Mahdi Garba (Lead writer)
Maimuna Hassan, a 37 year old resident of Dass Local Government Area (LGA) of Bauchi had prolonged labour during the birth of her second child, resulting in Vesicovaginal Fistula (VVF) — an unwanted opening that forms between the bladder and the wall of the vagina.
She explained that she had a failed medical procedure in Dass and was later referred to the capital city at least 63 kilometres away, “from there I was referred to the National Obstetric Fistula Centre (NOFIC) in Ningi”, the mother of two recounted. “They did not charge me for the treatment. They also gave me free food throughout my stay. Everything is free in this hospital.”
Image credit: Nigeria Health Watch
Nigeria has the highest prevalence of VVF in the world, with 400,000 to 800,000 women living with the condition and about 12,000 new cases annually. This is followed by Ethiopia, Bangladesh, the Democratic Republic of Congo (DRC) and Uganda. The challenges that result in the cases of VVF in these countries are mostly due to limited access to quality maternal healthcare, early marriages, and other socioeconomic barriers.
Women with VVF often face social stigma, economic hardship, and poor quality of life. Despite efforts by healthcare organisations, inadequate medical facilities and cultural barriers hinder progress in reducing VVF cases in the state.
“I have recovered. Out of the four post-repair sessions, I have done three. Only one is left for me. I will advise women at the stage of giving birth to go to the big hospitals. I also told many people in my community about the warm reception in this hospital,” Maimuna added.
As part of its efforts to reduce maternal morbidity and mortality while promoting equitable access to quality healthcare for women, the National Health Insurance Authority (NHIA), through the Fistula Free Programme (FFP), provides free fistula surgeries, comprehensive treatment packages, and support services such as feeding, transportation, post-care follow-ups, including family planning services, and health insurance enrolment.
Patient stability first
From July 2024, when the FFP commenced, 17 health facilities across Nigeria have benefitted, and 1,855 have received successful treatment for obstetric fistula, NHIA noted. At Ningi Fistula Centre alone, about 308 repairs have been conducted. According to NHIA, this intervention has not only restored women’s health but also renewed their hope and dignity.
According to Muhammad Sani Hardawa, Head of Medical Social Services at NOFIC in Ningi and NHIA-FFP committee member, the primary focus is on addressing patients’ trauma. This approach is necessary due to the rare nature of fistula, which often means patients are the only ones in their families dealing with the condition, making their individual experiences unique and requiring personalised care.
“When they come, to stabilise them, we offer psychosocial counselling so that they can understand that it is not the beginning and end of life for them. Through that, we improve their social condition”, he explained.
Muhammad explained that when new patients come into the facility, they teach them and their caregivers what a fistula is, its repair process and follow-up sessions. For those who have had the surgery, they engage them daily on the need for compliance with the instructions they get from doctors and nurses.
“The normal timeframe for fistula treatment is basically six months. It starts counting from the day of surgery. After the surgery, [the patient] can stay in the hospital for 15 days with a catheter, then after removing the catheter on the 14th day, she undergoes bladder training for a day,” Muhammad stated.
On the 16th day, the patient gets discharged. “After her discharge, she continues her management at home. We give her what she can do at home like drinking clean water, abstinence from sexual intercourse, laborious work. After four weeks, she is expected to come back for the first follow-up. Then we evaluate the condition until after eight weeks, then for another eight weeks, and then the last follow-up, which marks the end. That is when we will declare her fistula-free and fistula-treated.”
He noted that after six weeks, the patient can return to her family and continue with her matrimonial life on the condition of delaying pregnancy for at least six months to one year. “But we will advise her to never attempt a vaginal delivery again.”
Image credit: Nigeria Health Watch
Free Caesarean Section
In addition to providing free fistula repair, patients also have access to Caesarean Section (CS) services. Furthermore, they can receive care at NOFIC’s maternity facility without incurring any costs, ensuring comprehensive and affordable healthcare for those in need.
“[A patient] will continue to have free CS depending on the number of deliveries she may have, but strictly under the family planning method we placed her on,” Hardawa pointed out.
He added that whenever they receive a call from patients in remote areas who cannot afford transport fare to the facility, they are advised to borrow money and come. When NHIA pays out after the treatment, the patient can pay back, noting that this support from NHIA has increased the level of accessibility of their services.
Obstacles and challenges
Hardawa, however, observed that some patients exceed the three weeks they are expected to spend in the hospital, which strains the budget. As some patients do not heal within the stipulated timeline.
Some patients also come to the facility with underlying medical conditions that are not covered by the FFP.
Another challenge faced by the FFP is beneficiary identification. Many women from rural communities lack proper identification documents, which necessitates collaboration with the National Identity Management Commission (NIMC) to ensure they receive a National Identification Number before discharge.
The NHIA has identified additional challenges, including processing delays and administrative bottlenecks. Although systems have been streamlined, occasional delays in claims processing have hindered timely reimbursements to healthcare facilities, ultimately affecting their financial stability.
In addition, many beneficiaries, particularly those in hard-to-reach areas, are hard to track post-treatment, complicating efforts to ensure consistent follow-up care and social reintegration.
According to Hardawa, another challenge arises when patients, after recovering, face opposition from their husbands or families regarding family planning decisions and CS plans that were previously agreed upon during the repair process. This can create new challenges for the patients, particularly when their family members do not support their reproductive choices.
However, to address patients’ evolving needs, the NHIA stated that it is strengthening mechanisms for effective post-treatment follow-up, especially for women in remote or marginalised areas, so it can better support their long-term recovery and social reintegration.
It also plans to invest in digital tools to track patient data in real-time, improve beneficiary identification, and enhance communication between healthcare providers and community outreach teams. As part of the lessons learnt in the programme, the NHIA concluded that it will deepen collaboration with its stakeholders, including state health agencies, third-party administrators, and community-based organisations, to ensure the sustainable growth of the FFP.