‘With Teaching Hospitals, 13,000 Fistulas Can Be Repaired Yearly’

Nigeria currently has about 200,000 backlogs of women suffering from fistula, with 12,000 new cases recorded yearly. The Country Director, Fistula Care Plus, Chief Efem Iyeme, in this interview with Martins Ifijeh, he said if all teaching hospitals and federal medical centres join in free surgeries, as directed by the Minister of Health, not less than 13,000 fistulas will be repaired every year. 
Are there plans to tackle the high number of fistula cases in Nigeria?
In August last year, we had a meeting with the Honourable Minister of Health, Prof. Isaac Adewole, in his office where we discussed how to clear backlogs of 200,000 fistulas in Nigeria and the 12,000 new cases occurring every year. Considering that the total number of repairs we do yearly is 5,000, it means there is a deficit of 7,000 cases every year added to the backlog. And so the question was how do we ensure we clear backlogs and the deficit yearly.
We realised the repairs we are currently doing with the number of facilities available may not be able to clear backlogs. Hence, we said the best thing is to expand number of repairs and facilities. Secondly, the facilities currently doing repairs at state level don’t have the manpower and skill set of teaching hospitals. So the idea was now to have teaching hospitals start fistula repairs.
But then there was an issue of fee, since teaching hospitals are fee generating institutions. The minister then said it was best to wave the fee, and a memo was sent to that effect to the teaching hospitals. The fee include registration, bed cost, medication and all of that. So what Engender Health will support the teaching hospitals to do would be providing equipments and the consumables required to conduct repairs. In approaching this, we decided teaching hospitals need to set aside bed spaces for fistula repairs, put together core staff required for repairs.
 How many teaching hospitals have keyed into this since the release of the memo?
University of Calabar Teaching Hospital (UCTH) and Aminu Kano Teaching Hospital (AKTH) have keyed into this. First of all, we have started carrying these institutions along on how we organise our activities. That is why our pool effort right now in General Hospital, Ogoja, have a mix of health workers from teaching hospitals so they can experience the procedures, so that when they go back they will have background knowledge of how to repair fistula. The reason for this is because fistula repair is not a major component of health workers’ original training.
We have met the Chief Medical Directors of UCTH and AKTH and their team, and we are working towards implementation. Already, the University College Hospital, Ibadan, has long kicked off repairs even before the idea of free treatment for teaching hospitals was circulated as memo. There is also the Obafemi Awolowo University in Ile Ife. They have a centre in Ilesha where the minister himself led surgeries during one of our pool effort repairs.
Since the memo, you said two hospitals have keyed into the idea. Did the memo say it was optional for other hospitals?
 Everybody don’t have to key in at the same time. It requires setting up certain facilities and a team. So, those that have set these up are the ones that have keyed in. Others have to come in when they feel they are ready. Remember it is the fistula Care Plus Project, through Engender Health that is supporting it. So we will try as much as possible to do it incrementally. Once we support in setting up one, we bring people to see how it’s done, and they can go back to their own teaching hospitals, get themselves ready and call us so we can assist them set up theirs. And gradually we are increasing number of hospitals involved.
 What has the situation of fistula repairs been before now?
 Before now, there were not many fistula centres providing repairs. Only general hospitals and established fistula centres. Right now, we are supporting 13 fistula centres in the country, including the ones we helped the government establish.
 Before, state governments were the ones managing fistula repairs. The United State Government right now has the most structured process to address fistula internationally. In Nigeria they are supporting through funding to Engender Health for implementation.
Medicins Sans Frontiers has just one facility where they do repairs. I think they do about 400 plus repairs yearly. United Nations Populations Fund occasionally organises repairs. So when you are talking of consistent approach to fistula interventions in Nigeria, you are talking about Fistula Care Plus Project funded by the United States Agency for International Development (USAID).
 With that kind of approach, it will take a while to completely tackle fistula. This is for several reasons, including in the general hospitals where these women are repaired, doctors are transferred every now and then. You train a doctor, the next minute he is gone. You cannot stop a state from transferring its staff. So the number of repairs happening there are not as many as would have been. This is a challenge.
 Most patients don’t have money to pay for fistula repairs. So it’s only the general hospitals and fistula centres they get treatment. So in that case what else do you do? That’s why the minister sent out that memo. In general hospitals, many of our fistula trained doctors go for residency and don’t come back. So the best thing to do is move to teaching hospitals.
 If 12,000 new cases occur every year, and right now we are already doing 5,000 repairs yearly, it means we have a deficit of 7,000 repairs. If with the minister’s approach, all the 44 teaching hospitals and Federal Medical Centres conduct at least 15 repairs each in a month that’s not impossible. The one we are doing in Ogoja now, we already have 17 persons for repair. So if all our 44 teaching hospitals and federal medical centres do 15 repairs each month, it amounts to 660 repairs monthly in Nigeria, multiply that by 12 months, it means we will be having almost 8,000 repairs yearly. Remember the 5,000 we are already doing is there. This then means we will be doing 13,000 repairs yearly. This means we would have ended up tackling the new occurrence of 12,000 cases yearly, plus 1,000 from the backlog.
 This minister’s strategy shows this can work. However, there are other motherhood programmes also looking at prevention. If those programmes work effectively, we will then be reducing morbidity associated with childbirth. And if this reduces, we won’t be getting 12,000 new occurrence of fistula. So the less new occurrence we have, the more we can be digging into backlogs.
 How do we encourage fistula doctors to remain in the area, especially considering some complain that it is not lucrative?
 Fistula is not an emergency. It is also not a psychedelic area, therefore it doesn’t attract much attention. Private facilities are not doing fistula repairs because majority of fistula clients are poor. Only high class women can afford private centres, and they are not the ones we worry about. One way to keep fistula-trained doctors in this area is to set a career part.  Everyone wants to be able to move to next level. A career part in fistula will make health workers more interested. The good thing is that  there is a career part now. There is an MD in fistula repairs, and it’s been implemented in University of Ibadan, led by Professor Oladosu Ojengbede. Sending fistula surgeons out for conferences to improve their skills is a form of encouragement. Once skill is improved, such a doctor becomes known, and once you are known people start looking for you. That’s another incentive. There are several other ways to make people interested in fistula work.
The Fistula Care Plus Project will not last forever. Assuming you are winding down soon, what do we do?
Certainly the project won’t last forever. It’s ending this September. But we are hoping the minister’s approach will help in sustaining treatments, and hopefully USAID will see a reason to continue for another one year. However, our sustainability approach is that we have involved the teaching hospitals in a way that it is a voucher system, such that when these hospitals wave fee for treatment, they will submit the vouchers to the ministry and they will be reimbursed. That ensures that teaching hospitals don’t lose.
Remember also that states are also involved in fistula repairs. But our challenge with some of the states is the absence of routine repairs. That is because they don’t have permanent surgeons whose role it is to address fistula cases.
People worry about brain drain, but I don’t. What I worry about is brain shift. When our doctors and nurses move abroad to earn money, remember, they send that money back. Outside oil, the second highest money earner for Nigeria is brain drain because of the funds repatriated to Nigeria to help families and so on. The one I worry about is brain shift, where somebody leaves the hospital he is supposed to be providing services and goes to the office where he now carries files. That is brain shift. So I am hoping that the Minister of Health will look into suggestion I made before, which is that for every month a specialist with Ministry of Health works, two days at least should be used in the hospital to provide clinical services to patients. It doesn’t have to be in fistula alone. We have had many fistula surgeons who have moved to the ministry, they can be pulled out such that monthly, they spend two days in the hospital.
What should people know about obstetric fistula?
Obstetric fistula is an abnormal communication between various orifices; between either the urethra of the bladder and the vagina, or between the vagina and the rectum or sometimes in both cases occurring at the same time. When I’ts between the bladder and the vagina, it is called vesico-vaginal fistula. When it is the rectum and the vagina it is called recto-vaginal fistula.
It is caused due to prolonged obstructed labour. A lot of things could cause obstruction, maybe the ratio of the baby’s head is bigger than the pelvic area,  and what happens is that the baby’s head grinds on the soft tissues of the pelvic area, and when that continues, blood will no longer be able to flow through those areas. Then the tissues there die off, and holes will then appear. If it is at the rectum, then fecal matters will come into the vagina uncontrollably. If it’s at the vesico-vaginal area, urine will go through the vagina uncontrollably.
We also have situations where it is caused by medical personnel. That is the iatrogenic fistula, possibly due to caesarian session or medical procedure that was not properly done. We are working with medical groups so that we will be able to educate them on how to stop iatrogenic fistula.
Did Engender Health meet its target last year?
We almost met our target for last year. We met 98.7 per cent last year.