HIV/AIDS
Analysis and Results
The documents reviewed were gathered mainly in Lagos and Abuja the FCT from various government agencies and ministries, NGOs, donor agencies and individual researchers working on HIV/AIDS. Additional information were sourced from the internet as pointed out in the methodology. Although a reasonable amount of literature exists on HIV/AIDS in Nigeria, relatively little deals specifically with its policies implementation progress. More than 50 documents relating to HIV/AIDS were reviewed.Findings on HIV/AIDS Policies and its impact in Nigeria include: -The driving forces for the spread of HIV/AIDS are: Low risk perception (NARHS 2001); Cultural and religious influence (Isiramen 2003; FMOH 2003); Lack of adequate government funding; Gender inequalities and economic drivers. -These forces have not been tackled adequately hence the lag in implementation of the policy on HIV/AIDS.
The Implementation of the National Policy on HIV/AIDS
Several programmes targeted at HIV/AIDS care, treatment and prevention in the country are not being implemented as planned and targets are not being met. Since 1986 when the first case of HIV/AIDS was reported in Nigeria, the Government has had the fight against HIV/AIDS in its agenda but a lot still need to be achieved if the fight is to be won. A core set of conditions is essential as pre-requirements for a successful implementation of policies and in a general sense, Hogwood and Gunn (1984) for example, offer '10 pre-conditions of effective implementation' listed in chapter two
Has the Implementation been effective?
Using the Hogwood and Gunn (1984) framework, I will be looking at the factors that are necessary for the successful implementation of the National Policy on HIV/AIDS in Nigeria
The circumstances external to the implementing agency do not impose crippling constraints
Nigeria is an ethnically and religiously complex country with over 373 ethnic groups spread around the country (Ajaegbu et al. 2000). Although the official language is English, over 250 other languages are spoken thus making dissemination of messages difficult.Obioha (2008) pointed out that cultural and religious variations may need to be understood before an effective programme for HIV/AIDS prevention and treatment could be designed because these factors (culture and religion) are very influential to a successful implementation of the HIV/AIDS policy. What works for a particular society in terms of HIV/AIDS prevention programming may not work in another due to the cultural and human differences (Obioha 2008). There are cultures where spouse sharing is practiced. In a study by Osagbemi et al. (2007), they looked at the Okun tribe numbering about a million people. It is a cultural practice in the Okun tribe for men to have sexual relationship with wives of their kinsmen. Spouse sharing is not seen in this culture as a risk factor for the transmission of HIV/AIDS. Their knowledge of HIV/AIDS/STI, perception of risk and alternative behaviours to avoid contracting HIV/AIDS were equally low. Community-based interventions to address traditional and cultural practices that could transmit HIV/AIDS and also involve the people are not being addressed at the moment according to the study and this is one of the objectives of the national policy on HIV/AIDS.Around 50% of Nigerian population are Muslim, 40% Christian and 10% hold indigenous beliefs. According to a BBC 2004 survey, the average Nigerian attends a church, mosque or other religious place of worship when compared to other nationalities (BBC 2004). Polygamy is practiced among the Islamic and traditional religion. Even the Christian religion while emphasizing monogamy and fidelity, women cannot expect much from their husbands (Isiramen 2003). The issue of gender inequality is still very high especially in rural communities. Women suffer rape and domestic violence in silence; female genital mutilation is still practiced in some cultures and the woman does not have a voice. Religious leaders are very influential in the lives of Nigerians in matters pertaining to values and behaviours. Faith-based organizations (FBOs) have been playing important roles in providing about 40% of Nigeria's health services through hospitals and healthcare personnel. Despite the great gesture and contribution from the FBOs, some still uphold the view not to use condom as a preventive measure for HIV infection and contraception
Adequate time and sufficient resources are made available to the programme and the required combination of resources is actually available
Funding is key to an effective national response to HIV/AIDS and Nigeria gets most of its funding from external sources. Since its inception, the President's Emergency Plan for AIDS Relief (PEPFAR) has provided more than US$1.5 billion to fight HIV/AIDS in Nigeria (PEPFAR 2009). The World Bank approved a credit of US$90.3 million in 2001 towards the financing of HIV/AIDS programmes in Nigeria and another US$50 million was approved in May 2007 (World Bank 2007). In all, there have been many supports from International bodies but the question still remain as to what the Nigerian Government is contributing. The Health sector budgets have been dwindling over the years (Akosile 2008a; Rabiu 2009). The yearly budgetary allocation to the health sector is less than 4% of the total budget as against the 15% recommended by the United Nations (Thomas 2008). The problem is that there is no political will by the government to put resources into the health sector. Presently, financing from the government account for less than 5% of PLWHA on ART. Though most activities aimed at combating HIV/AIDS take place at the Local and State levels, they hardly make any meaningful contributions (Idoko et al. 2007). Funds from donor organizations in the US and UK have not been used judiciously in some instances. Corruption has lead to questions on how some of these funds are being spent and this lead to the Global Fund to Fight AIDS, Tuberculosis and Malaria, suspending about US$50 million worth of program funding for NACA in 2006
The dependency relationships are minimal
In addition to funds, Nigeria depends on international aid for most of the HIV/AIDS programmes and also its Antiretroviral (ARV) drugs. Some of the objectives of the National Policy on HIV/AIDS include the treatment of those infected with HIV/AIDS. - Cost-effective and affordable care shall be made accessible to all people with HIV-related illnesses, including access to anti-retroviral therapy; - A cost-effective drug list for the management of HIV/AIDS shall be developed and incorporated into Nigeria's essential drug list (FMOH 2003a p18). The Nigerian government in 2002 commenced the implementation of one of Africa's largest antiretroviral treatment programme (Idigbe et al. 2006). The target was to get 10,000 adults and 5,000 children living with HIV/AIDS on ARV drugs within the first year. About $3.5 million worth of generic ARV drugs were procured from India. These were then subsidized at a cost of $7 per person per month. As the benefits of the treatment trickled down, more HIV positive persons sought to be recruited into the treatment programme resulting in over recruitment, long waiting list and "drugs out of stock" syndrome. In 2003 the programme suffered a major setback when it was hit by a shortage of drugs as a result of lack of funds. This meant that some people did not receive treatment for up to three months before another order of drugs worth $3.8 million were received (Idigbe et al. 2006). In order to achieve the national ART goal of reaching infected persons, the Government announced a Presidential initiative of a massive scale up of putting 250,000 PLWHA on ARV drugs by June 2006 (Idoko et al. 2006). About 124,567 adults and 5,279 children out of the over 550,000 who actually require ART receive antiretroviral drugs as at March 2007. Currently, those that can afford private treatment and purchase of these drugs do so at very expensive prices. Poor health systems coupled with lack of adequate funding have been major obstacles to meeting the presidential targets. The cost of the series of preliminary screening and laboratory tests which PLWHA have to undergo before being included in the initiative and during periodic assessment while on the drug is a big barrier to adequate access to drugs even where they are available. Availability of ARV drugs for the estimated 2.9-4.0 million PLWHA in Nigeria could prolong their lives and restore economic productivityIt is a welcome relief that the Federal Government plans to begin the local production and bulk purchase of ARV drugs (Muanya 2009). Nigeria like many countries in the developing world relies on generic drugs from India which are much more affordable than their brand-name equivalents from Europe and the US for the treatment of life-threatening diseases.
Formulation of the HIV/AIDS
The formulation of the HIV/AIDS national policy was multisectoral so as to involve most segments of the society and most organizations in the country in the implementation of programmes and the fight against HIV/AIDS. The policy provided for various institutions and organizations to identify specific components, strategies, objectives and activities where they can fit in and participate actively. Since the formulation, there has been a sustained willingness on the part of civil society groups and organizations to respond in relevant ways in combating the epidemic (Falobi and Akanni 2004). More than 700 civil society organizations are currently associated with HIV/AIDS programmes in Nigeria. These include NGOs, religious organizations, private sector organizations, international organizations and youth groups. These organizations are involved in the fight against HIV/AIDS and are operating in the country and are addressing different aspects of the national response. While several are concerned with HIV/AIDS prevention, others are into providing care and support for PLWHA, HIV/AIDS research and human rights. The major impediment to the success of the activities of the civil society groups is funding (Idoko et al. 2007). While the Federal Government has recognized its role in ensuring that all entities responsible for the implementation of specific activities receive the financial and organizational support required to undertake such tasks, it has given very little funding to civil society organizations.
Most of these agencies are highly dependent on foreign sponsorships and donations for funds as well as drugs (UNAIDS 2002; Kates and Leggoe 2005) as pointed out in section 4.3.2 above. Despite some of the agencies having good intentions, some have capitalized on the multi agency approach, using it as a means of making money (Abah 2007) and there is uncontrolled duplication of duties by these agencies. NACA supervisory role in this regard has not been effective in a country where corruption is rife.
Those in authority can demand and obtain perfect obedience
According to Fagbadebo (2007), 'The Nigerian State is a victim of high-level corruption, bad governance, political instability and a cyclical legitimacy crisis; consequently, national development is retarded and the political environment uncertain' (p028). Since her independence in 1960, Nigeria has been governed by the military for 36 of the 49 years and this brought corruption and underdevelopment in most sectors of the economy. Nigerian politics lack accountability and transparency and this has led to an increased number of abandoned projects (Toyo 2006). Even when those projects are not abandoned, the enthusiasm seems to die with subsequent governments. Ayittey (2006) write, 'The African State has evolved into a predatory monster or a gangster state that uses a convoluted system of regulations and controls to pillage and rob the productive class-the peasantry. It is common knowledge that heads of state, ministers, and highly placed African government officials raid the African treasury, misuse their positions in government to extort commissions on foreign loan contracts, skim foreign aid, inflate contracts to cronies for kickbacks and deposit the loot in overseas banks. The very people who are supposed to defend and protect the peasants' interests are themselves engaged in institutionalized looting' (p029).
Communal and tribal unrest in parts of the country have led to lack of implementation in those regions. Most hit is the Niger delta in the South South geopolitical zone where 80% of Nigeria's oil is drilled. Violence in this region has resulted in economic and humanitarian tragedies (Joab-Peterside 2007). The incessant violence in this area has lead to disruption in oil production which in a wider sense affects the economy and lack of development (Watts 2004) in this area in particular and the country in general. This region has been declared a 'no go' zone for the past 3 years.
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