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Nigeria - Health
Primary Health Care Policies
In August 1987, the federal government launched its Primary Health Care plan (PHC), which President Ibrahim Babangida announced as the cornerstone of health policy. Intended to affect the entire national population, its main stated objectives included accelerated health care personnel development; improved collection and monitoring of health data; ensured availability of essential drugs in all areas of the country; implementation of an Expanded Programme on Immunization (EPI); improved nutrition throughout the country; promotion of health awareness; development of a national family health program; and widespread promotion of oral rehydration therapy for treatment of diarrheal disease in infants and children. Implementation of these programs was intended to take place mainly through collaboration between the Ministry of Health and participating local government councils, which received direct grants from the federal government.
Of these objectives, the EPI was the most concrete and probably made the greatest progress initially. The immunization program focused on four major childhood diseases: pertussis, diphtheria, measles, and polio, and tetanus and tuberculosis. Its aim was to increase dramatically the proportion of immunized children younger than two from about 20 percent to 50 percent initially, and to 90 percent by the end of 1990. Launched in March 1988, the program by August 1989 was said to have been established in more than 300 of 449 LGAs. Although the program was said to have made much progress, its goal of 90 percent coverage was probably excessively ambitious, especially in view of the economic strains of structural adjustment that permeated the Nigerian economy throughout the late 1980s.
The government's population control program also came partially under the PHC. By the late 1980s, the official policy was strongly to encourage women to have no more than four children, which would represent a substantial reduction from the estimated fertility rate of almost seven children per woman in 1987. No official sanctions were attached to the government's population policy, but birth control information and contraceptive supplies were available in many health facilities.
The federal government also sought to improve the availability of pharmaceutical drugs. Foreign exchange had to be released for essential drug imports, so the government attempted to encourage local drug manufacture; because raw materials for local drug manufacture had to be imported, however, costs were reduced only partially. For Nigeria both to limit its foreign exchange expenditures and simultaneously to implement massive expansion in primary health care, foreign assistance would probably be needed. Despite advances against many infectious diseases, Nigeria's population continued through the 1980s to be subject to several major diseases, some of which occurred in acute outbreaks causing hundreds or thousands of deaths, while others recurred chronically, causing large-scale infection and debilitation. Among the former were cerebrospinal meningitis, yellow fever, Lassa fever and, most recently, AIDS; the latter included malaria, guinea worm, schistosomiasis (bilharzia), and onchocerciasis (river blindness). Malnutrition and its attendant diseases also continued to be a refractory problem among infants and children in many areas, despite the nation's economic and agricultural advances.
Among the worst of the acute diseases was cerebrospinal meningitis, a potentially fatal inflammation of the membranes of the brain and spinal cord, which can recur in periodic epidemic outbreaks. Northern Nigeria is one of the most heavily populated regions in what is considered the meningitis belt of Africa, stretching from Senegal to Sudan and all areas having a long dry season and low humidity between December and April. The disease plagued the northern and middle belt areas in 1986 and 1989, generally appearing during the cool, dry harmattan season when people spend more time indoors, promoting contagious spread. Paralysis, and often death, can occur within forty-eight hours of the first symptoms.
In response to the outbreaks, the federal and state governments in 1989 attempted mass immunization in the affected regions. Authorities pointed, however, to the difficulty of storing vaccines in the harsh conditions of northern areas, many of which also had poor roads and inadequate medical facilities.
Beginning in November 1986 and for several months thereafter, a large outbreak of yellow fever occurred in scattered areas. The most heavily affected were the states of Oyo, Imo, Anambra, and Cross River in the south, Benue and Niger in the middle belt, and Kaduna and Sokoto in the north. There were at least several hundred deaths. Fourteen million doses of vaccine were distributed with international assistance, and the outbreak was brought under control.
Lassa fever, a highly contagious and virulent viral disease, appeared periodically in the 1980s in various areas. The disease was first identified in 1969 in the northeast Nigerian town of Lassa. It is believed that rats and other rodents are reservoirs of the virus, and that transmission to humans can occur through droppings or food contamination in and around homes. Mortality rates can be high, and there is no known treatment.
The presence of AIDS in Nigeria was officially confirmed in 1987, considerably later than its appearance and wide dispersion in much of East and Central Africa. In March 1987, the minister of health announced that tests of a pool of blood samples collected from high risk groups had turned up two confirmed cases of AIDS, both HIV Type-1 strains. Subsequently, HIV-2, a somewhat less virulent strain found mainly in West Africa, was also confirmed. In 1990 the infection rate for either virus in Nigeria was thought to be below 1 percent of the population.
Less dramatic than the acute infectious diseases but often equally destructive were a host of chronic diseases that were serious and widespread but only occasionally resulted in death. Of these the most common was malaria, including cerebral malaria, which can be fatal. The guinea worm parasite, which is spread through ingestion of contaminated water, is endemic in many rural areas, causing recurring illness and occasionally permanently crippling its victims. The World Health Organization (WHO) in 1987 estimated that there were 3 million cases of guinea worm in Nigeria--about 2 percent of the world total of 140 million cases- -making Nigeria the nation with the highest number of guinea worm cases. In affected areas, guinea worm and related complications were estimated to be the major cause of work and school absenteeism.
Virtually all affected states had campaigns under way to eradicate the disease through education and provision of pure drinking water supplies to rural villages. The government has set an ambitious target of full eradication by 1995, with extensive assistance from the Japanese government, Global 2000, and numerous other international donors.
The parasitic diseases onchocerciasis and schistosomiasis, both associated with bodies of water, were found in parts of Nigeria. Onchocerciasis is caused by filarial worms transmitted by small black flies that typically live and breed near rapidly flowing water. The worms can damage the eyes and optic nerve and can cause blindness by young adulthood or later. In some villages near the Volta River tributaries where the disease is endemic, up to 20 percent of adults older than thirty are blind because of the disease. Most control efforts have focused on a dual strategy of treating the sufferers and trying to eliminate the flies, usually with insecticide sprays. The flies and the disease are most common in the lowland savanna areas of the middle belt.
Schistosomiasis is caused by blood flukes, which use freshwater snails as an intermediate host and invade humans when the larvae penetrate the skin of people entering a pond, lake, or stream in which the snails live. Most often, schistosomiasis results in chronic debilitation rather than acute illness.
Whereas traditional medicine continued to play an important role in Nigeria in 1990, the country made great strides in the provision of modern health care to its population in the years since World War II, particularly in the period after independence. Among the most notable accomplishments were the expansion of medical education, the improvement of public health care, the control of many contagious diseases and disease vectors, and the provision of primary health care in many urban and rural areas. In the late 1980s, a large increase in vaccination against major childhood diseases and a significant expansion of primary health care became the cornerstones of the government's health policies.
Nonetheless, many problems remained in 1990. Sharp disparities persisted in the availability of medical facilities among the regions, rural and urban areas, and socioeconomic classes. The severe economic stresses of the late 1980s had serious impacts throughout the country on the availability of medical supplies, drugs, equipment, and personnel. In the rapidly growing cities, inadequate sanitation and water supply increased the threat of infectious disease, while health care facilities were generally not able to keep pace with the rate of urban population growth. There were several serious outbreaks of infectious diseases during the 1980s, including cerebrospinal meningitis and yellow fever, for which, especially in rural areas, treatment or preventive immunization was often difficult to obtain. Chronic diseases, such as malaria and guinea worm, continued to resist efforts to reduce their incidence in many areas. The presence of acquired immune deficiency syndrome (AIDS) in Nigeria was confirmed by 1987 and appeared to be growing.
History of Modern Medical Services
Western medicine was not formally introduced into Nigeria until the 1860s, when the Sacred Heart Hospital was established by Roman Catholic missionaries in Abeokuta. Throughout the ensuing colonial period, the religious missions played a major role in the supply of modern health care facilities in Nigeria. The Roman Catholic missions predominanted, accounting for about 40 percent of the total number of mission-based hospital beds by 1960. By that time, mission hospitals somewhat exceeded government hospitals in number: 118 mission hospitals, compared with 101 government hospitals.
Mission-based facilities were concentrated in certain areas, depending on the religious and other activities of the missions. Roman Catholic hospitals in particular were concentrated in the southeastern and midwestern areas. By 1954 almost all the hospitals in the midwestern part of the country were operated by Roman Catholic missions. The next largest sponsors of mission hospitals were, respectively, the Sudan United Mission, which concentrated on middle belt areas, and the Sudan Interior Mission, which worked in the Islamic north. Together they operated twenty-five hospitals or other facilities in the northern half of the country. Many of the mission hospitals remained important components of the health care network in the north in 1990.
The missions also played an important role in medical training and education, providing training for nurses and paramedical personnel and sponsoring basic education as well as advanced medical training, often in Europe, for many of the first generation of Western-educated Nigerian doctors. In addition, the general education provided by the missions for many Nigerians helped to lay the groundwork for a wider distribution and acceptance of modern medical care.
The British colonial government began providing formal medical services with the construction of several clinics and hospitals in Lagos, Calabar, and other coastal trading centers in the 1870s. Unlike the missionary facilities, these were, at least initially, solely for the use of Europeans. Services were later extended to African employees of European concerns. Government hospitals and clinics expanded to other areas of the country as European activity increased there. The hospital in Jos, for example, was founded in 1912 after the initiation there of tin mining.
World War I had a strong detrimental effect on medical services in Nigeria because of the large number of medical personnel, both European and African, who were pulled out to serve in Europe. After the war, medical facilities were expanded substantially, and a number of government-sponsored schools for the training of Nigerian medical assistants were established. Nigerian physicians, even if trained in Europe, were, however, generally prohibited from practicing in government hospitals unless they were serving African patients. This practice led to protests and to frequent involvement by doctors and other medical personnel in the nationalist movements of the period.
After World War II, partly in response to nationalist agitation, the colonial government tried to extend modern health and education facilities to much of the Nigerian population. A ten-year health development plan was announced in 1946. The University of Ibadan was founded in 1948; it included the country's first full faculty of medicine and university hospital, still known as University College Hospital. A number of nursing schools were established, as were two schools of pharmacy; by 1960 there were sixty-five government nursing or midwifery training schools. The 1946 health plan established the Ministry of Health to coordinate health services throughout the country, including those provided by the government, by private companies, and by the missions. The plan also budgeted funds for hospitals and clinics, most of which were concentrated in the main cities; little funding was allocated for rural health centers. There was also a strong imbalance between the appropriation of facilities to southern areas, compared with those in the north.
By 1979 there were 562 general hospitals, supplemented by 16 maternity and/or pediatric hospitals, 11 armed forces hospitals, 6 teaching hospitals, and 3 prison hospitals. Altogether they accounted for about 44,600 hospital beds. In addition, general health centers were estimated to total slightly less than 600; general clinics 2,740; maternity homes 930; and maternal health centers 1,240.
Ownership of health establishments was divided among federal, state, and local governments, and there were privately owned facilities. Whereas the great majority of health establishments were government owned, there was a growing number of private institutions through the 1980s. By 1985 there were 84 health establishments owned by the federal government (accounting for 13 percent of hospital beds); 3,023 owned by state governments (47 percent of hospital beds); 6,331 owned by local governments (11 percent of hospital beds); and 1,436 privately owned establishments (providing 14 percent of hospital beds).
The problems of geographic maldistribution of medical facilities among the regions and of the inadequacy of rural facilities persisted. By 1980 the ratios were an estimated 3,800 people per hospital bed in the north (Borno, Kaduna, Kano, Niger, and Sokoto states); 2,200 per bed in the middle belt (Bauchi, Benue, Gongola, Kwara, and Plateau states); 1,300 per bed in the southeast (Anambra, Cross River, Imo, and Rivers states); and 800 per bed in the southwest (Bendel, Lagos, Ogun, Ondo, and Oyo states). There were also significant disparities within each of the regions. For example, in 1980 there were an estimated 2,600 people per physician in Lagos State, compared with 38,000 per physician in the much more rural Ondo State.
In a comparison of the distribution of hospitals between urban and rural areas in 1980, Dennis Ityavyar found that whereas approximately 80 percent of the population of those states lived in rural regions, only 42 percent of hospitals were located in those areas. The maldistribution of physicians was even more marked because few trained doctors who had a choice wanted to live in rural areas. Many of the doctors who did work in rural areas were there as part of their required service in the National Youth Service Corps, established in 1973. Few, however, remained in remote areas beyond their required term.
Hospitals were divided into general wards, which provided both outpatient and inpatient care for a small fee, and amenity wards, which charged higher fees but provided better conditions. The general wards were usually very crowded, and there were long waits for registration as well as for treatment. Patients frequently did not see a doctor, but only a nurse or other practitioner. Many types of drugs were not available at the hospital pharmacy; those that were available were usually dispensed without containers, meaning the patients had to provide their own. The inpatient wards were extremely crowded; beds were in corridors and even consisted of mattresses on floors. Food was free for very poor patients who had no one to provide for them. Most, however, had relatives or friends present, who prepared or brought food and often stayed in the hospital with the patient. By contrast, in the amenity wards available to wealthier or elite patients, food and better care were provided, and drug availability was greater. The highest level of the Nigerian elite frequently traveled abroad for medical care, particularly when a serious medical problem existed.
In the early 1980s, because of shortages of fuel and spare parts, much expensive medical equipment could not be operated. Currency devaluation and structural adjustment beginning in 1986 exacerbated these conditions. Imported goods of all types doubled or tripled in price, and government and public health care facilities were severely affected by rising costs, government budget cuts, and materials shortages of the late 1980s. Partly as a result of these problems, privately owned health care facilities became increasingly important in the late 1980s. The demand for modern medical care far outstripped its availability. Medical personnel, drugs, and equipment were increasingly diverted to the private sector as government hospitals deteriorated.
Government health policies increasingly had become an issue of policy debate and public contention in the late 1980s. The issue emerged during the Constituent Assembly held in 1989 to draft a proposed constitution. The original draft reported by the assembly included a clause specifying that free and adequate health care was to be available as a matter of right to all Nigerians within certain categories. The categories included all children younger than eighteen; all people sixty-five and older; and all those physically disabled or handicapped. This provision was, however, deleted by the president and the governing council when they reviewed the draft constitution.
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