Health care Reform in Nigeria- a must.

Health care Reform in Nigeria- a must.- Dr Jide Obosi
Culled from obstacles to health reforms by Menadue John.
The problem with health reform is that even when major redesign is necessary, many ‘reformers' continue to think incrementally. Some believe that major redesign is impossible, that political timidity and acquiescence have become a way of life for many health ministers. They see the individual parts of the system working reasonably well, and fail to see that the system as a whole is inefficient and unfair. They ignore the obvious fact that the uncoordinated programs are provider-driven. Journalists are under-resourced to really understand a very complex system, yet patients encounter its failings every day.
Nigeria's so-called ‘health system' lacks clear underpinning values and direction. It lacks leadership - not money. Our health leaders lack the will for health reform because they are strongly influenced by the vested interests that abound in health - doctors (particularly specialists), state health bureaucracies, parochial political interests, private health insurance funds, pharmacies and the pharmaceutical companies.
The health ‘debate' is about placating these vested interests rather than listening to the community and patients. Ministers spend their energy in the financing of health programs, when production and delivery of health care is sclerotic. They are concerned with funding individual announcement-driven health programs, rather than integrating all health care.
Our health care structures have outlived their useful life. They were never designed as a ‘system'.
The need for major structural reform takes us well beyond the health portfolio as it is currently conceived. Our failure to invest in preventative health care, and the way we waste health resources have major economic consequences. Any government that is serious about micro-economic management must be concerned about the structural problems of health. Tony Abbott speaks of health as a ‘dog's breakfast', but has made no serious effort to fix the mess.
Fellow Nigerians, must we wait for the health care system to collapse completely before we address the rot? A proper health care reform agenda should be embarked upon by the present government. If this is not done, we are doomed for healthcare disaster in no distant future. As a major but important step, square pegs should be placed in square holes. The banking industry is flushing today because of the reforms through recapitalization, it was a painful process for many initially, but today the country is better in that sector. We need this reform in the healthcare sector; it is a matter of urgency.

Keeping Faith with Nigeria

It is good to be back home, after some weeks in USA. The air in Africa is wonderful, fresh and cool. when i touched down some days back, i realised how richly blessed Nigeria is as a country, from the natural vegetation to the great weather, the beautiful cloud and the most cheerful people on the face of planet earth.
Welcome back to my motherland, east or west, there is no place like home. I love this country, Nigeria can be great and can become one of the best in the world if we the citizens resolve to make her great. Our potentials are enomous. We can make her great, i believe. The big question is, do you believe?
If you believe, please rise up and contribute your own quota to make this great country the envy of all nations. This you can do by renouncing curruption, praying for good leadership, keeping our environment clean and most importantly keeping faith as a Nigerian.

ARISE OH COMPATRIOTS!

Health care crisis in Nigeria- When did it start?

TOPIC

“If health care is in “crisis” now, then it was in “crisis” ten, twenty, and forty years ago as well.”
By

Dr Jide Obosi, a term paper presented to school of Public Health, Department fo Health Services Management, Griffith University, Australia. March, 2006


Introduction

The health care system under review is the Nigerian Health care delivery system.
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. Healthcare issues have been an enigma in the life of Nigeria. Healthcare problem is a national emergency and it should be considered as such. Therefore, the present crisis in Nigeria’s Health care delivery system dates back to the colonial era of over forty years ago.
The continued stagnating healthcare system in Nigeria is of great social and economic consequence. Access to quality healthcare is either limited in Nigeria or nonexistent with staggering financial burden to families and the nation.

According to the American Heritage dictionary, crisis can be defined as,
a. A crucial or decisive point or situation; a turning point.
b. An unstable condition, as in political, social, or economic affairs, involving an impending abrupt or decisive change.
“A time of intense difficulty or danger; an unstable condition as in political, social or economic affairs” (Gerald W. McEntee, 2005)

Considering the Nigerian situation, it has been instability, disorganization, changes that are not maintained and followed up, forty years ago, the song was inadequate health facilities and few manpower, today it is poor management resulting in deterioration, rot and decay in the system with a drastic fall in quality and standard. Therefore, the crisis of forty years ago still persists but in a different context, this means that the health care system in Nigeria is in “Crisis” and was ten, twenty and forty years ago.
This essay will be discussed under the following headings,

· Overview
· Health care crisis of the colonial era
· Health care crisis post independence
· Health care crisis in contemporary Nigeria.
· Conclusion.








Overview of Nigerian Health Care System

Pre and colonial health care system

Before the arrival of Europeans in Nigeria, traditional medicine was the only recognized form of indigenous medical practice. The practitioners generally known as traditional healers throughout Africa are of several different kinds: some are herbalists, some bone setters and manipulators, and some dealt with spirits. An important part of their work is diagnosis which is practiced by divination rather than by the multiplicity of tests used in scientific medicine (Orley 1980).
In Nigeria, the practitioners of traditional medicine are referred to by indigenous names such as the adahunse or onisegun or babalawo of the Yoruba (Johnson and Johnson 1921), the gozan of the Nupe people (Nadel 1942), the mallam (religious scholar),wanzami (barber-surgeon), mai magan (herbalist), boka (magician-healer), masu bori (spirit possession cult), and sarguwa (midwife) of the Hausa (Stock 1983) and the dibia of the Igbo (Ecoma 1963). The advent of the Church Missionary Society in Nigeria in 1850 marked the beginning of modern scientific medicine there (Schram 1970, 1980); and Western scientific medicine came as a further alternative to the several existing indigenous systems of medicine (Orley 1980).
The establishment of colonial government, however, meant that the predominant proportion of modern health care was provided by the government, the Christian medical missions, and a small proportion of independent private medical practice (Lucas 1980).
The advent of the African churches which possibly now account for nearly one-half of all Christians in southern Nigeria, led to the emergence of faith-healing Christian churches. Thus there are three distinct kinds of health care providers: modern health care providers, traditional health care providers and faith-healers. Their services are often sought concurrently and sequentially depending on the nature of illness.

Post independence Health care system
Shortly after independence most government hospitals provided special facilities for civil servants, while the Christian medical missions provided hospital and community care for the most needy; and their programs were sometimes linked to their more vigorous activities in education (Lucas 1980).

Primary Health care System of the 90’s till date.

There is a three-tier system of health care, namely: Primary Health Care, Secondary Health Care, and Tertiary Health Care.
Primary Health Care The Provision of health care at this level is largely the responsibility of Local Governments with the support of sate ministries of health and within the overall national health policy. Private medical practitioners also provide health care at this level.
Secondary Health Care This level of health care provides specialized services to patients referred from the primary health care level through out-patient and in-patient services of hospitals for general medical, surgical, pediatric patients and community health services. Secondary health care is available at the district, divisional and zonal levels of the states. Adequate supportive services such as laboratory, diagnostic, blood bank, rehabilitation and physiotherapy are also provided.
Tertiary Health Care This level consists of highly specialized services provided by teaching hospitals and other specialist hospitals which provide care for specific diseases such as orthopedic, eye, psychiatric, maternity and pediatric cases. Care is taken to ensure an even distribution of these hospitals. Also, appropriate support services are incorporated into the development of these tertiary facilities to provide effective referral services. Similarly, selected centers are encouraged to develop special expertise in advantage modern technology to serve as a resource for evaluating and adapting these new developments in the context of local needs and opportunities.
To further the overall national health policy, governments of the Federation work closely with voluntary agencies, private practitioners and other non-governmental organizations to ensure that the services provided by these other agencies are in line with those of government.




Health care crisis in the Colonial era

The distribution of medical care and curative health services during the colonial era, as well as at independence, was uneven with heavy concentrations in the capital and in large urban centers to the detriment of the rural areas where the majority of the people live (Orubuloye and Caldwell 1975; Lucas 1980; Orubuloye and Oyeneye 1982).
This did not help the health care delivery system considering the fact that majority of the country’s population are in the rural area. This was a major crisis then with astronomical rise in infant and maternal mortality rate, reduced life expectancy and malnutrition ravaging the rural dwellers.
Another important crisis then was the issue of limited number of Medical personnel to man most of these scarce medical facilities, the only Medical College during the colonial era was the University College hospital Ibadan; this translates to very low turn over of doctors and nurses. During this period, every bed in government hospitals was filled, and there were long queues at the Out-patient departments.

Health care crisis Post Independence
Partly because of the existence of several systems of health care side by side, and the apparent uneven distribution of modern health facilities in Nigeria, much of the earlier social science health researchers in the 1970s and 1980s concentrated on health attitudes and treatment systems adopted: modern medicine, traditional healers, home remedies or faith-healing churches; or on the degree of access to health facilities (Caldwell 1994). One of the pioneering efforts was the research conducted in 1974 by Orubuloye under the supervision of J.C. Caldwell in southwest Nigeria on the effect of public health services on child mortality (Orubuloye 1974). The research showed that, when modern health facilities were available, most people used them; and there were significant differences by education of mothers and use of such services on the one hand, and child mortality on the other (Orubuloye and Caldwell 1975). The research also showed that modern medicines bought from chemists, patent medicine stores, and hawkers were also widely used. Several other subsequent studies such as that of Egunjobi (1983) in northern Oyo; Stock (1983) in Hadejia in northern Nigeria; Okafor (1984) in rural Bendel state; and Adedoyin and Watts (1989) in an indigenous area of the city of Ilorin confirmed the effects of accessibility and ability to pay with greater use of modern health facilities and improvement in health conditions. The cultural context of the decisions to use modern or traditional treatment also received a great deal of attention.

Nigerian society has changed from what it was during the oil boom years of the 1970s; the greatest changes have occurred in the area of health care. The charging for health services from 1984 is a major departure from the welfare philosophies of the pre- and post independence eras. The collapse of high export prices for petroleum, which accounts for 95 per cent of the nation’s gross national product, and the introduction of SAP, the economic structural adjustment adopted to meet the difficulties created by the end of the oil boom, are important changes in recent times. The Nigerian currency unit, the Naira, was worth US$1 before the 1987 float, but has now sunk to an all–time low value of US 25 cents. The floating of the Naira compounded the economic problem and made treatment compete with other personal and family costs as the cost of medicine rose sharply with other prices. In the first five years of the structural adjustment program, 1986-1990, government allocation of resources to the health sector ranged from just US 42 cents to US 62 cents per capita, an amount which was grossly inadequate to treat an attack of malaria (Popoola 1993), or a mere 1.6 to 1.9 per cent of the total federal government expenditure during 1980-90. The rising cost of health services and the imposition of user charges and fees where none previously existed have received the attention of other scholars in the health field (see Dennis 1992; Ogbu and Gallagher 1992).
Most government hospitals were almost deserted, as the number of people attending them dwindled rapidly, partly because of the expense of treatment caused by imposition of charges for government health services and a move towards selling prescribed medicines at market prices, and partly because most government hospitals have been reduced to mere consulting clinics due to lack of equipment and drugs. Many patients were attempting home cures or had turned to the traditional medical system or to the faith-healing churches (Orubuloye, Caldwell and Caldwell 1991).
The collapse of the government health care system has increased the proliferation of private medical practice and the establishment of private hospitals and clinics. Most of the private hospitals and clinics charge exorbitant prices, while some adopt a flexible pricing system that enables low income earners to benefit from the services they provide. One such private hospital is the Lifeline Children’s Hospital in Surulere (which means ‘patient pays’), Lagos, established in January 1994. According to the Associated Press report of 21 November 1994, the events that led to the establishment of the Lifeline Children’s Hospital are as follows:

When it became too painful to watch youngsters dying in government hospitals for lack of medicine and equipment, four women doctors from Lagos University Teaching Hospital (LUTH) bucked the system and opened Nigeria’s first private hospital for children. Their achievement is one of the few bright spots in a nation suffering from the greatest economic and political crisis in decades,
The report continued: a stream of patients flowed through the 20-bed hospital and consulting rooms during a recent evening and a mother remarked: ‘although treatment was expensive ... taking the kids to the government hospitals are like giving them the death sentence’. When one of the consultants was talking to the press, a nurse came in to report that a mother had no money for medicine. The consultant replied ‘Heavens the child needs it, give it (the medicine) to the mother and tell her to bring the money next week’.
According to the report, a bed at Lifeline Children’s Hospital costs 400 Naira or US$18 per night, about one-third of the monthly salary of the lowest-paid government worker. The above is an example of the frustration for most poor people since the introduction of the ‘user pays’ principle to the health care sector and the collapse of the exchange rate in 1987.
On realization of the imminent collapse of the health care systems, the federal government recently proposed a National Health Insurance Scheme as a complementary source of financing the health services. In a recent public statement by the government, it was emphasized that ‘it has become obvious that there was a great advantage in making the public to pay a little premium against the rainy days to ensure that the health services were readily available and acceptable’(West Africa 1994:874).



Health care crisis in contemporary Nigeria

In Nigeria, people die of minor illnesses that could have been prevented with simple medications and healthy lifestyle. 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 this phenomenon is catastrophic. In 2003, after religious and political leaders in the Kano region banned polio immunization, contending that it sterilized girls and spread HIV, an outbreak of polio spread through Nigeria and into neighboring 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.


Emeritus Professor of Medicine, University of Ibadan, Nigeria, Professor O.O. Akinkugbe, enunciated the healthcare problems in Nigeria and some recent improvements in his address entitled, “Nigeria’s Heath Status: Two Steps Forward, and One Back—The Enigma of Success in Retreat”. The excerpts:

“It is pertinent to note that the Alma Ata Declaration that triggered Health-For-All 2000 came on five years later and that today these are still the same conclusions that are being reached in present day proactive seminars in Health. A revisit of the 1973 Symposium was undertaken in 1995 to examine how far Nigeria has moved down the road of rebirth and repositioning in health.”

I will again quote from the mod-90’s revisit Symposium in which Professor Ransome-Kuti (now post-Ministerial) played a leading role. The preface to the 1995 Proceedings painted a series of scenarios:

“A child falls ill with fever, chills and convulsions in a village over half-a-day’s journey away from the nearest health center. 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 center. 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 a 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…”

Some other highlights were in Primary Health Care and its chronic deficiencies in terms of poor coordination of the functions of the Community Health Officers and the LGAs. Secondary Health Care was observed to be the weakest link in the chain, yet it is the area with the greatest potential for public/private sector partnership, and for the linkages both above all below that tier of health activity. It is observed that most secondary health care institutions had been totally run down and that a lot of funds were required to bring them back to shape.
On the Tertiary Health Care it drew attention to the cost-benefit implications of devoting a substantial portion of the country’s health resource to less than 1% of the entire population. But in doing so we must remind ourselves that Teaching Hospitals do much more than train undergraduates. Their other areas of responsibility include research that advances knowledge and training of high, intermediate and other levels of manpower. It is agreed that they should be funded a lot more than was being done right now so that they could discharge their various activities optimally and effectively.
With the dedicated leadership of Ransome-Kuti in the later half of the 80s considerable progress was made in articulating a National Health Policy in which Primary Health Care was positioned as its major thrust. Rural health effort was made synchronous in its distribution and shared responsibility with Local Governmental activities so that its benefits would readily permeate the communities that need it most. Rapid progress was made in the areas of Immunization, Communicable and Non-Communicable Diseases, Essential drugs and Vertical programs partly supported by international and non-governmental organizations such as WHO, UNICEF, UNDP and other development partners. The low funding of many laudable programs worked hardship on their successful implementation and by the end of the 1990s health care seemed to have reached its most pathetic level.

Conclusion

It is a sad reality that Nigeria has a healthcare crisis of ominous proportion. If the healthcare system had been adequate, we would not have countless wealthy Nigerians and government officials in foreign hospitals for medical check-ups. Some of these people are dying in hospitals thousands of miles away from the shores of Nigeria because they got there too late. From the above analysis, it is obvious that the Nigerian health care system is in serious crisis now, ten, twenty and forty years ago.



References


1. Ademuwagun, Z. A. 1977. Determinants of patterns and degree of utilization of health services in Western State, Nigeria. Israel Journal of Medical Science 13:896-907.

2. Caldwell, John C. 1979. Education as a factor in mortality decline: an examination of Nigerian data. Population Studies 33:395-413.

3. Christakis, Nicholas A., Norma C. Ware and Arthur Kleinman. 1994. Illness behavior and the health transition in the developing world. Pp 275-302 in Health and Social Change in International Perspective, ed. L.C. Chen, A. Kleinman and N.C. Ware. Cambridge MA: Harvard University Press.

4. Egunjobi, L. 1983. Factors influencing choice of hospitals: a case study of the northern parts of Oyo State, Nigeria. Social Science and Medicine 17,9:585-589.

5. Lucas, Adetokunbo A. 1980. What we inherited: an evaluation of what was left behind at Independence and its effects on health and medicine subsequently. Pp. 239-248 in Health in Tropical Africa during the Colonial Period, ed. E.E. Sabben-Clare, D.J. Bradley and K. Kirkwood. Oxford: Clarendon Press.

6. Nigeria, Federal Ministry of National Planning. 1940-56, 1962-68, 1970-74, 1975-80, 1981-85. The Nigeria National Development Plans. Lagos.

7. Okafor, Francis C. 1984. Accessibility to general hospitals in rural Bendel State, Nigeria. Social Science and Medicine 18,8:661-666.

8. Orley, John. 1980. Indigenous concepts of disease and their interaction with scientific medicine. Pp. 127-137 in Health in Tropical Africa during the Colonial Period, ed. E.E. Sabben-Clare, D.J. Bradley and K. Kirkwood. Oxford: Clarendon Press.

9. Orubuloye I.O. 1974. Differentials in the provision of health services and its impact on mortality: a study of Ido and Isinbode communities in Ekiti Division of Western Nigeria. M.Sc Thesis, Department of Sociology, University of Ibadan.


10. Orubuloye, I.O., J.C. Caldwell, Pat Caldwell and C.H. Bledsoe. 1991. The impact of family and budget structure on health treatment in Nigeria. Health Transition Review 1,2:189-210.

11. Popoola, Deji. 1993. Nigeria: consequences for health. In The Impact of Structural Adjustment on the Population of Africa: Implications for Education, Health and Employment, ed. Aderanti Adepoju. London: Heinemann.


12. The American Heritage Dictionary of the English language, Fourth Edition copyright 2004, 2000 by Houghton Mifflin Company. Published by Houghtin Mifflin Company.

13. UNICEF. 1992, 1994: State of the World’s Children. New York: Oxford University Press.

14. Uyanga, Joseph. 1979. The characteristics of patients of spiritual healing homes and traditional doctors in southeastern Nigeria. Social Science and Medicine 13A:323-329.

15. West Africa. 1994. Health insurance decree out soon. 16-22 May:874-875.

Health Care in Nigeria- The Malaria Burden.

Healthcare in Nigeria- The malaria burden

by

Dr Jide Obosi,a five minutes presentation at The Summer Institute, Blomberg School of Public Health, Johns Hopkins University, Baltimore, USA. June 2007.

Healthcare in Nigeria- the malaria Burden

Where is this country, called Nigeria? Located in the heart of Africa at the eastern boarder of West Africa. Nigeria is the most populous black nation in the world She is the giant of Africa with a population of over 146 million people, which is about half the population of the United States of America.

Her people are lovely and friendly; they love soccer (we call it football) and are endowed with rich culture.

After her independence in 1960, there was so much hope and determination, this translated to hard work and rapid development. But due to long period of military dictatorship, corruption and nepotism reigned supreme and democracy was raped in broad day light. This culminated to tribalism, (in a country with over 250 ethnic nationalities), greed and avarice, lack of credible leaders and policy makers, and then chaos and medical mayhem.

Presently, the healthcare delivery system rest on government hospitals which has deteriorated due to lack of government investment, strikes by public service workers. Also contributing to the health care delivery system are the private hospitals and clinics. These centres are very expensive; therefore, cannot serve the general population who eventually resort to the use of herbalists or voodoo doctors for medical treatment.

What do we get?

Malaria and other health maladies like,
Water borne diseases which include traveller diarrhoea, typhoid fever, cholera, others are, worms, HIV,tuberculosis, snake bites, flu, the list is endless.

Malaria a major headache.
Malaria is caused by protozoa which is transmitted to man through the bite of mosquitoes. This means that it is associated with poverty due to filth, stagnant water and untidy environments. Malaria has both perceived risk and real risk. Perceived risk due to beliefs and poor diagnosis with attendant drug resistance in endemic areas.
But the real risk is the high mortality rate it causes in the world not just Nigeria or Africa.
For more than 50years, the idea of one million deaths due to malaria has been on the lips of everybody especially cited by scientists and journalists. Unfortunately, it has gradually increased to 2.7 million deaths annually. In Africa, 75% of these are children. According to the American journal of tropical medicine and hygiene, over 85% of the malaria induced deaths are due to anaemia, low birth weight and malnutrition.

Having identified this monster, how do we prevent or reduce this figure in Nigeria?

Ladies and gentlemen, the time to act is now, as public health professionals, our attention should be turned to the third world especially Africa so that grants can be made available in curbing this disease called malaria. These grants can be ploughed into,
-awareness campaigns in malaria prevention as it is being done for HIV
-Provision of malaria prevention and treatment medications
- Provision of Laboratory equipment for early and proper diagnosis.
-Education on clean environment
- Good clothing for children
-Provision of mosquito repellents

Governments should be properly advised to increase funding for the health sector of the economy.

Finally, democracy should be sustained and supported by developed nations, this will invariably produce good leadership and policies which will translate into good health for the people of Nigeria and Africa.

Thank you.