5 May 2020
Nigeria was successful in eliminating Ebola, despite a weak public health system. In the latest in our blog series, expert on governance in Nigeria, Clare Cummings, uncovers why this was and whether Covid-19 could be addressed in the same way.
The number of cases of Covid-19 in Nigeria is rising rapidly. According to the Nigeria Centre for Disease Control (NCDC), by 4 May 2020, the total number of confirmed cases had reached 2492, with 70 fatalities. Of the 37 Nigerian states, 35 have recorded at least one case. Most have been in Lagos and the capital, Abuja, but now more have been identified in the northern city of Kano. On 17 April, many were shocked when President Buhari’s Chief of Staff, Abba Kyari, died from the virus.
But Nigeria may have an advantage in responding to the pandemic. It recently effectively addressed an Ebola outbreak. Will it be able to do the same against Covid-19?
The outbreak of Ebola Virus Disease began in Guinea in December 2013 and quickly spread to Liberia and Sierra Leone, causing devastation in all three countries. In July 2014, a case of Ebola was identified in Lagos, Nigeria, and there were fears that an outbreak in such an internationally connected city would soon spread the disease far beyond West Africa. Yet, the Nigeria government acted quickly and decisively and only 19 further cases were identified before Nigeria was declared Ebola free.
Arguably, Nigeria’s success in stopping Ebola demonstrates that its state has significant capacity to deal with particular problems when there is political commitment to mobilise it. Despite Nigeria’s very low level of public health spending, and its health system that repeatedly fails the poor, it was able to stop a very deadly and contagious disease. Will the same capacity and commitment reappear in time to tackle Covid-19?
Nigeria’s public health system is ordinarily debilitated by poor coordination, a lack of accountability, few incentives to improve performance and a lack of resources at the frontline. These problems can be traced back to Nigeria’s competitive clientelist political settlement (Watts, 2018). This means that the political elite frequently use state resources to maintain the support of their allies and to co-opt potential rivals into accepting the current power sharing arrangement.. While this enables relative political stability, it undermines the effectiveness of the public sector and leaves the poor without access to quality or affordable healthcare. Nigeria has recently had Lassa Fever and Avian flu epidemics, but these were not addressed with the kind of technical, coordinated and efficient leadership seen during the Ebola outbreak.
Why was there such a difference between the Nigerian government’s approach to basic public health and Ebola?
The critical difference seems, sadly, to have been the threat that Ebola posed to the interests of the elite. The disease spread to Nigeria when a senior Liberian diplomat flew into Lagos. Ebola could no longer be dismissed as a disease only affecting the poor in low-income countries. Unlike many other illnesses, Ebola threatened the health and wealth of political leaders and their networks. Suddenly, political and technical interests aligned and an Ebola Emergency Operations Centre (EEOC) was created, led by highly qualified public health practitioners. A special fund was approved to finance the federal and state governments’ response efforts. The then Minister of Health bridged the political and technical leadership, while also being the public face of the government’s response. Nigerians’ confidence in the government’s ability to manage public health is usually low. The health minister, however, was quickly able to gain the public’s trust and cooperation in adopting measures to prevent the disease from spreading.
Covid-19 presents a similar, if not greater, threat to the elite than Ebola did. With international travel largely suspended, the wealthiest Nigerians are no longer able to seek healthcare abroad. The elite are now dependent on domestic healthcare and cannot escape poor sanitation, densely populated cities, a large and vulnerable informal economy and weak public health. Accordingly, the political commitment to stop Covid-19 is high. Lockdowns have been announced in the states experiencing the highest cases and the NCDC is led by a much-respected physician, Chikwe Ihekweazu.
What will Nigeria need to do to combat Covid-19?
Although Covid-19 has a lower mortality rate than Ebola, it is also more contagious and less easily detected. The capacity of the state throughout the public sector must be very high if Nigeria is able to effectively track, test, contain and treat the disease. While the centralised and well-resourced NCDC was able to contain Ebola, containing Covid-19 requires coordinated, effective state capacity in all 37 states and at all levels of government. Here, Nigeria’s legacy of an underfunded healthcare system, poor public water and sanitation provision and very limited social protection may be a serious stumbling block.
Covid-19 is far from a ‘leveller’. As in other countries, the wealthiest are most able to adapt to the crisis. Able to stop work and still feed their families. Able to use the internet for information, communication, services and entertainment. And able to pay for the best healthcare, even if it is not the healthcare they would have otherwise chosen. After Ebola, the Nigerian health system did not, unfortunately, transform into a better coordinated or funded public service.
What might sub-national state governments do?
Yet, there may be reason to hold out some hope for small changes. Tragically, Covid-19 is affecting Nigerian society much more broadly and deeply than the Ebola outbreak did. To respond effectively, Nigeria will need to strengthen the capacity of the public sector across the board. State governments, as well as the overarching federal government, must each lead their populations through the health and economic crisis. The legacies of past governors will be significant, but each state can chart its own course through the epidemic. Some may generate narratives of unity, such as in Ekiti State, where the governor has announced a 50 percent pay cut for his political appointees in order to fund the state’s crisis response. Others may blame, perhaps justifiably, the federal government for abandoning its responsibility to the states, as the governor of Kano State has.
The epidemic may reveal how political incentives and ideas vary across Nigeria. The states differ enormously, and this creates different challenges and strengths. Lagos, for example, has the highest internally generated revenue and many private hospitals, but it is also densely populated and has large informal settlements, where people have little access to clean water. How each state manages to create public trust in its government and balance the competing needs for food, security, income generation and disease control will matter greatly. Unlike with the Ebola outbreak, sub-national politics are critical in confronting this public health emergency.