The current coronavirus pandemic brought to fore the importance of having a strong health system, as many countries were faced with a unique challenge on how to best handle a novel disease which was killing people around the world at a rapid rate. This has brought about the reassignment of resources in fighting the disease, affecting other health services available to patients.
Some countries, such as Nigeria were caught in a unique situation where we already had an underfunded and poorly resourced national health system, which saw a scrambling by the various state governments in the country to put in place temporary health facilities to deal with the lack of resources needed should the disease get a firm footing in the country.
Fortunately, it seems that has been avoided, but it did expose the geographical disparity in healthcare service availability and delivery across the country. Healthcare in Nigeria is largely influenced by different local and regional factors that impacts the quality or quantity of care received by its citizens, and largely denotes the efficiency of the health system in each state.
Health care efficiency is a comparison of delivery system outputs, such as health outcomes, with inputs like cost, time, or material. Efficiency can be reported then as a ratio of outputs to inputs or a comparison to optimal productivity using stochastic frontier analysis or data envelopment analysis. This is sometimes difficult to do, especially in a country where data is hard to come by.
To rank the most efficient states for healthcare in Nigeria we used a modified version of the model used by New York based Common Wealth Fund, a private foundation that aims to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, young children, and elderly adults.
We used 27 indicators that measure performance in four domains important to policymakers, providers, patients, and the public: Care Process, Access, Equity, and Health Care Outcomes. Our data come from a variety of sources including the National Bureau of Statistics, The Demographic and Health Surveys (DHS) Program, The World Health Organization (WHO), Oxford Poverty & Human Development Initiative (OPHI) and Kingmakers.com.ng. Except where stated, most of the data was from the year 2018.
Performances of the States
Care Process
This was primarily covered by three subdomains which closely looked at the standardised interventions in care delivery.
Patient Engagement: The role of the patient is no longer as a passive recipient of care. These days patients are expected to engage in their own health, care and treatment. We took a look at initiatives to encourage patient involvement in being more active in the health care by examining the following:
- The percentage of mothers with the knowledge of using ORS to treat diarrhoea in children
- The percentage of adults with knowledge of HIV preventive methods
- The percentage of adults with exposure to family planning messages
- The percentage of adults with the knowledge of female genital mutilation
Coordinated Care: This involves deliberately organizing patient care activities and sharing information among all the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient. We used rates of
- antenatal visits,
- assisted delivery,
- and postnatal visits that were handled by a health professional.
Preventive Care: This measures the efforts made by the individual states in taking precautions in reduce the toll of diseases have on the population. We looked at measures which included the
- vaccination rates to prevent communicable diseases,
- the percentage of households who use of mosquito nets to prevent malaria which is a major cause of death,
- the percentage of households that safely disposed child stool to prevent diarrhoeal diseases,
- proportion of teenage pregnancies which increases health risks for both the mother and child during pregnancy, at childbirth and after birth.
- proportion of women of reproductive age (aged 15-49 years) who have their need for family planning satisfied with modern methods.
- the proportion of household that had a hand washing facility to prevent spread of diseases.
The overall rankings for the care process is shown below:
Access
Access to health care means having "the timely use of personal health services to achieve the best health outcomes" (IOM, 1993) and consists of four components (Healthy People 2020):
- Coverage: facilitates entry into the health care system. Uninsured people are less likely to receive medical care and more likely to have poor health status.
- Services: Having a usual source of care is associated with adults receiving recommended screening and prevention services.
- Timeliness: ability to provide health care when the need is recognized.
- Workforce: capable, qualified, culturally competent providers.
We used the following metrics identified as barriers to accessing healthcare to capture some of the above elements
- Percentage of women needing to get permission to go to the doctor as a barrier (Timeliness)
- Percentage of women who citing not having money to seek medical advice or treatment as a barrier (Coverage)
- Percentage of women who cited distance to a health facility as a barrier (Services)
- Percentage of women who cited not wanting to attend alone, sometimes due to cultural issues or attitude of the health care worker, as a barrier (Workforce).
Equity
According to the WHO, equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification. "Health equity” or “equity in health” implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.
With that in mind, we used the following socioeconomic metrics which are likely to impact the quality of the health of individuals. These metrics, also known as social determinants of health are the conditions in which people are born, grow, live, work and age. The factors we used include
- Access to improved source of water: which are sources that, by nature of their construction, adequately protects the water from outside contamination, in particular from faecal matter, providing some protection form disease transmitted via the faecal-oral route. We looked at the percentage of households within each state that had access to improved sources of water which included:
- Piped household water connection
- Public standpipe
- Borehole
- Protected dug well
- Protected spring
- Rainwater collection
- Access to improved sanitation facility: which are facilities that usually ensure separation of human excreta from human contact, providing some protection form disease transmitted via the faecal-oral route. We looked at the percentage of households within each state that had access to improved sanitation facilities which included:
- Flush or pour-flush toilet/latrine to:
- Piped sewer system
- Septic tank
- Pit latrine
- Ventilated improved pit (VIP) latrine
- Pit latrine with slab
- Composting toilet
- Female Education: There are many studies that link the education of girls and women with reduced child and maternal deaths, improved child health, and lower fertility. Women with at least some formal education are more likely than uneducated women to use contraception, marry later, have fewer children, and be better informed on the nutritional and other needs of children. We ranked the states by the percentage of women that had no formal education.
- Poverty: Researchers have forged a solid, convincing link between low socioeconomic status and bad health, and demonstrating that there is a clear and established relationship between poverty, socioeconomic status, and health outcomes —including increased risk for disease and premature death. The rates of poverty between the states was examined as part of their rankings.
- Access to mass media: Mass media campaigns can directly and indirectly produce positive changes or prevent negative changes in health-related behaviours across large populations. They have been used to affect various health behaviours in mass populations with campaigns most notably aimed at tobacco use and heart-disease prevention, but have also been used to address alcohol and illicit drug use, cancer screening and prevention, sex-related behaviours, child survival, and many other health-related issues. A lack of access to mass media by the adult population was used to rank the states.
Health Outcomes
Health outcomes are an interrelated set of attributes that describe the consequences of disease for an individual. These include impairments, symptoms, functioning, participation in activities and social roles, and health-related quality of life. To measure health outcomes amongst the different states we used the following metrics:
- Life Expectancy: is a statistical measure of the average time a person is expected to live, based on the year of their birth, their current age and other demographic factors including sex. Life expectancy increases with age as the individual survives the higher mortality rates associated with childhood.
- Neonatal Mortality Rate: is the statistical measure of neonatal deaths, which is defined as a death during the first 28 days of life (0-27 days).
- Child Mortality Rate: also known as under-5 mortality or child death, refers to the death of infants and children under the age of five or between the age of one month to four years depending on the definition.
- Maternal Mortality Rate: The Maternal mortality rate (MMR) is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes).
The Results
States were allotted points for each variable based on their relative position in that category’s ranking. The states with the best-performance measure for each variable received 1 point, while the state with the least performance level received 37 points. All other states were scored depending on their position between the two extremes.
