The Nigerian health care system: Need for integrating adequate medical intelligence and surveillance systems.

OBJECTIVES: As an important element of national security, public health not only functions to provide adequate and timely medical care but also track, monitor, and control disease outbreak. The Nigerian health care had suffered several infectious disease outbreaks year after year. Hence, there is need to tackle the problem. This study aims to review the state of the Nigerian health care system and to provide possible recommendations to the worsening state of health care in the country. To give up-to-date recommendations for the Nigerian health care system, this study also aims at reviewing the dynamics of health care in the United States, Britain, and Europe with regards to methods of medical intelligence/surveillance.
MATERIALS AND METHODS: DATABASES WERE SEARCHED FOR RELEVANT LITERATURES USING THE FOLLOWING KEYWORDS: Nigerian health care, Nigerian health care system, and Nigerian primary health care system. Additional keywords used in the search were as follows: United States (OR Europe) health care dynamics, Medical Intelligence, Medical Intelligence systems, Public health surveillance systems, Nigerian medical intelligence, Nigerian surveillance systems, and Nigerian health information system. Literatures were searched in scientific databases Pubmed and African Journals OnLine. Internet searches were based on Google and Search Nigeria.
RESULTS: Medical intelligence and surveillance represent a very useful component in the health care system and control diseases outbreak, bioattack, etc. There is increasing role of automated-based medical intelligence and surveillance systems, in addition to the traditional manual pattern of document retrieval in advanced medical setting such as those in western and European countries.
CONCLUSION: The Nigerian health care system is poorly developed. No adequate and functional surveillance systems are developed. To achieve success in health care in this modern era, a system well grounded in routine surveillance and medical intelligence as the backbone of the health sector is necessary, besides adequate management couple with strong leadership principles.

The Nigerian health care has suffered several down-falls.[1-7] Despite Nigerian's strategic position in Africa, the country is greatly underserved in the health care sphere. Health facilities (health centers, personnel, and medical equipments) are inadequate in this country, especially in rural areas.[126] While various reforms have been put forward by the Nigerian government to address the wide ranging issues in the health care system, they are yet to be implemented at the state and local government area levels.[36] According to the 2009 communiquι of the Nigerian national health conference, health care system remains weak as evidenced by lack of coordination, fragmentation of services, dearth of resources, including drug and supplies, inadequate and decaying infrastructure, inequity in resource distribution, and access to care and very deplorable quality of care. The communiquι further outlined the lack of clarity of roles and responsibilities among the different levels of government to have compounded the situation.[3]

Unarguably, problems in the health care system of any country abound to a certain extent.[8-11] Although health has the potential to attract considerable political attention, the amount of attention it actually receives varies from place to place. In their commentary of the 3T's road map to transform US health care, Denise Dougherty and Patrick H. Conway rightly stated a step by step transformation of the US health care system from 1T →2T →3T which is required to create and sustain an information-rich and patient-focused health care system that reliably delivers high-quality care.[8]

Provision of timely information aimed at combating possible health menace among many other things is an important function of public health. Hence, inadequate tracking techniques in the public health sector can lead to huge health insecurity, and hence endanger national security, etc.[11-16]

For decades ago, communicable diseases outbreak was a threat not only to lives of individuals but also national security. Today it is possible to track outbreaks of diseases and step up medical treatment and preventive measures even before it spreads over a large populace.[17-20] Medical and epidemiological surveillance, besides adequate health care delivery, are essential functions of public health agencies whose mandate is to protect the public from major health threats, including communicable diseases outbreak, disaster outbreak, and bioterrorism.[17-20] To avoid the various threats and communication lapses to strengthen the health work force planning, management, and training which can have a positive effect on the health sector performance, one requires timely and accurate medical information from a wide range of sources.[12]

The Nigerian health care had suffered several infectious disease outbreaks and mass chemical poisoning for several years. Hence, there is immense need to tackle the problem.[1-621-24]

This study aims to review the state of the Nigerian health care system and to provide possible recommendations/solutions to the worsening state of health care in the country. To give up-to-date recommendations for the Nigerian health care system, the dynamics of health care in the United States and Europe with regards to methods of medical intelligence and surveillance (MIS) are also reviewed. In this article, MIS systems are suggested to be integrated into Nigerian health care system to serve the needs the health care system of the modern era.

Materials and Methods

Search strategy

Search for literatures for this review was conducted throughout the period of the study to track new developments and published reports and articles. The search period was from June 2010 to January 2011. This study adopted a qualitative approach, so as to adequately describe the study aims and objectives. The study was based on both primary and secondary data. The primary data for this study were collected through scientific database sources and web engine searches. Secondary data were based on direct observation and relevant documents from the Nigerian Ministry of Health.

Sources of literatures

Scientific databases: the following databases were included in the search process—PubMed and African Journals Online.

Internet searches were based on Google and Search Nigeria (http://www.searchnigeria.net).

Search design

Searches in peer-reviewed databases, Google, and Search Nigeria were conducted in the following phases [Table 1]. Once a preliminary list of articles was determined, the databases and Google were researched for additional articles/reports once a month to constantly track new reports and articles. Using an analytical and ancestry approach, the articles chosen were scanned for further relevant articles. The following techniques[25] were applied to further retrieve relevant articles for the review process.

Table 1

Number of literatures/web page documents in various searches

Backward references search: The references of high-quality articles were searched to retrieve important information about the state of the Nigerian health care system.

Forward references search: Reviewing additional articles that have cited the article/report to locate follow-up studies or newer developments related to the state of the Nigerian health care system.

The backward and forward searches were terminated when no new idea was found. The reference list represents part of the literatures retrieved during the data collection process.

Keyword search parameters

This study was limited to keyword searches that resulted in the most relevant results. A keyword combination search was used since in this way the study aims and objectives are better attained. The following keyword combinations were used in all cases of the literature searches. The keyword searches were performed in three phases:

First phase keyword search

Nigerian health care, Nigerian health care system, and Nigerian primary health care system.

Second phase keyword search

Additional keywords used in the search were United States (OR Europe) health care dynamics. This additional search was performed to ensure an up-to-date review and recommendations for the Nigerian health care system and was not meant to review health care in the United States, Britain, or Europe with regards to methods of medical intelligence/surveillance. Some of the literatures retrieved in this search phase are listed in the reference list.[8-1026-38]

Third phase keyword search

This third phase literature search was necessarily based on the retrieved results of the second phase backward reference searches. The third phase keywords combination included the following: Medical Intelligence, Medical Intelligence systems, Public health surveillance systems, Nigerian medical intelligence, Nigerian surveillance systems, and Nigerian health information system.

Backward and forward reference searches were carried out in all phases of the keyword search.

Literature selection process

Inclusion criteria

Original communications, review articles, reports, and web page documents that report on the aim of this study were included for the review process. The articles were selected based on their relevance to the topic of this study. The results of searches were filtered according to their relevance to the aim of this search. The tittles that were logged in the various databases searched were analyzed against the keyword terms. Reports not wholly focused on the topic of this study were not included for review. All the retrieved publications were reviewed with emphasis on the state/dynamics of the Nigerian health care system, role of medical intelligence/surveillance systems in the health care system.

This study included literatures that meant the following criteria:

Literatures that meant the parameters of the keyword search.

Studies that discuss the history and state/dynamics of the Nigerian health care system; flaws of the Nigerian health care; managerial/information technological aspect of the Nigerian health care system; and medical intelligence/surveillance system in the Nigerian as well as other countries’ health care system.

Data analysis and synthesis

Data were extracted and recorded in Excel and Word 2007. The statistical value for significance was set at P < 0.05. Studies were analyzed based on its relevance to the Nigeria health care system.

Results and Discussion

The provision of health care in Nigeria remains the functions of the three tiers of government: the federal, state, and local government.[39-41] The primary health care system is managed by the 774 local government areas (LGAs), with support from their respective state ministries of health as well as private medical practitioners.[40] The primary health care has its sublevel at the village, district, and LGA. The secondary health care system is managed by the ministry of health at the state level. Patients at this level are often referred from the primary health care. This is the first level of specialty services and is available at different divisions of the state. The state primary health care comprises laboratory and diagnostic services, rehabilitation, etc. The tertiary primary health care is provided by teaching hospitals and specialist hospitals. At this level, the federal government also works with voluntary and nongovernmental organizations, as well as private practitioners.[3942-44]

Health care reforms launched in Nigeria

Ten-year developmental plan

Before independence in 1960, a 10-year developmental plan (1946–1956) was introduced to enhance health care delivery. Several health schools and institutions (Ministry of Health, several clinics and health centers) were developed according to this plan. By the 1980s, there had been great development in health care—general hospitals and several other health centers (over 10,000) had been introduced.[4243]

The primary health care plan

August 1987, the federal government launched its primary health care plan with the following major objectives:[124243]

Improve collection and monitoring of health data

Improve personnel development in the health care

Ensure the provision essential drug availability

Improve on immunization programs

Promote treatment of epidemic diseases

Improve food supply and nutrition

Improve material and child care, and family planning

Educate people on prevailing health problems and the methods of preventing and controlling them.

This health care plan made little impact on the health sector, as it continued to suffer major infrastructural, and personnel deficit, in addition to poor public health management.

Nigerian health insurance scheme

As an effort by the federal government to revitalize the worsening state of health, the Nigerian health insurance scheme (NHIS) that was established in 2005 by Decree 35 of 1999 provided for the establishment of a governing council with the responsibility of managing the scheme.[41] However, Ladi Awosika noted that the scheme was first proposed in 1962 under a bill to parliament by the then Minister for Health.[43]

The objectives of the scheme were to[4145]

Ensure that every Nigerian has access to good health care services

Protect Nigerians from the financial burden of medical bills

Limit the rise in the cost of health care services

Ensure efficiency in health care services

Ensure equitable distribution of health care costs among different income groups; equitable patronage of all levels of health care

Maintain high standard of health care delivery services within the scheme

Improve and harness private sector participation in the provision of health care services

Ensure adequate distribution of health facilities within the Federation

Ensure the availability of funds to the health sector for improved services.

The objectives and functions of the NHIS[4445] according to this present review have hardly attained any height as health care delivery continues to be limited; not equitable and does not meet the needs of the majority of the Nigerian people. This is indicative of the high infant mortality rate/poor maternal care, very low life expectancy as at 2010, and periodical outbreak of the same disease, as well as the long period of time spent for control of the various outbreaks [Tables 2 and 3].

Table 2

Some health indicators for Nigeria[12]

Table 3

Disease outbreak and chemical disaster in Nigeria between 2006 and 2010[48]

The appendage program of the NHIS launched in October 2008—Millennium Development Goals—also reported little positive effect a year later. The Nigerian National Health Conference in 2006 which was attended by more than 400 participants, including high cadre dignitaries ranging from the presidency to local governments and their agencies were aimed at ensuring effective, qualitative, affordable, and accessible health care for all Nigerians beyond 2007.[3-6] According to the 2005 January issue of CARE-NET limited health insurance report concerning the NHIS, the Nigerian national health policy objective was the attainment of a level of health that will enable all Nigerians to achieve socially and economically productive lives.[46] Since its lunching primary health care has not gained its right place in the priority of things.[3-646] As part of the struggle to advance health care, the Nigerian senate in 2008 launched a bill for an act to provide a framework for the regulation, development, and management of a national health system and set standards for rendering health services in the federation and other matters connected with it.[45]

In spite of the several failures of the Nigerian health care system, recent study had suggested that if managed well, the NHIS could be a useful ground for good health care delivery.[47] At its present state, it is true that the scheme does not adequately account for the needs of the Nigerian people.

Indicators of health care in Nigeria

In spite of the huge development in the health care in relation to the last decades,[1242-44] much is still needed to be done in the health care system.[3940] This is evident in the various health indicators outlined in Table 2 and mortality from several outbreaks of diseases in Table 3.[48]

Although the total expenditure in health amounts to 4.6% GDP,[12] financial managerial competency, besides inadequate funding, remains a major problem. Current statistics show that health institutions rendering health care in Nigeria are 33,303 general hospitals, 20,278 primary health centers and posts, and 59 teaching hospital and federal medical centers.[40] This represents a huge improvement in regards to the last decades; nonetheless, health care institution continues to suffer shortage.

The backward and forward reference searches on second phase keywords search revealed increasing role of health information, communication as integral to leadership,[8-1118-2026-38] as well as increasing role of medical intelligence/surveillance in the health care system in the United States and Europe.[124950-83]

Health care dynamics in the United States and Europe with regards to methods of medical intelligence/surveillance

Literature data report on the huge developments of MIS systems in Europe and most especially in the United States in the last few decades. For instance, the MedISys is adapted and used by 11 national public health of Europe and 4 supranatural organizations, including World Health Organization and Euro-Surveillance. MedISys provides opportunity to monitor issues of health concerns to registered countries and organizations.[49727582] MIS has often been used in both military health care departments[70] and public health sector.[73] MIS systems have been used to combat and effectively monitor the outbreak of communicable diseases, bioattack. etc.[6173] Indeed, MIS systems were crucial to controlling SARS in 2003 and eradication of small pox in the 1970s.[61] Some MIS systems used today are listed in Table 3. Other monitoring systems in the health care setting are the Global Monitor and HealthMap.[497283]

Based on the analysis[718-20728250-85] of this study, MIS systems could be divided into three broad categories:

Manual-based medical MIS systems. A huge disadvantage of method of MIS: difficult to manage, poor access, data are not easily presentable, data processing is time–consuming, and large space storage space needed.

Automated-based medical MIS systems. Although this method of data processing has its peculiar shortcomings, the advantages exceed its disadvantages: data collection, aggregation, storing and analysis, sharing, and transmission is by hundreds of times faster and easier.

Integrated manual-web based MIS systems (use both manual data search and web-mining).

MIS match searched results against taxonomy of named entities, e.g., names of infectious diseases, countries, or cities. Using specialized principle (e.g., ontology principle), terms/words are organized into synonyms, symptoms, associated syndromes and hosts, etc.[497276-82] A combination of at least two MIS systems has always provided for a higher tracking precision. For example, analysis of documents by PULS, previously identified by MedISys, improves precision by almost 100%, although economically expensive.[72] However, a major disadvantage of the MedISys and PULS is their inability to perform deeper analysis of critical issues of public health concerns which is a major disadvantage.[72] Hence, integrated manual web-based medical intelligence/surveillance with professional analysis in the field provides a greater advantage over other methods of MIS (an example of such a model in shown in Figure 1).

Figure 1

A model of medical intelligence/surveillance

One of the most advanced MIS systems used today is the BioWatch which is presently installed in 30 US cities to constantly monitor biothreats.[67] The biowatch system consists of airfilter that collects air sample for genetic analysis of any bioweapon of specific interest. Targeted nucleic acid sequence associated with a pathogenetic agent is screened for in specialized laboratory. A positive result meant that the pathogenetic agent of specific interest is present in the air.[67-73] It is, however, pertinent to note that the present second-generation biowatch system carry a huge disadvantage as air filtered are not automatically analyzed by the system. Manual collection of filtered air sample for laboratory test has to be carried out before obtaining results. The next-generation BioWatch is presently been developed to solve this problem.[67] Several other MIS systems[73] work by syndromic approach and by analyzing signs and symptoms of diseases based on respiratory, gastrointestinal, hemorrhagic illness, etc. [Table 4].

Table 4

Medical intelligence/surveillance systems and their country of usage[73]

A major disadvantage that could be noted in all MIS systems is the detection of already present disaster (although the early detection allows for a faster action/control of the disaster). At this point, there could have been several fatal cases.[6772737983] To avoid this, the present-day MIS systems integrate their functions with the evaluation of risk. That means public health disaster can be tracked even before it affects a wide population of people. One example of MIS risk system is the Brief Spousal Assault Form for the Evaluation of Risk.[73]

Major flaws in the Nigerian health care system

In spite of the various reforms to increase the provision of health to the Nigerian people, health access is only 43.3%.[5] The inadequacy of the health care delivery system in Nigeria could be attributed to the peculiar demographics of the Nigerian populace. About 55% of the population lives in the rural areas and only ~45% live in the urban areas.[4049] About 70% of the health care is provided by private vendors and only 30% by the government.[4086-91] Over 70% of drugs dispensed are substandard. Hence, the ineffectiveness of the NIHS had recently been attributed to the fact that the scheme represents only 40% of the entire population, and 52-60% are employed in the informal sector.

Over half of the population live below the poverty line, on less than $1 a day and so cannot afford the high cost of health care.[49] Also, a recent study by Akande had reported a poor referral system between the various tiers of health care which probably tells on the poor managerial functions of the health care delivery system.[84]

At the primary health care level, some have sort solutions to the aforementioned flaws. For example, several community health financing schemes [Community Based Health Insurance (CBHI)] from individuals’ (taxi drivers, market women, etc.) effort to provide the health needs for their communities are documented.[584] Some urban subpopulations have also initiated the scheme. The number of CBHI probably exceeds 585 according to a recent report by Obinna Onwujekwe and colleagues (2010).[5] In that study, the authors reported high preferences for health care benefits both at the urban and rural areas [Table 5]. Problems encountered in the CBHI are its very small and inadequate funding capabilities. That notwithstanding, some CBHI have increased their scope to be registered as health maintenance organizations.[5] Also, quality of health care provided is not accessed, although this remains a problem for the NHIS too.

Table 5

Preferences for health care packages as reported by majority of people

While several studies have reported many aspects of the Nigerian health care system, no work has been done in the aspect of disease tracking, and MIS techniques to meet the need of the Nigerian populace in the modern era; practically, no attention is given to surveillance systems. Hence, a major shortcoming of the Nigerian health care system is the absence of adequate MIS systems to track disease outbreaks, mass chemical poisoning, etc.

The way forward for the Nigerian health care system/recommendations

Several flaws in the health care system could have been averted through adequate MIS, which is supposed to be the first line of approach to developing the Nigerian health care system. Of course, there is a long list of barriers which lie on the pattern of leadership, infrastructures, man power challenges, clinical training, standardized diagnostic instruments, etc.[7121-621-248691-95] The reforms and changes made to retain health security seem not to have made positive effect on the health care system.[134546] Considering the threats of health insecurity,[86] there is therefore immense need to revitalize the Nigerian health care system and provide specific project design to enhance cooperation and efficiency. To account for the modern day needs of Nigerians, the health care delivery system must adequately meet the following functions:

Effectively assess patients’ dilapidating state of health

Refer patients to specialists for appropriate treatments and supportive services

Recognize, treat, or refer comorbid medical and psychiatric conditions for specialists’ treatment

Perform age, gender, and culturally appropriate disease screening

Provide brief interventions to patients with dilapidating state of health

Chronic diseases management and prevention

Family planning to be cooperated effectively into the health care delivery system

Systematically and routinely measure the quality of services provided by the health system

Mortality data of specific project enrollees to measure the effectiveness of health care provided

Carry out health campaigns and awareness

Develop effective counseling methods

Comparative analysis with other countries’ experiences in addressing health changes

Calculate the economic gain or loss of health care provided

Economic distribution of services with adequate capitation rate

Verify delivery of health services

Provide performance based incentives on a regular basis

Strong knowledge base/research culture

The huge problems encountered by the Nigerian health care system[1-71221-2445468691-95] could partly be due to the absence of MIS system which holds the key to successful medical leadership, as well as health care delivery. Hence, there is necessity to setup a model of MIS systems for action to suit the interest of the Nigerian people. It is supposed that if adequately managed, MIS system model for the Nigerian health care will turn out to be the Cinderella of Nigerian health care system. A view of the model is shown in Figure 1.

The model not only specifically addresses the present problem but also put into consideration modern MIS techniques; it solves the problems encountered in several other models by adding a deeper professional analysis. Besides, it is multifunctional.

The model will perform the same functions as other MIS systems[6275] do text mining from a variety of sources and track bioterrorism (such as airport biothreat, etc.), diseases (contagious, sexually transmitted diseases. etc.), events etc. The central system will analyze current result of reports and internet data received against keyword entities and to undergo selective processing of results. By selective processing, the system sends information, where appropriate to local points, government organizations, and intelligence; perform professionalized and deeper analysis of critical information or search results of critical importance will be sent for a deeper professional analysis. The model for MIS will match searched/received results against taxonomy of named entities, names of infectious diseases, states, local governments or cities/towns, villages, health agencies, etc. Besides its basic functions, it will file-out reports, send requests, issue alerts, perform several system commands, and have several databases access. Also, it will track progression and capture ongoing events, and brief situation and dynamics of events to others by selective processing. The proposed model for MIS will be suited for the Nigerian interest. To optimized information, the system will be linked to other international monitoring systems to effectively manage and control outbreaks of communicable diseases and bioterrorism threats.

Conclusion

The Nigerian health care system is poorly developed and has suffered several backdrops, especially at the Local Government Levels. No adequate and functional surveillance systems are developed and hence no tracking system to monitor the outbreak of communicable diseases, bioterrorism, chemical poisoning, etc. To achieve success in health care in this modern era, a system well grounded in routine surveillance and medical intelligence as the backbone of the health sector is necessary, besides adequate management couple with strong leadership principles. The recommendations given in this study may as well be applicable to other countries (especially African countries, such as Niger) that suffer the same problem.