Senior Advisor, Global Health Policy Center
A few weeks ago, I was sitting in my Geneva hotel room watching BBC News – it’s always interesting to see the world through another country’s news lens – and they aired a story about lost oil and gas revenues in Nigeria. Billions lost, billions owed. Because I was in Geneva for meetings concerning the Global Fund’s Strategy, Investment, and Impact Committee, it had a particular punch because the Committee was spending so much time trying to figure out how to adjust to a more austere funding environment in the ongoing battle against AIDS, tuberculosis, and malaria. Here we are, trying to do more with less, and one of the most important countries for all three diseases is losing more in revenues than all of the Global Fund’s annual contributions combined.
Home to 170 million people, many of them desperately poor, Nigeria carries a huge and disproportionate share of burden for many of the world’s most deadly diseases. Look in the global strategies for HIV, TB, malaria, maternal and child health, polio eradication, NTDs, and NCDs – among many others – and you’ll see Nigeria at or near the top of the “Must Win” countries. The reason is simple. If there isn’t success in Nigeria, the global picture remains bleak.
Nigeria is not the only growing income country where providing aid is problematic, but Nigeria is an especially challenging case, which many donors increasingly believe is less worthy of outside aid due to notoriously high degrees of chaos and corruption, especially in its oil and gas industries. At the same time, time, others in the development community argue that holding Nigeria’s poorest citizens to account for their government’s incapacity and inaction by withholding funding for lifesaving services seems both cruel and short-sighted. So there’s a bit of a standoff. Donors begrudgingly continue to support the country while pressuring the government to step up and do more.
How bad is the health situation? In the sidebar below, you’ll find a range of key health indicators for the country. The statistics show a grim picture for Nigerians, who have a life expectancy of about 52 compared to 78 in the U.S. Put simply, Nigeria is in the inauspicious “top 10” list for under-five deaths as well as deaths in HIV, tuberculosis, and malaria. It’s also bearing a huge disability burden from various neglected tropical diseases and non-communicable diseases.
Nigeria’s economic picture, on the other hand, is a bit brighter. Estimated GDP growth for 2011 was 7%, far better than most developed countries. Though agriculture accounts for the single largest share of revenue, Nigeria’s economy is increasingly fueled by, and dependent on, oil and gas. According to Bloomberg, Nigeria depends on oil exports for more than 80 percent of government revenue and 95 percent of export income. Unfortunately, much of that oil revenue is lost. The BBC report I mentioned highlights that a government-commissioned study found $29 billion was lost in the last decade from price fixing, and another $6 billion from stolen oil – with as much as 10% of daily production stolen.
This means that many Nigerians don’t reap the rewards of the oil and gas under their homes. According to the African Development Bank, the country’s unemployment rate is currently 24% and unemployment among youth is 38% -- one of the highest in sub-Saharan Africa. Government spending on health is also low, about 5% of its budget, far below the 15% share committed to by African leaders at a 2001 Africa Union summit in Abuja.
While some donors continue to provide aid, they only do so by going around the national government in Abuja and working directly with some of Nigeria’s 36 states. This is a recent strategy for the U.S. PEPFAR program, but other donors including U.K. Department for International Development have been focusing on state-level work for years. This approach is probably not a great solution for problems that impact the country widely, like malaria, which is a risk for 97% of the population.
So, somehow, the Nigerian government needs to do a better job of capturing the revenues it’s due, and channeling a greater percentage of that revenue to the urgent health needs of its citizens, but that doesn’t seem to be happening. The 2013 budget proposal from President Jonathan raises health spending only slightly to 6%, leading one health expert to deride, “It is a paltry allocation and ridiculous. Nigeria should be more embarrassed because its government is a signatory to the Abuja Declaration where committee of nations pledged to allocate no less than 15 per cent of their annual budget to health.”
In terms of improved overall governance, there’s some good news to report. Nigeria has made progress in fighting a flood of counterfeit and stolen medicines, under the leadership of health minister Onyebuchi Chukwu, who has been lauded by some of my friends that work closely with him. The country’s minister of finance, Ngozi Okonjo-Iweala, has a strong track record of fighting corruption and supporting development (she sits on the board of the ONE Campaign, where I’ve worked). Both participated in a health conference last month, launching a “Saving One Millions Lives” campaign that left one local health commentator optimistic.
Yet despite these strong leaders, the country’s overall governance picture isn’t pretty. In his recent ratings, African billionaire philanthropist Mo Ibrahim (also a ONE board member!) has a foundation that scores African countries, and it recently put Nigeria in the bottom ten countries for good governance – 42nd out of the 52 countries reviewed. Modest improvements in Nigeria’s health score were noted, but the country is still in the bottom ten on that list as well.
I’m interested in comments and suggestions about solutions: How can the international community help Nigeria do more to improve the health status of its people? What should donors like the Global Fund and PEPFAR do?
My colleague Jennifer Cooke, who runs the Africa program here at CSIS, will be publishing shortly an excellent paper on maternal health in Nigeria, with a focus on Ondo State in the country’s southwest region. Keep an eye out for it!