Ending tuberculosis in Nigeria: a priority by 2030

Introduction

Most low- and middle-income countries (LMICs) still struggle with tuberculosis (TB), and Nigeria is among the top three countries, accounting for 80% of the total difference between reported cases and incidence in 2017.¹ Nigeria, with over 200 million people living within as of 2020, has a health system built around public and private healthcare facilities and has been reported as one of the 30 high-burden nations; 268 people in the nation pass away from the illness every day.^{2 3} In Nigeria, a notable increase in the prevalence of TB was reported between 2000 and 2021 with an increase in cases from 269 000 to 467 000. The country’s reported TB case count has increased steadily over the years, with Nigeria recording 403 000 TB cases and 157 000 TB-related fatalities in 2015, translating to a 39.96% mortality rate. Nonetheless, there is a consistent decrease in the ratio of deaths to cases between 2015 and 2021. The nation has recorded 125 000 fatalities and 467 000 TB cases by 2021, resulting in a death-to-infection rate of 26.77%.⁴ As of 2023, over 361 000 cases of TB have been reported in Nigeria, with 9% of those cases occurring in children. Compared with 2022, this represents a 26% increase in cases.² However, the significant risk of transmission is increasing due to the under-reporting of TB cases. One missed case is thought to have the potential to infect 15 people annually with TB.²

The WHO 2019 Global TB Report revealed the poor detection rate of 24% in Nigeria with only 20% of health facilities able to provide TB services. It was estimated that 20% of TB cases in Nigeria are estimated to be attributable to malnutrition, 12% to HIV, 3% to diabetes and 1% to alcohol use disorder.⁵ Stigmatisation, lack of GeneXpert analysers, poverty and other factors contribute to the country’s persistently high TB prevalence. Despite Nigeria accounting for the high burden of a disease that is preventable and treatable, it still has a 70% funding gap in programmes meant to curb its spread.⁶ Therefore, this study aimed to assess the progress made towards curbing TB in Nigeria by 2030.

Challenges towards ending tuberculosis (TB) in Nigeria

Socioeconomic status

TB primarily affects low-income populations in Nigeria, where economic challenges exacerbate its impact. Patients and their households often face significant financial strain due to high treatment costs and non-medical expenses like food and travel, worsened by delayed access to healthcare.⁷ A 2017–2018 survey revealed that over 54% of persons living with TB could not afford treatment from their income alone, relying on loans or selling assets, despite support from the government and development partners.⁷ Malnutrition further increases TB vulnerability, particularly among children.⁸ In nomadic populations, the situation is more severe due to limited access to healthcare, malnutrition, overcrowded living conditions and poor immunisation coverage. These factors contribute to poor TB detection and treatment outcomes, leading to high rates of relapse and mortality.⁹

Gender-related challenges

Gender-specific challenges in accessing diagnostic and treatment services further hinder efforts to end TB in Nigeria. In 2022, out of 467 000 people who fell ill with TB, 57% were men, and 29% were women, indicating a higher prevalence of TB among men.¹⁰ Despite this, assessments show that women generally adhere to treatment more consistently than men. While men often abandon treatment once they start feeling better, citing work-related pressures, women are more committed to completing treatment to ensure they can care for their children and families, presenting additional barriers to ending TB.¹¹

Limited funding

Nigeria’s overburdened healthcare system is yet to receive a significant budget from the government on multiple occasions. The country has fallen short of its TB target because of inadequate financing and delayed budgetary releases. In 2020, N150 billion ($373 million) was required to control TB in Nigeria; however, implementers only had access to 31% of this amount. The Nigerian government provided approximately 7% of the funds available, while donors provided the remaining 24%, creating less than 70% financing shortfall.¹²

Poor healthcare system delivery

A weak drug supply system, outdated infrastructure for service delivery and a lack of human resources all contributed to National Tuberculosis Control Program’s (NTP’s) ineffectiveness and inefficiency, which highlights the need for strengthening health systems to prevent infectious diseases.¹ Long waiting times, people lost to follow-up both pretreatment and during treatment levels, staff attitude toward person living with TB, inadequate management of drug reactions and lack of infection control measures all confirm that both the international standards for TB care and patient-centred TB care have been violated.^{1 13} Due to a lack of knowledge among families and communities, as well as health personnel at the facility and community level, and lack of the necessary skills to detect childhood TB, there has been a major gap in case detection among children, and regular children’s health interventions, including nutrition and immunisation programmes, do not fully integrate TB services.² However, insufficient human resources, non-compliance with patient monitoring requirements, a weak regulatory framework and poor organisational characteristics have limited the ability of private health facilities to provide TB services, leading to subpar TB care.¹

Impact of COVID-19 pandemic

Despite the efforts of the Nigerian NTP and its partners to achieve the 2030 target of Sustainable Development Goal 3 (SDG 3), TB remains highly prevalent in Nigeria.¹⁴ The COVID-19 pandemic and its associated control measures have significantly impacted various sectors, including health services, reversing the progress in ending TB. The first COVID-19 case was identified on 27 February 2020, and subsequent pandemic control measures led to nationwide lockdown in the second quarter of 2020. In the first week of the lockdown, Nigeria experienced a 30% decrease in GeneXpert testing, which is crucial for TB diagnosis. Furthermore, there was a 17% decrease in the number of notified TB cases, dropping from 33 119 in the first quarter of 2020 to 27 353 in the second quarter.¹⁵ Nigeria’s classification as a high-burden country for TB associated with HIV and multidrug-resistant/rifampicin-resistant TB for the 2021–2025 period revealed the current situation facing the country.¹⁴

Efforts towards ending tuberculosis (TB) in Nigeria

To ensure programme sustainability and mitigate the impact on ending TB, the National Tuberculosis, Buruli Ulcer and Leprosy Control Program (NTBLCP) was implemented in collaboration with the WHO, United States Agency for International Development, Stop TB Partnership, Global Fund to Fight AIDS, Centers for Disease Control and Prevention, Tuberculosis and Malaria, Department of Defense and Civil Society Organizations. As a result, from 120 266 in 2019 to 138 591 in 2020, the number of TB cases reported nationally has increased by 15%. With this accomplishment, Nigeria joined the select few nations where TB notifications increased in 2020, despite the pandemic.^{15 16}

Additionally, Nigeria’s TB prevention and care have received significant support from the Global Fund partnership, which provides funds to combat AIDS, TB and malaria. As of 2021, the Global Fund partnership has invested more than US$2.6 billion in Nigeria with assistance from donors and technical partners.¹⁴ Through the provision of life-saving HIV therapy to almost 1.5 million patients and the treatment of 138 500 TB patients in 2020 alone, these investments have contributed to the expansion of health services throughout the nation.¹⁷

The nation has documented 207 785 cases of TB in 2021, a staggering 50% increase in annual notifications.¹⁵ However, in 2023, the country reported over 360 000 TB cases provisionally, reaching roughly 70% of its cumulative target and approximately 90% of the 2022 target, owing to the efforts of the NTBLCP and its partners, as shown in figure 1^{18 19} . The Federal Ministry of Health¹⁸ reports that efforts to end the TB epidemic in Nigeria have led to the expansion of GeneXpert analyser. In addition, a robust specimen referral network was established using a hub-and-spoke model, which transported over 2.4 million samples for TB testing in 2023. These initiatives, along with other creative interventions and targeted actions, aim to address TB threat.¹⁸

Figure 1. Trends in TB notification in Nigeria between 2019 and 2023^{12 13}.

Recently, the Global Fund, Nigerian government and health partners have signed eight new awards totaling US$933 million.¹⁹ From 2024 to 2026, these additional funds will help combat TB while bolstering the national health systems and pandemic readiness. International collaborations and initiatives have greatly aided progress in reducing TB in Nigeria.¹⁹

Recommendation

We must intensify our efforts and resources to combat TB in Nigeria, and this can be achieved through the purchase and wide distribution of GeneXpert analysers. Furthermore, strengthening laboratory networks and providing necessary tools will help in early TB case detection and treatment. A more aware and engaged public can be created using social media, local media and community leaders to spread knowledge about tuberculosis: scaling up interventions, establishing mechanisms for monitoring and evaluation, investing in research to identify TB treatment, preventing gaps in terms of child immunisation against TB and developing new drugs to counter resistance to already available drugs. TB care and prevention initiatives could be further strengthened by using international collaborations and private organisations. To address the socioeconomic challenges, there is a need for improving access to health insurance especially to rural areas, and also more collaborative investment between the drivers of TB should address the issue relating to under nutrition among children. Also, addressing the TB prevalence among men, the TB drivers should bring the service closer to work place of people and also bringing more closer to men’s gathering. Furthermore, preparing TB programmes to include gender sensitive approaches with more focus on men will also assist in achieving the ending of TB in Nigeria by 2030. To support our recommendation, we highlighted a frame work that can be implemented to improve TB care and prevention in Nigeria (figure 2)

Figure 2. Conceptual model for integration of TB service. TB, tuberculosis.

Conclusion

As Nigeria strives to achieve its SDGs by 2030, ending TB remains a priority that requires concerted efforts from all stakeholders. This paper highlight the persistence of TB in Nigeria, driven by factors such as poverty, stigmatisation, gender related challenges, low capturing of nomadic population, limited funding, poor healthcare system delivery and the COVID-19 pandemic which resulted into low diagnostic power, increased morbidity and mortality. Several efforts have been rolled out through by the drivers of TB diagnostic and treatments services which has resulted in improving the increase in TB notification in Nigeria and improvement in treatment service but still leaves gaps which will prevent achieving the goal of ending TB. Therefore, we recommend increase in funding of the programme that will target not only the diagnostic and treatment power but also easy assess to people living with TB without financial risk and also bringing this service closer to rural area and other hard to reach area. Also, gender sensitive approach should be implemented to target the men who are reported to having high prevalence of TB.

Data availability statement

There are no data in this work.