Stakeholders reflect on the national survey that reports significant health sector corruption in Nigeria: a communique from the Health Anticorruption Advisory Committee (HAPAC)

In a 2016 published survey, of the 14 most significant problems faced by Nigerians, corruption was ranked in third place, while healthcare was in fifth position. In the second version of the survey published in 2019, healthcare and corruption switched positions. And in 2023, corruption ranked in fourth position, and healthcare fifth.

Both corruption and healthcare have consistently remained problematic to Nigerians for decades. And one can only imagine what happens when the two problems intersect. Health corruption has been studied by the Health Policy Research Group, University of Nigeria (HPRG) and the Bayero University, Kano (BUK) for about seven years, leading to the establishment of the Health Anticorruption Project Advisory Committee (HAPAC), which is in partnership with the International Centre for Investigative Reporting (ICIR).

July 2024, health sector actors in Nigeria were, again, implicated in the third edition of the National Corruption Survey (NCS) published by the United Nations Office on Drugs and Crime (UNODC) and the National Bureau of Statistics (NBS) with support from the MacArthur Foundation and the Ministry of Foreign Affairs of Denmark. Key findings from the report suggest that the health sector ranks among the top-4 homes for bribery in Nigeria, manifesting in private health providers collecting bribes, and bribes paid for free services, to speed up procedures, or as an appreciation for care. Despite significant accounts of bribery within the health sector, reports or whistleblowing by service users who have been asked or forced to pay bribes were scarce.

Commendations to the UNODC and co-publishers

First, as stakeholders, we commend the efforts of the UNODC, NBS, and the supporting organisations for consistency in the conduct of the NCS, robustness of the sample, and data analytical rigour. We recognise that the organisations have been genuinely intentional about the issue, eliciting compelling and comparable data over the years, while open to improvements. The robustness of the sample manages errors and secures a good representation of Nigeria’s large population. Thus, we encourage continuity and sustainability of the survey as a means of tracking the progression or retrogression of sector-by-sector anticorruption efforts in Nigeria.

Special focus on the health sector

The NCS covers key sectors in Nigeria like security, education, judiciary, health, and public service. Over the years, it has significantly focused on bribes, the diverse forms they take, and the actors involved. In corroboration, academic and journalistic investigations affirm the prevalence of bribes in the health sector, also documented in some pieces of work as “informal payments”. Beyond bribes, scientific investigations have equally documented much more damaging corruption in the health sector like absenteeism of health workers, procurement fraud, health financing malfeasance, and employment irregularities.

Explaining the focus on bribes by the NCS, a representative of the UNODC reflected on Goal 16 of the sustainable development goals (SDGs), which targets substantial reduction of the prevalence of bribery if strong institutions must be built. The significance of achieving this target for the health sector cannot be overstated due to the sector accounting for the highest patronage (30 percent) by Nigerian citizens, even when compared to the Police – according to the survey.

For most health corruption enquiries, the private sector has been silent. So, the NCS has unlocked an area for future enquiries and anticorruption intervention by reporting the collection of bribes among medical doctors in private practice. Reacting to this, a representative of Nigerian private practitioners alluded to some corrupt practices happening within the system but had reservations about the significant indictment of medical doctors despite other health and non-health personnel delivering health services in the private sector.

On the way out of health corruption in Nigeria, available, efficient, and responsive reporting mechanisms must be present. Unfortunately, the NCS recorded no reports of bribery in the health sector. Comments from a participant who is familiar with the Medical & Dental Council of Nigeria (MDCN) affirmed poor reporting of corrupt practices to authorities, suggesting an urgent need to build an efficient reporting mechanism for the health sector.

The representative also mentioned that some practitioners may be unaware of the content of the MDCN code abhorring some of such normalised practices like demanding informal payments and receiving gifts from service users. As stakeholders, we hope that the MDCN will scale up awareness of the contents of its code among practitioners using effective sensitization measures, including curriculum approaches.

Important takeaways to strengthen future National Corruption Survey as per the health sector and to improve anticorruption

While we commend the thoughts and efforts that have consistently gone into the production of the NCS, concerning the health sector, we recommend the following for consideration:

  • The inclusion of more health sector corruption concerns like absenteeism, procurement irregularities, etc., based on available ranking in published academic outputs.
  • The organisations should build partnerships with more stakeholders in corruption research.
  • A good description of ‘other health workers’ (non-medical doctors) or apply the use of “health workers” as a common name for all health practitioners in the health system.

Overall, an important takeaway from the NCS for the health sector is that anticorruption agencies must now intensify their work with the health sector and grassroots leadership to mainstream efficient, user-friendly, and responsive reporting mechanisms at the points of health service provision. This can be co-produced with academics and investigative journalists who have historically worked on health corruption in Nigeria, as well as health workers, policymakers, and community representatives.

In all, HAPAC looks forward to the next national corruption survey, with the hope that lessons from the 2023 version will be used to improve the anticorruption prospects of the health sector. It also expects that data gathering and analysis for the health sector will benefit from engagements with health anticorruption scholars in Nigeria. HAPAC commends the NCS for finding its place within Goal 16 of the SDGs – Peace, Justice, and Strong Institutions, which has strong implications for Goal 3 – Good health and wellbeing.

 
Click to download PDF version of the communique

 

Acknowledgement

  • Dr Idris Muhammad – Chairperson, HAPAC
  • Dr Tarry Asoka – Deputy Chairperson, HAPAC
  • Victoria Bamas – Secretary, HAPAC
  • Professor Obinna Onwujekwe – Convener, HAPAC
  • Dayo Aiyetan – ICIR
  • Prof Muktar Gadanya – Bayero University, Kano
  • Dr Moses, C – Association of Nigerian Private Medical Practitioners
  • Princess Chifiero – United Nations Office on Drugs and Crime (UNODC)
  • Health Policy Research Group, University of Nigeria (HPRG)
  • Accountability in Action Research (AiA)
  • SOAS-Anticorruption Evidence Consortium (SOAS-ACE)
  • London School of Hygiene and Tropical Medicine (LSHTM)

We thank Dr Prince Agwu for the review of the communique.

For correspondence, send an email to vbamas@icirnigeria.org, Cc prince.agwu@unn.edu.ng

Child healthcare isn’t for infants and under-5 alone: communique from a policy dialogue on the health and health rights of urban school-aged children in Nigeria

More than half of Nigeria’s over 200 million population are under the age of 18, and just about 29 percent of the over 100 million Nigerian children are under 5 years. Children between the ages of 5 and 17 comprise the larger share of Nigeria’s children population but are least catered to by the Nigeria’s health system that is more interested in the under-5s. As such, health rights of children between 5 and 17 years have remained threatened, calling for urgent attention.

Supporting our assertion above is the evidence of demarcation between under-5 and school-aged children (5 – 17 years) in Nigeria’s National Health Policy but the listing of child-health-related Key Performance Indicators (KPIs) for under-5s alone. Similarly, the guideline for the implementation of the Basic Health Care Provision Fund (BHCPF) recognises just under-5s as among the five vulnerable groups, again, leaving out children between 5 and 17 years.

Understandably, policies like the 2003 Child’s Rights Act (CRA), 2006 National School Health Policy (NSHP), 2019 National Policy on the Health and Development of Adolescents and Young People (NPHDAYP), and 2022 National Child Health Policy (NCHP), have made attempts to recognise the uniqueness of children aged 5 – 17 years and the need to dedicate special care to their health and health rights. However, academic assessments and other significant evaluations of these policies have shown that they have not been strategic enough or well-implemented to provide sufficient protection for school-aged children’s health and health rights. Unsurprisingly, the Nigeria’s National Development Plan (2021 – 2025) decried poor enforcement of children’s rights laws and the absence of children’s viewpoints in health policymaking/enforcement.

Indeed, Nigeria may not have come to terms with the significant harm this lack of intentionality towards the health and health rights of school-aged children has caused. This was revealed in a recent research conducted by the Health Policy Research Group – University of Nigeria and the School of Humanities & Social Sciences/Law, University of Dundee, under the CHORUS Urban Health Consortium, with support from the Rivers State Ministry of Health. As national and subnational level stakeholders in health, education, social welfare, and human rights fields, drawn from 24 ministries, agencies, and organisations in Nigeria, we have gone through the study, validated the data, and have come up with our position. But first, we present a summary of the research evidence.

Evidence from the research

Four levels of research inquiries involving document reviews, in-class observations of children, and interviews and policy dialogue with a broad collection of national/subnational stakeholders inclusive of children, caregivers, teachers, school owners, attorneys, and policymakers were applied to gather evidence on (1) the policy environment for the protection and promotion of the health and health rights of school-aged children (2) patterns of seeking healthcare for school-aged children, and (3) threats to the rights of school-aged children to quality, safe, and timely healthcare. The research was focused on urban settlements in Rivers State, inclusive of urban slums. Across the three areas of inquiries, the study found that:

  1. Policies and laws expected to protect and promote the health and health rights of school-aged children failed several set expectations when judged against evidence from academic investigations and other significant inquiries. Notably, the 2006 National School Health Policy designed to play a pivotal role in supporting other related policies, has largely failed in its implementation. Conflicts in the leadership of the School Health Policy undermined its implementation progress and significantly contributed to the isolation of schools away from the health system, especially primary healthcare.
  2. Health seeking for school-aged children largely defied the provisions of safety and quality in the Child’s Rights Act [CRA]. The dominant health-seeking routes were home management of illnesses using self-prescribed medications; drugs bought from drug vendors or self-mixed herbal remedies; herbal practitioners’ recommendations, and solicitation of spiritual interventions from religious clerics even at critical times. The significance of primary healthcare was hardly recognised, as many rather jumped to private clinics or secondary/tertiary facilities when prior self-help and informal arrangements failed them.
  3. The school-aged children decried the absence of health personnel and health facilities in their schools. More so, they complained about the absence of a responsive care and reporting system to either discuss their physical and mental health needs or to report risky health options and behaviours stimulated and encouraged by their caregivers. The children equally recognised inefficiencies and unsupportiveness of health facilities, particularly the unruly attitudes of health workers toward children and their caregivers, high fees for health services, poor emergency response to children in health crises, and constrained physical access to health facilities.

 

Cross-section of stakeholders

 

Policymakers and other stakeholders validate evidence and prioritize actions

On August 5 and 6, 2024, stakeholders met in Port-Harcourt, Rivers State, Nigeria, and without reservations we commended the now nationally accepted and domesticated CRA across the country’s federating units. We also appreciated the working groups for adolescents’ health based on the emergence of health programmes for adolescents and the progressive scaling of adolescent-friendly health centres. And importantly, we hailed the ongoing health systems strengthening blueprint that recognises the centrality of school health services to the health needs of school-aged children.

Notwithstanding these commendable efforts, we pointed out fifty-one concerns which we later condensed to five specific areas using a Modified Delphi Technique to deliberate and consensually rank priorities. Our agreed five areas and suggested actions for governments at all levels are:

  1. Leads of the health, education, and social welfare (women affairs in some cases) ministries must leverage current evidence for the review of school health-related policies with the aims of: (a) harmonization of contents (b) setting very feasible targets with realistic benchmarks to gauge progress, and (c) reaching a definitive consensus on the leadership of school health with clear definition of roles and responsibilities.
  2. Leads of the health, education, and social welfare ministries should work with the legislative committee on health, the criminal justice system, children’s parliament, and the child’s rights implementation committees to design and enforce clear and widely communicated standard operating procedures for reporting and responding to actions that violate the rights of school-aged children to safe, quality, and timely healthcare.
  3. The above actors should work with the national orientation agency, academia, civil society organisations, community-based organisations, children’s parliament, and media to design a simplified and effective communication framework for the harmonized policy contents and standard operating procedures which must include: (a) mainstream into school curriculums (b) pasted prints in health facilities and schools (c) repeated announcements in religious gatherings, and (d) unrestricted digitized accessibility.
  4. The lead of the state health ministry should work with the primary healthcare development agency, health insurance agency, and the education ministry to: (a) design schools’ clusters around designated functional primary health facilities with school health desks headed by appointed school health desk officers (b) encourage appointments of school health focal persons to link schools with the designated health facilities (c) design terms of reference and workflow modalities (d) explore inclusion of school-aged children in the basic healthcare provision fund, and (e) nudge schools toward employing at least one qualified health personnel and setting up equipped sickbays in the long-run.
  5. The consensually agreed leadership of school health will explore external funding while compulsorily including school health services in the annual operation plans and budgets to cover funding the desk offices, enforcement of the standard operating procedures, and all other health systems and wider responses to the health and health rights of school-aged children.

Our conclusive position

As stakeholders, we acknowledge the fragility of the under-5 population, hence the enormous attention accorded to their health needs, and we encourage even more. However, it is worrisome that the bulk of the country’s population between the ages of 5 and 17 years who are also children have not received as much attention as they deserve health-wise. The consequences are regrettable, evidenced by gross violation of their health rights, poor institutional responses to their health needs and rights, and avoidable cases of morbidities and mortalities.

As stakeholders from different fields, we underscore the need for a more coordinated, strategic, and inclusive approach to health policymaking that prioritizes the unique needs of school-aged children. This should begin with reviewing and implementing an effective school-health or holistic child-health policy that prioritises the health rights of school-aged children, school-health services, and easily accessible primary healthcare services for school-aged children. It should be supported by widely communicated and accessible deterrence mechanisms to put an end to the violation of the health rights of school-aged children in Nigeria. By adopting a more holistic and intentional focus on the health rights of school-aged children, Nigeria can make progress towards ensuring that all children, regardless of age, have access to safe, quality, and timely healthcare.

Acknowledgement

  1. Rivers State Ministry of Health
  2. Rivers State Ministry of Education
  3. Rivers State Ministry of Social Welfare and Rehabilitation
  4. Federal Ministry of Health (Family Health Department/Child Health Division)
  5. Federal Ministry of Education
  6. Federal Ministry of Women Affairs
  7. National Primary Health Care Development Agency
  8. Rivers State Primary Healthcare Management Board
  9. National Health Insurance Authority, Rivers State
  10. Rivers State Adolescent Technical Working Group
  11. National Child Rights Implementation Committee
  12. Rivers State Family Court
  13. Aret and Bret LLP Law Firm
  14. Results for Development, Nigeria
  15. Marine Base Community
  16. Assemblies of God Church, Amadi-Ama, Rivers State
  17. Police Station Mini-Okoro Mosque
  18. The Boy Child Support Network
  19. Rhema Care
  20. Channels TV
  21. Wish FM
  22. Model Senior Secondary School, Rivers State
  23. Pneuma Citadel Academy, Rivers State
  24. Dr Tarry Asoka (Independent Health Consultant)
  25. UNICEF, Rivers State Field Office
  26. CHORUS Urban Health Research Consortium
  27. University of Dundee, United Kingdom
  28. Health Policy Research Group, University of Nigeria

Research Team (L-R): Ifunanya Agu (Project Manager), Dr Aloysius Odii (Research Associate), Prof Uzoma Okoye (Research Co-Lead), Dr Adaeze Oreh (Hon. Commissioner for Health, Rivers State, Nigeria), Dr Prince Agwu (Research Lead), Chinelo Obi (Research Associate)

Correspondence: prince.agwu@unn.edu.ng

Click to download the communique in pdf

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Using scientific evidence to ensure value for investments in making vaccines available and impactful in Africa

 

Vaccines are among the most powerful inventions in human history, and it is not just a medical duty but a moral responsibility to ensure that everyone has unrestricted access to vaccines.

 

Vaccines are central to healthy societies because they prevent illnesses and effectively curb the spread of communicable diseases. They help create antibodies to resist illnesses like measles, meningitis, polio, yellow fever, etc. Since 1796 when Dr Edward Jenner created the world’s first successful vaccine against cowpox, vaccines have continued to save lives, estimated annually by the World Health Organisation at 2.5 million lives, the majority of whom are children.
Indeed, vaccines are among the most powerful inventions in human history, and it is not just a medical duty but a moral responsibility to ensure that everyone has unrestricted access to vaccines.
Keeping up with the call to ensure unrestricted access to vaccines may seem difficult in current contexts where it can be financially demanding to develop and/or procure vaccines, hence inaccessible by low-resource regions of the world and deprived populations. To address this challenge, efforts must be channelled toward procuring vaccines with the most impact on addressing disease burden and for the most effective cost.
To achieve the foregoing, a multi-country project on “vaccine economics” has been flagged in Nigeria, Kenya, and Zambia to promote economic evidence in vaccines administration. The project applies Health Technology Assessment (HTA) to systematically assess and evaluate the overall conditions of vaccines as a product of health technology and the economic, social, and ethical concerns they raise.
Click here to learn more about HTA.
Two main outcomes when vaccines are effectively deployed are: (a) improves the quality of the lives of people (Quality-Adjusted Life Years – QALYs), and (b) reduces incidents of disability and premature deaths that cut short the lives of people or reduces the quality of their being alive (Disability-Adjusted Life Years – DALYs).
Achieving these outcomes is contingent on how well the development, procurement, and administration of vaccines are budgeted for and financed. This is why Budget Impact Analysis (BIA) is a significant exercise that must be conducted to ensure optimal representation of vaccines in annual budgets in ways that would not compromise spending on other significant areas of development and wellbeing.
Click here to learn more about cost-effectiveness of vaccines and BIA.
Of priority to our work are vaccines for measles and malaria, and the 5-in-1 meningococcal vaccine that protects against different types of bacteria that cause meningitis. As these vaccines become available, delivering them is of prime importance, which also has cost implications.
Click here to learn more about vaccine delivery mechanisms and costing.
In summary, in one of our meetings, Prof  Abdul Aguye, Chairman, Nigeria Immunisation Technical Advisory Group (NGI-TAG) of the National Primary Health Care Agency (NPHCDA) reminded everyone that Nigeria has a high disease burden, and that prioritizing some of the vaccines based on their cost effectiveness would go a long way  to mitigate the effects of the diseases on the population.
Click here to read full press release.