A Corridor of Contrasts

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

The Abidjan to Lagos Transport Corridor

…a road winds along the West African coast…

…carrying 44 million people and 130 million
tons of goods every year.

The five countries connected by this road are as different as they are similar, both
within and across their borders.

The coastal cities, Abidjan, Accra, Lome, Cotonou, and Lagos, are growing rapidly and a
middle class is emerging in each.

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.

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.

“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

Poor urban women
struggle to receive
adequate antenatal
care when pregnant.

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

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.

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

The impact of these inequities is both immediate and life-long.

Poor children in cities are more likely to die before the age of five than
children in any other socioeconomic group.

109
72
106
177
85
134
188
121
153
Nigeria 2008 Ghana 2008 Benin 2006
Under-five mortality per 1,000 live births

And in some countries, their likelihood of dying is increasing.

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

They are also more likely to be malnourished, which hinders their success in
school and can permanently stunt their physical and mental growth.

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
Nigeria Ghana Benin

Cities along the corridor have grown faster than ministries of health can keep up.

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.

Furthermore, many poor urban residents feel unwelcome and disrespected in
public health facilities.

“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

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.

This growing trend, combined with cultural norms that embrace the informal sector,
leaves residents vulnerable to exploitation and poor care.

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.

“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.”

Seventy to eighty percent of West Africans use traditional medicine to treat
conditions such as malaria, hypertension, diabetes, HIV, and tuberculosis .

“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.

In Ghana and Nigeria,
traditional medicine is
the first line treatment
for 60 percent of
children with malaria.

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.

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.

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.

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.

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.

“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.”

Just 23 percent of people in need of antiretroviral medication in Nigeria
receive it.

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.

A regional approach to HIV education has improved knowledge and condom use
among these groups, but more must be done to provide treatment.

The benefits that the increased flow of money, jobs, and people to the
corridor’s cities will bring, fill the region with vitality.

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.

As always, West Africans will
continue to improvise,
adjust, and improve upon
the lives they were born
into.

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.

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

A Corridor of Contrasts

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