2014 was a remarkable year in the Nigerian health sector’s history. The first positive thing that comes to the minds of most people is the effective containment of the Ebola Virus Disease, which still inspires instinctive gratitude and laudatory comments. The heroism of Dr Stella Adadevoh will not easily be forgotten nor will government action when it mattered. The passing and signing of the National Health Act into law in late 2014 by President Goodluck Jonathan was also a progressive step, especially in light of the possibilities conceived by that Act and the decade-long delay in enacting it. Also positive was the introduction of the Pneumococcal Vaccine Conjugate (PCV) into the National Immunisation Schedule.
The severe decline in new Polio cases is another important reason for celebration. But other less positive issues made the news too – strikes by health care workers; lack of accountability in the vaccine sector in a country where about 200,000 children die yearly from vaccine-preventable diseases; and health crises engendered yet concealed by terrorist attacks in the North East of the country. Buried under these were continuing problems like those besieging rural health and primary health care generally. Almost forgotten are issues around non-communicable diseases like cancer, heart disease, diabetes, the rates of which continue to increase, as well as other unrecognised public health concerns like gender-based violence, and taboo health problems like mental illness.
In policy-making, it is often important to think in terms of issues and interventions which have large-scale impact and address problems systematically. However, I find that it is also frequently essential to think of issues, their urgency, and potential solutions by considering personal narratives, listening to the stories of real people and thinking of each individual life as important. Some of the stories I heard just this past Christmas holiday emphasise this point. Take, for instance, the story that I was confronted with as the year began. My husband had taken me to see a friend’s sick relative. I walked into a room in an uncompleted house to meet a woman bent over with pain, breathing in the stench of her decaying skin, cauliflower-like tumors spread around her breasts and torso, unable to talk above a whisper. This woman had been a trader in Onitsha before she was diagnosed with breast cancer but you could not tell by looking at her ravaged body. Although she began treatment at a teaching hospital at the time, she did not complete it. A combination of factors was at play: She and her family did not have money for all the tests that were required and the treatment that was prescribed. And the chemotherapy (not that she knew it by that name) made her very sick so her relatives told her to stop – what sort of treatment made you sicker instead of better, they questioned. Others told her it was witchcraft, projected by enemies at night. She did not go back for treatment. Now her relatives were relying on prayers and traditional herbs.
And that was how I found her on a recent afternoon, sitting in her dark room with her unbearable pain, fungating ulcers and decaying skin, the rotten smell of which clings to me even as I write this, days after. I was shocked by her state and expressed as much to my husband who wondered where I thought they could get money for her treatment. Even with the meagre help we could render to assist in getting her to a government hospital, at the very least for evaluation, I was informed that health workers were on strike and it was doubtful that she would receive any care. I reached out to ‘Run For A Cure’, an organisation which provides assistance to women diagnosed with breast cancer. One can only hope for the best but things look grim right now.
Take another instance: a relative whose adult child suffers from mental illness, listened patiently to me talk about the need to get a proper diagnosis. She let me finish and then she told me about the many efforts she had made through different health establishments. Now the infirm lady is at a spiritual facility where she receives spiritually based care, some of which, if I understood correctly, included corporal punishment for refusal to comply with instructions! Her family is enjoying some respite, able to trust that she is in somewhat safe hands and they are able to take a breath from the physically tasking, emotionally debilitating, often traumatic experiences they have borne in the past few years.
Or yet another story of the son who took his ailing mother from one health establishment to the next during the Christmas holiday when she suddenly developed a breathing problem, and how he eventually threatened to bring one facility down until they took his mother in, where she then died, possibly a victim of lack of emergency care. One could go on and on.
Policy issues calling for different kinds of policy interventions are embedded in these stories: health literacy, health communication, health insurance or lack of it, primary health care, mental health care, access issues. Health financing, in particular health insurance, requires attention. Finding ways to establish universal health coverage remains essential. Even those fortunate enough to be in the middle class in Nigeria would find life difficult indeed if they were to find themselves dealing with a serious illness like cancer let alone those already economically disadvantaged. The steps taken by the National Health Insurance Act to increase health using mobile technology to purchase insurance packages for as low as N250 need to be expanded and publicised. Primary health care particularly in rural areas must continue to receive attention. The populace living in rural areas already suffer marginalisation in many areas, decent primary health care is the least government can offer to alleviate existing challenges and redress inequities between urban and rural areas.
Further, health literacy and health communications are as important as the availability of effective interventions. It took a great deal to hold myself together when I heard that a woman whose cancer was caught at an early stage three years ago went without treatment in part because of lack of understanding of the diagnosis and treatment of her disease. Engaging other sectors like the religious sector, as was done, during the Ebola crisis is vital. That way, leaders of that sector are helpful rather than obstructive in these situations. Engaging health care professionals by way of training and advocacy on matters like explaining carefully and in easily understood language diseases, treatments, risks, benefits, which may seem beside the point and perhaps even unachievable in the prevailing environment of deference and doctor-knows-all, is essential. The policy question is “How can we do these in a systematic way?”.
Other policy questions must continue to be addressed. How can the provisions of the National Health Act be implemented to improve primary health care? Who monitors the implementation of the Act? What tools are available to the citizenry for enforcement? What incentives can be provided for health care providers to live and work in rural areas? It is clear that both macro (poverty reduction, addressing gender disparity, education etc.) and micro instruments (financial inducements for health care workers, health information accessibility) must be effectively adopted and utilised.
Moreover, the successes of the past year need to be built upon. Emergency preparedness systems need to be developed further to ensure adequate preparation against any epidemic. Addressing our policy on forgotten issues like non-communicable diseases including mental illness is crucial. Unheeded issues like caregiver burdens and exhaustion are also matters for policy. Although we may not be at the point to address some of these issues, they indicate why we must, by necessity, at the very least provide effective basic care for sufferers to help their families.
All hands must be on deck to change these stories. Many organisations, including in the non-profit sector, are doing their best to assist. I already mentioned the ‘Run for A Cure’ group which focuses on providing needy persons with funding assistance in the area of breast cancer. This year the Centre for Health Ethics Law and Development (CHELD), which I lead, will focus on the arising policy issues and continue to work to increase health literacy in particular in the areas in which we work – domestic violence, health legislation, sexual and reproductive health, mental health and health financing. On health legislation, in particular, we will keep working to make health legislation in Nigeria accessible to all on our website. We will continue to advocate through various platforms for the enactment of legislation such as the Mental Health Act, and for the implementation of existing health legislation like the National Health Act, 2014. Representing CHELD, I will be working with a team of experts appointed by the Federal Ministry of Health to revise the National Health Policy and ensure that the government, at all levels, have an effective policy to manage and develop the health sector for the benefit of all Nigerians for the next few years. In these and other ways, CHELD hopes that we can, along with other like-minded partners, change the stories that we hear about health in the country and make 2015 a better year for health in Nigeria. Other organisations are doing what they can, but more needs to be done, especially within government circles, in a systematic fashion to ensure that a majority of Nigerians have access to good health care.
Finally, we have probably heard these and worse stories. Every Nigerian has a health story that is less than positive. Yet we need to try to hold on to some of the horror we feel as propellant incentives for doing what must be done. For the government, this must serve as a call to action, to implement policies that improve the health of all Nigerians this year. As citizens, in an election year, these are the stories that we need to bring with us as we listen to politicians tackle health issues, the stories that we must take with us to the polls to decide who can best address the arising issues. As corporate and individual citizens providing financial support to grassroots organisations that meet the needs of the many who fall through the cracks it is a critical means of ensuring each life counts in 2015. For health workers, health advocates, health policy analysts, health journalists, civil society organisations focused on health and all involved in the health sector and who work to improve health at all levels – what we need to take away is that the figures we often bandy about, the jargons in which we often speak, are real people with real stories. Every life counts. Our work, our policies, our activism, must reflect this understanding; implementation and advocacy must be sped along by this knowledge.
Dr Cheluchi Onyemelukwe-Onuobia,
Executive Director, Centre for Health Ethics Law and Development (CHELD)
Senior Lecturer, Babcock School of Law and Security.
This article was first published in ThisDay. January 13, 2015
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