A healthcare vision for Nigeria
In December 2012, I visited several rural communities in northwestern Nigeria to assess the impact of our renewed efforts to improve the delivery of basic health services. One of our stops was a settlement of Fulani nomadic pastoralists, located far from the nearest road in Katsina state. We drove several kilometers into the bush, following cattle tracks. The settlement comprised huts built out of corn stalks. There were several children running around barefoot, with goats roaming freely and a strong stench of animal dung. There was no water, no toilets, no electricity, no school, and no clinic nearby.
In such an environment, every day is a struggle between life and death, particularly for children and women. There is a dearth of simple, cost-effective medical interventions that could save children from diarrheal diseases, malaria, or pneumonia. Women lack access to antenatal care and skilled attendance at delivery. The visit reminded me that despite recent progress toward improving health outcomes in Nigeria, more work remains to be done.
The death rate of children under five, for example, has been dropping at an annualized rate of 4.8 percent over the past few years. This rate will need to double for Nigeria to achieve the Millennium Development Goal of reducing child deaths to two-thirds of the 1990 rate by 2015. Every year, pneumonia, diarrhea, and malaria claim the lives of about 596,000 children in Nigeria. That’s 55 percent of total child mortality; these diseases account for 16 percent, 19 percent, and 20 percent of all under-five deaths, respectively. This situation is clearly unacceptable because simple, affordable, effective remedies exist for all these diseases.
For each of the program areas, we estimated the coverage gap and calculated how many lives could be saved by closing the gap in each state of the federation. In the case of childhood pneumonia, diarrhea, and malaria, we learned that the proportion of children who receive appropriate treatment in Nigeria stands at less than 30 percent for all three diseases (according to the 2008 Nigerian demographic and health survey). This poor coverage exists not only in the public health-services-delivery sector but also in the private sector, where more than 41 percent of Nigerians seek care outside the home for childhood illnesses. While there are barriers to appropriate treatment for each disease, there are also significant cross-cutting barriers that hinder access to treatment across all three diseases.
Significant inequities also exist in access to and utilization of critical-care services. When we compared the highest- and lowest-wealth quintiles, we found two- to threefold differences in access to medical treatment of fever, acute respiratory illnesses, and diarrheal diseases. The inequities are even more pronounced for other services such as full immunization coverage, antenatal care, and skilled birth attendance. The burden of morbidity and mortality from preventable diseases and conditions is disproportionately borne by the poorest members of our society. It follows logically that these illnesses may also contribute to further impoverishment.
Our healthcare vision
We have outlined a vision for the Nigerian health sector that focuses on the ultimate goal of all healthcare activities—saving lives. Given the size of our population and the prevalence of preventable diseases, it is clearly possible to save at least one million lives over the next three years by expanding access to well-known, cost-effective interventions.
This new approach requires shifting our mind-sets in two areas. First, we must focus relentlessly on the priorities and outcomes that matter. Second, we need to focus on delivery, which I define as the art of getting things done. We have identified healthcare priorities based on data from our latest demographic and household survey, as well as other tools. It is clear from the data that we need to focus on improving maternal and child health. We must expand access to immunization against polio and other diseases that can be prevented by vaccination. We need to stop mother-to-child transmission of HIV. We must expand our malaria-prevention and treatment programs. We need to deal aggressively with diarrheal diseases, pneumonia, and malnutrition. Finally, we must improve our healthcare logistics and supply-chain-management systems.
Several efforts will be necessary to improve delivery in all these areas.
Address demand-side challenges
Health programs that only focus on supply-side interventions—for example, medical professionals, commodities, and facilities—miss opportunities to close what are often sizable gaps in demand for health services. We must unlock demand for maternal and neonatal health services. About 60 percent of pregnant women in Nigeria seek antenatal-care services. Only about a third of women give birth in medical facilities, according to Nigeria’s last demographic and health survey. Meanwhile, unsafe pregnancy, birth, and postnatal care are among the biggest killers in Nigeria. By our estimates, more than 30,000 Nigerian women die each year due to complications from pregnancy and delivery. About 70 percent of these deaths are due to preventable and treatable causes.
Another 400,000 neonates die each year, also largely due to preventable causes. We cannot simply deliver health interventions and assume that women will use them. We must create incentives and reduce financial barriers so that women can access the services they need to keep themselves and their newborns healthy. In January 2012, the government of Nigeria, under the Subsidy Reinvestment and Empowerment Programme (SURE-P), launched a pilot conditional-cash-transfer program to offer incentives to pregnant women and new mothers to use maternal and child health services in primary health clinics. SURE-P will implement cash transfers in nine states across Nigeria’s six geopolitical zones this year, representing the first demand-side health intervention at scale in Nigeria.
Deploy effective technologies
Appropriate technology can dramatically increase the impact of our healthcare programs. Consider our emergency polio-response effort, in which we are deploying GIS/GPS technology to enhance data collection and focus our programmatic responses. We are using GIS technology to map and identify settlements missed by previous polio-vaccination efforts, improve polio surveillance, and track immunization teams in the field to ensure that they cover all households.
As a result, we are able to immunize many more children against polio. Despite the recent tragic killings of polio-immunization workers by gunmen in northern Nigeria, I am confident that this technology will play a central role in our effort to interrupt transmission of the wild polio virus in Nigeria this year and eradicate it by 2015.
Use data to drive fact-based decisions
Good data are an absolute prerequisite of effective delivery. With timely, high-quality data, we can focus our interventions and guard against actions based on unrepresentative anecdotes. Our SURE-P maternal and child health program has a dedicated data-collection function that provides program managers with reliable and timely information. Each month, the program deploys monitoring and evaluation officers to primary health facilities to collect data. They report data to liaison officers in each state, who send data on to the central program team in Abuja. This provides crucial, regular insight into what’s happening on the front lines so that the program team can identify issues that need further attention and intervention.
The road ahead
To save as many lives as possible, we must improve coordination of healthcare efforts undertaken by various states and development partners, as well as partners in the private sector and civil society. We need robust data systems that can collate, analyze, and synthesize program information from various sources and feed it to decision makers. Given the scope of our ambition, we also need a dedicated team in the program-delivery unit with the right attitudes, skills, and mind-sets to drive results.
How will all this work deliver better healthcare to underserved communities such as the Fulani settlement I visited in December? We need to mobilize community leaders and civil-society organizations to increase demand for healthcare services. Local government officials must be equipped with planning information, sufficient vaccines, and essential therapies such as zinc/oral rehydration salts to treat diarrheal diseases. Local health workers and state officials must be provided with accurate information on service coverage and held accountable for achieving better healthcare outcomes. Finally, the federal government must support the states with technical assistance and medical supplies.
It is indeed possible to save millions of lives that might otherwise be lost to preventable causes. To succeed in this vital work, we must focus on outcomes, pay relentless attention to detail in implementation, and track results consistently.