Rural women hit hardest by Nigeria’s worsening healthcare crisis

This report was produced in partnership with the Pulitzer Center.

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When medical personnel in Africa’s most populous country flee overseas, there is a big problem. Who caters to Nigeria’s over 200 million population when less than half of registered doctors practise in the country and the larger percentage have migrated to greener pastures? Worse still, there is less investment in healthcare infrastructure. Who bears the brunt of the exodus more?

In rural areas where most residents travel miles to access quality healthcare services, it has been one tragedy after another. For women and children, who seem to be more vulnerable, life has become a misery.

In Shakwata, a village in Bosso LGA of Niger state, the primary healthcare centre constructed in 2015 is managed by two community health extension workers. There’s no doctor or nurse. The facility has three beds; hence, only three patients can be admitted at once. Despite the dire state of the centre, women from Kachalla, Yawo, Buluko, Tachki, Dunkoshi, Tayegi, and many nearby villages visit Shakwata for antenatal care and immunisation.

The women complained of the scarcity of medicine in the facility. Basic services such as family planning and laboratory tests are also unavailable. So, they travel for 30 minutes through rough, untarred roads to Maitumbi, a town on the outskirts of Minna, the state capital, to visit the hospital and buy drugs. In the event of an emergency, pregnant women are attended to at home by traditional birth attendants. When the labour is prolonged and there is a complication, the woman is covered up and placed on a motorcycle or tricycle on a 15-kilometre tortuous journey to Maitumbi.

Mallam Shehu Yusuf, the Mai Unguwa (ward head) of Shakwata, sat under a huge mango tree in the compound, flanked by women in the extended family. Some were elderly women, some young and pregnant, while others looked recently married.

“The only thing we do there is provide immunisation services for children. The women usually help themselves deliver babies, especially when labour comes at night,” Yusuf said.

Hajara Abdullahi, 25, lives in Shakwata with her husband, a farmer. She is pregnant with her first baby.

“Gaskiya, I don’t go to the hospital every time. I started going when I got pregnant and had to enrol in antenatal care. Most of the women in the village rarely go to the hospital,” Abdullahi said.

“We usually have to go all the way to Maitumbi during emergencies at night because the health workers close from work at about 2 pm every day. They don’t give us any medical advice at the hospital or what kind of foods to eat as pregnant women. They only touch our stomachs and prescribe drugs that they don’t have. The crowd is always massive.”

SCARCE AND EXPENSIVE DRUGS: RURAL WOMEN RESORT TO HERBAL MEDICINE

Even in the city, drugs have become more expensive. As medical professionals exit the country in droves, major pharmaceutical multinationals are also taking their leave. With the rising cost of living and the volatility of the foreign exchange market, on which drug importation relies, the prices of medicines have increased. Rural dwellers have to grapple with waning affordability and accessibility.

Aisha Isah, 54, wife of Shakwata’s village head, is a traditional birth attendant and a mother of seven children.

She said the women in Yusuf’s household usually resort to alternative medicine; herbs are prepared for illnesses like typhoid or malaria, but they visit the hospital for serious illnesses. She said she is more worried about the non-availability of drugs and health workers at night.

Isah said they boil mango, banana, guava, moringa, pawpaw, and neem leaves to treat malaria, typhoid, constipation, and diarrhoea. There are also herbs for birth control.

“There were about five of them but they all left. Now, only two workers are here, and they don’t stay in the village. Sometimes, I take child delivery for women who cannot afford to go to the hospital or at night when there are no health workers at the facility. We don’t give the women in labour drugs or any traditional medicine to ease delivery. We just pray to God and hope that we don’t experience any complications. But when the situation gets complicated, we usually find a tricycle to take the woman to a hospital in town,” she said.

The primary health centre in SHE village, Shiroro LGA in Niger state, is also manned by health extension workers. Hadiza Shehu, a birth attendant at the centre, said women in the village rarely visit the facility since they do not get the services they need.

There is no equipment in the facility, except for the test tools for HIV. There is no water or electricity supply, and the toilet is in bad shape. Sometimes, patients sleep on the floor because there are just three beds at the centre.

Like the health centre in Shakwata, the one at SHE village also welcomes women from villages like Apomi, Tulu, Bagadnapka, Gidan Galadima, Akaita, Rugan and some Fulani settlements nearby.

“Honestly, we have a shortage of staff and drugs. A lot of them have come here and left. The only drug the LGA authorities usually give us is artemisinin-based combination therapy (ACT), but it is no longer coming,” Shehu said.

“We have stopped family planning services because we don’t have supplies of the items we need. We have told the women that we cannot deliver the service to them anymore. We don’t have anything here, but some of them keep coming. We go to Gunu village (3 km away from SHE village) to get vaccines for children. For child delivery, we usually use torch lights at night because the facility doesn’t have electricity.”

After Aisha Alheri, 26, had her fourth child, she wanted to do family planning. According to her, she was tired of childbearing and needed to rest. She went to the SHE village health centre almost every day for two months but they kept telling her that the injections had not arrived.

“When I am down with some illness, I use traditional medicines, I usually add some herbs together. My children also take the herbs. But when the illness is very serious, I usually buy drugs so that they can work hand in hand with the herbs. Even when I am pregnant, I usually take herbs because they are good for the baby and make them strong,” Alheri claimed.

“I take my children for immunisation but they didn’t finish all the vaccine dosage because sometimes when you go to the health facility, they usually say the vaccines have not arrived. There was a time when I was very sick. So, I went to the health centre here, and I was asked to bring N3,000 (less than $3) for drips, injections, and other things. I didn’t have the money; so, I went back home and started taking herbs until I got better.

“Yes, I experienced some complications when I was about to give birth. I was told the baby was breech. I was taken to the General Hospital in Minna and I gave birth safely.”

At Babangida She village in Shiroro LGA, when the situation became dire and help came from nowhere, the women started contributing money to make the health centre work, but now they are tired. Abarah Saleh, Mai Unguwa of the village, said it is stressful to make sure their families don’t go hungry and still be worried about them falling sick because of the poor state of the facility.

Zainab, Saleh’s wife, said the women are often scared of emergency health crises. The 54-year-old mother of seven said they prefer to stay at home to give birth.

But the situation is not peculiar to Niger state alone.

IN OYO, MISSION HOUSES OFFER MORE THAN SALVATION

In Iseyin, a community in Oyo state, the primary alternative is mission houses — maternity homes run by religious centres.

To some of these women, it is the “God-factor” first. These mission houses employ nurses and midwives who attend to the needs of their patients and help with child delivery. Alice Fulakaye is one of the midwives at the Christ Apostolic Church (CAC) Maternity Centre, Oluwole, Iseyin. She has spent thirteen years on the job, which she describes as “divine calling”.

During labour, dedicated prayer warriors go into prayer mode to smoothen things in the spiritual realm, which they believe will aid seamless delivery in the physical realm. Most importantly, their services are cheaper than those of hospitals.

“We prefer this place because we pray. In government hospitals, there’s nothing like that. Here, we pray as childbirth is going on,” Kehinde Deborah told this reporter at the CAC Maternity Centre.

Other times, it is more than the prayer that makes the mission houses attractive. At government hospitals, the waiting time is usually long because there are just a few medical personnel attending to many women, some of whom are heavily pregnant. When a doctor or nurse eventually attends to you, it is brief, and they quickly move on to the next person.

Damilola Adejoro said the midwives at mission houses offer empathy and check in with them from time to time, as opposed to government hospitals. So, she prefers to have her baby where she gets better attention.

“The midwives will look after you; but over there, the nurses won’t. They usually have their hands full with patients and tend to neglect you. Even when you are in labour, they will tell you to wait and that it isn’t your time yet, till you are on the verge of giving birth on your own. The midwives here would attend to you, try to check your vitals and stay with you,” Adejoro said.

If not for the slight complications Abibat Usman from Ipapo village is having with her current pregnancy, she would not have seen the need for a hospital. She had all other nine children either at home or at the farm. According to Usman, who spoke through an interpreter, she didn’t know the hospital was a better choice as most women in the village give birth at home.

POVERTY WORSENING MATERNAL HEALTHCARE IN KANO

Most of the women who spoke with this reporter in rural communities in Kano state said they also prefer to give birth at home. They go to the hospital for scans, antenatal care, and child immunisation, but deliver their babies at home. They only return to the hospital when there are complications. Maryam Lawan, a 38-year-old mother of eight, had all her children at home, as did Sa’Iha Ibrahim, a 25-year-old mother of two.

A senior worker at Doka Model Primary Healthcare, Tofa LGA, who didn’t want to be named, said some mothers-in-law also stop many women from delivering their children at the hospital, claiming that strong women give birth at home. In some cases, their husbands stop them.

On the surface, it has a cultural connotation. But it goes beyond that. Many of them cannot afford the money for hospital services, especially the cost of drugs and laboratory tests. They also complained that they needed more equipment and medical officials at the health centres.

Yet, women in these Muslim-dominated communities avoid health centres where the workers are only men. Such was the case of the Dan Isah Health Post in Rimin Gado LGA until Amina Mu’awiyya, a nurse, was transferred there and the attendance improved. Now, she’s the only female staff member attending to all women in the community and those nearby.

“We have improved from one or two women per day to 20–25 women per month. So, this is a great improvement. I can say that 50 percent of women from the community now attend antenatal. Women from the nearby towns also trek to this place for medical assistance,” Mu’awiyya said.

“Most of them are not coming for medical care because they don’t have money for drugs and tests. When they call a traditional birth attendant, they pay little. There was a time I had a conversation with one of the birth attendants who said they spit some Quranic verses on patients to ease delivery. She said the method was inherited from their elders.”

Twenty-four-year-old Halimatu Sadi took rubutu (holy water) and gamji (tree bark medicine) with zobo (hibiscus) at the early stage of her pregnancy, while her mother-in-law prescribed the dosage.

“Poverty is the main reason why women here don’t go to the hospital, because when you go there, they will inform you about the tests you need to conduct. You can be charged N4500 ($3.2) to N5000 ($3.6). You must spend money on every visit because they will prescribe the drugs you need to buy. So, it is all about spending money. Getting free medicines will draw the attention of more women,” Sadi said sharply

While the Doka Model Healthcare Centre closes at 2 pm and refers patients to hospitals in bigger towns for scans, the health post at Kwami Village is often deserted due to a lack of basic amenities and workers.

In April, Abubakar Yusuf, commissioner for health in Kano, said the state is committed to ending maternal mortality.

Meanwhile, in Kano, Nigeria’s most populous state, 1,477 registered medical doctors cater to its estimated 15 million population, according to 2022 data from the Medical and Dental Council of Nigeria (MDCN).

‘DON’T KILL US’: DOCTORS FLEEING IN DROVES

Nigeria’s healthcare sector is going through one of the worst brain drains in history, as half of its registered doctors and health professionals have fled abroad for a better life. The movement is known as ‘japa’ in local parlance. They cite poor remuneration, an inefficient work environment, and the constant abduction and killing of doctors as the major reasons for their departure.

Over time, the primary destinations of these migrating healthcare workers have been the United Kingdom (UK), the United States, Canada, and the Middle East. The Saudi Arabian ministry of health often conducts recruitment exercises for medical experts in Lagos and Abuja, the nation’s capital. The Nigerian Medical Association (NMA) said about 10,296 Nigerian-trained doctors are practising in the UK.

Stephen Chukwumah, a Lagos-based doctor, said he decided to leave the country during his housemanship due to the “bleak economic outlook” of the country and the substandard state of the health sector. In 2022, he finally moved to the UK, where he now works.

“But you barely realise how bad it is until you are in a better system,” Chukwumah told TheCable.

In April, the MDCN said that due to the increase in migration of medical workers, only 58,000 doctors, which amounts to 45 per cent, renewed their annual practice licence in 2023 – out of the 130,000 registered doctors in the country. Ali Pate, the minister of health, lamented that there is still a huge distribution challenge, as a significant percentage of the remaining doctors are in urban areas like Lagos and Abuja. This leaves rural areas with few or no qualified healthcare professionals.

Even in urban areas, the doctors have come out to complain of being overworked, which has led to strikes. In March, about 59 medical doctors were reported to have resigned from Dalhatu Araf Specialist Hospital (DASH), Lafia, Nasarawa state, over poor service conditions. Two months later, doctors at the Federal Teaching Hospital in Lokoja, Kogi state, protested over manpower shortage and burnout. “Don’t kill us,” one of the placards read.

The newspaper reports of the closure of the psychiatry ward at the Obafemi Awolowo University Teaching Hospital (OAUTH), Ile-Ife, Osun state, and five wards at the Lagos University Teaching Hospital (LUTH) due to a shortage of personnel led to an outcry on social media and also drew the attention of national legislators.

In April 2023, the national assembly debated a bill to mandate Nigerian-trained medical and dental practitioners to practice for at least five years before getting a full licence. But the federal government kicked against the bill.

The NMA noted that the exodus is causing a surge in maternal and infant mortality rates. In 2017, the World Health Organisation (WHO) estimated Nigeria’s maternal mortality rate at 917 per 100,000 live births; it increased by nearly 14% in 2020 to reach 1,047 deaths.

According to UNICEF, Nigeria currently contributes 10 per cent of global deaths for pregnant mothers, with the latest figures showing a maternal mortality rate of 576 per 100,000 live births, the fourth-highest in the world. UNICEF added that each year, approximately 262,000 babies die at birth, the world’s second-highest national total, as infant mortality currently stands at 69 per 1,000 live births. For under-fives, it rises to 128 per 1,000 live births.

WILL THINGS GET BETTER?

In recent media interviews, the minister of health said that to address the brain drain of the health sector, the federal government would engage retired medical workers, raise workers’ salaries, and train more personnel to bridge the gap. Pate said the enrollment in medical schools has increased from 28,000 to 64,000 yearly.

“We have also approved a managed migration policy for health and are looking at how best to address the excessive workload of medical providers, especially the medical doctors,” Pate said in May while presenting the one-year achievements of his ministry.

“We are working with the ministry of labour as well as the Salaries, Incomes, and Wages Commission to address long-standing legacy issues of compensation and allowances, which will take time and more patience from health workers.

“More than 2,400 health workers, including nurses, doctors, and midwives, have been recruited to provide services to Nigerians, many of whom are women in rural areas delivering essential services.”

However, stakeholders have raised some observations on the government’s sincerity to solve the challenges in the industry.

In an interview with Happy Adedapo, the Oyo state NMA chairman, he said the government is too clever by half and needs to back its words with actions.

Adedapo said a total sector collapse is imminent if urgent steps are not taken to halt the migration.

“This time last year, we had over 700 resident doctors at the University College Hospital (UCH), Nigeria’s first teaching hospital. They are now less than 400. Doctors are leaving every day, so it is difficult to state the number of those who have left the shores of the country. It’s a continuous process. Over 300 medical consultants left about two years ago, most of them to Saudi Arabia,” Adedapo said.

“The government is trying to employ more doctors, but they are not coming forward. They are not applying anymore. For example, the federal government gave the UCH allocation to employ 100 doctors, but we couldn’t fill half of the allocation. Some who were employed didn’t resume. It’s a big problem.

“The government is just too clever by half. Increasing the number of medical school admissions won’t solve it. You are actually increasing the number of doctors for export. They will leave in the long run. That’s the implication. Until you address what is driving these people away — what is pushing and pulling them — nothing will change. The medical association has always provided solutions, but it is up to the government to listen.

“Let’s start with remuneration. Let an average doctor get a living wage. Second, there should be incentives like car and housing loans that will encourage doctors to stay behind. A rural allowance will keep doctors in local communities. There should be training and re-training. Also, let the government refurbish the health institutions. Imagine getting to work when there is no electricity. We need to see the government in action.”

Speaking on the development, Uchenna Agu, community engagement director of Connected Development (CODE), a non-profit focused on empowering local communities, said there is a nexus between the country’s budgetary allocation for healthcare and the escalating brain drain in the sector.

Only about five per cent of Nigeria’s 2024 budget was set aside for healthcare, which contradicts the African Union’s 2001 Abuja declaration to allocate at least 15 per cent of annual national budgets to health.

“The Nigerian government’s investment in the healthcare sector has consistently fallen short. The budgetary allocation to healthcare for the past five years has been less than 6%. If the budgetary allocation is increased, it will boost investment in the sector, thereby discouraging brain drain,” Agu said in an interview with TheCable.

“CODE’s findings on the state of primary healthcare in Nigeria showed that 38% of the 783 primary healthcare centres (PHCs) we visited were not connected to the national electricity grid. About 137 of these PHCs do not have alternative sources like solar or power-generating sets; they rely on kerosene lamps and torchlights. About 90% of PHCs visited did not have the minimum number of nurses/midwives. Three out of 10 do not have nurses/midwives at all.”

While the medical flight from Nigeria remains unabated, citizens are forced to settle for alternative healthcare solutions, some of which are unsafe. For women in Niger and Kano states who have to battle with the scarcity of qualified health professionals and the bad roads leading to clinics, there is still a long way to go.