compliance to public health initiatives. To achieve polio eradication, the Nigerian government should follow the recommendations of the Report of the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (November 2012) which states that: 1. International Health Regulations Expert Review Committee should urgently issue a standing recommendation that will introduce pre-travel vaccination or vaccination checks in Afghanistan, Nigeria and Pakistan until national transmission is stopped. No country should allow a citizen from any endemic polio state to cross their border without a valid vaccination certificate. 2. Leaders in Afghanistan, Nigeria, Pakistan and Chad should discuss their country's plan and best practice elsewhere to write, with their partners, a list of no more than five priority goals that they will achieve, circulate these goals to all programme

staff, and maintain the focus and pace necessary to achieve them. 3. An analysis should be urgently commissioned to examine the relationship between the frequency and quality of vaccination campaigns, to guide programmatic decisions about the optimum interval between campaigns. 4. Every endemic country district-level task force (or equivalent) should be constituted to include a parent, representing parents of the district. 5. Every opportunity should be taken to 'pair' other health and neighborhood benefits with the polio vaccine.

6. The IMB should request a report on vaccine supply at each of its future meetings. 7. The Programme should accelerate planning to set out how the learning from polio eradication can be captured rigorously and comprehensively, overseen and funded with minimal distraction to current work. 8. An intensive 'Polio Watch' should be established in the countries at highest risk of a polio outbreak. The responsible WHO Regional Offices should issue an action plan for strengthening vaccination coverage and surveillance

in these areas. 9. A continual live audiovisual feed should be broadcasted online from the Nigerian Emergency Operations Centre, with a facility for the world's polio experts and the IMB to observe and provide input at any time. 10. REFERENCES 1. W o r l d H e a l t h Organization. (2012, November). Poliomyelitis. Fact sheet No 114. http://www.who.int/mediacent re/factsheets/fs114/en/

2. Sky

News. (2012, November 27). Gates to fight polio in Africa.

http://www.skynews.com.au/h

ealth/article.aspx?id=820672

3. Murdock,

H. (2012, November 12). Surge in Nigerian polio cases poses new African health crisis.

http://www.alaskadispatch.com /article/surge-nigerian-poliocases-poses-new-africanhealth-crisis

4. W o r l d

H e a l t h Organization. (2012). Eradicating polio in the African Region: 2011 a n n u a l r e p o r t .

http://www.afro.who.int/en/clu s t e r s - a programmes/ard/immunization - a n d - v a c c i n e s development/features/3619eradicating-polio-in-the-africanregion-2011-annual-report.html

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THE OFFICIAL IFMSA PUBLICATION FOR THE AFRICAN REGION

"CHALLENGES OF CARDIOVASCULAR DISEASES"

was the theme of the symposium and events held by the Standing commitee on Public health(SCOPH) NiMSA at Lagos State University Teaching Hospital (Lasuth) Ikeja, Lagos Nigeria. It was a mixed experience of learning and teaching the community about one of the world's leading cause morbidity and mortality. It was also a lot of fun as medical student from within the country and some of our international students made it memorable.

OYENDE OLAMIDE E. Nigeria.

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THE OFFICIAL IFMSA PUBLICATION FOR THE AFRICAN REGION

Involvement of Burundian youth in the fight against diabetes: ROLE OF THE MEDICAL STUDENT'S ASSOCIATION OF BURUNDI (ABEM) ADÉLARD KAKUNZE Burundi students (between 12 and 20 years old) from 10 high schools in Bujumbura, which revealed that In Burundi, a small country in East the level of knowledge on of these young Africa of 8,511,618 habitants, diabetes where 45.9% of the population is individuals was insufficient or less than fifteen years of age, the poor. burden of diabetes increases at an alarming pace. Although no One major factor related to the national study had been increasing trend in the national of conducted, diabetes is the 3rd and global prevalence diabetes is the lack of knowledge cause of hospitalization in the largest national hospital, behind of diabetes. malaria and HIV/AIDS. The NGO Handicap International While a few research studies with and ABEM developed the DEAR project, targeting schools in small sample sizes have shown the prevalence of diabetes to be Burundi, to raise awareness for 7-15%, the prevalence in the main city of Bujumbura is estimated at 2.87% (Source: National Program of the Fight against Diabetes/Ministry of Health and the Fight against HIV/AIDS). At the global level, statistics on diabetes predict that there will be a significant increase in the number of diabetics in the coming years! Who are these diabetics of tomorrow? In Burundi, since there is a belief that diabetes is a disease of the rich and elderly, the younger population does not pay attention to the diabetes awareness campaigns. In 2009, ABEM conducted a survey on 777

the adoption of a healthy lifestyle and fight against diabetes and noncommunicable diseases. Launched in 2009, the project created “diabetes clubs” to combat diabetes in 20 high schools of three Burundi provinces. Since the main objective of ABEM was to educate student members about these “diabetes clubs”, they formed a dynamic team of 45 ABEM peer educators to teach about diabetes. Over the past four years, with the help from the teachers (coaches) of these clubs, the peer educators trained and

educated the student members of these clubs about diabetes and its prevention by the adoption of a healthy lifestyle. To teach diabetes to a youth audience, we had to be innovative to raise awareness and motivate participation in the fight against diabetes. One first innovative activity included developing “budding genius games”, for student competitions of knowledge about diabetes. Inspired by the TV-5 game, “Questions for a Champion”, two students per school were grouped and asked various questions about diabetes. One example consisted of the following knowledge about risk factors for diabetes: Which item is not a risk factor for learning. diabetes? 1) tobacco, 2) stress, 3) family history of diabetes, 4) Another innovative activity meningitis. included the development of Since the game is based on practical sessions for healthy diet and physical activity towards the speed, the first school to raise their hand would respond to the prevention of diabetes. question. If the response was incorrect, another student had a Various women's community presented a chance to respond to the organizations selection of nutritious food plates question. Since many schools were eliminated for incorrect for students. responses, there were only two At the end of this DEAR project, schools left in the final competition. Game prices to the we are proud to have initiated a winning schools included a youth movement to combat diabetes, which we hope will television and hi-fi radio for the continue to grow and reverse the “diabetes club”. increasing trend in the In addition, artistic competitions prevalence of diabetes in the future years. on the prevention of diabetes were also organized as poems, songs, slams, sketches and drawings. These educational games and artistic competition in the three provinces increased student participation and enhanced

ABOUT THE MEDICAL STUDENT'S ASSOCIATION OF BURUNDI. The Medical Student's Association of Burundi (ABEM) was created in 2002 with an ideal to serve society and Burundian medical students by not only offering them the opportunity to use their knowledge to help this society, but also by providing a framework for professional exchange at the local and international level. Since 2008, ABEM is member of the International Federation of Medical Students' Associations (IFMSA) and has worked since 2009 with Handicap International on the DEAR project (Diabetes in the East Africa Region).

Involvement of Burundian youth in the fight against diabetes: ROLE OF THE MEDICAL STUDENT'S ASSOCIATION OF BURUNDI (ABEM)

The African Culture -

WEST AFRICAN REGI N TADE SOJI

D.A Publications, IFMSA AFRICA Africa', the West African Region. Africa is the world's second largest and second most populous continent.

The region is occupied by 16 countries: Benin, The talking drum. Burkina Faso, Cape Its culture is the richest worldwide Verde, Ivory Coast, The most common group that you with scientists, archaeologists Gambia, Ghana, Guinea, will find in West Africa are the and researchers still discovering Guinea-Bissau, Liberia, Mali, black Africans, they come mainly mind blowing solutions to Mauritania, Niger, Nigeria, from the Sub-Saharan region. problems of present day from the Senegal, Sierra Leone, Togo. They make up the bulk of the soil of Africa. With the exception of Mauritania, population and they are the ones all these countries are members who have been there the longest. Our focus is on the 'Bulge of of the Economic Community of West African States (ECOWAS) set up in May 1975.

West african traditional dance.

One of the features of West Africa is the huge number of languages that are spoken. Or maybe you won't as it is easy to assume that they are all the same. While the languages do have a lot of similarities they are very different languages

The African Culture -

WEST AFRICAN REGI N West African ethnic groups, regardless of their religion. The number of wives and children a man has is a major signifier of his wealth. Procreation is considered an obligation throughout West Africa, and societal cultures place a large importance on having children. Instead of relying on state governments to interpret divorce or child custody laws, many West

Geography The Sahara desert borders West Africa to the north; to the west and south is the Atlantic Ocean. This geography has helped ensure general similarities between the region's cultures that are not shared extensively with other regions. The major West African rivers are the Niger, the Senegal and the Volta.

Burkina-faso masquerade

CULTURE Bronze of IFE, Nigeria

These 16 countries have interwoven cultures as some tribes spread over the borders like Yoruba from spreading across the Nigerian border to Benin; there are also general similarities in dress, cuisine and music that are not shared extensively with groups outside the geographic region.

Marriage Marriage traditionally has been perceived in terms of its value as an alliance between two kinship groups. A girl may be considered marriageable at the time of puberty. Men are not allowed to marry unless they can provide support for a family. Polygamy is practiced by most

Africans turn to their tribal chiefs for guidance.

Cuisine A typical West African meal traditionally is cooked using a single pot and contains a lot of starch and fat but little meat. Cultures in West Africa use more seafood than the rest of the continent, and dishes usually contain generous amounts of chili peppers. The seasoning used on most West African dishes would be considered by the typical American to be extremely hot. The pilli pilli pepper is a hot red pepper used liberally in many dishes. Scotch Bonnets are another common pepper here. Ginger, cayenne and garlic are other typical seasonings. Rice is a staple food throughout

Sierria-Leone Diamonds the region, and so is the Serer people's sorghum couscous called "Chereh" particularly in Senegal and The Gambia. Jolof rice originally from the Kingdom of Jolof (now part of modern day Senegal which spread to the Wolofs of Gambia) and is enjoyed throughout West Africa. Akara (fried bean balls seasoned with spices served with sauce and bread) from Nigeria is a favorite breakfast for Gambians and Senegalese. Its origin is from Yorubaland in Nigeria.

Music The talking drum is an instrument unique to the West African region. Ghanian kente Mbalax, Highlife, Fuji and Afrobeat are all modern musical genres which listeners enjoy in this region. The Igbos aren't also complete without their red caps. Textiles are also either designed Dressing The "boubou" originated from the like "adire" from Egba people(Yoruba) of Nigeria or Senegalese, the "agabda" from hand woven like the "kente" Yorubas, "babariga" from Fulani. from the Ashanti people of Ghana.

The African Culture -

The pride of West Africa lies in its rich culture and a native would do anything to protect his or her dignity and self-respect. West Africans are warm, loving and receptive people and the unreserved demonstration of their culture has made them a force to reckon with among the comity of nations

WEST AFRICAN REGI N 18

No Mothers… No Country

JOSUÉ DEVARIÉ GONZÁLEZ (3rd-year) Iberoamerican University, Santo Domingo, Dominican Republic.

No country, province, region or continent exists without mothers who live there. If there were no mothers, then there would be no children. And if that were the case, then there would be no one to care for, protect or accompany them during their growth and development. No country would ever continue to prosper. For this reason, in any country, the importance is to achieve a low maternal mortality rate, as it is considered the leading indicator of a national health system, and therefore, the level of development. It is estimated that every two minutes, one woman dies somewhere in the world, mostly due to preventable causes related to pregnancy or childbirth complications. Of these deaths, the World Health Organization (WHO) states that by 2010, one-third of these mortality cases was concentrated in just two countries: India, with 20% of the world's total deaths (56,000 annual deaths), and Nigeria, with 14% of the world's total deaths (40,000 annual deaths).

LAURA LLABRE (2nd year) Iberoamerican University, Santo Domingo, Dominican Republic.

ranks among the nations with the highest maternal mortality rates. The maternal mortality ratio, which indicates the risk of death faced by women in each pregnancy, is a major problem in these countries, because high fertility means that women are at risk many times throughout their life. The lack of access to family planning, prenatal care during pregnancy, and health evaluations by a labor and postpartum care specialist are factors that can increase the mortality risk to women. Not only are these factors widely discussed, but they are also preventable.

It should be noted that, from 1990 to the present, several subSaharan countries have halved their maternal mortality rates. However, this is not enough, and it is not moving at the pace that it should. The figures remain alarming and inexcusable. Hard work is required to maintain the low maternal mortality rates. We must fight every day to reduce these existing inequalities and break the pattern that distributes money, power and resources between the few, while leaving As statistics show, this mortality many others with nothing. This burden has an uneven global causal agent (inequalities) is the distribution. Women in developing pathogen of this pandemic (high countries are at 15 times greater maternal mortality rates) which risk from dying during pregnancy must be tackled immediately. or childbirth complications, which Local, national and global corresponds to 99% of total global authorities, the public sector, the deaths. In sub-Saharan Africa, 500 private sector, and general society women die for every 100,000 live must unite towards a common births, occupying one of the top goal. Since most of the health

problems of a country can be attributed to socio-economic conditions of its habitants, this is why these mothers suffer. This has to stop! Like any other place in the world, Africa needs mothers, and it is our duty to protect them. We must strive tirelessly to “save them”,focusing on how we can reduce the social gap that persists and affects them. After all, one should not forget that if there are no mothers, there would be no country. BIBLOGRAPHY World Health Organization. 2012. World health statistics: A snapshot of global health.Retrieved November 16, 2012.http://www.who.int/gho/pu blications/world_health_statistics/ EN_WHS2012_Brochure.pdf World Health Organization. 2012. Maternal mortality. Retrieved November 17, 2012.http://www.who.int/mediac entre/factsheets/fs348/en/index.h tml The World Bank. 2012. Over 99 percent of maternal deaths occur in developing countries. Retrieved November 17, 2012 http://data.worldbank.org/news/ over-99-percent-of-maternaldeaths-occur-in-developingcountries

UBANYI TINA O. Bingham University Teaching Hospital, Jos, Nigeria ubanyitina@yahoo.com

TIZHE WAKWANJE Bingham University Teaching Hospital, Jos, Nigeria tizhewakwanje@yahoo.com A fistula is a pathologic communication between two epithelia surfaces or cavities. The most common form of fistula found in women is the vesicovaginal fistula (VVF), rectovaginal fistula (RVF) and uretovagina fistula (UVF). Of those aforementioned, the most common is the VVF, which is a communication between the bladder and the vagina. In a poorly managed obstetric delivery, a form of fistula found in women involved in early child marriage is the â&#x20AC;&#x153;obstetric fistulaâ&#x20AC;?. The 21st century was supposed to bring change, a revolution that bridged the gap between the past and the present. Due to historical neglect, many epidemiological statistics for the developing world are not readily available. However, although the Urologic Nursing Journal estimated that in developing countries, 30% of women over 45 years of age in the developed countries are affected by urinary incontinence, obstetric fistulas continue to remain prevalent in developing countries, especially subSaharan African- Kenya, Mali, Niger, Nigeria, Rwanda, Sierra

20-

Early Girl Marriage

& Vesicovaginal Fistula

Leone, South Africa, Chad, Malawi, Mozambique, Uganda and Zambia.

in northern Nigeria. She had two The World Health Organization uneventful obstetric deliveries at (WHO) estimates that 50,000home. However, at the obstetric 100,000 women develop delivery of her third pregnancy, obstetric fistulas each year and she had a 24-hour prolonged over two million women currently labor at home and rushed to the live with these fistulas across the hospital for a caesarian section of globe. In developed countries, her stillborn fetus. During her the frequency of these fistulas has post-partum recovery period, she been common in women under was leaking urine. However, the 30 years of age, with 50-80% in question remains: Why did she less than 20 years of age and the decide to give birth at home? Her youngest at 12 years of age. answer was that she believed in These statistics are influenced by God and that it was his will for her political, social and economic not to go to the hospital. factors that are centered on poverty, malnutrition, lack of Case study #2: A.D. is a 20-yeareducation, inadequate and old female, who was married at inefficient health care. 18 years of age to a teacher. She had two obstetric deliveries of Let's review two case studies prolonged labor, resulting in two where we can see how the triad of stillborn fetuses, where postpoverty, ignorance and disease, partum recovery of her second help to maintain this vicious cycle pregnancy resulted in in health disparities. observation of a VVF. Prior to the delivery of her second pregnancy, Case study #1: R.Y. is a 26-year- her husband was unable to old female, who was married at provide financial resources for 19 years of age to a cattle farmer antenatal care.

Early Girl Marriage & Vesicovaginal Fistula These two case studies describe some underlying factors and challenges during the pregnancy and care for the unborn child.

Factor #3: Retrospectively, Africa has faced many challenges as a developing continent, making giant strides to improve education and status of women. African women are becoming more aware of their rights as citizens and are receiving an

African woman. This woman will most likely have limited antenatal health visits, endure prolonged labor, and have limited access to the health center, increasing the risk for obstetric or post-partum complications (e.g. fistula) and receiving continued neglect from her husband and family members. With nowhere to turn to for financial help, this desperate woman may succumb to the pressures of being a prostitute, an increasing trend in Africa.

Factor #1: Africa continues to endure poverty and health disparities, where we see the need for health institutions in developing countries to combat the incidence of poor obstetric and post-partum health outcomes to the mother and fetus. Unless women are empowered with knowledge and skills, their status may continue to promote disparities in health Despite all that the African and society. In Africa, the woman has endured, she child marriage tradition fails still stands tall with pride This is A.A. 19year old Para 1 + 0, she has a 2month to identify the rights of the and hopes for the best to history of urine incontinenece due to a prolonged child, which may increase risk of obstructed labour. She has a deffect (hole) about happen. The sun never stops 4cm in her vagina wall and bladder. obstetric or post-partum shining on this beautiful African edu complications during her continent, especially as the cation. However, some schools pregnancies at an early age. In African woman becomes more and tertiary institutions are not addition, malnutrition may readily available to females. enlightened on her rights in continue to negatively impact There still remains the preference society and works toward making women and their pregnancy life beautiful for her and other for the male child to obtain an state, especially if their husbands women. Indeed, hope calls for education over the female child, consume the bulk of the meal, which will continue to create the African woman. leaving a small or undesirable gender disparities. BIBLOGRAPHY portion for the wife and children. Factor #2: Although many families produce or obtain agricultural products that are rich in basic nutritional requirements for the pregnant mother and child, there is limited knowledge of this nutritional importance. This situation may lead to malnutrition, which is a condition that complicates health status and management of other diseases. This identifies the picture of a young, ignorant mother, who herself as a child, lacks the knowledge to provide for her and her children.

路 Browning, A. Obstetric fistula in Ilorin, Nigeria. PLoS Med 2004;1 (1):e2.doi:10.1371 /journal.pmed.0010002 路 Cook RJ, Dichens BM, Syed S. The challenge to human rights. Int J Gynaecol Obstet 2004;87(1):72-77. 路 Creanga AA, Genadry RR. Obstetrics fistulas: A clinical review. Int J Gynaecol Obstet Although we have considered 2009;106(1):95. WedMD. Vagina fistula. two case studies and four 路 2012. Accessed October 22, underlying factors that serve as challenges in women's health, we 2012. Retrieved from: must reflect on the typical image http://women.webmd.com/tc/va of a rural, young, pregnant ginal-fistula-topic-overview. Factor #4: Health facilities are often linked to government policies that are established to provide health services to local communities. However, we must consider the availability of skilled medical personnel as well as health care access, including the existence of roads, transportation and distance to health center.

Dynamic PEACE ALAA IBRAHIM ABOALGASIM (2nd year) Ahfad University for Women, Khartoum, Sudan.

YOU CANNOT FIND PEACE BY AVOIDING LIFE We listen to the news, we read the news, we see the news in photographs, and it's almost too much in our mind, the news is not all important. There are dreams, and there are thoughts. There will be an end to this war; there will be both good and bad in that end. If the bad is greater than the good there will be another war. Sooner or later, there will be peace, and it is this that an old man must think about. It's unfortunate that the mind associates the word “peace” with “death, static or inactivity”; and the word “war” is often associated with “action.” War should in reality mean death while peace should mean life and healthy activities. Unless we can see the word “peace” as a dynamic sense, an active meaning and a progressive character, we had better find another word or phrase that truly denotes the normal peaceful activity of a nation that we are concerned

about when we pray for peace. If peace is merely the maintenance of the status quo, then, we cannot have peace, for the status quo has not been and cannot be maintained. Peace can also no longer be simply considered as the settlement that follows a war. It must be an active, organic and international life. Change, like growth, is a law of life. Political and economic as well as physical changes must be expected and provided for in the mechanism of peace. Revolution will come. There will be forces behind them even if not overt and blood-letting. We must do these things. We as medical students have a pivotal role to play to this peace a reality …….

“this is my resolve for the day:

- I shall not fear anyone on Earth. - I shall not bear ill will towards anyone. - I shall not submit to injustice from anyone. - I shall conquer untruth by truth. And in resisting untruth, I shall put up with all suffering. And say ……..

THERE IS NO 'WAY TO PEACE, PEACE IS THE ONLY WAY

Health Care Financing & Health Crisis In Nigeria - A CALL FOR ACTION NJOKU KINGSLEY KALU (Final Year) College Of Medicine, University Of Nigeria, Enugu, Nigeria.

INTRODUCTION The first wealth of a nation is its health. There is empirical evidence that the health of a nation significantly enhances its economic development and vice versa. The way a country finances its health care system is also a key determinant of the health of its citizenry. Selection of an adequate and efficient method of financing in addition to organizational delivery structure for health services is essential if a country is determined to achieve its national health objective of providing health for all. Health care in Nigeria is financed by tax revenue, out-of-pocket payments, donor funding, and health insurance (social and community). However, achieving successful health care financing system continues to be a challenge in Nigeria as infant, maternal and U5 mortality continues to be on the rise despite public display of governments' political commitment to ensure universal access to healthcare. A health care financing system involves the means in which funds are generated, allocated, and utilized for health care. It has three core functions of revenues collection, pooling of funds via different sources, and purchasing/payment services. Revenue collection must involve

considering the sources of the funds and the structures and means to collect the money. Some of the methods include out of pocket, copayment, voluntary and mandatory prepayment, indirect taxes on goods purchased and direct taxes. Pooling of funds involve collection of funds that can be used to finance healthcare. Funds are pooled through public insurance agencies, NGOs, central government and local government. With revenue collected and funds pooled, these funds are to be transferred to the healthcare providers-a kind of reimbursement for the services they provide. Fee for service, capitations, payment of salaries, budgeting are the various payment strategies.

OPTIONS FOR HEALTHCARE FINANCING There are various options for financing healthcare, most of which have become non-existent in countries of the world where universal access to healthcare has not been achieved-largely because of its lack of feasibility. The options include out of pocket payment, general tax revenue, health insurance, community financing, user fees, donor financing, exemptions and deferrals and subsidy. Irrespective of the option chosen, evaluation should be done on the basis of equity, efficiency,

impact on quality of care, and sustainability.

NIGERIA'S HEALTHCARE SYSTEMTHE CRISIS WITHIN The organization of health services in Nigeria is complex. It includes a wide range of providers in both the public and private sectors (private for profit providers, non-governmental organizations, community-based organizations, religious, and traditional care providers) .1 In the public sectors, Nigeria operates a decentralized health system run by the Federal Ministry of Health (FMOH), State Ministry of Health (SMOH), and Local Government Health Department (LGHD). The FMOH is the overall health policy formulating body. It coordinates and supervises the activities of the other levels. In addition, it provides tertiary care through teaching hospitals and federal medical centres. The SMOHs provide secondary care through the state hospitals and comprehensive health centres while LGHDs provide primary health care (PHC) services through the primary health centres. Although the local governments have the main responsibility of managing the PHC, all the three tiers of government and various agencies participate in the management of the PHC. This at times results in duplication, overlap, and confusion 2 of roles and responsibilities.

Health care in Nigeria is financed by a combination of tax revenue, outof-pocket payments, donor funding, and health insurance (social and community) 3 . Nigeria's health expenditure is relatively low, even when compared with other African countries. The total health expenditure (THE) as percentage of the gross domestic product (GDP) from 1998 to 2000 was less than 5%, falling behind THE/GDP ratio in other developing countries such as Kenya (5.3%), Zambia (6.2%), Tanzania (6.8%), Malawi (7.2%), and 4 South Africa (7.5%).

expenditure in Nigeria! User fee was introduced by the Nigerian government in 1998 under the Bamako Initiative which advocated for cost sharing and community participation to increase the sustainability and quality of health care.8 It was proposed that user fee will increase the resources available for health care and improve efficiency as well as equity to health care9, 10 . The available evidence on the impact of user fees is equivocalsoaring maternal mortality ratio, high infant and U5 death and general decrease both in the life expectancy and quality of life. In all ramifications, heath care in Nigeria has a sad story for posterity-unless efforts are made to address it.

Achieving a robust health care financing system continues to be an enigma in Nigeria. Limited institutional capacity, corruption, unstable economic and political context have been identified as factors why some mechanisms of financing health care have not worked effectively.5 The major problem which analysts have identified as being responsible for the failure in healthcare financing in Nigeria is the emphasis, HEALTHCARE tacitly though, on out of pocket UNIVERSAL COVERAGE TO ADDRESS HEALTH payment system. CRISIS IN NIGERIA - Call to Action

Social Health Insurance (SHI) is a system of financing health care through contributions to an insurance fund that operates within a tight framework of government regulations 12 . It is a form of mandatory insurance scheme (normally on a national scale). It provides a pool of funds to cover the cost of health care and it also has a social equity function which eliminates barriers to obtaining health care services at the time of need especially for the vulnerable groups.5 In SHI, every citizen is required to make contributions. Governments may contribute on behalf of the poorest and the unemployed; employers also usually contribute on behalf of their

Health Care Financing

& Health Crisis In Nigeria

- A CALL FOR ACTION

employees 6 . The Nigerian government established the National Health Insurance Scheme (NHIS) under Act 35 of 1999 with the Out of pocket involves payment for Certainly all hope is not lost in aim of improving access to health health care at the point of service. Nigeria's quest to ensure universal care and reducing the financial The charges levied for health care the burden of out-of-pocket payment for services are referred to as user fees. access to healthcare and address 11 health crisis in the country . If health care services13. [35] The NHIS The scope of user fees is quite a relatively less became fully operational in 2005. variable and can include any Rwanda, economically viable entity to combination of drug costs, medical Nigeria, can achieve universal The NHIS is organized into the material costs, entrance fees, and 6 healthcare, hope is glimmering! I following Social Health Insurance consultation fees . Out-of-pockets account for the highest proportion of advocate Health Insurance as a Programmes (SHIPs): Formal Sector; Urban Self-employed; Rural health expenditure in Nigeria. Out- means to achieve UHC and thus reduce health crisis in Nigeria. This is Community; Children Under-Five; of-pocket expenditure as a because out of pocket payments do Permanently Disabled Persons; proportion of THE averaged 64.59% 4 not allow for financial protection. It is Prison Inmates; Tertiary Institutions from 1998 to 2002. In 2003, it also impossible to achieve UHC and Voluntary Participants; and accounted for 74% of THE. It when enrolment is voluntary thus Armed Forces, Police and other decreased to 66% in 2004 and later 7 weakening voluntary prepayment. Uniformed Services 14. It is only the increased to 68% in 2005. This Indirect taxes have the concern of formal sector SHIP that is currently implies that households bear the relative progressibility. HEALTH operational15. Membership with the highest burden of health insurance is the key. formal sector SHIP is mandatory for

federal government employees and about 90% coverage has been achieved. The formal sector SHIP is presently extending to include all state and local government employees with Bauchi and Cross River States having achieved full coverage15. The act that set up the NHIS makes it optional, and this has been pointed out to be one of the reasons many Nigerians are not benefiting from it16. The NHIS is focused on making the scheme mandatory for every Nigerian and aims to get every Nigerian enlisted by December 2015. If the tempo seen in the organizational structure of the NHIS is sustained, Nigeria may be on her way to making a plausible headway by 2015!

CONCLUSIONS The Nigeria government uses different mechanisms for public health care financing. However, the health financing system is still characterized by low investment by the government, extensive out-ofpocket payments, limited insurance coverage, and low donor funding. Thus, achieving the objectives of good health outcome, equity, patients, and providers' satisfaction is very challenging. However, there may still be a way forward for Nigeria. This will require strengthening the health care financing system. The system should ensure that everyone who requires health care services is able to access them and not denied due to inability to pay. Citizens must be able to benefit from at least one of the financing mechanism in accessing health care services. To achieve universal coverage of health care services for the poor, Nigeria must move from out-of-pocket payments to other mechanisms of financing. The time has come for health care

financing to be seen by the Nigerian government as an investment, which certainly requires an effective management (political commitment) for it to be profitable. Other factors such as lack of awareness, corruption, and unstable economy that have undermined health care financing in Nigeria need to be addressed exigently17.

REFERENCES 1

World Health Organization. Country

Federal Ministry Of Health, Bamako Initiative Unit; 1994. 9

Griffin C. Welfare Gains from User Charges

for Government Health Services. Health Policy Plan 1992;7:177-80. 10

World Bank. Financing Health Care in

developing Countries: An Agenda for Reform. Washington DC; World Bank; 1987. 11 Njoku Kingsley K. Universal Access to Healthcare-Nigeria's Failures and Triumphs. Medical Student International "Universal Health Care." Medical Student International 26 (Aug. 2012): 7. Print. 12

Kutzin J. Health insurance for the formal

Cooperation Strategy: Federal Republic of

sector in Africa: "Yes, butâ&#x20AC;Ś". In: Beattie A,

Nigeria 2002-2007. Brazzaville: World Health

Doherty J, Gilson L, Lambo E, Shaw P, editors.

Organization Regional Office for

Sustainable health care financing in Southern

Africa.[Online]. Available from:

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Health Care Financing & Health Crisis In Nigeria

- A CALL FOR ACTION

http://www.who.int/countries/nga/about/ccs_

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strategy02_07.pdf [Accessed 2011 Apr 24]. 2 World Bank. Improving Primary Health Care Delivery in Nigeria Evidence from Four States. Working paper No 187. Washington DC: World Bank; 2010. 3 World Health Oranization. WHO Country Cooperation Strategy: Nigeria 2008-2013. Brazzaville: WHO Regional office for Africa; 2009. 4 Soyinbo A. National Health Accounts of Nigeria 1999-2002. Final report submitted to World Health Organization. Ibadan: University of Ibadan; 2005. 5 Adinma ED, Adinma BJ. Community based healthcare financing: An untapped option to a more effective healthcare funding in Nigeria. Niger Med J 2010;51:95-100. 6 Lagarde M, Palmer N. Evidence from Systematic Reviews to Inform Decision-Making Regarding Financing Mechanisms That Improve Access to Health Services for Poor People: A Policy Brief Prepared for the International Dialogue on Evidence-Informed Action to Achieve Health Goals in Developing Countries (IDEAHealth) in Khon Kaen; Thailand. 13-16 December 2006. Geneva: Alliance for Health Policy and systems Research; 2006. 7 Soyibo A, Olaniyan O, Lawanson AO. National Health Accounts of Nigeria 20032005: Incorporating Sub-National Health Accounts of States. Main report submitted to Federal Ministry of Health. Ibadan: University of Ibadan; 2009.

Federal Ministry of Health. The Bamako

Initiative Programme in Nigeria. Abuja:

National Health Insurance scheme. [Online].

Available from: http://www.nhis.gov.ng/. [Accessed 2011 Jun 10]. 14

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Programs. [Online]. Available from: http://www.nhis.gov.ng/index.php?option=co m_contentandview=articleandid=53andItemi d=57. [Accessed 2011 Jun 10]. 15

Kannegiesser L. National Health Insurance

Scheme to boost generics market in Nigeria. [Online]. Available from: http://www.frost.com/prod/servlet/marketinsighttop.pag?Src=RSSanddocid=155485216. [Accessed 2011 Jun 11] 16

Ogbonnaya R. NHIS-Meeting Health

Challenges Amidst Obstacles. Thisday. 4 th January 2010. [Online]. Available from: http://allafrica.com/stories/201001250876.ht ml?page=2. [Accessed 2011 Jun 19]. 17

Olakunde BO. Public health care financing

in Nigeria: Which way forward?. Ann Nigerian Med [serial online] 2012 [cited 2012 Nov 15];6:4-10. Available from: http://www.anmjournal.com/text.asp?2012/6 /1/4/100199

Algeria (Le Souk) Kurdistan - Iraq (IFMSA-Kurdistan/Iraq)

Argentina (IFMSA-Argentina) Kuwait (KuMSA)

Armenia (AMSP) Kyrgyzstan (MSPA Kyrgyzstan) Australia (AMSA) Latvia (LaMSA Latvia) Austria (AMSA) Lebanon (L eMSIC) Azerbaijan (AzerMDS) Libya (LMSA) Bahrain (IFMSA-BH) Lithuania (LiMSA) Bangladesh (BMSS) Luxembourg (ALEM) Belgium (BeMSA) Malaysia (SMAMMS) Bolivia (IFMSA Bolivia) Mali (APS) Bosnia and Herzegovina (BoHeMSA) Malta (MMSA) Bosnia and Herzegovina - Rep. of Srpska (SaMSIC)Mexico (IFMSA-Mexico) Brazil (DENEM) Mongolia (MMLA) Brazil (IFMSA Brazil) Montenegro (MoMSIC Montenegro) Bulgaria (AMSB) Mozambique (IFMSA-Mozambique) Burkina Faso (AEM) Nepal (NMSS) Burundi (ABEM) New Zealand (NZMSA) Canada (CFMS) Nigeria (NiMSA) Canada-Quebec (IFMSA-Quebec) Norway (NMSA) Catalonia - Spain (AECS) Oman (SQU-MSG) Chile (IFMSA -Chile) Pakistan (IFMSA -Pakistan) China (IFMSA -China) Palestine (IFMSA-Palestine) Colombia (ASCEMCOL) Panama (IFMSA-Panama) -Paraguay) Costa Rica (ACEM) Paraguay (IFMSA Croatia (CroMSIC) Peru (APEMH) Czech Republic (IFMSA CZ) Peru (IFMSA Peru) Denmark (IMCC) Philippines (AMSA -Philippines) Ecuador (IFMSA-Ecuador) Poland (IFMSA -Poland) Egypt (EMSA) Portugal (PorMSIC) Egypt (IFMSA-Egypt) Romania (F ASMR) El Salvador (IFMSA El Salvador) Russian Federation (HCCM) Estonia (EstMSA) Rwanda (MEDSAR) Ethiopia (EMSA) Saudi Arabia (IFMSA-Saudi Arabia) -Serbia) Finland (FiMSIC) Serbia (IFMSA France (ANEMF) Slovakia (SloMSA) Georgia (GYMU) Slovenia (SloMSIC) Germany (BVMD) South Africa (SAMSA) Ghana (FGMSA) Spain (IFMSA -Spain) Greece (HelMSIC) Sudan (MedSIN- Sudan) Grenada (IFMSA-Grenada) Sweden (IFMSA -Sweden) Haiti (AHEM) Switzerland (SwiMSA) Hong Kong (AMSAHK) Taiwan (IFMSA -Taiwan) Hungary (HuMSIRC) Tanzania (T AMSAz) Iceland (IMSIC) Tatarstan-Russia (TaMSA-Tatarstan) India (MSAI) Thailand (IFMSA -Thailand) Indonesia (CIMSA-ISMKI) The former Yugoslav Republic of Macedonia (MMSA-Macedonia) Iran (IFMSA -Iran) The Netherlands (IFMSA -The Netherlands) Israel (FIMS) Tunisia (ASSOCIA-MED) Italy (SISM) Turkey (TurkMSIC) Jamaica (JAMSA) Uganda (FUMSA) Japan (IFMSA-Japan) United Arab Emirates (EMSS) Jordan (IFMSA-Jo) United Kingdom of Great Britain and Northern Ireland (Medsin-UK) Kenya (MSAKE) United States of America (AMSA -USA) Korea (KMSA) Venezuela (FEVESOCEM)