Diagnostic Radiology in Nigeria: A Country Report

Nigeria is located in West Africa. The Nigerian healthcare system is stratified into three tiers corresponding to the three tiers of government: primary (local), secondary (state), and tertiary (federal). In addition to this public health structure, private facilities play a significant role in healthcare delivery. Nigeria has a shortage of healthcare equipment and personnel, with a doctor per 1,000 population ratio of 0.17, which is one of the lowest on the African continent.


Introduction
The Federal Republic of Nigeria is located in West Africa, having boundaries with neighboring countries including Cameroon to the East, Benin Republic to the West, and Northern boundaries with Niger Republic and Chad ( Figure 1). Southwards, Nigeria is bordered by the Gulf of Guinea and the Atlantic Ocean (1). Nigeria has 36 states and a Federal Capital Territory, which is the seat of power in the city of Abuja (1). Officially, Nigeria is a secular country with a democratic system of government (2).
English is the official language, but there are hundreds of ethnic nationalities, of which Igbo, Yoruba, and Hausa are the largest. With a population estimate of 197,403,529 in 2018, Nigeria is the most populous country in Africa and seventh in the world (3). Nigeria achieved independence from Great Britain on October 1, 1960 and became a republic on October 1, 1963 (2). There was a 30-month Civil War between 1967 and 1970 that left 1-3 million people dead from warfare, disease, and starvation (4,5). Besides a brief second republic between 1979-1983, Nigeria endured almost 33 years of military rule (from 1966 until 1999) (4,5). The country returned to democratic rule in May 1999 (4).

Socioeconomic overview
Nigeria has an estimated population growth rate of 2.5% and life expectancy of 54 years (6). The Nigerian economy is the largest in Africa and twentieth largest in the world, with a GDP of 509.9 billion dollars in 2013 (7). Since 2017, the Nigerian economy has continued to show evidence of recovery, with an estimated GDP growth rate of 0.8% in 2017 which represents an improvement from the recorded -1.5% in 2016 (8). In 2018 and years ahead, the Nigerian economic outlook is encouraging, with an estimated growth rate of 2.1% in 2018 and 2.5% in 2019 (8).

Healthcare structure and stratification in Nigeria
The earliest record of the introduction of modern medical services in Nigeria dates back to the early-to mid-nineteenth century, during the various early European tours in the country (10). One of the earliest modern health care facilities in the country was a dispensary established in 1880 by the Church Missionary Society (10). The Nigerian healthcare system is stratified into three tiers corresponding to the three tiers of government: primary (local government), secondary (state government), and tertiary (federal government). At the federal level, the federal ministry of health (FMOH) is tasked with the responsibility of formulating policies and providing organizational and technical support to the healthcare system as a whole (11). The federal government is also in charge of international relations on health, health information management, and the provision of tertiary healthcare through the federal teaching hospitals, federal medical centers and federal specialist hospitals (11). The states, through the state ministry of health (SMOH), are involved in healthcare regulation and healthcare provision through the state specialists and general hospitals, while the local governments are mainly involved with primary healthcare delivery through the comprehensive and basic health centers (11). In spite of these broad categorizations, the state governments have also been involved in the provision of tertiary healthcare through the state government-owned teaching hospitals and specialist hospitals.
The healthcare structure in Nigeria is similar to what is obtainable in other countries such as Rwanda, Liberia and Ghana (12)(13)(14), in which the healthcare structure utilizes a three-tiered approach (primary, secondary and tertiary) for healthcare delivery.
Additionally, the healthcare system in these countries involves an interplay of both private and public sectors, with the private facilities being on the forefront of primary care delivery in Nigeria (15). Non-governmental organizations play a limited role in primary care delivery in Nigeria (14).

Numbers of healthcare facilities
As of March 2015, there were an estimated 23,640 healthcare facilities in Nigeria, with approximately 85.8% of these being primary healthcare facilities, 14% secondary facilities; , and 0.2% of the total figure being tertiary facilities (6). According to the Nigerian Health Sector Market Study Report of 2018 (6), at least 70% of healthcare services in the country are provided by private facilities.

Healthcare human resources (medical doctors)
As of 2018, the estimated number of registered doctors was 72,000, but only about 35,000 of these doctors were actually practicing in the country (16). Consequently, the Nigerian doctor per 1,000 population ratio is 0.17 (3,16), one of the lowest ratios on the African continent (17). There is also a shortage of other categories of health workers such as nurses, radiographers, etc. (18). Besides the shortage, the distribution of health professionals is also skewed. For example, the North-East geopolitical zone is the worst hit, with the least number of physicians per 100,000 population, while the South-West zone has the highest number of medical practitioners per 100,000 population (19). Table 1 compares the percentage gross domestic product (GDP) spent on health and number of physicians per 1,000 people in some African countries (15).

Healthcare insurance in Nigeria
The National Health Insurance Scheme (NHIS), the main health insurance program in the country, was launched on With the projected improvement in the country's economy, it is expected that there will be an improvement in the healthcare budgetary allocations as well as health insurance coverage, which has persistently been lower than international recommendations (24).
For example, in 2018, the healthcare budgetary allocation was N 340.45 billion which represented only 3.9 per cent of the country's (Federal Government) total annual budget (25). This is a far cry from the 15% of the total budget recommended by the 'Abuja Declaration' of African leaders at an African Union (AU) summit in Abuja in 2001, of which Nigeria is a signatory (25). Improved budgetary allocation to healthcare is expected to have a positive effect on health insurance policy and the practice of radiology in Nigeria.

Healthcare facilities and capability in Nigeria
A wide range of healthcare services is available in the country, ranging from primary care to tertiary level of care. Treatment of minor ailments is obtainable at both private and public primary healthcare service clinics across the length and breadth of the country, while secondary centers -termed general and state specialist hospitals -offer a wide range of specialty care, including pediatrics, obstetrics and gynecology, ophthalmology, internal medicine and general surgery services. Limited radiological services, such as ultrasound and X-ray services, are also obtainable at this level.
A more robust healthcare service delivery, with more advanced forms of the services rendered by the secondary facilities, is available at the tertiary level. More specialized services such as open-heart surgeries, neurosurgical services and organ transplant services are available in some tertiary centers across the country (26)(27)(28).
Specialized orthopedic and neuropsychiatric hospitals are also located in most geopolitical zones of the country.
Radiological services are more advanced at the tertiary level, with access to equipment such as CT and MRI scanners. Some entrepreneurial radio-diagnostic service outlets are also present in major cities of the country and offer services obtainable in the tertiary centers, often with more advanced equipment.

Regulation, policy and radiation protection
The Nigerian Nuclear Regulatory Authority (NNRA), established under the Nuclear Safety and Radiation Protection Act of 1995, is tasked with the responsibility of policymaking, regulation, and monitoring for nuclear safety and radiological protection in the country (29).

Radiology environment and structure in Nigeria
The field of radiology is still evolving. Radiologists usually assume leadership positions and administrative functions where necessary, in addition to providing interpretation for acquired medical images. Radiographers are generally responsible for acquisition of medical images. The technicians provide auxiliary services to the radiographers, but also help with medical imaging acquisition in resourcepoor settings. Biomedical engineers are tasked with repairs and equipment servicing, and medical physicists function in radiation management and control, as well as rendering quality control services where necessary. Below is a breakdown of the radiology workforce in the country.

Workforce
The diagnostic imaging workforce in Nigeria and their regulatory framework are shown in Tables 2 and 3.

Radiologists in Nigeria
The latest estimate puts the number of radiologists in Nigeria at between 250 and 300 (29,30) which is approximately one radiologist for 658,000 people. No record was found on the number of nuclear medicine specialists in Nigeria, as the field is still somewhat nascent in the country.

Radiography in Nigeria
There are about 1,318 registered radiographers in Nigeria, with an average of one radiographer to about 150,000 people (31).
The Radiographers Registration Board of Nigeria (RRBN) is the body tasked with monitoring, training, registration and licensing of qualified radiographers in Nigeria. Radiography is offered in about seven universities in Nigeria as a fiveyear degree course (34), followed by a year internship before licensure. RRBN also conducts seminars, training and other continuous professional development courses for radiographers (35).

Biomedical engineering in Nigeria
According to the WHO, there were 280 biomedical engineers in Nigeria as of 2017 (32). The field of biomedical engineering is relatively new to the Nigerian university system, with only a few universities offering biomedical engineering as a degree course (36,37).

Medical physics in Nigeria
As of 2016, the number of medical physicists in Nigeria was about 70 (33). Most medical physicists in Nigeria are employed in radiotherapy and oncology departments with a few in diagnostic radiology and nuclear medicine departments (33).
Only about six universities in Nigeria offer the medical physics curriculum, and those that offer it do so without clinical or on-the-job training components (33,38). Currently, there is no formal or official recognition for the profession of medical physics in Nigeria and as such, there is no accreditation or registration process for the proper regulation of the profession. There is, however, a Nigerian Association of Medical Physicists (NAMP), which does not serve regulatory functions (38).

Radiology training in Nigeria
The National Postgraduate Medical College of Nigeria (NPMCN) and the West African College of Surgeons (WACS) are the two colleges responsible for organizing radiology training in Nigeria. They oversee the training activities, accreditation of training facilities, certification and management of radiologists in the country (39).
Radiology trainees in Nigeria undergo at least 48 months of rigorous clinical training in diagnostic radiology, after which they can be deemed eligible to take the certification examination. Candidates have the opportunity to attempt the examinations of either or both colleges twice a year (39). The examinations are organized by the colleges in three stages: Primary examination ("Primaries"), which assesses candidates' knowledge of basic medical sciences and O-level general physics. This is usually a prerequisite examination for admission into radiology training programs.
Part 1 (Membership) examination can be taken halfway into the training, following 24 months of rigorous clinical rotations in radiology. This examination assesses candidates' knowledge of radiologic anatomy, radiology physics, and clinical radiology.
Part 2 (Fellowship) examination is the final examination prior to certification. Candidates may take the final examination after completing 24 months of active clinical rotations (post-part 1 examination success). In addition, candidates are obligated to carry out a research study under the supervision of certified trainers during this period, and submit a dissertation to the college (39).
A number of radiology-oriented update courses and conferences are organized periodically by the radiology faculty of both the West African College of Surgeons (WACS), as well as the National Post Graduate Medical College of Nigeria (NPMCN). Attendance to a specified number of update courses is mandatory for residents in training, as prerequisites for each stage of their examinations. Practicing radiologists are equally mandated to obtain a minimum of 20 continuing medical education points before being eligible for annual license renewal. Radiology subspecialty fellowship programs are not readily available in the country, as sub-specialization in the field of radiology is still in its infancy. Table 4 shows a summary of the evolving radiology sub-specialties in the country.

Equipment audit and current radiology capability
There are basic radiology equipment and resources to support the service of specialists such as physicians, surgeons, pediatricians, orthopedists, ENT surgeons, ophthalmologists, obstetricians/gynecologists, etc. in some tertiary government hospitals and private health facilities in the country. Table 5 provides a synopsis of available radiological equipment in Nigeria.

X-ray machines
X-ray machines are relatively more available in Nigeria compared to other costlier radiological equipment, with approximately 5,000 machines (40) distributed across the country in both public and private radio-diagnostic centers. It is difficult to ascertain what percentage of these machines is currently functional.

Ultrasonography
Ultrasound machines are also readily available, though availability in the rural and remote areas is still quite limited.

Fluoroscopy
We were unable to ascertain the exact number of fluoroscopy units in the country. Most of the fluoroscopic machines are owned by public tertiary hospitals, with a few in some private hospitals and diagnostic centers in the major cities. Some of these units are used in operating theaters, while the vast majority are used in radio-diagnosis departments. In many of the centers, the fluoroscopy units suffer frequent breakdowns.

Mammography machines
Most mammographic units are installed in public tertiary hospitals and some private hospitals or private diagnostic centers. With the increasing awareness of breast cancer, breast cancer and mammography screening initiatives are springing up around the country, driven largely by non-governmental organizations, and mammography penetration is likely to improve (41).

Angiography
Only a few public tertiary institutions in the country, such as University College Hospital, Ibadan (South-West Nigeria), Aminu Kano Teaching Hospital, Kano (North-West Nigeria) and University of Maiduguri Teaching Hospital, Maiduguri (North-East Nigeria), are equipped with dedicated angiographic suites for various (interventional) angiographic procedures. The actual number of interventional radiologists in Nigeria is not known. However, the perception is that they represent a small percentage of the nearly 300 radiologists in the country. Interventional cardiology and uterine fibroid embolization facilities are also available in a few private facilities.

Interventional radiology
The vast majority of interventional procedures are ultrasound-guided or fluoroscopy-guided procedures. Interventional angiographic procedures are equally performed by few centers with the facilities, especially in Northern Nigeria (42). However, there are no published data on the number of interventional radiology examinations in Nigeria.

Computed tomography
Nigeria installed its first CT scanner on November 19, 1987 at the University College Hospital (43) in Ibadan, Southwest Nigeria (39). There are now many CT scanners installed across the country and the trend is expected to continue (39 (45)(46)(47). Currently, two 640 slice CT scanners are available in the country, one in a public hospital (Akwa-Ibom state) and the other in a private radio-diagnostic center in Lagos State. General Electric and JNCI are the foremost suppliers of diagnostic equipment across the country (29).

Magnetic resonance imaging
There are 58 installed MRI units in Nigeria (48). Nearly half of the units are low-field strength systems. However, there are some centers with 1.5T machines, especially in the cities. There is no 3T unit in the country yet. The distribution of MRI units in Nigeria is reasonably even across its six geopolitical zones, albeit most of the units are installed in urban areas, with Lagos state (South-West Nigeria), being home to 14 (25%) of the installed MRI scanners in Nigeria (48). The majority (approximately two-thirds) of scanners in the country are privately owned (48).

Nuclear medicine and radiotherapy equipment
Nigeria has nine radiotherapy centers. One is private, while the Federal Government of Nigeria owns the other eight (49). The distribution of facilities amongst these nine is as follows: five linear accelerators, three Co-60 treatment machines,

Picture Archiving and Communication System (PACS)
Functional PACS is available in only a few public teaching hospitals, some large multi-specialty private hospitals, and some of the dominant entrepreneurial private radiodiagnostic centers.

Needs and challenges of radiology practice
A major challenge of radiology practice in Nigeria is the unavailability of constant electricity to power the machines. Most radiology facilities, both public and private, rely on diesel-powered generators for the smooth running of the equipment, thereby adding considerably to the cost of investigations (29).
Many centers do not have a functional PACS system or a Radiology Information System for interpreting imaging studies (29). Due to the unavailability of effective PACS systems for storage, images are usually stored locally on the equipment (29).
Maintenance of equipment is another major problem. There are only a few qualified biomedical engineers with the technical know-how to service and maintain equipment; many of the centers rely on foreign engineers. Most centers try to overcome the challenge of equipment maintenance by entering service contracts or part-ownership with manufacturers to maintain equipment. The complex chain involved with repairs and maintenance makes equipment downtimes longer than necessary, often lasting several weeks to months (44,62,63).

Future expectations
With the current drive of the present government towards improving power supply in the country (64), it is expected that the power situation in the country will improve, thereby cutting down the cost of running radio-diagnostic facilities and, by extension, the cost of various investigations. Additionally, with improvement in the country's economic situation and the anticipated increase in health funding (8), the National Health Insurance Scheme (NHIS) is expected to achieve better insurance coverage of citizens, thereby allowing more access to radiology investigations.
Regarding servicing of equipment, it is anticipated that the proliferation of radio-diagnostic centers in Nigeria would attract more maintenance and service companies into the country, thereby obviating the problem of equipment maintenance and long downtimes.

Job opportunities
There is a wide gap between the number of personnel in the fields of radiology and the over 197 million estimated population of Nigeria: a ratio of 1.5 radiologists per million. Despite this mismatch, employment opportunities are not so readily available because governments at various levels are the major employer of labor in Nigeria. Nigeria spends less than 4% of its budget on health care (65), leaving the system with severe funding constraints. With the current surge in the number of private diagnostic centers in Nigeria, the employment outlook might improve.

Role of private sector and investment opportunities
The public healthcare system is weak due to lack of adequate funding, personnel, and equipment for optimum service delivery. Payment is made out-of-pocket by most individuals requiring radiological evaluation and management (31).
Despite the advent of entrepreneurial diagnostic centers, the radiological market is far from being saturated, with several goldmines still untapped. For example: No Health Management Organization (HMO) is listed on the Nigerian Stock Exchange (70,71). There is an opportunity for mergers of HMOs to enhance capacity to manage millions of enrollees and enhance coverage of radiological investigations.
No standard software exists for industry operations (29). Thus, there is an opportunity to provide technology solutions to drive healthcare and radiological operations. A huge market exists for costeffective Electronic Medical Records and PACS Systems in Nigeria.
Expanding the health insurance packages to include coverage of private radio-diagnostic centers in order to improve access to radiological services.

Availability of internet connection
There is high internet penetration in Nigeria, with over 98.3 million active internet subscribers (72). All major operators in the mobile telecommunication industry currently boast broadband internet services with available 3G and H+ (Evolved High-Speed Packet Access) in most towns and villages. 4G LTE technology is currently available in the major cities such as Lagos, Abuja, and Port-Harcourt, with gradual spread into the remote areas. Free Wi-Fi services are available at selected locations, such as hotels and airports. Various prepaid and post-paid data packages are available for individual and corporate entities on the major carriers.

Disease profile
With the increase in Westernization, there has been a gradual rise in the prevalence of lifestyle-related diseases such as hypertension (

Culture and tourism
There are at least 250 ethnic nationalities distributed across the 36 states (79) and the Federal Capital Territory of Nigeria. The three largest ethnic groups are Hausa, Yoruba, and Igbo. The large number of ethnic groups reflects great diversity in spoken languages as well as cultural practices (79). Nigeria is home to a large number of tourist attractions, including abundant waterfalls, warm and cold springs, game reserves, plateaus, beaches, and other natural attractions. Currently, Nigeria has two UNESCOdesignated World Heritage Centres and another 10 on a tentative list (80)(81)(82). Apart from these, there are many other tourist attractions in the country (83,84).

Climate and time to travel
Nigeria has only two seasons: the dry season and the rainy season. The rainy season spans from late March or April until November, while the dry season spans November to February or March.
The dry season is usually accompanied by a dusty air mass from the Sahara Desert, locally referred to as Harmattan. Abuja, the Federal Capital Territory located in central Nigeria, has an average temperature of 18.45 C to 36.9 C, with an annual rainfall of about 1,500 mm (85,86). Nigeria can be visited all year round, with international airports in Lagos, Kano, Abuja, and Port-Harcourt.

Local currency
The local currency is the naira (N). Major foreign currencies such as USD, Euro and GBP can be converted to naira and vice versa at any of the local banks or bureau de change. By law, the maximum allowable cash you can travel with is capped at $10,000 USD or its equivalent in other currencies.

Accommodation
There are standard hotels ranging from one-star to five-star accommodations. Depending on location and taste, a decent room could cost between N5,000 and N150,000 per night.

Health advisory
Like most sub-Saharan countries, proof of yellow fever vaccination is required for entrants into the country above nine months of age (87). There is also the risk of malaria. Malaria prophylaxis is needed while traveling in Nigeria. Insecticide-treated nets are recommended for prevention of mosquito bites. There are standard pharmaceutical stores, and it is relatively easy to schedule an appointment to see a physician in one of the numerous private health facilities. Hygienic bottled water is ideal for drinking. There is a wide variety of both local and continental dishes available at most hotels and restaurants.

Local safety and security
Most parts of the country are peaceful and safe. Boko Haram terrorism in the North-Eastern part of the country has been significantly curtailed (88). The restive Niger Delta has been enjoying stability and relative harmony due to renewed social inclusiveness and a commitment to implementing the comprehensive peace, security and development plan for the region (88).