In 2024, the global burden of infectious diseases has been significant, with the resurgence of diseases, including mpox. Since January, the mpox outbreak has resulted in 29,152 reported cases , marking a 177 per cent increase compared to the same period in 2023. The outbreak has spread across all five regions in Africa, resulting in 738 deaths. As a result, the Africa Centre for Disease Control (Africa CDC) declared mpox a Public Health Emergency of Continental Security (PHECS), while the World Health Organisation (WHO) designated it a Public Health Emergency of International Concern (PHEIC), highlighting the critical nature of the outbreak.
In addition, Rwanda's Ministry of Health declared an outbreak of Marburg virus disease (MVD) outbreak on Sept. 27, 2024. Within three days, 27 cases were confirmed, and 9 deaths had been reported, with healthcare workers representing the majority of confirmed cases. Similar to the broader African region, Nigeria's health security landscape is facing a multitude of challenges, including inadequate funding, insufficient infrastructure, and a lack of coordinated response mechanisms to public health emergencies.
Despite these challenges, the country has made significant strides in strengthening its health security. This is demonstrated in the 2023 Joint External Evaluation (JEE) conducted in August, where the country's score improved from 39% in 2017 to 54% in 2023, reflecting significant progress. Nigeria's national health budget remains far below the 15% recommended by the Abuja Declaration. In 2024, for example, only 5.15% of the national budget was allocated to health. At subnational levels, such as in some states, epidemic preparedness struggles to even secure dedicated budget lines.
In 2021, Kano State conducted its own JEE, evaluating 15 technical areas of infectious disease prevention, detection, and response. With support from the Nigeria Centre for Disease Control (NCDC) and partners, the state achieved a score of 46%, which falls into the "Work to Do" category according to PreventEpidemics.org's JEE score ranking. This indicated that Kano needed further efforts to strengthen its epidemic preparedness and response (EPR) framework.
Dr. Emmanuel Alhassan, Country Coordinator of the Prevent Epidemics Project at the Global Health Advocacy Incubator (GHAI), emphasised, "The COVID-19 pandemic, as well as other disease outbreaks, has really heightened and brought more into focus the need for us to be prepared, not only when there is an outbreak, but well ahead of time."
Advocacy for Change in Kano State
Kano State reported its first COVID-19 case on April 11, 2020 and the state has a history of dealing with endemic diseases like meningitis and seasonal outbreaks, making it a prime focus for advocacy initiatives. Recognising the need for improved epidemic preparedness, the Legislative Initiative for Sustainable Development Goals (LISDEL), supported by the Global Health Advocacy Incubator, selected Kano State as a target for budgetary advocacy under the Prevent Epidemics project. This project, implemented by Nigeria Health Watch and LISDEL, aimed to push for the inclusion of epidemic preparedness in state budgets.
LISDEL began its advocacy efforts in 2020, focusing on creating a budget line for epidemic preparedness. As Julianna Aribo-Abude, Executive Director of LISDEL, explained, "We started by conducting a stakeholder analysis to identify key players in improving domestic financing. We also analysed budgets and trends, which informed our engagement strategy."
LISDEL leveraged the existing state budget process to engage key stakeholders, including the Commissioner for Health, members of the state legislature, and the Executive Governor of Kano State. Together with the Global Health Advocacy Incubator (GHAI), LISDEL formed the Kano State Health Security Advocacy Team (KHESAT), a coalition of civil society and government advocates.
Through coordinated efforts, KHESAT, LISDEL, and GHAI engaged policymakers and stakeholders via public forums, workshops, and meetings throughout the budget process. These efforts emphasised the need for increased funding for epidemic preparedness, generating public interest and media support for infectious disease surveillance.
Taking advantage of new media channels
Alongside KHESAT's efforts to generate supportive media coverage for epidemic preparedness and response (EPR) funding, GHAI's partners launched a targeted media advocacy campaign. This campaign amplified citizens' calls to action on epidemic preparedness and highlighted stakeholders' commitments to improving health security policies and financing in Kano State. Key activities included the use of the hashtag #PreventEpidemicsNaija, developed by Nigeria Health Watch (NHW), on social media and the production of a 20-minute documentary emphasising the importance of epidemic prevention.
Additionally, NHW hosted a Journalism Master Class to raise awareness of the government's efforts, specifically around the development of the Kano State Action Plan for Health Security, which was officially finalised and disseminated in February 2023.
Evidence of Progress
In 2021, following concerted advocacy efforts, the Kano State government took a pioneering step by establishing a dedicated EPR budget line for the first time in Nigeria. An allocation of 300 million naira was made for the fiscal year 2021. This allocation increased to 400 million naira for the fiscal years 2022 and 2023. Recognising the widespread impact of outbreaks, Kano also secured EPR budget commitments in each of its 44 local government areas (LGAs) in 2021. These allocations saw a 50% increase in 2022, totalling 132 million naira, ensuring decentralised preparedness across the entire state.
GHAI, LISDEL, and KHESAT understood that securing budget allocations was just the beginning. They continued to assess budgetary needs, supported the development of the Kano State Action Plan for Health Security, and ensured monthly disbursements of 3 million naira for EPR activities through the Kano State Health Trust Fund (KHETFUND). This strategic measure, introduced in January 2023, has strengthened both accountability and sustainability in health security funding.
To further cement these gains and enhance public health resilience, a Public Health Security legal framework, also known as the Kano State Public Health Security Bill, was developed and passed. With support from the Africa Centre for Disease Control, e-Health Africa, GHAI, LISDEL, and Resolve to Save Lives, this legislation provides a strong foundation for a proactive response to future health challenges
What Next?
Next step has been to ensure that the appropriated funds are released and utilised for what its budgeted for. "For the effect of these changes to be felt, we must now continue to push for quick and early release of these funds as well as accountability and transparency for the funds", Hamza Abdullahi, Kano's Coordinator for the Global Health Advocacy Incubator reiterated.
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There's also a need for sustainability of achievements, and the health security bill must be signed into law, to provide a legal framework to sustain these gains and setup the structures necessary for implementation of health security strengthening activities within the state.
Next, the team will continue its partnership to combine the forces of federal- and state-level actors in bringing the Bill to fruition. While the passage of the Bill is a historic moment, it is also the beginning of a long road to implementation. While awaiting assent by the Governor, all necessary frameworks to implement the bill should be put in place.
Another potential challenge is the shrinking fiscal space in Nigeria. The country has been grappling with a high inflation rate over the last two years. The inflation rate reached 34.2% in June 2024, up from 22.8% in June 2023.
This surge is primarily driven by currency depreciation and an increase in imported food inflation at 36.4% year-on-year. The high inflation rate places immense pressure on government resources, potentially making it challenging for the government to allocate additional funding for epidemic preparedness and response initiatives as priorities shift toward managing the economic strain and addressing immediate domestic concerns.
Despite these challenges, the coordinated efforts of civil society and government advocates in Kano are paving the way for a more resilient and prepared health security framework by continuing to push for the release and proper utilisation of funds, ensuring accountability and advocating for the signing of the health security bill into law.
