By Alfred Ajayi
Nigeria’s health sector has a long history of dependence on international donor organizations which have over the decades supported various programmes related to maternal and child health, infectious disease control, immunization, and health system strengthening.
From pre-independence and early post-independence when interventions were largely driven by the British government, focusing on disease control (malaria, smallpox, and yellow fever) to the resumption of engagement from international organizations such as the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF), which started supporting immunization and basic healthcare services.
The World Bank introduced health system financing with the launch of projects like the Primary Health Care (PHC) Project in the late 1980s, while the United States Agency for International Development (USAID) and United Kingdom’s Department for International Development (DFID) (now the Foreign, Commonwealth & Development Office – FCDO) increased funding for family planning and maternal health.
Established in 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) has significantly boosted Nigeria’s response to HIV/AIDS, TB, and malaria, while the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) launched in 2003 has made Nigeria one of the largest recipients for HIV/AIDS treatment and prevention intervention. Gavi, the Vaccine Alliance, partnered with Nigeria to support immunization programs, particularly for polio and childhood diseases.
COVID-19 pandemic saw emergency funding from the WHO, World Bank, and IMF, supporting Nigeria’s pandemic response and vaccine acquisition through the COVAX facility.
Happily, from 2020, there has been a gradual decline in donor dependency, with more emphasis on domestic resource mobilization and public-private partnerships (PPPs). For instance, the Basic Health Care Provision Fund (BHCPF), established under the National Health Act (2014), is targeted at providing sustainable financing for primary healthcare.
Be that as it may, Nigeria continues to receive support from international donors for malaria eradication (Global Fund, USAID), polio (Gavi, BMGF), and health insurance expansion (World Bank). Programmes like the National Malaria Elimination Programme (NMEP), supported by USAID, the Global Fund, and the Bill & Melinda Gates Foundation, have distributed insecticide-treated bed nets, provided free malaria treatments, and improved diagnostic capacities.
PEPFAR and the Global Fund have offered free access to antiretroviral therapy (ART) for millions of Nigerians, while the country’s polio free status in 2020 was made possible by extensive vaccination campaigns funded by WHO, UNICEF, Rotary International, and Gavi.
Also, the National Tuberculosis and Leprosy Control Programme (NTBLCP) has been heavily dependent on donor support from The Global Fund and USAID, helping to provide free TB diagnosis and treatment. Approximately 24% of the available funding for TB control comes from international donors, while domestic funding accounts for about 6%, leaving a substantial funding gap of around 70%.
The donors are also helping to keep the nation’s Primary Healthcare and Maternal/Child Health afloat with initiatives such as Saving One Million Lives (SOML), supported by the World Bank. It was launched by the Nigerian government in 2012 to improve maternal and child health outcomes with a view to reducing preventable deaths, particularly among pregnant women and children under five, by expanding access to essential health services.
Challenges of Donor Dependency
While no country in international politics is self-dependent, over reliance on the global North for financial aid poses a great threat to countries of the global South including Nigeria, particularly without corresponding domestic funding. The consequences are even direr for health interventions any time such aid is suspended.
Sustainability is key to sustaining the positive outcomes recorded by those interventions. Lack of it has primarily accounted for the failure of many past programmes following the exit of donors, which provided the financial backbone. The recent U.S. presidential declaration cutting funding for international health interventions has a significantly negative impact on many critical global health programmes.
For instance, beneficiaries of the HIV/AIDS Treatment and Prevention are in palpable fear over possible relapse despite the swift response from the Federal Government to the suspension of U.S. health aid, particularly the PEPFAR funding for HIV programmes. It got the National Assembly to approve an additional $200 million in the 2025 budget to bolster the health sector, aiming to mitigate the impact of these aid cuts.
Commendable as it is, the funding gap created by the funding cuts needs a sustained domestic funding commitment from the federal, state and local government. Regrettably, Nigeria has a long history of allocating paltry sums to domestic health funding as all tiers of government always rely on donors to keep their citizens healthy. While the Federal Government allocates less than 5% of its budget to health, many states are doing better but only a few allocate up to 15% of their 2024 budgets to health, as recommended by the Abuja Declaration. They are: Abia, Bauchi, Nasarawa, Niger and Yobe.
Besides, donor funding is often targeted at policy and programmatic gaps with programmes prioritizing diseases or interventions based on international priorities rather than the most pressing local health needs. It focuses on service delivery rather than strengthening the country’s weak health infrastructure. This leads to short-term rather than long-term solutions.
Also, concerns have long been expressed about possible donor withdrawal as a result of fatigue caused primarily by changes in global priorities and economic downturns in donor countries. This reality is already dawning worsened by the huge cuts announced by the US with dire implications on millions of Nigerians, who rely on these interventions for survival.
Achieving Sustainable Health Interventions
For Nigeria to achieve sustainable domestic health funding, the Federal and subnational governments must show unflinching commitment to 15% Abuja Declaration. While there are pressures to pay equal or greater attention to other sectors of the economy, the long adage that a ‘healthy nation is a wealthy nation’ should guide our national priorities. Apart from drastic increase in domestic health financing, government should ensure that such available funds are properly utilized.
As witnessed in many advanced countries like the United Kingdom, the United States, Canada, Australia etc, Nigeria should maximize the gains of Public-Private Partnerships (PPP) to address impacts of inadequate domestic health financing. Government should court local industries to key into such arrangement to complement its efforts. Encouraging private sector investment in healthcare can help reduce reliance on donors and ensure sustainability.
The need is equally urgent to expand the country’s health insurance system by strengthening the National Health Insurance Authority (NHIA) to cover more Nigerians. This helps to provide alternative funding sources for healthcare programmes, while local capacity is built to enable companies within the country to produce vaccines, medical equipment, and pharmaceuticals. This will reduce dependency on external aid.
Above all, without accountability and transparency, increased domestic funding will mean be tantamount to more money available for diversion into private pockets, misappropriation, and outright embezzlement. Government must ensure that every fund made available is judiciously used for the purpose intended. Proper fund management, anti-corruption measures, and independent audits should be enforced to ensure efficient use of health funds.
