Healthcare Delivery in Nigeria: Any Hope?

Ayodeji Jeremiah

“We believe good health is a basic human right, especially among poor people afflicted with disease who are isolated, forgotten, ignored, and often without hope." — Former U.S. President Jimmy Carter

“A child falls ill with fever, chills and convulsions in a village over half-a-day’s journey away from the nearest health centre. After three sleepless nights of agonizing helplessness for the family, it succumbs.
A middle aged artisan in a State capital falls from a height at his workplace and sustains a compound fracture of the femur. He is taken to the general hospital where the surgeon, lacking the tools for the most appropriate treatment, undertakes what he euphemistically calls “conservative management” and watches helplessly as the patients deteriorates steadily and dies. A 19-year old Polytechnic female student becomes pregnant following sexual indiscretion with a married schoolteacher. She is petrified of the consequences and seeks the aide of a traditional abortionist in the backwoods of a city centre. A week later she is brought into the hospital with roaring septicaemia from pelvic infection. She rapidly passes from anuria to delirium to convulsions and eventually succumbs. A Government Minister trip sin his bath and injures his ankle. Clinical and radiologic examination in the Teaching Hospital show a soft tissue swelling with no fracture. Yet he is promptly flown out for treatment in a European country – cost to the tax-payer: 20,000 Dollars These four scenarios exemplify the cruel irony of our health care situation in Nigeria. The child with a fever and convulsions, probably malaria, need not die from it. Similarly, with good occupational health education the frequency of industrial accidents should be a great deal lower than it is today, and the mortality from relatively minor accidents should be insignificant. The young lady with the septic abortion, even if reckless, need not succumb had there been adequate measures to confront overwhelming infection and combat acute renal failure in a hospital setting. Her indiscretion may even have been averted with adequate and timely sex education of her “at risk” vintage. The fourth scenario, in which well over two million naira of public money is spent for overseas treatment of a minor ailment in a top government functionary, is clearly indefensible but all-to-familiar even today…”
Emeritus Professor of Medicine, University of Ibadan, Nigeria, Professor O.O. Akinkugbe, in his address entitled, “Nigeria’s Heath Status: Two Steps Forward, and One Back — The Enigma of Success in Retreat” during the 11th Annual Convention & Scientific Assembly of The Association of Nigerian Physicians in the Americas (ANPA) on July 6-10, 2005.

The above scenarios presented in the address of the eminent professor of medicine at the above mentioned conference are all too familiar in Nigeria. 49 years after independence, Nigeria cannot boast of a qualitative healthcare delivery system. Sometimes in late 2008 and again in January 2009, there was a furore in the public over the health status of President Umar Musa Yar’Adua. During his barely two years in office, every vacation taken by the President is now taken to mean he is travelling overseas for medical check-up. The president’s health has become a major source of concern for many Nigerians with some prominent groups even calling for his resignation. Political opponents and critics now use the opportunity to browbeat the government. All of these of course play down the real issue. It has now become the norm more than the exception for our leaders to routinely travel abroad for medical treatment. Most times, we only get to know when things go wrong and the person in question doesn’t make it back alive. 49 years after independence, shouldn’t our president be able to undergo comprehensive medical check-up and even treatment within the borders of our nation? The trips by President Umaru Yar Adua supposedly for routine medical check bring to the fore acute problems of Nigeria’s medical system.
The wealth of a nation, they say is its health. The sustainability and viability of a country’s economic and social growth depend largely on vibrant healthcare sector of that nation. No country can maintain a steady economic growth in the absence of an adequate healthcare system. Given the current state of health care in the country, we can only conclude that Nigeria is a very poor country. The Nigerian healthcare system is composed of decrepit health facilities and comatose medical institutions that have suffered from prolonged neglect and under-funding, leaving everyone open to risk of unwarranted death. Health care facilities in the country are generally in poor condition with chronic shortages of essential equipment, drugs and human resources. The most severe is the lack of adequate skilled attendants, which are the most essential element of quality health care, because they often leave to the private sector, or move to other facilities due to lack of resources or proper remuneration. Access to quality healthcare is either limited in Nigeria or nonexistent with staggering financial burden to families and the nation. While the prevalence of fake drugs and substandard products are compounding the problems, the AIDS epidemic and unhealthy lifestyles of many individuals are making the matter worse. In Nigeria, people die of minor illnesses that could have been prevented with simple medications and healthy lifestyle.
In such circumstances you only pray not to fall sick in Nigeria or develop any serious ailment that requires urgent care, you are more likely to be struck by lightening than to survive an emergency medical condition in Nigeria. The continued stagnating healthcare system in Nigeria is of great social and economic consequence. The health crisis in the country has taken an added significance because of the absence of constructive comprehensive national health policy. The federal government seems to have no meaningful collaborative effort with the state and local governments. The implication of this phenomenon is catastrophic.
Nigeria’s population estimate is 140,000,000 with a growth rate of 2.4%. While Nigeria has a birth rate of 43 births per 1000 (2008 estimates), the infant mortality rate is 74.2 deaths per thousand birth lives with a life expectancy rate of 51.6 years (2008 estimates). Out of the estimated 27 million women of reproductive age, one in thirteen die due to causes related to pregnancy. Recent figures indicate that the maternal mortality ratio (MMR) is 800/ 100,000 live births in Nigeria. Of the annual 3 million pregnancies in Nigeria, approximately 170,000 result in death that is mainly due to complications during pregnancy and childbirth. The main causes of maternal mortality in Nigeria are haemorrhage, which accounts for about a quarter of all maternal deaths, sepsis 15%, complications of unsafe abortion 13%, hypertensive diseases of pregnancy 12% and obstructed labour 8% (UNICEF). Approximately 35% of Nigerian women experience their first pregnancy by the age of 19. The Nigerian Demographic Health Survey further states that only 15.3% of married women are currently using contraception, of which only 8.6% are using modern methods (e.g. condoms and birth control pills). Only 60% of women receive antenatal care and approximately 31% of all deliveries take place in a health care facility. Moreover, only one-third of all deliveries are attended by skilled attendants in Nigeria. A study conducted in the northern part of the country indicates that 25% of all deliveries take place in the home with no assistance or attendance present. (WHO)
The statistics are pathetic and undoubtedly scary. Nigeria spends a total expenditure on health as percentage of gross domestic product of 3.5%. Most of these go into payments of salaries of the few remaining healthcare professionals in the government sector. Nigeria’s teaching hospitals once famous for training some of the best professionals in the world have all been reduced to glorified cottage clinics, as a result of which the best and brightest have left the country in search of better opportunities abroad. Estimate suggests that there are over 5000 doctors of Nigerian descent practicing in the US alone, ironically most were trained at home. Despite the tragedy of unnecessary loss of lives, from an economic standpoint funds channelled in training these professionals, or running the facilities become wasted, just as avoidable death depletes human capital of the country. Analysing the depth despair, the sheer number of such untimely deaths from preventable diseases, accidents and incompetence paints Nigeria as a country “at war”
In 2003, after religious and political leaders in the Kano region banned polio immunisation, contending that it sterilised girls and spread HIV, an outbreak of polio spread through Nigeria and into neighbouring countries the following year. The Kano region lifted its ten-month ban against vaccination in July 2004. On Aug. 24, there were 602 polio cases worldwide, 79% of which were in Nigeria. The WHO overall health system performance score places Nigeria 187 out of 191 countries. This composite measure of overall health system attainment is based on a country’s goals relating to health, responsiveness and fairness in financing. The measure varies widely across countries and is highly correlated with general levels of human development as captured in the human development index.
The above situation in Kano shows how the development of the healthcare sector is intertwined with literacy development and improved living conditions. In a country with a literacy rate of less than 70%, most citizens resort to poor traditional healthcare or self medication with adverse results. It is a common knowledge in the preventive medicine community that an individual who does not smoke nor use any tobacco products, eats good diet, wear car seat belts and exercise regularly is sure of living up to 70 years barring no unforeseen circumstances or "acts of men or God". Improving the healthcare system will involve empowering the average citizen economically and educationally. Improving the healthcare system will involve more than just throwing money at the hospitals, especially the teaching hospitals as most past governments have been doing. Primary Health Care continues to be the cornerstone of health development and the National Health policy in Nigeria. Focus on this sector has to be revitalised as follows:
1. Improving primary and public healthcare education especially with regards to preventive care will ensure that even the least literate of citizens have access to knowledge and information on what to do in every situation. A situation where diseases like tetanus, typhoid fever, cholera, dysentery are still killing many in the country is appalling. Even malaria, which still kills 2 million children every year, can be prevented through the use of treated nets, clearing of the environment and use of anti-malarials. A survey by the World Health Organisation shows that less than 6% of Nigerian children under five years of age sleep under mosquito nets. Even less than 1% sleep under treated mosquito nets. Less than 34% of this same group who have fever receive anti-malaria drugs. This area should also focus on behavioural change enlightenment programs for the people, which should focus on areas of diets, smoking, sanitation, exercise, sexual transmitted diseases and other behaviours that may impact the health of the country. 2. Primary Health Care facilities in Nigeria need to be improved to appreciable standards. 60% of health care facilities in the same survey above did not have any stock of nationally recommended anti malarial drugs. At least one standard primary health care centre built and equipped with required facilities and staff should be the goal for each local government area in the country. How can this be funded? State and local governments can partner with foundations to receive grants that will be used to build and equip such centres. Drugs and equipment can be donated by pharmaceutical companies and manufacturers. Staff can be sourced from agencies and organisations that provide volunteer staff on a revolving basis. 3. Improving sanitation facilities and drinking water sources. Less than 48% of the population have access to improved drinking water sources. 44% use adequate sanitation facilities (UNICEF). Communicable diseases account for more than 60% of diseases in sub-Saharan Africa. Providing drinkable water and improved sanitation facilities will help cut down on transmission of such communicable diseases. Again, state and local governments working in collaboration with international agencies can build safe and improved drinking water and sanitation facilities that communities can share. By providing sanitary environments, such as provision of portable water, sewage, sewage control and refuse management and reduction of overcrowding, most of the causes of infant and maternal deaths, which are infectious can be prevented and reduced.4. Improving nutrition amongst school age children: UNICEF statistics shows that 29% of children under five are underweight. The government in collaboration with aid agencies and NGOs should ensure that every child from age 6 yrs till 13 years eats quality breakfast and lunch (provision of school mid day meal and lunch in government schools). Poor nutrition does not only impair learning but also lowers resistance to diseases.5. Aggressively ensure that vaccination rates, which have improved over the years is not only maintained but improved on. Vaccines have saved thousands of young lives and with proper use they will continue to do so. Diseases such as Polio, Chickenpox, Measles, Mumps, Rubella, Diphtheria, Whooping Cough, and Tetanus are amongst infectious diseases that have been greatly controlled through the use of vaccinations in children, who are most susceptible. 6. Refocus healthcare funding on the primary healthcare sector with public health being treated as a priority issue. The core functions of public health are to prevent epidemics, to protect the environment, the workplace and to ensure safe housing, food and water. To further promote healthy behaviour, to monitor the health of the states and the country, to help mobilise communities for action on health related issues, to respond to disasters, to target outreach communities for health services, to train employees for the investigation and prevention of disease, and to protect policies to protect the health of the environment and the people. By attacking the primary and public health sector, we will be able to effectively deal with over 85% of health problems in the country. Many of the most severe afflictions are entirely preventable. Yet people living in developing nations such as Nigeria die or are disabled because they do not have access to the services they need to treat their illness or avoid infection entirely.7. Partner with international organisations such as the Carter Centre, the Bill and Melinda Gates Foundation, UNICEF, WHO in improving research, attracting funding, training personnel, developing vaccines and delivering health solutions to those that need them most.
The Carter Centre building on village-based drug distribution systems now in place in Nigeria to prevent river blindness, is also reducing incidences of the parasitic disease schistosomiasis, enhancing children's abilities to grow, develop, and learn. The same health care delivery infrastructure in Nigeria also is helping to prevent and treat lymphatic filariasis, a disfiguring and shame-ridden disease afflicting the poorest of the poor.
The Bill & Melinda Gates Foundation works with organisations around the world that are using innovative methods to improve health in developing countries. They focus on discovering new insights to fight serious diseases and other health problems affecting developing countries, developing effective and affordable vaccines, medicines, and other health tools and delivering proven health solutions to those who need them most. They also support advocacy efforts to build awareness of global health challenges, develop new ways to finance health programs, and improve health data. The Gates Foundation targets diseases and health conditions that cause the greatest illness and death in developing countries, yet receive little attention and resources. Their focus includes Diarrhoea, HIV/AIDS, Malaria, Maternal, Newborn, & Child Health, Nutrition, Pneumonia, Polio, Tobacco, Tuberculosis, and Vaccine-Preventable Diseases.
Governments and NGOs can take advantage of the opportunities provided by these organisations by working in close partnerships with them. This will require a strategic change in the way our government works and in the way our leaders think as in Nigeria, it's always a problem if you work through the government. Individuals, corporate bodies and religious organisations must therefore step in even where the government has failed.
One of Bill Gates' top health strategists, Dr. William Foege, thinks Nigeria "provides an important model for the rest of the developing world" and some key lessons the Gates Foundation must take to heart if it wishes to accomplish any lasting change. Those lessons come from the resilience and resourcefulness of Nigeria's people, not its government. And they can be found in the work of Nigerians like Dr. Emmanuel Miri, who was educated in the United States and has devoted his life to improving the health of his homeland. Miri directs Global 2000 in Nigeria, a project sponsored by the Carter Centre in Atlanta. The first waterborne disease Miri targeted was river blindness (onchocerciasis). It's caused by a worm transmitted to humans through biting black flies that live near fast-moving rivers. The worms often migrate to the eyes, damaging tissue and making this disease the leading cause of blindness in West Africa. Another, even more common disease, is snail fever (schistosomiasis). It's caused by a blood fluke transmitted from snails to people when they swim or bathe. It's a debilitating, chronic and occasionally lethal infection characterized by bloody urine that afflicts about 200 million people worldwide. Elephantiasis (lymphatic filariasis) is an infection that causes massive swelling of the leg or, in men, the scrotum. The parasite, a worm that infects and blocks the lymph system, is transmitted by mosquito bites and, occasionally, person-to-person. None of these diseases can be prevented by vaccines: the Gates Foundation's weapon of choice. The common link for all is water, whether directly through drinking or bathing, or indirectly as a breeding ground for the parasites.
"Many people don't think of water as a public health issue," Miri said. But he said it is the biggest public health challenge for Nigeria and for many poor nations. Most rural Nigerians get their drinking water directly from rivers, streams or ponds. But even in urban areas, water safety is an issue. In Lagos, only about 30 percent of the city's 8 million residents have direct access to potable water. And in Jos, one of Nigeria's main cities in the north, the regional hospital draws its water from an open well outside the children's ward. "If you have good water, many of the diseases of Africa would disappear," said Gen. Yakubu Gowon, a former Nigerian head of state who now works with Miri promoting water safety programs throughout the country. "Clean water is the key to health in Africa. It is paramount." Global 2000, a non-governmental organization, has made clean water its top priority. But even with the donations it has received from the Gates Foundation and from drug companies, it lacks the resources for the major, capital-intensive projects that are needed to fix the problem. Those agencies that have the budgets, UNICEF, the World Health Organisation, and the United Nations Development Program acknowledge the need for clean water. But it doesn't really fit their public health agenda. As a result, Miri said, "very little has been done about it." Part of the problem is a lack of coordination among the various international bureaucracies. But another reason is that the big aid agencies, unlike non-governmental organisations, must work in partnership with government.
Nigeria’s current state using the WHO health indicators can only be compared to the health status of the developed countries in the 19th century. The solution to the current health status of the country will require us learning from the experience of the developed countries. That Nigeria’s health care system is in a comatose state is no longer in doubt. What is required is urgent and immediate intervention by all well meaning Nigerians who are in a position to do so.