A different perspective: After years of being a low priority, the sector is now a major focus

Overall indicators in Nigeria paint a picture of a country in need of developing its health sector, but prospects for growth and further modernisation are bright, as the industry has been improving gradually. Previously the federal government was relatively lax in facilitating the advance of the health care industry, but recent developments show that greater attention is being paid to a sector with the potential for substantial growth, given its consumer base of 160m.

INDICATORS: Life expectancy for the average Nigerian is low, at just 53 years for males and 54 for females, according to the World Health Organisation (WHO). Government funding of health care remains low, at just 5.9% of the 2012 budget. This figure is well below the 15% target established by the Abuja Declaration in 2001, when African Union countries pledged to spend at least that amount of their budgets on health care.

The delivery of quality health care in the country was inhibited by a health sector strike in Lagos State declared in April 2012 by the Joint Health Sector Union (JHSU), which includes doctors, nurses and other health care personnel. In response, the state government fired 788 striking doctors in May, only to reinstate them less than a month later. As a result, the JHSU suspended its strike, and as of July 2012 it was in negotiations concerning the consolidated medical salary structure — a salary benchmark used to adjust the salaries of government health providers to be in line with professionals in other sectors. The possibility of large-scale strikes in this vital sector stresses the need for greater private sector participation in the system.

ACCESS: As of 2008 just 4% of children under the age of one had received the BCG vaccination against tuberculosis, 3.6% a yellow fever injection, and 2.1% the measles, mumps and rubella vaccinations. Similar to other shortcomings in the health sector, these low inoculation rates are due to the lack of a robust primary care system. Further compounding the issue is the lack of access — financially and geographically — for many Nigerians to quality care. According to the WHO’s figures, Nigeria has just four physicians and five hospital beds for every 10,000 residents. The problem of access is especially prevalent in the northern states, which are primarily rural and poorer than their southern counterparts. In line with this, some 44% of physicians were working in the south-west of the country in 2007, according to the Ministry of Health. Additionally, more than half of all specialist physicians and about 60% of all nurses in the country work in the southern regions.

PROGRESS: Tangible progress has been made in the health sector as evidenced by several key metrics.

Reductions in under-five child mortality rates have been encouraging, dropping from 201 per 1000 live births in 2003 to 143 by 2010. Maternal health, though in need of further attention, has also seen improvement, with 800 deaths per 100,000 live births in 2003 reduced to 545 in 2008, according to the UN Development Programme (UNDP). Strides have also been made in curbing infectious diseases. Nigeria has already reached its Millennium Development Goal (MDG) by reducing the HIV rate among pregnant women ages 15 to 24, from 5.8% in 2001 to 4.2% in 2008, thanks to greater use of protection and increased awareness of sexually transmitted diseases, according to the UNDP.

The UNDP also notes a decrease in malaria prevalence rates, crediting much of the decline to the distribution of 72m bed nets laden with insecticides. It is estimated that the percentage of children protected by the nets nearly doubled to 10.9% in 2009, up from 5.5% in 2008. The UNDP expects tuberculosis to be only a minor public health burden by 2015. However, while progress has been made in reducing the prevalence of communicable diseases, challenges are now emerging with respect to rising rates of non-communicable diseases, according to Folashade Laoye, the chairman of Hygeia, a local provider of health care services. “There has been a shift in communicable diseases to more sophisticated diseases – such as diabetes and heart disease – and the treatment of these is undermined by a lack of infrastructure,” she told OBG.

FUNDING: The 2012 federal budget allocated some $1.81bn for the health sector, amounting to 5.9% of the total. In 2011 that figure was 4.7%, and in 2010 just 3.98%. Funding for health care in Nigeria tends to be low in general, at approximately $13 per capita annually. The WHO Commission on Macroeconomics and Health considers $34 per capita an adequate amount of yearly funding for quality health care. In addition to government funding, the health care sector is financed through public and private insurance, external funding and out-of-pocket spending. Total spending on health is low, coming in at about 5% of GDP according to the WHO. Part of this difficulty is due to the small tax base, given the huge role played by the country’s informal economy, which is estimated to be between two-thirds to three-quarters the size of the formal economy.

INTERNATIONAL SOURCES: Realising the need for greater financing of the health sector, the government has embarked on several joint initiatives designed to improve access to and quality of health services in the country. One such venture is the $150m Nigeria State Health Investment Project approved by the World Bank in 2012. The project focuses on bringing better health care access to 9m Nigerians in the states of Adamawa, Nasarawa and Ondo and it is being implemented as the target date for the United Nation’s Millennium Development Goals for Nigeria nears in 2015. The country is also scheduled to receive $21.5m from the World Bank’s Health Results Innovation Trust Fund. These initiatives will incentivise the delivery of quality care by rewarding workers and institutions that produce positive results. Also, some government entities operating in the country’s health sector have increased their fees to compensate federal funding. As such, at the end of August, the Nigerian Nuclear Regulatory Authority (NNRA) increased its charges on various categories of operators seeking to obtain certificates for import, registration and transportation of radioactive material used for medical facilities. The move followed announcements by the NNRA’s acting director general Dr. Martin Ogharandukun that supervision on registration and certification of X-Ray facilities would be stepped up following concerns over an increase in use of unapproved equipment employing radioactive materials. If successful, the project could be used as a model for future works.

The number of confirmed cases of polio declined by 95% in Nigeria in 2010, but cases in 2011 nearly tripled, according to the WHO. Although confirmed cases are at least numerically low for a country of 160m, the government remains frustrated, given the amount of resources it has expended in an effort to eradicate the disease. In addition to the government’s efforts, Nigeria has been receiving crucial assistance from international players, such as the World Bank and the US Centres for Disease Control (see analysis).

INSURANCE: As few as 3% of Nigerians have health insurance; most of these individuals receive insurance through employers or trade groups. Typically, health maintenance organisations (HMOs) do not offer coverage to individuals due to associated risk factors. One is the possibility of adverse selection, whereby uninsured individuals with pre-existing conditions attempt to enrol in health plans, a common concern among HMOs in all countries. The second reason HMOs tend to shy away from individual coverage is due to the lack of fully functioning information technology (IT) infrastructure. Such a computerised network would be able to give health care providers immediate access to information in order to determine patient eligibility and would involve the industry-wide use of smart cards, as well as the establishment of uniform system of payment.

As such, there is demand for health care IT. As of now, HMOs cannot keep exclusively electronic records, as they deal with providers nationwide, the majority of which do not use electronic recordkeeping. According to Ladi Awosika, the CEO of Total Health Trust (THT), a leading Nigerian HMO, 90% of providers still use paper recordkeeping. Awosika told OBG that this presents a challenge to delivering quality health care in a timely fashion. “It slows down things. You cannot guarantee that the provider has the ability to transmit information to you at the point of use. The IT system simply is not in place. There needs to be a complete IT system along with an industry-specific standard to streamline the processes of purchasing care, billing, payments, monitoring and reporting,” he said.

THT, the Health and Managed Care Association and the International Finance Corporation have been working on a solution to the IT shortage with the National Health Insurance Scheme (NHIS), the national health regulator, but there is some disagreement regarding where the system should be domiciled, either in the industry or with the NHIS. Awosika added that there are strong feelings in the industry that the regulator needs to develop its capacity for oversight, monitoring compliance and sanctioning.

PAYMENT: As so few Nigerians are insured, most pay out-of-pocket, said Dr Ladi Okuboyejo, the managing director of Premium Health, a local health insurance company. “Out-of-pocket payment is a huge financial burden on the payee. The consensus in the industry is to make health insurance mandatory by law to improve access to standard facilities and drive down costs. The current law is changing to include this,” he said. Those who are not in health collectives have few options.

The main one is the NHIS — the country’s socialised system that provides insurance to certain segments of the population, such as young children, the disabled and the unemployed. Recipients are asked to make nominal contributions on a regular basis. However, the NHIS is greatly underfunded as it primarily relies on contributions made by the government on behalf of civil servants, and is yet to tap value added tax (VAT) sources.

In August 2012 Abdulrahman Sambo, the acting executive secretary of the NHIS, suggested one possible solution would be to amend the law regulating the health insurance scheme to make registration within the system mandatory on a national level. The move could have an impact by encouraging the health sector to provide qualitative care, he stated to local press.

MATERNAL HEALTH: Midwives play an important role in the Nigerian health system. In 2009 the National Primary Health Care Development Agency (NPHCDA) established the Midwives Service Scheme (MSS) to be carried out by federal, state and local governments in an effort to improve maternal health. Given the lack of access to health care facilities and medical professionals, midwives have been deployed throughout the country to provide skilled birth attendance, particularly in the country’s rural areas. The decreases in maternal and child deaths show the tangible results of such initiatives. More than 2600 skilled midwives have been enlisted and deployed throughout the country by the MSS. The programme faces immense demand, however, as only one in three births is attended by a professional.

Ugo Okoli, the national coordinator of the MSS, said in May 2012 that although nationally the country has increased the number of midwives; a disproportionate number of them currently work in urban centres. “The problem is we end up having a cadre of workers that we call community health workers, community health practitioners, who are not as well trained as midwives in terms of providing antenatal care and delivery. So you end up seeing quite a high number of risky births in most of these rural areas and actually having a high maternal mortality rate in such areas,” she said.

BRIDGING THE DIVIDE: The gap between the standard of care in cities and rural regions is a significant obstacle to the progress of the sector. Improving rural health has been identified as a key factor in achieving MDGs, and in order to increase the quantity and quality of service in rural areas, the NPHCDA established the Community Health Services Department with a primary mission to ensure that the Ward Minimum Health Care Package is available at community levels across the country. The “package” has several areas of focus, such as health promotion and community mobilisation; maternal, newborn and child health care services; nutrition; communicable and non-communicable disease control; and sexual and reproductive health services.

Nigeria has adopted the model of employing community health workers and centres across the country, a popular system throughout Africa. Community-based health workers essentially function as a hybrid nurse, health advisor and manager able to provide basic services, such as immunisations, while at the same time acting to engage communities in becoming more aware of contributing factors with regard to health care.

Other mitigating factors preventing progress in rural areas include the lack of developed infrastructure, particularly regarding to potable water and sanitation services. In 2008 the National Demographic and Health Survey found that urban areas had potable drinking water in 75% of all homes, while the figure for rural areas was significantly behind, at 45%. Meanwhile, just one in four rural households claimed to have improved toilet facilities. Additionally, rural road infrastructure in areas far from hospitals and clinics make the treatment of emergency medical situations difficult as well.

EMERGENCY MEDICAL SERVICES: Given the immense size of its population and the substandard state of emergency medical services (EMS), Nigeria’s demand for a viable EMS is high. This subsector requires vast improvement if the country is to see declines in fatalities associated with sudden medical events. Given the sharp rises in cardiovascular disease and automobile accidents, a quality EMS system can serve as an important last line of defence. In 2012 the MoH and the Israeli government teamed up to enhance Nigeria’s EMS infrastructure. The arrangement includes the training of Nigerian doctors in Tel Aviv by Israeli physicians who are well-versed in administering emergency care.

SUBSTANCE ABUSE: Another area prohibiting progress in health care stems from societal alterations over the past decade, which has seen increased alcohol, drug and tobacco use. Substance abuse has become increasingly embedded within society and many stakeholders are alarmed by the problem. While the National Drug Law Enforcement Agency oversees the control of banned substances, many private treatment facilities and other governmental organisations are more directly involved with the rehabilitation of substance abusers.

Alcohol abuse has increased significantly in recent years. Consumption averaged 12.7 litres of pure alcohol per person per year in 2008, according to the WHO – which is on a par with many Western nations but significantly more than other African nations. Several studies have found that the most at-risk population to substance abuse is unemployed single males.

A January 2012 report by Freedom Foundation, a local NGO, stated that Nigeria is also now the number-one consumer of cannabis and amphetamines in Africa. At the Developing Effective and Sustainable Substance Abuse Intervention conference in March 2011, poverty and unemployment were found to be decisive factors. Punishment, rehabilitation, and restricted demand and supply may be the most effective methods of combatting the problem, though funding remains an issue.

OUTLOOK: Greater education on the particular benefits of quality care, as well as strengthened ties with private providers and investors in order to determine the appropriate financing mechanisms, would serve the sector well. Health pools should be arranged based on patient needs so insurance packages can be tailored to specific groups. With an increasing number of multinationals, the country’s leaders understand the need for and rewards of ensuring access to quality care.