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A Corridor of Contrasts

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On the road from Abidjan to Lagos, urbanization offers risk and opportunity, hardship and hope

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A Corridor of Contrasts

  1. 1. A C O R R I D O R O F C O N T R A S T S On the road from Abidjan to Lagos, urbanization offers risk and opportunity, hardship and hope AFRICAN STRATEGIES FOR HEALTH
  2. 2. The Abidjan to Lagos Transport Corridor
  3. 3. From Abidjan…
  4. 4. …to Lagos…
  5. 5. ….through Accra…
  6. 6. …Lomé…
  7. 7. …and Cotonou…
  8. 8. …a road winds along the West African coast…
  9. 9. …a road winds along the West African coast…
  10. 10. …a road winds along the West African coast…
  11. 11. …carrying 44 million people and 130 million tons of goods every year.
  12. 12. …carrying 44 million people and 130 million tons of goods every year.
  13. 13. …carrying 44 million people and 130 million tons of goods every year.
  14. 14. The five countries connected by this road are as different as they are similar, both within and across their borders.
  15. 15. The five countries connected by this road are as different as they are similar, both within and across their borders.
  16. 16. The five countries connected by this road are as different as they are similar, both within and across their borders.
  17. 17. The five countries connected by this road are as different as they are similar, both within and across their borders.
  18. 18. The coastal cities, Abidjan, Accra, Lome, Cotonou, and Lagos, are growing rapidly and a middle class is emerging in each.
  19. 19. The coastal cities, Abidjan, Accra, Lome, Cotonou, and Lagos, are growing rapidly and a middle class is emerging in each.
  20. 20. With this growth comes opportunity, but also risk. As urban populations increase, so do informal settlements, where access to health and social services is challenging.
  21. 21. With this growth comes opportunity, but also risk. As urban populations increase, so do informal settlements, where access to health and social services is challenging.
  22. 22. Cities on the corridor are growing 3 to 4% per year. The proportion of urban populations living in slums is either growing or declining by just .5 to 1.3% per year.
  23. 23. “There is more unmet need in peri-urban slums than anywhere else in West Africa. We place community health workers as close to people as possible in rural areas and reinforce the systems in cities, but we never think of the people in between. They are in that no-mans land. That is where there is no health system.” - Dr. Rouguiatou Diallo, EngenderHealth
  24. 24. Poor urban women struggle to receive adequate antenatal care when pregnant.
  25. 25. 90 93 91 96 88 91 43 34 50 73 50 55 67 42 72 81 32 35 1990 2008 1993 2008 1996 2006 Percent of women who receive antenatal care urban highest quintile rural urban poorest quintile BeninNigeria Ghana
  26. 26. This photo was taken in an Abidjan slum on January 28, 2015. And poor urban children are the least likely of any socioeconomic group to receive preventive health care.
  27. 27. 65 94 75 38 90 64 33 86 57 Nigeria 2008 Ghana 2008 Benin 2006 Percent of children fully immunized against measles urban rural urban poorest quintile
  28. 28. The impact of these inequities is both immediate and life-long.
  29. 29. Poor children in cities are more likely to die before the age of five than children in any other socioeconomic group.
  30. 30. 109 72 106 177 85 134 188 121 153 Nigeria 2008 Ghana 2008 Benin 2006 Under-five mortality per 1,000 live births urban rural urban poorest quintile
  31. 31. And in some countries, their likelihood of dying is increasing.
  32. 32. 209 177 128 85 174 188 116 121 1990 2008 1993 2008 Increase in under-five mortality per 1,000 births for poor urban children in Nigeria and Ghana rural urban poorest quintile Nigeria Ghana
  33. 33. They are also more likely to be malnourished, which hinders their success in school and can permanently stunt their physical and mental growth.
  34. 34. 31.1 20.2 35.8 45.0 31.9 46.8 45.0 30.7 47.1 2008 2008 2006 Chronic malnutrition in children under five years of age urban rural urban poorest quintile Nigeria Ghana Benin
  35. 35. Cities along the corridor have grown faster than ministries of health can keep up.
  36. 36. In many places, even those who can afford to pay for services must wait in interminable lines for basic care, often finding that the facility is out of the medicine that they need.
  37. 37. Furthermore, many poor urban residents feel unwelcome and disrespected in public health facilities.
  38. 38. “Those services are not for us. Because we are dirty, they don’t treat us well.” - Fofana Karamoko, a trucker from Abidjan, speaking about public health centers
  39. 39. Filling the void left by the government system, private providers and medicine sellers—some qualified, some not—are setting up shop at record pace in these coastal cities.
  40. 40. This growing trend, combined with cultural norms that embrace the informal sector, leaves residents vulnerable to exploitation and poor care.
  41. 41. One quarter of Benin’s registered health care providers are privately employed. As many as 88 percent of private providers may be unregistered and thus could be entirely unqualified. This growing trend, combined with cultural norms that embrace the informal sector, leaves residents vulnerable to exploitation and poor care.
  42. 42. “Those who are illiterate have no way of knowing the quality of the care they are receiving. But if someone makes them feel comfortable, they will return,” she said, explaining why the poorest residents of Cotonou are most likely to use unqualified private providers. “They don’t see the difference. The baby comes out on its own whether the mother is at home or the hospital. If a mother or a baby dies, they see it as a matter of destiny.”“Those who are illiterate have no way of knowing the quality of the care they are receiving. But if someone makes them feel comfortable, they will return,” said Dr. Laurinda Gbagui Saizonou, Médecin Chef, at the Cotonou 4 Health Center. “They don’t see the difference. The baby comes out on its own whether the mother is at home or the hospital. If a mother or a baby dies, they see it as a matter of destiny.”
  43. 43. Seventy to eighty percent of West Africans use traditional medicine to treat conditions such as malaria, hypertension, diabetes, HIV, and tuberculosis .
  44. 44. “Everyone consults traditional healers first. It is a problem because then they wait until they are too sick to come here.” - Dr. Hector Atiobgé, Médecin Chef at the Grand Popo Health Center in Benin.
  45. 45. In Ghana and Nigeria, traditional medicine is the first line treatment for 60 percent of children with malaria.
  46. 46. Fifty to sixty percent of all medicines sold in the region, many of them at roadside stands or privately-owned pharmacies, are counterfeit or sub-standard.
  47. 47. A study found that 31 percent of facilities in Benin were out of stock of antimalarial medication. Of those that had stock, just 5 percent were public facilities.
  48. 48. The quality of care provided in the private sector is variable, but with creative and coordinated support, it could be a powerful resource to improve health equity in urban populations.
  49. 49. From the beginning of the epidemic, urban life has fueled transmission of HIV. AIDS is the leading cause of death in Cote d’Ivoire and Togo and the second and third in Nigeria and Ghana, respectively.
  50. 50. Prevalence rates among sex workers, men who have sex with men, and truck drivers are as much as 15 times higher than in the general adult population along the corridor.
  51. 51. “Keeping commercial sex workers and men who have sex with men in care seems to be even harder than the general population,” said Serwaa Owusu-Ansah of FHI360’s SHARPER project. “They are more mobile and don’t trust providers.”
  52. 52. Just 23 percent of people in need of antiretroviral medication in Nigeria receive it.
  53. 53. Among sex workers in Cote d’Ivoire, 25 percent stopped treatment after six months and after three years less than 50 percent were still taking their medication.
  54. 54. A regional approach to HIV education has improved knowledge and condom use among these groups, but more must be done to provide treatment.
  55. 55. The benefits that the increased flow of money, jobs, and people to the corridor’s cities will bring, fill the region with vitality.
  56. 56. To harness this energy, governments and international partners must act quickly to support a regional approach to providing equitable access to high- quality health care for all residents.
  57. 57. As always, West Africans will continue to improvise, adjust, and improve upon the lives they were born into.
  58. 58. With support from their governments and international donors, the residents of the Abidjan to Lagos transport corridor will be well placed to act on the power of urbanization and create a healthier, more prosperous future.
  59. 59. Author: Mary K. Burket, Management Sciences for Health (MSH) Photographer (except photos 4, 12, 31): Pinky Patel, USAID Photo 4, Kunle Ajayi; 12, Olunosen Louisa Ibhaze ; 31 Akintunde Akinleye The author and photographer would like to thank the countless people along the corridor, and in the US, who shared their expertise or lent their time to assist with logistics of the trip. These include, but are not limited to: Dr. Joseph Addo-Yobo, SHOPS Ghana; Armand Aguidi, PSI Benin; Francis Aduteye, MSH Ghana; Ayi d’Almeida; Natacha d’Almeida, MSH Benin; Dr. Eloi Amégan Ayaménou, EngenderHealth Togo; Dr. Hortense Angoran-Benie, FHI 360 Côte d’Ivoire; Donatien Beguy, African Population and Health Research Center (APHRC); Dr. Nana Fosua Clement, FHI360 Ghana; Christina Chappell, US Agency for International Development (USAID) Côte d’Ivoire; Donna Coulibaly, MSH Nigeria; Dr. Bedel Evi, MSH Ghana; Clea Finkle, The Bill & Melinda Gates Foundation; Nartey Tetteh David, FHI360 Ghana; Dr. Rouguiatou Diallo, EngenderHealth Togo; Adama Doumbia, MSH Côte d’Ivoire; Andrea Halverson, USAID Côte d’Ivoire; Dr. Theophilus Hounhouedo, La Nouvelle Vie; Jules Hountondji, PSI Benin; Chimaraoke Izugbara, APHRC; Dr. Edmond Kifouly; Dr. Serge Kitihoun, L’Association Beninoise Pour La Promotion De La Famille; Dr. Zipporah Kpamour, MSH Nigeria; Tony Kolb, USAID Washington; Dr. Idrissa Kone, Abidjan-Lagos Corridor Organization (ALCO); Dr. Jules Venance Kouassi, ALCO; Michelle Kouletio, USAID Benin; Dr. Tiffany Lillie, USAID Côte d’Ivoire; Dr. Margarète Molnar, UNAIDS Benin; Amarachi Obinna-Nnadi, MSH Nigeria; Ifeoluwa Ogunkanmi, MSH Nigeria; Katharine McHugh, PSI Côte d’Ivoire; Pepin Miyigbena, MSH Côte d’Ivoire; Dr. Christian Mouala, UNAIDS Togo; Dr. Antoine Ndiaye, MSH Côte d’Ivoire; Laura Nurse, EngenderHealth; Kweku Owusu, Drumming Up from Poverty; Serwaa Owusu-Ansah, FHI 360 Ghana; Dr. Edmund Rutta, MSH; Dr. Laurinda Gbagui Saizonou, Cotonou 4 Centre de Santé; John Sauer, PSI; Judicael Ses, MSH Côte d’Ivoire; Jesse Shapiro, USAID Washington; Dr. Diana Silimperi, Abt Associates; Dr. Assétina Singo-Tokofai, Ministry of Health, Togo; Andrea Sternberg, USAID Washington; Rachel Wax, PSI Côte d’Ivoire; Xavier Weti; and Sara Zizzo, USAID Washington African Strategies for Health www.africanstrategies4health.org

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