Editor’s Note: As Nigeria celebrates its 59th year of Independence, Dr. Ifeanyi Nsofor reflects on Nigeria’s healthcare journey through the lens of an average 59-year-old Nigerian woman. Dr. Ifeanyi Nsofor is Director of Policy and Advocacy at Nigeria Health Watch, a 2019 Atlantic Fellow for Health Equity at George Washington University and a Senior New Voices Fellow at the Aspen Institute.
Today Nigeria celebrates its 59th year as an independent nation. Special prayers are being offered in churches and mosques. Speeches will be made and wreaths laid by politicians. Businesses are tapping into the occasion to make brisk sales.
Beyond the celebration, let us imagine that Nigeria is a 59-year-old woman named Wazobia. This is a fair assumption because a society’s level of development is measured by looking at the status of women and the level of their empowerment. What has been the state of Wazobia’s health since Nigeria’s independence in 1960? Is she living her best life? What about her children and family? The questions are numerous.
Nigeria’s 59th independence anniversary comes right after the 74th session of the United Nations General Assembly (UNGA). This year, Professor Tijjani Muhammad-Bande, Nigeria’s Permanent Representative to the United Nations presided over the assembly. A major output from UNGA was the adoption of a high level political declaration on universal health coverage (UHC) which recommitted member nations to achieving universal health coverage by 2030. A core component of the UN UHC resolution recognised that “universal health coverage means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose individuals and families to financial hardship”.
Nigeria’s UHC journey began in 1962 by then federal minister of health, Dr. Majekodunmi presenting a healthcare bill in parliament, however this was rejected. The nation existed in UHC limbo until 1988 when the template for the present-day National Health Insurance Scheme (NHIS) was developed. In 1999, Former President Olusegun Obasanjo signed the NHIS Act. 14 years after NHIS became operational in 2005, it has barely increased access to affordable healthcare for Nigeria, with no more than 1% of Nigerians insured under the scheme. Nigerian states began to establish mandatory health insurance schemes three years ago, and this is increasing the pool of Nigerians with access to health insurance. At last count, 20 states had passed health insurance bills into law. State health insurance schemes have cumulatively enrolled above 2 million Nigerians.
The current life expectancy for a Nigerian woman is 55.7 years. So, Wazobia has a high chance of not surviving to even celebrate her 59th birthday. The UN UHC resolutions bring to light the health challenges Wazobia faces. The most inequitable of all the health challenges, is death during pregnancy, childbirth or 42 days after delivery. About 58,000 women die every year in Nigeria simply because they are about to give birth. Imagine how many women have died this way since 1960! These maternal deaths have been likened to deliberately crashing a commercial jet full of pregnant women daily, and what really underscores the waste in human life, is that many of the pregnancy-related deaths were preventable. Nigeria has refused to act to stop these maternal deaths.
To stop maternal deaths, there has to be accountability. The is the goal of the #GivingBirthInNigeria project being implemented by Nigeria Health Watch, EpiAFRIC and Africare. Working with community based organisations, maternal deaths in communities across seven states in Nigeria are being recorded to understand the reasons women are dying in communities and to seek solutions to prevent more deaths. The project, funded by MSD for Mothers, began with a baseline assessment and selection of community-based organisations to report maternal deaths in selected communities in the Federal Capital Territory (FCT), Lagos, Bayelsa, Bauchi, Kebbi, Ebonyi and Niger State. Since June 2019 when data collection began, 110 women have died in pregnancy or childbirth in the Local Government Areas (LGAs) being monitored, across the seven states. Most deaths occurred at home, with excessive bleeding after birth being a leading cause of the deaths. This should not be happening in a country celebrating 59 years of independence.
Education is known to lead to better health outcomes. Unfortunately, it is unlikely that Wazobia would have attended school (or, if given the opportunity, completed her secondary schooling) because more girls than boys are out-of-school. According to UNICEF, 10.5 million Nigerian children are out-of-school. Globally, one out of every five children who are not in school is a Nigerian child. Research shows that an educated woman is more likely to immunise her children, ensure better health for her children and use contraceptives to plan her family.
Good health does not depend on just functional health facilities. Social determinants of health such as access to clean water, sanitation and poverty ensure better health for the woman and her community. In many communities in Nigeria, Wazobia will be the one who walks long distances to fetch water from streams that are not clean. She is most affected by the lack of toilet facilities, especially when she is menstruating. The duo of poor sanitation and lack of clean water will expose Wazobia to some Neglected Tropical Diseases (NTDs) such as trachoma, river blindness, schistosomiasis and lymphatic filariasis. Trachoma and river blindness can lead to irreversible blindness. Even when males are affected by these diseases, the girl-child is the one who becomes the caregiver to the blind and mortgages her own future as a result. Also, female genital schistosomiasis increases the risk of HIV transmission among women. On the whole, inequality disproportionately affects women, compared to men and this is further seen in the wage differences. Wazobia would be earning far less than her male counterpart.
HIV disproportionately affects women in Nigeria. Based on 2018 estimates by UNAIDS, one million of the 1.8 million Nigerians living with HIV are women. There were 26,000 new HIV infections among young women aged 15–24 years compared to 15,000 among young men of the same age range. Sixty-eight percent of women living with HIV are on treatment compared to 37 percent of men.
There is a rise in non-communicable diseases such as cancers in Nigeria. In fact, the World Health Organisation views this as a double burden of disease. As a 59-year old woman, Wazobia is at risk of cancer. She would not have received the Human papillomavirus (HPV) vaccine in her teens. Despite strong evidence from Scotland that the HPV vaccine greatly reduces the risk of cervical cancer when given to girls aged 12 and 13 years, it is not available in Nigeria’s routine immunisation schedule. Consequently, Wazobia could be one of the 14,943 cases of cervical cancer cases reported annually and one of the 10,403 who died from the disease. The HPV vaccine is a very important vaccine not just for women but also for men — it reduces the risk of other cancers such as vagina, vulva, head and neck, penis and anus.
To be sure, Nigeria has been supported by donors to improve Wazobia’s health. The Midwives Service Scheme and SURE-P Maternal and Child Health Project are nationwide projects meant to improve maternal health in Nigeria. In 2015, the SURE-P MCH was evaluated by EpiAFRIC. One of the major findings was the centrality of village health workers to the success of the SURE-P MCH project. Village health workers were tasked with going into communities and encouraging women to visit the health facilities for care during pregnancy and after delivery. Donors have also supported the government of Nigeria to improve girl-child education, reproductive health, addressing the HIV challenge, improving women economic empowerment and tackling the NTDs.
In January 2019, President Buhari launched the Basic Health Care Provision Fund (BHCPF), to provide a basic package of health care to women, children under five years of age and the elderly in Nigeria’s underserved communities. In June 2019, the first tranche of the BHCPF was released. To address challenges linked to the social determinants of health, Nigeria’s Infrastructure Concession Regulatory Commission is introducing gender perspectives into infrastructural development, to eliminate the current gender disparities in public-private-partnerships processes, procedures and executions. This will include considering the impact of poor infrastructure on women during the design stage of a project.
As we head towards our 60th year as an independent nation, it is about time for the government of Nigeria to take a closer look at Wazobia and put in place the necessary policies and measures to safeguard her health, education and wellbeing. By ensuring that women like Wazobia have access to education. This will provide them with the necessary tools and ability to gain skills so they are economically empowered and can provide for themselves and their families. Ultimately, when Wazobia prospers, Nigeria prospers, because a healthy nation has a better chance of embarking on a path of greater prosperity for all its citizens. We look forward to a Wazobia, healthier at 60.