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Closing the $215m funding gap for TB control in Nigeria

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By Luminous Jannamike

“WHEN (young) Winner came for treatment, she was in such pain she had to be carried around. But after just two weeks, she showed significant improvement and is out of danger,” says Anyanwa Beatrice, the health care worker who supervised the girl’s treatment for tuberculosis at the University of Port-Harcourt Teaching Hospital, Rivers state.



Winner, 7, fell while playing at their home in Obio Akpor local government area of the state. She later developed a lump on her back. Although it looked strange, it didn’t initially hurt much, so her family dismissed it as “just a bump.”

But the swelling grew, and became tender and painful for Winner, who also began having trouble moving her limbs properly.

Now concerned, her mother, Blessing Ihunwo took the child to a traditional healer, which did little to improve the situation. She then sought more spiritual help rather than medical help because of lack of resources to settle the necessary hospital bills.

But workers at her church looked at the child and advised Ihunwo a mother of four lovely kids to seek medical help for Winner. They also provided a small sum to pay for the visit.

Winner’s mother, who reactivated faith in the efficacy of modern medicine to save her young daughter, took the girl to the hospital where the doctor diagnosed and treated an otherwise potentially deadly variety of juvenile tuberculosis (TB).

The hospital admitted the girl to the thoracic clinic, where a paediatrician from a USAID program, Challenge TB, immediately recognized the swelling as a symptom of a form of childhood TB known as Pott’s disease, and not related to her fall at all.

Pott’s disease strikes the spine rather than the lungs. The bacteria are transmitted the same way.

Children are especially prone to this form of spinal TB, which, if left untreated, can lead to a collapse in the vertebrae and cause paralysis in one or both legs.

The diagnosis was confirmed with a chest X-ray, and Winner was immediately placed on the appropriate anti-TB treatment regimen.

Less than two months later, Winner was already showing signs of improvement. The pain and swelling had diminished almost completely, and function in her legs restored to where she could walk, run and play again. And a slight case of scoliosis, or curvature of the spine, brought on by the TB had straightened.

Ihunwo was also taught how to adhere to the 12-month treatment regimen that Winner had to complete before being completely rid of the disease and other orthopaedic anomalies.

Winner’s story probably ended on a happy note because there was adequate resources and support for her treatment and her family. But could that be said of the over one million other Nigerian children who are diagnosed with tuberculosis annually?

According to the 2017 Global TB Report, Nigeria is among the 14 high burden countries for TB, TB/HIV and MDR-TB.

The country is also ranked 7th among the 30 high TB burden countries and 1st in Africa.

Nigeria was among the 10 countries that account for 64 percent of the global gap in TB case finding in 2017.  India, Indonesia and Nigeria account for almost half of the total gap.

The National Strategic Plan, NSP, on tuberculosis, says Nigeria requires $336m to address TB challenges by 2020.

But, a breakdown of the funding for the disease in Nigeria so far shows that $31m (9%) has been provided domestically, and $90m (27%) has been raised through international donors; leaving a $215m (64%) funding gap.

Can the Nigerian government close the funding gap through direct investments in the production of tuberculosis products and services?

The Minister of Health, Prof. Isaac Adewole said: “In 2017, only 36% of the total funding required for TB control was available, which is grossly inadequate to make the desired impact.

“In recent years, donor resources have continued to dwindle thus threatening sustainable TB control financing in the country.

“The Median cost for patients treated for susceptible TB in 2016 was $1256 while that of Drug Resistant Tuberculosis is $9529. Thus, it is evident that TB control requires considerable financial outlay; it is important to note too, that the cost of increasing efforts is even much higher.”

Other experts say Nigerian government alone is unlikely to increase its funding for TB.

According to them, the Debt Management Office (DMO) recently reported that Nigeria’s total debt has increased by about 90% in almost three years from N12.6 trillion in December 2015 to about N22.71 trillion as at March 2018. In addition to the figures, there are the N1.95 trillion deficit in the 2018 budget, the $475 million loan agreement recently signed with the French government, and the $328 million agreement with China recently signed by President Muhammadu Buhari.

But, they are unanimous on the view that a robust and universal health insurance scheme and the mobilisation of domestic resources especially from the private sector will address the funding gap.

A representative of a major Western donor, who spoke to Vanguard in a background interview said: “Domestic resource mobilisation means that there are many ways a country can look at its internal resources and not be donor-dependent.

“Corporate organisations; the banks, telecommunications companies, IOCs and the likes have corporate social responsibility funds. Tuberculosis is a critical health issue for Nigeria. They can begin to support TB control programmes.”

The source, a medical doctor, also said until the government gets the question of infrastructure right in the country, Nigeria can look to partnerships with foreign drugmakers in order to enjoy economies of scale in the manufacturing and distribution of tuberculosis treatment products.

“The answer is not always in 100% local manufacturing. Sometimes doing so can make the market prices of the TB products higher for the final user, because of the challenges of unstable power supply, bad roads and other infrastructural gaps which significantly shoot up  costs of production.

“For now, most TB drugs in Nigeria are donor-funded. At some point, they will ask Nigeria to fund its drugs.

“So, it is better Nigeria begins to look at established drug manufacturers that can enable the country enjoy economies of scale. It can also find ways to bring them in to invest in the TB control programmes,” she said.

On her part, the coordinator, National Tuberculosis and Leprosy Control Programme, Adebola Lawanson, said Nigeria already has a platform (the Public Private Mix summit on Tuberculosis) for reaching out to the private sector in order to mobilise their resources.

She said: “The TB prevalence rate in Nigeria is alarming and many people are nonchalant about it. So, we want solutions that will enable us treat more patients with the least amount of resources.

“If you cure TB for one person you are saving the lives of so many others because one TB case has the potential of  transmitting infection to ten to fifteen persons.

“We are not producing TB drugs locally; the drugs we are buying are from the global drug facility. So, we are discussing with the private sector to see how we can raise resources. We already have a platform; we are reaching out to them.

“In saying that, we are not talking about their cash alone, we want them to affect the lives of the patients directly. For the various equipment, they can support us with consumables to do what we have to do.

Meanwhile, Private sector involvement in the TB challenge programme has began to gather steam.

Dr. Cliff Ogbede, the CEO of Kleef & Helixor Pharmaceuticals Nigeria Ltd, has said that plans are underway for YURiA Pharm, a foremost Ukrainian manufacturer of TB treatment and preventive drugs, to support Nigeria in the fight against TB by providing pediatric friendly Isoniazid Syrup which, he said, would be used for the effective and safe treatment and chemical prophylaxis of tuberculosis for diseased and infected children with BCG vaccination complications, as well as for those who had come in contact with tuberculosis patients.

According to him, Kleef & Helixor in collaboration with Yuria Pharm will build a manufacturing plant in the country which will make their TB drugs readily available for patients in the country, as well as create jobs that will translate into economic growth and development.

“Through the necessary support from the Federal Government, the proposed plant will enable us to satisfy the local market, improve the health of TB patients in Nigeria and equally export to the neighbouring countries within the region,” he said.

It is noted that through other public-private partnership arrangements and support from other stakeholders, Nigeria currently has 6,753 DOTS centres compared to 3931 in 2010. The total number of microscopy centres has risen from 1,148 in 2010 to 2,650 in 2017. GeneXpert machines installed in the country have increased from 32 in 2012 to 390 in 2017.

Treatment centres for patients with DR-TB have expanded from 10 in 2013 to 27 in 2017. The number of TB reference laboratories has also increased from 9 in 2013 to 10 in 2018.

Over 90% of the TB patients notified in 2016 have documented HIV test results compared to 79% in 2010.

In addition to these, shorter drug regimen for the treatment of DR-TB has been introduced in Nigeria to reduce the treatment duration for patients with DR-TB and ensure better treatment outcomes especially for adults.

However, for children suffering the disease, experts have called for the quick introduction into the market, a very affordable paediatric anti-TB formulations that are both dispersible and flavoured and also meet the WHO optimal dosing recommendations for all children in order to improve adherence and treatment outcomes for them.

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