Inside Nigeria’s malnutrition plague

Nigeria, Africa’s biggest economy, has yet to make a big dent in the malnutrition problem plaguing millions of its people, especially children.

The country has high child malnutrition despite the nearly N60 trillion allocated by the Federal Government to the health sector since 2001, as well as trillions of naira in budgetary spending by the 36 states and 774 local governments.

In 2020, agriculture contributed around 24.14 percent to Nigeria’s GDP. It contributed 24.17% to nominal GDP in the fourth quarter of 2021 and accounts for nearly 40 percent of the country’s total economic activities, employing a little above 60 percent of the working population.

Yet, Nigeria’s agricultural productivity is insufficient to meet the food required by its growing population, thus increasing the demand and supply gap in the country.

At the subnational level, budgetary allocation to agricultural interventions is grossly inadequate. The contribution of the public sector investment in agricultural infrastructure is low, with no systematic pattern in government capital spending on agriculture.

A recent OXFAM report found that in nearly all the states where a study was carried out, “agricultural investment is remarkably low and falls short of the 10 percent Maputo declaration recommendation, which has been adopted by the states, with states averaging between 1 and 3 percent”.

The absence of government investment and political will have coalesced to worsen the malnutrition problem in Nigeria, with the country having the second-highest burden of stunted children in the world. Nigeria is facing a crisis of malnutrition and ranks second behind India among all countries with the highest number of stunted children.

Thirty-seven percent of Nigeria’s children under five years, according to a 2021 USAID country profile report, are stunted. The prevalence of stunting increases with age, peaking at 47 percent among children 24 to 35 months, while 70 percent of children ages 6 to 23 months are not receiving the minimum acceptable diet. Twenty-two percent are underweight, with an estimated 2 million children in the country suffering from severe acute malnutrition, and only two out of every 10 children affected being currently reached with treatment.

“Out of 100 patients that we see every day, 99 come from poor homes,” a health care worker in Kaduna State told BusinessDay on condition of anonymity. “All of them are not getting enough food; they come from large families and are illiterate”.

Nigeria’s public spending on health care, according to a January 2022 World Bank data, is a paltry 3.89 percent of its $495 billion GDP, compared to 8.25 percent in South Africa and 5.17 percent in Kenya. This is far below the 15 percent agreed in the 2001 Abuja Declaration, when African Union member countries pledged to improve spending on their health sector and urged donor countries to scale up support.

More than 70 percent of Nigeria’s health budget is used for recurrent expenditure, including office maintenance, salaries and allowances. About 28 percent dedicated to capital projects including procurement of drugs, and micronutrients, whose shortage constitutes a major public health problem in the country.

Corruption, bad policies and ethno-religious violence are hindering agricultural production and distribution in the country.

A July 2018 Carnegie Endowment report on corruption in Nigeria found that the impact of agricultural corruption was disproportionately great because the sector is the backbone of Nigeria’s non-oil economy, accounting for roughly 30 percent of GDP. “It also has an outsized impact on the country’s poorest citizens,” the report said.

Nigeria’s land tenure laws, according to the report, “give corruption-prone state and local officials power to grant — and revoke —occupancy rights, discourage farmers from investing in their smallholdings. These laws also make establishing mechanised, well-irrigated, industrial-scale farms inordinately difficult. Smallholders are also hurt when government officials misappropriate agricultural subsidies by granting them to family and friends or to shell companies owned by political elites”.

“Between 1980 and 2010, agricultural subsidies totalled N873 billion ($5.8 billion in 2010 dollars); of that amount, an estimated N776 billion ($5.2 billion) was lost to corruption. Government programmes to supply cheap fertiliser to smallholder farmers were especially fraud-prone. Farms have also been used by political elites to launder money skimmed from government coffers,” it said.

In the 2021 Global Hunger Index (GHI), Nigeria ranked 103rd out of the 116 countries. With a score of 28.3, Nigeria has a level of hunger that is serious. The GHI is a tool designed to comprehensively measure and track hunger at the global, regional, and national levels.

It is not just in the health sector that misalignment of priorities exists in Nigeria. The country spends on average 21 percent of its total budget on capital expenditure, with recurrent expenditure as a percentage of total expenditure being as high as 115 percent on average in the last 10 years. In the Federal Government’s 2022 budget, non-debt recurrent expenditure of N6.83 trillion is the largest expense item, with 60 percent relating to personnel costs at N4.11 trillion.

What this inevitably means is that critical drugs and nutrients required by Nigeria’s children to develop, especially for those who face malnutrition, are unavailable in government hospitals and health centres.

“The problem is that we do not get as many micronutrients as we used to get years ago. It started very well,” a doctor who works in one of the health facilities in Bauchi State told BusinessDay. “What we get now are very small quantities of micronutrients. So, the food pack a child is supposed to get has been heavily reduced. This further denies them the quality and quantity of micronutrients they need.”

But it is also not just an issue of poor budgetary allocation. While concerns about budget are valid, says a 2020 School of Oriental and African Studies Anti-Corruption Evidence report, of equal weight “is the issue of the optimal management of presently allocated funds”. “This continues to be an underlying problem,” it added. Structural and facility-level corruption and accountability issues affect access to adequate health care by Nigeria’s malnourished children.

Nigeria ranks 154th out of 180 countries on the Transparency International 2021 Corruption Perceptions Index. Its health sector has been identified as one of its most corrupt sectors. This has been attributed to weak governance structures and accountability. Several studies have identified corruption as one of the major factors behind the adverse health outcomes in the country.

While budgetary allocations from the Budget Office of the Federation are made directly to ministries, department and agencies, including hospitals, the use of those funds by the facilities’ management is sometimes a source of concern. The Bauchi-based doctor said: “Most needed drugs that have been budgeted for are not available in the hospitals in Bauchi State. You have to go to private pharmacies to get these drugs.”

Drugs donated by international agencies including the World Health Organization and the United Nations Children Emergency Fund (UNICEF) are routinely sold to private pharmacies.

A 2016 descriptive survey by California-based PLOS Corporation found that “lower availability of medicines in Nigerian public health facilities which is the most affordable option for the masses undermines global health reforms to improve access to health for all, especially the chronically ill and poor”. It added that “a sizeable proportion of healthcare users, irrespective of purchasing power, buy medicines at higher costs from for-profit pharmacies”.

The supply of micronutrients to Nigeria’s public health facilities was hitherto facilitated by UNICEF and the Howard Schiffer-founded Vitamin Angels. In many northern states, this was done through the supply of Plumpy Nuts, a ready-to-use therapeutic food specifically formulated for the nutritional rehabilitation of children from six months of age and adults suffering from severe acute malnutrition.

Read also: 14.5 million Nigerians facing acute food insecurity – UNICEF

After years of supporting Nigeria with this product, it was found out that the product was not reaching its target population of malnourished children. According to several healthcare workers including those working on donor-funded projects in the North, it was found out that hospitals were selling the Plumpy Nut products to bakers who use them to fortify their bread and children who actually need this product are not getting it.

“Because the product was not getting to the targeted children, there was no improvement in outcomes and so UNICEF and Vitamin Angels had to pull out of the programme,” the doctor said.

The dearth of the much-needed micronutrients in health centres across the country currently poses an obstacle to the fight against malnutrition. Nigeria’s federal and state governments on their own do not possess the moral, ethical and policy capacity to end malnutrition that plagues tens of millions of Nigeria’s children.

According to UNICEF, states in northern Nigeria are the most affected by the two forms of malnutrition – stunting and wasting. Nigeria’s 2018 National Nutrition and Health Survey said: “The prevalence of stunting was 32.0 percent and has remained the largest burden of malnutrition, with stagnated rates of above 30 percent since 2014, and with many states in the North-West and North-East recording prevalence above 40 percent – the WHO critical levels.”

According to the 2018 Nigeria Demography and Health Survey, the proportion of stunted children is highest in the North-West at 57 percent and lowest in the South-East at 18 percent. By state, stunting is most prevalent in Kebbi at 66 percent, Jigawa at 64 percent and Katsina at 61 percent. It is least prevalent in the South-East states of Anambra at 14 percent and Enugu at 14.8 percent.

In addition, the proportion of children who are wasted – where a child is too thin for their height – is approximately twice as high in the North-East at 10 percent and North-West at 9 percent. In the other zones, the percentage is from 4 percent to 6 percent. This gap in child malnutrition between northern and southern Nigeria has been constant over time.

The underlying causes of malnutrition in Nigeria are poverty, inadequate food production, and inadequate food intake. There is a close nexus between malnutrition and poverty. “One of the consequences of poverty,” said Dr Blessing Akombi-Inyang, a lecturer in Global Public Health at the University of South Wales, “is the lack of access to nutritious food, which predisposes people to poor nutrition. Poverty increases the chances of malnutrition. Malnutrition, in turn, traps communities in poverty. Poverty and malnutrition are inextricably linked.”