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.
    Register one hundred and sixteen (116) Europeans
  • 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
    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
    Prevention and control of local endemic and
    Payment by individuals for service and drug
    epidemic diseases;
    purchases
    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
    14
    122
    Pakistan
    87 130
    3.0
    45.3
    120
    India
    7044 240
    2.1
    40
    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
    48
    16
    Crude death rate per 1,000 population
    16
    9
    Rate of natural increase of population (%)
    3.2
    0.7
    Period needed to double the population (years)
    22
    100
    Medium age (years)
    16
    27
    Life expectancy at birth (years)
    54
    74
    Proportion of deaths in < 6years old (%)
    50
    4
    Maternal mortality rate
    15
    0.2
    Under 5year old mortality rate
    160
    16
    Childhood (1-4year old) Mortality rate
    70
    5
    Infant mortality rate
    90
    11
    Percentage of population under 15years (dependents)
    48
    20
    15-64years (Labour Age Group)
    49
    66
    65years and above (Senior Citizens)
    3
    24
    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
    rate
    rate
    rate
    rate
    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
    86
    1932
    27.5
    12.9
    102
    1951
    61.2
    15.2
    74
    1933
    24.9
    13.8
    137
    1953
    45.0
    15.6
    104
    1934
    27.8
    13.0
    119
    1954
    44.8
    13.2
    82
    1935
    26.3
    13.9
    129
    1955
    47.6
    12.5
    81
    1936
    23.8
    13.8
    140
    1957
    49.1
    14.2
    80
    1937
    22.9
    23.3
    130
    1958
    50.4
    12.7
    80
    1938
    24.0
    21.6
    127
    1959
    55.8
    13.6
    77
    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
    No
    100,000
    No
    100,000
    No
    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
    No
    100,000
    No
    100,000
    No
    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
    75
    0.1
    Typhoid &
    1,362
    1.4
    673
    0.7
    1,219
    1.3
    Paratyphoid
    Yellow Fever
    1,102
    1.1
    6
    0.07
    898
    1.0
    Syphills
    1,026
    1.0
    1,641
    1.7
    1,214
    1.3
    Sleeping Sickness
    716
    0.7
    74
    0.1
    83
    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
    1)
    )
    (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%
    in
    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
    a.
    Poor immunization status.
    of Nigeria is fresh in our memory.
    b.
    Household poverty.
    c.
    Maternal illiteracy.
    Neonatal tetanus was responsible for eleven percent
    d.
    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
    rd
    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
    th
    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
    th
    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
    th
  • 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
    28
    encompassing the state of complete physical, mental
    Nurses
    210,000
    170
    and social well being of the individual, the family and
    Dentists
    2,500
    2
    the community.
    Pharmacists
    6,350
    5
    Laboratory
    Some reports of the health situation in Nigeria are
    as follows:
    technicians
    690
    1
    In 2,000 WHO put Nigeria in the 187 position
    th
    Community health
  • Workers
    115,800
    91
    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
    1
    world in terms of overall Human Development.
    In contrast, Ghana is ranked 120 . It is also noted that
    th
    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.
    1.
    Dr. IshayaAudu (Professor of Paediatrics)
    2.
    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
    3.
    Dr.AsuquoAntia (Professor of Paediatrics
    manner. We need to tackle brain drain by investing
    heavily in training of new manpower and retraining
    4.
    Dr. Ralph Hendrickse (Professor of
    of existing ones. In this global village type world, we
    Paediatrics)
    must strive to provide the necessary tools and
    5.
    Dr.AnjorinAnimashaun
    equipment for the health workers in addition to
    6.
    Dr. Aaron Ifekwunigwe (Professor of
    ensuring that these quality staff are given abundant
    Paediatrics)
    incentive to retain them.
    7.
    Dr. Winifred Kaine
    8.
    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
    9.
    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: