The Sustainability Agenda: Which Way Nigeria?

By Ikenga Chronicles January 21, 2018

The Sustainability Agenda: Which Way Nigeria?

Dr. Adaeze C. Oreh

Nigeria has been a beneficiary of international development aid in various sectors, notable among which is healthcare. Usually, this aid comes in the form of grants directed at specific disease entities with clearly delineated targets and objectives. Some of the diseases that have attracted international global funding include HIV and AIDS, malaria, tuberculosis, river blindness, poliomyelitis and guinea worm amongst others.  Donors in the African health ecosystem include the United States Agency for International Development (USAID), United States President’s Emergency Plan for AIDS Relief (PEPFAR), United Kingdom’s Department for International Development (DFID), Bill and Melinda Gates Foundation, The World Bank, The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), Clinton Health Access Initiative, Global Alliance for Vaccines Initiative (GAVI) Alliance and The Carter Foundation. This funding would usually be presented in a structured vehicle for delivery specifically designed for implementation for the particular disease entity.

The programmes typically have distinct administrative structures, personnel, accounting and budgeting structures, and reporting channels with no cross-benefitting of programmes as they are structurally separate and removed from the general health system. Where the government could have provided a more holistic monitoring and supervisory function in these programmes, the ministerial divisions overseeing each disease control or prevention programme are often structurally separate with few internal structures for harmonising the objectives of the programmes and aligning them with national health objectives.  There is a consensus that such programmes can be beneficial in certain circumstances –where weak national health systems exist; rapid results are required; economies of scale needed; where hard-to-reach populations need to be targeted and where complex services need to be delivered by a highly skilled workforce. However, there is evidence to show that such vertical or ‘stand-alone’ programmes have negatively affected the effective management of health systems in areas like HIV, tuberculosis, substance abuse and mental disorders. According to the World Health Organization (WHO) reports, balancing these vertical programmes with elements which cut across the health sector are needed to achieve sustainability.

In a rapidly changing world plagued by sudden epidemic upsets with huge potential for global harm like the Ebola epidemics of recent years, it is only prudent, pro-active and cost-efficient to ride on the back of vertical programming with clear targets and gains to build on foundational health systems. It is these strengthened systems that would be able to withstand and resist the shocks and threats posed by unforeseen disease entities. It makes little sense to increase the longevity of people with communicable diseases such as HIV/AIDS, Tuberculosis and Malaria, only to have their lives cut short by preventable epidemics such as Cholera, Dengue and even Ebola; not to mention co-morbidities from noncommunicable diseases (NCDs) –which are growing in prevalence in Nigeria– such as cancer, hypertension, and diabetes and which rely on strong health system delivery frameworks to reduce morbidity and mortality from these conditions.

Asides from epidemics and NCDs, recipients of interventions for these infectious diseases stand the risk of dying from complications of their diseases inappropriately or insufficiently managed in a backdrop of weak health systems. There is therefore a need to “actively de-emphasize” vertical health programming, and focus on strengthening existing health systems. One of the achievements of the MDGs in Nigeria was the marginal reduction in the number of underweight children from 27.40% in 2012 to 25.50% in 2015. However, in a backdrop of weak health systems, conflict, terrorism and insurgency, Nigeria has seen malnutrition and stunting in children aged below five years in northern Nigeria rise to 50% in the last year alone. Successes in areas such as reductions in deaths in children below the age of five and maternal death rates are being threatened by the challenges in access to quality health care in areas of conflict and insurgency. Where the numbers of skilled birth attendants overseeing child deliveries and access to antenatal care and child immunization services increased substantially over the period of the MDGs, those gains have been heavily denigrated by present conflicts which have led to millions of Nigerians in parts of the country being displaced from their homes or having their communities over-run by terrorism, thereby rendering them inaccessible to health care services. In addition, health financing constraints in the country prevented Nigeria from achieving MDG targets such as universal access to reproductive health services and treatment for HIV/AIDS.

Acute severe malnutrition now affects 14% of the population, and diseases like polio which had been declared eliminated from Nigeria by the WHO in a widely publicized and disseminated news release in 2015 which not only declared Nigeria “polio-free” but involved her removal from WHO’s list of polio-endemic countries have resurfaced nearly a year later due to pockets of wild polio virus detected in areas of conflict and have led to the paralysis of infected children; with internal displacement of persons putting many unaffected communities and millions of Nigerians at great risk. Prior to the declaration of Nigeria as a “polio-free” country, as at 2012, Nigeria accounted for over 50% of cases of polio worldwide. The successful fight against polio in Nigeria was attributed to collaborative efforts by The Global Polio Eradication Initiative (GPEI) – a public-private partnership involving national governments such as the Government of Nigeria and development partners like WHO, Rotary International, the United States Centers for Disease Control and Prevention (CDC) and United Nations Children’s Emergency Fund (UNICEF), and supported by the Bill & Melinda Gates Foundation. These disease elimination efforts while focused and well-meaning could have been bolstered by a comprehensive and holistic health system integrated effort. With a strengthened health system, surveillance activities would have been more robust and led to a more sustained disease elimination.

Current local and global economic challenges also provide a major incentive to build on health systems and rethink health systems delivery on the continent. Dwindling funding from international donor agencies in Europe and the United States have occurred because of slow recovery from the global financial crises, and issues of corruption and mismanagement of development funds have led to huge funding gaps from global donors. Given that funding from the Global Fund to Nigeria have contributed immensely to improving the access of people living with HIV/AIDS to medication, testing and treatment of cases of tuberculosis and distribution of insecticide-treated bed nets to help combat the spread of malaria; it is crucial that recipient countries start looking inwards at how to organically strengthen their health systems with in-built programme fund monitoring and oversight mechanisms to ensure the appropriate deployment of funds. These donor funding limitations highlight the need to strengthen local health systems to avoid programme paralysis when international donors leave or limit funding.

“Leaving no one behind” means ensuring that entire populations regardless of age and gender, entire communities whether rural or urban, and the entirety of prevalent disease entities including those that have long been stigmatized such as mental health disorders and neglected tropical diseases are deemed worthy of intervention efforts.  One of the fundamental principles in the Sustainable Development Goals is the provision of universal health coverage to ensure access to safe quality healthcare for every citizen regardless of age, gender, location or socioeconomic status at costs that are affordable to them and will not tip them into financial ruin. In Nigeria, out-of-pocket expenditure constitutes about 96% of health expenses, rendering many families penniless after incurring healthcare expenses where health services are available.

A major reason for this inequity of access is the fact that the Nigerian National Health Insurance Scheme (NHIS) is grossly underfunded, with only 4% of the total population having access to services under the NHIS, over ten years after the scheme came into existence in Nigeria. This therefore means that given the present economic provisions under the existing social insurance scheme, 96% of the populace are being “left behind”. The NHIS is beleaguered by perceptions of minimal clarity in its structure, purpose, governance, accountability and scope. It was created as an autonomous agency, and in practical terms appears to work with and engage health care provider facilities and health management organizations in the various states of the federation, bypassing the structure of the Federal or State Ministries of Health. This operational framework would appear to not only hinder the process of health system strengthening, but actively weaken the system.

The rural poor in Nigeria, majority of whom belong to the informal sector and whose means of livelihood comprise mainly farming, fishing and trading in addition to having little or no access to social insurance, also have limited access to adequate health care services. One reason for this is that the health system is plagued by multiple inefficiencies which lead to the over-population of health care delivery resources in the urban areas to the detriment of the rural areas.

Another reason is the scarcity of community health financing initiatives in majority of the rural areas. Primary health care centres (PHCs) which are built and located in the rural areas are often under-equipped and under-staffed. The few healthcare workers deployed to these PHCs are not attractively remunerated, and coupled with the difficulties inherent in Nigerian rural community living such as irregular power supply, poor transportation, and inadequate water and sanitation facilities, it is difficult to motivate well-trained healthcare personnel to relocate to these areas when cushy jobs and attractive positions exist in the cities and even outside the country.

Conflict, leadership and governance challenges, and economic and budgetary constraints have in addition contributed to a reduced ability of governments in Africa to attract, employ and re-train well-trained health workers, further worsening an already bad situation as evidenced by vast numbers of health workers emigrating outside the country. The adoption of the SDGs therefore provides the opportunity for governments to seek innovative and strategic ways of capitalizing on the benefits of ‘stand-alone’ donor programmes while building and integrating existing systems.

Under the MDGs, a large number of health workers were employed and trained by international donor agencies in order to deliver the specialized services required to meet targets in specific areas. Many of these trainings could be stepped down to local work-forces and translated to basic health service provision, using those trained by the international donor programmes as resource persons and thereby minimizing funding requirements for capacity building. Another opportunity afforded by the SDGs is that by promoting sustained, inclusive and sustainable infrastructure and economic growth, with full and productive employment with the empowerment of women and the use of clean, affordable and renewable energy, home-grown solutions to funding constraints can be realized. These will open up multiple investment opportunities and the potential for innovative healthcare financing mechanisms such as public-private partnerships in healthcare delivery and revenues from taxation of new and emerging industries for example.

Admittedly, current healthcare delivery models are very facility-based, doctor-centred and disease-specific; leading to over 400 million people worldwide unable to access much-needed services. A re-thinking of healthcare delivery to embrace more patient-centred and community-centric services has enormous potential to ‘carry more people along’ and provide access to good care. The cost-effective and equitable achievement of universal health coverage in Nigeria would therefore require a well-integrated primary health care system. Emphasis on the five key principles of primary health care namely accessibility, health promotion, use of appropriate technology, inter-sectoral collaboration and community participation in the implementation of an efficient primary care system in the country will help address many of the challenges inherent in achieving not only the health SDG3, but many of the other 16 SDGs.

The healthcare workforce and its deployment to rural or urban locations needs to be strategically addressed as a revitalized PHC system cannot function without sufficient thought into the human resources and manpower that will be required to deliver care to previously under-served populations. Planning for the deployment of healthcare professionals such as primary care doctors, nurses, midwives, birth attendants and community health workers to rural versus urban areas must be strategic, and conceptualized even from the time health workers are undergoing pre-service training in the professional institutions of learning. A recognizable challenge in Nigeria and indeed Africa, is the training of an exceedingly large proportion of the healthcare workforce for hospital-based practice at the expense of strengthening the community-based workforce leading to unavailability of health services at the point of the most need. Many of the existing primary health care centres are thus under-utilized, with a lack of confidence on the part of community residents and citizens. Recently, the Nigerian Society of Family Physicians offered to collaborate with the government on the deployment of trained family physicians to oversee these rural centres and ensure availability of quality services in rural communities that are home to the larger population and have the greatest healthcare needs.

This offers the government a large pool of skilled personnel already trained and prepared for community work. Government should capitalize on this offer as an opportunity to begin the process of strengthening the Nigerian health system from the bottom up and therefore ensuring a stronger foundation for healthcare service delivery. Furthermore, achieving the SDG targets for health would require a departure from global health practice of times past. To achieve the targets over the next fifteen years, there is a need for multi-sectoral collaborations within and between countries in the spirit of true global partnering. These collaborations and partnerships will ensure that the social and economic determinants of health are taken into consideration in the planning, development and implementation of programmes. This method stands the best chance of strengthening and enriching the background health system by harnessing strengths and opportunities from multiple sectors. This is therefore the time for governments and global health organizations such as the World Health Organization to ensure that investments in energy, infrastructure, food and gender equality have maximum health impact. The WHO has been criticized strongly for a seeming lack of engagement with other sectors to determine risk factors for many of the SDG health targets. Now is therefore as good a time as any for the WHO, and other health stakeholders to step away from that perception and build strong local and global multi-sectoral partnerships.

By creating new platforms and providing opportunities and incentives for intersectoral engagement, Nigerian health stakeholders would be broadening the chances of achieving and even surpassing the SDG health targets. Civil society can also play a vital role, by transforming data into moral arguments, helping build coalitions beyond the traditional health sector, democratizing policy debates and offering innovative options, enhancing the local legitimacy of global health initiatives and institutions, serving as watchdogs and advocates for accountability at all levels of health care delivery, and demanding action to address and confront commercial determinants of ill health. However, for civil society to add value and work to achieve these, they must be fully engaged by health institutions, in addition to being informed and empowered as stakeholders in the health sector.

If there is any hope for the achievement of the SDGs, now more than ever there is a need to harness existing opportunities and systems through multiple inter-sectoral collaborations. This is especially important for a country like Nigeria which due to its large population and poor health indices stands to contribute greatly to the achievement of the global goals following local achievement of the SDGs. The development of appropriate policy has never been an area where Nigeria has fallen short. It is however, the implementation of those policies that has proven a ubiquitous challenge to the country in the areas of health, economic and social development. Nigeria, the African continent and the world at large must therefore join forces in truly robust multi-sectoral collaborations to bring about a shift in the way policies have been implemented in the past in order to realize lasting and sustainable change. Such partnerships would have to bring to bear varying degrees of experience and expertise which stand to benefit weak and fragmented health systems and result in stronger health systems by the year 2030. It is time for the gentrified world of ‘global health’ to emerge from its shell and embrace partners from beyond its walls in order to achieve the global goals for people, the planet and prosperity.


  • This paper is based on excerpts from Dr Oreh’s paper “Moving the Goal Post – Sustainability and the Global Goals, Which Way Nigeria?” published in the American Journal of Public Health Research of December 2016.