Public Policy for Reproductive Health in Nigeria

¶ … 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.

Literature Review

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.

Commitment

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 include the Society of gynecology and Obstetrics of Nigeria (SOGON) which now holds annual conferences on relevant themes. The National Council of Women's Societies, besides lobbying for abortion law reform, promotes free maternal health care services. Safe abortion is publicly promoted by The Campaign against Unwanted Pregnancy and Ipas.

Other improvements noted by Shiffman and Okonofua include pronouncement of clear commitments from the Federal Ministry of Health in studies and documents concerning a national reproductive health policy. These efforts involved coordinated participation by the United Nations Population Fund (UNFPA) and the United Nations Children's Fund (UNICEF). The first budget committed to projects funding safe motherhood was obtained by the FMOH 2004. The government adopted WHO Millennium Development Goals (MDGs) toward reducing maternal mortality and improving child health in 2005.

However, in their 2006 study, Shiffman and Okonofua state that there was no top down push for effective coordination of the Safe Motherhood efforts. The state still only provided minimum funding to reduce maternal mortality. And significantly, "state and local governments pay virtually no attention to the issue" (p. 129).

Health Development Plan 2010-1015

The National Strategic Health Development Plan 2010-2015 concluded that Nigeria's health care system was "unable to provide basic, cost-effective services" at local government levels (p. 29). It found only a fifth of local clinics capable of providing sufficient obstetric services. Communication and the spread of information were limited, especially in the North West and North East zones (p.29).

The government report found most of the country's public health facilities, operated by the LGA councils had only limited equipment. This lack partly explained the high maternal mortality rates. Two-thirds of Nigerian woman do not deliver at these health facilities and their births are attended without medically skilled attendants (Okonofua and Shiffan, 2006). In an interview study published in 2010, Doctor and Dajori (2010) found that among 5,091 of 6,809 women respondees who had pregnancies, 89% of those women who had pregnancies over the last five years had been attended by non-skilled birth attendants.

The government's report faulted mismanagement and lack of transparency as the main culprits for the country's poor performance of health care delivery (p. 31). The government is currently formalizing the overseeing body, the National Primary Health Care Development Agency (NPHCDA), to oversee management and enforce transparency of finances from state to local transfer.

Financing Health Care

"[A]n estimated 150 million people globally suffer financial catastrophe each year and 100 million are pushed into poverty because of direct payments for health services" (WHO, 2010a, p. 9).

The World Health Organization in their 2010 World Health Report (WHR) made Health Systems Financing the primary topic. The subtopic was The Path to Universal Coverage. Recognizing the inequality of world health systems between developed and developing countries, the report emphasized several points toward improving health care in developed countries. First it must be recognized that 20% to 40% of all health care spending is wasted. Transparent systems must be established to distribute and spend funds efficiently. Second, direct payment systems comprise the greatest obstacle to progress. The most important point was drawn from the 2005 World Health Assembly resolution 58.33. A well-functioning health financing system is based on universal health coverage for all where everyone should have access to health services without financial burden (WHO).

WHO suggests that the form of direct payment, or cost sharing, for medical expenses, should be replaced with the prepayment approach, in which risks for all are pooled together and everyone is universally covered. All countries have poor people who cannot pay income taxes or insurance premiums. In Nigeria, these people make up the 'informal system' and are 70% of the population as contrasted to the 'formal system' (Onwujeke et al., 2010).

The overriding basis of a universal health care system is that it requires compulsory participation from all. It is a plan that spreads the burden of financial risk. Contributory schemes must be mandatory or else the rich will eventually opt out of the plan.

WHO also proposed that developing governments must prioritize health spending and raise levels of committed government funding to health care services (WHO, 2010a, p. 25). For developing countries, the WHO report suggests the state must use creative financing to provide subsidies to finance the poor who cannot pay. The governments must innovate other sources of domestic funding, such as taxes on pharmaceutical companies or even mobile phones. They could raise taxes on sin goods such as alcohol and cigarettes.

Also, the developing countries must improve their tax collecting/compliance efforts. For the third source of external donors, WHO reports that donor contributions from such as OECD countries are strongly affected by inflation and foreign exchange rates, along with regular delays in payments. These could be improved by better governance between countries (WHO, p. 32).

Economic systems would also have to be developed to lie more in consort with development opportunities for employment for all citizens so that they may be able to help subsidize health care plans.

Committed Goals

Representing a take charge attitude toward build sustaining health care systems, Nigeria proposed the Abuja Declaration which was adopted by African countries at a 24-27 April 2001 summit. The African leaders, in response to the AIDS epidemic committed themselves toward "allocating at least 15 per cent of our annual budget to the improvement of the health sector" (Abuja Declaration). For Nigeria, the intent is good, but the goal is realistically challenged, as it is among all developing nations. WHO reports Nigeria's total health expenditure from government expenditure rose to 6.5% in 2007, from 4.2% in 2000 (WHO, 2010b, p. 134). The figure tends to fluctuate depending on general economy and also the changing state of government.

The funding commitment goal, however possible, was followed by the several Millennium Declaration Goals (MDGs) drawn up by the United Nations and developing countries in September, 2000. The MDGs sought to concentrate efforts toward bringing up the quality of life of poor nations. The goals regarding reproductive health that were committed to by Nigeria and other developing countries were to reduce the child mortality rate by two-thirds in 2015, and to reduce by 75% the proportion of women dying in childbirth by 2015 (Igbuzor, 2006).