After a full year without any new polio cases in Nigeria, the World Health Organization (WHO) announced earlier this month that the disease is no longer endemic in the country. This development has come at a time when we really need some good news, so a little self-congratulation is not amiss. This is especially true considering the major polio eradication setback the country faced in 2003 when five states boycotted the oral polio vaccine (OPV), leading to a jump in reported cases between 2002 and 2006.
That boycott stemmed from allegations that the OPV contained HIV and sterility-causing agents and it took a concerted effort by imams, Islamic school teachers, traditional rulers, doctors, journalists, and polio survivors to restore confidence in the campaign. It also took a team of over 200,000 people, including Nigerians who worked to administer the vaccine even in the remotest areas, under difficult and sometimes life-threatening conditions. As recently as 2013, nine female polio vaccine workers lost their lives in the process. As it stands, polio eradication is certainly an achievement we should collectively be proud of.
A Exodus of Funding
But (and there’s always a but) Nigeria is not officially polio-free. The WHO will continue to monitor the situation over the next two years and only if we still have a clean bill of health by then will it be safe to conclude that polio eradication efforts have been truly successful. Even at that, the country will need to continue administering the vaccine to avoid the emergence of new infections.
In a sense, the biggest effect of the WHO announcement is that it shifts a larger share of the responsibility for keeping Nigeria polio-free on to the Nigerian government. Although Nigerians were involved in mobilisation and education efforts, the financial weight of polio eradication was largely borne by external donors, particularly Rotary International and the Bill and Melinda Gates Foundation. Nigeria’s total contributions to the Global Polio Eradication Initiative (GPEI) has amounted to roughly $111 million donated between 2006 and 2013. This doesn’t seem that low until you consider that estimated funding needs for eradication efforts in Nigeria alone were $301 million in 2014, $268 million this year, and $170 million for 2016.
And long-term costs are unlikely to decrease. The government will need to continue administering the polio vaccine to any babies born in the future and these vaccines are set to be more expensive.
Currently, Nigeria’s polio vaccination strategy mainly utilises the oral polio vaccine (OPV) because it is cheaper and more easily deployed than the injectible Inactivated Polio Vaccine (IPV). However, in many polio-free countries, use of the OPV has been discontinued as it does not prevent the disease from being transmitted through faeces in areas with poor sanitation. Additionally, since the OPV passes through the gastrointestinal system, the vaccine is less effective if a child has diarrhoea. Seeing as Nigeria faces challenges in both proper sanitation and clean drinking water, the logical move would be to switch to the IPV to bypass these hurdles. The main drawback, however, is that it currently costs a whopping $20-$40 per dose compared to the OPV which the country gets for about $1 per dose.
And while some help may continue to come from external sources, the government should be prepared for much lower funding than it has been used to. For instance, when India reached the same one-year milestone in 2012, it also had to prepare for a reduction in aid from the US, a significant financier of the polio eradication efforts in the country. As it stands, GPEI is gearing up for a greater focus on Afghanistan and Pakistan as its goal of a polio-free world has never seemed so tantalisingly close. Therefore, this means that we will have to fend for ourselves to a greater extent than before.
More Money More Problems
As with many things in Nigeria, management, not funding, will be the biggest hurdle to keeping polio at bay. The country’s healthcare system is a mystifying combination of large funding and little results. Granted, the share of the federal budget on health care has generally stayed below 7%, far from the 15% stipulated in the African Union’s 2001 Abuja declaration. The 2015 federal budget allocated about ₦237 billion for recurrent and ₦22 billion for capital health expenditure, which forms about 5.7% of the total.
However, the country also gets substantial funding from external sources for health-related spending. Over the last 15 years, Nigeria has received roughly $430 million from GAVI for routine immunisations and this year, the World Bank approved a $500 billion International Development Association credit to help Nigeria improve maternal and child health care. This was in addition to $150 million World Bank financing plus a $21.5 million grant from the UK and Norway in 2012 for the Nigeria State Health Investment Project in Adamawa, Nasarawa and Ondo states. Meanwhile, the United Nations Population Fund (UNFPA) earmarked $75 million this year to boost reproductive health services and data generation in Nigeria.
Against this backdrop of money pouring into the sector, Nigeria continues to lag behind in key indicators. A quick comparison with Ghana yields some interesting observations – the country boasts higher life-expectancies, lower infant mortality rates, and fewer incidences of HIV/AIDS and tuberculosis than Nigeria. Most startling of all is that while Ghana’s National Health Insurance Scheme (NHIS) has 65% enrolment, lowering out-of-pocket healthcare spending from 80% to 66% of total spending, Nigerian households are still paying over 90% of their health care expenses out-of-pocket, and NHIS membership is at a measly 3%. Given that the countries have similar profiles, even in terms of financing, this suggests a deeper structural issue in Nigeria’s health sector that goes beyond availability of funds and the $2.2 million GAVI refund debacle is one clue that suggests mismanagement is the cause.
Cleaning Out The Sector
Being polio-free is a commendable target but Nigerians would benefit from a more broad-sighted government. One powerful critique of donor-funded programmes such as the GPEI is that they focus on a narrow range of issues and measure progress through one-dimensional targets, often excluding important concerns. This makes sense for goal-oriented organisations that have to answer to financiers but government cannot afford to adopt the same attitude as the creation of a healthier society requires a more integrated approach.
India provides a compelling lesson in this respect. One year after it was declared polio-free, the country experienced an increase in the reported cases of acute flaccid paralysis (AFP) – from 8,500 reported cases in 2003 to 18,000 this year. AFP is a symptom of acute polio but may also be caused by other kinds of viruses. One explanation for the rise in cases is a higher rate of reporting due to routine testing for polio resurgence. The key takeaway is that in the fight against polio, less attention was paid to these other illnesses which, like polio, are easily transmitted in areas with high population density and poor sanitation and hygiene. Had the polio eradication scheme gone beyond strict polio targets and focused more on transmission mechanisms, the situation would have been different.
Nigeria needs to focus on addressing gaps in access and affordability of health care and improving living conditions. Reasonable progress may take time, perhaps longer than it took to cut down polio cases to zero, but longer-term thinking usually yields greater rewards. If there was ever a need to choose between providing basic healthcare infrastructure and fighting a single disease, it seems the former option is likely the smarter choice. Ultimately, a more resilient health sector will be able to cope with a wide variety of illnesses, not just one.
Hopeful For Today
And the journey to better healthcare in Nigeria may not be as difficult as it seems. The Nigeria Health Innovations Marketplace, an initiative of the Private Health Alliance of Nigeria (PHN) is aimed at giving the health sector a much-needed transfusion. 42 projects shortlisted in the 2014/2015 PHN-sponsored Health Innovation Challenge proffer solutions that target three broad areas: improved collection of and access to medical data for both patients and health workers; new approaches for the prevention, diagnosis or treatment of disease; and technologies for improved maternal and child health services.
Two projects stand out in the third category for their potential impact on the delivery of routine immunisations: Alma Sana Vaccine Bracelets and Wemunize. The former targets the demand-side of the equation by using bracelets on children’s hands to remind mothers of the right immunisation dates, while the latter additionally targets the supply side of the equation by using data management to help immunisation clinics to cope better with the demand for their services. A combination of such innovations with other tried and tested strategies like cash and non-cash incentives could give our health sector a booster that’s been long overdue.