Health systems and high burdens

Nigeria has been classified as one of the main high burden malaria endemic countries.  The World Bank Booster program notes that the per capita investment in malaria is disproportionately low in largest high burden countries, and this threatens progress across the continent.

The results of this low level of per capita investment were highlighted by Oresanya and colleagues recently when they reported that, “Household ownership of any net was 23.9% and 10.1% for ITNs.” Furthermore, “Utilization of any net by children under-five was 11.5% and 1.7% for ITN.” The Abuja targets look a long way off from Abuja and environs.

One of the key “predictors of use of any net among under-five children … [was] the presence of a health facility in the community.” The implication is that the high burden malaria problem is not only characterized by low relatively investment in malaria control, but a similarly low level of investment in the health system through which malaria interventions can be delivered.

This assumption is reinforced in a report by Michael Reid in the WHO Bulletin stating that, “Despite several attempts at reform over the past 30 years, Nigeria still lacks a clear and coordinated approach to primary health care.” In only two years during the 30 years since the Alma Ata Primary Health Care (PHC) Declaration has the Nigerian budget for health exceeded 5% of the total, despite the formulation and reformulation of PHC policies and the training and re-training of front-line health care workers.

Recently we reinforced the point that malaria control must have a strong health system to reach all in need with life saving interventions. One wonders whether the challenge of high burden malaria countries can be addressed without major health care reform. Reid provides other disheartening documentary and interview evidence:

  • Nigeria has never learnt or developed any system of authentic and full-scale community health care before Alma-Ata or after it
  • The world health report 2000 ranked Nigeria 187 out of 191 countries for health service performance
  • Infant mortality rates have been deteriorating from 85 per 1000 live births in 1982, 87 in 1990, 93 in 1991 to 100 in 2003

Reid notes a tendency to blame the problem in part on a colonial legacy of two health systems – one for the elite and the other for the poor.  Other countries with fewer resources than Nigeria have overcome this legacy. Is it a matter of political will?

“Peripheral health facilities have huge potential to make a difference to health and survival at household level in rural Tanzania, even with current human resources,” according to Schellenberg et al. (2008). These peripheral facilities in Nigeria and primary health care for that matter, are the constitutional responsibility of local government in Nigeria. A visit to many of these in Akwa Ibom State last month found shortages of staff and medicines, lack of basic furniture, damaged roofs, abandoned rooms, lack of water supply and light, and staff quarters overgrown by weeds. It would appear that in high burden countries the neglect of PHC is the same as the neglect of malaria control.

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