Oil-rich Nigeria still suffers from massive health inequities

Nigerian President Muhammadu Buhari meets with President Obama in the White House, July 2015, in Washington, D.C. The U.S. has refused to provide Nigeria with weapons to assist their battle with the terrorist organization Boko Haram due to allegations of abuse by the Nigerian military. (Credit: The Associated Press)

Nigeria is widely known for its oil wealth, widespread corruption and massive inequality, all of which are not unrelated.

Newly elected Nigerian President Muhamadu Buhari recently visited President Obama in the Oval Office to discuss how the two nations could cooperate more closely on counter-terrorism – specifically the threat of the extremist group Boko Haram in the north of the country where the population is predominantly Muslim and also poor.

In addition to addressing violence and corruption in his country, Buhari will be challenged by persistent health inequalities between Nigeria’s oil-rich south and the impoverished north according to a new study by the Institute for Health Metrics and Evaluation (IHME). You can explore the study results through the Nigeria Health Map visualization tool.

Buhari was born in Northern Nigeria, so many Northerners are hopeful that he will address the inequalities between the north and south that are among the root causes of the conflict between Boko Haram and the Nigerian government. Buhari is a former military dictator who shuns luxury and has a reputation for being incorruptible. In a nation where religious differences between the largely Muslim north and Christian south are exacerbated by inequalities in health outcomes and poverty, the challenges Buhari faces are daunting. In a New York Times op-ed, Buhari wrote: “Boko Haram feeds off despair. It feeds off a lack of hope that things can improve.”

The good news for Buhari and his country is that under-5 mortality decreased 30% nationwide between 2000 and 2013 according to the IHME study. Across the country, all states made progress in reducing under-5 deaths (see screen grabs below). At the same time, inequalities between states remained stark: in 2013, under-5 mortality in the state with the highest rate (Zamfara: 209 deaths per 1,000 live births) was nearly three times higher than in the state with the lowest under-5 mortality rate (Edo: 72 deaths per 1,000 live births).

The study shows Zamfara state has had the highest rates of under-5 mortality in Nigeria since at least 2000. In its Strategic Health Development Plan, the Zamfara State Ministry of Health noted “significant challenges of human resource, limited health funding, poor health infrastructure and equipment, and poor utilization of services.” Also, the state was thrust into the media spotlight in 2010 due to a lead poisoning epidemic that was brought to the world’s attention by Médecins Sans Frontières (MSF). MSF estimated the epidemic caused the deaths of 400 children.

Under-5 mortality in Nigeria, 2000

u-5 mortality 2000Source: “Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013,” published in BMC Medicine; this chart comes from the Nigeria Health Map: http://ihmeuw.org/3m1b

Under-5 mortality in Nigeria, 2013

u-5 mortality 2013Source: “Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013,” published in BMC Medicine; this chart comes from the Nigeria Health Map: http://ihmeuw.org/3m2j.

The study found that certain areas in the north of the country have child mortality that is similar to countries with the highest child mortality in the world. In 2013, seven northern states had levels of under-5 mortality comparable to Guinea Bissau, Mali and Chad. Child mortality in these seven states was greater than 150 deaths per 1,000 live births. In contrast, under-5 mortality in the top-performing states (Edo, Lagos and Oyo), which was around 70 deaths per 1,000 live births, was similar to levels seen in Ghana (71 per 1,000 live births), Mauritania (69 per 1,000 live births) and Zimbabwe (69 per 1,000 live births). However, the lowest levels of under-5 mortality in Nigeria are still twice as high as some of the top-performing states on the continent, Botswana (31 deaths per 1,000 live births) and Namibia (35 deaths per 1,000 live births).

Encouragingly, the gap between the states with the highest and lowest under-5 mortality has narrowed over time from a difference of 206 deaths per 100,000 live births in 2000 to 137 deaths in 2013.

Similar to trends for under-5 mortality, southern states tend to have higher levels of childhood vaccination against measles and diphtheria, pertussis and tetanus (DPT3) than northern states. For example, measles vaccination coverage in the country ranged from 7 percent in the northern state of Sokoto to 92 percent in the southern state of Ekiti (see screen grab). Similarly, vaccination rates for DPT3 ranged from 3 percent in Sokoto to 88 percent in Ekiti.

Measles vaccination coverage rates, 2013

measles 2013 Note: coverage rates calculated based on vaccination coverage among children 12-59 months of age. Source: “Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013,” published in BMC Medicine; this chart comes from the Nigeria Health Map: http://ihmeuw.org/3m1c

One major success story is childhood polio vaccination in Nigeria. For polio vaccination, there is much less disparity in coverage between states, ranging from 40 percent in Borno State to 73 percent in Federal Capital Territory (see screen grab). These successes are largely thanks to donors’ commitment to the eradication of polio coupled with close coordination between national and international health workers.

Polio vaccination coverage rates, 2013

polio 2013Note: Oral polio vaccine coverage rates are shown in this graph; coverage rates calculated based on vaccination coverage among children 12 to 59 months of age.

Source: “Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013,” published in BMC Medicine; this chart comes from the Nigeria Health Map: http://ihmeuw.org/3m1f.

Coverage of maternal and newborn health interventions in Nigeria, such as antenatal care – having a skilled attendant present when giving birth and giving birth in facilities – was much lower in northern states. Similarly, a greater proportion of children suffer from malnutrition in northern states. The disparities in childhood underweight between states in the north and south were large, ranging from 7 percent in Enugu State in the south to 47 percent in Kebbi State in the north.

In addition to the persistent disparities in child health between the north and the south, another challenge President Buhari faces is childhood underweight in the north of the country appears to be worsening (see screen grab). However, with the exception of Gombe State, where underweight rose from 22 percent in 2000 to 33 percent in 2013, the increases for most states were not statistically significant.

Percentage of children under 5 who are underweight in Nigeria, 2000

u-5 underweight 2000Source: “Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013,” published in BMC Medicine; this chart comes from the Nigeria Health Map: http://ihmeuw.org/3m1g.

Percentage of children under 5 who are underweight in Nigeria, 2013

u-5 underweight 2013

Source: “Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013,” published in BMC Medicine; this chart comes from the Nigeria Health Map: http://ihmeuw.org/3m1h.

Even as the fight against Boko Haram is at the forefront of President Buhari’s mind, he cannot afford to neglect the plight of the nation’s most vulnerable and voiceless population – its children.

Acknowledgements: Nancy Fullman, a co-author on the Nigeria benchmarking paper and an IHME Policy Translation Specialist, provided data and graphics for this post.

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About Author

Katie Leach-Kemon

Katherine (Katie) Leach-Kemon is a policy translation specialist at the Institute for Health Metrics and Evaluation (IHME). Katie specializes in two of IHME's research areas, the Global Burden of Disease and health financing. Katie has helped produce IHME's Financing Global Health report since it was first published in 2009. She received an MPH from the University of Washington and served as a Peace Corps volunteer in Niger. Her work has been published in The Lancet, Health Affairs, and the Journal of the American Medical Association. You can follow her on Twitter @kleachkemon.