72274-157676-1-PB-Paediatrics Health Care in Nigeria Yesterday, Today and Tomorrow

Nigerian Journal of Paediatrics 2011;38(4):146 -158

COMMENTARY

Ajenifuja B

Paediatrics Health Care in Nigeria:

Yesterday, Today and Tomorrow

Received: 28th September 2011

In Nigeria the path towards emergence of paediatric

Accepted: 28th September 2011

care by paediatricians has been very long and

tortuous. In the pre-colonial era it was the traditional

Health practitioners who passed knowledge from

Ajenifuja B OFR

( )

generation to the other. They earned their living

Faculty of Paediatrics National Postgraduate

through their art and so kept it as a guarded secret in

Medical College Ijanikan Lagos. 2011 Guest

the family. These local practitioners obviously

Lecturer,

treated children in addition to conducting birth of

Dr. Bolaji Ajenifuja served as Secretary of Faculty

babies. Though they also used witchcraft and herbs,

of Paediatrics of the National Postgraduate Medical

they were treated as experts in their own field.

College of Nigeria for the first 14years after its

inception and organized the early postgraduate

Children especially females were subjected to female

examinations in Paediatrics.

circumcision and newborn babies had their umbilical

cord cut with bamboo stick. The result of this

My dear colleagues and guests,

primitive treatment of children was high infant

morbidity and mortality. As a result of the fetal

Thank you for allowing me to deliver this annual

wastage and childhood deaths, families tended to

lecture of our Faculty. It is a great honour and

have more children to make up.

privilege indeed, as I virtually requested to be staffed

into this role.

The advent of the Europeans by

boat into the

Nigerian sphere for trade subjected the foreigners to

Looking round I find that most of those brilliant men

locally endemic diseases as malaria, yellow fever and

of paediatrics with whom we started this College

diarrhea diseases. As could be expected quite a lot of

over four decades ago have left the scene partly as a

the visiting traders succumbed to illnesses and those

result of old age, some form of infirmity or even

lucky to get back to their home destination

death. It appears that even as the best minds in

transmitted the medical diseases to their destination.

medical jigsaw, we cannot not stop death in its

In response, the foreigners introduced some form of

onslaught. Therefore, as we progress to write the

medical care for their staff and self.

history of child health and life in Nigeria, it is

imperative that we put the record straight for the

The initial traders and later, the slave traders limited

coming generation to know how it all started and

their activities to the shores while dealers in other

grew in Nigeria.

commodities

ventured into the hinterland. Other

Europeans came as missionaries and made inroad

Paediatrics is that branch of medicine dealing with

into the hinterland by road and boat along the River

the medical care of infants, children and adolescents

Niger and its tributaries. This third wave of

essentially up to the age of seventeen which is the

missionaries and trading explorers no doubt primed

age of majority in Nigeria. An American doctor

by stories of diseases, deaths of their predecessors

Arthur Jacobi 1830 1919 has been acclaimed as the

brought some western medical care into Nigeria, the

father of paediatrics because of his many

first of which was in the Benin districts.

contributions to this field of medicine. He was one of

the early pioneers who drew attention to the link

Archives show that one Dr. Williams of Great Britain

between the environmental milieu of children and

carried out several vaccinations sessions and dressing

their diseases.

of ulcers in indigenous populations along the West

Coast ofAfrica including Niger Delta up to Lokoja.

Most of my colleagues assembled here today are

paediatricians.

147

Gradually, health care facilities were established

Massey Street Dispensary was later upgraded to a

followed by recruitment and training of human

maternity hospital in 1920. It metamorphosed into the

resources for health delivery. History also shows that

FIRST CHILDREN HOSPITAL in West Africa in

European traders brought few doctors and nurse to

1962. The Creek Hospital was built in 1925 by one

look after themselves and their immediate host

Dr. G.M.Gray, but was later bought over by

communities.

government.

With time, the missionary societies, Catholic and

Development of human resources

Presbyterian, provided health facilities in Lagos,

Abeokuta (Sacred Heart Hospital) and in south

The colonial administration trained staff for health

Eastern Nigeria. One notable example was Mary

and other public service. The Religious mission also

Slessor in Calabar. Reverend Hope Waddell from

established institutions for training nurses and

Ireland recruited colleagues who were not health

paramedical personnel. Examples of these are the

professionals but were trained to give health

Mission Hospitals in Shaki, Ogbomosho, Ilesa and

treatment in clinics and dispensaries in and around

Eku. In addition, the missions sponsored many of the

Calabar. Archives also reveal that Reverend Waddell

first generation Nigerian doctors for professional

conducted the first vaccination against small pox in

training in Europe.

Calabar in the mid 1950s.

With the First World War 1914 to 1918, there was

The Baptist mission and Qua Ibo mission established

need for European Health personnel in war zones to

a number of dispensary and maternity services in

cope with war victims. Army medical corps AMC

southern Nigeria. The Ogbomosho Hospital and Iyi

was formed and this paved the way for government

Enu Hospital near Onitsha in 1906 are living

medical services in Nigeria in 1946.

examples of their efforts. In the middle belt, the

Sudan Interior Mission provided medical facilities as

As part of the 10 year development plan, the Federal

well.

Ministry of Health was established in 1946 to

coordinate health services throughout the whole

The Baptist colonial government provided clinics

country. At that time Nigeria had a unitary form of

and hospitals in Lagos and Calabar. The first

government.

government hospital was built in Calabar and was

named Margaret Hospital in 1896. With time, health

In 1948, the University College Ibadan (UI) was

facilities spread to other parts of the country. Services

founded with a faculty of Medicine and a teaching

were initially partly limited to Europeans, but later

hospital, University College Hospital (UCH). It

extended toAfrican staff or European organizations.

started with fourteen students. I must point out that

before the University of Ibadan was established, and

During the First World War, bush hospitals

precisely in 1930 the Yaba Medical School (YMS)

constructed with grass thatch, bamboo and mud were

was established to train a cadre of medical assistants.

built to meet military needs. Later European

Hospitals called Nursing Homes and African

The YMS was part of Yaba Higher College, a post

Hospitals were built and these were made to become

secondary institution which folded up with the

General hospitals.

establishment of University of Ibadan. In 1954 Kano

Medical School was inaugurated.

In the early colonial era, the colonial masters made

effort to establish specialized health institutions

In 1937, records show that there were one hundred

mostly in Lagos viz.

and thirty-five (135) doctors in Nigeria Medical

The Infection Diseases Hospital.

MentalAsylum in Lagos and Calabar.

and nineteen (19) Africans. Nearly a third of the

Orthopaedic Hospital.

Europeans were medical missionaries and a few were

Massey Street Dispensary, 1903.

industrial medical advisers.

Father Coguard an ordained priest, with some

Post-colonial era

medical training established the first leper

settlements in 1897.

With independence in 1960 and attainment of

In 1877 Inspector of Nuisance was gazetted.

Republic status in 1963, Nigeria became an

In 1897 a medical and sanitary department was

automatic member of the WHO and the United

created in Lagos.

Nations Organization (UNO). More than a decade

later, the country still fell short of the WHO

recommended one doctor to ten thousand patients.As

of 1972 Nigeria had one doctor to twenty two

thousand patients.

148

Since 1960, Nigeria has adopted five successive

With the annulment of 1993 presidential election,

National and twenty-four sectional health policies

most sectors of activities including health came to a

most of which were incorporated into the various

near standstill and this continued for about five years.

national development plans. The last was adopted in

Despite Nigerians high human and material deposit,

1988 during the Babangida regime when the

poverty was still rampant in Nigeria.

Perspective Planning and National Health Policy

were adopted.

The StructuralAdjustment Programme (SAP)

The Key Elements of the Policy

SAP led to exodus of medical personnel to the Middle

East principally Saudi Arabia, the United Kingdom

ü Education on prevailing health problem and

and the United State of America. The result of this

methods of preventing them.

was that in 2000, Nigeria ranked one hundred and

The promotion of food supply and proper

eighty-seven (187) out of one hundred and ninety-one

nutrition;

(191) member states of world Health Organization in

Material and child care including family

decreasing order of health system performance.

planning ;

Funding of the National Health System

Immunization against major infectious

diseases.

Government provides major allocation

ü Prevention and control of local endemic and

Payment by individuals for service and drug

epidemic diseases;

purchases

ü Provision of essential drugs and supplies

Contribution by employees

Foreign loans and grants

Primary Health care was seen as the goal of health

for all people in the country.

Unbelievable, tertiary institutions receive two thirds

of total budget allocation to health of which two third

Health remains in the concurrent list in the

is spent on personnel and administrative exercises.

constitution of the Federal Republic of Nigeria,

Obviously, this type of disbursement leaves little for

implying that Federal, State and Local authorities

the main pursuits of excellence for which the

can exercise supervisory roles over health matters.

institution is established. Worse still, delay in

releasing required funds naturally leads to lack of

Though after independence each region was to

maintenance of facilities. Repeated representations

develop at its own pace with little interference from

have been made to the Federal and State

the central government, incursion of military

Governments to increase health service allocations in

dictatorship indirectly overruled that by

line WHO recommendations.

formulating legislation on health usually without

consultation of the States. The National Council of

As an alternative or supplementary fund for the health

Health considered draft National Policies as

system the National Health Insurance Scheme

advisory forum twice a year. Militarism led to lack

(NHIS) was started in 2005. The success or not of this

of true federalism thus depriving the States the

scheme is still being evaluated as some believe there

initiative of implementation of their plans of health

is inequity in its operation.

for the people though States like Lagos, Enugu and

Anambra did initiate health facilities.

In a paper I presented in 1988 on the Nigerian Child

in the International Perspective at the annual

A lot of pressure

exerted by other independent

conference of Paediatric Association of Nigeria at

international agencies on developing countries like

Onitsha, Anambra State, I showed the following

ours urged us to identify specific health problems and

slides which I am showing today to stir our

design to tackle them. This prodding helped the

conscience on how far we have come since then in the

Nigerian authorities to formulate the National Health

welfare of the Nigeria child.

Policy in 1988. Once promulgated, a lot of effort was

put into implementation between 1988 and 1992

under the stewardship of late Prof. Olikoye

Ransome- Kuti apostle of primary health as minister

of Health. There was 80% immunization coverage, a

bold achievement. He later established the National

Primary Health Care Development Agency in the

country.

149

Table 1:

Situation of children in Asia and Africa

Country

Total population

Population growth

Children 0-14 total

Infant

(thousands)

rate (percentage)

population

mortality rate

(percentage)

per 1,000

Indonesia

154 ’ 661

1.9

39.3

90.3

Bangladesh

92 ’ 616

2.3

122

Pakistan

87 ’ 130

3.0

45.3

120

India

7044 ’ 240

2.1

122

Japan

119 ’ 200

0.7

23.9

7-1

Table 2: Tuberculosis and BCG

Parameter

1982

1983

1984

1985

1986

Population at risk (9% Total)

4,475

4,591,590

4,710,290

4,832,075

4,957,065

BCC Vaccination Reported

603,394

456,514

372,485

930,655

1,873,381

% Population At Risk Vaccinated

13.5

9.9

12.2

19.3

37.8

Mid-Year Population Estimate

89,518,600

91,831,800

94,205,800

96,641,500

99,141,300

Tuberculosis Cases Reported

10,949

10,212

10,677

14, 934

14,071

TB Cases Per 100,000 POP

12.2

11.1

11.3

15.5

14.2

Tuberculosis Deaths Reported

334

208

161

354

515

TB Cases Fatality Rate (%)

3.05

2.04

1.51

2.37

3.66

Table 3: Nigeria compared with a typical developed country

Details

Nigeria

A developed country

Crude live birth rate per 1,000 population

Crude death rate per 1,000 population

Rate of natural increase of population (%)

3.2

0.7

Period needed to double the population (years)

100

Medium age (years)

Life expectancy at birth (years)

Proportion of deaths in < 6years old (%)

Maternal mortality rate

0.2

Under 5year old mortality rate

160

Childhood (1-4year old) Mortality rate

Infant mortality rate

Percentage of population under 15years (dependents)

15-64years (Labour Age Group)

65years and above (Senior Citizens)

Nigeria: Land area =923,768 Sq Kilometers

Key:Source = National population Bureau, Lagos (January 1984)

150

Table 4a: A history of the Nigerian health services:

Table 4b : A history of the Nigerian health services:

Lagos vital statistics 1900 - 1939

Lagos vital statistics 1940 - 1960

Date

Birth

Death

Infant mortality

Date

Birth

Death

Infant mortality

rate

1900

1940

29.3

22.5

132

1909

42.4?

37.2

450 (per 1,000)

1941

28.3

21.6

114

1910

4.4?

35.8

315

1942

31.5

25.4

124

1919

30.2

27.0

324

1943

24.8

23.2

140

1920

33.5

28.8

285

1944

37.3

29.1

116

1921

30.4

25.1

285

1945

45.0

23.3

128

1923

32.7

23.8

1946

46.0

19.0

110

1924

32.2

26.9

236

1947

48.6

21.7

126

1927

28.9

20.2

175

1948

51.0

15.5

105

1930

28.6

16.5

129

1949

44.7

17.5

104

1931

24.9

12.6

112

1950

55.7

16.2

1932

27.5

12.9

102

1951

61.2

15.2

1933

24.9

13.8

137

1953

45.0

15.6

104

1934

27.8

13.0

119

1954

44.8

13.2

1935

26.3

13.9

129

1955

47.6

12.5

1936

23.8

13.8

140

1957

49.1

14.2

1937

22.9

23.3

130

1958

50.4

12.7

1938

24.0

21.6

127

1959

55.8

13.6

1939

27.6

21.4

127

1960

62.9

Table 5a: Major causes of morbidity from notifiable diseases in Nigeria 1984 1986 (Top twenty)

1986 Cases

1985 Cases

1984 Cases

Notifiable Diseases

100,000

Malaria

1,020,071

1,028.9

1,284,402

1,329.0

1,242,882

1,319.3

Dysentery (all types)

185,904

187.5

259,052

268.0

222,879

236.6

Measles

115,743

116.7

161,768

167.4

182,591

193.8

Pneumonia

82,312

83.0

120,285

124.5

101,455

107.7

Gonorrhea

42,306

42.7

70,514

73.0

55,139

58.5

Whooping Cough

42,193

42.6

92,266

95.5

62,751

66.6

Schistosomiasis (all

26,975

27.2

31,788

32.9

36,710

39.0

types)

Chicken Pox

21,387

21.6

76,266

78.9

65,932

70.0

Meningitis (both

17,168

17.3

1,425

1.5

1,302

1.4

types)

Leprosy

14,659

14.8

8,293

8.6

8,800

9.3

Turberculosis

14,071

14.2

14,934

15.5

10,677

11.3

Viral Influenza

9,991

10.1

18,156

18.8

5,941

6.3

Filariasis

9,247

9.3

16,586

17.2

12,756

13.5

Ophthalmia

8,234

8.3

7,518

7.8

3,610

3.8

Neonatorum

Food Poisoning

6,285

6.3

5,287

5.5

2,827

3.0

Infective Hepatitis

3,766

3.8

7,647

7.9

5,316

5.6

Relapsing Fever

3,616

3.6

1,514

1.6

1,778

1.9

Trachoma

3,327

3.4

4,359

4.5

5,042

5.1

151

Table 5b: Major causes of morbidity from notifiable diseases in Nigeria 1984 1986 (Top twenty)

1986 Cases

1985 Cases

1984 Cases

Notifiable Diseases

100,000

Tetanus

2,269

2.3

2,679

2.8

2,437

2.5

Onchocerciasis

1,944

2.0

7,317

7.6

5,046

5.4

Diphtheria

1,871

1.9

1,996

2.1

733

0.8

Infectious Yaws

1,687

1.7

1,154

1.2

0.1

Typhoid &

1,362

1.4

673

0.7

1,219

1.3

Paratyphoid

Yellow Fever

1,102

1.1

0.07

898

1.0

Syphills

1,026

1.0

1,641

1.7

1,214

1.3

Sleeping Sickness

716

0.7

0.1

Mid- Year Population used: 1984 - 94, 205, 800; 1985 - 96, 641, 500; 1986 - 99, 141, 300

(Source: National Population Bureau, Lagos Publication dated January, 1984.

Table 6a: Measles in Nigeria

State

1985

Measles Statistics

1986

Measles Statistics

Population

Vaccination

Deaths

Population

Vaccination

Deaths

at risk (5%)

(%)at risk

Reported

at risk(5%)

(%)at risk

Reported

Anambra

309,105

27,610 (8.9)

647 (-)

316,930

71,718 (22.6)

514 (-)

Bauchi

208,500

35,737 (17.1)

19,714 (78)

214,240

96,029 (44.8)

122,196 (40)

Bendel

211,500

42,408 (20.1)

5,397 (38)

216,855

83,484 (38.5)

1,293 (38)

Benue

208,585

24,378 (11.7)

4,564 (6)

213,865

62,904 (29.4)

5,269 (14)

Borno

257,610

36,129 (14.2)

2,686 (32)

264,135

65,392 (24.8)

7,903 (50)

Cross

298,920

27,720 (9.3)

1,810 (34)

306,485

58,396 (19.)

1,312 (30)

River

Gongola

223,905

36,129 (16.1)

29,460 (240)

229,570

70,844 (30.9)

30,070 (345)

Imo

315,640

28, 818 (9.1)

2,066 (1)

323,630

67,203 (20.8)

2,234 (88)

Kaduna

352,220

54,318 (15.4)

14,473 (242)

361 (135)

92,313 (25.6)

15,402 (485)

Kano

496,305

64, 080 (12.5)

17,275 (411)

508,870

47,129 (9.3)

14,893 (434)

Kwara

147,345

14,879 (10.1)

8,005 (-)

151,080

28,514 (18.9)

2,233 (2)

Lagos

171,710

70,248 (40.9)

15,672 (269)

178,715

175,286 (98.1)

7,895 (118)

Niger

102,660

25,755 (25.1)

2,672 (115)

105,260

76,107 (72.3)

1,378 (22)

Ogun

133,295

11,655 (8.7)

3,476 (-)

136,670

35,483 (26.0)

1,719 (2)

Ondo

234,595

44,676 (19.0)

2,124 (-)

240,535

51,341 (21.3)

1,688 (3)

Oyo

447,665

33,849 (7.6)

2,537 (-)

459,000

78,838 (17.1)

1,143 (-)

Plateau

174,175

47,020 (27.0)

8,592 (77)

178,585

131,485 (73.6)

1, 208 (18)

Rivers

147,815

15,758 (10.7)

1,473 (12)

151,555

41,460 (27.4)

526 (-)

Sokoto

390,075

20,875 (5.4)

9,125 (165)

399,950

65,127 (16.3)

6,867 (302)

All

4,832,075

662,439 (13.7)

161,768

4,957,065

1,399,053

115,743

States

(1721)

(28.2)

(1991)

FCT

4,751

3,744

Abuja

Total

4,832,075

667,190 (13.8)

161,768(172

4,957,0651

1,402,797(28.3

115,743

)

(1991)

152

Table 6b : Measles in Nigeria

Parameter

1982

1983

1984

1985

1986

Population at risk (5% total)

4,475,930

4,591,590

4,710,290

4,832,075

4,957,065

Measles vaccination reported

1,851,453

958,324

834,231

667,190

1,402,797

% Population at risk vaccinated

41.4

20.9

17.3

13.8

28.3

Midyear population estimate

89,518,600

91,831,800

94,205,800

96,641,500

99,141,300

Measles cases reported

139,785

136,778

182,591

161,768

115,743

Measles cases/100,000

156.2

148.6

193.8

167.4

116.7

population

Measles deaths reported

985

983

1,431

1,721

1,991

Case fatality rate (%)

0.70

0.72

0.78

1.06

1.72

In the early 1990's Nigeria had routine immunization

Child survival in Nigeria

rates over 80% which gradually dropped to 25% and

is now only picking up. The international body

Records show that more than one million African

recommended a public expenditure per capita of

babies die in the first month of life. Nigeria has one of

thirty-four US Dollars for the purpose. In Nigeria,

the highest under-five mortality rates in Africa with

less than ten US Dollars per capita is made available.

figures of 235 and 198 per 1000 live births in 1990

and 2003 respectively as well as a high neonatal

Malaria assumes the pride of place as cause of

mortality rate of 48 per 1000 live births. Low

morbidity and mortality in infants and young

immunization coverage, malaria, diarrhea, acute

children. It causes up to two hundred thousand deaths

respiratory infections (ARI) and vaccine preventable

among under-five annually. Specifically. Malaria

disease in concert with malnutrition still account for

affecting pregnant mothers causes intrauterine

ninety percent of childhood death irrespective of

growth restriction and low birth weight, consequently

government's effort to reduce under-five mortality

lowering child survival. It can also cause preterm

rate compared with other development countries.

birth, prenatal and neonatal mortality as well as

severe anaemia requiring blood transfusion.

Factors that tend to overwhelm conscious

government efforts include:

The Roll Back Malaria Initiative was introduced and

a. Lack of coordination of vertical and horizontal

it promised access to effective anti-malaria drugs,

activities by government officials and donor

prompt treatment and use of insecticide treated nets.

agencies.

b. Poverty at household level.

Diarrhea illnesses rank second as cause of infant

c. Poor government funding.

death, obviously more in rural areas. Children in

d. Uncoordinated and haphazard vital registration.

North East are five times more likely to have diarrhea

than their South West counter parts.

Some children die of multiple causes since

underlying malnutrition is present in half of the

Vaccine preventable diseases are third in the list of

children who die from:

cause of mortality. Records show that diphtheria,

a. Malaria.

tetanus, poliomyelitis, measles and tuberculosis

b. Acute Respiratory Infections (ARI)

cause two hundred thousand deaths annually among

children. This scourge can be reduced by sustained

c. Measles.

routine immunization if supplemented with

d. Diarrhea.

cerebrospinal meningitis vaccine and tetanus toxoid

e. Tuberculosis.

for pregnant woman. The greatest decline in routine

f. HIV/AIDS

immunization

was

13%

2003

which

embarrassingly was the lowest vaccination rate

Other factors contributing to morbidity and death of

amongst African countries. The publicity about wild

these children include:

polio virus in North West and North Central regions

Poor immunization status.

of Nigeria is fresh in our memory.

Household poverty.

Maternal illiteracy.

Neonatal tetanus was responsible for eleven percent

Poor living conditions with consequent poor

of infant mortality in 1999 a poor reflection of

child care during illness.

antenatal care of pregnant women as two doses of

153

tetanus toxoid immunization during antenatal period

perinatal mortality, premature delivery and low birth

would protect for three years. If kept up, a woman

weight and increased susceptibility to infections. In

requires total of five doses to acquire protection

Nigeria it is claimed that twenty-nine percent of

during child bearing years.

children under-five years of age are anaemic.

Malnutrition as mentioned earlier, malnutrition is

HIV/AIDS: Mother to child transmission (MTCT) of

the underlying factor in more than fifty percent of

HIV can occur during:

childhood mortalities. The range of disorders

Pregnancy in 10% - 30% of cases.

includes protein energy malnutrition (PEM)

Delivery in 40% - 60% of cases

manifesting as weight deficits and stunting as well as

Breast feeding in 15% - 20%

deficiencies of micronutrients like vitamin A, iron,

iodine and zinc. This could be evidence of food

As expected, the scourge of HIV/AIDS truncated the

shortage or severe disease within a short time.

modest gains of child survival strategies in terms of

reducing infant and under five morbidity and

UNICFE and WHO recommend exclusive breast

mortality. By the end of the year 2000 an estimated

feeding for six months, introduction of semisolids

2000,000 children under five years had died from

and solid at six months while continuing with breast

HIV/AIDS acquired through mother to child

feeding for eighteen to twenty-four months of life.

transmission and further projections forecast up to

Unfortunately in Nigeria only seventeen percent of

700,000 deaths by 2010.

infants below six months are exclusively breast feed.

Maternal Morbidity and Mortality: Child survival

During my over fifty years of practice, both in the

is closely bound to maternal health and mortality. We

government teaching hospital and private sectors, I

are all aware that children who lose their mothers are

found that quite a lot of our female compatriots both

more likely to experience increased risk of death and

illiterate and so called educated ones really did not

other complications like malnutrition. A study

have a full grasp of successful breast feeding

showed that children, especially females, who lose

practice. Some mothers give plain water to babies

their mothers at birth, are ten times more likely to die

with attendant risk of diarrhea and infection. They

than those whose mothers survive. WHO reports state

knew no better. In addition to this, some introduce

that annual maternal death in Nigeria is 55,000 per

complementary feeds too early. Records show that

annum. Many other women end up with serious post

thirty-six percent of babies at four to five months of

natal complications further increasing the risk of

life are not having adequate food for their age. This

children at risk of morbidity. Improvement in

obviously leads to malnutrition, frequent illnesses

maternal care and comprehensive maternal care

and even death. Breast milk alone is estimated to be

during pregnancy and labour would help strengthen

able to prevent thirteen percent of under-five death.

child survival.

As stated earlier, micronutrient deficiencies also

Health Services : As a nation, we adopted the

abound among Nigeria children. Vitamin A, for

National Health Policy in 1988 and this was revised

instance, is essential for proper development of the

in 1996. The main objective of the exercise has been

immune and visual systems of children. If deficient,

to provide Primary Health Care (PHC) as well as

there is reduced resistance to infections. Vitamin A

secondary and tertiary health care by referral.

dietary intake has been found to be inversely

Primary Health Care includes:

associated with risk of diarrhea. Deficiency of this

vitamin is widely recognized as cause of night

Health Education

blindness and xerophthalmia. In Nigeria more than

Adequate Nutrition

nine million children and six million mothers are

Safe water

vitamin A deficient. Effort has been made to give

Sanitation

vitamin A supplements but studies show that in 2003

Reproductive Health including family

only thirty-four percent of children aged six months

planning

to fifty-nine months received vitamin A

Immunization against five major infection

supplementation.

diseases

Provision of essential drugs

Other micronutrients of high importance are iodine

Disease control

and iron. Iodine deficiency not only leads to goiter,

impairment of mental and physical development in

Unfortunately, the laudable objective of this policy

children but also to increased rate of abortion,

has been shattered by poor and irregular funding. It is

stillbirth, and congenital abnormalities of babies and

a well known fact that the Nigerian government

cretinism in children if deficient in mothers. Iron

allocates far less than the WHO recommendation of

deficiency in the mother can lead to maternal and

15% of her annual budget to the health sector.

154

The little amount allocated is often subject to official

Efforts at improving child survival in Nigeria

bureaucracy and delay leading to failure to maintain

infrastructure. This, taken with poor staff attitude the

Some effort has been made by government to reduce

Nigerian factor seriously affects efforts to provide

mortality from malaria, vaccine preventable diseases,

optimum childhood immunization services aimed at

diarrhea and acute respiration infections. There are

promoting child survival.

also effort directed at ensuring food security at

household level and reducing micronutrient

Vulnerability of children

deficiencies through fortification of food and

supplementation these efforts are supported by many

Maternal care in the early formative years of

international donors and partners who donate funds

childhood is crucial to physical and mental

and provide technical assistance. These international

development. Any form of deprivation at this tender

agencies include:

age may affect quality of life in the future and in

WHO

extreme cases, prevent realization of full potential.

World Bank

African Development Bank

This deprivation may be due to extreme poverty, poor

United States Agency for International

governance, armed conflicts or HIV/AIDS. Such

Development through its implementation

deprived children, and particular orphaned ones, are

partners UNICEF

usually exposed to all kinds of exploitation. Without

ratification of the Convention of the Rights of the

Funds from these agencies support:

Child and a solemn pledge to safeguard children

from harm and abuse, exploitation and neglect, we

Formulation of policies

must answer the question. Are we doing enough?

Plans and guidelines

Advocacy

The way out of course, is to embark on a crusade of

Dialogue

female education as it is known that poor educational

Health Sector Reports

level of females is related to higher infant and under-

Capacity Building

5 morbidity. Poverty coincidentally, goes hand-in-

Child and maternal health

hand with poor female education.

Service delivery including

Access to adequate immunization services

Maybe a few more unsettling statistics will provide

the right perspective:

VitaminAsupplementation

In 1980 poverty level was 27% or 17.7 million out

And also NGO research about child survival

of 65 million people.

Malaria control : Nigeria adopted the Roll Back

In 1996 the level doubled to 65.6% or 67.1

Malaria (RBM) initiative funded by WHO, UNICEF,

million

World Bank and UNDP in 1998 with the goal of

In 1998 the level was 70.2% or 71% of the

reduce malaria burden worldwide by 2010. The

estimated 105 million inhabitants

Nigeria Government hosted the African summit on

RBM initiatives in 2000 which led to the signing of

In 2003, Nigeria was classed as having the 3 largest

the ABUJA DECLARATION by the Presidents and

population of the poor in the world. The poor are

Head of States of African countries. Following the

mostly in the rural areas and because they are unable

Abuja Declaration, the National Malaria Programme

to get health facilities at close quarters, they

was declared at National and Local GovernmentArea

experience a lot of ill health and obviously default in

Levels.

immunization schedules of their children. The poor

mother herself has little, if any, access to maternal

Vaccine Preventable Diseases and Immunization

care

with

avoidable

maternal

and

fetal

complications, while lack of adequate sanitation and

The Expanded Programme on Immunization (EPI)

safe water compound her problem. In 1999, only

was initiated in 1979 by World Health Assembly

54% of Nigeria population had access to safe

(WHA) and was re-launched in 1984 due to poor

drinking water while 53% lived in households with

coverage. EPI was changed to NPI (National

poor sanitary means of human waste disposal.

Programme on Immunization) and the supervising

agency became a parastatal by Decree 12 of 1997.

Other problems hindering child survival is the belief

The object was to effectively control vaccine

of some of our compatriots in spiritual and

preventable disease like TB, poliomyelitis,

supernatural forces. This quite often causes delay in

Diphtheria, whooping cough, tetanus and measles as

seeking medical help for children.

well as diseases of women of child bearing age

through immunization and provision of vaccine. The

155

primary responsibility of NPI has been to support the

Child rights act : The child rights act was enacted

States and local governments in their immunization

in 2003. The objective has been to put the best

programmes by supplying them with vaccines,

interest of the child paramount in all actions

needles and syringes and cold chain equipment as

involving the child.

may be required.

The salient points of the Act are as follows:

In 2003, UNICEF took over the job of international

a. Every child has a right to survival and

procurement of vaccines because of chronic shortage

development

in the country. In addition, the WHO helped NPI with

b. Every child is entitled to enjoy the best

surveillance and technical assistance while USAID

attainable state of physical, mental and

helped with social mobilization at grass root level.

spiritual development

Late or non release of funds for NPI however, led to

c. Every government in Nigeria shall:

poor success of immunization in 2004.

Endeavour to reduce infant and child

mortality rate;

In 1995, Integrated management of childhood

illnesses (IMCI), was initiated by WHO to provide

Ensure the provision of necessary medical

quality health care for children. Prior to introduction

assistance and health care services to all

of IMCI, emphasis had been on vertical programmes

children with emphasis on development of

aimed at controlling rampant diseases like ARI,

primary health care;

diarrhea. In 1997 with the backing of WHO and

Ensure the provision of adequate nutrition

UNICEF the Nigerian government adopted the IMCI

and safe drinking water;

and this became the main host for child survival

Ensure the provision of good hygiene and

effort.

environmental sanitation;

Combat disease and malnutrition within the

Food and Nutrition Policy was approved by Nigeria

framework of primary health care through

in 1998 and published in 2001. The factors identified

the application of appropriate technology;

as major causes of malnutrition in Nigeria were:

Ensure appropriate health care for expecting

Poverty

and nursing mothers;

Inadequate investment in social sector

Support through technical and financial

Inadequate Dietary Intake

means the mobilization of national and local

Disease

community resources in the development of

The aim of the policy was to reduce under nutrition in

primary care of children.

children, women and the aged. Of particular interest

Every parent, guardian or person having the

was a 30% reduction of severe and moderate

care and custody of a child under the age of

malnutrition in under

5 children and to remedy

two years shall ensure that the child is

micro nutrient deficiencies by 50% of current level

provided with full immunization.

by 2010.

Other components include:

Achievements made in children nutrition include

formation of National Committee of Food and

The right of the child to free, compulsory and

Nutrition (NCFN). The partners in this venture

universal primary education to be provided by the

include NCFN, WHO, UNICEF, USAID and the

government.

International Institute of Tropical Agriculture

It prohibits child marriage and makes it a

(ITTA). Other achievements include launching of

punishable offence to marry or give out in

National Breast Feeding Policy and encouragement

marriage any person below the age of eighteen

of exclusive breast feeding through the Baby

years.

Friendly Hospital Initiative (BFHI) which now

stands as women and child friendly health services.

It also prohibits child labour and makes it a

This move undoubtedly broadened the awareness of

punishable offence.

exclusive breast feeding.

Consequent upon the Act, some States in Northern

Other efforts include

micro-nutrients, salt

Nigeria have abolished child marriage while some in

iodinazation, and vitamin supplement of staple food.

the South have abolished female circumcision.

The activities of NAFDAC promoted and

encouraged the moves. In addition, school meals and

More States are passing the child rights bill into law.

school health service are being implemented in over

The implementation of the Act will strengthen child

twelve states including the Federal Capital Territory.

survival in Nigeria and facilitate the attainment of

In addition to all these, improve maternal care

desirable health status of the Nigerian child as well as

service, safe mother hood initiative and health

the MDGS.As a result of international concern for the

education services were put in place.

implementation of the child rightsAct, UNICEF

156

Established child friendly rights based school

Only about 41% have access to adequate

initiative in some educationally disadvantaged areas

sanitation

of Northern Nigeria, while the Ford Foundation

Overall adult literacy is about 56% in females and

support enhanced female education. Orphans and

47% in males

vulnerable children are also helped by UNCEF,

These adverse factors limit access to adequate

UNAIDS and Government Millennium Goal (MDG)

nutrition, quality health care and other basic services

agency.

with special reference to the vulnerable groups

woman and children.

As a signatory to the MDG declaration, Nigeria is

obliged to reduce extreme poverty, hunger, child and

Ninety percent of childhood morbidity and mortality

maternal mortality, combat HIV/AIDS and other

are preventable if we regularly deal with malaria,

disease. She should also promote universal primary

diarrhea diseases, acute respiratory infection and

education, gender equality and ensure environmental

vaccine preventable diseases. Two

thirds of

sustainability amidst global partnership for

childhood death could be prevented by effective

development by 2015. Each of the MDGs is directly

preventive and therapeutic intervention which are

or indirectly linked to the wellbeing of the child.

packed and made available today as child survival

Some responses of the federal Government of

strategies. At household level, there must be

Nigeria were to initiate poverty alleviation

promotion of breast feeding, correct use of ORT,

programmes, Universal Basic Education Scheme

education on complementary feeding and use of

and the National Policy on Women.

insecticide treated nets. These strategies are tools for

achieving the 4

MDG of reduction of childhood

Some other laudable concurrent programmes

mortality rate by two-thirds in 2015.

include:

Roll back malaria programme

HIV/AIDS without doubt helped in reversing health

National water supply

development gains especially in sub-Saharan Africa.

Free treatment of some diseases

Nigeria accounts for 10% ofAids burden in the world,

Provision of safe drugs strengthened by the

4 million individuals live with the infection and there

founding of NAFDAC to curb the menace of

is a possibility of upsurge if serious action is not

fake and substandard drugs.

taken. As of 2005, one million Nigeria children were

already orphaned by the disease. With HIV/AIDS, the

The objectives of the MDGS as laudable as they are,

scourge of tuberculosis naturally increased.

are being frustrated by funding and equivocal

political will. Recently again Nigeria ranked 13

Statistics UNAIDS 2000

poorest country in the world as 66%. Of the

population live below poverty line

3.3 TO 3.8 Million people are living with

HIV/AIDS

Conclusion

An estimated 520,000people are in need of

Despite the acclaimed enormous wealth of Nigeria,

antiretroviral drugs

and in spite of successive several intervention

About 300,000 have died of aids

programmes for child survival in Nigeria, no

About 1.2millionhave been orphaned

significant impact seems to have been made. Nigeria

still has the worst childhood mortality record in

Access to health care services and health care

Africa as indicated by the under five mortality, as

infrastructure

testified by the Federal Ministry of health report

for2004-2006.

Unless the poor has insurance cover, they can have no

access to health care when it is needed.

We have achieved 10% reduction in under 5

Not only cost but also distance and travel time

motarlity the least in Africa, while the average

militate against the poor receiving quality health care.

improvement in sub-Saharan Africa was about 34%.

In the light of this, the health sector reform

The reasons for this debacle have been repeatedly

programme was initiated in 2003 to improve access to

recounted in this presentation.

quality health services. These include:

We rank as the 13 poorest country in the world

National HealthAct Bill

despite our wealth of human and material

Traditional Medicine bill

resources because:

Policies on Health care finance

The health budget is low

Human Resources Development

Less than half the population has access to safe

Health Promotion

water

Public Private Partnership in Health

157

National drug policy

Low pay

National Food and Nutrition Policy

Poor career prospects

The Blood transfusion Services

Lack of opportunity for professional

advancement.

The poor are at the losing end as they are exposed

Adverse social and political condition.

to health risks and have less resistance to disease.

They have reduced access to preventive and

Education and Training

curative intervention just as they are more

undernourished surrounded by poor hygiene and

Eighteen fully and five partially accredited medical

sanitation.

schools in Nigeria provide:

2,000 Doctors

The wide gap in mortality between the rich and the

5,000 Nurses

poor seems to be widening and this can only be

800 pharmacists between 2002 and 2003.

bridged if sincere effort is made by the government

and the governed to implement to the last letter the

Nigeria's medical workforce is bedeviled by lack of

enumerated programmes. Overall, improving access

coordination, failure to develop teamwork and

to health services and infrastructure especially for the

annoying professional rivalry sometimes between

poor is feasible if the health reform programme is

doctors and nurses and perpetually between

pursued vigorously with sincere commitment from

pharmacists and doctors.

the presidency and the policy implementers.

Our unfortunate colleagues in remote areas suffer

from poor working condition, lack of basic

In 2004, the National Health Bill came into place

equipment, late payment of salary if paid at all, lack

with provision for the respective roles of each tier of

of drugs, physical dilapidation of infrastructures,

government. Health system was decentralized under

poor or nonexistent comfortable accommodation.

Federal structure. The federal level became

Oftentimes, they are forgotten and promotion

responsible for overall policy as well as tertiary

delayed.

services while the state level is responsible for the

primary services.

Present Health Situation in Nigeria

Number of Health workers in Nigeria, 2003/2004

Staff type

No of Staff

No of Staff per

In the context of this presentation, let us look at health

100,000population

not simply as absence of disease or illness but as

Doctors

35,000

encompassing the state of complete physical, mental

Nurses

210,000

170

and social well being of the individual, the family and

Dentists

2,500

the community.

Pharmacists

6,350

Laboratory

Some reports of the health situation in Nigeria are

as follows:

technicians

690

In 2,000 WHO put Nigeria in the 187 position

Community health

Workers

115,800

out of 191 countries,

In 2005, UNDP Human Development reports

Rounded figures source: World Health Report

ranked Nigeria 158 out of 177 countries in the

2006

world in terms of overall Human Development.

In contrast, Ghana is ranked 120 . It is also noted that

The number of paediatricians in Nigeria is about 750.

Egypt and South Africa are the two countries

infant mortality and maternal mortality rates are

surpassing Nigeria in stock of human resources for

higher in Nigeria than in SouthAfrica or Ghana .

health inAfrica.

Malaria and tuberculosis remain major causes of

Brain drain

death especially among children under five years of

age. In 1999, malaria accounted for 30% of all deaths

A study showed that of 5,334 physicians from Sub-

among infants under one year old and 20% of all

Saharan African practicing in USA, nearly 80%

deaths among children under 5 years between 1960

originate from three countries Nigeria, South Africa

and 1999.

and Ghana. Apart from Great Britian, USA,Canada,

Nigerian doctors are in Saudi Arabia,Quatar, South

To make matters worse, Nigeria ranks low among

Africa, Namibia, Lesotho, Jamaica, Trinidad and

countries in efforts aimed at reducing death among

Tobago. We are all conversant with the reasons for

children age 5 years due to malaria. The average

the migration:

percentage reduction for the least developed

158

countries in the world is 42% while that for Saharan

Ministry ofAgriculture

Africa is 34%.

Ministry of Education

The figures for individual countries are:

Ministry of Sanitation

Ministry of Water resources.

Ghana

53%

SouthAfrica

47%

Most importantly, if as it seems we cannot eradicate

Kenya

42%

corruption, it must be minimized at all levels.

Cameroon

40%

On our part as Paediatricians, events over the years

Sierra Leone

19%

have shown that we have been relevant in the long

Liberia

18%

going struggle to child survival in the last four

Nigeria

10%

decades of our venture on the scene. We have helped

in putting in place the concern of child health and life

Without much argument we can conclude that the

despite recurrent frustrations most of the way.

health situation in our beloved country is in a

deplorable state, despite our vast human material and

The Paediatric Association of Nigeria has over the

abundant natural resources.

years helped in establishing and promoting all the

necessary institutions to promote the well being and

I am sure that if some of us here today are given the

care of the Nigerian child up to the establishment of

necessary tools, incentive and encouragement and

the Faculty of Paediatrics of the Nigeria Medical

genuine cooperation of all stakeholders in the healing

College which we are celebrating today. Our

profession, we can reverse this worrisome trend.

founding fathers would no doubt rest happily with the

Perhaps paramount in the way forward is improving

knowledge that the acorn which they planted

the stewardship role of the government as honestly as

unwittingly is gradually becoming an oak tree.

possible. In addition, unless theArticles of the Health

Reform Programmes and Research are honestly and

Permit me to mention those colleagues who started

religiously implemented to the letter, we would not

the crusade:

make progress.

Dr. IshayaAudu (Professor of Paediatrics)

Dr. Olikoye Ransome Kuti (Professor of

The human resources that abound in Nigeria need to

Paediatrics)

be managed in a dedicated, sincere and a purposeful

Dr.AsuquoAntia (Professor of Paediatrics

manner. We need to tackle brain drain by investing

heavily in training of new manpower and retraining

Dr. Ralph Hendrickse (Professor of

of existing ones. In this global village type world, we

Paediatrics)

must strive to provide the necessary tools and

Dr.AnjorinAnimashaun

equipment for the health workers in addition to

Dr. Aaron Ifekwunigwe (Professor of

ensuring that these quality staff are given abundant

Paediatrics)

incentive to retain them.

Dr. Winifred Kaine

Dr. Theodore Okeahialam (Professor of

The powers that be need to strengthen the Primary

Health Initiatives. It is imperative that we as a body

Paediatrics)

should join hand with other stakeholders in children's

Dr. Mike Ogbeide (Professor of Paediatrics)

health to put pressures on the government to fund

10. Dr. Calvin Sinnette

health in line with World Health Organization

11. The author of this lecture

guidelines and recommendations.

Thank you.

More effort should be put into education of our

teeming populace on Exclusive Breast Feeding.

Most of the agencies put in place to make life worth

living for all of us must be coordinated effectively not

only to promote food security, improve literacy and

hygiene but to make potable water available to the

populace at all levels. These include: