Nigeria’s weak health sector confronts Ebola
Spread of Ebola contained, but health system is having trouble dealing with treatable diseases which kill thousands.
Lagos, Nigeria – When 17-year-old Ibrahim Abbas came down with a fever in Lagos, Nigeria’s commercial capital, health providers in over 10 hospitals refused to admit him. Some feared Ebola, but blood tests showed he had malaria, a curable illness that kills over 200,000 Nigerians annually, according to Nigeria’s latest Demographic and Health Survey. Others lacked supplies needed to treat his severe form of malaria. He died the next morning.
“He was helpless… He needed oxygen to enhance his breathing,” Magu Abdul, Abbas’ 27-year-old cousin said, recounting what happened on August 22 when the family rushed then-unconscious Abbas from one hospital to another. Out of options, they took Abbas home at midnight and simply prayed. That morning, Abdul saw Abbas take his last breath.
Abbas is one of hundreds of thousands of Nigerians who die each year from treatable diseases. Most of these deaths affect the most vulnerable: children under five and pregnant women. In 2010, an estimated 209,000 Nigerians died of malaria – 32 percent of global malaria deaths – according to Nigeria’s 2013 Demographic and Health Survey.
Africa’s biggest oil producer and largest economy has one of the world’s highest child and maternal mortality rates. In 2012, an estimated 827,000 children under five died, while the reported maternal mortality rate was 550 per 100,000 live births, according to UNICEF.
Most of Nigeria’s childhood deaths are due to preventable or curable diseases: mainly malaria, pneumonia, and diarrhoea. Primary healthcare, run by local governments – Nigeria’s smallest unit of government – is tasked with handling these common illnesses.
The level of care in each centre varies, but generally, primary facilities do not have enough health workers, supplies, equipment, training, or transport – including ambulances to take patients to state or federal hospitals, says Michael Asuzu, a public health and epidemiology professor at the University of Ibadan.
In its five-year 2010 National Strategic Health Development Plan, the health ministry acknowledged that “although accountability problems affect all levels of government, at the local level they present a particular challenge”.
Lack of coordination
According to the document and health experts interviewed for this story, the most unaccountable area of government is responsible for implementing health services that deal with Nigeria’s deadliest diseases.
Nigeria’s 2013 Millennium Development Goals report shows while there is progress, it is slow particularly for poor communities.
A lack of coordination and clarity on responsibilities between the different tiers of government “seems to have led to a situation where government primary healthcare services are perceived as the responsibility of everyone and of no one,” the health ministry said in 2010.
Lack of coordination among donors can also lead to contradictory programmes or overlapping efforts, said Mike Egboh, programme manager of the Partnership for Transforming Health Systems Phase II, which is funded by the UK’s Department for International Development.
If you don't have the right laboratory and diagnostic support, you will not be able to really treat the patient.
While the current minister is “trying as much as possible” to coordinate programmes, more government funds are needed “because you won’t coordinate with empty hands”, said Egboh.
“Yes, as minister of health I actually need more resources, but so do other ministers,” Onyebuchi Chukwu told Al Jazeera. “In a situation where we’re not generating enough, you can only not be too surprised at what you have.”
On August 25, the Nigerian Medical Association suspended a public sector doctors’ strike which began on July 1. Among issues that sparked the protest was “the endless circle of incomplete salary payment” of doctors in some hospitals. In Rivers state, one of the two locations affected by the Ebola outbreak, primary health workers have been on a separate strike since late July protesting against low pay and work conditions.
“The doctors and the nurses are very, very few,” said Wecheonwu Reuben, Rivers’ state chairman for primary healthcare in the health workers union. In most primary health facilities “you find out that you have just one doctor”, leaving technicians and assistants to see most patients, Reuben says. While the situation has improved, he cites other problems such as unreliable electricity.
Nigeria had 41 doctors per 100,000 people as of 2009, according to the World Health Organisation.
Cost is also a major barrier: 61 percent of Nigerians lived on under $1 a day in 2010, according to Nigeria’s statistics bureau, while 69 percent of health payments were out-of-pocket, the health ministry said in 2010. Those with good sources of income seek specialised care outside Nigeria.
“There are people that have sold their houses in order to take somebody to India for treatment,” said Egboh.
Lawrence Obembe, president of the Nigerian Medical Association, estimates Nigerians spend 80 billion naira, or $491m, annually on medical tourism. Most popular destinations include India, Egypt, the UK, and the United Arab Emirates.
While generally better equipped, private hospitals must provide their own electricity and water and import equipment, constituting challenges, said Egboh. Basic supplies such as oxygen run out in many hospitals, he said.
Some of the best doctors have sought jobs in places like the US and Europe. Nkem Chukwumerije, president of the Association of Nigerian Physicians in the Americas, says the number of Nigerian doctors in the US alone is between 4,000 and 5,000. Better salaries and education entice some doctors to emigrate, as well as frustration over poor conditions in Nigeria, Chukwumerije said.
“If you don’t have the right laboratory and diagnostic support, you will not be able to really treat the patient,” said Chukwumerije, adding that one of the reasons doctors leave “is to have better equipment and tools to diagnose and treat patients”.
Our healthcare system is desperately sick. Ebola is providing the whole of us a chance to think about what we're doing.
Egboh says doctors who stay in Nigeria face these challenges.
“It’s frustrating because a doctor who can cure malaria and then doesn’t have the tools, doesn’t have the drugs, then watches a malaria patient die,” says Egboh. Doctors face two choices: “Leave the country instead of just sitting down, watch patients just come in and die… Or you stay and die with the system. So it’s a hard decision.”
Despite these challenges, Nigeria’s coordinated Ebola response has prevented the virus from spreading unchecked since Liberian-American Patrick Sawyer brought the virus to Lagos in July. The government was able to react quickly, said Nancy Knight, who is leading the US Centers for Disease Control and Prevention team on Ebola, which is supporting the Nigerian government’s response.
Nigeria kept confirmed cases to 19, 12 of whom recovered – all of them were traced back to Sawyer. The spread has been contained in Lagos and the oil industry hub of Port Harcourt, the capital of Rivers state.
Battle being won
Babatunde Fashola, the governor of Lagos state, insisted on the importance of containing the virus while it is still manageable. “We must not get to epidemic proportions. We will lose control if that happens. That said, we are making progress,” Fashola told a news conference on September 1.
The government is coordinating the response with support from the CDC, WHO and Médecins Sans Frontières.
“Here we have fewer patients compared with other countries, so it’s clear that we’re very focused on an individual base,” said Miriam Alia, MSF’s medical team leader in Port Harcourt.
Early treatment increases patients’ survival chances, “and here, the contacts were very controlled”, says Alia. “They have a list of contacts from the very beginning.”
CDC’s Knight says “Nigerian staff who work in the facility go through intensive training, including hands-on mentorship” by international experts.
“So far we are winning this battle in Nigeria, but the fight is not over,” Knight said.
Epidemiologist Asuzu says Ebola may be a “blessing that god is sending in this kind of a disaster”, a threat that is attracting government and public attention to health preparedness.
“Our healthcare system is desperately sick,” said Asuzu. “Ebola is providing the whole of us a chance to think about what we’re doing.”