National and subnational efforts to secure sustainable domestic funding for Nigeria's health security
Civil Society Advocacy for Domestic Investment in Epidemic Preparedness
From 2018 to 2025, Resolve to Save Lives, the Global Health Advocacy Incubator and more than a dozen civil society organizations from nine countries—Ethiopia, Ghana, Kenya, Nigeria, Senegal, South Africa, Tanzania, Uganda and Zambia—partnered to increase domestic investment in epidemic preparedness.
Activities spanned coalition building and toolkit development, advocacy and media training and targeted engagement with political and financial leaders to make the case for investments in epidemic preparedness. The program is a testament to civil society’s potential to change policy, catalyze change, bolster domestic resources and safeguard communities.
Country context
The Nigeria Centre for Disease Control and Prevention (NCDC) was established in 2011 to prevent, detect, and control diseases of public health importance. From day one, it made significant progress in preparing for and responding to outbreaks, including cholera, yellow fever and mpox, but it lacked the legal authority to perform functions that could only be granted by an act of parliament. The NCDC also had insufficient resources and no formal budget, making it reliant on ad hoc financial support from the Ministry of Health; this hindered its ability to effectively manage multiple outbreaks.
Timeline and key achievements
| 2011 | NCDC founded |
|---|---|
| Jun 2017 | Nigeria conducts first JEE |
| Sep 2018 | Nigeria Health Watch, first CSO partner joins campaign |
|
Nov 2018 |
NCDC Act signed into law |
| Jan 2019 | Nigeria approves US$4.1M in funding for NCDC |
| Sep 2020 |
Advocacy for EPR budget begins in Kano State |
| Jan 2021 |
Nigeria (fed.) allocates US$30M to health security; Kano State creates new budget line and allocates US$777K to EPR; 44 localities in Kano allocate US$228k to EPR |
| Apr 2021 |
Advocacy for EPR budget begins in Lagos State |
| Sep 2021 |
Launch of Budget Advocacy Framework for Epidemic Preparedness |
| Jan 2022 |
Lagos State creates new EPR budget line and allocates US$14.8M |
| Jun 2022 |
Launch of Budget Advocacy Toolkit for Epidemic Preparedness |
| Dec 2023 |
Launch of Budget Advocacy Toolkit for Epidemic Preparedness: Facilitators Guide |
| Jan 2024 |
Federal health security budget up by one-third since ’21; NCDC budget reaches ₦4.1B (x3 increase since ’19); Lagos EPR budget reduced to US$3.5M; Kano CDC established with US$1.1M budget |
Nigeria underwent its first WHO-led Joint External Evaluation (JEE) of its ability to prevent, detect, and respond to epidemics in June 2017. At that point, the process to develop legislation to give the NCDC adequate legal status was underway. But as the legislation was yet to be enacted and because there was insufficient domestic funding earmarked to address epidemics, Nigeria received a 1—the lowest score for indicators related to national legislation, policy, and financing. The JEE urged action to finalize the NCDC bill and noted the need for funding across issue areas including risk communications, surveillance, national laboratory system, biosafety and biosecurity. The JEE specifically noted that there was heavy dependence on donors for surveillance system operations.
In 2017, Nigeria allocated just 4.2% of its budget to health,1 despite committing, in signing the 2001 Abuja Declaration, to spend at least 15%. Nigeria needed sustained, domestic funding to prevent epidemics.
Early days of partnership
Nigeria’s JEE highlighted underlying challenges to improve health security; it needed to strengthen the legal framework by passing the NCDC Act; secure increased funding from domestic sources; and ensure that domestic and donor funds were used effectively.
RTSL’s senior staff had ties to NCDC, enabling a solid partnership which rapidly materialized into support to access funds from the World Bank’s REDISSE program to strengthen disease surveillance and epidemic preparedness. Specific World Bank requirements—including the submission of an operational plan—made it difficult for NCDC to access available funds. While the JEE had identified gaps, the next step was for Nigeria to create a costed National Action Plan for Health Security (NAPHS) to outline how to address those. RTSL supported government-led efforts to develop the NAPHS, building a national consensus on priorities and how domestic and donor funding would be mobilized to meet them.
While supporting the effective use of World Bank funds, RTSL identified a pathway to increase domestic financing and strengthen NCDC’s legal framework by partnering with the Global Health Advocacy Incubator (GHAI) to mobilize civil society organizations (CSO) to advocate for sustained investment in health security. Like RTSL which had established an early presence in Nigeria, GHAI— working under the Campaign for Tobacco Free Kids—had a Nigeria office with a track record of success on tobacco policy using a CSO-led advocacy model. As a large, federated state confronting significant epidemic risks, Nigeria presented unique advocacy challenges and opportunities. This combination of need and assets, including enlightened public health leaders and a vibrant civil society space, made it a logical choice to test a CSO-led advocacy approach.
Launching the campaign
As the team organized and laid the campaign groundwork, the NCDC Act was passed and signed into law in November 2018, giving the NCDC needed legal authority and a budget line for the first time. The initial budget of ₦1.5B (US$4.1M) was below the projected needs but provided advocates a base from which to build. The NAPHS for 2018-2022, anticipated a total five-year cost of ₦53 billion (US$174M) for all activities across government, including but not limited to NCDC. The World Bank program was able to cover a portion of costs, and the NCDC received its first installment in April 2018. Domestic funding, however, needed to be dramatically increased to fully realize the NAPHS’ aspirations.
The RTSL team, GHAI in-country coordinators, and civil society organizations partners—BudgIT, which focuses on budget analysis and transparency; Nigeria Health Watch (NHW), with expertise in media engagement, advocacy skills, broad multi-sector network and influence on health policy reforms; and later the Legislative Initiative for Sustainable Development (LISDEL), focused on legislative advocacy—each brought complementary expertise. While GHAI had tested a multi-year, multi-prong advocacy model on other issues, advocacy for epidemic preparedness funding was new and took refining, allowing the model to develop over time.
Based on the experience we have acquired, it is important to understand your stakeholders extremely well, and do a very strong landscape and stakeholder analysis before you start to pursue any targets because at the end of the day, it’s about interests and making sure interests can be aligned.
Ibukun Oguntola Program Manager, Nigeria Health Watch
Advocates did a landscape analysis which gave an understanding of the budget cycle and political players. Through these preparatory processes, the teams recognized that preparing for and responding to epidemics is a whole-of-government effort that demands involvement from ministries far beyond health. Those with responsibilities for wildlife and water, for example, must be involved to manage zoonotic disease spread and mitigate cholera transmission via contaminated water sources. Plans were devised to partner with CSOs to sensitize policy makers and the public to the need for sustained epidemic preparedness funding via the NCDC and wider government, to improve Nigeria’s capacity to prevent epidemics.
The Nigeria teams collectively made a powerful force and built a coalition bringing together traditional and religious leaders with deep community ties, NGOs with links to a wide range of constituencies, elected stakeholders and government officials. LISDEL, for example, chaired the health financing committee of the Health Sector Reform Coalition of NGOs and coordinated the work of the Legislative Alliance for UHC, a network of political leaders and advocates. These connections provided both input on strategy and asks while amplifying key messages. Together, they elevated the importance of epidemic preparedness to the attention of local, state and federal elected officials, federal ministries and both houses of the Nigerian National Assembly to push for dedicated funding for epidemic preparedness. This work was carried out over several years via numerous meetings, field trips, and educational workshops that spotlighted epidemic preparedness gaps.
The lack of knowledge about epidemic preparedness was a key challenge. With all the stakeholders we engaged from the Ministry of Health, the Ministry of Finance, lawmakers, and others, it was important to first increase their knowledge as to why this was such a vital issue. We need to recognize that this was a priority that underpinned the other achievements we had.
Ibukun Oguntola Program Manager, Nigeria Health Watch
Campaigners also realized that there was little media on health security and most reporting that did exist only occurred after an outbreak. Therefore, in addition to direct engagement, CSO partners sensitized policymakers and the public via traditional and social media. NHW carried out evidence-informed trainings and bestowed awards for journalists to support and encourage high quality reporting on epidemic preparedness, driving home the message that epidemic preparedness was a national priority.
In the past, health reporting was often sensational and lacked depth. Throughout the project, we consistently worked to change this by training journalists through masterclasses, fellowships, and other tools that introduced the concepts behind health security. As a result, when journalists had the opportunity to engage with stakeholders, such as legislators and officials from the ministries of health and finance during press briefings and media roundtables, they were equipped to ask informed questions and produce quality stories. This helped advance the agenda of preventing infectious disease outbreaks in the country.
Ibukun Oguntola Program Manager, Nigeria Health Watch
Throughout the campaign, the Nigeria CDC was a true cornerstone of the work, advising on needs and working hand-in-hand on developing plans and building capabilities. And the campaign saw great success.
For NCDC, advocates focused both on a budget line and an ongoing allocation from the Basic Health Care Provision Fund (BHCPF). The BHCPF is a sustainable funding mechanism granted via statute– and as such, it does not have to be appropriated by parliament each year but, rather, comes from a regular pool of money set aside by the government. NCDC had received 2.5% of the fund for one quarter in 2018, but a new Minister of Health changed the guidelines to exclude NCDC. GHAI and RTSL worked with NCDC and the Ministry of Justice, and BHCPF funding was restored to NCDC in 2021.
Funding for NCDC has been stable because of advocacy early on. One of the things we did was a budget process mapping to understand the various steps involved in the budget cycle and also to identify the various sticky points where there were likely to be bottlenecks or bureaucratic issues due to competition for the same pot of funds.
Prof Emmanuel AlhassanNigeria Coordinator, Prevent Epidemics, Global Health Advocacy Incubator
The partnership saw a great deal of success in sustaining and increasing the NCDC budget line. By 2021, advocacy resulted in the NCDC budget increasing to ₦5 billion. Funding for the NCDC budget line peaked at ₦7 billion in 2023 before being reduced to ₦4.4 billion, nearly triple its initial allocation in 2019, primarily due to lower capital expenses after needed early investments had been made, while personnel or overhead stayed steady. Reductions were also partially offset by increases in allocations from the BHCPF from ₦437 million in 2021 to ₦1.6 billion in 2024.
Critical allocations were also made to other ministries, departments, and agencies (MDAs) for NAPHS activities. When campaigning started, many of the MDAs did not submit budget requests. However, with support from the RTSL team and in collaboration with NCDC—including a workshop with the MDAs—requests dramatically increased. As a result, allocations to these entities for health security rose sharply, with non-Ministry of Health MDAs seeing an increase of over 100% between 2021 and 2022.
RTSL and GHAI also worked to strengthen the legal framework for preventing, detecting, and responding to epidemics, including the creation of statutory funding mechanisms, through educational workshops and policy dialogues on the Public Health Emergency Bill and the National Health Act. Both bills passed the National Assembly but neither were signed by the President. Work continues to revive the legislation. The NCDC Amendment Bill which would clarify and strengthen the legal standing of the NCDC and create an Emergency Preparedness Fund, supported by the teams through technical support, also remains under consideration.
State level advocacy
With RTSL developing a focus on strengthening subnational level capacities and given the important role of states in health security under the Nigerian constitution, the application of budget advocacy methods to Kano and Lagos States was a logical next step. In consultation with NCDC and health experts, Kano and Lagos were identified as high-risk areas for outbreaks due to their demographics and geographic profiles, combined with political will to make change, a strong CSO presence, and unspent health security funds.
BudgIT, LISDEL, and NHW joined work at the state level, supported in Kano State by a GHAI in-state coordinator. Kano State saw the establishment of the Kano CDC, Africa’s first sub-national public health institute, to manage public health threats. Lagos and Kano State also experienced tremendous increases in epidemic preparedness budgets. Lagos’ budget line initially saw an allocation of ₦6.1 billion, which was eventually reduced to ₦3.2 billion, but nevertheless represented a dramatic increase. Kano State’s budget line increased by 67% while each local government established a preparedness budget line which increased by 50% between 2021 and 2024.
To build political will to scale the wins of Kano and Lagos States, LISDEL worked with the Nigeria Governors Forum to create an epidemic preparedness and response report card. The goal was to incentivize improvements by showing leaders explicitly where their states stood in comparison to other states. Report card data is currently being gathered, with plans for publication under consideration.
Funding accountability
From the beginning advocates knew that funding increases alone would not be sufficient. In the Nigerian health sector, once money is allocated by the national or state legislative body, it still must be released by the government, and then effectively utilized by the MDAs—a process often marked by delays and inefficiencies. The MDAs to whom funding is allocated need well-prioritized plans to spend the money, and capacity to absorb it. Funding needs to be tracked in a transparent manner so it is clear whether the proposed activities are implemented, and to identify glitches and gaps to advocate for improved utilization. In some cases, agencies such as the NCDC and states must meet stringent requirements to receive certain federal funds. Finally, effective budgeting is a dynamic process that requires ongoing vigilance and accountability to ensure allocations are sustained over time.
In some years, less than 60% of Nigeria’s health sector capital budget was released, and less than 60% of the released funds were utilized. In 2022, for example, only 36% of funds allocated to the health capital budget were used.2 BudgIT, which had been collecting data to map onto health security priorities, found that these same issues affected health security funding.
The teams collectively addressed all these issues. They engaged with the MDAs that received allocations, ensuring the necessary memos for fund release were issued at both the national and state level. In Lagos, for example, in 2022, the first year of the new epidemic preparedness allocation, only 2% was released for use. By 2023 the team’s efforts saw this increase to 15%. They supported both the NCDC and states to meet the Federal requirements necessary to access federal funding. They worked with MDAs that needed funding to ensure that they had plans in place to carry out effective epidemic preparedness and that they drafted annual budget requests backed up by these plans. Advocates participated in national and state level Joint External Evaluations , to understand preparedness gaps and in the drafting of costed NAPHS and advocated for spending accordingly.
To further bolster budget accountability, LISDEL and BudgIT created the Health Security Accountability Framework, which was validated in June 2022 at a meeting of civil society and government officials who provided feedback. The framework has been used to track allocations and spending while identifying bottlenecks, which help inform campaign planning. A major challenge in implementing the framework, however, has been a lack of access to data, requiring extensive engagement with government stakeholders to access the needed information. While LISDEL, in partnership with BudgIT, initially managed the Framework at the federal level and in Kano State, a platform in Kano has since evolved into an ongoing mechanism: a coalition of CSOs populates and regularly reviews the Framework, which is becoming a key tool for health officials there. At the federal level, the NCDC is in the final stages of validation to adopt the Framework as an internal tool. These steps are intended to ensure sustainability and transparency in future years.
Capturing learnings
Implementation of the program in Nigeria raised important questions about return on investment (with the risk that advocacy infrastructure and operational costs over several years might exceed the epidemic preparedness funds ultimately mobilized in epidemic preparedness funding), replicability and scalability. The original model, though showing results, relied heavily on resource inputs, and as such proved difficult to scale across new countries or subnational jurisdictions. Recognizing the need for a more adaptable and sustainable approach, RTSL and GHAI worked to synthesize lessons learned, particularly from Nigeria to guide others through a less resource intensive and hands-on approach.
Lessons from early efforts were synthesized into the Budget Advocacy Framework for Increased and Sustained Investment in Epidemic Preparedness, which launched in September 2021. Building on the Framework, the Budget Advocacy Toolkit was completed in June 2022, detailing key actions for each campaign step. In December 2023, a Facilitator’s Guide with 11 modules was released to train advocates to use the toolkit.
You have to understand the context. That is one of the key strategies that GHAI’s advocacy action guide teaches. You do mapping and analysis to understand what the intricacies are that you have to take on, and work based on what the findings are.
Abdullahi Hamza HassanIn-country coordinator for Kano State, Nigeria and coordinator for Kenya, Global Health Advocacy
Nigeria Health Watch also created a Media Advocacy Toolkit to codify and share the strategies that had proven effective in working on epidemic preparedness, including building public health professionals’ communication capacity, strategically integrating media into public health discussions, highlighting the positive impacts of preparedness, engaging communities, and leveraging media to shape the agenda. The toolkit was launched at the third Conference on Public Health in Africa; this event brought together policymakers, CSO representatives, and public health practitioners to discuss media’s role in shaping public perception about health emergencies, disseminating accurate information, and influencing policy decisions to build resilient health systems prepared for infectious disease outbreaks. The toolkit was later used to train CSOs working on budget advocacy campaigns in Kenya, Uganda, and Zambia.
Lessons learned and legacy
- A systems thinking approach to health security challenges is essential to lasting impact. The teams recognized significant gaps—from problem identification to budget allocation and release, absorption, transparency and accountability. Through its structure and careful selection of CSO partners, the campaign focused on key bottlenecks across the entire needs chain, creating a sustainable infrastructure from which to continue to build epidemic preparedness with domestic funds.
- Finding the right advocacy model is an iterative process. The Nigeria campaign, which achieved notable wins over seven years, benefited from a long runway, consistent support, and GHAI and RTSL’s strong in-country presence. It also demonstrated that large-scale investment over many years is not the only viable path; emerging models—such as the CSO Academy, which builds on tools informed by the Nigeria learnings—show the strength and scalability of targeted, strategic investments combined with sustained relationship-building.
- Sharing lessons learned prevents others from having to recreate the wheel. Because Nigeria was the first country for epidemic preparedness funding advocacy, it served as a testing ground and produced valuable lessons that were shared to inform future campaigns. Key outputs—the Framework, Toolkit, Facilitators Guide, and NHW’s Media toolkit—allowed effective, generalizable tactics to be taken on and used by a wider ecosystem not necessarily linked to either RTSL or GHAI.
- When advocates have credibility and invest time in building relationships, policymakers can be invaluable partners. In Nigeria, RTSL was already embedded in NCDC as a technical partner, and NHW had its own connections to the organization. This combination facilitated relationships between GHAI and CSO partners, enabled the teams to understand the landscape and ensure messaging aligned with NCDC’s needs. In turn, NCDC trusted the teams and was a key and enthusiastic partner, making budget advocacy work in Nigeria a success.
A key enabler was the fact that we were able to go beyond advocacy and engagement with stakeholders. We were also able to work very closely with them to understand what challenges they face doing their work, particularly filling the gaps that were identified during the landscape analysis, supporting them with capacity building and technical assistance which were very useful.
Damilola AdemuyiwaDirector of Programs, Legislative Initiative for Sustainable Development
Conclusion
Like many other African countries, Nigeria is experiencing profound shifts following the United States’ sudden aid withdrawal in early 2025 and subsequent negotiations of new health bilateral agreement between the US and the Nigerian governments and related co-financing requirements. Advocates and Nigerian leaders are galvanized to meet the moment and chart their path through increased domestic funding.
It’s a double-edged sword. On the one hand, funding from USAID and indeed other bilateral and multilateral funders has been quite helpful in strengthening Nigeria’s health system That said, for a long time many of us have been advocating for domestic resource mobilization because you cannot depend on other countries using their taxpayer money to support you ad infinitum.
Prof Emmanuel AlhassanNigeria Coordinator, Prevent Epidemics, Global Health Advocacy Incubator
Over seven years of advocacy created important change across Nigeria, mobilizing domestic investments toward outbreak prevention activities. Years of campaigning created an ecosystem of parliamentarians, government functionaries, and civil society organizations knowledgeable committed to supporting greater epidemic preparedness. These actors will be more important than ever as Nigerian leaders navigate a changing and unstable environment.
Part of what we infused into the strategy across all the activities we implemented was to ensure sustainability even after the grant expired. And that’s why we never worked in isolation. We worked with several CSO and media coalitions. One of the coalitions we worked with last year has been able to include health security in their projects going forward. We will continue to use resources we have elsewhere to continue to push the gains from Kano, Lagos, and at the national level.
Damilola AdemuyiwaDirector of Programs, Legislative Initiative for Sustainable Development