Hauwa Lassa worked 35 years as a nurse and midwife. Her retirement package is a camp for displaced people on the outskirts of Maiduguri.
In the three states worst hit by the Boko Haram violence in its eight year, health facilities have been damaged and health workers have fled.
Estimates suggest nearly 40% of health facilities have been destroyed in the violence, and skilled health workers have had to leave the area entirely.
The result is tents put up for health care, buildings undergoing reconstruction—and an alarming shortage of skilled workforce.
“I have been working in the field of maternal health in this country for more than 35 years,” Lassa say.
“It is now with this crisis going on that the women need support. So I decided to come back to the health centre and help.”
Some 190km away in Biu, Mdapilawa Yatzubu, works in a health centre with a specific challenge: she and her colleagues must take on average 150 deliveries a month.
She is familiar with complications to expect. Some women bleed a lot, others show signs of hypertension. Some get seizures during or after giving birth, a condition called eclampsia; others pick up a range of infections, called sepsis.
“If the women have complications that we cannot manage, we refer them to the general hospital,” says Yatzubu.
Yatzubu and Lassa are a few hundreds of health workers across the north that women may see in their lifetime. They are becoming the bedrock of saving the lives of women and girls affected by conflict in the region.
Millions may never see a gynaecologist in their lifetime.
For every 100,000 Nigerians, there are 100 nurses, or 68 midwives or 19 community health extension workers, says NPHCDA
Maternity unit at Comprehensive Primary Health Centre, Liman-Katagum, Bauchi. The entire centre, commanding status of a general hospital, is run by an in-charge, community health extension workers and two midwives who work under the Midwives Service Scheme
2, 20, 200, 2000
The word “states of emergency” now describes the three states that have borne the brunt of Boko Haram violence—Borno, Adamawa and Yobe.
Yobe is the sixth largest state by area—and has only two experts in obstetrics and gynaecology.
The dearth of skill in the northeast is the maldistribution of workforce in the rest of the country.
The Society of Gynaecology and Obstetrics of Nigeria (SOGON) boasts 1,054 members. At least 46% of them work in Lagos and Ibadan alone, according to Brian-D Adinma, a former president of the society.
Kano is physically removed from the north east conflict but nine out of every 10 OBGYNs there work in the Bayero University Teaching Hospital or in private practice.
The lone teaching hospital in Sokoto is attached to Usmanu Danfodiyo University and has a share of OBGYNs since it opened in 1989. It has more than 100 consultants, 400 resident doctors and 750 nurses, at last count, according to its administrators.
In 2015, SOGON spoke of plans for its members to volunteer at primary health centres even while working in inner-city tertiary hospitals—in efforts to bridge the gap in access to skilled health workers.
But there still are less than two doctors for every 1,000 population, estimates suggest.
That’s around 30 doctors for every 100,000 Nigerians, according to the National Primary Health Care Development Agency, which coordinates primary health services across over 30,000 centres.
For every 100,000 Nigerians, there are 100 nurses, or 68 midwives or 19 community health extension workers, said Nneka Onwu, director of community health services at NPHCDA.
The shortage of heath workforce ranks Nigeria seventh among countries of health worker crisis. Across Africa, the shortage is 7.2 million, and is predicted to rise to 12.9 million by 2035.
Critics point to differing conditions of service from primary to secondary and tertiary health care—and between state and federal civil service.
“Politicians don’t understand that buildings don’t make services or hospitals,” says Emmanuel Otolorin, country director of Jhipego, on a panel at SOGON’s 51st scientific conference in Sokoto.
“Salary difference is so huge, people are gravitating toward federal,” continues.
“In teaching hospitals, you can disengage 50% [of staff] and not feel the difference. Some people go around doing nothing. They spend time in their private clinic and are first to go on strike when salaries aren’t paid.”
Trainee nurses and CHEWs on rotation at a health centre in Okelele, Ilorin
The wages is death
Dr Oladipo Ladipo presides over the Association for Reproductive and Family Health. He first saw a woman die from childbirth complications while working as a senior registrar at University College Hospital, Ibadan. That was nearly four decades ago.
“And I have since seen many more,” he says.
Every 10 minutes, one woman dies from pregnancy-related complication, according to the United Nations Population Fund.
Equivalently, for every 100,000 babies born alive, 576 mothers die. It is a maternal mortality ratio Nigeria hopes to reduce to 70 in the next three years.
Advocates have crafted simple messages about the country’s maternal deaths and put a face to it: Fatima—any young girl or women whose life is in danger from carrying a pregnancy or giving birth.
“Naturally, there are many more Fatimas, and it seems our women are disposable,” says Ladipo.
“They should not be [disposable], for giving life.”
A range of services are considered available for women and children under a comprehensive maternal, newborn and child health care services (MNCH).
But a burden of out-of-pocket spending on health and a lack of insurance cover to cushion spending makes the services inaccessible and unaffordable.
Last year, Nigeria’s per capita spending was estimated at $1,688—much of it borne by patients and their families.
By contrast, per capita health spending in the UK and US topped $6,000 to $7,000.
Nigeria’s National Health Act has taken 10 years to struggle through the legislature before becoming law in 2014. Moves to implement the law have not shown up in three budget cycles since then.
“Now we are advocating for it to be reflecting in 2018 [budget],” says Otolorin. “Nearly four years after it was passed, it is not happening and we are all sitting, looking.”
The act stipulates some national funding and basic health package. But proponents want the barrier of out-of-pocket health spending lifted to encourage more women to seek health care.
The absence of proper primary care is one reason secondary and tertiary care are burdened by complications of chilbirth and pregnancy, including obstetric fistula, morbidities related to stilbirth, maternal and infant mortalities
N100 for services
“MNCH [maternal, newborn and child health] services must be free of charge,” says Salma Anas-Kolo, former Borno health commissioner and now team leader for the second phase of MNCH2—a project to improve life quality and strengthen health systems in Zamfara, Katsina, Kano, Kaduna, Jigawa and Yobe.
“Ninety percent of the recipients in the north cannot pay N100 for services. Government must take responsibility to ensure continuous funding for MNCH services even after funding donors have left.”
Nearly one in two persons displaced by the conflict in the north east is a woman.
UNFPA estimates that 1.7 million women are of reproductive age. That means around 276,000 pregnancies this year would require lifesaving reproductive health services, including health personnel to perform emergency obstetric care and treat survivors of sexual violence.
“In teaching hospitals, you can disengage 50% [of staff] and not feel the difference. Some people go around doing nothing. They spend time in their private clinic and are first to go on strike when salaries aren’t paid.”
“Well trained doctors, nurses and midwives like Hauwa Lassa are the bedrock of our mandate to save lives”, says Ada Pouye, humanitarian coordinator for UNFPA in Nigeria.
Lassa is among 300 health providers to undergo a training in providing a minimum service package for reproductive health, run by UNFPA.
“I did not like to give family planning to single ladies before but now after the training I know that I can give it to everyone who needs it,” she says on her return to the health centre in the camp for displaced people.
“It’s to protect people from sexual transmitted infections like HIV and I learned it’s important to give it to everyone who wants to delay pregnancy. I will inform people about female and male condoms because giving choices is important.”
The health centre where Yatzubu works has been spared damage in the Boko Haram violence. She and her colleagues provide antenatal care for pregnant women, give family planning advice, help deliver 150 babies a month and immunise children.
“We have a special way of making women come back for the second immunization shot of their baby after 40 days,” says Yatzubu.
“We give them a small gift, mostly soap. They all come back to collect the soap and have their health checked and the baby immunized with the second dose. This is how we follow up on them.”
And in one woman’s world, Yatzubu could be last—and only—resort.
