HEALTH SECTOR IN NIGERIA

BY

CHRISTIANA OLORO

SUPERISED BY MRS EKEKWE

A RESEARCH WORK PRESENTED TO THE DEPARTMENT OF INTERNATIONAL

FOUNDATION PROGRAM (IFP), GILGAL EDUCATION FOUNDATION, WUSE ZONE 6
ABUJA

MARCH, 2015
INTRODUCTION

Importance of Health Sector in Nigeria cannot be over-emphasized. Although the health

sector has its achievements, it has its challenges and the problems seem to outweigh the
achievements in the sector.

In this project, I am going to discuss the roles of the health sector in Nigeria. These roles
include the provision of health care services, administration of safe drugs and so on. I am
also going to discuss the problems that the health sector is experiencing and the causes of
these problems. These problems include the gross under-funding of the health sector and
shortage of skilled medical personnel at the primary health care level.

The solutions which are the most important part of the project are going to be discussed
effectively. The provision of proper health care services and facilities can solve problems
in the health sector as well as construction of hospitals and employment of skilled and
well educated doctors to attend to attend patients.
TABLE OF CONTENT

Title Page

Introduction

CHAPTER 1

Roles of the Health Sector in Nigeria

Activities carried out in the Health Sector

CHAPTER 2

Achievements

List of Achievements of Health Sector in Nigeria

Chapter 3

Benefits gotten from the Health Sector by Nigerians

Insurance

Chapter 4

Problems of Health sector in Nigeria

Chapter 5

Solutions to the problems the Nigerian Health sector is facing and the way forward
CHAPTER ONE

1.0 Roles of health Sector in Nigeria

The roles the health sector in Nigeria plays in the Economy has been dealt with upon by
various researchers. The health sector promotes and protects population and community
health. It also delivers both health protection and health promotion activities, such
monitoring food safety and providing information to the public about nutrition and
physical activities.

The health sector ensures that potential risks to the health of the population are
monitored, managed and promoted. These can be done by monitoring our environment
to ensure air, land and water pollution are managed. Licensing health organization,
hospitals and premises and enforcing public health legislation including investigating
complaint and taking appropriate actions are also part of the roles in the health sector.

The health sector provides environment advice for the government, local bodies and the
people on required basis. It also raises public awareness of the health issues and manages
population based screening Programmes.

The roles of the Nigerian health sector also include hospital management, health
management, biotechnology and a variety of medical products. The federal government’s
role is mostly limited to teaching hospitals, federal medical centers while the state
government manages the various general hospitals (secondary health care ) and the local
government focus on dispensaries (primary health care ) which are regulated by the
federal government through the NPHCDA (Nation Primary Health Care Development
Agency).

Health sector in Nigeria also provides health insurance scheme for government
employees and private firms entering contracts with private health care providers. NHIS
(National Health Insurance Scheme) is an example of health insurance provided by the
health sector to people. In May 1999, the government created NHIS; the scheme
encompasses government employees, the organized private sector and the informal
sector. Legislative wise, the scheme also cover children under five, permanently disabled
person and prison inmates. In 2004, the administration of Obasanjo further gave more
legislature powers to the scheme with positive amendments to the signal 1999 legislative
act.

In Nigeria, the health sector cannot be discussed without a goal understanding of national
health care delivery strategy. The provision and delivery of health services is the
responsibility of the health sector together with the federal, state and local governments
as well as religious organizations and individuals

(National Population Commission, 2000). This means the sector operates as a three-tier
health care system. The first tier which is the tertiary health care is in the domain of both
the federal and state government. The level of health care provides highly specialized
referral services to both the first and second tiers of health care delivery system. The
second tier is the domain of the state government; it is the secondary health care. It
provides special services to patients referred from the primary health care level. The
third tier is the primary health care. This is the domain of the local government but with
the support of the state ministry of health. It essentially provides health care for people at
the grass roots, over the years; the Nigeria Government has formulated several policies
and programs which are aimed at improving health care delivery service in the country.
The fourth national development plan (1981-1985) established a government
commitment to provide adequate and effective primary health care that is primitive,
protective, preventive, restorative and rehabilitative to the entire population.
Consequently, the Nigeria government adopted a national health policy in 1988 to
provide formal frame work for the management of the country’s health system. The
policy was approved by the ruling Armed Forces in 1987 and launched in 1988. It goals
was to provide the population with access not only to primary health care, but also the
secondary health care and tertiary health care as needed through a functional referral
system. It is obvious that the primary health care became a major component of the
national health policy regards primary health care as the frame work to achieving
improved health for population with this focus, it may be said that the national health
policy takes cognizance of the health needs of both urban and rural people.

The health sector ensures interventions are implemented as planned, identifies specific
problems as they arise and allows continuous feedback. Monitoring primary health and
interventions ensure that the activities are carried out according to the objectives. The
sector also monitors and regulates the activities of health officials and health workers.
CHAPTER TWO

2.0 Achievements of health Sector in Nigeria

The recent donation of 50 million Naira by the governor Babatunde Fashola-led

administration to first consultant medical care in Lagos where the Liberian-American,
Mr. Patrick Sawyer had died after being diagnosed to have acquired the Ebola Virus
Disease is most commendable. Also, the presentation of 26 million naira to all the 13
casualties and survivors in the state to enable them to carry on wastes their lives. The
rapid response exhibited by the Health sector to the clarion call from the first consultant
medical centre on the discovery of the first case of Ebola virus disease, through Sawyer
had gone a long way towards steaming the tide of spread across the country, but with the
collaboration of the Lagos state government in the same regard. One can only imagine the
huge death toll, disruption to business and social activities and the huge economic
burden the spread of EVD would have caused the country given a population of over 170
million Nigerians. So good to note too that the government is not resting on its oars as
according to the Commissioner of Health, Dr. Jide Idris, ‘’the Research Core Group on
Ebola will add to the body of knowledge on Ebola Virus Disease.’’

Beyond these salutary effects, it is necessary to put in proper perspective other laudable
initiatives by which the administration had made its mark in the Health sector, as the
administration wounds up in May 2015. To start with, it sets a template by raising the
standard in the critical area of Primary Health Care Delivery especially from the grass
roots. For instance, there are several free care missions speeding up the implementation
of its provision of Health infrastructure in all Local Government /Local Council
Development Areas. The administration upgraded the infrastructural facilities to
international standards.

With the Eko free Malaria the State Government instituted a frontal approach to the
threat malaria posed poses to almost all the residents. The provision of each household
with at least two Long Lasting Insecticides Nets (LLIN), has saved many lives that would
have been lost. This pro-active and pragmatic approach has assisted its malaria
prevention strategy. In addition, the ‘’Eko Free Malaria Program’’ was adapted as a policy
on the treatment of malaria, with adults, children and pregnant women reporting with
malaria in Different Health facilities in the state for free treatment. Similarly, the Eye Care
Health System Development initiative has put in place durable measures with the aim to
reduce to the barest minimum, the high rate of preventable blindness in the state.

The Fashola-led administration was able to identify capacity building in delivering its
mandate to the people on health care delivery. This has been made possible through the
continuous training of primary health care personnel, especially for eye care units all
over the state.

Still on capacity building as at 2012 there were newly employed health personnel. These
included nurses at the local Government Areas (LGA)levels, medical officers of health
councils, 14 serving medical officers and 28 nursing students from the local government
councils as well as 7 senior ophthalmic nurses from the secondary eye care units who
have not been trained before that benefitted from the new policy.

Taking note of the high rates of both infant and maternal mortalities in Nigeria which as
far back as 2008 had taken the attention of the world health organization (WHO), the
foxhole administration established the integrated maternal, Newborn and child health
(IMNCH) strategy. As a high-profile initiative, the aim is to accelerate the attainment of
the millennium development goals (MDGs) 4and 5 in Nigeria. This would save some
200,000 mothers and six million children who die every year through no fault of theirs.

Good enough this salutary initiative is being implemented simultaneously in all the 57
Local Government and Local Council Development Areas. So far this has raised the level
of awareness at the community stage to the health care services that are available at the
Primary Health Care Centers. There are also mobile teams who visit schools and crèches
to render free health care services.

By the end of 2011 the State Government had constructed eight (8) Maternal and Child
Care Centers at Ikorodu, Isolo, Ifako-Ijaw, Surulere(GBAJA), Gbagada, Alimosho, Amuwo-
Odofin, Eti-Osa(Lekki). From available statistics, over 8000 residents of Lagos State have
so far benefitted from Lagos State Government Limb Deformity Corrective Surgery
Program. This was initiated as a poverty alleviation program and aimed at alleviating the
pains of patients who suffer deformity as a result of polio mellitus; especially the indigent
as most children and others are from very poor families who cannot afford the high cost
of surgery. It has recorded tremendous success. The lessons from all these life-saving
initiatives is for state governors to identify the most pressing health challenges of their
people and get adequate and well-trained man power to alleviate them.
CHAPTER THREE

3.0 Health Insurance

Health Insurance is insurance against the risk of incurring expenses among individuals.
By estimating the overall risk of health care and health expenses, among a targeted
group, an insurer can develop a routine finance structure, such as a monthly premium or
payroll tax, to ensure that money is available to pay for the health care benefits specified
in the insurance agreement. The benefit is administer by a central organization such as a
government agency, private business, or not-for-profit entity-is often included in
employer benefit packages as a means of enticing quality employees.

The cost of health insurance premiums is deductable to the payer, and benefits received
are tax-free. Health insurance has many cousins, such as disability insurance, Critical
(catastrophic) illness insurance and long-term care(LTC) insurance.

3.1 Nigerian Health Insurance Scheme (NHIS)

Introduction: The Nigerian National Health Insurance Scheme (NHIS) is planned to

attract more resources to the health sector and improve the level of access and utilization
of healthcare services. It is also intended to protect the people from the catastrophic
financial implications of illnesses. However, whether it will work in practice and whether
the present model of the NHIS is appropriate is also a matter of diverse opinions.

Method: A literature review of the principles and models of health insurance and a
critical examination of the National Health Insurance Scheme and Community Based
Health Insurance (CBHI) were carried out. Grey literature (conference papers, technical
reports, dissertations, e.t.c), journal articles, abstracts, relevant books and internet
articles were reviewed. The review covered the period 1986 to 2010. The search words
used were insurance, health insurance, health insurance models; principles of health
insurance, market failure, community based health insurance, Nigerian national health
insurance Scheme.

Results: There are many forms of insurance schemes ranging from Social (Compulsory)
health insurance to Private (Voluntary) health insurance, and both have much different
subversion. In addition, they all have different modes of operation. These models of
health insurance as well as the strengths, weaknesses, opportunities and threats of the
NHIS and CBHI are outlined.

Conclusion: For any social health insurance scheme to offer full coverage of its citizens
the government should not focus on only one type of health insurance scheme. A
comprehensive benefit package is needed and the disconnect between the three tiers of
government should be addressed. The different tiers of government should be
encouraged to buy into the scheme and avenues for funding through general taxation,
donor financing etc should be explored in Nigeria.
In order to ensure that every Nigerian has access to good health care services, the
National health Insurance Scheme has developed various programs to cover different
segments of the society, and these are:

i. Formal Sector Social Health Insurance program

ii. Urban Self-employed Social health Insurance Programme
iii. Rural Community Social Health Insurance Programme
iv. Children Under-Five Social health Insurance Programme
v. Permanently Disabled Persons Social Health Insurance Programme
vi. Prison Inmates Social Health Insurance Programme
vii. Tertiary Institutions and Voluntary Participants Social health Insurance
Programme
viii. Armed Forces, Police and other Uniformed Services

The development programme that has been undertaken has brought about tremendous
relief and has made impact on the lives of the rural people. The free health care
programme has gone round vitally in all corners of Niger Delta, healing the sick and
giving hope to the medically challenged. At Oguta, the free medical train did not only
prove medical services, it also gave a tremendous boost to the facilities of the general
hospital. The commission donated a mammogram for the benefit of breast cancer
patients, an ambulance, a 30KVA generator and other important equipment to the
general hospitals, as part of its efforts to provide good health care services delivery in the
Niger delta region. Also, free awareness campaign, health care promotion and malaria
roll back campaign are benefits of Nigerians including vaccination or 10,000 children
against typhoid fever and 3,500 children received 3 doses each of hospitals and
vaccination.

Nigerians have also benefitted from the prevention of HIV/AIDS and malaria by public
enlightenment and distribution of preventive materials e.g. mosquito nets, condoms, e.t.c.
Access to anti-retroviral drugs for persons living with the virus has also been made
possible with trained community health workers on the distribution of insecticide
treated nets including handling malaria cases.
CHAPTER FOUR

4.0 Problems in the Health Sector in Nigeria

Among the many challenges facing the health system in Nigeria, is acute shortage of
competent health care providers. As a result of inadequate infrastructure and poor
compensation packages, a sizeable number of physicians, nurses and other medical
professionals are lured away to developed countries in search for fulfilling and lucrative
positions. In fact, some of these countries have established recruiting agencies and
examination protocols targeting the best and brightest medical minds in Nigeria,
prompting the government to require that these agencies register with the Federal
Ministry of health and operate within an established framework. Nigeria is a major
health-staff-exporting nation, accounting for 347 (recent revised upward to 432) out of a
total of 2000 nurses that emigrated out of Africa between April 2000 and March 2001.
This figure appears to be underreported as it fails to take account the vast number of
nurses who migrate abroad under different pretexts. The efflux has resulted to acute
shortages in local health facilities and drastically impacted access.

Related to brain drain is the problem of geographical distribution of health care

professionals. There is a disproportionate concentration of medical professionals in
urban areas. While access to medical personnel is readily available in cities, rural
dwellers often have to travel considerable distance in order to get treatment. Health
workers in underserved areas usually have motivational problems at work which may be
reflected in a variety of circumstances, but common manifestations include:

1. Lack of courtesy to patients

2. Failure to turn up at work on time and high levels of absenteeism
3. Poor process quality such as failure to conduct proper patient examinations
4. Failure to treat patient on timely manner

Doctors and nurses are reluctant to relocate to remote areas and forest locations that
offer poor communications with the rest of the country and few amenities for health
professionals and their families. Urban areas in Nigeria are more attractive to health care
professionals for their comparative social, cultural and professional advantages. Large
metropolitan centers in the country offer more opportunities for career and educational
advancement, better employment prospects for health professionals and their family
(spouse), easier access to private practice and life style-related services and amenities,
and better access to education opportunities for their children. In addition, the low status
often conferred to those working in rural and remote areas further contributes to health
professionals’ preference for setting in urban areas, positions are perceived as more
prestigious this has significant consequences on the health of inhabitants of rural areas as
unavailability of physicians and nurses within close proximity often leads to delaying and
postponing visits to health care facilities until the condition becomes unbearable.
Transporting the patient on treacherous roads to urban facilities may take several hours
and this may mean the life or death.
In Nigeria scarce data on the availability, distribution, and trends in human resources for
health (HRH) has been a barrier to effective HRH planning Nigeria has 13 doctors,
92nurses/midwives, and 64 community health workers (CHWs) in the public sector per
100,000 populations. However, an urban resident has access to 3 times more doctors and
twice as many nurses/midwives, compared to a rural resident. Attrition rates are
between 1.3% and 2.3% and are highest among doctors and pharmacists. Rates for
doctors and nurses are much higher at the primary level of care than at
secondary/tertiary level. Attrition rate in rural areas is 3 times higher for doctors and 2
times higher for nurses than in urban areas.

FACTORS DRIVING HUMAN RESOURCE CHALLENGES IN HEALTH SECTOR IN

NIGERIA.

The main factors driving this problem have been identified and these identified and these
include:

(i) insufficiently resourced and neglected health systems;

(ii) poor human resources planning and management practices and structures;
(iii) unsatisfactory working conditions characterized by; heavy workloads; lack of
professional autonomy ;poor supervision and support; long working hours;
unsafe workplaces; inadequate career structures; poor remuneration/unfair
pay; poor access to needed supplies, tools and information; and limited or no
access to professional development opportunities;
(iv) internal and international migration of health workers

The continual drain of health workers from Nigeria, combined with decades of harsh
economic policies, has led to chronically under- funded health systems. Health workers
are paid meager salaries(for instance the purchasing power of a Nigerian doctor is 25%
lower than that of a doctor even in eastern Europe) an they work in insecure areas and
have heavy workloads, but lack the most basic resources, including insufficient drugs or
medical equipment ; they have little chance of career advancement . Doctors complain of
brain waste and seek better opportunities for professional development in countries with
better medical infrastructure. Furthermore, scores of Nigerian doctors currently overseas
are willing to return to Nigeria provided appropriate employment opportunities are
available. Unfortunately, not only are such appropriate very scarce there is growing
unemployment among registered doctors in Nigeria. Furthermore there is little
enthusiasm by locally based senior medical staff to create openings for overseas-based
doctors. Also , accreditation processes tend to be based on the principle of reciprocity,
thus disadvantaging overseas-based doctors willing to return .in Nigeria the main source
of increase in health workforce comes from new graduates (83% of total new incoming
staff); 60% of new graduates nurses accounted for only 1% increase in the number of
public sector nurses.
WAY FORWARD

Adequate human resources for health (HRH) are a key requirement for reaching health
goals. Quality data and accurate projection of future HRH requirements are needed to
inform the health policy planning process. In Nigeria, as in many countries in the region.

Scarce data on the available, distribution and trend in HRH has been a barrier to effective
HRH planning. Some of the recommendations can be adopted to address the human
resource challenges in the health sector in Nigeria. The types of interventions could
include

(i) Reforms in medical education which stipulates a special allocation of student

admission quota to candidates from rural areas into state university medical
school and sitting of other Tertiary institutions of health Sciences in the rural
areas
(ii) Provision of housing for health workers in under-served areas;
(iii) In-service training and career development opportunities;
(iv) Subsidy for school fees and transportation for in-service training
(v) Hardship pay for rural/undeserved areas
(vi) Unemployment and retired health workers :- expand and contracting
(vii) Use of community health workers and new health workers.

Since human resources for health is influenced by incentives it can be seen as an

interrelated system involving staff with a complex mix of skills and motivations. Hence it
is obvious that effects of salaries and benefits aimed at one group of professionals will
reverberate through the entire system. Therefore because policy makers need to know if
specific incentives will reinforce health system goals or upset a delicate balance, this
situation would create an excellent opportunity for findings to be used in making
appropriate decisions. Incentives are relevant to the issue of health worker mobility. A
number of ‘push’ and ‘pull’ factors affect movement of health personnel. Available
information affect indicate that financial incentive is an option to aid recruitment and
retention in under serviced areas. Multiples incentives to make working in unattractive
areas more appealing have been proposed with variable success. More generous benefits,
such as health insurance and vacation time are the most commonly used incentives.
Other benefits may include tuition reimbursement, flexible work hours, benefits based on
experiences or length of commitment, study and recreation leaves, employment
opportunities for doctors’ spouse, better accommodation facilities and improvements in
educational institutions for doctors’ children.

In conclusion, effects to strengthen health workers motivation must protect promote and
build upon the professional ethos of medical doctors and nurses. This entails
appreciating their professionalism and addressing health workers’ professional goals
such as recognition, career development and further qualification. It is important for the
government to develop the work environment so that health workers are enabled to
meet personal and organizational goals. This requires strengthening health workers’ self-
efficiency by offering training and supervision, but also by ensuring the availability of
essential means, materials and supplies as well as equipment and the provision of
adequate working conditions that enable them to carry out their work appropriately and
effectively. Governance and leadership in health must now be expressed as tangible
actions that result in senior managers and policy –makers valuing and respecting health
workers. New careers and incentive system must be developed, along with better social
and technical support for health workers. These recommendations would help to address
the human resource challenges in the health sector in Nigeria and other developing
countries of similar setting.

CORRUPTION IN THE HEALTH SECTOR

On a macroeconomic level, corruption limits economic growth, since private firms see
corruption as a sort of ‘tax’ that can be avoided by investing in less corrupt countries. In
turn, the lower economic growth results in less government revenue available for
investment, including investment in health sector. Corruption also affects government
choices in how to invest revenue, with corrupt governments more likely to invest in
infrastructure – incentive sectors such as transport and military, where procurement
contracts offer potential to extract larger bribes, rather than social sectors like health and
education. Within the health sector, investment may tend to favor construction of
hospitals and purchase of expensive, high-tech equipment over primary health care
programs such as immunization and family planning, for the same reason. Corruption in
health sector also has a direct negative effect on access and quality of patients care. As
resources are drained from health budget through embezzlement and procurement
fraud, less funding is available to pay salaries and fund operations and maintenance,
leading to de-motivated staff, lower quality of care, and reduced service availability.
Studies have shown that corruption has a significant negative effect on health indicators
such as infant and child mortality, even after adjusting for income, female education,
health spending and level of urbanization. (There is evidence that reducing corruption
can improve health outcomes by increasing the effectiveness of public expenditures.) A
review of research in Eastern Europe and Central Asia has evidence that corruption In
the form of informal payments for care reduces access to services, especially for the poor,
and causes delays in care-seeking behaviors. However, where the payments are cost
contributions, they can enhance efficiency because more people can be treated at
relatively low additional cost. But generally, there are better ways to enhance efficiency,
and we find that secret payments are more open to abuse. In Africa, studies has shown
that about 35% of births in rural areas take place at home, in part because of high
charges for care in facilities where care was supposed to be free ( World Bank 2005). In
many countries, families are forced to sell livestock or assets, or borrow money from
extended family and community members, in order to make the necessary informal
payments to receive care. Beside formal payments, other types of corruption which
clearly affect health outcomes are bribes to avoid government regulations of drugs and
medicines, which resulted in the dilution of vaccines in Uganda and have resulted in the
raising problems of counterfeit drugs in the world. Dora Akunyili, Director General of the
National Agency for Food and Drug

Administration and control in Nigeria, writes eloquently about her struggle to lead
Nigeria’s battle against counterfeit drugs (Akunyili , 2006). Unregulated medicines which
are of sub-therapeutic value can contribute to the development of drug resistant
organisms, increase the threat of pandemic disease spread, and severely damage
patients’ health as counterfeit drugs might have the wrong ingredients or include no
active ingredients at all and undermine public trust in important medicines according to
WHO IMPACT (2006). In addition to fake and sub-therapeutic drugs on the market,
corruption can lead to shortages of drugs available in government facilities, due to theft
and diversion to private pharmacies. This in turn leads to reduced utilization of public
facilities. Procurement corruption can leads to inferior public infrastructure as well as
increased prices paid for inputs, resulting in less money available for service provision.
Unethical drug promotion and conflict of interest among physicians can have negative
effects on health outcomes as well.
CHAPTER FIVE

SOLUTIONS TO THE PROBLEMS THE NIGERIAN HEALTH SYSTEM IS FACING

Improved resource control and accounting systems health system require a legal and
institutional framework that provides clear and simple accounting and procurement
standards based on transparency, comprehensiveness and timeliness. They should also
have effective supervision and auditing systems to improve fiscal oversight and ensure
effective enforcement of rules and sanctions for financial misconduct. Because in corrupt
system people may be benefiting from the lack of transparency, there could be resistance
to putting in place better control system. Budget transparency and participation
accountability supposes that public policies, practices and expenditures are open to
public and legislative scrutiny and that civil society is involved at all stages of budget
formulation, execution and reporting. Budget transparency requires an information
system that produces timely, reliable and accurate information in order to hold public
officials accountable for the use of allocated resources. Civil society must also be enabled
to use the information and take action when irregularities are detected. Participatory
budgeting initiatives encourage a wide range of stakeholders to have a voice in allocating
budgets accordance with those priorities, and monitoring the quality of goods and
services purchased with budgets

Decentralization- decentralization is a favored strategy to improve technical as well as

allocation efficiency, with the view to enabling broader public participation, improving
local oversight of fiscal resources, enhancing indicates that in poorer countries, higher
fiscal decentralization is consistently associated with lower mortality rates and appears
to improve health outcomes in environments with high levels of corruption.

Privatization of health services-when institutions are weak and accountability for the use
of public funds is low, privatization of health services can be seen as an alternative
method of improving the quality and effectiveness of health services. Privatization
reduces the power-monopoly of public providers and limits their opportunity to charge
bribes.