World Report
Will Nigeria’s new government fix the health system? Nigeria’s health system has not received the attention or finances it needs to address the country’s disease burdens. Will the new government address the problems? Andrew Green reports.
www.thelancet.com Vol 387 January 9, 2016
improvements in overall vaccination coverage, “immunization coverage remained low for most vaccines, including measles”. By 2013, no vaccine exceeded 65% national coverage, the researchers found. Substantial gains have also occurred in maternal and child health, including a drop in the mortality rate for children younger than 5 years from 213 deaths for every 1000 livebirths in 1990 to
“Nigerian politicians erect hospitals, but fail to stock them with drugs and supplies or fail to spend the money on primary health-care centres to provide basic services at a community level...” 117 in 2013, according to WHO. In the same period, maternal mortality plummeted from 1200 deaths for every 100 000 livebirths to 560. Yet, on an international scale, the country still has a large burden of maternal deaths— responsible for 14% of the world’s total, according to the UN Population Fund. Ultimately, Ike Anya, the principal consultant for EpiAFRIC, a health
consultancy firm, said it remains a challenge to accurately represent any gains the country has made or identify major gaps in the health system. “There are no regular surveys examining access to health care”, he said. “Some of the health indices have shown some modest improvement over the last 10 years or so, which may be indicative of some level of improvement in access. There is, however, still widespread variation within the country.”
For the IHME study see http:// bmcmedicine.biomedcentral. com/articles/10.1186/s12916015-0438-9
Health expenditure Nigeria has been one of Africa’s economic success stories. An average growth rate of 7% during the past decade made it the 22nd-largest economy in the world by gross domestic product in 2014, according to the World Bank—and easily the biggest on the continent. Those gains have not led to consistent improvements in people’s access to primary health care. Nigeria does not crack the top 100 countries in terms of health expenditure per head, according to World Bank rankings, falling well
Karen Kasmauski/Corbis
The demands on Nigeria’s public health system, already under-resourced and overstretched, are mounting. Health workers must continue to respond to the communicable diseases responsible for most of the country’s deaths, along with the ongoing humanitarian crisis that stems from the Boko Haram insurgency in the northeast. But, thanks to one of the world’s fastest-growing economies, they are increasingly expected to also diagnose and treat the non-communicable diseases (NCDs) common in more high-income countries. The public health system simply cannot keep up with all the demands, officials and observers say. Although its swift reaction to an Ebola outbreak last year showed the country’s capacity to rapidly and effectively marshal a health response, officials are not convinced the lessons can translate into other areas of the imbalanced system. To a large extent, progress will depend on what kind of commitment the country’s new president, Muhammadu Buhari, is willing to make to improving health care in Nigeria. “It’s taken us quite a long time to get to where we are”, said Oyewale Tomori, a professor of virology and the former chancellor of Redeemer’s University, Ede, Osun, Nigeria. “But what you see as success is in spots, not in the general state of health in the country.” Nigeria’s health sector has seen uneven developments over the past several decades. The country’s most-heralded recent success was being removed from WHO’s list of polio-endemic countries in September, 2015, after more than a year without reporting a case. But a study from the University of Washington’s Institute for Health Metrics and Evaluation (IHME) published in 2015 reported that despite
Patients wait to be seen at a primary health-care centre, Gusau, Nigeria
111
World Report
behind South Africa, the continent’s other economic powerhouse. And even where money is spent, Tomori noted, it is often on misplaced priorities. Nigerian politicians erect hospitals, but fail to stock them with drugs and supplies or fail to spend the money on primary health-care centres to provide basic services at a community level, he said. “We’re focusing more on those highly structured teaching hospitals and the result is, we’ve neglected primary health care”, he said. “People with rudimentary illnesses are coming to teaching hospitals.” This imbalance exacerbates the disparities created by the already lower-than-average ratio of doctors to patients in some of the country’s more remote areas. While Nigeria’s overall ratio, at 39 for every 100 000 people, is one of the highest on the continent, according to WHO, doctors are concentrated in the cities and semiurban areas. The rural northeast, home to 13% of the population, according to the 2006 census, has less than 5% of the country’s doctors. Meanwhile, unrest within the health worker ranks has led to extended strikes within the public system. M Oladoyin Odubanjo, the executive secretary of the Nigerian Academy of Science, said disputes have arisen over a host of different issues, including accusations of corruption and the adoption of policies that seem to favour some cadres over others. These perceptions can ultimately trigger vast swathes of the country’s health workforce to walk off the job. It has created what Odubanjo described as “a professional war between the groups. It’s largely the doctors, but also the rest”, including disputes between technicians and specialists. These issues converge to create an environment of uneven health care. “While it’s widely known that Nigeria experiences high levels of wealth inequality”, said Emmanuela Gakidou, IHME’s director of academic development and training, “I was definitely struck by 112
how large and persistent the health inequalities were across states”. While Nigeria’s economic gains are neither broadly shared nor reflected in the country’s health response, they have fuelled a rising middle class whose lifestyles—becoming less active, eating fattier foods—are having an effect on the health system. “Even as we still struggle with the burden of communicable diseases”, EpiAFRIC’s Anya said, “we are indeed seeing a rising incidence of NCDs like cancer, diabetes, and cardiovascular disease”. WHO estimates the probability of dying between the ages of 30 and 70 years from one of the four major NCDs—cancers,
“‘There are a lot of expectations that the government will take advice and make a lot of progress.’” diabetes, cardiovascular diseases, or chronic respiratory diseases—at 20% in Nigeria. Meanwhile, the country has virtually no NCD response in place. And then there are the humanitarian needs driven by the 6-year Boko Haram insurgency in the country’s northeast. At least 1000 people have died in fighting since May, 2015, and more than 2 million people are now displaced—including 1·6 million internally—following attacks by the extremist group. Despite a year-long government crackdown on the group, violence continues and people remain unable to move from the crowded camps. Médecins Sans Frontières has complained that poor water and sanitation conditions are contributing to disease outbreaks, including a bout of cholera in late 2015 that killed at least 16 people.
New government The task facing the new government, which took office at the end of May, 2015, is to figure out how to respond more effectively to all of these challenges. “Doing this requires
leadership, prioritisation, and proper planning and allocation of resources”, Anya said. “It is a challenge, but not unachievable.” Several experts highlighted the country’s Ebola response, suggesting it offered lessons to improve the health system. Ebola arrived in Nigeria in late July, 2014, when an undiagnosed patient flew to Lagos and collapsed at the airport. A few days later, he died—but not before infecting several others, including health workers at the private hospital where he was being treated. Nevertheless, the country quickly contained the outbreak and was declared Ebola-free by October. Odubanjo said the patient’s diagnosis prompted a flurry of activities—trainings, construction of isolation wards, and widespread contact tracing. The most important feature of the response, though, might have been the government’s willingness to provide its experts with the necessary resources and then step out of their way. It proved, he said, “we have the capacity to deal with most things if only we could put in the same kind of drive, will, money, management, and finances that we put into these emergency situations”. It is still too early to tell if Buhari, who only swore in his new cabinet in November of last year, is willing to commit those resources to the health system. There was little discussion of health care during the campaign, which was dominated by issues of terrorism and corruption. But there is some hope he might. “It is expected that the new government will take stock and review strategies that have been in use before now, which have not yielded the level of results desired”, said Akin Osibogun, who recently stepped down as chief medical director of the Lagos University Teaching Hospital. “There are a lot of expectations that the government will take advice and make a lot of progress.”
Andrew Green www.thelancet.com Vol 387 January 9, 2016
Will Nigeria’s new government fix the health system? Nigeria’s health system has not received the attention or finances it needs to address the country’s disease burdens. Will the new government address the problems? Andrew Green reports.
www.thelancet.com Vol 387 January 9, 2016
improvements in overall vaccination coverage, “immunization coverage remained low for most vaccines, including measles”. By 2013, no vaccine exceeded 65% national coverage, the researchers found. Substantial gains have also occurred in maternal and child health, including a drop in the mortality rate for children younger than 5 years from 213 deaths for every 1000 livebirths in 1990 to
“Nigerian politicians erect hospitals, but fail to stock them with drugs and supplies or fail to spend the money on primary health-care centres to provide basic services at a community level...” 117 in 2013, according to WHO. In the same period, maternal mortality plummeted from 1200 deaths for every 100 000 livebirths to 560. Yet, on an international scale, the country still has a large burden of maternal deaths— responsible for 14% of the world’s total, according to the UN Population Fund. Ultimately, Ike Anya, the principal consultant for EpiAFRIC, a health
consultancy firm, said it remains a challenge to accurately represent any gains the country has made or identify major gaps in the health system. “There are no regular surveys examining access to health care”, he said. “Some of the health indices have shown some modest improvement over the last 10 years or so, which may be indicative of some level of improvement in access. There is, however, still widespread variation within the country.”
For the IHME study see http:// bmcmedicine.biomedcentral. com/articles/10.1186/s12916015-0438-9
Health expenditure Nigeria has been one of Africa’s economic success stories. An average growth rate of 7% during the past decade made it the 22nd-largest economy in the world by gross domestic product in 2014, according to the World Bank—and easily the biggest on the continent. Those gains have not led to consistent improvements in people’s access to primary health care. Nigeria does not crack the top 100 countries in terms of health expenditure per head, according to World Bank rankings, falling well
Karen Kasmauski/Corbis
The demands on Nigeria’s public health system, already under-resourced and overstretched, are mounting. Health workers must continue to respond to the communicable diseases responsible for most of the country’s deaths, along with the ongoing humanitarian crisis that stems from the Boko Haram insurgency in the northeast. But, thanks to one of the world’s fastest-growing economies, they are increasingly expected to also diagnose and treat the non-communicable diseases (NCDs) common in more high-income countries. The public health system simply cannot keep up with all the demands, officials and observers say. Although its swift reaction to an Ebola outbreak last year showed the country’s capacity to rapidly and effectively marshal a health response, officials are not convinced the lessons can translate into other areas of the imbalanced system. To a large extent, progress will depend on what kind of commitment the country’s new president, Muhammadu Buhari, is willing to make to improving health care in Nigeria. “It’s taken us quite a long time to get to where we are”, said Oyewale Tomori, a professor of virology and the former chancellor of Redeemer’s University, Ede, Osun, Nigeria. “But what you see as success is in spots, not in the general state of health in the country.” Nigeria’s health sector has seen uneven developments over the past several decades. The country’s most-heralded recent success was being removed from WHO’s list of polio-endemic countries in September, 2015, after more than a year without reporting a case. But a study from the University of Washington’s Institute for Health Metrics and Evaluation (IHME) published in 2015 reported that despite
Patients wait to be seen at a primary health-care centre, Gusau, Nigeria
111
World Report
behind South Africa, the continent’s other economic powerhouse. And even where money is spent, Tomori noted, it is often on misplaced priorities. Nigerian politicians erect hospitals, but fail to stock them with drugs and supplies or fail to spend the money on primary health-care centres to provide basic services at a community level, he said. “We’re focusing more on those highly structured teaching hospitals and the result is, we’ve neglected primary health care”, he said. “People with rudimentary illnesses are coming to teaching hospitals.” This imbalance exacerbates the disparities created by the already lower-than-average ratio of doctors to patients in some of the country’s more remote areas. While Nigeria’s overall ratio, at 39 for every 100 000 people, is one of the highest on the continent, according to WHO, doctors are concentrated in the cities and semiurban areas. The rural northeast, home to 13% of the population, according to the 2006 census, has less than 5% of the country’s doctors. Meanwhile, unrest within the health worker ranks has led to extended strikes within the public system. M Oladoyin Odubanjo, the executive secretary of the Nigerian Academy of Science, said disputes have arisen over a host of different issues, including accusations of corruption and the adoption of policies that seem to favour some cadres over others. These perceptions can ultimately trigger vast swathes of the country’s health workforce to walk off the job. It has created what Odubanjo described as “a professional war between the groups. It’s largely the doctors, but also the rest”, including disputes between technicians and specialists. These issues converge to create an environment of uneven health care. “While it’s widely known that Nigeria experiences high levels of wealth inequality”, said Emmanuela Gakidou, IHME’s director of academic development and training, “I was definitely struck by 112
how large and persistent the health inequalities were across states”. While Nigeria’s economic gains are neither broadly shared nor reflected in the country’s health response, they have fuelled a rising middle class whose lifestyles—becoming less active, eating fattier foods—are having an effect on the health system. “Even as we still struggle with the burden of communicable diseases”, EpiAFRIC’s Anya said, “we are indeed seeing a rising incidence of NCDs like cancer, diabetes, and cardiovascular disease”. WHO estimates the probability of dying between the ages of 30 and 70 years from one of the four major NCDs—cancers,
“‘There are a lot of expectations that the government will take advice and make a lot of progress.’” diabetes, cardiovascular diseases, or chronic respiratory diseases—at 20% in Nigeria. Meanwhile, the country has virtually no NCD response in place. And then there are the humanitarian needs driven by the 6-year Boko Haram insurgency in the country’s northeast. At least 1000 people have died in fighting since May, 2015, and more than 2 million people are now displaced—including 1·6 million internally—following attacks by the extremist group. Despite a year-long government crackdown on the group, violence continues and people remain unable to move from the crowded camps. Médecins Sans Frontières has complained that poor water and sanitation conditions are contributing to disease outbreaks, including a bout of cholera in late 2015 that killed at least 16 people.
New government The task facing the new government, which took office at the end of May, 2015, is to figure out how to respond more effectively to all of these challenges. “Doing this requires
leadership, prioritisation, and proper planning and allocation of resources”, Anya said. “It is a challenge, but not unachievable.” Several experts highlighted the country’s Ebola response, suggesting it offered lessons to improve the health system. Ebola arrived in Nigeria in late July, 2014, when an undiagnosed patient flew to Lagos and collapsed at the airport. A few days later, he died—but not before infecting several others, including health workers at the private hospital where he was being treated. Nevertheless, the country quickly contained the outbreak and was declared Ebola-free by October. Odubanjo said the patient’s diagnosis prompted a flurry of activities—trainings, construction of isolation wards, and widespread contact tracing. The most important feature of the response, though, might have been the government’s willingness to provide its experts with the necessary resources and then step out of their way. It proved, he said, “we have the capacity to deal with most things if only we could put in the same kind of drive, will, money, management, and finances that we put into these emergency situations”. It is still too early to tell if Buhari, who only swore in his new cabinet in November of last year, is willing to commit those resources to the health system. There was little discussion of health care during the campaign, which was dominated by issues of terrorism and corruption. But there is some hope he might. “It is expected that the new government will take stock and review strategies that have been in use before now, which have not yielded the level of results desired”, said Akin Osibogun, who recently stepped down as chief medical director of the Lagos University Teaching Hospital. “There are a lot of expectations that the government will take advice and make a lot of progress.”
Andrew Green www.thelancet.com Vol 387 January 9, 2016
