AFRO-NETS> Trouble with Nigeria's healthcare system...

[A Odutola <chpss_abo@yahoo.com>]

Trouble with Nigeria's healthcare system...
-------------------------------------------

Trouble with Nigeria's health system is more than 'A Question of Po-
litical Will'
 
The report on Nigeria's health system by Omololu Falobi, titled: "Ni-
geria - A question of political will" (see below and available at: 
http://www.panos.org.uk/briefing/TRIPS_nigeria.htm), is laudable and 
brilliant. It catalogues succinctly, the problems confronting the 
health sector, but it is somewhat short on remedial policy proposals. 

Political will for remedial action on its own will amount to nothing 
if not linked with carefully thought through, well designed and 
achievable process of change. 

To be sure, Nigeria has some of the best-trained workforces, techni-
cal capacity and Africa?s largest market. But these positive factors 
will not add up to any meaningful health benefits in a country 
plagued by weak governance institutions, poor social insurance infra-
structure, in-grained corruption at all levels, over-centralization; 
mis-application of funds, etc.; which all together fuel the institu-
tionalization of what I prefer to call "randomised chaos" rather than 
"organised chaos" referred to by Prince Adeluyi - former Minister of 
Health in the report.

Civil society members and the health leadership systems would do well 
to: 
a) establish on an on-going basis, a non-partisan forum for purpose-
ful engagement in policy advocacy for change and crafting workable 
blue-prints for reform, and 
b) facilitate the faithful implementation of the change programme. 
Political will on its own is of no consequence.

Best,
A. Odutola
Centre for Health Policy & Strategic Studies
34 Town Planning Way, 
Ilupeju, Lagos, Nigeria
mailto:chpss_abo@yahoo.com 

--
Stop-TB <stop-tb@healthdev.net> wrote:
Nigeria: A Question of Political Will 
By Omololu Falobi*

Patents are only one of many factors preventing widespread access to 
drugs in Nigeria. Other obstacles include high cost, poor infrastruc-
ture, government policy and corruption.

Up to 30,000 Nigerians die of tuberculosis every year. Most of these 
lives could be saved if Directly Observed Treatment, Short-course 
(DOTS), involving a series of non-patented drugs was more widely 
available. At market prices, DOTS costs 17,000 naira (US$ 130). Al-
though DOTS is theoretically free, government clinics often run out 
of the drugs, forcing patients either to interrupt treatment - risk-
ing development of the drug-resistant form of the disease - or to 
purchase the drugs themselves, an option beyond the means of many 
citizens when the minimum wage is 7,000 naira (US$ 53) and most mid-
dle income workers earn N20,000 per month.

Cheaper options for treatment of tuberculosis include Streptomycin, 
but its use is discouraged because the disposable needles and sy-
ringes needed to inject it are not always available. Clinics there-
fore sometimes replace streptomycin with ethamebutol, a much more ex-
pensive drug, stretching already scarce resources.

Access to medical care

In the late 1980s, government health services were commercialised. 
Apart from tuberculosis and malaria, free treatment facilities are no 
longer provided.

Nigeria has one of the poorest doctor-to-patient ratios in Africa, 
with one doctor per 3,500 people. In the last decade, less than four 
percent of the government?s annual budget has been allocated to 
health. In 1998 health received four billion naira from a total 
budget of 164 billion naira (2.5 percent), while defence was given 16 
billion naira.

Lack of modern, functioning facilities and lack of medical personnel 
mean long waits for patients and inefficient service, including inap-
propriate prescription or lack of prescription of necessary drugs. 
Patients also have to pay for a registration card (about 50 cents) 
and transport to the hospital, prescriptions have to be bought at 
pharmacies at prevailing market prices and necessary laboratory tests 
are at the patient?s cost. These factors all discourage people from 
seeking health care.

Self-medication

Aside from tuberculosis, Nigeria faces many other health epidemics, 
including malaria, cholera, HIV/AIDS, guinea worm and meningitis. Ma-
laria kills more Nigerians than any other disease despite the fact 
that treatment is cheap, well-known and widely available.

?The main problem is drug resistance, caused by the wide practice of 
self-medication, late diagnosis and early stoppage of treatment?, 
says Dr. Taiwo Adewole, one of Nigeria?s top malaria experts. Self-
medication is common among low income earners. Walking to the nearest 
drug hawker to buy a few tablets of chloroquine avoids the cost and 
time involved in visiting public hospitals. ?The result is that ma-
jority of malaria cases are improperly treated and only report to 
hospitals when the parasite has developed resistance to the cheaper, 
first-line treatment and complications have set in?, Adewole ex-
plains.

Industry collapse

Nigeria once hosted one of Africa?s best pharmaceutical industries. 
?The local pharmaceutical industry is at its worst ebb?, says Mrs. 
Stella Okoli, chair of the pharmaceutical manufacturing group of the 
Manufacturers? Association of Nigeria ?In 1990, up to 137 indigenous 
and foreign-owned pharmaceutical firms were operating; now, only 77 
are?.

In the early 60s and 70s, a substantial share of commonly-prescribed 
drugs such as paracetamol were produced by state-owned manufacturers, 
many of which, due to alleged mismanagement and poor funding, are now 
out of production. Recent efforts by one company to start manufacture 
of a treatment for sickle cell, for which it has proprietary rights, 
have been stymied by non-release of capital voted by government.

Counterfeiting

Access to medicines is compounded by the problem of smuggling of 
counterfeit or adulterated drugs into the local market. Dr. Niyi 
Ogundiran of the World Health Organization estimates that up to 40 
percent of all drugs circulating in Nigeria are either smuggled in 
illegally or are counterfeit versions of the original products. The 
National Agency for Food and Drugs Administration and Control 
(NAFDAC), claims that between April 2001 and April 2002, it seized 
and destroyed over 2 billion naira worth of imported fake drugs. Lo-
cal pharmaceutical companies have also announced a yearly loss of 10 
billion naira to the adulterated drug market.

Many deaths have resulted from counterfeit drugs. In 1991, batches of 
paracetamol syrup sold across the country contained poisonous sub-
stance; 196 children died after taking the ?medicine?. Such practices 
continue. NAFDAC has recently identified seven different types of 
adulterated paracetamol tablets and five different adulterated ver-
sions of chloroquine circulating in Nigeria.

Distribution

Another factor restricting access to safe, effective and inexpensive 
drugs is the poorly regulated distribution system. Most trained phar-
macists set up retail outlets in state capitals and urban centres, 
leaving wholesale distribution and retailing in the rest of the coun-
try almost exclusively in the hands of non-pharmacists. Many distri-
bution systems are controlled by cartels which in some cases have 
been likened to mafias. ?The drug distribution system is ?organised 
chaos?,? says Prince Julius Adelusi-Adeluyi, a pharmacist and past 
Nigerian health minister. ?Organised because people still manage to 
get the drugs they need by special legal or extra-legal means; cha-
otic because operators have defied laid down rules and regulations?.

The system of registering pharmacies is often ignored. A 2000 study 
by a team of pharmacologists from the College of Medicine, University 
of Lagos found that over 6 percent of drugs sold in drugstores in La-
gos were past their expiry dates. Of the 117 stores visited during 
the study, 54 were unregistered.

Recently reformed and with a new management team, NAFDAC has taken 
steps to re-organise the drug distribution system and stem the spate 
of counterfeiting. It has embarked on strong promotional campaigns 
and taken measures to stop the operations of cartels believed to be 
controlling the fake drug market.

Corruption

A key obstacle to efficient use of funds is corruption. Sharp prac-
tices by unscrupulous medical personnel at state-owned pharmacies is 
a common practice. Malaria or TB drugs clearly labelled ?not to be 
sold; for free distribution only? have appeared at private pharmacies 
located next to the gates of public hospitals. Patients who are sup-
posed to receive these drugs free at hospitals are told they are out 
of stock and referred to the pharmacies outside, or quietly told they 
could be helped if some amount of money is paid.

?There are clearly a lot of leakages in the system?, says Dr. Dan On-
wujekwe, a clinician who has done extensive research on tuberculosis 
treatment in Nigeria. ?Pilfering goes on. Drugs are not well ac-
counted for?.

Political Will

Experts believe many of the barriers listed above can be overcome. 
Onwujekwe points out that although if TB treatment were procured us-
ing bulk-purchase, the cost could be reduced by up to 70 percent 
(N5,000 or US$ 38 per patient).

Local manufacture by state-owned companies of commonly-prescribed 
off-patent drugs such as chloroquine, paracetamol and tuberculosis 
drugs could significantly reduce prices and discourage counterfeit-
ing. Other developing countries with similar populations and infra-
structural challenges, such as Brazil, India and Thailand have state-
owned and private indigenous pharmaceutical companies producing a 
high percentage of their nation?s drug needs.

Boasting one of the best-trained workforces, technical capacity and 
Africa?s largest market, Nigeria already has the wherewithal to pro-
duce off-patent drugs at cheap rates. ?The one thing that we need is 
political will?, says Onwujekwe.

Another strong need is treatment advocacy and activism by civil soci-
ety actors. Current efforts by government to provide treatment liter-
acy, stamp out counterfeiting and corruption and reform the drug dis-
tribution system needs to be strengthened; equally important is ac-
tivism by civil society to ensure that the reforms are sustained and 
institutionalised.

* Omololu Falobi is project director of Journalists Against AIDS 
(JAAIDS) Nigeria, a media-based non-governmental organisation that he 
helped to establish in 1997. He can be reached on: 
mailto:omololuf@hotmail.com

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