According to UNICEF (2017), the future of many Nigerian children is insecure, with an under-5 mortality rate of 39.1/1000 births. Malnutrition, a significant cause of mortality, remains a significant public health problem: 37% of children under-five years of age are stunted, 18% are wasted, and 29% are underweight (National Population Commission, 2014; The World Bank, 2013).
In terms of the stunted population, this represents an average of 12 million children failing to meet their development potential to survive, thrive, and contribute to the economic progress of the nation. The future prosperity of Nigeria’s children is a major public health concern, however, there is limited fiscal space for social protection provision targeted at children in the country.
The danger of having a large burden of unhealthy children lies in its link with other social issues within the country, such as, high school dropout rates, high rates of unemployment, and a high prevalebce of disease and poverty.
Therefore, in order to target social protection, the looming questions are:
- Are the poor health outcomes spread equally across the nation?
- Are there clusters of states with higher rates of poor child health exist?
- What is the fiscal space for social protection for child health in Nigeria?
Mapping inequality of opportunity in child health
Inequality of opportunity for child health is mapped using the Human Opportunity Index (HOI), which measures how equitably children have access to services needed for a healthy life. “The HOI measures the availability of services that are necessary to progress in life, discounted by how unfairly the services are distributed among the population” (Molinas et al., 2010).
In simpler terms, it measures a child’s playing field, which is shaped by the circumstances beyond their control, such as their demographic factors and their family’s socioeconomic status, which can affect their health outcomes. The demographic factors include: Gender, age, reported size-at-birth and birth order. The family’s socioeconomic status includes: Parental education, parental age, mother’s height, wealth index, and whether the household dwells in a rural/urban location.
Photo Credit: Author's Construct
Photo Credit: Author's Construct
Photo Credit: Author's Construct
For all three measures of child health, there exists significant variation within the Northern part of Nigeria, which is home to poorer child health outcomes. All the states in the North West and North East regions, except the Adamawa and Taraba states, have a significant population of either stunted, wasted, or underweight children.
While there are identifiable populations of children with poor child health outcomes in the South, these are significantly lower than in the North. For instance; Abia, Akwa Ibom, Anambra, Enugu and Imo states have the lowest rates in at least two of the child health outcomes.
Child sensitive social protection in Nigeria:
1. In care of the Poor (COPE)
Social protection has been widely used in developed countries, beginning with the European welfare state. However, in Nigeria, it is indeed a recent phenomenon. Social protection was only introduced nationwide in 2007, with the conditional cash transfer (CCT), COPE programme. The social assistance programme was introduced with the aim of reducing vulnerabilities and preventing the intergenerational transmission of poverty in the poorest households in the nation (The Cash Learning Partnership, 2014; Holmes et al., 2011).
The targets of the programme include female-headed households, HIV/AIDS patients, people living with disabilities, and vesicovaginal fistula (VVF) patients who have children of basic school age. The beneficiaries of the scheme receive a Basic Income Guarantee (BIG) between $US 120 - $ US 396, with an additional lump sum poverty reduction accelerator investment (PRAI) of $ US 560 dollars, provided as compulsory savings over a one-year period to the head of the household. In return, the recipients are expected to participate in all free health care programmes, in addition to the enrolment of their children in basic education and attendance at business and life-skills training to increase the impact of the PRAI.
2. The Maternal and Child Health Care (MCH) programme
The defunct MCH programme, funded by the National Health Insurance Scheme (NHIS) and the Millennium Development Goal (MDG) -Debt Relief Gain (MDG-DRG) was introduced in 2008. The fee-waiver programme had, at its core, to accelerate the improvement of MDGs 4 and 5, through primary and secondary care, including for birth complications and caesarean sections, for pregnant women up to six weeks after childbirth and primary care for children under five.
851,198 women and girls were targeted in June 2010 (Phase 1: 651,101, Phase 2: 236,097) or less than 0.01% of the poor (based on the assumption of a 54% poverty rate). Though not specifically targeted at the poor, it is included as one of the nation’s social protection schemes because of the objective of maternal and child health, which considerably affects the poor in Nigeria.
3. The Nigeria Child Development Grant Programme (CDG)
In 2013, the CDG programme, which is directly targeted at children, was first implemented in five local governments across two states: Anka and Tsafe in Zamfara state, and Buji, Gagarawa and Kiri Kasama in Jigawa state. It targets children during their window of opportunity (the first 1000 days of life).
The programme is funded by UK Department for International Development (DFID), and spearheaded by Save the Children in partnership with Action Against Hunger (ACF). The programme was introduced as a direct approach to improve the Nigerian child’s potential to survive and develop, through its focus on reducing widespread poverty, hunger, and malnutrition.
Up to 90,000 recipient mothers were either pregnant at the time of selection or with a child who was under two years of age. The programme has two components: An unconditional cash transfer (UCT) and a counselling and behaviour change campaign (BCC), with the latter aimed at improving maternal and child care practices (Carneiro, Mason et al., 2017a; Carneiro, Mason et al., 2017).
As part of the UCT, each woman was initially expected to receive 115, 500 Nigerian Naira (NGN) over 33 months (NGN 3500). However, in January 2017, the amount was increased to NGN 4000 per month. The UCT is expected to improve child nutritional outcomes through its contribution to increase food security and improve the intake of more nutritious food.
The BCC and Counselling component of the programme was expected to be a long-term modification for nutritional outcomes for children in the targeted communities, through education and advice about child nutrition and health. To ensure the objective of modifying child nutritional outcomes, the counselling and BCC campaign targeted influential community leaders, men, and the direct beneficiaries of the programme. It provided them with information bordering on key areas of child nutrition: Breastfeeding and other infant diet practices.
Children are the future of nations. Thus, for any nation to have a healthy future, it must have healthy children. According to UNICEF (2015), a poor start in life can leave indelible imprints in the future life of a child. The early years of a child’s life comes only once, and without proper attention to improving the child’s health, there are long-term consequences for their adult outcomes.
Tackling child health remains a significant public health problem, specifically in the Northern part of Nigeria. The high rates of poor child outcomes in the Northern region calls for significant interventions to help address these issues. As the region also has high rates of poverty, it is imperative that social protection programmes be used to address the vulnerabilities children and mothers face.
However, there is currently only one social protection programme targeted at child health in Nigeria, the CDG. Even where present, this programme remains small scale in terms of fiscal space with high economic costs of implementation.
The government of Nigeria faces an enormous challenge in addressing the child nutrition challenges across the nation: Collaboration across all levels and tiers of governance and implementation is crucial. Inter-sectoral and/or federal-state collaboration should range from the design to the implementation stages, and include institutional knowledge and capacity building, as well as financial support (increasing the budget to social protection) and generating political will.
Finally, it is critical that a national policy on social protection, which explicitly targets vulnerable children of all ages and their care-givers, be introduced. Currently, there is no over-arching social protection policy that covers all children in all states of their development in Nigeria.
Carneiro, Pedro, Giacorno Mason, Lucie Moore, and Imran Rasul (2017). Nigeria Child Development Grant Programme Evaluation, Quantitative Midline Report Volume 1: Midline findings, e-Pact, Oxford Policy Management, UKAID, 1-152.
Carneiro, Pedro, Giacorno Mason, Lucie Moore, and Imran Rasul (2017a). Nigeria Child Development Grant Programme Evaluation, Quantitative Midline Report Volume II: Midline technical compendium, e-Pact, Oxford Policy Management, UKAID, 1-235.
Hagen-Zanker, Jessica, and Rebecca Holmes (2012). Social Protection in Nigeria, Synthesis Report, UNICEF Nigeria, Overseas Development Institute.
Holmes, Rebecca, Banke Akinrimisi, Jenny Morgan, and Rhiannon Buck (2011). Social Protection in Nigeria: an overview of programmes and their effectiveness , Project Briefing Paper No. 59, Overseas Development Institute, 1-4. Accessible: https://www.odi.org/publications/6003-social-protection-nigeria-overview....
Molinas, Jose R, Ricardo Paes de Barros, Jaime Saavedra, Marcelo Giugale, Louise J Cord, Carola Pessino, and Amer Hasan (2010). Do Our Children Have a Chance?, Human Opportunity Report, The International Bank for Reconstruction and Development/The World Bank, Washington, DC: The World Bank, 1-173. Accessible: http://siteresources.worldbank.org/INTLACREGTOPPOVANA/Resources/840442-1....
National Population Commission (2014). Nigerian Demographic and Health Survey 2013, Survey Report, Abuja: National Population Commission.
Nigerian Bureau of Statistics (2012).
The Cash Learning Partnership. 2014. "Planning for government adoption of a social protection programme in an insecure environment: the Child Grant Development Programme in northern Nigeria." CALP Case Study, The Cash Learning Partnership, 1-28. http://www.cashlearning.org/downloads/calpcasestudynigeriaengweb.pdf.
The World Bank (2013). Early Childhood Development, SABER Country Report, Systems Approach for Better Education Results, The World Bank, 1-33. Accessible: https://openknowledge.worldbank.org/bitstream/handle/10986/20145/900890W....
UNDP (2016). Human Development Report. Annual report, United Nations Development Programme (UNDP), United Nations, 1-286.
UNICEF (2017). Nigeria, Annual Report, UNICEF, 1-81. Accessible: https://www.unicef.org/about/annualreport/files/Nigeria_2017_COAR.pdf.
World Development Indicators (2017). The World Bank.