Despite the collaborative efforts of both Nigerian Government, Donor Agencies and NGOs to provide an efficient and effective health care delivery in Nigeria, confronting problems render these efforts much less than desired. Some of these challenging problems include emerging and re-emerging health problems such as HIV/AIDS pandemic, inadequate payment of health workers salaries, poor quality of care, inequitable health care services, brain drain, and irrational appointment of health workers among others. The weight of these problems is further compounded by insufficient budget allocation, lack of strategic plan and preparedness for epidemics/pandemics
Nigeriaâs Public Health: Gains and Challenges
by Marycelin Baba*
and Babatunji Omotara
Professors, College of Medical Sciences, University of Maiduguri, Nigeria
Nigeria, the most populous country in Africa with 140 million people, has more than 250 ethnic groups http://www.columbia-icap.org/wherewework/nigeria/index.html. The vast oil wealth accounts for 40% of the countryâs gross domestic product. However, years of military rule, and mismanagement have limited the country’s economic growth and resulted in rising levels of poverty. The rating by the United Nations Human Poverty Index in 1999 revealed that Nigeria has been ranked among the poorest nations in the world. Per capita income is estimated at $692 25th USD, with an estimated two-thirds of the population living in poverty. However, in addition to rebuilding the economic and political system of the country, the Nigerian government embarked upon rebuilding its heath infrastructure and since Nigeria operates a mixed economy, private providers of health care significantly contribute to health care delivery. Health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country and is structured such that, the Federal government’s role is mostly limited to coordinating the affairs of the University Teaching Hospitals, Federal Medical Centres (tertiary health care) while the state government manages the various general hospitals (secondary health care) and the local government focuses on dispensaries (primary health care) [1], (which are regulated by the federal government through National Primary Health Care Development Agency-NPHCDA). Although the recurrent expenditure on health has risen from Nigeria nairas 12.48 million in 1970 to 98.200 million in 2008 [2], health care system remains inefficient and plays a key role in the poverty status of the country. Over the last two decades, Nigeria’s public health care system has deteriorated in large partly because of a lack of resources and a “brain drain” syndrome of Nigerian doctors as well as skilled health workers to other countries. For instance, infant mortality rates have been deteriorating from 85 per 1000 live births in 1982, 87 in 1990, 93 in 1991 to 100 in 2003, according to the Nigeria Demographic and Health Survey, 2003. And in 2007, the Federal Ministry of Health reported 110 deaths per 1000 live births. Its under-five mortality rate is 197 deaths per 1000 live births, and HIV, malaria and diarrheal disease account for about a quarter of the deaths among adults http://www.psi.org/nigeria . In rural areas, access to even basic health care services is difficult. According to the world development indicators, the life expectancy at birth in 2006 for male and female in Nigeria was 46 and 47 years, respectively [3].
Map of Nigeria showing the different states
National Health Insurance Scheme
In May 1999, the government created the National Health Insurance Scheme (NHIS), which encompasses government employees, the organized private and informal sector. Legislative wise, the scheme also covers children under five, permanently disabled persons and prison inmates. Health insurance in Nigeria can be applied to a few instances: free health care provided and financed for all citizens, health care provided by government through a special health insurance scheme for government employees and private firms entering contracts with private health care providers http://www.nigeria.alloexpat.com/nigeria_information/healthcare_nigeria.php
However, there are few people who fall within the three instances. Moreover, for the past two or more decades, many Donor agencies and Non-Governmental Organizations (NGOs), usually in partnership with the States and Federal Ministries of Health, have played prominent roles in intervening in the provision of public health services to the teeming Nigerian population. Many of Donor Agencies and NGOs concentrated their activities on the prevention and control while few others focus on therapeutics and management of many endemic, emerging and reemerging diseases. Below are some of the public health interventions.
HIV/AIDS
Nigeria has 2.9 million people living with HIV/AIDS, the largest number in the world after India and South Africa. The HIV/AIDS pandemic, which has already left at least 930,000 children orphaned, and the high rates of maternal death and disability, are outstanding public health issues in Nigeria [4]. A high incidence of unsafe abortion is driven by legal restrictions and social stigma, while an extremely low rate of contraceptive use contributes to an estimated 1.4 million unintended pregnancies each year. In response to the growing HIV/AIDS pandemic treatment, USAID/Nigeria provides antiretroviral drugs and services to eligible patients, as well as laboratory support for the diagnosis and monitoring of HIV-positive patients. The treatment program features reduced target costs, cost-leveraging, and health care worker training by all implementing partners to harmonize and standardize treatment services. This program provides much-needed drugs to many Nigerians with HIV but can nowhere near address the growing HIV/AIDS infection rate. The Nigerian government has set a 2010 goal of providing universal access to HIV prevention, care, and treatment. To this end, it has implemented a number of strategies to scale up HIV services, including a national counseling and testing program and increased collaboration with external donors and non-governmental organizations.
Mental Health
The majority of mental health services are provided by 8 regional psychiatric centers and psychiatric departments and medical schools of 12 major universities. A few general hospitals also provide mental health services. The formal centres often face competition from native herbalists and faith healing centres. The ratio of psychologists and social workers is 0.02 to 100,000 [5].
Malaria
Malaria remains the foremost killer disease in Nigeria. It accounts for over 25% of under-5 mortality, 30% childhood mortality and 11% maternal mortality (http://www.psi.org/nigeria , Federal Ministry of Health-FMOH, 2002). To address the importance of both malaria treatment and prevention, the Society for Family Health (SFH) malaria programming centers on Pre-Packaged Therapy (PPT) and Long Lasting Insecticide Treated Nets (LLINs). Recently, the Federal Ministry of Health has implemented the new treatment policy on malaria which includes the use of Artemisinine-based Combination Therapy (ACT) as the new first line drug for the treatment of uncomplicated malaria. A new brand of ACT for Children KidACT was developed and launched in 2008. The brand is heavily subsidized for affordability to poor and vulnerable Nigerians who bear the brunt of malaria. Like other NGOs, SFH is promoting the government policy and in addition distributes PermaNet which is a long-lasting insecticide-treated net. The nets are inexpensive and distribution is an easy way of preventing malaria and possibly other vector-borne diseases from burdening the health and economic well-being of Nigerians.
Reproductive Health
Despite considerable gains in the past decade, Nigeria’s reproductive health indicators are still very poor. Country-wide, the total fertility rate is 5.7 children per mother, with a contraceptive prevalence rate of less than 10%. Furthermore, these statistics mask wide regional variationsâfor example, the total fertility rate in the northwestern region is as high as 7.3, with a contraceptive prevalence rate of 3% http://www.pathfind.org/our-work/where-we-work/nigeria/ . Lack of sexual health information and services make young people vulnerable to sexually transmitted infections (STIs) and unintended pregnancy. However, Nigerian government both at Federal and State is working in collaboration with many organizations to improve adolescent reproductive and sexual health through advocacy and prevention programming.
Child Survival
Child survival in Nigeria is threatened by nutritional deficiencies and illnesses, particularly malaria, diarrhoeal diseases, acute respiratory infections (ARI), and vaccine preventable diseases (VPD), which account for the majority of morbidity and mortality in childhood. Other threats include high maternal morbidity and mortality. Regarding child health, the country has adopted and implemented to a certain extent a number of major global initiatives affecting children, such as the Safe Motherhood Initiative and its follow-up Making Pregnancy Safer, Baby-Friendly Hospital Initiative (BFHI), and Integrated Management of Childhood Illness (IMCI). Others are Roll Back Malaria Initiative (RBM), Elimination of Iodine âDependent Diabetes, Vitamin A Deficiency Control, and National Program on Immunization (NPI), the latter with a special emphasis on the eradication of poliomyelitis. Yet the impact of interventions in child survival to a large extent have not achieved as much as would have been expected despite the amount of funds and resources that have been put into these programs. For instance, Nigeria is still one the three countries of the world harboring and spreading the three serotypes of wild polio viruses to different parts of the world despite ongoing intensive immunization activities because of non-compliancy to polio vaccination. It may be recalled that in 2003, there was a political propaganda that Polio vaccine contained infertility agents, spread HIV and was reported generally unsafe [6]. Although the safety of the polio vaccine was later proven beyond all reasonable doubt globally, and frantic efforts have been made to disabuse the minds of the people, pockets of parents still refuse their wards/children to receive the vaccine.
Tuberculosis control
Nigeria is ranked 4th among the 22 worst affected countries in the world and the first in Africa [7]. As such, about 460,000 new TB cases occur yearly in Nigeria (FMOH 2010 http://www.who.int/hiv/pub/guidelines/nigeria_tb.pdf).
Lagos state carries 8.4% of Nigeriaâs TB burden and consistently has been responsible for about 11% of the cases of TB registered in Nigeria (Lagos State Ministry of Health – www.lagosstateministryofhealth.com/programme_info.php?programme_id=13).
The State program is implementing the internationally recommended STOP TB Strategy.
USAID/Nigeria implements its HIV/AIDS and TB activities under a comprehensive approach with other United States Government agencies, including the Centers for Disease Control and Prevention and the Department of Defense, which are all working as part of the Presidentâs Emergency Plan for AIDS Relief (PEPFAR) (USAID, 2012 http://nigeria.usaid.gov/program/3). Activities are designed to reduce TB transmission, improve diagnosis, and manage multi-drug-resistant-TB cases, especially among HIV positive patients. Routine HIV testing is also a priority in USAIDâs TB Directly Observed Treatment Short-Course. The control and prevention of Tuberculosis in contemporary times has many faces and challenges. These, among others, include the impact of HIV/AIDS and the emergence of multi-drug resistant tuberculosis (MDR-TB). The HIV/AIDS pandemic is not only fuelling the burden of Tuberculosis but also poses great challenge to its diagnosis and management. The recorded HIV prevalence among TB cases in Nigeria is estimated at 27% (FMOH 2010 http://www.who.int/hiv/pub/guidelines/nigeria_tb.pdf).
Leprosy control Program
It has been estimated that about 5,000 leprosy cases occur yearly (FMOH 2010 http://www.who.int/hiv/pub/guidelines/nigeria_tb.pdf). By the 1940s and 50s Nigeria was ahead of many countries in its leprosy control activities. There has been significant reduction in the registered prevalence of leprosy with some evidence of reduced transmission. This has been attributed to increased and sustained control activities resulting in the elimination of the disease as a public health problem at national level. However, there are still endemic pockets at the sub-national level. An issue of concern in leprosy control remains the rehabilitation of a large number of ex-leprosy patients who have been cured of leprosy but have disabilities. In collaboration with many NGOs, effective, integrated leprosy control programs in which both female and male patients are identified, diagnosed and treated in the early stages of leprosy by the health system are ongoing. These programs also work to prevent and reduce impairments associated with leprosy, and to provide appropriate rehabilitation and education and vocational training opportunities for persons affected by leprosy [8].
Regulation of pharmaceuticals
In 1989 legislation made effective a list of essential drugs. The regulation was also meant to limit the manufacture and import of fake or sub-standard drugs and to curtail false advertising. However, the section on essential drugs was later amended [9]. Drug quality is primarily controlled by the National Agency for Food and Drug Administration and Control (NAFDAC). Several major regulatory failures have produced international scandals:
⢠In 1993, adulterated paracetamol syrup entered into the health care system in Oyo and Benue State, the end result of was the death of 100 children. A year after the disaster, batches containing poisonous ethylene glycol, the major cause of the deaths, could still be purchased.
⢠In 1996, about 11 children died of contamination from an experimental trial of the drug trovafloxacin. The usually long delayed action of the government to prosecute the perpetrators is considered a tragedy on its own.
⢠In 2008-2009, at least 84 children died from a brand of contaminated teething medication http://www.rtbot.net/Health_in_Nigeria
Geographic inequality
Health care in Nigeria is influenced by different local and regional factors that impact the quality or quantity present in one location. Due to the aforementioned, the health care system in Nigeria has shown spatial variation in terms of availability and quality of facilities in relation to need. However, this is largely as a result of the level of state and local government involvement and investment in health care programs and education. Also, the Nigerian ministry of health usually spends about 70% of its budget in urban areas where 30% of the population resides. It is assumed by some scholars that the health care service is inversely related to the need of patients.
Emigration
Migration of health care personnel to other countries is a taxing and relevant issue in the health care system of the country. From a supply push factor, a resulting rise in exodus of health care nurses may be due to dramatic factors that make the work unbearable, and knowing and presenting changes to arrest the factors may stem the tide [10]. However, because a large number of nurses and doctors migrating abroad benefited from government funds for education, it poses a challenge to the patriotic identity of citizens and also the rate of return of federal funding of health care education. The state of health care in Nigeria has been worsened by a physician shortage as a consequence of severe ‘brain drain’. Many Nigerian doctors have emigrated to North America and Europe. In 2005, 2,392 Nigeria doctors were practicing in the US alone, in UK the number was 1,529. Retaining these expensively trained professionals has been identified as an urgent goal. Within the country, 70% of the population reside in rural areas yet many health professionals prefer urban cities for their practice leaving the rural poor void of adequate medical care.
Challenges
⢠As a multiethnic, cultural, and religious country, many Nigerians still attribute many health problems to witches, demons and other mythical beliefs. Therefore, even when health care facilities are available, affordable and accessible, many prefer seeking treatment from untrained herbalist to orthodox health care institutions.
⢠Many health intervention programs fail because the decision and the implementation started from the top to the bottom. For example, people who never had fever are compelled to take paracetamol. The beliefs, attitudes and the behaviors of the community on a particular health problem usually is not sought before imposing the intervention strategy on the people.
⢠Professional conflict in the health sector is another canker worm that is killing the system. The claim of superiority of a particular health professional over others has greatly impacted negatively to health care delivery in Nigeria.
⢠Persistent âbrain drainâ is a ghost that is hunting efficient health care delivery in Nigeria.
⢠Lack of maintenance culture allows waste of resources in terms of equipment, finance and human resources. For instance, there is no need to procure sophisticated equipment if the operators are not properly trained to use and maintain such equipment. This negates one of the strategies of implementing Primary Health Care-Use of Appropriate Technology. Also after procuring the equipment, trained engineers are not engaged to regularly service and repair the equipment. Similarly employing experts without proper motivation and basic facility to work is effort in futility.
⢠Nepotism where health workers are employed based on sentiment (tribal or religious) certainly impedes the efficiency of health care delivery in Nigeria
⢠Improper implementation of health policy or intervention strategy affects health care delivery adversely.
⢠Drug resistance, due to indiscriminate drug use and abuse, has been on the increase and poses a serious threat to treatment efficacy
⢠Stigmatization associated with HIV/AIDS, Tuberculosis and Leprosy hinders early detection and control of spread.
⢠CORRUPTION is a plague that must be eradicated even before wild polio viruses if health care delivery in Nigeria must meet expected impact.
Conclusion
Despite the collaborative efforts of both Nigerian Government, Donor Agencies and NGOs to provide an efficient and effective health care delivery in Nigeria, confronting problems render these efforts much less than desired. Some of these challenging problems include emerging and re-emerging health problems such as HIV/AIDS pandemic, inadequate payment of health workers salaries, poor quality of care, inequitable health care services, brain drain, and irrational appointment of health workers among others. The weight of these problems is further compounded by insufficient budget allocation, lack of strategic plan and preparedness for epidemics/pandemics.
References
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3. Nathaniel Umukoro (2011):Governance and Nigeriaâs Public Health Care System: A Study of their Role in the Acceleration of Poverty Trap in the Niger Delta
4. Planned Parenthood (2012): Nigeria country program www.plannedparenthood.org/about-us/newsroom.htm
5. Oyedeji Ayonrinde, Oye Gureje, Rahmaan Lawal; ‘Psychiatric research in Nigeria: bridging tradition and modernisation’, The British Journal of Psychiatry (2004) 184: 536-538.
6. Guerrera M. 2007. Finish Polio: Evolutionary medicine principles and the eradication ofpolio in evolutionary medicine, Central Connecticut State University. Topics in Biology (Bio 490 / 540).
7. Dim CC, Dim NR, Morkve O. (2011):Tuberculosis: a review of current concepts and control programme in Nigeria. Niger J Med. 2011 Apr-Jun;20(2):200-6.
8. Canadian International Development Agency: Project Browser. Project profile for Leprosy Control project in Sokoto State (www.cida.gc.ca).
9. National Drug Policy in Nigeria, O. Ransome Kuti. Journal of Public Health Policy > Vol. 13, No. 3 (Autumn, 1992), pp. 367-373
10. Clark D A, Paul F. Clark, James B. Stewart; The Globalization of the Labour Market for Health-Care Professionals. International Labour Review, Vol. 145, 2006
*Corresponding author: Professor, Department of Medical Laboratory Science and Director, WHO National /ITD Laboratory, University of Maiduguri, Maiduguri Borno State, NIGERIA marycelinb@yahoo.com