health status in low-income countries: addressing health inequities in nigeria health status in...

HEALTH STATUS IN NIGERIA

Health status in low-income countries: Addressing

health inequities in Nigeria

Olanike Kehinde

Walden University


Health status in low-income countries: Addressing

health inequities in Nigeria

Sub-Saharan Africa is the poorest region of the world and it

bears the brunt of global health inequalities (Rispel, Palha de

Sousa, & Molomo, 2009). There are high levels of under-nutrition,

50% of maternal and child deaths, and a high burden of infectious

diseases (UNDP, 2008). A child born in Africa, may not live

beyond 47 years of age, has a high risk of being HIV positive at

birth, and is more likely to lose his/her mother at birth than in

any other region of the world (WHO, 2006). According to the World

Health Organization (2006), a child born in Africa is also likely

to be affected by drought, famine, floods, or civil war at least

once in his/her short life.

According to the Commission on Social Determinants of Health

(CSDH), there is a social gradient in health irrespective of the

country, and the lower the socioeconomic status (SES), the worse

the health of the people (WHO, 2008). These inequities are unfair


and must not be allowed to continue as the injustice contributes

to premature deaths; they must therefore be addressed by

governments at all levels and all stakeholders in health

including civil societies and communities. The social gradient in

health within countries, the poor health of the poor, and health

inequities amongst countries are as a result of unequal

distribution of power, income and resources globally and

nationally (WHO, 2008).

This paper will focus on health inequities in Nigeria, one

of the largest countries in Africa with a population of

177,155,754 (year 2014 estimates from The World Factbook 2014)

and a high level of inequalities and inequities in population

health. Current efforts being made to reduce health inequities

and the development of a health policy to address some inequities

will also be discussed.

Rationale for country selection

The rationale for selecting Nigeria by me for this project

is because of the poor health status of Nigeria on most health


indicators and a dearth of social policies targeting the social

determinants of health especially policies affecting early life

experiences.

Table 1

Comparison of Health Status in Nigeria with Global Averages

Health indicator (2014 est.)

Nigeria World ranking World (average)

Birth rate/ 1000 live births

38.03 12th 19.2

Death rate/ 1000 population

13.16 19th 8.1

Population Growth rate 2.47% 33rd 1.09%Maternal Mortality rate/100,000 live births

630 11th

Infant (<1 yr) mortality rate/1000 live births

74.09 10th 41.6

Children (< 5yr) mortality rate/1000 live births

138

Life expectancy 52.62 years

212th 67.1

Rural Population 50% 49.5Literacy rate (2010 est.) 61.3%GDP US$ 2600 US$ 11,800% Below Poverty line 70%Access to clean drinking water

64% 87%

Basic sanitation (2012 est.)

27.8%


Table 1 above shows a comparison of health status in Nigeria with

global averages (statistics from The CIA - World Factbook 2014).

Nigeria has also not met the targets for the three nutrition

- related millennium development goals (MDGs) 1, 4, and 5. As at

2008, Nigeria recorded 25%, 33% and 26% reduction respectively in

underweight children, under-five mortality, and maternal

mortality. The expected targets for these indices by 2008 were

36%, 54%, and 54% respectively (Alles et. al., 2013). There is

gender disparity in education in favour of boys and girls in the

rural areas are half as likely to receive education as those in

urban areas (National population commission of Nigeria as cited

in Alles et. al.).

In Nigeria there is no universal access to health services.

Most people still pay for health care out of their pockets. The

health insurance scheme only works for government workers and

those in the organized private sector. There are inequities owing

to the high cost of medical care, uneven distribution of health

facilities, with the rural areas at a disadvantage (Alles et.

al., 2013).


A study by the Federal Ministry of Health (FMOH) in Nigeria

(cited in Alles et. al., 2013) indicated under-utilization of

ante natal care. Communicable diseases (topmost of which are

diarrhea, malaria, and pneumonia) are the major causes of child

mortality. These disease conditions contribute to malnutrition

which in turn predisposes to the same disease condition resulting

in a vicious cycle (Alles et. al., 2013).

Undernutrition in early life can affect brain development

and health of the individual in later life. The WHO recommends

exclusive breastfeeding in the first six months of life for

optimal growth, development and health. A study by Alles et. al.

(2013) showed that only 32% of children born in Nigeria are put

to the mother’s breast in the first hour of life. The study also

revealed that only 13% of babies are exclusively breastfed in the

first six months of life and 33% are given water in addition to

breast milk (Alles et. al., 2013).

Nigeria was also selected for this project because it is my

country and I intend to make a positive social change there as a

scholar practitioner and social change agent.


Social determinants of health in Nigeria

Social determinants of health (SDH) are those conditions

under which people are born, live, work and age that affect their

health outcomes (WHO, 2008). A person born and who lives in a

highbrow area of a city where public smoking is banned will

likely be healthier than one who resides in a slum where living

conditions are poor and there is no access to potable water.

Social determinants of health also refer to social, economic, and

political resources and structures that influence health outcomes

(Barnett and Casper as cited in Baker, Metzler, & Galea, 2005).

They include conditions as access to affordable healthy food,

potable water, safe housing, access to healthcare, supportive

social networks, and socioeconomic policies (Baker, Metzler, &

Galea, 2005; Gehlert et. al., 2008).

In Nigeria, the social determinants of health to be

addressed include universal access to health care, poverty and

equitable income distribution, decent and affordable housing,

safe environment, social exclusion and isolation, education,

gender disparity, crime rate, socioeconomic policies, and social


networks. These determinants influence inequalities and

inequities in health and so they must be addressed if population

health is to be improved in Nigeria (WHO, 2008).

Description of social determinants of health in Nigeria and the

need for addressing them

Access to healthcare: A study in Southeast Nigeria showed that a

large proportion of respondents (46.2%) considered public health

facilities to be inaccessible to the poor for reasons of cost and

insufficient number of facilities (Nnonyelu & Nwankwo, 2014).

According to The World Factbook 2014, there were 0.53beds /1000

Nigerians in 2004 and 0.4 physicians/1000 people in 2008 (Central

Intelligence Agency, 2014). There is disparity in access to

healthcare across regions in Nigeria. The rate of utilization of

healthcare facilities in Northern Nigeria in 2003 is 11% compared

to 60% in the South (Osazuwa - Peters, 2011).

Education: The literacy level of the Nigerian population aged 15

and above who can read and write is 72.1% for males and 50.45%

for females (The World Factbook, 2014; 2010 estimates). The


higher the level of education of a people, the more likely they

are to seek treatment and the better their health is likely to be

(Nnonyelu & Nwankwo, 2014).

Poverty and Income distribution: 70% of Nigerians live below the

poverty line of less than $1 a day (Table 1). There is income

distribution inequality in Nigeria with high rural/urban

disparity (Bakare, 2012). The measure of income inequality – Gini

index for Nigeria in 2010 was 43 (World Bank data, 2015). The

greater the income inequality in a country, the worse off the

health of the people is and this cuts across all socioeconomic

strata. Poor nations are also worse affected (Weir, 2013).

Gender disparity: Women are being discriminated against right

from childhood and so they are more likely to be poor, uneducated

and without political power than men (WHO, 2005). Discrimination

will likely affect the health status of women negatively and so

it must be addressed. For instance, because women lack control

over their sexual activities, they become vulnerable to STIs and

HIV/AIDS (WHO, 2005).


Decent and affordable housing: a large proportion of Nigerians

still live in squalid accommodation and 65% live in rural areas

(WHO, 2005).

Safe environment: only 64% of Nigerians have access to clean

drinking water and 27.8% have access to basic sanitation services

(Table 1).

Crime rate: The overall crime rate in Nigeria was given as 31% in

2012 with 75% of the population claiming they were fearful of

being victims of criminal activities (Cleen Foundation, 2012).

Security has to be improved upon in Nigeria so that crime rate

can be reduced, people can feel safer, and their emotional and

physical health can be improved.

Socioeconomic policies: In Nigeria there is a dearth of policies

that affect early life development, income redistribution, safe

and comfortable housing and that encourage increasing physical

activity. These need to be addressed in order to reduce

inequities so as to improve the health status of the population.


Social exclusion and isolation: Rapid urbanization is related to

inequality and exclusion in Nigeria. The increasing numbers of

slum dwellers in Nigerian cities like Lagos suffer social

exclusion from access to resources and opportunities offered by

the city (Fotso et. al., 2010). For instance, social exclusion

through denial of education is common in slums as a result of

poverty. The rich may feel isolated in their homes as a result of

fear of being attacked by criminals.

Improvement in access to healthcare and other SDH will help

to reduce morbidity and mortality amongst Nigerians and thus

improve life expectancy. Education is a major factor influencing

health (WHO, 2005). The probability of children born to

illiterate mothers is two times higher than for those born to

educated women; Illiteracy is directly related to poverty,

malnutrition, ill health and high infant and child mortality

(WHO, 2005). Therefore addressing inequities in education will

help to improve the quality of life of Nigerians and thus life

expectancy and other health outcomes.


An understanding and assessment of the extent of the

influence of social determinants on health will help the

government of Nigeria and policy makers to formulate and

implement appropriate social policies that will help to reduce

inequities in health, engender the health of the people and thus

improve health status of the Nigerian populace. There is the need

to formulate policies that will improve the welfare of the poor

and create access to education as illiteracy is associated with

many of the determinants of health.

Issues in health literacy and cultural awareness in Nigeria

Cultural issues and poor health literacy contribute to poor

health status in Nigeria. Gender inequality is an aspect of

culture that affects health status in Nigeria. A study by

Nnonyelu & Nwankwo (2014), showed that some women in Southeast

Nigeria needed to obtain permission from the male family head

before they can access healthcare. In some other parts of the

country, women need to be given money by their husbands to be

able to access medical services. These point to the need to


empower females in order to improve population health status in

Nigeria.

At least 80% of rural dwellers go to traditional healers for

healthcare in Nigeria and they believe that there are spiritual

causes for illnesses (Yahya, 2007). For instance, among some

people in Zaria, Northern Nigeria, polio is believed to be caused

by an evil spirit who drinks the blood of his victims, and causes

paralysis or even death (Renne, 2006). The health practitioner

needs to understand the cultural beliefs of the people in order

to communicate health information effectively so as to influence

health outcomes. Cultural beliefs affect the uptake of

immunization in some parts of Nigeria. The belief in Northern

Nigeria that the polio vaccine was introduced in 2003 to reduce

the population led to massive boycott of the immunization

programme. This led to fresh outbreaks of polio that has hindered

eradication of polio out of Nigeria till date (Osazuwa - Peters,

2011). A study in Southeast Nigeria also found that 46.3% of the

subjects believed that herbalists can cure diabetes (Nwankwo,

Nandy, & Nwankwo, 2010).

http://scialert.net/asci/author.php?author=Chinyere%20H.&last=Nwankwo

http://scialert.net/asci/author.php?author=Benjamin%20O.&last=Nwankwo

http://scialert.net/asci/author.php?author=Bikash&last=Nandy


Health literacy may be defined as the ability of an

individual to acquire, communicate, process and understand health

information with which informed decisions about health can be

made to achieve positive health outcomes (CDC, 2011). WHO (2015)

also defined health literacy as “the cognitive and social skills

which determine the motivation and ability of individuals to gain

access to, understand and use information in ways which promote

and maintain good health.” Poor health literacy contributes to

health inequities in Nigeria and improvements in health literacy

will help to reduce inequities (Onotai, 2008). A study in

Southeast Nigeria found that 96.3% of respondents lacked basic

knowledge of diabetes management (Nwankwo, Nandy, & Nwankwo,

2010).

My findings show that there has not been a lot of documented

evidence on the effect of health literacy and culture on health

inequities in Nigeria. There is the need for more studies to be

conducted on these aspects with a view to reducing inequities and

improving health outcomes.





Relationship between health inequality/inequities and life

expectancy for the Nigerian

Population

According to Wilkinson and Pickett (2010), inequalities

affect the health status of a population. The level of literacy

also affects health- seeking behaviors and health. High level of

illiteracy in Southeast Nigeria was found to contribute to low

life expectancy (Nnonyelu & Nwankwo, 2014). Equality in a society

also affects health outcomes. People that have the same level of

education, income, or social class are healthier in a more equal

society than in a society with higher level of inequality

(Wilkinson & Pickett, 2010). This implies that the quality of

life is higher in countries where there is a higher level of

equality. Greater equality affects the lower class more

positively than those who are in a higher economic class

(Wilkinson & Pickett, 2010).

Inequities lead to increased healthcare costs (Dankwa-Mullan

et. al., 2010). Gehlert et. al. (2008), stated that upstream


determinants of health (as socioeconomic status) influence and

regulate events at the cellular level to cause disease and thus

can affect life expectancy.

The Nigerian health policy does not focus directly on early

life experiences, and so the level of morbidity and mortality

increases and this impacts life expectancy negatively. For

instance, a pregnant woman in Nigeria prior to year 2000 was

entitled to six weeks maternity leave before and after delivery

(Federal Republic of Nigeria Laws, 1990). This meant that she

only had six weeks to bond with the baby before resuming work

unlike the woman who is self employed or who does not work at all

who can spend up to six months with the baby after delivery.

Policies that affect families early in life have been found to

produce health benefits throughout life (Laureate Education,

2011). In Sweden for instance, a woman is entitled to compulsory

maternity leave lasting 12 months which gives ample time to bond

with the baby (Laureate Education, 2011).

The disparities in access to education between genders and

in access to drinking water and sanitation between the rural and


urban areas contribute to health inequities which must be

addressed in order to improve life expectancy. The literacy

levels are 72.1% for males and 50.4% for females (Central

Intelligence Agency, 2014). In some cultures in Nigeria, the

female child is not educated and she is instead married off at an

early age. Only 49.1% of rural dwellers have access to clean

drinking water in Nigeria compared to 78.8% of urban dwellers

while 24.7% and 30.8% of rural and urban dwellers respectively

have access to basic sanitation services (Central Intelligence

Agency, 2014). These disparities contribute to disadvantages in

health for the female child and rural dwellers. There is no

support for the elderly in government policies and so they are

more prone to ill health and this will affect the health status

of the population negatively.

Low socioeconomic status of the rural dwellers and urban

slum dwellers in Nigeria also contribute to the low life

expectancy in Nigeria (Oyesola & Kadiri, 2010). Poor access to

healthcare for disadvantaged groups in Nigeria also contributes

to low life expectancy. In order to improve the life expectancy


of Nigerians, the governments at all levels must aim at reducing

inequities by addressing issues of poverty, living and working

conditions, universal access to healthcare irrespective of

location, and the physical environment.

Two current efforts in Nigeria aimed at reducing health

inequities

In addressing health inequities, the World Health

Organization [WHO] (2008), through the Commission on social

determinants of health advocates three levels of action:

Improve daily conditions in which people are born, grow,

live, and age.

Tackle the inequitable distribution of power, money, and

resources locally, nationally and globally.

Measure the problem, evaluate action, expand the knowledge

base, train appropriate workforce, and raise public

awareness about the social determinants of health.


The Nigerian government through its poverty alleviation

programmes – SURE-P and NEEDS; and the National programme on

immunization (NPI) aim to tackle health inequities in the

population. In tackling MDG 1, the Federal Government of

Nigeria initiated the National Economic Empowerment and

Development Strategy (NEEDS). It is aimed at reducing poverty

by empowering people through job creation through the National

Directorate of Employment (NDE) and the National Poverty

Eradication Program (NAPEP). It also aims to create an

enabling environment for investment and local entrepreneurship

(Rispel, de Souza & Molomo). Through NAPEP many young people

in Nigeria have benefited from training and job creation

opportunities.

The Subsidy Reinvestment and Empowerment Programme (SURE-P)

is designed alleviate poverty through provision of critical

infrastructure and safety net projects. It aims to provide

necessary infrastructure and human resource empowerment

projects such programs as improvement in maternal and child

health programmes, public works, employment schemes, mass


transit programs, vocational training and skills acquisition

schemes (Federal Republic of Nigeria, 2013). The programme has

achieved some success. Within two years it has been able to

reduce the maternal mortality rate by 26% and reduce neonatal

mortality by 22% (Federal Republic of Nigeria, 2013).

The National Program on Immunization (NPI) was renamed in

1997 and it has a mandate to protect children from vaccine

preventable diseases through the provision of vaccines,

devices and technical support (National Primary Healthcare

Development Agency [NPHCDA] (2013). Since inception in 1979,

the vaccination coverage has reached above 80% (NPHCDA, 2013).

This initiative targets MDG 4 and it has a slogan, “to save

one million lives”. The under – 5 mortality rate has gone down

from 191/1000live births in 1990 to 94 in 2012 even though

this is still short of the 2015 target of 63.7/1000 live

births ((Federal Republic of Nigeria, 2013b).

To reduce health inequalities the Nigerian government must

continue to design social policies and effectively implement

them; address identified constraints; monitor and evaluate the


implementation policies; and ensure community participation by

providing enabling environments (Rispel, de Souza & Molomo).

Developing an acceptable health policy for Nigeria

According to Lee, Buse, & Fustukian (2002), health policies

aim to provide frameworks for filling gaps in the health field.

An appropriate health policy must take into consideration the

health problems of the population, equity, and interventions that

are culturally appropriate and affordable (Alem & Gureje as cited

in Kehinde, 2014b). The Nigerian health system focuses on

improving access to care, addressing issues of health manpower

and healthcare financing and costs, in addition to related social

issues (Federal Ministry of Health, 2004). It does not explicitly

focus on the life course approach to health even though it has

policies on reproductive and child health.

An acceptable health policy must be culturally relevant and

must involve community engagement in its formulation. It must

cater to the perceived needs of the population (Gregory, Hartz-

Karp, & Watson, (2008). Since the cultures of people influence


their beliefs in disease causation and health-seeking behaviors,

the culture of the people must be taken into consideration when

formulating health policies for them to be acceptable (Horton, &

Dickinson, 2011). A process for monitoring and evaluation must

also be built into health policy formulation (Rispel, Palha de

Sousa, & Molomo, 2009).

For instance, to develop a policy on childhood nutrition

with Nigerian local foods , the following steps will be followed:

Situation analysis: This involves identifying the need and

purpose for the policy. MDG 1 talks about eradicating extreme

hunger and poverty. Nigeria only achieved a 25% reduction in

underweight children in 2008; 33% reduction in under-5 mortality

rate, and 26% reduction in maternal mortality rate in 2008. The

targets were 36%, 54%, and 54% reduction in those indicators

respectively (Alles et. al., 2013). The need for healthy

nutrition in children and women in the reproductive age bracket

must be highlighted and met. The policy working group must

research into the traditional healthy foods across the nation and

identify how they can be prepared in a healthy way for children


and pregnant women. The goals and objectives are to be stated

including to promote eating of healthy foods such as soya beans

that are locally available to promote the health of the citizens

and reduce malnutrition. Other policy options will be debated

before finalizing the document.

Community engagement: community and opinion leaders, mothers,

grandmothers, fathers, carers, religious leaders, community

health workers, members of the community and other stakeholders

will be engaged through town hall meetings and focus group

discussions to get their input as well as to inform, educate and

communicate the issues at stake to them. They must be carried

along at each step to ensure acceptance of the policy and a

commitment to make it work (CDC, 2014).

Policy adoption and enactment: key policy actors and stakeholders

will agree on the final document and pass it on for enactment

into the national health policy. There will be massive

sensitization of the public about the policy. The framework will

include on healthy eatin habits, basic sanitation, and health

promotion activities. The community health workers will work hand


in hand with mothers and other carers, and schools and the need

for referral to appropriate health facilities when necessary in

severe cases of malnutrition will be emphasized in the policy.

Policy implementation will take place and the Nigerian citizens

will be made to know that there is a policy on eating traditional

healthy foods especially for children to aid their development.

The need to cultivate more of such foods will be emphasized.

Monitoring and Evaluation: processes will be built into the

policy to assess and monitor its impact on the health outcomes.

Ways for revising the policy as appropriate based on impact will

be sought. The impact will also be communicated to government and

the people to build up evidence in favour of the policy or

otherwise.

Further insights from learning resources

Solutions to population health issues must be both upstream

and systemic (Ontario Prevention Clearinghouse [OPC], 2006).

Upstream interventions focus on the root causes of problems

relating to socioeconomic and environmental factors while


systemic involve policy formulation to address the problems (OPC,

2006). The socioeconomic factors are more than behavioral factors

and access to healthcare; they include living and working

conditions, social networks, poverty and the physical environment

(OPC, 2006).

Early child development affects both cognitive and affective

domains later in life. It influences their subsequent risks of

developing obesity, heart disease, diabetes, malnutrition, mental

health problems and criminality (WHO, 2008). It is said that,

“inequalities in health occur as a result of inequalities in the

society” (United Nations International Children's Emergency Fund

[UNICEF], 2010). Healthcare may only be able to mitigate the

effect of morbidities that develop later in life not cure them

and it is also expensive where available (Kehinde, 2014a).

According to a study by Shonkoff, Boyce, & McEwen, 2009, the risk

of coronary heart disease was found to be four times more in low

birth weight individuals (weighing less than 2.5kg) than those

with birth weights above 4kg; and61% of those who suffered

emotional disturbance in childhood developed depression later in


life compared to 18% for those who did not experience emotional

abuse. The society must therefore put in place conditions that

will enhance early childhood experiences and thus promote

population health. For instance, inequalities in poverty and

access to prenatal care must be addressed (WHO, 2008). In order

to promote population health there must be equitable distribution

of health care facilities and schools, equitable access to

education, conditions of work and leisure, and living

environments (WHO, 2008).

According to Stegeman et. al. (2010), health inequality is

a matter of life and death. Therefore, there must be successful

advocacy by the health sector for governments and others to

tackle inequities. Effective leadership at the societal,

organizational, and individual levels is necessary in tackling

health disparities (Koh & Nowinsky, 2010). To reduce mortality

rates in the 21st century involves partnership and long-term

commitment between the fields of public health and medicine.

A population centered approach of vulnerable groups is best

for tackling inequities (Stegeman et. al., 2010). Responsible


leadership must promote a sense of togetherness so that people

can focus on the common good and not just on personal well-being

(Koh & Nowinsky, 2010). The pathway for eliminating disparities

in health also involves improving daily living conditions,

addressing the distribution of power, money, and resources for

greater equity, and an assessment and evaluation of the problem

and taking necessary action (WHO, 2008).

Conclusion

Solutions to tackle health inequities must be both practical

and sustainable (Baker, Metzler, & Galea, 2005). Governments of

low-income countries as Nigeria must exercise political will and

strong commitment towards improving the health of their

populations. This can be done through the formulation of

appropriate social policies and laws that will help to reduce

inequities, redistribute income and provide conditions for a more

equitable society. All these will bring about an improvement in

population health. The process of policy formulation and

implementation must have built into it processes for community

engagement, as well as monitoring and evaluation to assess the


impact of outcomes. The issue of tackling inequalities and

population health is not for the government or health sector

alone, it requires a collaborative and multisectoral approach

involving governments at all levels, the private sector, NGOs,

religious organizations, communities, individuals, researchers,

public health practitioners, healthcare professionals,

environmentalists, transport, housing, and education sectors, as

well as other stakeholders in health.

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