How years of underfunding the health sector affected Nigeria’s response to COVID-19 (Part 1)

By Nigerian journalist Justice Nwafor, first published in Nigerian Tribune.

In 2001, African heads of state met in Abuja and agreed to appropriate no less than 15% of their annual budget to healthcare. But ever since, Nigeria has failed to inch any closer to the agreed percentage, leaving the country’s healthcare system grossly unable to respond to outbreaks. Justice Nwafor, after an investigative tour of three states and Abuja, in this first of a two-part report relates how poor funding from 2012 to 2018 affected Nigeria’s healthcare system.

Samuel Adegbite Memorial Hospital, outside Ibadan in southwest Nigeria, was built and donated to the Oyo state government by Samuel Adegbite but has endured poor funding since its takeover.

For two days, Rebbecca Oluokun felt her fetus move more often than it had in the previous days. This wasn’t her first pregnancy, but Rebbecca was cautious to adhere to all instructions she received at antenatal sessions and even to the informal advice from her friends who had given birth multiple times.

The ‘bloody show’ had gone, the weight loss episode, too, but she never expected the back pain to be very intense. So, as the pain left her with little strength, she figured out the time was right — the delivery day — though her expected day of delivery was still about 24 hours away. But the other signs she waited for hadn’t come. Perhaps there was no need to rush to the clinic or call a local birth attendant, she thought, and stayed at home with her bag ready.

All day, the pain endured and she groaned and snapped at anyone who came close.

The time was 12:30 am and Rebecca felt her baby coming. Confusion ensued: there was no vehicle to move her to a hospital and engaging an untrained traditional birth attendant was risky.

Rebecca’s father, Ajibode Oluokun, had maintained a good relationship with a cab driver in the community, so he made a call him. The erratic telecom network in the community was fair this night, and thankfully, the driver answered on the first ring. In a few minutes, he arrived and they moved. The bumpy ride lasted about 30 minutes and she was eventually delivered of a baby boy.

Rebecca was lucky but the World Health Organisation (WHO) says between 2005 and 2015 about 600,000 women in Nigeria died in the process of child birth and left their families in agony. For context, this number is about the entire population of Luxemburg, twice that of Barbados or a third that of Nasarawa State in north-central Nigeria.

Though she had access to antenatal services, as many as 39% of pregnant women in Nigeria don’t have access to such services, according to HealthCare for Women International and Relief Web.

Back home, Samuel Adegbite Memorial Hospital, Igbo-Oloyin, run by the Oyo State hospitals management board, is about 700 meters from Rebecca’s home — 6.5 miles off the city centre of Ibadan, southwest Nigeria. The hospital is a comprehensive healthcare facility designed to serve more than 25 communities in Igbo-Oloyin. But residents of the communities have to seek healthcare services elsewhere due to poor facilities at the hospital.

Rebbeca, for one, had to travel more than 30 minutes on a bad, bumpy road to another hospital because Samuel Adegbite Memorial Hospital shuts down by 4 pm on weekdays and much earlier during weekends.

“The transformer in the community has broken down and we have no generator to power electric bulbs at night,” a senior nurse at the hospital, who pleaded not to be named, told Nigerian Tribune.

Nigeria has some of the poorest health outcome indices in the world, practically because of systemic problems which revolve around neglect and poor funding.

The WHO declared COVID-19 a public health emergency of international concern on January 30, 2020, seven days after its International Health Regulations (IHR) Emergency Committee had advised that “all countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of 2019-nCoV infection, and to share full data with WHO.”

Twenty-eight days later, an Italian expatriate was diagnosed with the virus and Nigeria was drafted to the map of infected countries, days after the Nigeria Centre for Disease Control (NCDC) said it had set up a ‘Coronavirus preparedness group’ to ensure point of entry screening for travellers coming into the country.

How years of underfunding the health sector affected Nigeria’s response to COVID-19.

Basking in its earlier success in dealing with the Ebola Virus Disease (EVD) outbreak, the NCDC said it strengthened the National Reference Laboratory with diagnostic capacity for epidemic-prone pathogens. Through this process, it supported 22 of the 36 Nigerian states to establish emergency operation centres (EOC) and trained rapid response teams in all the 36 states.

But experts say Nigeria’s pre-COVID-19 preparedness was grossly inadequate.

Nigeria had been warned in 2017 by the WHO. The organisation’s Joint External Evaluation (JEE) — an assessment of the capacities of countries to prevent, detect and respond to public health risks — of the IHR showed that the country was not ready for any pandemic. It garnered an average score of 1.9 across the 15 JEE indicators in the ‘prevent’ category. This poor score suggested that overall, there was limited capacity to prevent biological, chemical or radiation health risk in the country.

In the ‘respond’ category, with an average score of 1.5 across the 20 indicators, it became glaringly obvious that Nigeria has limited capacity to respond to any sudden health risk. So, when the country started scampering for help as confirmed cases surged, not many analysts were surprised.

Poor health infrastructure: the Abuja Declaration

In 2001, African heads of state met in Nigeria’s capital, Abuja, and pledged to allocate at least 15% of their respective annual budgets to health. It became what is now known as the Abuja Declaration.

How years of underfunding the health sector affected Nigeria’s response to COVID-19.

The aim, among others, was to strengthen the health systems of the countries, make quality healthcare available and accessible to Africans, while getting them ready to respond not just to epidemics but pandemics. But 19 years later, nothing has changed significantly, especially in Nigeria. While countries like Mauritius, Seychelles and Eritrea had met the target as of 2011 and South Africa inched closer at 13.5%, in 2017, Nigeria has consistently underperformed.

For this report, Nigerian Tribune obtained data from the office of Nigeria’s Accountant-General and analysed the capital health budget of Nigeria from 2012 to 2018. The analyses revealed a very disturbing trend: no year under review had 100% release of the budgeted amount.

In 2012, the Federal Government budgeted N60.95 billion (US$385 million) but only N45.000 billion (US$284 million) was released. The next year, both the budgetary allocation and total amount released worsened; N60.047 billion (US$373 million) was allocated but a little above 50% was released, N34.782 billion (US$216 million). Sadly, it worsened the next and the following, both in allocation and releases.

2015 was a very significant year not just because it was an election year but the year an opposition political party took over power. More worrisomely, it was the year the health sector got the least allocation and releases among the years analysed. Only N22.676 billion (US$114 million) was allocated and N16.445 billion (US$82 million) released.

The next year witnessed an upward trend with well over 90% of the allocated N28.650 billion (US$94 million) released — N28.592 billion (US$93 million). But the figures still inched nowhere near the 15% expected of Nigeria. The upward trend continued in 2017 with N55.609 billion (US$154 million) budgeted and N52.656 billion (US$154 million) released. 2018 was the peak. N86.485 billion (US$238 million) was budgeted but an abysmal N44.499 billion (US$122 million) was released.

The analyses revealed that in seven years, Africa’s most populous country and largest economy budgeted N307.937 billion (less than $1 billion) for the capital development of its health sector and eventually released only N201.002 billion, which is less than 70 per cent of the budgeted amount. This means that N106.935 billion of the budgeted amount was not released. This deficit confirms the long-held concern of stakeholders and development partners that the government of Nigeria has not shown enough commitment to develop the nation’s health sector and make healthcare available and affordable to Nigerians, about 80 million of whom live below US$2 per day.

BudgIt says its analysis of both the recurrent and capital budget of the sector between 2011 and 2018 revealed that 78-95% of the total funds allocated to it was spent on personnel and overhead costs.

Experts agree that the problem with Nigeria’s political leadership is not the paucity of funds but the inability to prioritise the needs of the country’s masses.

Ayuba Wabba is the President of Nigeria Labour Congress (NLC), the umbrella body of labour unions in the country. For him, it’s a problem of outright neglect.

“With the massive resources at our government’s disposal, Nigeria can afford to build and effectively equip some of the best hospitals in the world, with global best practices and personnel”, he told Nigerian Tribune. “But successive governments failed to take health care as a top priority beyond mere policy statements.”

The three-bed ‘General Hospital’

From a rusty black gate competing for growth with lush green weeds spluttered around the hospital, even a first time visitor would agree to the good intentions of Samuel Adegbite who built and donated what is now known as Samuel Adegbite Memorial hospital, Igbo-Oloyin, to the Oyo State Government.

It’s a serene environment, an expansive landmass able to accommodate three of the building’s size. A perimeter fence completely erected but not high enough to wade off the typical ‘Nigerian hoodlum’. No uncoated electric wire dangling from an electricity pole across the perimeter fence to the building’s rake. No loud generator buzz and smoke belch. This silence, though good, is a pointer to inactivity.

Further steps into the wide makeshift reception, which also serves as a store, present disappointment which dwarfs the sting of hope met at the entry. There’s a dusty fan above a fairly light-complexioned nurse, but she couldn’t stop fanning herself with a plastic hand fan while introductions were made.

To the left is a room originally meant to be one of the wards, but Dr Adeyemi Mayowa, the doctor at the hospital, told Nigerian Tribune that it now serves not just as the only ward in the hospital but as the operating theatre too. No laboratory. A small, empty oxygen cylinder. Empty drug stacks. No blood bank. No surgical table. No recovery room. Just three beds in the single-room ward. Yet, it is a ‘secondary’ healthcare facility.

“I tell the nurse to lift the examination couch in my office to the ward. I operate on the couch, they clean and return it afterwards”, Dr Adeyemi said of what happens when he needs a surgical table.

Originally designed to be a primary health facility, the state government converted it to a secondary health facility as the population of Igbo-Oloyin increased. Nigerian Tribune confirmed the hospital’s status as it was listed among the secondary healthcare facilities on Oyo State’s hospitals management board website alongside general hospitals.

But Dr Adeyemi said nothing has really changed. “Everything is against operations. At the secretariat, they don’t want to hear anything. All they want to hear is, what have you made? What is your revenue over the month? And it’s not just what you’ve made; is it improving?”, he said. “I use my car as the hospital bus. It’s just like an ambulance. It does all the job. I shouldn’t be the one to go through such experiences.

“I can do a wide range of surgeries in three different sub-units: O&G, general surgery and urological surgeries. But because of limitations in terms of staffing, poor working conditions, lack of some hospital facilities, I can’t do much.”

An analysis of the state’s budgetary allocation to health shows it is in the lower half of Nigeria’s 36 states. BudgIt analysis shows that in 2018, the state allocated N3.25 billion (US$9 million) to health from its 2018 state annual budget of N267 billion (US$733 million). This represents just 1.22% of the entire budget. According to the Abuja Declaration, the state should have allocated N40.05 billion (US$110 million) to the sector, which is 15% of the entire budget. This poor allocation left a gap of N36.8 billion (US$101 million).

Dr Bahir Bello is the state’s commissioner for health. Nigerian Tribune called his mobile line several times and sent SMS’ twice, seeking an audience in respect to this report but he never took calls nor called back. Dr Bashir also did not reply to any of the messages sent to him.

The problems at FMC, Abeokuta

Federal Medical Centre, Abeokuta, is one of the 23 medical facilities of its kind spread across Nigeria. It holds a significant place in the city of Abeokuta in Ogun State, Southwest Nigeria, as one of the city’s tertiary health institutions. There were high hopes when it was converted from a state hospital because the new status meant there should be more funding and better facilities at the hospital.

Federal Medical Centre, Abeokuta, in Ogun State in southwest Nigeria.

So, it was no mistake that, about three decades later, the hospital raced to Olaniyi Gbenga’s (not his real name) mind when his sister-in-law fell ill and required blood transfusion. While his brother ran along to make payments and ensure she got quick attention, Gbenga decided to donate the required pints of blood.

Due to poor funding, the sterilizing unit at FMC Abeokuta doesn’t have large efficient sterilizing machines.

Well, for the donation to take place, he was required to undergo some screening at the laboratory first. But there was no power supply. “I went there in the morning, they said there was no light. I left and returned in the afternoon, still, there was no light. This time, there was no explanation unlike during my previous encounter when they said their generator had spoilt”, he explained to Nigerian Tribune.

A hospital of FMC Abeokuta’s status shouldn’t have this kind of sterlising unit.

The hospital may not be alone in the power challenge but a facility of its status is expected to have overcome the basic challenge of power supply to a critical unit like the laboratory. On a visit to the hospital, Nigerian Tribune had access to some facilities and found that there were some outdated equipment still being used while efforts to procure new ones had been dogged either by inadequate funds or outright neglect.

At the sterilising unit, outdated sterilising machines with limited efficiency were seen while two female staff, as of the time of visit, sweated it out working in the somewhat dingy room.

Earlier this year, the hospital’s Chief Medical Director (CMD), Prof. Adewale Musa-Olomu was accused of selling the hospital’s CT scan machine worth N300 million (US$784,000); an allegation he denied and stated that the machine was repaired but failed to work. A new one was purchased, but it spoiled three months later due to a power surge. This means the facility has no functional CT scan machine.

FMC Abeokuta is among the Ministries, Departments and Agencies (MDAs) in the health sector which had a capital budget (2012-2018) of N307.937 billion (US$843 million) of which only N201.002 billion (US$552 million) was released.

The situation couldn’t have been worse, but Prof. Musa-Olomu said it really was before he assumed office in 2017. At the “radiology department, there was no single x-ray machine and no ultrasound machine. In the theatre, only one was functional out of eight rooms. In the laboratory, there was no equipment,” he said in a July report.

Nigerian Tribune analysed the hospital’s capital budget from the Federal Government between 2012 and 2018, obtained from the office of the Accountant-General of the federation. It was found that the highest amount budgeted was N1.261 billion (US$3.5 million) in 2018, while less than half of the amount, N528.578 million (US$1.5 million), was released. In 2012, N288.308 million (US$1.8 million) was budgeted but only N205.385 million (US$1.3 million) was released. In 2013, it improved to N641.136 million (US$4 million) but the releases worsened at N264.594 million (US$1.6 million), less than 50%.

The next year wasn’t any better: N202.724 million (US$1.2 million) was budgeted but N79.725 million (US$472,000) was released. 2015 was the worst. N60.463 million (US$303,000) was budgeted but only N30.231 million (US$152,000) was released. There was an improvement on the 2015 figures in 2016: N196.929 million (US$645,000) was budgeted and N125.851 million (US$412,000) was released. The upward trend continued in 2017 as N361.929 million (US$1 million) was budgeted for the hospital and N180.964 million (US$500,000) was released.

In the final analysis, N3.013 billion (US$8.3 million) was budgeted for capital projects at FMC Abeokuta in seven years (2012-2018). Of the amount, less than half, which is N1.260 billion (US$3.5 million), was released, leaving N1.753 billion (US$4.8 million) unreleased.

‘Our response not as swift as it should be’

Dr Tomi Coker is the commissioner for health in Ogun State where FMC Abeokuta is situated. For her, the years of inadequate funding of the health sector affected Nigeria’s response to COVID-19, particularly, Ogun State. She told Nigerian Tribune that the response could have been more effective if priority had been given to the sector by successive governments.

For her, inadequate funding “meant that our response was not as swift as it could be because we had to start procuring essential equipment like the mobile x-ray, dialysis machine and the beds. We were procuring at very expensive prices.

“If we had adequately funded the healthcare sector, we could have been responding like other countries like the UK. Yes, they were challenged, they were overwhelmed, but at least they had basic things they could use, [but] we were starting to buy as little as PPEs and beds. We have to continue to build because there is always one outbreak or the other.

“Nigeria cannot afford not to spend on health. We need to look at the performance of the budgets. Performance of the budgets must improve in the health sector.”