|Year : 2019 | Volume
| Issue : 2 | Page : 107-113
Unregulated drug use and consequences in the Nigerian health sector
Chinwe L Onyekonwu1, Chijioke G Onyekonwu2, Emmanuel O Ugwu3
1 Subdepartment of Dermatology, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
2 Department of Ophthalmology, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
3 Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
|Date of Web Publication||18-Nov-2019|
Dr. Chijioke G Onyekonwu
Department of Ophthalmology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Ituku-Ozalla, Enugu.
Source of Support: None, Conflict of Interest: None
Background: The Nigerian health system is bedeviled with poor regulatory services, frequent interruption of services as a result of disharmony among different cadres of health-care providers, inadequate manpower, poor management and leadership, and poor access to care due to non-enrollment in health insurance. Health-care spending is often catastrophic in most cases as payment is usually out of pocket for most service users. This has led to proliferation and patronage of unlicensed and unregulated health-care providers. Some patients are able to afford out of pocket payment but often meet suboptimal functioning services when they present to the hospitals which are also bedeviled by inadequate manpower and health-care facilities. Others who cannot afford the payments first patronize quacks and present later to the hospitals, sometimes with complications and attendant increase in morbidity and mortality. Aims and Objectives: The aim of this study was to highlight some problems that may arise as a result of unregulated drug use in the Nigerian populace and the role of an efficient health system with improved health insurance access, in curbing these problems. Materials and Methods: The reality of the Nigerian Health Care System as it stands today was highlighted and objectives of the National Health Insurance Scheme at inception cited. Three clinical cases of complications arising from poor access to health care and drug use regulation were described. Conclusion: Access to health care in Nigeria has remained poor and mostly out of pocket despite the goal of the National Health Insurance Scheme to provide health care at reduced costs. Patronage of unlicensed health-care providers remains high due to poor access to health care, poverty, and illiteracy with untoward effects on affected individuals. There is an urgent need to scale up access to health insurance across all sectors and ensure efficient service delivery through regular monitoring by appropriate regulatory agencies and constant education of the populace to discourage patronage of quack health-care providers.
Keywords: Consequences, health insurance, Nigerian health sector, provider perspectives, unregulated drug use
|How to cite this article:|
Onyekonwu CL, Onyekonwu CG, Ugwu EO. Unregulated drug use and consequences in the Nigerian health sector. Int J Med Health Dev 2019;24:107-13
|How to cite this URL:|
Onyekonwu CL, Onyekonwu CG, Ugwu EO. Unregulated drug use and consequences in the Nigerian health sector. Int J Med Health Dev [serial online] 2019 [cited 2020 Apr 9];24:107-13. Available from: http://www.ijmhdev.com/text.asp?2019/24/2/107/271084
| Introduction|| |
The total Nigerian population was estimated at over 190,000,000 in 2017. With a population density of 221 per km2, total land area of 910,770 km2, and 51.9% of the population living in the urban area, Nigeria ranks number 7 in the list of countries by population.
Nigeria was ranked 157 of a total of 189 countries and territories in the Human Development Index (HDI) according to 2017 figures, down from 156 and thus classified under the low HDI rank. With a life expectancy at birth of 53.9 years and Gross National Income per capita (PPP $) of 5231 HDI(Value) was estimated at 0.5323, Nigeria’s 2017 HDI was estimated at 0.5323. HDI is a composite index measuring average achievement in three basic dimensions of human development—a long and healthy life, knowledge, and a decent standard of living.
The percentage of the population that is multidimensionally poor, adjusted by the intensity of deprivations in education, health, and living standards, is known as the Multidimensional Poverty Index, and this value was 0.294 (52%). Approximately 16.9% of the population were said to be vulnerable to multidimensional poverty, whereas 32.7% were in severe multidimensional poverty; deprivation in health contributed 27.1% to overall multidimensional poverty. Although 46% of the population were estimated to be living below the national poverty line, 53.5% were estimated to be living below the international poverty line of $1.90 (in purchasing power parity terms) a day.
Health-care provision in Nigeria is the concurrent responsibility of the three tiers of government—the federal, state, and local government. The lowest level of health care in Nigeria is the primary health-care (PHC) system, which is managed by the local government areas, and receives support from the respective state ministries of health and private medical practitioners. The secondary health-care system managed by the ministry of health at the state level receives referrals from the PHC system, whereas tertiary health care is provided by the teaching and specialist hospitals.
At the Alma Ata Declaration of 1978, PHC was conceptualized as a grassroots approach toward universal and equitable health care for all. It is the initial level of interaction between individuals, families, and communities with the national health system, essentially bringing health care as close as possible to where people live and work. The National Health Policy, which aims to provide comprehensive health care based on PHC, was launched in 1988, and PHC implementation commenced in 1992.
Challenges to appropriate implementation of the PHC in Nigeria are multifactorial and appear daunting. They include lack of political will, poor funding, defective inter-sectoral collaboration, and conflicts between local and state governments. Others include poor community participation due to misconceptions, unhealthy rivalry between various categories of health-care workers, and poor remuneration, among others.
The National Health Insurance Scheme (NHIS) was first proposed in Nigeria in 1962 under a bill that was introduced to Parliament; there were challenges to the bill and thus it did not sail through; however, in 1999, following the passage of Decree 35 (NHIS) by General Sani Abacha, the first launch of the scheme took place. The aim of the NHIS was to provide universal health coverage for Nigerians using financial risk protection mechanisms. Specific objectives at the inception of the NHIS included providing easy access to qualitative and efficient health care among its enrollees, providing financial risk protection to illness, addressing the misdistribution of health facilities in the country, and promoting public private partnership in health-care delivery, among others. The NHIS programs were organized under various sectors—formal and informal sectors and the vulnerable group.
The main program of the NHIS, the Formal Sector Social Health Insurance Programme (FSSHIP), targeted at employees of the federal government, was flagged off on June 5, 2005, and was given a presidential mandate to ensure universal coverage by 2015. This was to be followed by the implementation of Community-based Social Health Insurance Program at 37 pilot sites and subsequently, the voluntary contributor program meant to cater for self-employed Nigerians or those in firms of less than 10 employees.
| The Health-care System: Reality on Ground|| |
Health-care financing in Nigeria is through various sources including health insurance, donor funding, out-of-pocket payments, and tax revenue, among others. Despite the earnest kickoff of the FSSHIP in 2005, only approximately 4% of the population, mostly federal government workers, had subscribed to the NHIS as of December 2016. Furthermore, due to the fact that NHIS participation has remained largely nonmandatory, many state and local governments have not adopted the plan, leading to low participation.
One factor, among others, which has been found to influence adoption at the state level is the way political power is shared and used by actors at various levels of government; states feel they have no influence over the use of their own funds due to the noninclusive nature of the NHIS Act, thus creating opportunities for them to modify the design to conform to their local interests or to suspend discussions on adoption. Very low enrollment rate in the health insurance scheme with only 1% of households having a resident who is a primary enrollee in a health insurance scheme was a major finding in a study carried out in southeastern Nigeria.
In Nigeria, private expenditures account for 70%–80% of total health expenditures (THE), whereas public expenditures account for approximately 20%–30% of THE; the dominant private expenditure is out-of-pocket spending (OOPS)., Catastrophic health expenditures are said to occur when such expenditure risk sends a household into, or further into, poverty. This has a high possibility of occurring in Nigeria due to the high level of prevalent user fees and major use of OOPS to pay for health expenditures.
Corruption, political instability, limited institutional capacity, and an unstable economy are major factors responsible for the poor development of health services in Nigeria. Another problem in the Nigerian health-care industry is the absence of tight regulatory control over who provides medical care as health provision, this has become an all-comers affair with all cadres of health-care personnel playing the role of the clinician. Hence, in addition to bearing the burden of a dysfunctional and inequitable health system, there are also delays in seeking health care due to the predominant user fee system as these limits the poor from accessing basic health care. Many patients therefore resort to the use of herbs, concoctions, and prayers, and only present to the hospital when they have developed complications. Others patronize the myriad of quack patent medicine dealers and other unlicensed health-care providers as these serve as the cheaper options, many times with deleterious effects.
This article highlights some of the untoward effect of poor access to health care and the bane of poor regulatory control of providers in the Nigerian health-care industry.
| Clinician Perspectives|| |
In developed countries, there is a clear divide between over-the-counter (OTC) medications and drugs that can only be accessed by prescription. Such prescriptions remain the prerogative of licensed clinicians who are expected to prescribe responsibly, bearing in mind the possible adverse effects from the drugs, including drug–drug interactions. This regulation is lacking in most developing countries, including Nigeria. For example, some drugs with teratogenic potentials have been known to be freely sold OTC by drug vendors. Thus, patients are exposed to potential harm from medications given by untrained health-care providers, the popular ones being the patent medicine dealers, whom even the enlightened occasionally patronize to “mix drugs” for them.
Adverse effects from drugs can affect every system of the body. Dermatological presentations may range from mild effects such as fixed drug reactions to severe life-threatening effects such as toxic epidermal necrolysis (TEN). Apart from these, there is the problem of misdiagnosis with subsequent late presentation of the patients for proper care at which time they may have depleted all their resources.
It may be argued that at the root of patronage of these unlicensed health-care providers are poverty, poor access to health care, and illiteracy. It has also become clear that most of the objectives for setting up the scheme have been unmet. Under a properly functional health insurance scheme, which should ideally insure patients for most basic health-care needs, coverage, equitable distribution of health services, and access to health care is ensured, obviating the need for patronage of unlicensed drug vendors. Even in individuals who have access to health insurance, certain drugs and chronic diseases are excluded, thus creating the need for those who are insured to seek alternative means in order to meet up with their health challenges. Although the health insurance scheme does not have the role of oversight function of discouraging the unregulated use of drugs, individuals would not see the need to buy OTC drugs without proper health evaluation if they have access and coverage.
| Ophthalmology and Abuse of Drugs|| |
Common eye conditions for which patients abuse drugs, include allergic eye diseases, eye trauma, foreign body in the eye, and infections, especially viral infections. The drugs, which patients commonly procure for these conditions, include chloramphenicol drops, gentamicin drops, antibiotic ointments such as penicillin, and prednisolone tablets. These drugs are usually bought OTC from patent medicine dealers. They may be self-prescribed or prescribed by other ancillary health workers or doctors who are not ophthalmologists.
These patients make the decision to present to the ophthalmologist following failure of symptoms resolution, exacerbation, or complications either from the initial disease or from the medications used. The usual complications include glaucoma, cataract, and endophthalmitis in patients who had corneal ulcers ab initio with increase in ulcer depth, width, and associated dehiscence. Patients may also present with pain, blindness, infections, and very severe headaches. They may also combine medications with traditional/homeopathic treatment, for example, patients with allergic eye disease may have tried instilling urine, holy water, breast milk, herbal medications, and salt/sugar solutions.
Despite public health outreaches to discourage such practices, poverty, ignorance, and poor access to health-care services still fuel these negative practices.
| Dermatology and Skin Manifestations of Nonprescription Drug Use|| |
Adverse drug reactions to medications commonly present to the dermatologist. Recognized as major health problems with considerable cost to the health-care system, they are benign although 2% of all adverse cutaneous drug eruptions are severe and life-threatening. Most cutaneous adverse drug reactions are drug-induced allergic reactions. Presentation could vary from mild conditions such as fixed drug eruptions, exanthems, urticaria, and pruritus to severe potentially lethal conditions such as Stevens–Johnson syndrome and TEN.
Cases abound of patients who may present with these adverse cutaneous conditions or who may present with worsening of diseases due to inappropriate medications.
A 25-year-old woman [Figure 1] and [Figure 2] presented to the emergency room with extensively denuded skin following ingestion of medications bought from a patent medicine dealer, which were prescribed for the treatment of a febrile illness. She was diagnosed with TEN. Although she responded to treatment, she had post-inflammatory sequelae from the lesions. The patent medicine dealer denied prescribing any medications when confronted by the patient’s spouse.,
A 17-year-old boy [Figure 3] developed a small anal eruption for which he visited a patent medicine dealer who administered intravenous and topical medications over two weeks after carrying out a laboratory investigation on the patient for an undetermined etiology. Lesions gradually increased in size and led to difficulty with defecation and ambulation; he also developed an offensive stench from the mass. On presentation, he was found to have anogenital warts, and tested positive to the human immunodeficiency virus.
These are just a few cases among so many patients who are mismanaged as a result of poverty, ignorance, and a noninclusive health-care system that has minimal health insurance provision and access for a majority of the populace.
| Oral Corticosteroids: Prednisolone/Dexamethasone—The Magic Pills|| |
One other menace to health care in the country is the unregulated prescription of oral corticosteroids by every cadre of health-care provider. The drugs, especially prednisolone and dexamethasone, are commonly administered by patent medicine dealers for any ailment. They are viewed as drugs that respond promptly to inflammations or infections; whichever option is in the mind of the provider.
Off-label uses of these drugs include such conditions as eczemas, asthma, arthritis, eye diseases, pruritus, and any other conceivable condition where the untrained provider is at a loss of what to prescribe. Not only do these patients (adults and children) not commence them without an appropriate physician prescription but their intake is continued, sometimes for years, with such resultant adverse effects as ocular affectation, bone fractures, osteoporosis, susceptibility to infections, and hyperglycemia, among others. A 28-year-old woman [Figure 4] and [Figure 5] was placed on prednisolone by a patent medicine dealer when she requested for weight gain tablets. She had been on the medication for over three years by the time she presented to the clinic with moon face, obesity, striae, and dermatophytosis.,
Some patients, who have a need to be placed on oral corticosteroids by their physician for whatever reason, have also been known to default to follow-up while continuing to refill their prescription and presenting subsequently with side effects. Abuse of this drug cuts across all disciplines and all age-groups and has grave consequences. Not only do the adverse effects from oral corticosteroids have a deleterious effect on the health of patients, they also have economic and societal costs.
| Recommendations|| |
There is an urgent need to scale up access to health insurance across all sectors. This will make patronage of quack health-care providers unattractive. Within existing health insurance provisions, it is important to ensure efficient service delivery through regular monitoring by the regulatory agencies in order to prevent user apathy. Information and education of the populace, especially with regard to adverse reaction from wrong drug use, should be regularly provided. Agencies that have the role of health-care policing should enforce health laws, and defaulters should be seriously dealt. This will serve as deterrent to others.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The World Bank. 2019. Population total. Available from: https://data.worldbank.org/indicator/SP.POP.TOTL. [Online]. [Last accessed on 2019 Feb 14].
Worldometers. 2019. Nigeria population (live). Available from: http://www.worldometers.info/world-population/nigeria-population/. [Online]. [Last accessed on 2019 Feb 14].
United Nations Development Program. 2018. Human development indices and indicators. 2018 Statistical update. Available from: http://hdr.undp.org/sites/default/files/2018_human_development_statistical_update.pdf. [Online]. [Last accessed on 2019 Feb 23].
Asuzu MC. The necessity for a health systems reform in Nigeria. J Community Med Primary Health Care 2004;16:1-3.
Omoruan AI, Bamidele AP, Phillips OF. Social health insurance and sustainable healthcare reform in Nigeria. Ethno Med 2009;3:105-10.
Welcome MO. The Nigerian health care system: Need for integrating adequate medical intelligence and surveillance systems. J Pharm Bioallied Sci 2011;3:470-8.
World Health Organization-United Nations Children Fund (WHO-UNICEF). 1978. Declaration of Alma Ata. Available from: https://www.unicef.org/about/history/files/Alma_Ata_conference_1978_report.pdf. [Online]. [Last accessed on 2019 Feb 26].
Alenoghena I, Aigbiremolen AO, Abejegah C, Eboreime E. Primary Health Care in Nigeria: Strategies and constraints in implementation. Int J Community Res 2014;3:74-9.
Awosika L. Health insurance and managed care in Nigeria. Ann Ibadan Postgrad Med 2005;3:40-6.
General Abdulsalami Alhaji Abubakar Head of State, Commander-in-Chief of the Armed Forces Federal Republic of Nigeria, Decree made in Abuja 10th May, 1999. National Health Insurance Scheme Decree No 35 of. 1999. Laws of the Federation of Nigeria. Available from: http://www.nigeria-law.org/National%20Health%20Insurance%20Scheme%20Decree.htm. [Last accessed on 2019 Feb 26].
Dogo-Mohammad M. Importance of standards in a demand driven Health Insurance System. 3rd Annual SQHN Conference: Safety, Standards and Customer Service. Lagos, Nigeria: Society for Quality of Health Care in Nigeria; 2011.
NHIS National Health Insurance Scheme (2018) Programs. Available from: https://nhis.gov.ng/programmes/. [Online]. [Last accessed on 2019 Feb 26].
Uzochukwu BS, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing in Nigeria: Implications for achieving universal health coverage. Niger J Clin Pract 2015;18:437-44.
] [Full text]
Oxford Economics/Haver Analytics. 2018. Global analysis of health insurance in sub-Saharan Africa. Available from: https://www.ey.com/Publication/vwLUAssets/EY-global-analysis-of-health-insurance-in-sub-saharan-africa/$File/ey-global-analysis-of-health-insurance-in-sub-saharan-africa.pdf. [Online]. [Last accessed on 2019 Mar 14].
Onoka CA, Onwujekwe OE, Uzochukwu BS, Ezumah NN. Promoting universal financial protection: Constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria. Health Res Policy Syst 2013; 11:20.
Onwujekwe O, Hanson K, Uzochukwu B. Examining inequities in incidence of catastrophic health expenditures on different healthcare services and health facilities in Nigeria. PLoS One 2012;7:e40811.
Soyibo A. National health accounts of Nigeria, 1998–2002. Ibadan, Nigeria: University of Ibadan; 2004.
Soyibo A, Olaniyan L, Lawanson O. National health accounts of Nigeria, 2003–2005. Ibadan, Nigeria: University of Ibadan; 2009.
Ichoku HE, Fonta W. The distributive effect of health care financing in Nigeria. PEP Working Paper, No 2006–17. Quebec, Canada: University of Laval; 2006.
Aregbeshola B. 2019. Health care in Nigeria: Challenges and recommendations. Available from: http://socialprotection.org/discover/blog/health-care-nigeria-challenges-and-recommendations. [Online]. [Last accessed on 2019 Mar 16].
Hoetzenecker W, Nägeli M, Mehra ET, Jensen AN, Saulite I, Schmid-Grendelmeier P, et al
. Adverse cutaneous drug eruptions: Current understanding. Semin Immunopathol 2016;38:75-86.
Khan DA. Cutaneous drug reactions. J Allergy Clin Immunol 2012;130:1225-1225.e6.
Manson SC, Brown RE, Cerulli A, Vidaurre CF. The cumulative burden of oral corticosteroid side effects and the economic implications of steroid use. Respir Med 2009;103:975-94.
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