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Uh right. All right. Hello. By a very good afternoon, everyone. My name is Jean. I am the guest sock secretary and I'm an anesthetic registrar in the UK. And joining us say we also have Jen man who's UK guess stock anaesthetic representative. And uh so we are going to the uh pouring um uh understanding. I'm not global needs in sort of care, which is module to for the Frugal Innovations course today. And then later at four o'clock, we will do module three, which is technology designed for low resource settings for that. Further do I'm going to introduce to you our very first speaker who were very proud to present his doctor E G Lambert, who's a senior registrar in plastics and reconstructive surgery. He works at the Ahmadu Bello University Teaching Hospital in Zaria Nigeria. Lambert is also our guest of international surgical rep. So over to you, Lambert. All right. Thank you so much then. Um I'm very grateful to be here to talk to us today about the challenges and on meth needs um as regards surgery, um lower middle income countries. Um I reside in Nigeria were also work and um these challenges um cut across um, West Africa, sub Saharan Africa, and also other law, middle income countries. Um For by way of introduction, I mean 2015, um 1015 the Land Set Commission on Global Surgery um identified the fact that um um surgeries have been relegated to the background. Um First of all, sorry, um we came to understand the challenges of um global surgical care. We also um see how we can appreciate the challenges faced um in low and middle income countries. Then we also attempt to identify some workable solutions to these problems. Um Like I said earlier, um in 2015, the Lancet Commission on Global Surgery um discovered that surgery has been relegated to the background um in the discuss regarding public health. Um So they met and then they came up with the concept of global surgery and global surgery is basically um has to do with the study and practice of improving access to timely quality and affordable um surgical care for everyone. Um That's just what global surgery is all about and that's what got suck. Also helps to propagate. Um I don't know whether my slides are moving. I, since I'm seen, I seem to uh to get um some sluggish um reaction over here. Um Sorry about that. Um Global surgery is essentially like I said, what it seems to do is to ensure that everyone has access to timely quality and affordable um surgical I'm kid. Um an estimated five billion people globally don't have access to quality and affordable um surgical interventions. Um from statistics that we have gathered and done because of this. Um the last committee had to define certain criteria um that had to be met before we can say that um there's access to um surgical um care. Um Let me see if I can turn off my camera. I don't know why my slides are not moving, but I'm sorry about that. Okay. So sorry. My slide seems to be stuck on slight tree, John. Is it moving at your end? And my slides moving, you're muting. I'm sorry, looking mistake. We can hear you, Lambert. How about this? You send your Power Point Gene to presentation going on and you can upload it in a moment but you can keep going with what you've got. Okay, but just a couple of minutes now. So everyone who's listening so numb, but you just send your Power 0.0.2 gene. Um And then we'll sort it into a PDF and then we'll get onto the main stage. Let me do that. Is that all right? That's good while we're waiting. Welcome everyone. I see that we've got a lot of people around. We've got people from Kenya, we've got people from Lebanon, Uganda. Um and Ireland um in case you have missed out, we've also got a chat box on the side. Um The plan is we've got three very esteemed speakers today. So there'll be 15 minutes um for the first talk, then 15 minutes for a second talk, 15 minutes for the last talk. And at the very end, we will do um the question and answer. I've got my own questions, but ob obviously the best questions comes from the audience. So, um you're more than welcome um to ask some questions. Now, I'm really sorry that this has been um rescheduled, but hopefully everyone is gonna enjoy today. Um, as you can see, Lambert's got some very snazzy slides um for everything else as well. So that's all right. Um You know, I've sensed them. I don't know if you've received. Yeah. So while this is going on Lambert, um I think Genes received it. So probably you can go on. So where we left office about the Lancet Commission in 2013, if I'm not wrong. Um And then you can carry on from there. All right. Um So do I need to stop sharing my, my slides trying. Yeah, or it's all right. Um So I've, I've stopped showing my slides. So, can you see the snow? Yes. Thank you. Thank you. So you want here. All right. Thank you very much. Yes. So, as I was saying, um, the last Health Commission on Global Surgery, um, not notice the fact that surgery had been relegated to the background, um, when discussing public health. Um, they definitely came up with the concept of global surgery, which is basically trying to make um surgery affordable and accessible to everyone. Um Globally. Um Next slide please. Yes. Uh And in this um aim to achieve global surgery, the lower and middle income countries are not left out. And then it was also discovered that an estimated five billion people globally lack access to quality and lifesaving um surgical interventions. Um Next like this. Yeah. So as a result of this, um the community decided that they will define um six indicators that will be used to monitor access surgery um for everyone. And one of them is access to timely an essential surgery where they look where they can start. The fact that um at least people should be able to access a facility where the bellwether procedures can be carried out within two hours or where they live. Um They also looked at the workforce density and they proposed that um at least um there should be 20 surgical, personal bit surgery and aesthetics of ophthetic physicians per 100,000 population by 2030. And then um for the surgical volume, um they proposed that uh the numbers should be increased to at least 5000 procedures, uh 100,000 population by 2030. And also they look to reduce perioperative mortality as much as possible by 2030. And they also aims to protect against improv improvisation, expend expenditure to stop people from spending so much out of pockets that will leave them um broke and impoverish study. And so these are some of the indicators that were proposed by the committee um to help achieve um global surgery. So let's look at the challenges um and the unmet needs that we face and low a million compounds. One of them is um socioeconomic challenges and well, we'll see that poverty's um arrive in most L M Icees and statistics have it that um at least about 2040% of population in Nigeria um live below the poverty line as a as a 2019. And this number has increased drastically over time. Um Therefore, people have to pay, people find it difficult to pay out of pocket um for um their surgeon, surgical needs. Um due to poverty, another issue there is health insurance, um low and middle income countries find it um find it difficult um covering most of the population when it comes to insurance. And in Nigeria, just 5% of the population have health insurance. Hence, you have a large majority of the population. Um how they have to pay out of pocket to access um surgical care because of this. They have to resort to pour authorities like traditional healers, traditional bone, uh setters and traditional better attendance, um living them with more mobility and increasing the mortality. Next slide, please. Um A second challenge that um we have discovered also is um timeliness of care. People are not able to access timely care because they don't live near this. The facilities that can provide this bellwether procedures uh also scored that road networks are quite poor. So um accessing these facilities actually difficult and even where they're decent road networks, transport facilities, ambulance facilities are not readily available to move them from their point of emergencies to the point um of care. And also um call center facilities, network services also make it difficult to um call for help when emergencies arise. Next leg, please. Um Another challenge is the workforce density in lower middle income countries which whether there is in drought of surgical personnel um in these countries as a result of um immigration for greener pastures better be and better working environment. Also discovered that um younger doctors are not um wanting to choose surgery or aesthetics as their core specialty. They prefer to do public health and some other um easier specialties because essentially the pay is the same across board. And also those who have chosen to work as surgeons um suffer from born hours because of the increased workload. Next life, please. Um Also discovered that there's lack of political will form leaders in these countries. Um They don't want to invest in healthcare because they find probably better alternatives abroad. So the results to health capitalism and where they can meet their um surgical needs and they also don't have uh fit in the system to solve their problems. Hence the um seek care abroad. Next slide, please. Another challenge. And uh we've discovered is that um most of the surgical instruments reduced and the consumables are not manufactured in our countries. We have to import them. Um Also our, our equipment's spare parts, imaging materials are also not locally sourced. And since we have to buy these things from high income countries, we also grapple, grapple with rising exchange rates. And so the Mahdi exchange with the more difficult it ease um to source um foreign exchange to buy this material. So this material are not readily, I'm available um for surgery. Mm Next like this. Um So these are some of the challenges that we have faced and there are workable solutions that to these challenges that we have identified. One of them is improving um insurance coverage um for Nigeria. Well, we're looking to um see how the national health insurance scheme can cover um much of the population s tried those in dural areas that don't have to pay out of pockets for um surgical care. Um On, on that solution is to upgrade the facilities in neural areas from primary healthcare centres to even secondary healthcare centers where the bellwether procedures can be performed. Um This has actually started in some states across the country and also in West Africa. Um these facilities are being upgraded. Um also looking to incentivize um surgeons to agree to work in the royal areas. Um The right areas are not exactly attractive for surgeons because of poor power supply poor living conditions. But then we can make this place is conducive and attractive for surgeons to work. Um where I work the hospital where I work, we've started it, we usually send residents surgeons to um do a one month traditional neural areas to both gain experience and also provide surgical care for the population. Um Also we also increase um surgical workforce by encouraging younger doctors to do such as a specialty because of um the shortage of surgical stuff that we have. Then we can also continue to engage our leaders. It's not a one off thing, we have to keep doing it because the more we do it, um they're more likely that they're going to understand that um surgical care um is needed in countries and eventually they will respond to us and then not forgetting global interventions uh from organizations that could come in to also assist in carrying out. So um surgeries to ease the surgical body, for example, um small train is um an opposition that has come into Nigeria and other um low and middle income countries to pioneer free clear flip and palate surgeries and other organizations are also coming in from time to time and this is easing the body um of this of surgical care in um these countries. Next slide, please. Um the solutions to these challenges and unmet needs that we face in the middle income countries are not far fetched and um it is obvious that gas stock is one of the bodies that at the forefront of championing these solutions with the workshops and the trainings um that actually being organized as well as interactions between high um train insurgents in high income countries and also um in low and middle income countries. And thank you very much for listening. Um Have you have a good afternoon? Okay. Thank you so much, Linda, much and really enlightening for all of us here and we'll keep the, keep the questions coming guys and we'll tackle all the questions at the end when we have all three speakers online. So next up, I'm just gonna start presenting, I'm gonna share my next slide. So next up, I'm going to introduce to your doctor Finger Cut Chiro, who is our guest talk International Obscene Gaining representative. And she's also a senior registrar at the Ahmadu Bello University Teaching Hospital in Zaria Nigeria. So just give me the Chantix. It's green. Let's see. Yeah. All right. Uh Thank you. Okay. Yeah. Mhm Sweeter. Can you hear this? Fever? Am I audible? Yes, you are over to you. Good day, everyone. Um I'm actually pleased to be a speaker at this forum to just highlight some of the challenges faced with. So to care in any Mrs and I'll be coming from an obstetric perspective. Okay. So, next slide, okay. This will be the outlined for this presentation. Next slide. Okay. So, um conditions that are actually are mean able to surgical obstetric trauma and anesthesia. Quite significant. However, they are largely underestimated source of uh global boarding of diseases because the focus initially Australian and um eyes is your base on communicable diseases where by vaccines where um vaccine coverage was improved in L M is is which are seen to a drastic reduction in communicable disease. However, no communicable disease of which most of the conditions are been able to sorta careful on that have actually been underestimated. And then um the largest one, med meat, meat for. So take a a coin L M I C is where the poorest one sort of the world's population received only um 3.5% of the surgical procedures conducted globally. Now for us to have like a proper so take care. It requires a side energy between all pillars of the health care system, including infrastructure foundations like uh as basic as having um the minimum standard for a structure bit standard structure for theater, for the labor, world, constant running water and electricity. Then human resources also another important pillar to ensure. So talking because apart from skilled health workers, there has to be a proportional description of health workers among all regions in order to actually ensure universal cooperate and then equipment, the thought pillar. Because even if you have skilled resources kill human resources, you have infrastructure without equipment to work with and there will definitely not be an adequate attack it. Uh next slide please. So um basically for obstetric care, you know, the hallmark of uh obstetric case actually to ensure a safe, modern and a safe baby. And then usually the best indicator to ascertain and the quality of obstetric care is actually maternal mobility, maternal mortality and then severe maternal morbidity. So that's why the concept of an essential obstetric care actually came about which is actually the basic minimum that either primary health center or other secondary facilities should have put in place. Now to ensure a positive pregnancy outcome. So the essential obstetric has been better into two. We have the basic emergency obstetric and newborn care in which it's actually focused on primary health centers which are usually where, which are usually uh centers are usually found in the most remote of places. Is Schering S M I C is and it ensures that administering antibiotics are into electronics, drugs and convulsants. And there should be uh skills for mana level of class center, removal of routine products of conception after a miscarriage or abortion. And then there should be provisions for assisted vaginal deliveries and basic unitary cessation. Once 100 facilities. In addition to all these basic emergency obstetrical new banker should actually be able to perform abdominals produce like senior section have a safe drug transition and permission to forced to care for sick and no better tweet newborns. Now, these are just the minimum standard that have been put in place and actually ensure that at least people in L M, especially in the most remote emotional places in L M. I actually have the basic minimum of etiquette now to ensure a positive pregnancy outcome next slide next night. Okay. So now focusing on barriers to obstetric care in L M I C S. Well, according to the sustainable development goal, 31 of the target is actually to reduce global maternal mortality ratio, less than 70 per 100,000 live births by 2023. However, between 2020 20 the global mortality ratio has declined by 24% which is just about one third of the 6.4%. And order indeed to actually achieve this S D G. Now, most of this reduction improvement in maternal mortality ratio has actually been from developing countries while the stagnation even decline has actually been in developing countries of which LMS is make a lab trunk. So now they're according to wh you for every maternal date and for every life threatening complication, it's actually a story behind and it's our duty to actually understand the lessons from that story so that we can actually avoid such outcome. Next slide, next slide. So now this is a map map showing um just the burden of maternal mortality ratio as I said earlier, for STD tree is expected that by 2030 which have less than 8500 like. But so you're looking at this map if you can see Africa, right? I think in all regions in Africa, there's actually no country that has a maternal mortality should less than 8500 live apart from Egypt. And then you can see countries like Nigeria like Imuran actually having more than 566 per 100,000 like, but that's just to show you the actual distribution of this burden of this maternal debt burden in the world, which is actually been focused on L M I C is like in Africa like the Middle East, next like, okay. So now generally when we're talking about barriers of secretary can actually relate it. Like I said earlier, the Hallmark is actually see them maternal morbidity and maternal that you can relate it um due to to the phases of maternal daily, I'm sure most of us are familiar with the three phases of the leg of maternal deaths. We have the first delay which is this is play in decision to seek care for whichever problem or complication. And then the second delay is actually the delay in identifying and reaching the medical facility. The top delay is actually the delay in received of adequate and appropriate treatment. Now, the there are factors that actually directly or indirectly influence each of these days. I have the social cultural factors which directly affect decisions, even recognize and seek here for any obstetrical problem. And then we have a delay, uh factors affecting accessibility of facilities which actually has an indirect influence on decision to seek here and a direct influence on identifying an emergency medical facility. And then we have the type of quality of care which also has an indirect influence on delay in decision to seek here and also a direct influence on delay in receiving adequate and appropriate treatment. Next like so now for this social economic and uh you know, previous slide for the social economic and cultural factors that actually affect of Tetrick it that might lead to maternal morbidity or mortality. We have the high poverty index. Doctor Lambert has already highlighted us about the burden of how many percentage of people actually below the poverty index and then it has increasing constantly. So now when we with with very poor people, you know, even if you recognize that you have a problem and then you're not thinking of how am I going to afford this care actually delay, you can actually deciding to actually re spend sick for health. Now there's poor health seeking behaviors which is actually a direct correlation to either our social cultural um social cultural factors showing in this environment. Now, there are some people that actually don't believe in going to hospital to seek for help. Even if they have the money, there are people that actually need permission from their spouses to go ask for help. There's people that actually don't believe in actually giving birth in the hospital and then they just do home deliveries be it's whether in hygienic, often hygienic areas. So these poor health can behavior actually contributes significantly to this um maternal morbidity. Now, unhealthy cultural practice, like I said earlier, also decision not with the hospital decision to get better at home decision um practice that you have to take permission from your spouse is the lack of health insurance is actually a very big body because we all know that medical care is actually expensive and just very few can actually pay out of pocket. Now, when you have about less than 10% of the whole population, actually accessing health insurance, it's going to cause a big problem because even if you have a problem in it, I have to go to hospital, you can't afford it. There's no health insurance might actually think twice before going to the hospital. Then high levels of unemployed women, like I said, the whole month of upset, your care is just to give is to ensure safe, modern and a safe baby, right? So now when you have an empowered women, women that really don't have money, women, they need to take permission from spouses or for families to seek for help, even when they have complications. It's like um it's actually a very big problem and then it actually the day in either seeking here help or even the day and get into the facility. Now, various accessing medical facilities, we have four road net or actually for people that actually in the most remote oral areas in these countries, right. There are some people that they are um wherever they are, there's actually no road networks even need to uh the closes or still next to them. So that cause hospitals and family several kilometers away. And there's actually no road network to actually live there. So I actually have have to enter like maybe Keanu actually get to a landed hospital. So it's actually a very big problem in some areas. Now, even if there's a proper road network, transportation is actually a problem because how do you do you get to see 24 hours transportation in some of these places? Right. And then if you have a problem in the night and then you are no mobile and then there's no public transportation to take you to the nearest hospital. So it actually post delay in actually reaching the medical facility. Now, insecurity, we've been having uh increasing rates of insecurity in our environment, straining, minimize this instability here and there. Now when I was growing up, like even in the middle of the night, it's everywhere where you'll see people walking out in the middle of the night because everywhere was it. But now of recent times, once it's like nine pm, you see everybody in the arms, nobody really wants to go out at night because of care, fear of so many things kidnapped, I'm robbers. So now if you have a problem in the middle of the night, even if you decide to go the hospital, right, you might actually think to have actually, I'm, I sit actually live in the middle of the night with the hospital which will actually indirectly pulse at the league in actually reaching their facility. Now, I've had this proportional distribution of health facilities. It's, it has been recommended that according to the W H O that for every 500,000 people, that should be about four facilities that can cater to a group of 500,000 people. But now there are some areas I used to get to see more than 500,000 people in a particular local government. And then you're not have really a dissenters facility cater to them. So that means that and then you might not see some urban areas that have like congestion of different caters of health facilities be tertiary, secondary primary health facilities. So there's actually disproportionate distribution of health facilities in some of these areas. And then poor coverage is directly linked to disproportionate decision of health facilities when you have poor coverage of health facilities across the uh across the region across the country, and it will actually lead to barriers in accessing medical facility. Next light next slide. Okay. So for the quality of care, right, um I'll just portray the point that doctor number had made. Well, there's lack of uh adequate number of well trained health professionals because of the high turnover, immigration here and there, even the high turnover among skilled workers, even within the country. Right. There are some, yeah, she's condi a states that have uh that most health workers would like to walk there. And there are some states that have actually have a high turnover of health workers. So you might have a well trained professionals, but then the numbers might actually be very little. So it's the quality of the Toviaz cannot be compared to areas that actually have a large number of well trained skilled professionals, discretionary distribution of schoolwork has actually pose a problem because most of the skilled workers, we have actually concentrated in the urban areas. Then the rule remote areas where you actually have these problems where these these obstructive problems are actually predominant. You might get just once killed, health worker in uh covering a large local government of a large region which is definitely not enough health financing challenges. Now the health finance is not just for the patient as as to the health insurance also health financing. It's a big problem because when you look at the budget, the health budget of some of these lme's and you compared to the health budget of some of the developed countries, you can actually see a very marked difference. Now there is no health system that can try without adequate health budget to finance the hospitals and all be it was coming from the government but coming from the private sectors, so poor health financing to the hospitals actually put uh problems these and then sculpt resources like doctor A Gyn mentioned earlier about the equipment to use. And it can it will surprise that even in some of the tertiary hospitals, some of the basic equipment that are like routine in some developing countries actually like very scarce even in tertiary hospitals and most minimizes next slide. So I'll just talk about some of my personal experiences. Um Last two weeks, I was in Jigawa State and then um let me talk about infrastructure. Yeah. Right. So I was in a hospital that is supposed to be a tertiary hospital and then we had night problems for the two weeks that I was there. So we had emergency cases and then you know that you need to actually operate on this woman and then you know, have problems like there's no constant life supply and you need to look for back up and then the backup that is not already available. So now there's actually a skilled personality to do whatever needs to be done for the pressure. But then there's actually an infrastructural problem. Right. So now my experiences incanus, it, I've worked in so many centers in Kaduna sit tertiary secondary hospitals and in each of these places actually have peculiarities while some secondary actually have problems with adequate manpower, adequate skilled personnel, because most of them are concentrated in tertiary hospitals. That's a long time. The test trackers told actually they have the skilled manpower. Sometimes even the equipments user to work with is actually a problem. So it's just uh to portrait the point that they're there needs to be a sign that there needs to be in harmony in the infrastructure, the human resources and then the equipment not and show adequate obstetric here next cycle. So um what are the strategies that have been put in place to actually ensure uh adequate obstetric care? So, like I said earlier, the early focus was on infectious diseases. However, just like doctor E G said the Lancet Commission and Global Score to introduce the framework of the National surgical obstetric anaesthesia planning. And then this framework actually offered a systematic approach, strengthen health system. Now, initially, most of this approach, Tension Health Extension in L A ISIS were from primary volunteer work from like developed countries or from non non governmental organizations, but then it's actually not sustainable. So that's why this framework actually came to place another to ensure that is a national framework that will ensure uh straightening of health systems in L M I C is now this framework actually covered and six domains. However, this framework is still faced with challenges because the national framework post propose and then each country is actually supposed to modify it based on their own identified needs. But then we still have challenges of developing a framework of implementing the framework. And then even after implementation, calm commitment to the framework itself and then there's also problems of indicator collections, also financing the framework and then regionalization amongst other problems identified next slide. Okay. So now these are the six um these are the six domains for the framework, infrastructure, workforce, service delivery, financing, information management, and governor. So each country is actually supposed to walk towards developing their own framework, identifying their own challenges. I'm putting things in place. So the the focus on on one part of the female for a country might not be where another country might actually focus on depending on their own identified deficit or however, it's important that all of these domains are putting the police are being considered not to ensure global surgical obstetric anaesthesia. Okay. Okay. Next slide. So this is a map showing some of the country's a few countries that have actually developed and implemented their framework like uh Utopia, Nigeria, Senegal, Tanzania, Zambia, Rwanda, they actually um personalized the framework and actually have implemented, yeah, framework, AIBA, we still have challenges of commitment to this framework while countries like Pakistan are still in place of develop India on framework. So next like so now apart from that, like I said earlier, the idea of that framework was just to move from a place of voluntary or mission based. Uh so tuck it to like a national framework for so Turkey. However, we cannot, you know the rule that key players and Ngos have played a have played in actually improving obstetric care in Lme's. Yeah, Ngos like the Clinton Health Access Initiative. My so part final share governmental organizations like UNICEF U N F P A W H U which have actually uh actually champion campaigns that many targeted and that is targeted to improve human resources and also to ensure adequate equipments also in these regions. And then these ngos and organizations do not actually working and actually collaborate with ministries of health, with healthcare agencies. Another governmental organizations not to ensure that they actually put things in place. Now, each country has their own peculiarities. So depending on the identified challenge from the country, these these players actually come into play and collaborate with the ministry is not actually tackled that challenges. So personally, like Nigeria, I know that some of these engines actually championed uh programs like train on essential obstetric care trainings and essential in case if abortion you need postpartum contraception and even community based distribution of family planning. Now another strategy one that I actually love personally because in as much as you want to like help people, you actually have to ensure that every person can actually afford mate. Okay, that's a home a copies, right. So now the National Health Insurance Act of the National Nigerian National Head Insurance after I was just signed actually has in one of its domain actually has a rule, it actually considered indigent people, vulnerable people, like under five unemployed people, very elderly people, very poor people. So that in as much as they cannot afford to, to get an insurance came, the federal government is actually supposed to like uh sponsor, like paying something into their own insurance. You have to be able to keep it up for the needs of these indigent people. And then the beautiful part about this National Health Insurance Act now that has been signed is that for default has also be it's the practitioners or be it has to actually turn out is for default that just in order to ensure that this National Health Insurance actually actually uh it's actually successful. So hopefully it does not, I said it doesn't have been implemented, but hopefully in Nigeria it should be implemented. And then I think um we should be able to see at least an improvement in in how people access of strategy and medical care generally. So generally, um I've just highlighted some of the challenges and barriers that we've identified um towards assessing ulcer tricare in L M Icees. And then it's important that courses like this is important that we are aware of this challenges. It's important that we are aware of the strategies that have been put in place. And it's important that we actually bring storm on solutions naturally to help and these elements actually catch up with developing countries in ensuring and general global obstetric care. So, thank you. Next slide. These are my references. Thank you. Thank you so much. Thank you know, it's so far we so removed three speakers for, for this second. And unfortunately, our first speaker, uh Doctor Maria causing this true history going to log in. So you might just move on to question and uh session uh for our two speakers. So for a favor and uh presenting as you can see us for a favor and uh land up if you can just pop your cameras and microphones on again. Okay. We can see uh all our audience joining us from all over the world. We're really excited to hear from you. Please let us know if you think questions. Uh uh huh. Okay. I might just take some completely flashes. You guys don't mind. Um Very thorough talk. Thank you very much, everyone. Um So my first question is a bit of an imaginary question uh headline. So if time my niece were at least is just a question. Um What would be your first priority? You as just as dr favor, Doctor Lambert, what will be your first priority you wanted to come or the efforts into if we get that question? Okay. Yes, I, I had, I had the last part of the question but the first part's I didn't really get this. Can you come in uh time? Power, money, resources for in a problem. Let's say we have an imaginary funder that's gonna come um and say because you're in the front line, I will trust you and put all my efforts into one thing. So where would, where would you want to meet? Where would you want to sort the um ethnic? Okay. Um Thank you very much John. Uh I think human, human resources is human resources. They would be priority because no matter how much money you have, no matter how much equipment you have, no matter how much instruments you have. If you don't have the manpower to get things done, all those resources, all those documents would just be a waste. One of the major problems we are facing now, like I said, it's workforce. Um Currently, um we, we uh when I started residency were about 20 registrars in the department of Surgery. Currently, there are just four registry department of Surgery. So people are immigrating in their numbers and it's not just here, it's across the board. So human resource is very, very important. Thank you. Okay. So thank you Jan for the question. Um Personally, I think, I don't think there's a right or wrong answer for your question because it kind of depends on where you're coming from. Like I said, each region actually have their own peculiarities, right. Yeah, we actually work in the same century. Doctor et and even in my own department actually have that challenge. We have more of senior residents now compared to junior residents. Right. Because they have not been like employment for a couple of years to actually augment junior residents that have moved to senior resident sick. But then there are some regions that you cannot be talking about workforce when you don't actually even have like an infrastructure. Like I said, there are some regions I have to travel several kilometers from. So I think the game if you actually have a lot of money to come and if you, I will not just commentary that okay. This is where you that form on its face that actually have to do a grassroot analysis because the problem that you might have in Syria right is different from parent that you might have in maybe gabby local government because they don't even have hospitals or they might not have adequate hospice even cater. So even if you do human resources, so where will those people? So I think different regions with your own challenges and that is why that framework was actually built in. It's they're supposed to personalize it, find out your own popularity at that point and then know where to channel your energy you're starting from. That's right. Every, every place has their own unique situation even within a big, big country that I think is resonates with all of us in all different places. Um There are a couple of sessions in it. I'm not sure I'm getting the right hand of mistake, but I will try. Um first when I just want to go with blood or your or do or last one, that amazing presentation. However, the whole healthcare structure in Nigeria needs needs to be changed as well as active engagement with government for doctor retention and utility insurance. And I think that's what do you think about that? Um, that comment, um They say there, there needs to be active engagement with the government or doctor retention and utility of insurance infections or your thoughts about that, that the idea. Yes. Uh holiday. Oh, thank you very much. You're absolutely right. Um These structures, but when the foundation of the structure has a problem, the entire structure is bound to before tea or we eventually collapse. Uh So we have to really dig deep into the roots of this matter and begin to take healthcare seriously. Um The truth of the matter that our leaders have not really taken healthcare seriously. Um That's why you have uh them traveling to seek healthcare abroad and things. They find that these things that the goods look for outside can be done here. And um like I said, the engagement will not just happen once we are doing it, we are working on it. Additional resident doctors, the Medical Association's, we keep going to them, we keep engaging them using both the currents and the stick approach. And at some point they listen to us, they do some intervention, some point it done. But then the back is definitely going to be one di di uh we'll continue with the engagement on the issue of insurance. Um I think we've come a long way actually, as a 10 years ago or 15 years ago, almost nobody was insured, health wise, everybody was paying out of pocket. But now, um once your civil servants, you're entitled to health insurance, at least to a certain extent. And then even for those who are not civil servant, those who are not government workers, there is a particular arrangements for them where they can pay um little contributions. And then they also captured um in the health insurance scheme and education also plays a role because some people don't really know about the availability of these insurance packages. So they are just the believing that um nothing is there for them. So it also falls on us as practitioners to reach out to these people and tell them ok, their packages like it's available for you. Um You can paste, it depends as a community into a particular fund. And then when there's a health crisis, is a surgeon, surgical crisis and ophthetic problem from that fund, it can be used to take care of you and you don't need to pay out of pockets. Thank you so much Lamberg for highlighting um the positive changes that have already been happening and we hope we'll continue to happen and improve. Um I just had one quick question for favor and I I picked up on your presentation about, um sort of cultural beliefs and uh certain cultural practices that might not be, let's see, that might prevent women from seeking healthcare, uh, you know, in, in labor or in antenatal period. I just wonder if you're aware of any say, innovative ways in which may be the community has, maybe the secondary care components have sort of reached out into the community because that's where, you know, a lot of things that affect outcomes in secondary care actually start from the community. So are you aware of any innovative ways that maybe we can or maybe that is already going on instead of reaching out to the community to kind of change or challenge these um cultural beliefs? Okay. Thank you Gene for that question. Yeah. So I think I totally missed it in my presentation. So, um you know, like I said, some people actually don't believe in going to the hospital. Some people actually have to take permission to go to the hospital. So one of the ways in which the government has actually tried to help that is actually to drink traditional birth attendant because there are people that are not skilled, there are no well trained that actually go to this, that in their communities actually take deliveries and then do all sorts. And then by the time the patient is actually coming to the hospital, you know, they have like severe complications, right? So one of the ways that it, there was actually to train traditional birth attendant, they have been campaign driving workshop to train them just for them to actually have the basic minimum skills, actually be able to conduct a norm delivery and then to actually be able to detect any complications that they will know that. Okay. Now, right now, there's actually a problem. So because we need to identify a problem before you can even know what to do. So they've been trained, you know that to identify the problem and then appropriate referral systems, right? And then, and that's where one of the that I think that's one of the things that brought up about the popularity of miserable store in our environment that everybody even in the mail and lose the use of these post online environment because like that was one of the quickest of the topics that uh this traditional but attendance could actually used to prevent hospital him. And this is a major killer of pregnant two main environment, right? So they've been trained on that, which are very easy taking a delivery because most of these women actually deliver industrial areas are actually those are very high priority. So they are prone to retry it. To me, they are prone to postpartum hemorrhage. So they maintain to actually administer miSOPROStol. And then even when they're inside Misoprostal, right? And enough, they're okay, they're still an issue or they still see signs, they now know how to refer them and they've actually, and they've actually been linked to like hospitals close by to them. Now, another way they say I was actually involved in this training. There was a couple of years back in which we actually trained community based distributors because there's some uh some in some seconds there, there's adversion to use of contraception. Right? So, but you know, when you're coming as a health worker, you're just trying to like put the gospel of contraception, another space family and then prevent conditions that comes with two frequent childbirths, right? They might not actually listen to you. But then when you're not hearing this from like people in their community, you know, they might tend to give a listening here. So a couple of years back, I think it was championed by Clinton Health Access Initiative, Community distributors for control. We actually trained at least for the basic conception like barrier methods of contraception and all and even the natural methods of contraception so that it will go door to though like talk to these women enlighten them, tell them about the importance of contraception that it's not like I'm telling them to give breath for at least space your Children, right? So these are some of the ways that they try to like reach out to reach out to many industrial areas. Cute, we have just one more question. Should we just do one more? I'm trying to assess out the annals questions but you know, feel free to jump in if I'm interpreting it wrong. Um So they're now choke, um, which we have met in Uganda is the Cameroonian Meniscus. So, she was talking about, what about, I suppose in the place of an unmet need discussion. What about the place of law responsibility when there's a def, so I think it's talking about medical negligence, the infrastructure of malpractice and error and how, and it's insect on your met need. So, I suppose, um whether it has a place um first and if so what, what we're gonna do about it and how we make it um to suit your met need. And that's what I can try. Course about sets up. So I suppose that's the question to the speakers. So what your thoughts about that? All right. Thank you, you know, um for, for negligence and practice. Um Yes, it happens. We're not going to deny that it doesn't happen. It happens. But for, for where we are currently, Nigeria have the Medical and Dental Council um that has recently launched the campaign against them negligence and errors. Um in the past, um patient's didn't know their rights. Patient didn't understand that they had the right to certain things. They had the right to be treated, they had the right to refuse treatments, they had the rights to whoever they wanted um to treat them. Um But then with the passage of the Patient's Rights Act, um by the National Assembly, um patient's have begun, begun to understand that. Yes, um they have a right to appropriate and timely treatment. So, in the event of event of negligence, um there are bodies that um this can be reported to and addressed and eventually the case will be taken to the Medical and Dental Council of Nigeria where the case to be reviewed and um the offending practitioner um adequately reprimanded. And we've had a lot of cases like that, um licenses withdrawn, um license is suspended. And the like, so yes, we've worked on that tremendously and um negligence has just ically reduced. I hope that answers the question. And if I may just add some things about the negligent, I think, um you know, for you to even know that there's some as a patient coming from a patient perspective, for a patient actually even know that uh something went wrong, you have to be self aware, right? So like when you have patient's are ignorant, when you have patient's that like have low education, like it's actually going to be difficult for that patient even know that I should, I actually deserve a better care competitive. So I think that's one of the things that actually brings about like the law, like most people just in this environment, actually, we're limited from that prosthetic perspective. So you have a woman that actually, or a family that actually suffered maternal deaths, right? And they just accept like choking his job. The window of God, it's just meant to happen right now, in most cases, the problem is not actually from the hospital, medical negligence, right? But here's some instances that he has the hospital or the health workers should have done better, especially in setting, especially in this hospitals in quotes because there are so many buildings that are labeled hospitals that are actually no hospitals, right. So actually in those settings, so they just accept it like that. But I think it continues education, the first thing that a patient need to know there, right? They need to know that it deserves better, right? And then we as health workers actually need to do better. And after that, it's actually going to be quite difficult actually, um I really don't know how to put it right? Or because in as much as you want to help a patient yet, you know that this patient deserves better, right? For your handicap because probably I need this patient access I C U K. And then at this point time, the center that there's no I C U K. So will you call it negligence kind of? But then it's not on me because I can only do I can only provide care extent that I can provide. So how do you actually defend this? So I really don't, there's like a disparity and then they're like blurry lines in order in which you can actually say outside it is negligent is not negligent. Well, most of the, most of the cases I've actually seen about medical legal issues actually, in like well established hospitals. I know that the physical because yes, you have establishments that almost have all standard facilities, almost actually private facilities. So those are the places that I know that. And as you see like a couple of cases and then obviously patient that patronized those places actually have the funds. Actually, we'll learn it actually exposed to the new their rights and anyone else's something or they actually voice that and actually seek for help for justice. Uh mhm. Thank you so much favor and thank you to Lambert's. Well, thank you to the both of you for giving us your time today and for highlighting unmet needs and hopefully, you know, throughout the rest of the course, we'll we'll come up with more ideas, strategies to, to deal with these problems and move forward in a positive manner.