‘At the end of the day, malnutrition is really a proxy indicator for a weak healthcare system.’
By Idris Mohammed – A malnutrition emergency is stalking northern Nigeria, driven by a cost of living crisis, the shambolic state of the country’s primary healthcare system, and staggering levels of insecurity, health workers warn.
Close to 32 million Nigerians – roughly 15% of the population – are going hungry as a result of the government’s sudden removal of fuel subsidies last year. That sent food prices soaring, pushing inflation to a near 30-year high, with wages lagging far behind.
But it’s in Nigeria’s rural north, where poverty is more deep-seated, that aid agencies have been reporting the most alarming increases in malnutrition.
In the Shinkafi and Zurmi districts of northwestern Zamfara state, one out of every four children aged under five was found to be acutely malnourished in a mass screening in June by the medical charity Médecins Sans Frontières (MSF). A malnutrition rate of 15% is classified as an emergency by the World Health Organization.
In the northeast, the International Committee of the Red Cross has also flagged a jump in admissions of severely malnourished children to health centres it supports.
The nutrition crisis has been compounded by a stockout of ready-to-use therapeutic food, used to save the lives of vulnerable infants, as UNICEF, the UN’s children’s agency, struggles with a West Africa-wide funding crunch.
The spike in malnutrition in the north is driven by the cost of living crisis, but also insecurity. In the northeast, food production has been dampened by a still-active jihadist insurgency. Formerly displaced households – cut off from aid and sent home by the state government – are too scared to cultivate beyond a narrow perimeter around garrison towns.
In large swathes of northwestern Zamfara, Sokoto, and Katsina states, criminal gangs, commonly referred to as “bandits”, extort farmers or drive them off their land, and close roads and markets at will. They have also torched clinics and targeted medical staff, and as a result, only an estimated 200 out of 700 primary healthcare centres (PHCs) in hardest-hit Zamfara remain open.
“The reality is that malnutrition has always been chronic in the north,” Karsten Noko, head of mission in Nigeria for MSF-Belgium, told The New Humanitarian. “The baseline was already very high, but these additional shocks have exacerbated the problem.”
A health system in crisis
Aid agencies have been sounding a warning for the past three years over the uptick in food insecurity in the north – but also view it as part of a deeper healthcare problem. “At the end of the day,” said Noko, “malnutrition is really a proxy indicator for a weak healthcare system.”
The evidence of that crisis is not hard to find. Out of Nigeria’s roughly 34,000 primary healthcare centres, only 20% are believed to be fully functional. The vast majority of PHC’s are dilapidated, understaffed, and lack essential drugs – especially in the north.
As a result, Nigeria has among the world’s highest infant and maternal mortality rates, with only 38% of births attended by trained health workers.
Money is part of the problem. Aggregate health budget allocations to Nigeria’s 36 states fell by 2.5% between 2020 and 2022, from $1.92 billion to $1.87 billion. But capital utilisation has also been poor, with less than 50% of the available funding in the last quarter of 2022 actually being spent, according to the NGO Nigeria Health Watch.
“Inadequate funding is a significant factor contributing to the decline in PHC services,” said Zainab Idris, a consultant public health physician and coordinator of the Accelerating Nutrition Results in Nigeria (ANRiN) project in northwestern Kaduna State. But she noted that entrenched mismanagement and a lack of accountability are also to blame.
That’s exemplified by the regular leakage of what drugs are available onto the black market. “A lot of drugs and materials meant for the facilities are diverted or sold,” explained Abdurrahman Zaharaddeen, a nurse in Katsina’s Kankara district. “Sometimes, drugs are sold within the facility at prices some patients cannot afford.”
Staffing represents another hurdle. Nigeria has 20 nurses, midwives, and doctorsfor every 10,000 people – less than the minimum recommended by the WHO, but better than many other African countries. However, staff are unevenly distributed. Most choose to work in urban areas in the south, leaving acute shortages in the less-connected north.
Trained healthcare workers are also quitting the system, with Nigeria the largest exporter of health staff in Africa. The UK – one of the favoured destinations – has red-listed Nigeria to try and stem active recruitment, while the Nigerian government has also announced plans to tackle the exodus of frustrated health professionals.
That’s going to be a heavy lift. Low wages, difficult working conditions, absenteeism, and a “lack of commitment to duty” are among the hallmarks of Nigeria’s health services, said a healthcare professional in the capital, Abuja, who asked not to be named so they could speak freely.
“Most of us come from far away places. The allowances and other benefits are not coming to us at all,” said a PHC nurse in Sokoto, who also asked for anonymity. “How do you expect us to be going to these remote communities in this very harsh economic climate?”
The rural violence in the northwest has also had a marked impact on access. “Many residents fear being kidnapped or killed while travelling to health facilities, forcing them to abandon PHCs or flee their communities altogether,” said Umar Wurno, a Sokoto traditional leader.
Two countries in one
In its health demographics, Nigeria is really two countries. Women marry and give birth far earlier in the north than the rest of the country. Child vaccination results are also significantly lower, and illiteracy dramatically higher. All of this contributes to the fact that the mortality rate for under-fives in the northwest is more than triplethat of the southwest.
Rural PHCs visited by The New Humanitarian in Sokoto lacked not only basic drugs but also clean water and electricity. For many women, unable to afford transport, attending PHCs involves walking long distances in the heat, often with young children in tow.
“I rather consult traditional medical providers than waste my time in a place where they have nothing to offer apart from paracetamol.”
When they do arrive, “their experiences are so awful – the manner in which they are treated by some of the health workers – it’s unsurprising people stay away,” said the Abuja-based healthcare professional.
Traditional healers and herbal medicine, viewed by many as more accessible and cost-effective, help fill the treatment gap. “I rather consult traditional medical providers than waste my time in a place where they have nothing to offer apart from paracetamol,” said Rashidat Achida, 37, from Sokoto’s Wurno district.
In many rural communities in Zamfara, Sokoto and Katsina, deeply rooted traditions play a role in shaping access to primary healthcare. These cultural norms dictate that women should not leave their homes without a male guardian. While this is commonly justified on the grounds of “protecting” women, it restricts their mobility and ability to seek timely medical attention.
“When I was pregnant, I wanted to go for antenatal care,” said Aisha Nura, 27, from Dogon Daji, a remote Sokoto village. “But my husband was away working in the city, and there were no male family members around to accompany me. I had to wait until he returned.” Nura ended up giving birth at home.
Healthcare professionals unanimously told The New Humanitarian that there was an urgent need for government intervention to fix the health and malnutrition crisis.
Yet the problems are so multi-layered, with even the basics like ensuring vaccine coverage for children in the north so daunting, that solving Nigeria’s health dilemma will be a “long arduous task”, said Noko.
Additional reporting – by Obi Anyadike.
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