In 2020, the Covid-19 emergency briefly catapulted public health to the top of government agenda in Nigeria. As the health crisis unfolded globally, it became clear that most people in the country were spared from severe sickness or death due to the pandemic in contrast to many other countries especially in the developed world.
Albeit encouraging this should not detract attention from Nigeria’s multiple public health challenges that require priority attention. If anything, the pandemic-induced urgency must be sustained to prepare for the likely more complex health challenges in the future. Evidence-based planning, resource mobilisation and intelligent allocation is essential as health holds the key to both human development and a productive economy.
Double burden of disease
Nigeria’s epidemiological transition is characterised by a rapidly growing burden of non-communicable or chronic diseases alongside a persistently heavy infectious disease burden. The latter is compounded by structural problems, such as high levels of child undernutrition, infant and child mortality and air pollution as well as limited access to safe water and sanitation (WASH) infrastructure. In other words, Nigeria is facing a double burden of disease in a context of multiple structural constraints. According to the International Futures system (IFs), an integrated forecasting system housed at the University of Denver, in 2019 chronic diseases already accounted for about a quarter of deaths in Nigeria. Chief among them is cardiovascular conditions such as heart attack and strokes followed by different types of cancer and digestive diseases. IFs forecasts that deaths from cardiovascular diseases are expected to more than double from over 100 000 per year at present to close to 250 000 in 2040.
By then, the share of chronic diseases is forecast to represent as much as 43 percent of overall deaths; an expected increase of more than 70 per cent over the coming two decades. On the other hand, deaths from infectious diseases, predominantly malaria, lower respiratory infections, HIV/AIDS and diarrhoea are set to account for roughly half of deaths by then, down from about 70 per cent at present. Deaths from injuries, including traffic accidents account for the rest.
Managing the double burden of disease is a balancing act. It increases the pressure on Nigeria’s chronically underfunded and overstretched health system in addition to being a tall order for a government that is generally inept in strategic policy implementation. Ignoring the wave of chronic diseases will backfire in the future and undermine social and economic development. At the same time, shifting attention and resources away from reducing the infectious disease burden will prove problematic. Nigeria therefore needs to improve prevention, treatment and management of all types of diseases. It is obvious that this will be extremely difficult given scarce resources, competing priorities and a general drift in planning.
Read also: WHO warns preventable disease back on the rise in Africa
Halting progress
Overall, the health of Nigerians has improved greatly over the past decades, not least due to the commitment of both official development assistance and private initiatives, particularly the Bill and Melinda Gates Foundation. This manifests in longer life expectancy which is mostly attributable to lower infant and child mortality rates and fewer deaths from communicable diseases. Life expectancy rose from close to 55 years in 1990 to almost 65 years in 2019.
According to IFs, by 2040 the average Nigerian could reach about 72 years of age. Infant mortality dropped by approximately 35 percent from 104.5 in 1990 to 67.5 deaths per thousand life births at present and child mortality also declined.
Nevertheless, Nigeria performs worse than many of its African lower middle-income peers. Partly, this is due to poorer health system coverage, lower rates of infant immunization and inadequate WASH infrastructure. According to World Bank data close to 1.2 million Nigerians still died from communicable and in fact preventable diseases in 2019. And due to rapid population growth, the number of deaths is likely to remain essentially unchanged in 2040. Exacerbating this, the pandemic has reversed some of the gains as it strained health systems and disrupted access to key services, such as routine vaccination as well as malaria, tuberculosis and HIV/AIDS control programmes.
Conclusion
Going forward, policy interventions in Nigeria need to continue to fight the infectious disease burden via targeted interventions as well as curb the rise in chronic diseases. Nigerians deserve to live longer, but they also need to live healthier lives. This requires addressing different risk factors, including rapid urbanization that typically lead to changes in lifestyles, such as unhealthy dietary habits, reduced physical activity and/or increased tobacco consumption. All those factors are associated with hypertension, diabetes and obesity. Otherwise, chronic diseases will become an intolerable burden as they often result in long-term health consequences that lower productivity and require ongoing long-term treatment and care.
The double burden of disease, therefore, challenges Nigeria to work for greater resilience in its healthcare provision and delivery. To be sure, investment in healthcare has been low.
According to World Bank data, in 2019 health expenditure accounted for just over 3 percent of Gross Domestic Product (GDP) compared to 4.6 percent in Kenya, for example. Further, the Global Burden of Disease Universal Health (effective coverage) index estimates a score as low as 38 for Nigeria (on a scale from 0 to 100). Ghana and Cote d’Ivoire score 49 and 43, respectively.
The areas where Nigeria performs the worst are treatment of lower respiratory diseases and antenatal, peripartum and postpartum care for new-born babies. Most Nigerians in need of care pay out of pocket. Individual out-of-pocket costs account for more than 77 percent of all health expenditure, higher than anywhere else in West Africa. With roughly 45 per cent of Nigerians living in extreme poverty, this reinforces access inequality and leaves many without care.
Ultimately, there is need to shift from out-of-pocket towards greater public investment in health, ideally horizontal health programmes. Policymakers need to understand the inter-linkages between infectious and chronic diseases, maternal and child health and key risk factors outside the health system, such as malnutrition, unsafe WASH infrastructure, and exposure to air pollution.
Focusing on preventive and primary healthcare will also go a long way in curbing the growing burden of chronic diseases which are more difficult and more costly to treat and manage. Will the renewed attention to health worldwide translate into the building of effective resilience in Nigeria to this coming double burden of disease?
Bello-Schünemann is senior associate, Good Governance Africa (GGA-Nigeria)
