Change Nigeria Project

‘A Good Leader Is A Dealer In Hope’ - Napoleon

Introduction

Nigeria’s health status

Nigeria is the eighth most populous country in the world and ranks among the thirteen poorest.

• According to the UN, average life expectancy is 43.3 years, which has been declining from about 58 years. As a result, 45% of the population is under age fourteen. Only 3.1% are over age 65.

• Infant mortality is the second highest in the world at 9.8%. The mortality rate for children under age five is 19.8%. One child dies every ten minutes.

• Of children under age five, 28.7% are underweight.

• 35% of one-year olds are immunized.

• While Nigeria counts 2% of the world’s population, it accounts for 10% of global maternal mortality -- 54,000 women die in pregnancy and childbirth annually.

• For every maternal death, another 15 to 20 women suffer from related problems such as a ruptured uterus or pelvic inflammatory disease.

• Nigeria has the second highest HIV/AIDS infection rate in Sub-Sahara Africa. More than four million people are living with the virus, yet most don’t know it -- 3% are receiving treatment.

• By 2010 10 to 15 million people will be infected with HIV.

• About 40% of the world’s sickle cell anemia patients live in Nigeria.

• The bird flu virus claimed the life of the first Nigerian in 2007.

• There are 19 physicians per 100,000 people, whereas the United States has 279 for every 100,000.

• The country is served by eight tertiary care university teaching hospitals.

• National expenditures on public healthcare totals $50 per person.

A Kaiser/Pew Global Health Survey conducted in the spring of 2007 revealed that healthcare issues are the top concern of 40% of Nigerians. Among the greatest needs, more than half of Nigerians cited treatment for HIV/AIDS and chronic diseases, and prenatal care. Forty-nine percent said that improvement in facilities and access to care should be one of the most important priorities for the government. Forty-eight percent of them reported that they didn’t have enough money for health care at some time during the year, down from 60% in the 2002 survey.  Nearly every Nigerian you meet will relate a story of a family member or friend who had received substandard care in Nigerian hospitals or had died as a consequence of inadequate care.

Healthcare system in Nigeria

The logical question is “What health system?”

Most medical experts and non medical novice will describe the Nigerian healthcare system as a “man-made disaster.” Successive governments have neglected primary, secondary, and tertiary health services for decades to the point that few public facilities have even basic services.

Nigeria developed a comprehensive healthcare policy for the period 1995-2005, but there has been little funding for implementation. Even now less than 10% of the national budget is directed to health care, which is below the 15% benchmark set by WHO.  Now don’t get too excited about the 10% budget provision, because if you factor in the effects of corruption, the 10% will actually go down to 5%.  When you factor in the overhead cost, we are down to zero.

Public hospitals are generally divided into general wards for which patients pay a small fee and “amenity” wards, which charge higher fees but provide better conditions. The general wards are typically crowded with some patients in corridors or on floors. There are long waits for registration and treatment. Patients often are not seen by a doctor, only nurses. Many drugs are not available. Food is free for very poor patients with no family or friends to attend to them. Most, though, have family to bring food to them and often stay in the hospital with them. These conditions have driven well-to-do Nigerians abroad for medical care and have propelled the creation of private hospitals.

The country imports most of its medical equipment. Used and refurbished equipment is in high demand, particularly in the private sector. According to the US Commercial Service there is “a near absence of cutting-edge technology application in most healthcare institutions in Nigeria.”

According to the US Department of State, the best health care available is in private and nonprofit medical facilities, some of which meet US standards. “The quality of government medical facilities are unacceptable by US standards....The blood supply is not safe. Blood-banking services are unacceptable by US standards.” Put differently, the standard of care in the country is quite low.

The government historically has provided most of the secondary and tertiary care. “The primary care facilities are rundown and no one is going to them anymore.” The private sector is trying to fill the gap. Only a few private facilities provide tertiary care because of the set-up cost. Those are mainly in Lagos and other major cities. The private hospitals are taking the lead in obtaining accreditation, an effort supported by most Nigerians.  However, most of them do not measure up to basic standard.

Forty-six percent of those interviewed in Nigeria by McKinsey sought private health care for their children from 1990-2001 while 47% utilized public facilities. A 2006 World Bank report found that 51% of Nigerians in the lowest-income quartile and 64% of those in the highest quartile received care from private healthcare providers. The report also found that 58% of rural Nigerians had used private providers while 55% of urban residents had done so. McKinsey learned in interviews that patients choose private providers because they believe that: caregivers have greater autonomy allowing them to respond more fully to patients’ needs; physicians and pharmaceuticals are more available; quality is higher as judged by cleanliness, convenience, wait times, and friendliness; and there is continuity of care.

Lagoon Hospital, a tertiary care facility operated by Hygeia in Lagos serving upper- and middle-income patients, offers modern equipment and a higher level of services necessary to attract this clientele. McKinsey postulates that hospitals such as this can serve as a benchmark for other providers including public facilities and raise the public’s expectations, which benefits the entire population. It also found that private facilities in Lagos often outperform the public sector on the same measures valued by patients. The private sector is leading the creation of the Society for Quality Healthcare in Nigeria (SQHN) to establish quality standards and benchmarks for HMOs.

Necessitated by decades of underfunding, the state facilities charge fees for services. Lagos University Teaching Hospital (LUTH), for example, only provides about $35,000 a year for indigent care. As a public institution, it is not able to cover its cost in fees alone, according to Professor Akin Osibogun, Chief Medical Director. Whether friends and family can pay for treatment often determines whether an individual will live or die. The patients, on most cases, even have to purchase their own blood for surgeries and other supplies including medications.

Procurement of equipment for the university teaching hospitals is centralized in Abuja, often with no consultation with the institutions that have ordered equipment. In some cases there are no contracts for installation and in other cases equipment literally does not fit into the intended space.

There has been criticism that a large portion of government health funding goes to the national teaching hospitals, which benefit less than 1% of the population. According to McKinsey, this is explained in part by the high cost of operating teaching hospitals and that they generally are located in urban areas where higher-income households are located.

Other quality healthcare facilities

While a perception of quality hospitals may vary depends on who you speak to, the following generally are well regarded though still falling short of US standards.

Notable Hospitals in Nigeria:

Four in total (two each cited in Lagos and Abuja):

Reddington Hospital started in 2003 as a cardiac center to provide services that previously required travel abroad. The nine-story, 50-bed facility bills itself as a “fully comprehensive tertiary hospital” offering mainly single rooms and a few doubles. It also has MRI and CT machines, a three-bed CCU/ICU, and a Neonatal ICU. The hospital began in 2001 as a cardiac center in association with Cromwell Hospital in London. Dr. Neil Davidson is the medical director and previously was medical director of National Hospital in Abuja from 2002-04. He also established the Clinical Medical School at Ahmadu Bello University in Zaria, Nigeria between 1969 and 1974. Dr. Laurent Luciani, medical director for SOS International in Nigeria, described the hospital as beautiful with private rooms on a VIP floor including lounges and small kitchens. It has an ICU of questionable capability.  Generally, in Nigeria once equipment is out of order, it stays that way.

Lagoon Hospital owned by Hygeia has established a reputation for quality care that is attracting patients who can afford care. This self-described “first class tertiary hospital” was established in 1986 by husband and wife physicians Professor E.A. and Dr. O.W. Elebute who were among the founding faculty of LUTH at its inception in 1962. Shareholders include African Alliance Insurance Company, Lion of Africa Insurance, and City Securities. Lagoon Hospital Apapa includes 45 beds comprised of single private rooms and air-conditioned wards. It commissioned its Centre of Excellence in Critical Care &Trauma in 2006 including new MRI and CT machines. There is also a 15-bed clinic in the suburb of Ikeja and a primary care clinic on Victoria Island. A total of 60 physicians, approximately 100 nurses, 11 pharmacists, 12 lab technicians, and 8 radiographers work in the system. The hospital has a management agreement with Apollo Hospital Group in India. That management arrangement has enabled the hospital to upgrade equipment, receive technical assistance, and access telemedicine capabilities. Apollo Hospitals Group has 65 hospitals with 6,400 beds under management. It also offers “affordable” out-of-country treatment. Lagoon also has relationships with SOS International, Europe Assistance Medical Services, and Oracle Med for evacuation. This hospital is believed to meet western standards. Most expatriates living in Nigeria are comfortable having their family treated at Lagoon Hospital.

The Bridge Clinic was cited by McKinsey as an example of a high-end clinic that is attracting well-to-do patients by offering a well-equipped facility that also attracts well-qualified physicians and nurses.

National Hospital was established by decree of the National Assembly and began operations in 1999 initially to address the needs of women and children in Nigeria and West Africa to reduce morbidity and mortality rates. It has since expanded its mission to provide comprehensive care for all people. Phase I (current status) contains 200 beds with plans to expand to 500. It provides 24-hour emergency room service, ICU, pediatric and neonatal intensive care, x-ray, mammography, CT, MRI, and dialysis. It offers private and semi-private rooms and wards. In 2007 it admitted 8,429 patients and recorded 154,482 outpatient visits. The occupancy rate was 71.9%. It provided approximately $330,000 in fee waivers to indigent patients. It depended upon government subsidy for 78.5% of its operating costs of approximately $7.9 million.  One ward is reserved for non-English speaking patients.

State of the Nation Committee:

Robert Ngwu, Chair

Hadjia Fatima Wali

Dennis O. Balogu, Presenter.