Need for more funding to prevent epidemics

Ateneh Idris, 27, lost her mother and brother to Lassa fever. The disease, which her family initially thought was malaria, ended up infecting three other members of the household but they were lucky to survive after they were referred from their hospital in Kogi State to the Irrua Specialist Teaching Hospital in Edo State.

A total of 157 deaths from Lassa fever have been recorded from the beginning of this year to the 5th of May, according to data from the Nigeria Centre for Disease Control and Prevention (NCDC). The number of confirmed cases recorded within the period is 869 cases while 6, 106 suspected cases were recorded. Health care workers are part of those affected. Lassa fever has remained a perennial outbreak in Nigeria for about 55 years.

Naziru Ja’afar is a father, whose nine-year-old twin, Hassana and Hussaina were treated for diphtheria during the peak of the outbreak of diphtheria in some states of the country last year.

He is a resident of Dandinshe in Ungogo Local Government Area (LGA), which recorded the highest number of diphtheria cases in Kano State.

He was happy the twins survived as some children in his community had died of the disease. He recalled how they had fever, pains and difficulty swallowing.

Data from the NCDC showed that Nigeria had recorded 12, 086 confirmed cases (58.4%) across 148 LGAs in 20 states as at the end of 2023. Kano State had the highest number of cases and deaths from the diphtheria outbreak in Nigeria with 9,613 confirmed cases within the same period.

Many people have continued to fall ill or die from diverse epidemics in Nigeria. The country is bedevilled with a myriad of disease outbreaks, which leave in their wake a lot of cases and deaths in households and communities annually.

The NCDC said this year alone it has responded to several outbreaks of epidemic-prone diseases in Nigeria, including meningitis, measles, Lassa fever, cholera and diphtheria outbreaks in various states.

The Centres for Disease Control and Prevention (CDC) describes an epidemic as an unexpected increase in the number of disease cases in a specific geographical area.

Preparedness is key in epidemic management as it not only helps in prevention, early detection, reduction of number of cases and deaths as well as protects against future epidemics and pandemics.

However, poor funding has continued to affect epidemic preparedness and response in the country. Despite some level of progress made at the federal level over the years, poor funding for the health sector and absence of dedicated funding for health security has continued to stall progress for epidemic preparedness.

At the sub-national level, many states of the country do not have dedicated budget lines and accountability frameworks for epidemic preparedness and response, and are often caught unawares or helpless when there are outbreaks.

Also, only a few states can also boast of a centre for disease prevention and control as obtainable at the federal level. Thus, epidemic preparedness and response cannot be improved until there is an increase in the budget.

According to the Global Health Advocacy Incubator (GHAI) , the sources of health financing in Nigeria is another major challenge in achieving epidemic preparedness and response in the country.

It said, “Nigeria’s healthcare system is mainly financed by private expenditure, federal government budget and international donations. Out-of-pocket (OOP) expenditure is the largest source of health financing in Nigeria, accounting for about 6075% of the total health expenditure in the country, as against the WHO recommendation of maximum OOP health expenditure of 30-40% of total health expenditure.

“The poor funding of health systems by the government is also responsible for degradation in the health system functionality, which results in poor epidemic preparedness and response and inadequate preparedness for health emergencies. Specifically, poor investment in epidemic preparedness and response has been a major issue. The COVID-19 pandemic exposed the country’s suboptimal capacity to cope in the face of epidemics and pandemics.”

Till date, the country is yet to achieve its commitment to the 2001 Abuja Declaration, to increase government’s health budget by 15%.

A health budget analysis by the development Research and Projects Centre, dRPC shows that the highest share of the health budget to the total budget size was only 6.23% in 2012, falling significantly short of the target.

“To put this in perspective, over the last decade of signing the Abuja Declaration, the cumulative FGN total budget would amount to N133.15 trillion, out of which only N6.50 trillion has been actually allocated to healthcare in that time, leaving a cumulative funding gap of N13.46 trillion in ten years for health. The share of healthcare allocation in ten years is only 4.89%, which is well below the promised 15%. The underfunding of the healthcare sector has resulted in a significant health deficit in Nigeria,” the report said.

Analysing the 2024 health budget , the report said while the total health budget increased by 28.43% compared to N1.17 trillion in 2023, it constitutes only 5.21% of the budget size.

The dRPC analysis said the implication of this among others is that “The low and unpredictable public funding for health makes the health system dependent on external donors and private sources, which poses challenges for long term planning and resilience. The health system is also ill-prepared to cope with shocks and emergencies, such as the COVID-19 pandemic, which can exacerbate the existing gaps and weaknesses.”

Medical experts say improved budgetary allocation and sustained financing for epidemic preparedness is key to strengthening the country’s public health security and emergency preparedness and response systems.

The Director General of the NCDC, Dr Jide Idris said that the first pillar of health security, which is prevention, had the weakest link in the country, noting that only very few states have budgets for health emergencies.

He said that local funding for the NCDC was paltry with 80% of its budget funded by international donors.

Explaining how NCDC collaborates with other agencies and organisations to address epidemicprone diseases, Dr Idris said states lead in detection, investigation and response to small outbreaks while NCDC provides guidance and support in technical and material terms where needed. In large outbreaks or outbreaks involving many states, NCDC provides leadership and coordination across states, he said.

He further explained that challenges faced by the NCDC in addressing epidemic-prone diseases include inadequate funding, weak healthcare infrastructure at subnational levels for both treatment and laboratory confirmation of diagnosis, late reporting of cases, poor public awareness and outbreaks occurring in security compromised locations.

He said ,“To address these challenges, the agency advocates for increased investment in public health, strengthens partnerships, collaborates with security agencies, improves health literacy and implements innovative strategies to improve disease prevention and control.”

Dr Emmanuel Alhassan, Nigeria Coordinator, Global Health Advocacy Incubator (GHAI), said one of the major reasons epidemics persist is because efforts and funding in the country are more channelled towards responding to the outbreaks than preventing them.

He said, “You know, rather than spending less money to put structures in place to prevent, we are always reacting and it costs much higher to react after something has happened. So it is a huge challenge.”

The Director of programmes, Legislative Advocacy Initiative for Sustainable Development (LISDEL) Ademuyiwa Damilola, said the outcome of the last Joint External Evaluation (JEE) of Nigeria’s International Health Regulations (IHR) capacities showed that Nigeria scored a total of 54 % which is an improvement compared to the score of 39% of 2017 and the mid-term assessment of 46% in 2019.

He said the budgetary allocation to NCDC and other Ministries, Departments and Agencies (MDAs) implementing health security has improved compared to before , adding that however releases and implementation of budgets for epidemic preparedness was still a major challenge.

He said the efforts of some states like Kano in improving funding for health security is commendable. He said Kano state has introduced a budget line for health security, taken steps to do its JEE, developed a state action plan for health security, and is also working towards establishing a centre for disease control.

He also commended Lagos for actions taken to improve health security, adding that LISDEl contributed to strengthening health security outcomes in the states by providing technical assistance and support.

Gafar Alawode who was Project director, Prevent Epidemics project also applauded Lagos and Kano states for their policy and institutional frameworks for health security.

He said enjoined other states to follow suit saying two states were not enough as the country has 36 states and the Federal Capital Territory (FCT).

He said there is a need for a financial framework at sub national level because state governments also have responsibility, as the federal government and partners alone could not adequately fund health security.

Dr. Joseph Enegela, chief executive officer of the Africa Disease Prevention and Research Development Initiative (ADRAP) said the country needs to strengthen its surveillance system. “It is also important for us to understand the simple principle, ‘in times of peace, prepare for war’. So in times of peace before the outbreaks starts, what do you do? If you know that what you need is ABCD for response to yellow fever outbreak, have some in your store waiting. Don’t wait till the outbreak occurs. All these preparedness are what we require, and we are not there yet.”