Leveraging the Latent Dedication of Health Care Workers in Nigeria
January 23, 2017
In 2005, the Nigerian Ministry of Health grew increasingly skeptical of the WHO estimated tuberculosis (TB) prevalence for the country. Despite the implementation of DOTS (Directly Observed Treatment Short Course) in 2003 to control TB, the estimated burden continued to rise, and the country consistently ranked among the top four or five most endemic TB nations in the world. Up until that point, strategies to increase case detection had been largely unimpressive, with the National TB Control Program focusing on passive identification of patients presenting at health facilities, as opposed to more active case finding strategies. The decision was then made that a more reliable estimate was needed to capture the true burden of TB in the country.
In 2012, a new prevalence study showed the burden of TB in Nigeria to be nearly three times greater than previously realized. As a result, there arose a need for innovative strategies to increase case detection, as many with TB remain reluctant to enter the health system.
In October, I traveled with CSIS to Osogbo, in the southwest of Nigeria, to examine efforts to control tuberculosis. Osogbo is the capital of Osun state, one of 14 states selected by the United States Agency for International Development (USAID) to pilot new outreach strategies through the Challenge TB program, implemented by the non-governmental organization KNCV Tuberculosis Foundation.
We first met with enthusiastic representatives from the state TB control program and KNCV, who gave us an overview of the state’s TB activities. Despite little financial support from the State government and a limited workforce, case detection has increased under the Challenge TB program. Between the first half of 2015 and the first half of 2016, the number of TB cases detected rose from 548 to 671, showing modest improvement.
Later that day we visited the Oke-Baale Chest Clinic, a primary health center in the heart of Osogbo, to learn how progress had been achieved. The Director of the Oke-Baale Chest Clinic is Ms. Bosede Oladosu, a keenly observant woman with a motherly countenance. The clinic she runs is a decaying stucco edifice with all of the accoutrements of a Nigerian health facility: posters highlighting TB symptoms in local languages; power converters, essential given the unreliable electricity; and boxes of essential medicines, scattered haphazardly across the clinic.
At length, Ms. Oladosu related the most impactful interventions taking place in her clinic. She moved to her desk and grabbed a large, worn registry that held the names of all presumptive TB patients within the past three years. As her fingers traced through pages of patient names, she described how community outreach efforts had been indispensable in teaching the community how to recognize the telltale symptoms of TB. She recounted how the clinic staff march into the streets of Oke-Baale with dancers and drummers and act out the disease’s varied symptoms, resulting in twice as many patients coming to her clinic to get tested. Once a patient is diagnosed, she assists the patient in identifying family and friends who can support the patient through treatment for several months.
Currently, most Nigerians have little faith in the government. Electricity is still not readily available, food is in scarce supply, and oil earnings –the backbone of the economy – are at their lowest levels in years. All of these factors fuel nationwide pessimism. Given her prominence in the Oke-Baale community and personal ties to her patients, Mrs. Oladosu exhibits the fidelity to community most Nigerians still possess. When necessary, she purchases the generator fuel out of her own pocket, so that the Gene Xpert diagnostic remains operational, and more TB cases can be detected.
The devotion displayed by Ms. Oladosu contrasts with the larger picture of severe strains between public health providers and the fiscally strapped federal and state governments. In the past year, health care workers in nine states in Nigeria, including Osun, have gone on extended strikes, refusing even to admit patients. Health systems across the country have shut down entirely for about three months on average, in large part due to the state government’s inability to pay remunerations. During that time, the Oke-Baale Chest Clinic has remained open – even when Ms. Oladosu and her staff are not paid their salaries.
In a time of rampant pessimism, this devotion to community demonstrates one of Nigeria’s strengths that, if channeled appropriately, could be leveraged. How can this dedication be harnessed in a way that motivates government to match the commitment of local health workers?
One possible avenue is through unified advocacy efforts. Last October, the National Medical Association organized a rally for implementation of the 2014 National Health Act in all 36 states throughout the country. The Act, which provides that a minimum of 1% of total federal revenue be allocated to a fund for basic healthcare, was signed by former President Goodluck Jonathan in 2014 but has yet to be implemented. These clinicians and civil society advocates have been determined to do their job of advancing the health of all Nigerians but have felt that, to date, their government has failed to invest adequately in health. As a result, these health workers have unified their voices in hopes that the federal government will meet their demands. The ONE Campaign similarly organized a rally in Lagos, Nigeria, on International Youth Day, calling for “greater government investments in the health sector”.
As Nigeria looks to find a more effective approach to controlling TB, the role of individual responsibility and the power of collective action become increasingly relevant. Unified advocacy efforts could prove effectual in ramping up additional financial support from the federal and state governments in the fight against TB in Nigeria. If government can match the commitment exhibited by health workers at the grassroots level with the appropriate financing and resources, then Nigeria can finally begin to get a handle on TB.