Kill The Mosquito — A 5 Why look at Nigerian Health care system.

Why am I bothering with health? The easy answer is that health is wealth. The preservation of life is of the highest priority. I’ve also had a varied exposure to the Nigerian health system as a care receiver, a care giver and also as some one who pays for the care of a whole lot of dependents. I have also had the privilege of trying to define, build and market a digital health management solution. Before that I had had the privilege of conducting research in biomedical engineering including building a digital ECG monitor as a post graduate project and developing syntactic techniques for the analysis of ECG rhythms.

More importantly , the health care sector seems to have a serious issue with a lot of people treating malaria while mosquitoes keep breeding. So what is the problem with Nigeria’s health care system and what are the root causes? Like other things in Nigeria, the default evaluation of the Nigerian health care system is that it is poor. How poor is it? Really? It is important to establish this so that we can start looking at the root cause of this poverty. Unfortunately, trying to establish how poor the poor health care system from the writings of supposed experts or agencies like the FMH, you immediately run into the thicket of anecdotes that go as analysis. You also get inundated with statistics and measures that seem only to be tied to how much money is spent or budgeted for.

The big question still remains how bad is the Nigerian healthcare system in an objectively measurable way? In trying to solve a problem, it is always good to have a good measure of the state of ‘badness’ so that causes and solutions can be measured. How bad is malaria for instance? People die of malaria but then people die of so many other causes. But 5000 people die everyday of malaria. Malaria is one of the top ten killers in Nigeria and prime cause of death and disability. Deaths by malaria is a major reason why Nigeria’s life expectancy is lower than the average for low income countries. Now this defines the malaria problem in a way that we can decide whether it is worth addressing or not. We can also project the impact of fixing this problem and be able to do a cost benefit analysis.

The best way to define the state of the Nigerian health care system so that a proper root cause analysis can be done is to define a set of benchmarks for a good healthcare system and then measure the Nigerian health care system against these benchmarks. This approach has most recently been applied to addressing the ease of doing business in Nigeria with measurable progress being achieved thereafter. Of course health may be a bit more complex. Defining health care system benchmarks has been an ongoing struggle. The WHO published a set of benchmarks and ranking a few years ago but found the variability and blow back so much that it has basically abandoned making those rankings since then. Many countries have established their own benchmarks in order to rank subnational organisations or providers. In Nigeria, the NBS and the FMH measures different parameters that could ordinarily be used for setting and ranking benchmarks but sadly these benchmarks and measurements are consistently out of date. A very interesting set of benchmarks is published by the Institute of Health Metrics And Evaluation http://www.healthdata.org/nigeria and they represent the nearest thing to an objective view of the Nigerian health care system.

The last of these measurements published in 2017 paints a fairly stark picture of the Nigerian health-care system which can be surmarized as follows

1. Life expectancy is low, lower than the average even for low income countries.
2. Infant mortality is high
3. Death by communicable diseases is higher than average.
4. Most payment for health is out of pocket.
5. Government share of the health spend is minuscule.

Obviously these statistics will vary region by region, state by state and even local government by local government. But in the aggregate, that is where any national scale intervention to improve the system should start.

So let us try a 5 whys approach to get to the root cause of this sad state. If we can get to the root cause, we can work our way back to a set of actionable recommendations. The 5 Whys approach to root cause analysis believes that by asking why the primary condition occurred and recursively asking why on the answers, you will arrive at the root cause before you go beyond a fifth why.

Why is the life expectancy in Nigeria lower than even nations at war? Turns out that according to a recent study, the top ten killers of Nigerians are

1. Malaria 20%
2. Lower Respiratory Infections 19%
3. HIV 9%
4. Diarrheal Diseases 5%
5. Road Injuries 5%
6. Protein-Energy Malnutrition 4%
7. Cancer 3%
8. Meningitis 3%
9. 3%
10. Tuberculosis 2%

So, 40% of deaths in Nigeria can be traced to malaria and lower respiratory diseases. Worse still the death rate from these diseases is very high compared to the rest of Africa or even emerging market according to the medical metrics report here.

Why are these diseases so deadly in Nigeria? The second why. The American Embassy malaria information card gives a very good idea.

1. Poverty
2. Insecticide Resistance
3. Wrong treatment

https://healththink.org/malaria-in-nigeria-where-are-we-now/ also gives a good discussion of the malaria problem in Nigeria.

Poverty makes this list because many of those dying of malaria are dying because they cannot afford the preventive or the prophylactic actions recommended for treating malaria. Recall that 67% or more of Nigerians are living in abject poverty. The solution here will be to either lift majority of Nigerians from poverty or reduce the cost of treatment. Insecticide resistance means that mosquitoes are resistant to both preventive and prophylactic measures. This resistance is the natural reaction of the mosquito and the malaria parasite to the treatments being used. New methods need to be found to more effectively kill the mosquitoes or kill the parasites or prevent the parasites from infecting people. Wrong or poor or inadequate treatment also contribute to the deadliness of malaria. However, the real reason why malaria accounts for 20% of deaths is not any of these. The simple reason is that malaria infects a lot more people. 97% of Nigerians are projected to be at risk of malaria while some agencies claim that 100% of Nigerians are at risk. If we were able to reduce the rate of exposure to malaria infection, we will be able to reduce the mortality due to malaria and also improve the life expectancy in Nigeria.

We can go ahead to ask the 3rd why. Why are so many nigerians at risk of malaria? Malaria incidence in Nigeria is partly a natural phenomenon and partly a man made phenomenon. Malaria parasites have been shown to survive best in tropical regions and to die totally if the temperature goes below 60degrees Fahrenheit. Nigeria is in the tropics so mosquitoes are rampant and the malaria parasite has a favourable climate. Mosquitoes breed in stagnant pools and consistently bite people who are not well covered up. So the answer to this why is that Nigerians are in a region where malaria is naturally disposed to be prevalent in that it is conducive to mosquitoes breeding and to malaria parasites also surviving. Since we cannot move Nigeria and Nigerians from this location, the fact that Nigeria is living in an area that is conducive to mosquitoes is now the root of the problem and this is where we can start to solve it. Moving Nigerians out of Nigeria is not a viable option.

If we are formulating health policy without doing a realistic and detailed root cause analysis, we will forever be treating the malaria and not getting rid of the mosquitoes and the malaria parasites. In this case of malaria, our entire policy should in my opinion focus relentlessly on eradicating the conditions that allow malaria bearing mosquitoes to breed or thrive, preventing the mosquitoes from biting people ( especially children and pregnant women ) and if possible rendering people in Nigerian resistant to malaria. Without being an expert, I can see possible solutions in ensuring regular public inspection and spraying of insecticides in gardens and open/stagnant water pools as is done in places like Jamaica, Brazil and even Ghana, in distribution of nets and repellants, and in significant investment in biotechnology and vaccine research.

We can do similar 5 why’s analysis of the other contributors to the poor state of the Nigerian health care system and then come up with recommendations that will improve the entire health are system.