public policy for reproductive health in Nigeria should not be without first recognizing the global issues that bear upon the country's public health system and the state of its people. Today the country continues to renew its effort in sustaining public health with vigorous plans and new programs that will be reviewed in this study. But any new proposal must also understand the depth of the country's problems and some of the reasons for it. This would help in the formulation of a proposal for public policy for reproductive health.
Nigeria reflects the devastation of health of the people of Sub-Sahara Africa. It is a reflection shared by the struggling health systems of most of the countries of that realm. Across the region these country's have poverty levels that result in some of the world's lowest life expectancy rates along with the world's highest maternal and child morality rates. Nigeria carries one of the lowest life expectancy rates, 44 years of age, of the Sub-Saharan countries.
The health systems of these countries are all evolving to coordinate as best they can as many resources that can be managed. Among these resources are a host of international public and private agencies, NGOs, and donors helping to improve the public health. These agencies include several from the UN including the EU, UNDP, WHO, and the World Bank. Among private donors who have had significant impact include the several funding agencies attributed to Bill Gates, Jimmy Carter, and Bill Clinton.
There are many good suggestions and strategies for improving Nigeria's public health system. But they should all be drawn within the reality of structural world policy issues in poverty. The citizens of Nigeria and all the African countries, along with other developing countries, have the most people in the world but share the smallest percent of its resources (O'Neil, 2009). There are any number of reasons for this inequality. But its existence makes only more poignant the challenge of public health in the developing countries. These countries are confined to developing appropriate programs and results while receiving only limited world resources.
Nigeria experienced wealth during the 1970s during its oil boom (Igbuzor 2006). Military dictatorships leading to weakened and ineffective governance ruined the country's prospects toward social advance and the eradication of poverty. In 1988 Nigeria entered the infamous Structural Adjustment Program foisted upon it by the International Monetary Fund and the World (Ogbimi 1998). This program resulted in "the virtual collapse of government health care services" in Sub-Saharan countries (Adinma et al. 2010). The economic program resulted in most federal income serving relief of external debt while seriously reducing spending on social and health policy programs and greatly exacerbating the wealth income gap.
After returning to civilian rule, in 2002 Nigeria finally left the IMF (Fotso et al. 2011, p. 8). While still facing debt from the 'Paris Club' consortium of foreign lenders, the country has more or less been in control of its own resources. Since moving from military rule in 1999 and despite the left over practices of institutionalized corruption from that experience, Nigeria has recently demonstrated good measure in a willingness to determinately pursue social, economic, and health policies under the civic government.
Problematic Health System
Over 52% of Nigeria's population live in rural areas. Poverty rates have been as high as 65.6% in 1996 and today 53% of the Nigeria's citizens are mired in poverty (Scott-Emuakpor, 2010, p. 60; Igbuzor, 2006). The country has a decidedly low human development index (HDI) of 0.439, a composite of life expectancy scores, schooling, and income. Its Gini index of 50.6, measuring wealth distribution (0 equals perfect equality), places it among the poorest countries (Igbuzorv 2006). In spite of rich oil fields, because they are governed unequally by multinational corporations, poverty remains one of the major factors for the poor health levels.
Nigeria has experienced recent setbacks in its morality rates, demonstrating uneven courses or directions in public policy. The maternal mortality rate in Nigeria is among the world's highest, 800 per 100,000 live births, 2000-2009 (WHO, 2010). It is estimated that the country has 760,000 abortions annually with a significant amount of these occurring in poorly equipped facilities (Okonofua et al., p. 194)
Infant mortality trends increased from 97 to 99 per thousand from 1993-1998, and decreased to 75 per thousand in 2008. Child deaths under five decreased from 199 in 1998 to 157 per thousand in 2008 (NDHS, p23). Life expectancy years is below the mid 40s, and the country has experienced no meaningful reduction in child mortality rates over the past 40 years (Adinma, 2010).
Poverty impacts the rural Northern regions more than it does the wealthier Southern regions. Immunization efforts are not very well coordinated in the Northern regions and children are prey to unmanaged outbreaks of malaria, dysentery, pneumonia, and measles (WHO, 2002). Cholera, meningitis and yellow fever have raged periodically over the years in Nigeria. Infants and poor children under the age of five in the North East and North West zones are more likely to die from impoverished conditions than in the southern areas. High mortality rates in the northern zones reach over 200 for children under five (NSHDP, 2010, p 24). The northern zones reflect traditional cultural beliefs and behaviors related to fertility that seem to only heighten maternal and child mortality (Doctor and Dahiru, 2010, p. 38).
Many other health issues compound the dire state of Nigeria's public health system. The annual rate of women with obstetric fistulae is 50,000-100,000. Chronic malnutrition affects 41% of children under five with 14% suffering extreme malnutrition (NSHDP, 2010, p. 25). Access to safe drinking water is limited to 46% of the country's residents. This figure, itself, must be adjusted as 50% of urban homes do not have access to water even when it is available (Scott-Emuakpor, 2010, p. 61).
Nigeria has very restrictive abortion laws. They are usually ignored but it is believed that unsafe abortions account for significant parts of the high maternal mortality rate (Okonofua et al., 2009). Intimate partner violence (IPV) is a factor that affects not only reproductive ability of women but also bears directly on the status of women and how they are treated in Nigeria's multicultural and ethnic world (Okenwa, 2009).
Poverty rates are compounded by low literacy rates, but Nigeria has seen literacy actually climbed to 72% of the adult population, 2000-2007 from its previous low rate of 55%, 1990-1999 (WHO, 2010b). Still, the spector of poverty especially in the rural areas, is imposed by Spartan living standards portrayed by open pools of defecation, and other evidence of primitive social amenities (Awofeso, 2010).
After assessing the state of Nigeria's public health system by meeting with officials of the federal government and those of six states, the World Health Organization drew up a Country Cooperating Strategy (CCS) in 2002. The plan helped the country identify priorities and coordinated goals of WHO agencies and other participating international organizations between 2002 to and 2007. The assessment found Nigeria's health system declining, losing confidence of external partners, and faced with widespread diseases and endemic.
Federal Ministry of Health
The Federal Republic of Nigeria is drawn from a constitution which recognizes a federation consisting of a nationally elected central government, operating from the Federal Capital Abuja, and 36 state governments. The states distribute national funds to the councils of some 774 Local Government Areas and are, themselves, grouped and administered through six regional zones (Okonofua et al., p. 194). The county's 151 million citizens have over 250 ethnic tribes but has several groups comprising the majority. These include he Hausas and Fulani who populate the north. The Hausas are primarily Muslims. There are Yoruba majorities in the southwest while Ibos who populate the southeast. Christians are mainly in the south. Islam has recently taken over 50% of the country while Christianity populates 48%.
Nigeria's public health policy is formulated by the Federal Ministry of Health (FMOH) which places Public Health Care centers in service through State Ministries of Health (SMOH) who supply and coordinate LGA administration of local PHCs. One report describes the northern Nigeria PHC services as "virtually dysfunctional" (Doctor and Dahiru, 2010, p. 39).
The health system has a number of parastatals. The National Agency for Food and Drug Administration and Control (NAFDAC), National Primary Health Care Development Agency (NPHCDA), National Programme on Immunization (NPI), Nigerian Institute for Medical Research (NIMR) and National Action for Prevention and Control of AIDS (NAPCA) were created to deal with priority health issues.
Shiffman and Okonofua (2006) argue for political and moral commitment to goals of 'safe motherhood' (the rallying cry for a UN initiative during the 1980s) (p. 126). They note that the country's adoption of democratic principles has led to the fostering and mobilization of advocacy social groups that had not been possible under the "predatory governance" of the military rule (p. 126). Nigeria now has several civic groups who are actively pushing for policies for safe motherhood. They…