On a dirt road, shivering under a sunless January Nigerian sky, three men stand shoulder to shoulder totally naked, stripped by the angry mob that flank them on every side. Suspected of being homosexuals, members of their local community dragged them out of their homes and beat them.
A vivid contrast against their dark brown skins is the single yellow rope tied around each man’s waist; linked together, trying to escape will be harder.
Fear, shame and anger play across their faces, as their accusers take pictures with mobile phones while hurling insults and obscenities.
Assaults like this would escalate exactly a year later and become even more gruesome when in 2014, the Nigerian president Goodluck Jonathan signed into law a decree banning same-sex relationships, public displays of homosexuality and association with gay groups. Violators face the possibility of being jailed for 14 years. This drew strong condemnation from many countries, global institutions and activists, denouncing the Nigerian leadership for failing to protect the human rights of the homosexual population.
In the months that followed, some Western donors would exert more pressure on the country, restricting funding to its most foreign aid-dependent sector – HIV-AIDS-related health programmes. This reprimand has however had unintended positive effects as the often negligent Nigerian government has grown more innovative and responsible towards the community of people living with HIV-AIDS (PLWHA).
Couched in veiled statements, officials from the United Kingdom, the United States and multilateral donor groups like the Global Fund to Fight AIDS essentially told Nigeria to rescind the decree or say goodbye to the millions of dollars in foreign aid annually poured into the country to support its HIV-AIDS fight. Nigeria has the second highest HIV burden in the world with 3.4 million infected people. The US in 2011 through its President’s Emergency Plan for AIDS Relief (PEPFAR) programme allocated approximately $488.6million to Nigeria for HIV/AIDS prevention, treatment and care, while the Global Fund had approved over $360million.
“Taxpayers in many countries will not keep forking-out for countries that are willing to take the contributions for anti-retroviral drugs but are not willing to protect their own citizens,” said Michael Kirby, former Australian High Court judge, delivering a keynote speech at the 2014 International AIDS Conference hosted in Melbourne.
With about 97% of Nigerians, according to PEW research, supporting the anti-homosexuality laws, these “threats” were unsurprisingly met with ire. The local press and social media swelled with an outpour of criticism and outrage describing Western reactions as another example of imperialist coercion and a direct assault on Nigerian national sovereignty.
“Saudi Arabia beheads gay men, they kill them, but have you heard America threatening them? No! They [Saudi Arabia] are allies of America,” says Vincent Oni, a local clergyman based in Abuja, Nigeria’s capital city. Echoing the sentiments of many of his countrymen, Oni adds: “They threaten us with their dollars because they have no regard for us and our culture. They do not care about us. They just like talking down at Africa. They should keep their money. I think we have had enough of their insults.”
Against this backdrop and with general elections a little over a year away, it was not surprising that the Nigerian leadership towed popular domestic lines. Their response to the West was “keep your foreign aid” – and so the West did. Deprived of crucial medicine and other services in the inevitable health crisis that has since resulted, many PLWHA have died in the country. “So many people stopped taking their drugs. They cannot afford to get medicine again. There is no medicine,” says Gloria Asuquo a 36-year-old HIV-AIDS activist who has been living with the virus for over a decade.
The flip side is that in the months since the government has been forced to develop a measure of political-will that was long absent. One example of this is Nigeria President’s Comprehensive Plan (PCRP) for HIV/AIDS launched to accelerate the implementation of key interventions against HIV, including mother-to-child transmission of AIDS. Under the direct supervision of the presidency (relatively) better access to anti-retroviral drugs has ben recorded. Also long delayed plans to produce HIV medicines locally have been revived.
The way foreign funding works in Nigeria is that majority-funding load for HIV-AIDS schemes is passed to donors, but the recipient nation must invest a measure of their budget as well to show commitment – something Nigeria has failed at. In the 2012 national health budget, none of the N2.1billion (about $1.5million) allocated to the National Agency for the Control of AIDS (NACA) – the agency responsible for HIV-AIDS response, went towards providing millions of PLWHA life-saving antiretroviral treatments, something Nigeria Health Watch describes as a worrying trend.
“In the past years, when there was full foreign aid support we still experienced some issues accessing drugs, so just imagine what we are going through now,” says Asuquo. Recounting the euphoria that gripped the community when in 2006 buoyed by donor grants HIV medicine was made free. “Even then I knew this would not last. I said it! The government should have started planning then how we can maintain on our own for the many poor people who will not be able to afford on their own,” lamented Asuquo.
Zambia-born economist Dambisa Moyo notes that prolonged aid expenditure makes it almost impossible for African governments to break free from dependence on foreign aid. In her critically acclaimed 2009 book “Dead Aid: Why Aid Is Not Working,” she argues these governments are caught in the aid world of free money with no incentive to seek other, more sustainable ways of raising development funding.
Nigeria is the 12th largest oil producer in the world and the wealthiest economy in Africa. So it is rather shocking that most of its responsibilities in the health sector, ranging from maternal health to HIV prevention, is shouldered by foreign donors, making it one of the continent’s biggest recipients of foreign aid from Western nations like the US, UK and even the European Union (EU). So with the aid pullout, Nigeria has finally found an incentive to be innovative in finding solutions to its problems and is finally deploying its enormous resource wealth to do just this; something it would most likely never have done if the aid was never cut.
One of such innovations being pursued is a finance-redirection strategy where funds scraped from reduced subsidies paid on petroleum products is reinvested in the health sector. Programmes targeting PLWHA is currently a major recipient with “more than N167 billion (over $835 million)” says Onyebuchi Chukwu, Nigeria’s minister of health 2010-2014, delivered through the PRCP.
Akinjide Babalola, a former political aide to a Nigerian senator, says that Nigeria should not count any restriction on foreign aid as punishment. “As far as I am concerned countries like Nigeria should not be receiving foreign aid.”
However, Asuquo maintains that while it is praiseworthy that the Nigerian government is doing more to be responsible to PLWHA, the nation is still a long way from getting its act together. “It is easy for most in Nigeria that are HIV-negative to say to hell with foreign money. I wish that the funds will come back because the problems we are facing are huge and many people are dying.”
But in addition to funding cuts, donor groups like Global Fund and the World Bank Multi–Country HIV/AIDS Program have reformed their HIV-AIDS financing model towards Nigeria with funds being re-assigned to primarily focus on marginalized populations in the country, specifically men who have sex with men (MSM) and other populations that fall within the Lesbian, Gay, Bi-Sexual and Transgender (LGBT) community.
“Despite high prevalence and incidence, programme reach and coverage remains low and governments have historically allocated inadequate resources to MSM, transgender people, other LGBT groups,” reports a January 2015 Global Fund document which defends decisions to increase targeting of HIV funding specifically at MSM.
However, this argument has not gained legitimacy in Nigeria, where the predominating argument is that donors unfairly blame the government for LGBT populations going ‘underground’. Nigeria has an inherently homophobic local culture, tradition and religion which government policies have no sway over, and this is what tends to do more to isolate individuals that are of any other sexual orientation diverging from the mainstream. Recent Global Fund data has MSMs accounting for about ten percent of the HIV epidemic in Nigeria while heterosexual transmission accounts for 80%.
“A person living with HIV and AIDS is a person living with HIV and AIDS irrespective of who you are – irrespective of sexuality,” argues Isa Dansallah, the executive director of Destiny Resource Center, a non-profit active in HIV-AIDS programming funded by donor aid. Dansallah echoes a pervading sentiment that donors are punishing the majority because of the minority, adding that it was sad Global Fund was “pursuing its own agenda … which is against our culture”.
Nigeria is the second most religious nation in the world; most of its 173 million citizens identify staunchly as either Muslim or Christian, it is not surprising then that many of the non-governmental agencies delivering on HIV programmes are faith-based or at least affiliated with such. So stipulations that ‘force’ them to acknowledge the LGBT community as legitimate creates tension, caught in a moral debacle that forces them to choose between the dictates of their faith and the source of their operational funds. This general feeling of frustration constitutes a wane in the approval for Western aid. It further signifies continued support for the government’s posture towards LGBT, which encourages the Nigerian leadership to ignore calls to repeal anti-gay law.
Most Nigerian PLWHA are poor; add to that high prices, and you have a major barrier to affordable access to HIV medicines and related services. Hence, as prescribed by UNAIDS and echoed by Nigeria’s health policy, it is an ethical imperative for the Nigerian government to provide treatment to its infected population. However, a lot of this has been more rhetoric than reality. Because donor dollars represented a safety net, the PLWHA community rarely held to account the government for failed promises.
Protests and pride
After being donor-dependent for so long, it would take a whole lot more than a few million dollars to reverse years of neglect and bridge the systemic gaps. Chikwe Ihekweazu, a Nigerian public health physician credited by the Associated Press, says that 95% of anti-retroviral drugs consumed by PLWHA was paid for by donors. Meanwhile, they were also responsible for providing free access to a range of tests that help maintain quality of life. Viral load tests, which used to be free for all, now alone cost $10 to $25, a monumental sum for a population where 70% live on less than $2 a day.
Asuquo notes that many people have been forced to discontinue their treatment, while others who can afford to buy the anti-retroviral drugs have to access them from the private market at much higher prices with some of the products turning out to be fake or expired.
Soon individual discontent morphed into protests erupting in states across the country. By November of 2014, this culminated in the shut down of NACA’s head office in Abuja. Media reports note that over 500 PLWHA under the aegis of the Network of People Living with HIV and AIDS in Nigeria (NEPWHAN), stormed the offices of NACA demanding the government set in motion definite solutions to provide affordable medicines. This was an unprecedented move for the usually tame and politically uninvolved group.
With the world watching how things evolve, it seems what Nigeria may hate more than being told what to do is being told I-told-you-so. And so with uncharacteristic swiftness director general of NACA, John Idoko, as reported by several media, addressed the group acknowledging failures and promising interventions were already on the way to ensure treatment eventually transits to being free nationwide. In the months since, Asuquo testified that access to antiretroviral drugs has been scaled up. “The drugs are somehow free again though we have to now pay a service fee of a thousand naira (about $5) at the hospital before they give us the medicine to last three months. In some states some are paying as high as six thousand naira (about $30),” says Asuquo. In 2013, the actual retail value for effective antiretroviral treatment (which involves the combination of two or more HIV drugs), is estimated by AVERT, an international HIV and AIDS charity, to range from $115 to $1500 per patient per year.
Nigeria announced late last year that three local pharmaceutical companies had met the World Health Organization (WHO) prequalification standards and would soon begin the production of HIV drugs. “We are now thinking outside the box,” says Babalola. “Our leaders have no choice but to find solutions. The world is watching.” While all this may just be a face-saving scheme, one that does not favour Nigeria’s gay population, at least other Nigerians may be slowly getting the government they deserve – which is more than a small victory. The relatively new president of Nigeria Mohammed Buhari is being watched closely – what strategy would he take in the health sector, would he repeal or try to circumnavigate the anti-gay laws, what health financing policies would be adopted in a time of limited donor support? What we can say with near certainty is Nigeria is moving forward, snail pace by snail pace.
. Akpe is a Nigerian journalist, a 2014 Nieman Fellow at Harvard and currently a Mundus Journalism Scholar in Denmark