Joseph Ana / Illustration by Kyungduk Kim
Inspiring Lives: Joseph Ana
Health Commissioner on a MissionNigerian born Joseph Ndemana Enebieni Ana returned to his lush, forested home state of Cross River after 22 years in the U.K. to find Nigeria’s healthcare “poor and non-functional,” and brimming with dismal statistics: only 52 doctors and 1,000 midwives and nurses served three million people. Maternal mortality was 1%, and child mortality, 20%. But, during four years as Commissioner of Health, Ana figured out how to reboot the failed medical system.
By collaborating with religious leaders, creating a network of community health workers, and uniting the stigmatized “traditional birth attendants” within the public health system, he quadrupled the immunization rate and cut the prevalence of HIV in half. He increased the supply of essential drugs, created an ambulance service, hired new staff and boosted salaries, and provided more training and governance.
After completing his residency in Nigeria, Ana relocated to the U.K. in 1982 where he honed his skills as a general surgeon and urologist. He visited Nigeria intermittently to launch the British Medical Journal West Africa Edition. In 2004, the governor of Cross River, Donald Duke, offered Ana the challenging opportunity to lead the state’s Ministry of Health and revamp public health services.
Ana spent three weeks visiting every town and village in Cross River—even those nestled in dense forest or perched on motorcycle-only accessible slivers of the coastline—documenting his people’s health needs. “The infrastructure was dilapidated, equipment not available, human resources were very short,” he says.
The hospitals and clinics were almost deserted. Patients had lost confidence in the public health service. Even in Calabar, the state capital, the general hospital lacked running water and reliable power. There was no functioning resuscitation equipment in the operating theatres, the emergency room, or the labor wards. There were no x-ray departments and the labs performed only crude tests. The ambulances, which lacked lifesaving equipment, were more like hearses, and there were no emergency care physicians—the most frightening defect of the system, says Ana.
Infrastructure challenges aside, Ana was more disturbed by the abysmal 20% immunization rate, and the 12% infection rate of HIV.
As part of his strategy to change the medical system he recruited and trained charismatic, popular and trusted imams and priests to catalyze attitude shifts toward routine immunization and HIV/AIDS prevention and control. One reverend, says Ana, was particularly influential. “People knew he was very religious and not a health professional,” explains Ana. The imam convinced mothers of the need for immunizations and reassured them it didn’t negate their religious beliefs. Ana used him as a “change agent” at many public health outreach events.
Ana also reached out to “traditional birth attendants” (TBAs) whom the health system had shunned. These women were generally untrained and illiterate but delivered more babies than the trained midwives, because they lived in the rural villages along with 70% of Cross River’s population. Ana recognized that TBAs, who were in regular contact with many pregnant women, were well positioned to convey the advantages of immunization for preventing childhood illnesses. By 2008, when Ana completed his tenure, the immunization rate had climbed to 84%.
Ana melded the TBAs and midwives into an organization that trained them to recognize risky pregnancies and refer these women to hospitals. The TBAs were monitored and given delivery kits with sterile instruments, and in 2006 the group created a training video so that the message would reach all the members.
When it came to HIV and AIDS, Ana knew this wasn’t just a health issue. He formed a high-level task force with the Commissioners from the Ministries of Youth, Education, Women’s Affairs, and Information, and asked the governor to chair the meetings. Ana regularly invited people with HIV/AIDS to attend these meetings so that the ministers could “hear real live stories from real people about how they were coping.” This sent a powerful message that HIV-infected people could work and contribute to society if they received the right medication, tests and counseling. By 2005, he says, the prevalence rates for HIV/AIDS declined to 6.1%.
“He made healthcare accessible to everyone in the state,” says Donald Duke, the former governor. “Too often there was trial and error in our medical system. But [Ana] changed that with clinical governance, and he brought quality and quantity.”
Today Ana, an independent consultant, lives in Calabar continuing the work he began as commissioner. He is most proud of his efforts to provide continuing education for all medical professionals. With training programs, workshops, and statewide audits of morbidity and mortality, he built a system where staff could reflect on their performance, its outcome and could learn from mistakes. “For me that was one of our major achievements because it encouraged every health worker to start lifelong learning—to start reading again and improve on their practice.”
Photo: Joseph Ana / Illustration by Kyungduk Kim
