Editor's note: Dr Adaeze Oreh, a family physician with the federal ministry of health and Fellow of the West African College of Physicians whose work involves emergency preparedness, response and recovery, writes on why emergency services in Nigeria are not efficient like in other climes.
SUMMARY - Nigeria and other low-middle income countries bear 90 percent of the burden of traumatic deaths and injuries worldwide, but our emergency services are weak, leading to the loss of thousands of lives.
A few weeks ago, a fuel truck exploded in Morogoro, Tanzania, killing about 85 people. The initial explosion killed dozens, with others dying later of burns and serious injuries. It was one of the deadliest oil tanker blasts in Africa in recent years although these events are not rare. Barely a month before, in Central Nigeria, at least 50 people were killed and over 100 people injured after they rushed to scoop fuel from an overturned tanker which subsequently exploded.
The death and injury tolls from these oil tanker explosions are truly tragic and rightly grab headlines, but there are many causes of traumatic death and injury in Nigeria and across Africa – with the major causes being road traffic accidents and blood loss due to trauma in childbirth. Each day in Nigeria, approximately 159 women die from pregnancy and childbirth-related causes. That’s more than 58,000 Nigerian women who will never see their child take their first step. Road traffic accident numbers are also horrific and disproportionately affect young men.
These two major causes of death and injury often hit people hardest in their most productive years with huge social and economic costs. Families and children are left bereft of their loved ones with considerable economic losses, untold grief, hardship and mental health challenges. Many children may be unable to continue their education, forced into child labour and vulnerable to alcohol and drug abuse. For the injured and disabled, costs of treatment can be catastrophic for both the individual and the family, as they take time off work or school to care for the injured. Globally, on average, road traffic crashes cost most countries 3% of their gross domestic product. This is likely to be even higher in Nigeria – amounting to not less than 4.2 trillion naira (approximately $12 billion).
Preventing these deaths and injuries requires many courses of action including improving road safety and ensuring every woman has access to appropriate care in pregnancy and childbirth. But these are longer term changes that do not address the crises faced by hundreds of people right now and every day.
For that to improve, we need to address the weakness of our emergency response systems. It is not surprising that people are angry about the serial loss of life and endangerment in fuel tanker explosions and see this as a sign of “government insensitivity.”
While low and middle income countries such as Nigeria carry 90% of the entire global burden of traumatic injuries, with significant impact on both mortality and disability, emergency services remain underdeveloped. High-quality emergency medical services need a number of components to work effectively including pre-hospital systems such as ambulance services as well as hospital-based services and links to ongoing care. In order for the system to function, it needs trained personnel, equipment, medications, blood products, data and information systems at all levels, but all are sorely lacking across the country.
Also inadequate is our emergency blood supply system, especially in maternal health. Severe bleeding is the number one cause of maternal deaths in Nigeria, with lack of sufficient safe blood supplies and robust emergency services being key factors in this country accounting for 19% of global maternal deaths.
System deficiencies delay the detection and provision of care and increase the risks as emergency care is extremely time-sensitive: delays of minutes can make the difference between life and death and no one is safe from this lottery. In April 2016, twelve medical doctors and their driver travelling to Sokoto for a National Medical Association conference were involved in a bus accident about 60 kilometres from Kaduna. The Federal Road Safety officers who first arrived at the scene were not trained as first responders. Several of the victims died on the spot, but no emergency ambulances were available and the survivors were packed into a van and driven to a hospital about 70 kilometres away. The hospital was not equipped to manage such an emergency and the lives of six of the medical doctors were lost.
Blood services, which usually rely on regular donations by voluntary, unpaid blood donors are also not working as well as they need to. In Nigeria, less than 5% of blood donations are sourced from voluntary donors and the rest commercially provided. According to the National Blood Transfusion Service, the World Health Organization recommends a stock of 2 million screened blood units for a country this size, leaving a shortfall of about half a million units. In 2016, Nigeria’s federal budget appropriation for the National Blood Transfusion Service for the entire year was 30 million naira (approximately $85,000) – an astonishingly small sum for a country of this size. True, this low figure was largely due to the withdrawal of US donor funding for the NTBS in 2015 but shows how vulnerable our systems are.
For day-to-day emergency responses, there are no specific budget allocations; instead they are built into hospital and health centre budgets, leading to enormous variability between different places. At the same time, across sub-Saharan Africa, we face a range of critical emergencies on top of the traumatic injuries I have described. Ebola, cholera, armed conflict and natural disasters regularly strain our emergency care systems.
Emergency care is often the first point of contact with the health system for many individuals. An efficient emergency medical system, integrated into functional healthcare delivery systems, could have hugely positive impact on health outcomes.
Estimates suggest that implementation of basic trauma care such as resuscitation, burns management and wound repair at primary care clinics and hospitals could potentially avert 21% of the total injury burden in low and middle income countries, thus reducing 18% of the total global burden of disease. By ensuring that these facilities are equipped with basic emergency kits and staffed by skilled health workers with a network for swift communication and transportation during emergencies, many deaths from accidents and childbirth could be averted.
However, poor quality care not only exacerbates suffering, but erodes the confidence of communities, discourages use of such facilities in emergencies and probably contributes to resistance to paying taxes for public services.
Emergency care has been on the back burner of national health priorities for too long. Strengthening emergency services is a vital component of universal health coverage and is an essential part of integrated health care delivery. By committing to providing basic maternal care and emergency and resuscitation services following trauma, bleeding and other emergencies, deaths and disabilities from accidents and childbirth complications can be greatly reduced. Enhancing the ability of community health centres to adequately respond to day-to-day emergencies will bolster emergency preparedness at the community level, saving the lives of tens of thousands of Nigerians and preventing economic losses of billions of naira each year.
Nigeria’s state and federal governments should commit to prioritising health care. The 2018 budget ranked health 12th in the national priority list after other sectors such as power, works and housing. As a country, we should be spending not less than 60 percent of the total health budget on primary care, ensuring that basic emergency services are clearly captured in federal and state budgets and not merely implied in operational allotments. As Nigerian citizens, we have a responsibility to insist that our leaders keep the goal of affordable, universal healthcare at the top of the development agenda. Too many of our people currently suffer needless death and disability, falling through the cracks of our inadequate emergency services.
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