Democracy and the crises in Nigeria’s health sector

By UZODINMA ADIRIEFE
After the failure of previous efforts at enthroning democracy, Nigeria once more embraced the government of the people, by the people and for the people, in the twilight of the 20th Century. May 2010 marked ten years of unbroken democracy in the country, the longest period of civilian rule since the country was granted political independence by the British on the first day of October 1960.

These last ten years have witnessed relative peace, with changes in the economy occasioned by steady growth, a large reduction in external debt, and structural reforms of the financial and telecommunications sectors. That these changes have significantly rubbed off positively on the standard of living of the majority of the citizens is debatable. As the world marked the international Democracy Day, September 15, and Nigeria celebrated its 51st independence anniversary, it is worthwhile to discuss the country’s health situation over the last decade.

In Democracy and Mental Health: The Idea of Post-psychiatry, Pat Bracken explained democracy as being about ordinary people having control of their lives and that this is a bigger issue than who is allowed to vote, when, where and for whom. In 1918, some one hundred years ago, while addressing a meeting of the American Public Health Association on the subject of “Democracy and Public Health Administration,” the then president of the association, Dr. Charles J. Hastings, said: “under our present public health administration, we require people to conform to certain regulations. We endeavour to teach them how to live. We tell them that plenty of nutritious food, fresh air and sunshine are the best and only reliable remedies for tuberculosis and other wasting diseases.

We insist on mothers nursing their babies, assuring them that by doing so, they give their infants ten chances to one than they would have it if artificially fed …what our nation requires is a fitter race, and what every individual is entitled to is the development of the best, mental and physical, of which he is capable; and, no government is worthy of being called a democracy that does not make this possible. The World Health Organization (WHO) defines health as “a state of complete physical, mental, and social-well-being and not merely the absence of disease and infirmity.” Therefore, improving the health of the worst-off can improve a country’s aggregate performance in health, and her health and development indices. Democratic institutions are expected to affect health positively through policies and actions that translate to universal access to high quality health services and products that improve the lives of the citizenry.

Health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country. However, because the country operates a mixed economy, private providers of health care also play visible roles in the country’s health care delivery. The federal government’s role is mostly limited to coordinating the affairs of the university teaching hospitals, while the state governments manage the various general hospitals and the local governments focus on primary health care and dispensaries.
This article takes a look at how the actions and inactions of the players in Nigeria’s present democratic set-up have impacted on the country’s persistent health crises in the last ten years. Certainly, a country’s democratic structure affects virtually every aspect of society, including health.

A review of the 2010 and 2005 World Health Statistics published by the World Health Organization (WHO) shows that although Nigerian government’s general expenditure on health as a percentage of total government expenditure has marginally increased over the years, from 4.2% in year 2000, down to 3.2% in 2002, and up to 6.5% in 2007, this has consistently fallen short of the 15% that was recommended by the African Union in the Abuja Declaration of 2001. This picture is replicated in most of the Federal Capital Territory, the thirty-six States of the Federation, and their Local Government Areas. On the other hand, during the same period, the governments of Ghana and South Africa allocated well over 10% of their annual expenditure to health.

Nigeria’s health indices and those of Ghana and South Africa are also very similar. As revealed by the WHO, in 2003, these three countries had under-five or U-5 mortality rates of 198, 95 and 66 respectively, while the same index was 186,76 and respectively in 2010. The U-5 MR is the probability of a child born in a specific year or period dying before reaching the age of five, and is usually expressed per 1,000 live births. Over the same period also, Nigeria’s average life expectancy increased from 47.5 years in year 2000 to 49 years in 2008. Life expectancy is the number of years a person is expected to live as determined by mortality in a specific geographic area. The country’s adult HIV prevalence also improved from 5.4% in 2003 to 3.1% in 2007.

Although no single factor can be attributed with improvement in health of the country, Nigeria’s marginal improvements can be largely attributed to the increase in health expenditure over the preceding years. These improvements would surely increase if the expenditure on health is increased to the level recommended in the Abuja declaration.

Unfortunately, the country’s maternal mortality ratio or NMR – a critical measure of the state of health of every country – took a plunge for the worse during this period, increasing from 800 in year 2000 to 1,100 in 2010. The NMR represents the annual number of deaths of women from pregnancy- related causes per 100,000 live births. Sadly too, both the boost given to primary health care by the late Professor Olikoye Ransome-Kuti, and the impetus given to health sector reforms by Professor Eyitayo Lambo, appear to have run into mucky waters. Indisputably, the tenures of both men as Ministers of Health in Nigeria had been our most glorious in the last twenty-five years.
The relationship between democracy and health outcomes has also been the focus of recent research interest. With an estimated 158 million people in 2010, Nigeria is the most populous country in Africa.

In the health sector, progress has been slow and many challenges remain: from weak health system to tackling HIV/AIDS; from improving immunization coverage (which in the past has impeded the global goal of eradicating polio) to implementing the new International Health Regulation (IHR); from achieving the Millennium Development Goals (MDGs) to preparing for pandemic flu. In many communities of the country, critical infrastructure that support health e.g. water, good sanitation and electricity are still lacking; while health facilities remain dilapidated … waiting for GA Vi, the Global Fund, Bill and Melinda Gates, PEPFAR, World Bank and other donors and multilateral/bilateral partners. At the same time, workers in many government health institutions occasionally ‘down tool’ over unpaid entitlements. Yet, we are just four years away from 2015, the magical year for the MDGs. Government officials still readily go to health institutions in other countries for their health care needs at the expense of taxpayers. Shouldn’t we do better?

Adiriefe writes from Lagos.
http://www.sunnewsonline.com/webpages/opinion/2011/nov/18/opinion-18-11-2011-002.html