Jump to ContentJump to Main Navigation
Hospice and Palliative Care in AfricaA Review of Developments and Challenges$

Michael Wright and David Clark

Print publication date: 2006

Print ISBN-13: 9780199206803

Published to Oxford Scholarship Online: November 2011

DOI: 10.1093/acprof:oso/9780199206803.001.0001

Show Summary Details
Page of

PRINTED FROM OXFORD SCHOLARSHIP ONLINE (oxford.universitypressscholarship.com). (c) Copyright Oxford University Press, 2021. All Rights Reserved. An individual user may print out a PDF of a single chapter of a monograph in OSO for personal use. Subscriber: null; date: 17 April 2021

Nigeria

Nigeria

Chapter:
(p.309) Chapter 15 Nigeria
Source:
Hospice and Palliative Care in Africa
Author(s):

Michael Wright (Contributor Webpage)

David Clark

Jennifer Hunt

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780199206803.003.0015

Abstract and Keywords

Nigeria (population 137.25 million) is a country in Western Africa that covers an area of 923, 768 km2. Palliative care services are provided by two organizations in Nigeria, the Palliative Care Initiative (Ibadan) and Hospice Nigeria (Lagos). Palliative care services in Nigeria are undeveloped. There is continuing resistance to some palliative care concepts including opiate use, the multidisciplinary team approach to the management of medical problems, and the inclusion of patient and family as the unit of care. Reimbursement and funding for services are shown. There is no national association in the country. The history and development of hospice-palliative care in Nigeria is covered. The chapter specifically describes life/oral histories, the public health context, health care system, and political economy.

Keywords:   Nigeria, Palliative Care Initiative, Hospice Nigeria, public health, health care system, political economy

                      Nigeria

Nigeria (population 137.25 million) is a country in Western Africa that covers an area of 923 768 km2. Its boundaries border the Gulf of Guinea, between Benin and Cameroon, Niger and Chad. The capital city of Nigeria is Abuja.

According to the United Nations human development index (HDI), Nigeria is ranked 151st out of 177 countries worldwide (0.466)1 and 21st out of 45 in African countries for which an index is available. This places Nigeria in the group of countries with low human development.

Palliative Care Service Provision

Current Services

Palliative care services are provided by two organizations in Nigeria, the Palliative Care Initiative (Ibadan) and Hospice Nigeria (Lagos) (Table 15.1).

Palliative care services in Nigeria are undeveloped. There is continuing resistance to some palliative care concepts including opiate use, the multidisciplinary team approach to the management of medical problems and the inclusion of patient and family as the unit of care.

Table 15.1 Palliative care provision in Nigeria, 2004

Free-standing unit

Hospital unit

Hospital support team

Home care

Day care

Clinic/drop-in centre

Total

Palliative Care Initiative, Ibadan Hospice Nigeria, Lagos

1

1

1

2

1

Total services

1

1

1

3

(p.310) Palliative Care Initiative, Nigeria (PCIN)

Palliative care is being introduced to Nigeria through the Palliative Care Initiative, Nigeria based at the College of Medicine, University of Ibadan. PCIN is a multidisciplinary group of medical specialists who implement the major objectives of training, service and research in this area of medical care. The group was formed in January 2003 and, in addition to sensitizing the public on the importance of palliative care, it has sponsored some of its members to attend palliative care courses and conferences in other countries. It operates a pain and palliative care clinic at the University College Hospital, Ibadan. This was commissioned in February 2005 to provide support for patients with chronic pain and for cancer patients.2 The group is working towards including palliative care in the curriculum of medical and nursing students, based upon guidelines developed by Hospice Africa Uganda. Funding is being sought to develop home-based palliative care services. A train the trainers programme is expected to produce locally trained palliative care practitioners. Olaitan Soyannwo summarizes the current situation:

So what we have in terms of palliative care right now is a lot of individuals—oncologists, surgeons, physicians—just managing patients as best as they can. But the holistic approach is missing. We've just introduced that using a small clinic in the radiotherapy unit and a group of us—two anaesthetists, one oncologist, one nurse and a psychooncologist (who does counselling)—run a clinic once a week. Patients with terminal illness on the ward are referred to us, but one major problem is the availability of opioids. We don't have oral morphine in the country: we have injectable opioids but even that was not available for about four years. We had to do a lot of advocacy because some years back there was a regulatory problem and opioids were banned because they were grouped with narcotics. So although it's on the National Drug Formulary, we don't have the oral form—even on the Formulary—so we are doing a lot of advocacy to get that in now for palliative care and management of ill patients.3

She envisages palliative care as a helpful approach in managing the HIV/AIDS epidemic in Nigeria.

We had a group, an international group—a collaborative between my university, the Medical Women's Association from Lagos, and a group from Chicago, who were mainly alumni of the university and are interested in cancer care. Although we focused on cancer of the breast and cervix, which are the two commonest cancers, we want to use the template to do a lot of advocacy for patients with cancer and HIV/AIDS. And the good thing that I think we have in my institution is that we're already on the national programme in terms of ARV therapy and also prevention of mother to child transmission. Since that is already established, I am hoping that it will not be too difficult, with the support from APCA, for this new organization to be able to convince them back home that palliative care should be part of the AIDS programme in the country.3

PCIN organized a 1-day workshop on the art and science of palliative care and the management of terminally ill patients in Nigeria on 27 January 2005. Participants included the Provost and Principal Officers of the College of Medicine, The Chief Medical Director, Chairman, Medical Advisory Committee and Director of Administration of the University College Hospital, Ibadan. Also present were representatives of the Commissioner of Health (Oyo State), Permanent Secretary, Ministry of Health (Osun State), retired and serving members of the judiciary, clergy, health (p.311) professionals, students, the public and the press. There were also representatives of Hospice Nigeria based in Lagos and the Palliative Care Association based in Abeokuta. International guests included Anne Merriman, Founder of Hospice Africa Uganda, and Jack Jagwe, a Senior Adviser on Drugs Policy in Uganda.2 A primary focus for the workshop was to advocate for palliative care in Nigeria. The main outcomes of the workshop are as follows:

… to promote a greater awareness of the benefits of palliative medicine in the population at large, and among all cadres of professional and traditional health care providers. The workshop also recommended a review of the existing restrictions on the availability of oral morphine and other opioids in recognized hospitals and clinics for the relief of severe pain, especially in terminal care situations. It recognizes palliative care as a specialty in itself and the need to train trainers in the field.

The workshop recognizes the leadership roles of the Federal Ministry of Health (FMOH) and the National Agency for Food and Drug Administration and Control (NAFDAC) in these endeavours and urges the Palliative Care Initiative of Nigeria (PCIN) to seek the co-operation of these institutions in these matters.

The workshop strongly recommends the formation of a National Committee or a National Association on Palliative Care to coordinate the activities of satellite groups nationwide, to establish the standards and ethics of terminal care, and to foster relations with similar organizations worldwide.2

Hospice Nigeria

This NGO in Lagos was registered in 1993 and provides home-based care to the terminally ill. It is most often utilized by patients returning home to Nigeria from abroad. The founder, Olusola Fatunmbi, explains the system:

I had more patients referred to me from London at Lagos Hospitals than within Nigeria, but they knew I had drug problems, and on that basis they promised to see that the patients come with enough oral morphine and some other palliative drugs for their use. And my home care service with my husband and occasionally some of the members of the Trustees, was acquired, was free because we had no funding from anybody, and the counselling, the only thing is that the patients buy their own drugs.4

A cancer public awareness campaign has resulted in a few local patients benefiting from the organization's help although scarce supplies of oral morphine result in poor pain management.

Several other organizations and individuals may offer some elements of palliative care in clinics and support services for HIV/AIDS patients. Two doctors based at Federal Medical Centre, Abeokuta (Ogun State) and Zaria have formed a Palliative Care Association and are understood to be promoting palliative care.

Reimbursement And Funding For Services

The Diana, Princess of Wales Memorial Fund sponsored a visit by Olaitan Soyannwo and two of her colleagues to Hospice Africa Uganda. The aim of this visit was to develop a strategy towards training of trainers within Nigeria in order to build palliative care (p.312) capacity. The visit of a third colleague was later sponsored by the College of Medicine, University of Ibadan.

A 1-day palliative care workshop in Ibadan in January 2005 was co-sponsored by Help the Hospices, UK and the African Palliative Care Association (APCA).

Initial funding is being sought by Hospice Africa Uganda to develop home-based care services by PCIN. This programme has not yet been established.

President'S Emergency Plan For Aids Relief (Pepfar)

During the 2004 financial year (FY), funding of around US$55.49 million was enacted for country-managed programmes in Nigeria and US$15.43 million for central programmes. During FY2005, it is anticipated that a total of US$108.86 million will be enacted: US$84.36 million for country-managed programmes and US$24.50 million for central programmes5 (Appendix 2).

The Diana, Princess Of Wales Memorial Fund/hospice Africa Uganda

In Central and East Africa, Hospice Africa Uganda became the Diana Fund's partner agency in a 3-year project which attracted funding of £300 000. It was expected that during this period, Hospice Africa Uganda would:

  • Provide technical support and advice on the identification of countries with the capacity and political will to initiate palliative care services

  • Provide guidance and training to such countries

  • Set up and run a distance learning Diploma in Palliative care for African countries

  • Set up a resource centre of palliative care materials for Africa, at Makindye, Kampala

  • Improve services within Uganda so that a model can be developed that works for the poorest and that can be duplicated in other African countries.

    Anne Merriman comments:

    In 2001, the Diana, Princess of Wales, Memorial Fund in London, invited Hospice Africa Uganda to be their technical experts in assisting other African countries to start or strengthen palliative care services using the public health approach and integrating with existing health systems. Working with World Health Organisation, this initiative has brought the Hospice training programmes to several other African countries.6

As part of this vision, Hospice Africa Uganda has assisted PCIN in its efforts to introduce palliative care into Nigeria.

The UK Forum for Hospice and Palliative Care Worldwide has awarded grants to

  • PCIN—for a 2-day regional advocacy workshop involving health professionals, policy makers and others from the south west of Nigeria: £2000.

  • Federal Medical Centre—support for Folaju Oyebola (Master's degree in Palliative Medicine): £1500.

(p.313) Opioid availability and consumption

The International Narcotics Control Board7 has published the following figures for the consumption of narcotic drugs in Nigeria: codeine 296 kg; Pholcodine 19 kg; and pethidine 5 kg.

For the years 2000–2002, the average defined daily dose consumption of morphine for statistical purposes (S-DDD)8 in Nigeria was 0 (Appendix 1).

Olaitan Soyannwo confirms that opioid analgesics (parenteral and oral) are not available in government stores and health facilities.2

National and Professional Associations

There is no national association in the country. This has been identified as a priority by the participants of the palliative care workshop held in February 2005 in Ibadan.

Palliative care coverage

In January 2005, representatives of APCA presented papers at a workshop convened in Ibadan to promote advocacy for palliative care in Nigeria

Palliative Care Initiative, Nigeria

There are approximately 3000 patients per year who attend the radiotherapy unit at the University College Hospital in Ibadan either as inpatients or as outpatients. About 30 cancer patients admitted to the hospital each year are referred to the PCIN team.

Hospice Nigeria

The majority of patients seen by this home-based care programme are Nigerians recently returned home from abroad. Very few local Nigerians utilize the service.

Education and training

In the absence of formal palliative care policies, palliative care education has been undertaken by individuals.

Palliative Care Initiative, Nigeria

Olaitan Soyannwo uses her position as lecturer and senior academic to spread knowledge of palliative care.

Right now at Ibadan we have a new group in the College of Medicine and we've introduced palliative care into the curriculum of medical students and nursing students. The proposal has been sent from the Faculty, it's now awaiting approval at the College level so that once that is passed it can go into the curriculum.3

From April 2005, an oncology nurse from PCIN will undertake an 8-week course at Hospice Africa Uganda.

(p.314) Hospice Nigeria

This home-based care programme has identified the model of training used by Hospice Africa Uganda as appropriate for its training development. Nurse Olusola Fatunmbi comments:

I now know that the Uganda model is much, much more relevant to us in Africa, I mean in terms of setting something up. The facilities are very limited here, and I'm thinking that it would be easier to incorporate palliative care training and teaching into the existing health care model that is within the country, so that everybody, even right up to the village health workers, are trained. Because in terms of malaria, for example, they are training people to give home care; so if people are trained at every level on palliative care, then even if the patients are discharged to distant places, you can have some contact point. And after training a few experts in palliative care—I mean doctors, nurses, social workers—they can now train the others locally. That's the way.4

History and development of hospice—palliative care in Nigeria

Palliative Care Initiative, Nigeria

As Professor of Anaesthesia and Dean of Clinical Sciences at the College of Medicine, Olaitan Soyannwo developed an interest in pain management, especially of patients undergoing acute surgery and trauma. Expanding her interest to cancer pain, she attended the World Pain Congress in 1996 and thereafter established a palliative care team in her home country. The Palliative Care Initiative, Nigeria is being registered as an NGO. Three members of the group have experience in palliative care.

Hospice Nigeria

Olusola Fatunmbi is a nurse and became aware of international hospice programmes during the 1990s. A combination of training courses at St Christopher's Hospice in the UK and a visit by Anne Merriman to Nigeria provided her with the confidence to establish a home-based care programme in Lagos for people living with terminal illness.

Life/oral histories

Professor Olaitan Soyannwo—dean of clinical sciences, College of Medicine, University of Ibadan: interviewed by David Clark, 4 June 2004. Length of interview (West Africa group): 40 min.

Professor Olaitan Soyannwo explains how her interest in pain management arose out of seeing the suffering of surgical and trauma patients. Realizing that cancer patients received no pain management at all, she attended the World Pain Congress of the International Association for the Study of Pain (IASP) in 1996 and returned to Nigeria inspired to establish a pain and palliative care team at the University Teaching Hospital. This led to inauguration of the Society for the Study of Pain which is now a chapter of IASP; the Palliative Care Initiative, Nigeria to be established by her team. She lists the fora through which she (p.315)                       Nigeriaspreads the word of palliative care principles, including the West African College of Surgeons and the Faculty of Anaesthesia. Advocacy for palliative care and accessibility to oral morphine is a priority. Introduction of palliative care methods into the curriculum for medical and nursing students has been presented for ratification by the university authorities. Hospice Uganda has been the model for training health professionals. Without oral morphine in the country, health professionals do what they can with injectable morphine. Beginning with cancers of the breast and cervix, this group of professionals is developing a protocol of holistic care that can be applied to other conditions, including HIV/AIDS. The hospital is already registered for ARV therapy and prevention of mother to child transmission. She hopes that palliative care will be implemented by these programmes. Turning to the APCA and her role as board member, Olaitan Soyannwo reflects on Anne Merriman's efforts to introduce palliative care to Nigeria before moving to Kenya and Uganda. She hopes that APCA will give the necessary impetus to the implementation of palliative care by both the public health system and the private sector in Nigeria. She identifies the need to form a national palliative care association in the country in order to gain an accurate picture of the various services.

Olusola Fatunmbi—nurse, founder of Hospice Nigeria: interviewed by David Clark, 4 June 2004. Length of interview (West Africa group): 40 min.                      Nigeria

Olusola Fatunmbi attended the Sixth International Conference at St Christopher's Hospice in 1991 and was inspired to return to Nigeria to implement home-based palliative care. Having met Anne Merriman at the conference, she invited her to Nigeria in 1993 to advocate with the Ministry of Health for the necessary systems to be put in place for palliative care. Talks were held at the Lagos Teaching Hospital, but there was little political will at the time to embrace this medical speciality. Having attended further palliative care courses at St Christopher's Hospice, she began to network with an oncologist in the region who shared her vision of home-based care for the needy. Establishing a home-based care service with her husband and other interested professionals, she facilitates palliative care for many Nigerian patients referred from St Christopher's Hospice. She describes how oral morphine is unavailable in Nigeria, necessitating patients arriving from the UK with their own supply of palliative drugs. Referrals of patients from the diaspora continue to account for the majority of her patients. Olusola Fatunmbi gives a moving account of one of her patients whose symptoms were well controlled using locally available vegetables. She concludes by sharing her vision for palliative care education to be incorporated into existing health care systems in Africa in general and Nigeria in particular, using the model championed by Hospice Africa, Uganda.

(p.316) Public health context

Population

Nigeria is Africa's most populous country (137.25 million), it is composed of 〉 250 ethnic groups; the following are the most populous and politically influential: Hausa and Fulani 29 per cent, Yoruba 21 per cent, Igbo (Ibo) 18 per cent, Ijaw 10 per cent, Kanuri 4 per cent, Ibibio 3.5 per cent and Tiv 2.5 per cent

Religious groups include: Muslim 50 per cent, Christian 40 per cent and indigenous beliefs 10 per cent.9

Epidemiology

In Nigeria, the WHO World Health Report (2004) indicates an adult mortality10 rate per 1000 population of 453 for males and 392 for females. Life expectancy for males is 48.0; for females 49.6. Healthy life expectancy is 41.3 for males; and 41.8 for females.11

Nigeria is one of the worst HIV/AIDS-affected countries in Western Africa. Estimates suggest that in Nigeria, between 2.4 and 5.4 million people were living with HIV/AIDS at the end of 2003. In the same year, up to 490 000 adults and children are thought to have died from the disease (Table 15.2).

Unaids Reports:

While Nigeria's infection rate is lower than those of neighbouring countries, it nonetheless represents higher number of infections, given the large population; the country now has the highest number of HIV/AIDS-infected adults in West Africa. HIV/AIDS was first reported in Nigeria in 1986. Since then, the epidemic has been growing rapidly. In 2002 alone, more than 200,000 AIDS-related deaths occurred, and it was estimated that Nigeria had more than one million children orphaned by AIDS. Many factors that favour a rapid spread of the virus are prevalent in Nigeria, including high mobility, trafficking of young girls, marginalization of women, poverty, social and economic inequality, and specific socio-cultural practices. The ‘Next Wave of HIV/AIDS’ report of the US National Intelligence Council predicts an estimated 10–15 million people living with HIV in the country by 2010.

Table 15.2 Nigeria HIV and AIDS estimates, end 2003

Adults (15–49) HIV prevalence rate

5.4 per cent

(range: 3.6–8.0 per cent)

Adults (15–49) living with HIV

3 300 000

(range: 2200000–4 900000)

Adults and children (0–49) living with HIV

3600000

(range: 2400000–5400000)

Women (15–49) living with HIV

1900000

(range: 1200000–2700000)

AIDS deaths (adults and children) in 2003

310000

(range: 200000–490000)

(p.317) Nigeria has put in place the necessary coordinating and decision-making bodies: the Presidential AIDS Council is chaired by the president of the country and includes the main line ministries. The federal coordination mechanism, the National Action Committee on AIDS (NACA), has been fully established with adequate infrastructure and capacity. Civil society participation in the fight against HIV/AIDS has been institutionalized through the establishment of coordination mechanisms such as the Network of People Living with HIV in Nigeria (NEPWAN), the Civil Society Consultative Group on HIV/AIDS in Nigeria (CiSCGHAN), the Faith-based Forum on HIV/AIDS, and the Nigeria Business Council on HIV/AIDS (NIBUCAA). The timeframe of the HIV/AIDS Emergency Action Plan (HEAP) 2000–2003 has elapsed and a review of the HEAP is being planned in the context of the participatory development of the new National HIV/AIDS Strategic Framework 2005–2009. Preparations for the drafting of the National Health Sector Strategic Plan and an advocacy strategy are well under way.12

Health care system

In 2001, the total per capita expenditure on health care was Intl $31; 3.4% of GDP13 (Appendix 3).

The WHO overall health system performance score places Nigeria 187th out of 191 countries.14

Political economy

Before the colonial period, the area that comprises modern Nigeria had an eventful history. More than 2000 years ago, the Nok culture in the present Plateau state worked iron and produced sophisticated terra cotta sculpture. In the northern cities of Kano and Katsina, recorded history dates back to approximately 1000 AD. In the centuries that followed, these Hausa kingdoms and the Bomu empire near Lake Chad prospered as important terminals of north-south trade between North African Berbers and forest people who exchanged ivory and kola nuts for salt, glass beads, coral, cloth, weapons, brass rods, and cowrie shells used as currency. In the south-west, the Yoruba kingdom of Oyo was founded about 1400, and at its height from the seventeenth to nineteenth centuries attained a high level of political organization and extended as far as modern Togo. In the south central part of present-day Nigeria, as early as the fifteenth and sixteenth centuries, the kingdom of Benin had developed an efficient army; an elaborate ceremonial court; and artisans whose works in ivory, wood, bronze and brass are prized throughout the world today. In the early nineteenth century, the Fulani leader, Usman dan Fodio, launched an Islamic crusade that brought most of the Hausa states and other areas in the north under the loose control of an empire centred in Sokoto.15

Since independence, the economy has increasingly come under the influence of the oil industry which has moved the country away from its agricultural base. However, oil has affected the way in which successive military regimes have approached economic management as well as investment and consumption patterns.16 The capital-intensive oil sector provides 20 per cent of GDP, 95 per cent of foreign exchange earnings and about 65 per cent of budgetary revenues. The largely subsistence agricultural sector has failed to (p.318) keep up with rapid population growth—Nigeria is Africa's most populous country—and the country, once a large net exporter of food, now must import food. The IMF have proposed a number of market-oriented reforms, such as modernization of the banking system, the curbing of inflation by blocking excessive wage demands, and the resolution of regional disputes over the distribution of earnings from the oil industry.

During 2003, the government deregulated fuel prices and announced the privatization of the country's four oil refineries. GDP growth will probably rise marginally in the future, led by oil and natural gas exports. The country faces the daunting task of rebuilding a petroleum-based economy and institutionalizing democracy if it is to build a sound foundation for economic growth and political stability.9

There has been a long-term, halting diffusion of the liberal democratic state. Key contextual factors of transition include: international pressure for democratization, geopolitical dynamics of pro-democracy coalitions, and local and translocal political economic relationships. Nigeria, under the military governments of Babangida and Abacha (1985–1998), was in a perpetual half-hearted state of transition to democracy. The country's status as a major oil exporter allowed it relative immunity from international pressure for democratization. Mobilization for state creation served to divide opposition to military government because it focused attention at the local scale, as new state movements competed for access to centrally controlled resources and political recognition of their ethno-regional group(s).17 In 1999, following 15 years of military rule, a new constitution was adopted and a peaceful transition to civilian government was eventually completed; the first civilian transfer of power in Nigeria's history.

GDP per capita is Intl $915 (Appendix 4).

References

Bibliography references:

1 Report of the United Nations Development Programme 2004 (HDI 2002). Launched by the United Nations in 1990, the Human Development Index measures a country's achievements in three aspects of human development: longevity, knowledge and a decent standard of living. It was created to re-emphasize that people and their lives should be the ultimate criteria for assessing the development of a country, not economic growth. Current values range from 0.956 (Norway, first of 177 countries) to 0.273 (Sierra Leone, 177th out of 177 countries). Countries fall into one of three groups: countries 1–55 = high development; 56–141 = medium development; 142–177 = low development. See: http://hdr.undp.org/statistics/data/indic/indic_8_1_1.html

2 Personal communication: Olaitan Soyannwo-25 March 2005.

3 IOELC interview: Olaitan Soyannwo-4 June 2004.

4 IOELC interview: Olusola Fatunmbi-4 June 2004.

5 Engendering Bold Leadership. The President's Emergency Plan for AIDS Relief. First Annual Report to Congress, 2005: 115. http://www.state.gov/documents/organization/43885.pdf

6 Merriman A. Hospice Africa Uganda: 10th Anniversary (1993–2003). In: Proceedings from Palliative Care: Completing the Circle of Care, 16–17 September 2003.

7 International Narcotics Control Board. Narcotic Drugs: Estimated World Requirements for 2004. Statistics for 2002. New York: United Nations, 2004.

8 ‘The term defined daily doses for statistical purposes (S-DDD) replaces the term defined daily doses previously used by the Board. The S-DDDs are technical units of measurement for the purposes (p.319) of statistical analysis and are not recommended prescription doses. Certain narcotic drugs may be used in certain countries for different treatments or in accordance with different medical practices, and therefore a different daily dose could be more appropriate’. The S-DDD used by the INCB for morphine is 100 mg. International Narcotics Control Board. Narcotic Drugs: Estimated World Requirements for 2004. Statistics for 2002. New York: United Nations, 2004: 176–177.

9 See: http://www.cia.gov/cia/publications/factbook/geos/ni.html

10 This refers to adult mortality risk, which is defined as the probability of dying between 15 and 59 years.

11 See: WHO statistics for Nigeria at: http://www.who.int/countries/nga/en/

12 http://www.unaids.org/en/geographicalarea/bycountry/nigeria.asp

13 Total health expenditure per capita is the per capita amount of the sum of Public Health Expenditure (PHE) and Private Expenditure on Health (PvtHE). The international dollar is a common currency unit that takes into account differences in the relative purchasing power of various currencies. Figures expressed in international dollars are calculated using purchasing power parities (PPP), which are rates of currency conversion constructed to account for differences in price level between countries.http://www3.who.int/whosis/country/compare.cfm?countrys&indicator strPcTotEOHinIntD2000&language+english

14 This composite measure of overall health system attainment is based on a country's goals relating to health, responsiveness and fairness in financing. The measure varies widely across countries and is highly correlated with general levels of human development as captured in the human development index. Tandon A, Murray CLJ, Lauer JA, Evans DB. Measuring Overall Health System Performance for 191 Countries. GPE Discussion Paper Series: No. 30; WHO.

15 US Department of State, Bureau of Public Affairs, Office of Public Communication. Background Notes on Countries of the World 2003. Washington, DC: US Department of State, Bureau of Public Affairs, Office of Public Communication, 2003.

16 World of Information Business Intelligence Report, 2001. Nigeria: Economy, Politics and Government. Business Intelligence Report: Nigeria 2001;1(1): 1–46.

17 Kraxberger B. Geo-historical trajectories of democratic transition: the case of Nigeria. Geojournal 2004; 60(1): 81–92. (p.320)