Nigeria, popularly referred to as the "giant of Africa" is the most populous country in Africa. The country has 36 States and a Federal Capital Territory with the overall estimated population of 154,729 000milllion in 20091. Health service in Nigeria has undergone metamorphosis over the years. The provision of Nigeria health system can be categorized into Public and Private Health services. The public health services serves as the main backbone of Nigeria health care is funded by the government on non-profit bases. These are divided structurally into the Primary Health Care (PHC), Secondary Health Care (SHC) and the Tertiary Heath Care (THC) 2, 3. Although Nigeria is classified as a low-income country, she seeks to provide adequate care for the population with assistance from both national and international organizations such as USAID, Stop TB Partnership and others.
The National Health Service provides not only care for the people but also as a regulator of care in the country.
The case of Tuberculosis and state providing care
Although, tuberculosis is a curable airborne disease it is associate with high morbidity and mortality rate in Nigeria. This is due to ignorant, malnutrition, HIV, poor sanitation condition and poverty that affect both children and adult. The signs and symptoms include unexplained weight loss, night sweat, and tiredness, loss of appetite, fever, chest pain or pain on breathing, coughing up blood and prolong cough of more than 2 weeks duration. Diagnosis is by sputum smear test or tuberculin skin test which is free.
In April 2006, Nigerian Federal Ministry of Health made TB a national emergency and launched National TB-HIV/AIDS Working Group in June 20064. In 2007, United Nations estimated the new cases of tuberculosis as 9.3million out of which Nigeria's estimated new cases was said to be more than 460,000 thus making Nigeria the fourth largest tuberculosis burden globally4, 5, 6. The data from WHO in 2007 pin-points that at the global level there was 1.4million new HIV positive estimated cases of tuberculosis6.
In 2009, Nigeria was one of the 21 countries recommended by the WHO Task Force on TB impact Measure from 2009-2015 for funding for the control programmes on the TB burden, Fight AIDS and Malaria6, 7. This was later approved by the global fund.
Management: The complexity and cost of treating tuberculosis has made the National health services a large player in the programme. Management of any disease includes history taking, examination as well as investigation. All the state in Nigeria has properly trained medical staff, manning centers (treatment centers) and liaising with patients that have tuberculosis. These centers are supplied with standardized diagnostic and investigative units.
However, many people cannot afford tuberculosis treatment if they are meant to pay the test to check their status nor have access to diagnosis or treatment due to poverty, gender discrimination, and armed conflict8.That it is why the National Health Service and some international organizations provide the public with free sputum test. . They also provides free HIV test for all the tuberculosis patients especially for those who have MDR-TB (multidrug-resistant tuberculosis) 6, 9. This is however usually presided by pre- test counseling between counselors
Free medication and Treatment: With the help of international organizations such as USAID, the National Health Services are able to provide free treatment and medications to the Tuberculosis patients so that many people will have access to be diagnosed and treated. The national health services provide treatment of patients at both tertiary and the secondary level and also receive referrals from the primary care level.
In Nigeria, patients undergo standardized short-course chemotherapy for the period of 6-8months9 at the initial phrase is for 2 months treated with for drugs followed by 4 months of 2 drugs which similar in the UK, in cases 6months of therapy is usually appropriate but this is increased if the patient is HIV positive or if drug resistance occurs10. Due to the prolong therapy, there is usually poor compliance/ adherence and this has led to prolong infectious illness, risk of relapse and emergent of resistant. The government have also adopted the DOTS (directly observed therapy) service delivery in which their various tuberculosis treatment units /centers. As the name implies there is supervised therapy two to three times week to improve adherence.
Patient taking TB medication. Photo by MSH staff Fig. 1
Patients receiving their TB medication at the one of the TB units
http://www.msh.org/global-presence/tb-cap.cfm8
Staff: The National Health Services employ and provide adequate training for the staffs that will or may be in contact with Tuberculosis patients or TB-HIV/AIDS patients such as General practitioners, TB nurses, infection control advisors as well as the laboratory technicians whom are also trained to work in the various new microscopy centers.
Infrastructure: National Health Services provides vehicles and motorcycles for TB/HIV programs. This is for easy accessibility of the staff to the various treatment locations and home visits as well as safe conveying of the TB drugs to the appropriate locations. This also makes it possible for the coordinators to go around and supervise treatments as well as diagnosis of TB at the various TB units.
Prevention: this is very important aspect when it comes to tuberculosis and treatment. Since TB is said to be an airborne infectious disease which spreads by a prolonged close contact. The National Health Service provides BCG (Bacille Calmette Guerin) vaccination for young children prevent them from being infected by TB at an early stage.
National Health Service enlightens members of the public through seminars and workshops are just one of the various ways in which the state health service demystifies the myths about tuberculosis. Some of the issues that are often addressed are need for adequate ventilation, Sanitation, diet as well as impact of clean drinking water all in relation with Tuberculosis. Also the need for patients to adhere to tuberculosis treatment. This is further enhanced by the distribution of leaflets made available in the dialect and local language of the people.
http://alignmap.com/wp-content/Graphics/tb%20poster%202x.jpg Fig 2
alignmap.com11
Attendance at these meetings and workshops have been far from satisfactory but continually the National Health Service has sort to actively encourage attendance by the use of incentives.
Nigeria National Health Service as regulator:
For any project or programme to be successful, there should be certain guidelines or policies in place. To ensure that these policies are carried out properly there should be a regulatory body11. In this case, the National Health Service also serves as a regulator. They ensures that the of number cases of tuberculosis in Nigeria are significantly reduced.. Since medication and treatments are free almost all private hospitals are not interested. Therefore, state health services only carry out these regulations in government hospitals and missionary hospitals that have tuberculosis units. This is to ensure that a good quality of health-care are being provided for the patients as well as that the funds allocated for the programme are used for the good course and the outcome12, 13.
The National state health service as regulator, they ensure the following:
Training of all staffs that works under TB-HIV/AIDS services as well as on DOTS (directly observed therapy) service delivery.
That all staffs in all locations maintain standardized documentation and reporting system as this will allow assessment of treatment results or progress.
They collect data from Local Government Areas to Federal Government Level to ascertain the incidence, prevalence and mortality rate of tuberculosis.
They supervise the actual service delivery also assess regularly the logistics that is distribution of the essential drugs to the various centre's, checking the stock levels and volumes, review the vehicles and motorcycles capacity as well as the storage facilities.
National Health Service through the public health nurses do referral tracking and follow-up of most patients to their home both on short or long time treatment of care. This is made possible through provision of referral forms and directories.
Educating the patients need for drinking clean water, need for good ventilation in their various homes as well as good sanitation.
Administering and monitoring the patients taking their medication in their various treatment centers
TB Fig 3
A nurse prepares daily medications for patients at the treatment unit http://www.msf.org.uk/ourwork_medical_work.aspx14
The National Health Service ensures that hospitals adhered to the guideline laid down for waste disposal, isolation issues concerning tuberculosis
National Health Service ensures that the patients receive appropriate dosage, high-quality medication as well as monitor that the anti-TB drugs are taken by patients correctly.
The treatments are monitored especially for those that their sputum is positive. This is done by sputum smear examination 2 months after treatment also other patients are equally monitored clinically.
In conclusion, the incidents of tuberculosis have increased tremendously globally over the years and Nigeria is not an exception. Nigeria National Health Service has been playing active in reducing the cases of tuberculosis in the country serving both as provider and regulator of health-care. By providing free treatment for TB and HIV patients, applying DOTS and monitoring the progress of treatment.
2a.The current role of Nigeria National Health Service in provision services for tuberculosis are enormous:
They provide training for healthcare workers on tuberculosis as well as the laboratory technicians on the laboratory techniques relating to HIV and TB diagnosis.
They provides counseling for TB and HIV/AIDS patients
They integrate management of tuberculosis by providing free testing and treatment for tuberculosis patients. They also go an extra mile for some patients for instance in military service anyone that have of suffer from TB is mandated to go on a full paid sick leave.
They designate a special or isolation wards for tuberculosis patients.
They provide mandatory screening such as chest screening for all health-care especially those working with TB patients.
They provide free BCG vaccination against TB for children
They provides upgrading courses/ skills for health-care workers and community volunteers such as DOTS (direct observed therapy) or short course for TB, palliative care and need to support or persuade patients to complete their medication.
Though the National Health Service currently plays a vital role in provision of services for tuberculosis but they are still face with some challenges such as:
Non-compliance: This is a situation where the patient does not comply fully with the treatment program thereby develop TB drug resistance, reduction in cure rate as well as complication in TB control. To tackle this menace, the National Health Service has to expand the DOTS TB control programme in eventually all the parts of the country and free treatment.
Late presentation or poor morbidity: Some of patients stay at home and self medicate only come to the hospital when it is almost too late to treatment. This is due to the fact that people can easily buy drugs behind the counter without prescription. The National Health Services tackle this problem by organizing seminars and workshops to enlighten the public on the need to go for a test in order to identify TB in time.
Stigma association: The National Health Service enlightened the public on the need to support the sufferers and preventive measures on how to protect themselves from contacting the disease through leaflets, workshops and seminars.
Poor sanitary condition: They educate the patients as well as the public need to keep their sanitation clean as well as the need to for uneducated parents to bring their children for vaccination against tuberculosis.
2b. Policy might change depending on the progress of the expectation set out in the Global plan. In next decade the policy might change due to development of new strategic directions to meet up with the recommendation towards health-care reformed that period. WHO review data collected by countries on TB, HIV and Malaria based on three main indicators of impact such as incidence, prevalence and mortality rate per 100,000 population6 on yearly bases. This is to monitor the progress of every country concern in meeting the target for a stipulated period. For instance, in 2007 estimated new cases in Nigeria for TB were more than 460,000 therefore making Nigeria the fourth largest tuberculosis burden globally4, 5, 6. Base on tthis statistics global funding was available as one of the measures taken by WHO to aid developing country such as Nigeria in order to reduce prevalence of tuberculosis and the associated mortality rate and improved general health and well being. There are numerous health policies for tuberculosis such as:
Cost of treatment: Some years ago patients do pay for their TB treatment but there were concise that most poor patients do not complete their treatment for the fact that they cannot continue to afford it. Now the policy has changed globally to free TB-HIV/AIDS treatment making it treatment accessible to all. This policy might change in the next decade depending on the health outcome in future.
HIV testing of TB patients: This is to facilitate provision of CPT and ART for HIV positive patient. But I do not think that this policy will change in the next decade but having that more recommendation may arrive depending on future statistics regarding TB, TB-HIV and this will form new statistics direction which will intent to form new policy changes.
Checking progress against global plan target: the progress of Nigeria for example can be compared with the target set out in the global plan. This demonstrates whether or not the country is achieved target (target will be based on stipulated outcome within the time scale).
Implementation of the DOTS programme: One of the strategies used in treatment of tuberculosis is the implementation of DOTS. In 2005, DOTS was practice in Nigeria in few TB treatment units and the result shows that 65% progress was made then DOTS implementation was extended in few more units and the results shows 75% progress6. Another progress of 91% was made due to implementation of DOTS in additional units6. One of the policies is that every TB treatment units should be implement DOTS maybe policy might change if a better strategy is adopted in the next decade.
In conclusion, policy changes in order to improve our current strategies to meet the needs as well as tackle recommended public health issues like TB, HIV and MALARIA. This is made possible by improvement our current skills and technology (high quality laboratory test), invention of other suitable medication. Any new intervention in foreseeable future will mean significant changes in the policy in the next decade regarding tuberculosis management. Adopting a collaborative approach 'common risk approach' will also help to improve general health and well being as priority will be given to 'diseases link by common, preventable and lifestyle related risk factors'15.
