This is a joint post with David Bryden from RESULTS.
Nigeria’s response to Ebola has drawn high praise now that the concerted effort by government has stopped the disease in its tracks. Nigeria rapidly mobilized domestic resources and used house-to-house information campaigns to educate the populace.
Unfortunately, the same cannot be said about the response of Africa’s most populous country to another, much larger health crisis, that of tuberculosis (TB), a disease more easily transmitted than Ebola.
Last week the World Health Organization (WHO) revealed higher global estimates of the burden of tuberculosis, driven mainly by a more reliable survey of TB in Nigeria (once a new survey for Indonesia is published the global estimate will be revised upward again). The global death toll from TB is now 1.14 million a year. If you add in 360,000 TB/HIV deaths, TB-related deaths are at roughly the same level as HIV-related deaths. Estimated TB mortality in the African region is now 44 percent higher than the previously published estimate for 2012.
Nigeria’s figures are shocking. TB prevalence and incidence are double and triple, respectively, what was previously reported. Nigeria has more TB than any other country in Africa and more new cases per year (590,000) than even South Africa, heavily burdened by TB and HIV. Active TB case finding, going out into the community to find people with TB and get them into proper care, has been so neglected that –according to the WHO report- only 16 percent of cases are detected by the health system. Case detection in the Africa as a whole is at 52 percent. Ethiopia, which has trained health extension workers in TB, is detecting 62 percent of cases, and Kenya detects 75.
In a statement released by RESULTS by email, Dr. Baba-Gana Adam, a leading Nigerian advocate on TB, recently called the survey result a “wake-up call” and asked that “the same approach that was accorded Ebola needs to be adopted to curtail the projected spread of TB in Nigeria.”
We agree. Despite the TB emergency in Nigeria, surveys have found low levels of public awareness, along with widespread myths on the causes of TB. Adam says: lack of capacity is also a major concern; only 25 percent of primary health clinics are considered “partially functional” (according to Adam). Patients encounter “stigma and an unfriendly attitude from public health workers," according to another Nigerian advocate, Chibuike Amaechi.
To its credit, Nigeria has drafted a National Strategic Plan on TB to be published next month, with President Goodluck Jonathan expected to attend the launch event. The plan frankly lays out the program’s successes and weaknesses and puts forward a plan for a scaled up, community based response. It includes a strong infection control component, given the significant risk faced by health-care personnel of exposure to TB, as in Ebola. But the plan notes that “a massive scale-up of effort is required to meet the overwhelming needs of people with all forms of TB,” noting that, “facilities and trained personnel are inadequate to match the rapid scale-up in diagnosis that is envisioned under this Plan.”
Government is currently funding only 20 percent of the TB response. The new plan sets a target of 50 percent from domestic funds—but how to get from here to there? In Nigeria’s system, state-level governments receive basket funding for health from the federal government, and in most state budgets there is no line item and no direct incentive for better TB responses. And even assuming a 50 percent contribution from domestic funds, the National Strategic Plan projects a $504 million financing gap over 2015–2017.
If only TB could elicit the same urgency and action as Ebola; can Nigeria allocate to get more health for the money? Can they create incentives for states to dedicate more money and effort to TB? We’ll be watching to find out, and stay tuned for forthcoming work from CGD on ways national governments can use their inter-governmental fiscal transfers to promote health priorities like TB at the state level.