A review of the Nigeria Demographic and Health Survey (NDHS) for 2018 indicates that a crucial opportunity has been missed. While the survey has seen some improvements since the year it started, once again, data on non-communicable disease (NCD) is absent from this all-important document.
The Demographic and Health Survey (DHS) is a household survey that provides data on a variety of monitoring and impact evaluation indicators in the health domain.
It is significant for being perhaps the greatest source for generating health indices in a country and indeed in Nigeria. This worldwide survey programme was devised by the United States Agency for International Development (USAID) along with other international donor organisations; to support countries such as Nigeria in conducting household sample surveys within their national boundaries.
These surveys are even more important in the Nigerian context where data and surveillance systems are optimistically limited and at worst non-existent, thus the NDHS serves an even greater purpose in the country of being a primary data repository. This is no understated role, as data is imperative in all spheres of health and this is how new and emerging health issues are detected. It also serves as an indicator of progress made in pre-existing interventions and how health policy and strategies are directed and guided.
Samuel Oyeniyi, a Deputy Director in the Safe Motherhood Division at the Federal Ministry of Health, who worked on the NDHS, said “the aim of the Nigeria Demographic and Health Survey is focused on health planning in Nigeria. It is the most acceptable source of data on health indices in the eyes of the ministry.
“This is not to say that the others are not acceptable but this is the most for health and policy planning,” Mr Oyeniyi said.
“Going by what the preliminary report of the NDHS shows, this is an improvement in health indicators in the country,” Mr Oyeniyi said.
The 2018 NDHS is the sixth in the series with the previous ones undertaken in 1990, 1999, 2003, 2008 and 2013. It has been conducted in partnership with the National Population Commission (NPopC) and the Federal Ministry of Health. The release of this NDHS has been anxiously awaited by the government and partners, policymakers, professionals in their various fields and Non-Governmental Organisations (NGOs), all of whom benefit from necessary data they need for their work. As the former Nigerian Minister of Health, Isaac Adewole, stated, “the 2018 Nigeria Demographic and Health Survey would provide information to address the health challenges in Nigeria for evidence-based planning”.
What is different about this particular year? Many, including the Federal Minister of Health, have noted that “the 2018 NDHS, unlike the previous exercises, has been designed with additional components on malaria and genotype testing.”
This is to say that this year, the NDHS sought to take blood samples from Nigerians for malaria, anaemia and genotype testing.
The NDHS aims to serve as a means to “better understand the population, health, and nutrition situation”, and so it is a gaping error that data on non-communicable diseases is once again omitted from this report.
Since the first demographic health survey conducted in 1990 in Nigeria, the survey has very gradually evolved to include information relevant to the time. For instance, gender-based violence, an issue of utmost importance, was previously omitted from this report. However, with time and growing awareness, the fight for women’s empowerment has emerged at the forefront of topical issues and made its way into the DHS target topics.
It is thus surprising that despite the attempt at evolving the NDHS into a document relevant for the times, it has erroneously shunned the subject of non-communicable diseases.
The World Health Organisation (WHO) reported in 2018 that mortality rates attributed to non-communicable diseases account for 15 million deaths each year. A significant 85 per cent of these deaths were classified as premature and in low- and middle-income countries.
So, with this in mind, why is the issue of non-communicable diseases or indeed their biomarkers (biological marker used in identifying a pathological or physiological process of disease like blood pressure testing, body mass index, fasting blood glucose and blood cholesterol) not being targeted?
Considering that blood has already been taken from 14,000 households of consenting Nigerians for testing, this proposed less invasive means of collecting biomarkers such as blood pressure tests which highlight a number of cardiovascular events in the body could have very easily been incorporated into this one.
Countries in Africa where the DHS has in some way collected data, whether it be biomarkers or self-reported data on any NCD, include: Benin where data on hypertension and diabetes were collected; Burkina Faso, data on cervical cancer; Côte d’Ivoire, data on breast and cervical cancer; Egypt, data on hypertension and diabetes; Lesotho, data on hypertension, diabetes, breast and cervical cancer; Namibia, data on hypertension, diabetes, prostate, breast and cervical cancer; South Africa, data on hypertension, diabetes, prostate, breast and cervical cancer; and Tanzania with data on cervical cancer.
In South Africa, for instance, we find that the rates of these same conditions (hypertension, diabetes, prostate cancer, breast cancer and cervical cancer) in relation to the population, is just as relevant if not more so in Nigeria. The World Health Organisation’s country profile shows that where the rate of total NCD-attributed death in South Africa was 269,500 in 2016, the rates in Nigeria in this same year was strikingly about three times that number at 617,300.
The civil society organisation PACFAH (Partnership for Advocacy in Child and Family Health), when commenting to PTCIJ on the omission of NCDs, said that while they commend the Federal Ministry of Health on completing the report of the NDHS, “the narrative that non communicable diseases (NCDs) affects only the developed countries has been made obsolete by data series evidencing that Nigeria is undergoing epidemiological transition with incremental rise of NCDs.”
It appears Nigeria and those responsible for conducting the NDHS might be following the recommendations of a report entitled ‘The Measurement of non-communicable diseases in 25 Countries with Demographic and Health Surveys’ where justification appears to have been provided for the exclusion of NCD data in certain regions.
The report says, “that the expansion of NCD data collection must necessarily be judged by weighing increased cost against the potential utility of the data”. The report further stated that “systematic data collection on NCDs may be more relevant in middle-income countries than in low- income countries”.
Contrary to this report, all the available evidence regarding the burden of NCDs tells us that lower and middle-income countries do indeed suffer more from NCDs. Notably in 2012, the age-standardised NCD attributed deaths were 673 deaths per 100,000 people, in low and middle-income countries.
To put this into perspective, the global NCD attributed deaths stood at 539 deaths per 100,000 people, in this same year.
The projections for many of these countries are even more worrying as NCDs presence in low- and middle-income countries have been described as an ‘impending disaster’ for health, societies and economies. With Nigeria classified as a lower middle-income country, one would think that this warrants intentional surveillance into this area especially because as Africa’s most populous country, Nigeria contributes significantly to the global burden.
Suggesting a new focus on NCDs in the NDHS does not take from the importance of prioritising communicable diseases, but rather proposes a joint focus on both; with the former representing a dominant health challenge in Nigeria and the latter, an imminent one that is prevalent. After all, we are experiencing what is called the double burden; characterised by the challenge of the emerging (HIV/AIDS, hepatitis) and re-emergence (cholera, malaria and tuberculosis) of communicable and infectious disease as well as a rise in the number of chronic illnesses (cardiovascular disease, cancer, diabetes mellitus and chronic respiratory illnesses), both concurrently existing.
PACFAH explained: “the burden of NCDs and its avoidable aetiology has been established in Nigeria, there is a need for strategic individual and population-wide prevention oriented interventions that are properly integrated into the national health system.”
They added “this prevention strategy should be evidenced by the data from the NDHS”. More so, this is necessary for determining many of the strategies in our collective reach toward the UN’s Sustainable Development Goals (SDG). With data on NCDs, corresponding action plans can be developed towards the greater cause of meeting the SDG target of reducing NCD attributed mortality by one third by 2030. Nigeria could also be among the low and middle-income countries which, according to the WHO, can collectively save an estimated $7 trillion in economic losses attributed to NCDs between 2011–2025.
The Ministry of Health remarks on the issue
Mr Oyeniyi from the department on Family Health also commented on the issues.
“It is not entirely omitted”. He said “this report that has been made available to the public is a preliminary report, so before making assertions, Nigerians who make use of the data should await the final report”. “It is in the works and would likely be released August or September,” he promised. It is also worth noting, he said, that “Sickle cell anemia is in the preliminary report and this is an NCD,” he said.
However one could argue that sickle cell anemia is not a noncommunicable disease in that it is not acquired from the customary way, risk factor way. On the contrary, sickle cell is a congenital but also a non-infectious disease, placing it somewhere in between. An author argues that sickle cell can be classed as a neglected tropical disease (NTD). This, Russell Ware, says, is because sickle cell anemia falls into the NTD characteristics of having (1) worldwide distribution; (2) high burden among impoverished populations; (3) high morbidity and mortality rates with overall quality of life reduced; (4) probability of comorbidities; (5) relatively simple diagnosis methods; and (6) inexpensive treatment options. Hence he said sickle cell is “long overdue for membership in this elite but tragic club of global medical maladies”