Nigeria’s High Child Mortality and Rickety Primary Healthcare: How to Kill Two Birds with One Stone

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“There are only two countries in the world- the Central African Republic and Chad-where you are more likely to die younger than in Nigeria. Both of these are klepto-dictatorships ravaged for decades by war with GDP of $2.52 billion and $11.78 billion respectively. In contrast, Nigeria has a GDP of $440.78 billion.”

Nigeria is Africa’s largest economy but its life expectancy is one of the lowest in Africa and the world. The average Nigerian dies at age 54, 18 years lower than the global life expectancy.

These depressing statistics underscore not only the decrepit state of healthcare in Nigeria but also a host of atrocious indicators of social and economic wellbeing. There is no other country with anything close to Nigeria’s economic endowment or size in which people die so young. People live longer in much smaller and poorer countries. There are only two countries in the world- the Central African Republic and Chad-where you are more likely to die younger than in Nigeria. Both of these are klepto-dictatorships ravaged for decades by war with GDP of $2.52 billion and $11.78 billion respectively. In contrast, Nigeria has a GDP of $440.78 billion.

But Nigeria’s low life expectancy is a blanket statistic that hides an even more hideous figure-a very high rate of infant mortality. In 2020, the United Nations Children Emergency Fund (UNICEF) announced that Nigeria has overtaken India as the country with the highest number of under-5 deaths. That year, around 858,000 of children aged 5 or below died in Nigeria. This represents around 42% of all deaths in the country. Children dying early is actually the major explanation of Nigeria’s low life expectancy. Surprisingly, the loss of so many young lives is not on the list of the national woes we gripe about. The government has not deemed it fit to declare a “state of emergency” on the problem.

Death stalks the Nigerian child in the ugly shapes of largely preventable and easily treatable afflictions. Malaria kills more children in Nigeria than anywhere else in the world. When a child dies in our country, 45% of the time the inadequate quantity and/or poor quality of their food, i.e., the condition of malnutrition, is either the cause of death or a contributing factor. According to UNICEF, we have the “second highest burden of stunted children in the world, with a national prevalence rate of 32 percent of children under five”. Pneumonia is the third major killer of Nigerian children.

Also Read: Impact of Covid-19 on Public Finance in Africa: Challenges and Opportunities – Dr. Abebe Shimeles

We want the next President of the Federal Republic of Nigeria to make saving the lives of Nigerian children a priority. Despite formidable institutional barriers, a presidential initiative could cut child mortality by 50% in 5 years. We propose the following measures to achieve this goal:

1. 50% of all additional healthcare spending should go towards extending the reach and improving the quality of primary healthcare. Nigeria needs to spend more on healthcare and spend more of what it spends on primary healthcare, the level of healthcare best suited to saving Nigerian children from the simple ailments that kill them. This additional spending should include increases in the federal healthcare budget, donations from foundations, lending or grants from international development agencies etc. The funds should be invested in building, equipping, refurbishing and hiring staff for primary healthcare centres across Nigeria.

Nigeria spends about 3.5% of its budget on healthcare, much below the 15% the country promised to spend 20 years ago. Nigeria’s healthcare budget is also very low compared to the average of 12.49% of high-income countries and the 9.83% global average. Nigeria’s healthcare budget also falls short of 4.97%, the average for Sub-Saharan African healthcare systems. Just to be able to fight malnutrition effectively, the World Bank estimates that Nigeria needs to spend N301 Billion every year. Yet, in 2020, about N800 million that was allocated for Ready-to-Use Therapeutic Food (RUTF), a life-saving supplement for children suffering from severe acute malnutrition (SAM) was removed from the federal health budget.

2. 100% Free Access to Prevention and Treatment: Nigerian children should have free access to services to prevent or treat the three main ailments that kill them – malaria, malnutrition, and pneumonia. The aim of the presidential initiative is to have all that is required – primary healthcare centres, medications, qualified personnel etc., – within 30 minutes reach of every Nigerian child in five years.

3. Campaign to Identify, Mobililse, Incentivise, and Reward (CIMIR): Nigeria has a per capita income of $2,085; 72 infants out of 1,000 live births die in the country. In contrast, Turkey and the United Arab Emirates have per capita incomes of $9,587 and $36,285 and have 8 and 6 infants dying out of 1,000 live births respectively. So, it is obvious that so many children die in Nigeria because we are a poor country? No. Senegal, Tanzania, Rwanda, Sudan and Togo have per capita incomes of $1,606.5, $1,135.5, $833.8, $764.3, and $992.3 respectively but lower child mortality rates (per 1,000 live births) of 29, 35, 30, 40 and 44. Nigeria clearly needs to spend much more on healthcare. But it is also very clear that Nigeria needs to spend its current healthcare budget much more honestly and efficiently. Despite the vast need for funds, only 70% of the healthcare budget is released and 22% of the released budget allocation is returned to the treasury at the end of the year due to capacity and governance challenges.  Hence, it has to be understood that any presidential campaign to save the lives of Nigerian children is fundamentally an awareness campaign that identifies the areas of the greatest need and the biggest barriers to solving those needs, mobilises government and society, and incentivises and rewards actors in the public and private spheres towards rapidly reducing Nigeria’s disgraceful rate of child mortality. It will be a campaign to focus eyes on the problem and thereby enhance transparency as much as it is a drive to boost funding.

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4. Digitise healthcare expenditure, monitoring and evaluation: A junior healthcare worker was going to be examined on a final project for a nursing diploma. As an incentive to or appreciation of her teachers and other senior staff, she gave everyone five treated mosquito nets. This illustrates how materials and budgets disappear at every level of Nigeria’s healthcare system. The impunity escalates the higher you go. Information technology could be used to link the materials that budgets are spent on, the quantities procured, the primary healthcare facilities they have been delivered to and the identity of the ultimate individual beneficiaries. The presidential initiative should organise an annual hackathon that will crowdsource the best ideas on using information and communication technologies to monitor Nigeria’s healthcare expenditure. This could generate ideas like digital infographic maps that enable Nigerians to access readily data like the state of healthcare facilities in their local governments, the position of their local governments in a national ranking of infant and child mortality, monthly ranking of children who die at birth and from malaria, pneumonia, and other causes, quantities of materials such as mosquito treated nets, RUTF, etc., supplied.  Nigerians should also be able to use such digital primary healthcare maps to monitor budgeted sums for building or rehabilitating primary healthcare centres in their local governments and the progress of such projects. The annual hackathon would finetune and improve on ideas and strategies that employ digital technologies to enhance capacity, transparency and efficiency in Nigeria’s primary healthcare system.

5. Presidential Monitoring and Evaluation Council on Primary Healthcare Delivery (PMEC): If frustrating monitoring and evaluation systems were to be a field of academic endeavor, half of Nigerian public sector workers would have a Ph.D. in the discipline. The envisaged presidential initiative to save the lives of Nigerian children would achieve only a fraction of its potential if entrusted to the existing healthcare system no matter how much funding is increased. The proposed Presidential Monitoring and Evaluation Council on Primary Healthcare Delivery will not be an addition to the litany of government agencies in the health sector. It will have full authority to control and spend 50% of the additional funding for Nigeria’s healthcare (see 1 above). The PMEC will be co-headed by the head of UNICEF or WHO in Nigeria and a prominent Nigerian businessman or businesswoman (think of Aliko Dangote, Fola Adeola, Ifueko Omoigui Okauru, Atedo Peterside, or Yewande Sadiku). Membership will include representatives of major private sector organisations and international donor institutions and foundations as well as the Federal Ministry of Health and the National Primary Health Care Development Agency (NPHCDA). The key responsibility will be two-fold; a planning function that identifies needs-versus -capacity gaps and designs strategies to plug the gaps and a funding function that enjoys the autonomy to invest, monitor and control funds (i.e., 50% of additional healthcare funding) to close capacity gaps and procure primary healthcare inputs (facilities, manpower, etc.). The PMEC’s capacity building remit will include training existing staff and recruiting additional staff; it will also reward performance through enhancement of the welfare and remuneration of frontline staff. The council will ensure that the Nigerian president, the healthcare system and the nation have up-to-date information on the current state of primary healthcare across the country and the progress of interventions to improve healthcare delivery.

Also Read: Impact of Covid-19 on Public Finance in Africa: Challenges and Opportunities – Dr. Abebe Shimeles

The quality of Nigerian institutions is a direct outcome of the sort of politics we practice. Bad governance cannot be designed away. Yet, the courage to initiate bold institutional tweaks could deliver significant benefits, in this case saving Nigerian children from dying of easily preventable diseases. It should hence be an easy choice for Nigeria’s next president to make – increasing the funding, transparency, and capacity of the healthcare system to save children’s lives through collaboration with the private sector and international institutions versus pumping more funds into national institutions that lack incentives to improve governance and capacity.

International funding has previously been withdrawn from the Nigerian agency that fights malaria and the counterpart AIDS agency over misuse of funds. A presidential initiative that increases transparency and boosts capacity would see a greater inflow of funds into healthcare from Nigeria’s private sector and international foundations. The initiative to reduce child mortality through improving primary healthcare delivery in Nigeria will have a significant spillover effect as it would become easier for primary healthcare facilities to acquire the capacity to treat a host of ailments that affect Nigerians in poorly served communities. It could also become a model for improving the delivery of public services in other areas.

To contribute to this series, “Ask What Your Candidate Can Do For Nigeria”, send your article to info@arbiterz.com. Contributions should be at least 450 words.

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