Guidance

Country information note: medical treatment and healthcare , Nigeria, December 2021 (accessible version)

Updated 12 August 2022

Version 4.0

December 2021

Preface

Purpose

This note provides country of origin information (COI) for decision makers handling cases where a person claims that to remove them from the UK would be a breach of Articles 3 and/or 8 of the European Convention on Human Rights (ECHR) because of an ongoing health condition.

It is not intended to be an exhaustive survey of healthcare in Nigeria.

For general guidance on considering cases where a person claims that to remove them from the UK would be a breach of Article 3 and/or 8 of the European Convention on Human Rights (ECHR) because of an ongoing health condition, see the instruction on Human rights claims on medical grounds.

Country of origin information

The country information in this note has been carefully selected in accordance with the general principles of COI research as set out in the Common EU [European Union] Guidelines for Processing Country of Origin Information (COI), dated April 2008, and the Austrian Centre for Country of Origin and Asylum Research and Documentation’s (ACCORD), Researching Country Origin Information – Training Manual, 2013. Namely, taking into account the COI’s relevance, reliability, accuracy, balance, currency, transparency and traceability.

The structure and content of the country information section follows a terms of reference which sets out the general and specific topics relevant to this note.

All information included in the note was published or made publicly available on or before the ‘cut-off’ date(s) in the country information section. Any event taking place or report/article published after these date(s) is not included.

All information is publicly accessible or can be made publicly available, and is from generally reliable sources. Sources and the information they provide are carefully considered before inclusion. Factors relevant to the assessment of the reliability of sources and information include:

• the motivation, purpose, knowledge and experience of the source
• how the information was obtained, including specific methodologies used
• the currency and detail of information, and
• whether the COI is consistent with and/or corroborated by other sources.

Multiple sourcing is used to ensure that the information is accurate, balanced and corroborated, so that a comprehensive and up-to-date picture at the time of publication is provided of the issues relevant to this note.

Information is compared and contrasted, whenever possible, to provide a range of views and opinions. The inclusion of a source, however, is not an endorsement of it or any view(s) expressed.

Each piece of information is referenced in a brief footnote; full details of all sources cited and consulted in compiling the note are listed alphabetically in the bibliography.

Feedback

Our goal is to continuously improve our material. Therefore, if you would like to comment on this note, please email the Country Policy and Information Team.

Independent Advisory Group on Country Information

The Independent Advisory Group on Country Information (IAGCI) was set up in March 2009 by the Independent Chief Inspector of Borders and Immigration to support him in reviewing the efficiency, effectiveness and consistency of approach of COI produced by the Home Office.

The IAGCI welcomes feedback on the Home Office’s COI material. It is not the function of the IAGCI to endorse any Home Office material, procedures or policy. The IAGCI may be contacted at:

Independent Advisory Group on Country Information
Independent Chief Inspector of Borders and Immigration
5th Floor
Globe House
89 Eccleston Square
London, SW1V 1PN

Email: chiefinspector@icibi.gov.uk

Information about the IAGCI’s work and a list of the documents which have been reviewed by the IAGCI can be found on the Independent Chief Inspector’s pages of the gov.uk website.

Overview

1. Sources and prices

Section 1 updated: 30 November 2021

1.1 MedCOI

1.1.1 This note makes extensive use of medical country of origin information (COI) compiled by Project MedCOI, which was set up and operated by the immigration authorities in Belgium and the Netherlands until 31 December 2020, and since then by the European Asylum Support Office (EASO).

1.1.2 The EASO MedCOI sector website explains how the project has and currently operates: ‘EASO MedCOI relies on a worldwide network of medical experts that provides up-to-date medical information in countries of origin. Based on this information and combined with desk research, the EASO MedCOI Sector produces responses to individual requests from EU+ countries, general medical country reports, and maintains a portal with a specific database where the information can be found… The database is only accessible to trained personnel in EASO and the EU+ countries’ relevant administrations…

‘The high quality and medical accuracy of the information is guaranteed by specifically trained medical advisors and research experts who also provide guidance to the users of the portal.

‘The MedCOI Sector at EASO has incorporated all services that were previously delivered by project teams in Belgium and the Netherlands in an ERF/AMIF funded project until 31/12/2020 (MedCOI4).’ ^{[footnote 1]}

1.1.3 The UK Home Office ceased to be able to make requests to or access the database of MedCOI on 31 December 2020.

1.1.4 The UK Home Office has, however, retained copies of all MedCOI documents referred to in this note should they be required in individual cases.

1.2 Costs and currency

1.2.1 This note includes the cost in Nigeria Naira for various medications and treatments, mostly provided by MedCOI. These prices have been converted into British Pounds wherever possible. The exchange rate as of 23 November 2021 is:

• £1 = 547 Nigerian Naira^{[footnote 2]}
• For comparison where a table in this CPIN provides costs in Naira 100 Naira = £0.18
  • 500 Naira = £0.91
  • 1,000 Naira = £1.82
  • 5,000 Naira = £9.13
  • 10,000 Naira = £18.26^{[footnote 3]}

1.2.2 However information about prices is based on information obtained at a particular point of time, in some cases 2 or more years ago, during which time Nigeria has experienced relatively high rates of general inflation and increases in prices of consumer goods and services of around 15% a year. It is therefore possible that the prices cited are no longer accurate^{[footnote 4] [footnote 5]}.

2. The healthcare system

Section 2 updated: 30 November 2021

2.1.1 A 2020 Lancet publication of global health care access, which is based on Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, and was designed to assess UHC (Universal health coverage) effective coverage for 204 countries and territories from 1990 to 2019 gave the percentage index value for UHC effective coverage in Nigeria in providing effective, essential health services as 38.3% in 2019. This is compared to 31.6% in 2010 and 22.6% in 1990^{[footnote 6] [footnote 7]}.

2.1.2 The 2018 Nigeria Demographic and Health Survey was ‘designed to provide data for monitoring the population and health situation in Nigeria.’ This extensive document contains behavioural and statistical information, particularly about the health of women and children, and conditions such as HIV, malaria and sickle cell anaemia^{[footnote 8]}.

2.1.3 A report by Medic West Africa, a healthcare business platform in the West African region^{[footnote 9]}, 2019 Healthcare – Nigeria: Market insights stated: ‘The Federal Government’s health policy under the Economic Recovery & Growth Plan 2017-2020 aims to improve the availability, accessibility, affordability and quality of health services by increasing access to primary health care services, expanding health coverage and improving the quality of the services provided.’^{[footnote 10]}

2.1.4 The same report also provided the following statistics

• ‘Patient-to-doctor ratio 2500:1
• ‘NCDs [Non Communicable diseases] are estimated to account for 29% of all deaths
• ‘Spending on healthcare to reach NGN 5,762 billion [£10 billion^{[footnote 11]}] by 2021
• ‘US$ 1 billion [£735 million^{[footnote 12]}] spent annually on outbound medical tourism.’^{[footnote 13]}

2.1.5 The Institute for Health Metrics and Evaluation (IHME) ‘An independent population health research organization based at the University of Washington School of Medicine’ ^{[footnote 14]} provided the following statistics on their website

• Life expectancy at birth - 65.8 for females (57.1 in 1990)
• Life expectancy at birth 62.8 for males (54 in 1990)
• Neo-natal disorders were the number 1 cause of death in 2019, followed by malaria and diarrheal diseases^{[footnote 15]}.

2.1.6 The US Embassy in Nigeria noted that ‘Nigeria imports the majority of its pharmaceutical and medical supply needs, primarily from European sources. Medical shortages have hindered medical practice, research, and training.’ ^{[footnote 16]}

2.1.7 The Australian Department of Foreign Affairs and Trade (DFAT) Nigeria Country Report published in December 2020 noted:

‘Article 17(3)(d) of the Constitution commits the State to ensuring there are adequate medical and health systems for all persons. Health care is provided by the public and private sectors, with the private sector providing around 60 per cent of health service delivery while owning only 30 per cent of health facilities. The government spent around USD3.2 billion [£2.3 billion^{[footnote 17]}] on health in 2019, compared to over USD10 billion [£7.3 billion^{[footnote 18]}] spent in the private health sector. This indicates there is a high reliance on out-of-pocket health payments to finance the health system in Nigeria, despite a consensus to develop a universal health care system.

‘Nigeria’s health system faces significant challenges in meeting the needs of its population. The prevalence of infectious diseases, such as tuberculosis and HIV/AIDS, remains high. According to the World Health Organization (WHO), Nigeria’s health statistics indicate significant adverse outcomes, and there is a significant disparity in health status across states, urban and rural areas, education and social status.’ ^{[footnote 19]}

2.1.8 The Foreign, Development and Commonwealth Office (FCDO) travel advice aimed at British travellers stated: ‘Medical facilities in some parts of Nigeria may only be very basic.’^{[footnote 20]}

2.2 Organisation of healthcare system

2.2.1 Udo, Reuben Kenrick , Kirk-Greene, Anthony Hamilton Millard , Ajayi, JF Ade and Falola Toyin O, (Udo and others) in an article, ‘Nigeria’, published in the Encyclopedia Britannica, updated 8 December 2020, stated:

‘Medical and health services are the responsibility of all levels of government. There are hospitals in the large cities and towns. Most of the state capitals have specialized hospitals, and many are home to a university teaching hospital. There are numerous private hospitals, clinics, and maternity centres. Medical services are inadequate in many parts of the country, however, because of shortages of medical personnel, modern equipment, and supplies.’^{[footnote 21]}

2.2.2 A MedCOI response from June 2020 and including information from a MedCOI country contact stated:

‘The Nigerian healthcare system is organised into primary, secondary and tertiary healthcare levels… Public healthcare provision remains a concurrent responsibility of the three tiers of government: the federal, state and local governments… The Federal Government is responsible for policy development, regulation, overall stewardship and providing healthcare at tertiary level (teaching hospitals and specialist hospitals). The state governments are responsible for secondary healthcare, while the local government areas manage primary healthcare… The healthcare system has been described as “deeply fragmented, with only a small fraction of the healthcare coming from a unified and organized centre…”

‘The Nigerian healthcare system can also be divided into private and public health networks.’ ^{[footnote 22]}

2.2.3 A MedCOI response from July 2020, noted that ‘the information on the organization of the healthcare system and referral system contained in the Belgian Immigration Office 2017 Nigeria CFS [Country fact sheet] remains ‘still very valid and up to date’^{[footnote 23]}. The 2017 CFS stated: ‘There is a referral system between these three levels [of public healthcare – Primary, secondary and tertiary]. However, it is not always respected. Ailments that are supposed to be managed at the primary level are often managed at the tertiary level. This happens because the other levels especially the primary level is very weak, with inadequate infrastructure, personnel and other deficiencies.’^{[footnote 24]}

2.2.4 A Pulse, a Nigerian newspaper, article from December 2020 noted:

‘The 2021 proposed health budget is 4.18% of the total Federal budget an increase compared to 3.83% in the revised 2020 budget. However, this is still significantly below the 15% recommended in the National Health Act, 2014 and the 2001 Abuja Declaration.

‘…The trend of allocation to health budget as a proportion of the total Federal budget has been downward…For example, the allocation to health dropped from 5.95% of total budget size in 2012 to 4.18% in 2021. The enactment of the National Health Act in 2014 and introduction of the Basic Health Care Provision Fund in 2018, did not improve allocation to health, as a proportion of the total Federal budget. Indeed, allocation as percentage of Federal budget has dropped, with the lowest in 2020 at 3.83%.’ ^{[footnote 25]}

2.3 Number of facilities and personnel, including specialists

2.3.1 The Nigerian Federal Ministry of Health website holds a Nigeria Health Facility Registry (HFR), an electronic information system developed in 2017, which provides an up to date^{[footnote 26]}, state by state list of of hospitals and clinics in the country.

2.3.2 The HFR stated that there are 40,127 operational hospitals and clinics in Nigeria^{[footnote 27]}.

2.3.3 The HFR stated that the overall percentage of hospitals by level care as 0.4% tertiary, 14.3% secondary and 85.3% primary, with 26.8% of hospitals and clinics owned privately and 72.3% public^{[footnote 28]}.

2.3.4 An article by the International Centre for Investigative Reporting (ICIR), which describes itself as ‘an independent, nonprofit news agency’ of March 2020 noted that ‘Nigeria [has] 0.9 hospital beds per 1,000 people [which is] less than the global average of 2.3 while its Intensive Care Unit, ICU, beds for emergencies is estimated at 0.07 per 100,000 people.’^{[footnote 29]}

2.3.5 An Aljazeera article from April 2019 noted that ‘there is one doctor per 5,000 people in Nigeria, according to… the health minister, compared with the World Health Organization (WHO) recommendation of one per 600 people. There are 72,000 doctors registered with the Medical and Dental Council of Nigeria (MDCN); over half practise outside the country.’ ^{[footnote 30]}

2.3.6 A news and press release by WHO in August 2019 announced:

‘The Department of Health Planning, Research and Statistics of the Federal Ministry of Health (FMoH) in collaboration with The World Health Organization(WHO) has successfully updated and validated Nigeria’s health workforce profile from 2012 to 2018 with funding from the Government of Canada through Global Affairs Canada (GAC) under the “Enhancing the Ability of Frontline Health Workers to Improve Health in Nigeria” project.

‘In his remarks, the Permanent Secretary FMoH Alhaji Abdullahi Mashi represented by Dr .Evelyn Ngige stated “This document will not only better our understanding of our health workforce’s stock, characteristics and performance, it will also further help to generate insights into gaps and possibilities for health workforce strengthening”.

‘She reiterated, “The document will assist policy and decision makers at all levels to develop appropriate strategies to ensure that the correct numbers of professionals are trained, equitably distributed and retained towards achieving Universal Health Coverage.”

‘Validating the Nigeria Health Workforce Profile 2018 provides the national health workforce information needed for planning and it is a crucial milestone in the health sector considering that the last country profile was developed and published in 2012.’^{[footnote 31]}

2.3.7 A MedCOI response from June 2019 stated: ‘Diagnostic imaging by means of X-ray, CT scan, USS and MRI and the other investigations can be carried out in most secondary and tertiary centres in Nigeria.’ ^{[footnote 32]}

2.3.8 A MedCOI response from August 2019 stated: ‘There are no clinical geneticist[s] in Nigeria, but there are persons trained in genetic counselling in many secondary and tertiary institutions.’^{[footnote 33]}

2.3.9 A MedCOI response from December 2020 noted: ‘Medical devices orthopaedics: wheeled walker (“rollator”) can be purchased from private suppliers such as Americare Medical Distributors Ltd, Plot 269 M. Buhari way, CBD, Abuja.’^{[footnote 34]}

2.3.10 MedCOI stated the availability of the following:

‘Anaesthesiology, craniofacial surgery, dentistry, dental surgery, ENT (ear, nose and throat) specialist, occupational therapy, plastic surgery, pulmonology and CPAP (continuous positive airway pressure) therapy, dermatology, dietitians, endocrinology, gastroenterologist, hepatologist, infectionologist, internist, ophthalmology , orthopaedic surgery, paediatric neurology, rheumatologist, speech therapy and urology^{[footnote 35] [footnote 36] [footnote 37] [footnote 38] [footnote 39] [footnote 40] [footnote 41] [footnote 42] [footnote 43] [footnote 44] [footnote 45] [footnote 46] [footnote 47] [footnote 48] [footnote 49] [footnote 50]}’.

2.3.11 In a March 2020 press release by the Ministry of Health at the launch of the Health Workforce Profile and National Registry it was noted that not all Nigerian States had commenced their workforce registries^{[footnote 51]} , the release stated: ‘… the registry is a single and authoritative source of authenticated and validated health workforce information in Nigeria which provides up-to-date information on all health workers under the employment of National and Sub- National entities in both public and private sectors.’^{[footnote 52]}

2.3.12 An article in Leadership, a Nigerian online newspaper, from May 2020, also referring to the the Nigeria Health Workforce Profile 2018, noted:

‘The profile revealed that Nigeria has a ratio of one doctor to 2,753 members of the population whereas WHO recommends one doctor to 600 members of the population.

‘It also shows that the number of medical doctors registered with the Medical and Dental Council of Nigeria (MDCN) is 74,543 which equates to 36.3 medical doctors per 100,000 population; a doctor to population ratio of 1: 2753.

‘The data shows a variation in the distribution of medical doctors by state of practice from the reported 2012 density, as the Federal Capital Territory (FCT), in 2012, had the highest density of 82 medical doctors per 100,000 population, whereas that of Katsina [a state in northern Nigeria] reduced from 2.5 per 100,000 population in 2012 to 2.0 per 100,000 population, and Zamfara increased marginally from 2.5 per 100,000 population to 2.7 per 100,000 population.

‘… According to the new profile, there are 180,709 registered nurses. This equates to 88.1 nurses per 100,000 members of the population (nurse to population ratio of 1: 1,135). Registered midwives are 120,870 which equates to 58.9 midwives per 100,000 members of the population (midwife to population ratio of 1:1,697).

‘The data shows a reduction in the density of midwives by 1.7 per cent from the 2012 density of 59.9 per 100,000 population to 58.9 per 100,000 population in 2018.

‘24,668 pharmacists were registered with the Pharmacists Council of Nigeria (PCN) in 2018, and this equates to 12 pharmacists per 100,000 members of the population (pharmacist to population ratio of 1:8,317). Also, the profile captured 5,793 registered pharmacy technicians, which is 2.8 pharmacy technicians per 100,000 population (pharmacy technician to population ratio of 1:35,417).’ ^{[footnote 53]}

2.3.13 A Journal of Public Health April 2021 paper about staffing needs in the 20 local governments of Bauchi State noted:

‘In Nigeria, adoption of the primary healthcare approach led to the establishment of numerous primary healthcare facilities, and training of new cadres of community health officers (CHOs), community health extension workers (CHEWs) and junior community health extension workers (JCHEWs). These new groups complemented the work of nurses and midwives.

‘…Findings show a total of 128 existing nurses/midwives, a calculated requirement of 402 and a shortage of 274 nurses/midwives. Existing CHOs/CHEWs were 735, a calculated requirement was 948 and a shortage of 213 CHOs/CHEWs. The JCHEWs were 477, a calculated requirement of 481, with a shortage of four JCHEWs.

‘Results from this study highlight the unequal distribution of health workers; the abundance of some frontline workers in some communities and dire need of others. We emphasize the need to strengthen health workforce planning to deliver essential primary healthcare services, particularly in rural and remote communities with high levels of vulnerability to disease.’ ^{[footnote 54]}

2.3.14 Ola Uduku, Taibat Lawanson, Oghenetega Ogodo in an article, ‘Lagos – City scoping study’, published by African Cities Research consortium stated: ‘While private hospitals provide at least 70% of the healthcare in the country, there are also federal, state, local government and community-funded health institutions… Most residents, especially those living in informal communities, rely on patent medicine vendors and traditional medicine.’^{[footnote 55]}

2.3.15 The DFAT 2020 country information report stated:

‘The national policy on mental health services delivery was initially formulated in 1991 and last updated in 2013. There are eight federal neuropsychiatric hospitals in Nigeria (totalling around 4,000 beds), as well as three state-run hospitals in Port Harcourt, Ondo and Anambra. The WHO last estimated (in 2006) that, for every 100,000 persons, Nigeria had around 0.4 mental health beds, 4 psychiatric nurses, 0.09 psychiatrists and 0.02 psychologists and social workers. These ratios are unlikely to have significantly improved, with many Nigerian-trained health professionals migrating to western countries, particularly the UK and Canada.’^{[footnote 56]}

2.3.16 The British Embassy in Abuja has produced a list of doctors/medical facilities in Nigeria aimed at British nationals visiting Nigeria.

2.3.17 The Federal Ministry of Health website listed public facilities including Federal Teaching Hospitals, Federal Medical Centres, and Federal Specialty Hospitals.

2.3.18 The US Embassy in Nigeria produced information for US nationals on Medical Assistance in the country which included details of facilities in different states.

2.4 Paediatric healthcare

2.4.1 A MedCOI response from June 2020 stated:

‘There are paediatricians, paediatric haematologists and dietitians in most tertiary centres including: University of Abuja Teaching Hospital, Abuja, Lagos University Teaching Hospital, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria. The mentioned investigations, feeding supplements for malnourished children and tube feeding/dietary supplements are available at most secondary and tertiary centres.’^{[footnote 57]}

2.4.2 A MedCOI response from June 2019 stated: ‘Paediatric heart surgeries are usually done in collaboration with other paediatric surgeons from other centres.’^{[footnote 58]}

2.4.3 A MedCOI contact in a response from September 2020

‘…[T]he NHIS covers the general treatment costs for all children, including those with developmental disabilities… According to The Children Under Five Social Health Insurance Programme (CUFSHIP),… all Nigerian children under the age of 5 can receive free medical care for diseases connected to the major causes of death. Consequently, if children are suffering from malaria, diarrhoea, respiratory tract infection, pneumonia, measles, skin infections, domestic accidents or typhoid, they are entitled to get medical services free of charge; immunization and hospital care expenses are also free and included under the CUFSHIP. However, special treatments like speech therapy, child psychologist assessment and occupational therapy are outside the scope of NHIS benefit package, hence such treatments must be paid by the patient.’ ^{[footnote 59]}

2.4.4 The same MedCOI contact who as of September 2020 confirmed that information concerning health care provision for children contained in the MedCOI CFS 2017 (pages 129 to 131) was up to date. The report stated:

‘…According to the CFS, “[p]arents who have enrolled their children in the National Health Insurance Scheme can access the limited funds available. The scheme covers paediatric care”. Hence, under the NHIS what is applicable to any child also applies to children with developmental disorders, i.e. treatments for common pediatric [sic] illnesses that are covered for a child without developmental disorder, is also covered for a child with a developmental condition. Special services related to disabilities are not waived for children with developmental disabilities, but in some cases these treatments can be accessed free of charge within government facilities (for example, in the Modupe Cole memorial center in Lagos). In private facilities, such disability-related medical services must be paid by the patient.’ ^{[footnote 60]}

2.4.5 A MedCOI response from September 2020 gave the following information in two tables with regard the cost of paediatric treatment in Nigerian Naira (see section Costs and currency for note on prices cited). The first table provides information on the healthcare professional who provides the treatment, the cost of public outpatient and inpatient treatment as well as the costs of private outpatient and inpatient treatment and whether that treatment cost is covered by NHIS or not.

	Public outpatient treatment price in NGN	Public inpatient treatment price in NGN	Private outpatient treatment price in NGN	Private inpatient treatment price in NGN	Reimbursement/special program/free/comments
Pediatric psychiatrist	1,000/first consultation 500/other consultations	Depends on the case complexity and duration of the admission*	25,000/consultation	Depends on the case complexity and duration of the admission*	Covered by the NHIS
Pediatrician	1,000/first consultation 500/other consultations	Depends on the case complexity and duration of the admission*	25,000/consultation	Depends on the case complexity and duration of the admission*	Covered by the NHIS
Child psychologist	1,000/first consultation 500/other consultations	Depends on the case complexity and duration of the admission*	25,000/consultation	Depends on the case complexity and duration of the admission*	Not covered by the NHIS
Speech therapist	1,000/first consultation 500/other consultations		5,000/hour		Not covered by the NHIS
Occupational therapist	1,000/first consultation 500/other consultations		5,000/hour		Not covered by the NHIS

‘*The inpatient treatments by a pediatric psychiatrist and by a pediatrician for a child with a developmental disorder are covered by the NHIS. NHIS enrollees are entitled to 21 cumulative hospitalization days in standard wards, meals not included. The cost for the first 15 days shall be borne by the Primary Healthcare Facilities while the remaining 6 days are paid by the Health Maintenance Organisation (HMO). If a NHIS patient needs more than 21 days of hospitalization, the HMO will have to negotiate with the patient and the hospital on what percentage they will be able to pay. However, in most instances, the patient will have to bear the total costs of inpatient treatments after these 21 days’^{[footnote 61]}

The second table below provides information on the type of treatment or care available, the cost of public outpatient and inpatient treatment as well as the costs of private outpatient and inpatient treatment and whether that treatment cost is covered by NHIS or not.

	Public outpatient treatment price in NGN	Private outpatient treatment price in NGN	Reimbursement/special program/free/comments
Pediatric care such as special schooling	Free in facilities fully owned by the government (such as the Modupe Cole memorial school)	665,500 per term	Not covered by the NHIS
Pediatric care, such as day care	Free in facilities fully owned by the government (such as the Modupe Cole memorial school)	One-hourly session: 37,500/month (150,000 per term) Two-hourly session: 75,000/month (300,000 per term	Not covered by the NHIS
Laboratory research of full blood count; e.g. Hb, WBC & plateles	1,000	4,000	Covered by the NHIS

^{[footnote 62]}

2.4.6 A MedCOI response from October 2020^{[footnote 63]} gave the following costs for treatment by a range of paediatric specialists. The table provides information on the healthcare professional who provides treatment, such as cardiologist / physical therapist, the cost in Nigerian Naira (see section Costs and currency for note on prices cited) of public outpatient and inpatient treatment as well as the costs of private outpatient and inpatient treatment and whether that treatment cost can be either reimbursed, supplied via a special program or is free.

	Public outpatient treatment price in NGN	Public inpatient treatment price in NGN	Private outpatient treatment price in NGN	Private inpatient treatment price in NGN	Reimbursement/special program/free/comments
Specialist
Pediatric neurologist	1,000/first consultation 500/other consultations	Depends on the case complexity and duration of the admission	10,000/consultation	Depends on the case complexity and duration of the admission	Covered by NHIS
Pediatric physical therapist	1,000/first consultation 500/other consultations	Depends on the case complexity and duration of the admission	3,000/ consultation	Depends on the case complexity and duration of the admission	Covered by NHIS
Pediatric pulmonologist	1,000/first consultation 500/other consultations	Depends on the case complexity and duration of the admission	10,000/consultation	Depends on the case complexity and duration of the admission	Covered by NHIS
Pediatrician	1,000/first consultation 500/other consultations	Depends on the case complexity and duration of the admission	10,000/consultation	Depends on the case complexity and duration of the admission	Covered by NHIS

2.5 Pharmaceutical sector

2.5.1 The MedCOI country contact in the CFS of 2017 noted that people purchase drugs from both public and private medicine stores. In rural areas, ‘patent medicine stores’, which are usually unregulated/ unsupervised, are the most frequent kind of private drugs store^{[footnote 64]}. The same MedCOI source noted that the drugs supply system follows the federal structure of the country. The Federal Government stocks drugs and pharmaceutical products in the Central Medical Store (CMS) in Lagos. From the CMS, drugs are transported to different states. States also have their State Medical Stores, where medical consumables are stored and transported to local government stores. From the local government stores, drugs are taken to the health facilities^{[footnote 65]}.

2.5.2 According to the European Journal of Pharmaceutical and Medical Research (EJPMR), the current system of drugs’ distribution in Nigeria is chaotic. ‘The most notable fallout of the chaotic and unorganized drug distribution system is the unrestricted circulation of fake, substandard, and adulterated pharmaceutical products.’^{[footnote 66]} The EJPMR report also noted that figures from different sources show that between 15% to 75% of total drugs circulating in the country are fake^{[footnote 67]}. In addition, the EJPMR document noted that poor coordination of medicines procurement and supply to public facilities leads to a shortage of medicines, which are very common in governmental hospitals particularly in primary healthcare facilities^{[footnote 68]}.

2.5.3 The Nigeria Essential Medicine list is available on the Nigerian Federal Ministry of Health website. The list, however, does not indicate whether the drugs identified are currently available in the country.

2.5.4 A 2019-published Intechopen, an online academic publisher, paper noted:

‘The high cost of accessing government specialist hospitals as well as teaching hospitals and the bureaucratic structure of general hospitals has increased the demand for private health provision, which predominantly caters for the middle-class cadre. Because of the availability of genuine drugs and the services rendered by private practitioners, the costs are generally high and are, thus, not easily accessible to the masses. Although the licensed pharmacist on the other hand sells genuine drugs, there are instances where some have engaged in sharp practices by mixing genuine and fake drugs or sometimes.’^{[footnote 69]}

2.5.5 A MedCOI response from July 2020 gave the following general information from March 2018 and provided by a local doctor about the procedure of parallel import with National Agency for Food, Drug Administration and Control (NAFDAC) pre-authorization:

‘Parallel import is a legal special procedure that allows pharmacists to import drugs who [sic] are not registered with NAFDAC but are required for special cases.

‘Explanation how this procedure works for the pharmacists: ‘Summary of relevant guidelines :

• (A) ‘Applicant shall purchase Registration Form per product
• (B) ‘An application letter addressed to the Director (R&R) for permit to import samples of drug products shall be made by the Local Agent holding the Power of Attorney.
• (C) ‘Documentation accompanying the application shall be:
  • 1) ‘Power of Attorney or Contract Manufacturing Agreement.
  • 2) ‘Manufacturing Licence / Certificate (for India and China only) . * Indicate the name and address of manufacturer and products to be registered.
  • 3) ‘Certificate of Pharmaceutical Products (COPP – WHO FORMAT)
  • 4) ‘Current Good Manufacturing Practice (GMP) Certificate of the manufacturing facility.
  • 5) ‘Certificate of Brand Name with the trademark Registry in the Ministry of Commerce in Nigeria/Evidence of Trademark approval from Federal Ministry of Commerce & Tourism Abuja.
  • 6) ‘Current Annual License to Practice for the Superintendent Pharmacists issued by the Pharmacists Council of Nigeria.
  • 7) ‘Current Certificate of Registration Retention of Premise issued by the Pharmacists Council of Nigeria.
• (D) All documents must be found satisfactory before any payment is made. If the above documentation is satisfactory, Permit to Import samples shall be issued upon payment of relevant fees.’^{[footnote 70]}

2.5.6 A December 2020 (Nigerian) Independent news article noted that ‘Lack of access to quality affordable medicines has contributed to illegal trade in substandard and falsified medicines in Nigeria.Prof. Mojisola Adeyeye, the Director-General, National Agency for Food, Drug Administration and Control (NAFDAC), [stated].’^{[footnote 71]}

The US Overseas Security Advisory Council (OSAC) Nigeria 2020 Crime and Safety report – Abuja, published in April 2020, and aimed at US travellers stated: ‘The availability of dependable and safe over-the-counter and prescription medications is a concern. Counterfeit medical products, including medications, are common.’^{[footnote 72]} The OSAC 2020 report for Lagos observed: ‘Many medicines are unavailable, including medications for diabetes and hypertension… [C]ounterfeit pharmaceuticals are a common problem and may be difficult to distinguish from genuine medication.’^{[footnote 73]}

2.6 Availability and accessibility to medical treatment and drugs

2.6.1 The MedCOI country fact sheet of 2017 (CFS 2017) noted that the EML [Essential Medicines List] is the national package that all stakeholders (medicine sellers, pharmacists and physicians) operate with. However, ‘access to drugs depends on many factors among which are availability of medicine stores in the areas concerned and the financial capacity to purchase the medicine.’ ^{[footnote 74]}

2.6.2 The MedCOI country fact sheet of 2017 noted: ‘Prescribing by generic name has been identified as a way of reducing health care costs’^{[footnote 75]} and according to the MedCOI country contact in the CFS 2017 patients in Nigeria have access to generic drugs, which are cheaper [than a marketed brand] and therefore more affordable to the majority of people^{[footnote 76]}.

2.6.3 Medic West Africa, in their 2019 Healthcare – Nigeria: Market insights report stated: ‘Although the healthcare system in Nigeria has been evolving steadily since the country’s independence in 1960, over 90% of the Nigerian population is living without health insurance coverage. A number of healthcare reforms have been implemented, aiming to address the country’s public health challenges. This includes:

• ‘National Health Insurance Scheme (NHIS),
• ‘National Immunisation Coverage Scheme (NICS),
• ‘Midwives Service Scheme (MSS)
• ‘Nigerian Pay for Performance scheme (P4P).

‘The NHIS, launched in 2005, is a combination of both compulsory and voluntary contributory health insurance schemes targeted at formal sector workers as well as informal sector workers. It aims to ensure access to quality health care services, provide financial risk protection, reduce the rising cost of healthcare services and ensure efficiency in healthcare.

2.6.4 A MedCOI response from July 2020 stated:

‘In Nigeria, over 60% of the population still lack access to medicines in general, and the proportion of people with access to essential medicines required for the treatment of chronic diseases [such as HIV and malaria^{[footnote 77]}] is estimated at 40%… The accessibility to drugs is much better in urban areas, with rural areas having few or even no medicine stores. Poor coordination of medicines procurement and supply to public facilities has led to shortages of medicines, and there are issues related to circulation of fake or adulterated pharmaceutical products… According to [a] MedCOI contact…, the situation has improved in terms of fake drugs, as a result of measures taken by NAFDAC (Nigeria’s Agency for Food and Drug Administration and Control) such as the use of mobile and radio frequency identification systems… Nevertheless, last year alone [2019], NAFDAC seized counterfeit drugs worth more than NGN 12 billion [£21,488,737^{[footnote 78]}] and destroyed more than NGN 2.3 billion [£4,119,183.30^{[footnote 79]}] of fake drugs…’^{[footnote 80]}

2.6.5 A paper on the ‘Impact of the COVID-19 Pandemic on Consumers’ Access to Essential Medicines in Nigeria’ by Emmanuel Awucha, Nwoke et al in the American journal of tropical medicine and hygiene, and published on line 18 August 2020, examined the impact on the ease of access to essential medicines by end users caused by Covid-19. The paper found:

‘… A cross-sectional survey using electronic questionnaires was conducted on study participants across the 36 states of Nigeria… The results showed that 35.2% of the respondents managing chronic illnesses had difficulties accessing essential medicines during the COVID-19 lockdown, with 84.0% experiencing deteriorating chronic health conditions in the light of difficulty in accessing their medicines. The proportion of respondents who sourced for orthodox medicines before COVID-19 lockdown (98.4%) was significantly (P < 0.05) higher than that of those who sourced for the same during the lockdown (89.0%). Increase in cost of medicines was observed by 77.7% of participants, with 73.9% of respondents living with chronic illness affirming that their income was negatively affected by the pandemic. The COVID-19 pandemic had minimal impact on consumers’ ability to access essential medicines. However, important challenges identified were poor availability of means of transportation, reduced income, and high cost of medicines, as well as fear of contracting the virus.’^{[footnote 81]}

2.6.6 MedCOI in a response from September 2020 stated: ‘The NHIS is a body corporate aiming to improve the health at an affordable cost and provide social health insurance in Nigeria…’^{[footnote 82]}

2.6.7 The following table gives the cost per box in Nigerian Naira of a number of a range of medicines along with availability and whether covered by NHIS, the information used is from a MedCOI response dated October 2020 and provided by a local doctor / MedCOI contact. The table gives the generic and brand name for drugs listed, along with dosage, form (injection or tablet for example), number of units per container, price per box in Nigerian Naira (see section Costs and currency for note on prices cited), the place (pharmacy or hospital) the drug can be obtained and whether that drug cost can be either reimbursed, supplied via a special program or is free:

Generic name	Brand name	Dosage	Form	Number of units in the container	Price per box in NGN	Place (Pharmacy, hospital,…)	Reimbursement/special program/free
Pneumococcal vaccine	Synflorix®, Prevnar®	0.5ml/dose	pre-filled syringes	-	Given to patients free of charge through the Government National Immunization Program	Given to patients free of charge through the Government National Immunization Program	Given to patients free of charge through the Government National Immunization Program
Palivizumab	See below*	See below*	See below*	See below*	See below*	See below*	See below*
Tiotropium	See below*	See below*	See below*	See below*	See below*	See below*	See below*
Ipratropium	Atrovent® by GSK	250 mcg per 1ml of ampoule	nebulized	4 ampoules	4,950	Airen Pharmacy, 87A, Sapele Road, Benin	Covered by NHIS, but requires a 10% co-payment by the NHIS enrollee
Montelukast	Montelukast by Teva	10 mg	tablet	28	1,800	Airen Pharmacy, 87A, Sapele Road, Benin	Not covered by NHIS
Salbutamol	Ventolin®	2 mg	tablet	10	200	Teal Pharmacy, 22, Benin-Oluku-Lagos Expressway, Oluku, Benin	Covered by NHIS, but requires a 10% co-payment by the NHIS enrollee
Salbutamol	Ventolin®	100 mcg per dose	inhaler	1 inhaler tube with 200 doses	1,500	Teal Pharmacy, 22, Benin-Oluku-Lagos Expressway, Oluku, Benin	Covered by NHIS, but requires a 10% co-payment by the NHIS enrollee
Salmeterol + Fluticasone (proprionate)	Seretide® evohaler 25	25/125 mcg	inhaler	1 inhaler tube with 200 doses	2,000	Teal Pharmacy, 22, Benin-Oluku-Lagos Expressway, Oluku, Benin	Covered by NHIS, but requires a 10% co-payment by the NHIS enrollee
Salmeterol + Fluticasone (proprionate)	Seretide®	50/250 mcg	inhaler	1 inhaler tube with 60 doses	4,400	Teal Pharmacy, 22, Benin-Oluku-Lagos Expressway, Oluku, Benin	Covered by NHIS, but requires a 10% co-payment by the NHIS enrollee

‘* Palivizumab and tiotropium are available but with supply problems and the time for resupply is unknown, as these medications are not stocked routinely, but they can be imported to Nigeria and be made available to patients in pharmacies in Benin city.

-‘Tiotropium bromide (Spiriva®), supply for 1 month, will cost about NGN 100,000 [£178^{[footnote 83]}] (including importation costs), but the price can vary according to the naira-dollar/pounds rate… - Palivizumab (Synagis®), 50mg vial, will cost about NGN 296,700 [£529^{[footnote 84]}] (including importation costs), but the price can vary according to the naira-dollar/pounds rate…’^{[footnote 85]}

2.6.8 The same MedCOI report gave the following costs for diagnostic research and various pulmonological medical devices^{[footnote 86]}, the table gives a description of either the Diagnostic research or Medical devices pulmonology and alongside gives the price in Nigerian Naira (see section Costs and currency for note on prices cited) for both public treatment and private treatment cost and whether those costs can either be reimbursed, free or covered by NHIS (National Health Insurance Scheme):

	Public treatment price in NGN	Private treatment price in NGN	Reimbursement/special program/free/comments
Diagnostic research
Diagnostic research, in the form of lung function tests (i.e. spirometry)	5,000	15,000	Covered by NHIS
Diagnostic research: measuring blood oxygen/arterial blood gas (Astrup)	10,000	15,000	Not covered by NHIS
Medical devices pulmonology
Space (with mask) for inhaler with asthma medication	1,500	2,900	Not covered by NHIS
Oxygen therapy with device and nasal catheter	15,000/day	20,000/day	Covered by NHIS
Oxygen therapy with O2 pressure tank	15,000/day	20,000/day	Covered by NHIS

2.6.9 A MedCOI response from December 2020 noted:

‘There are general practitioners, internists, physical therapists, psychologists… in most tertiary centres including: Lagos State University Teaching Hospital, National Cardiothoracic Centre at University of Nigeria Teaching Hospital, Enugu, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria.’^{[footnote 87]}

2.6.10 An April 2021 paper by Osufafor et al on the Evaluation of availability, price, and affordability of cardiovascular, diabetes, and global medicines in Abuja, Nigeria stated:

‘The availability of cardiovascular, diabetes, and global medicines was below 80% across the different pharmaceutical sectors in Abuja and the medicines were unaffordable. Although the prices were generally exorbitant, private pharmacies offered the best options in terms of availability, pricing, and affordability of medicines. Therefore, the results of this study emphasize the pertinence of enforcing policies that facilitate the availability, pricing, and affordability of cardiovascular, diabetes, and global medicines.’^{[footnote 88]}

2.6.11 An article on Nairametrics, a ‘financial information and content creation company based in Lagos Nigeria’^{[footnote 89]} in June 2021 stated:

‘The cost of providing healthcare services in Nigeria has surged to unprecedented levels despite various strategic interventions by the central bank and the government to mitigate the effect of the covid-19 pandemic on the economy.

‘Data from the National Bureau of Statistics shows the composite consumer price index for health surged by 15.8% year-on-year in May 2021 having reached a ten year high in April 2021 at 15.9%. Urban health inflation also skyrocketed to 16.7%, while rural health inflation tallied behind at 15.1% for May 2021.

‘According to the latest GDP numbers, the economic size of Human Health Care and Social Services is about N487 billion [£859 million^{[footnote 90]}] making up about 0.7% of Nigeria’s GDP. The sector also recorded a GDP growth rate of about 4.65% in the first quarter of 2021, ahead of the broader composite growth rate of 0.51%.’^{[footnote 91]}

2.6.12 For further information regarding the costs of medicines in Nigeria see: Comprehensive list of medicine/drug prices in Nigeria - Nigerian Health Blog.

3. COVID-19

Section 3 updated: 30 November 2021

3.1.1 Up to date figures on COVID cases and deaths are available on the African Union dashboard.

3.1.2 The Nigeria Centre for Disease Control (NCDC) ‘provides comprehensive and updated information on the situation in Nigeria^{[footnote 92]}.

3.1.3 Our World in Data provides a range of information including numbers of vaccinations.

3.1.4 Human Rights Watch in its annual world report 2021 (HRW 2021 world report) on the human rights situation in 2020 observed: ‘The pandemic also brought into focus the country’s inadequate healthcare infrastructure, which created inequitable access to Covid-19 testing and treatment for the poor and vulnerable.’^{[footnote 93]}

3.1.5 The same HRW report stated: In Lagos State… ‘Barriers to access to testing and treatment and inadequate Covid-19 education campaigns targeting those living in poor communities have also denied them equal access to healthcare.’^{[footnote 94]}

3.1.6 A Premium Times article from April 2021 noted:

‘Nigeria commenced COVID-19 vaccination on March 5 after receiving 3.94 million doses of the Oxford-AstraZeneca vaccine through COVAX, a UN- backed effort that promises access to free vaccines for up to 20 per cent of participating countries’ population.

…Going by the current pace of vaccination, less than nine million people would have been vaccinated in Nigeria by the end of 2021. The figure is less than 40 per cent of Nigeria’s population that was targeted by the end of this year.’^{[footnote 95]}

3.1.7 United Nations Africa Renewal magazine, an information programme which provides information and analysis of economic and development challenges facing Africa to promote the work of the United Nations, Africa and the international community^{[footnote 96]}, stated in an April 2021 article:

‘In total, Nigeria is expecting 84 million doses of COVID-19 vaccines from AstraZeneca and Johnson & Johnson. That should cover about 20 per cent of the country’s 200 million population. The AstraZeneca vaccine requires two doses per person.

‘Nigeria’s Minister of Health, Dr. Osagie Ehanire, says that, from its arrangements with African Export-Import Bank (Afrexim Bank), about 80 to 85 million doses of vaccines are guaranteed for the country…

‘Vaccine hesitancy, however, is strong among Nigerians according to a poll by the National Primary Healthcare Development Agency, which showed that only 50% of the population would like to be vaccinated.

‘Despite government’s repeated assurances, many citizens still believe that the vaccines have long-term side effects.’^{[footnote 97]}

3.1.8 Reuters in an article from October 2021 reported that Nigeria had received approval from the World Bank of US$400 million (£294 million^{[footnote 98]}) for COVID- 19 vaccinations which would provide vaccines for 18% of the population or 40 million people, and that 51% of the population would be vaccinated within two years^{[footnote 99]}.

3.1.9 Nigeria Centre for Disease Control (NCDC) provides weekly updates of the COVID-19 outbreak in Nigeria.

3.1.10 For the latest travel advice and restrictions in place see Nigeria: Foreign Travel Advice – Coronavirus and Entry requirements.

Specific diseases and conditions

Section 4 updated: 30 November 2021

Official – sensitive: Start of section

4. The information on this page has been removed as it is restricted for internal Home Office use.

Official – sensitive: End of section

5. Cancer

Section 5 updated: 30 November 2021

5.1.1 The MedCOI country contact noted in the CFS 2017 that ‘Nigeria has a National Cancer Control Programme and Nuclear Medicine. Its role is to maintain a cancer register in the country and to develop cancer policies.’^{[footnote 100]}

5.1.2 According to the same MedCOI country contact in the CFS 2017, ‘availability of human resources cannot be considered as adequate as such, but it could be [more] efficiently utilised to provide needed care.’^{[footnote 101]}

5.1.3 The MedCOI contact in the CFS 2017 stated that ‘The geographical accessibility is another explanatory factor [that limit the access to healthcare for the patients suffering from cancer]… virtually all the health facilities that can handle cancers are in urban settings. Thus, distance is another major factor limiting access to healthcare.’^{[footnote 102]}

5.1.4 The MedCOI CFS 2017 noted that ‘most public and private hospitals do not stock cancer drugs. Patients have to buy them from private pharmacy stores.’^{[footnote 103]}

5.1.5 The same MedCOI CFS 2017 citing various sources stated: ‘The cost of chemotherapy and radiotherapy is high and in most cases not affordable to the majority of patients… ‘Patients that require surgery spend on the average N 15,000 [£27^{[footnote 104]}] on lumpectomy, while mastectomy cost on the minimum about N 50,000 [£89^{[footnote 105]}]. Twenty sessions can cost up to N 100,000 [£178^{[footnote 106]}] and above.

Even radiotherapy for cervical cancer costs about N 50,000 and above. Cost of these services are often higher in private cancer clinic.’ ^{[footnote 107]}

5.1.6 With regard cancer awareness MedCOI reported in 2017: ‘There are local NGOs that work in the cancer field, mainly in women cancer [sic]. They promote awareness about the existence of the conditions, health education, and empowerment of women especially in recognising the signs and symptoms to help detect early common cancers such as breast, cervix/uterine.’ ^{[footnote 108]}

5.1.7 A Nigerian Clinical Oncologist’s March 2019 lecture noted:

‘Most University Teaching Hospitals lack a basic pathology laboratory and rarely do molecular studies on cancer. There are less than 70 consultants radiation and clinical oncologists in Nigeria. This figure is equally reflected in the number of medical physicists, therapy radiographers and oncology nurses involved in cancer treatment in Nigeria. There are prolonged waiting times and delays due the limited number of health care workers and the large patient load. Critically lacking in Nigeria are linac engineers for proper maintenance of the machines and repair in order to reduce machine down time. Nigeria lacks health care specialists at secondary and primary levels with basic knowledge of cancer. Hence there are always delays in the diagnosis and referral stages.

‘…There is no availability of an up-to-date National Drug Formulary in Nigeria, hence no practical guide on drug administration and use. Most of the hospitals do not have enough drugs in their pharmacy stores, thereby worsening access to oncology drugs by patients. There are challenges of affordability, quality assurance and access to oncology drug as most pharmaceutical companies have their plants outside Nigeria.

‘…Most of the cancer patients pay out of pocket for their treatment… There is limited health insurance coverage for those not working in the government sector. Also, our National Health Insurance Scheme (NHIS) has limited coverage for oncology drugs for the treatment of cancer. There is a limited number of donor agencies involved in cancer screening, diagnosis and treatment in Nigeria.’ ^{[footnote 109]}

5.1.8 A MedCOI response from June 2020 stated: ‘There are urologists and oncologists in some tertiary centres…’^{[footnote 110]}

5.1.9 A MedCOI response also from June 2020 stated:

‘According to a MedCOI contact person… access to medications for cancer patients remains limited because of the cost, and only a few medications are covered on the NHIS (National Health Insurance Scheme) drug list. Moreover, some medications are not available and have to be imported, which increases the costs even further… A press article published in 2017 in the newspaper Vanguard stated that “most cancer drugs are available in Nigeria but none is manufactured in Nigeria, thereby making the costs prohibitive.”…

‘Since 2011 the Max Foundation, in partnership with Novartis Pharmaceuticals, has established the Glivec® International Patient Assistance Program (GIPAP) that operates in specific low and middle- income countries, including Nigeria… According to MedCOI contact person

… the Max Foundation is currently operating and financially supports the treatment of all types of cancer. The Lagos University Teaching Hospital and Obafemi Awolowo University Ile-ife are partners of the Max Foundation. In addition, organisations like Project Pink Blue in collaboration with the Union for International Cancer Control also support cancer treatment costs, but the Nigerian Cancer Society’s primarily focus is on building human and physical capacity for diagnosis, prevention and treatment of cancer.

‘Nigeria does not have a state programme that entirely or partially covers the cost of cancer treatment… 10% of diagnosed cancer cases have access to care and only 5% of patients have resources to access centres with more differentiated resources. There are also no facilities specialised in cancer treatment, with most cases being managed at tertiary institutions…’ ^{[footnote 111]}

5.1.10 The same MedCOI report added:

‘According to MedCOI contact person… the treatment costs are paid out of pocket if cancer patients have no health insurance. For patients covered by NHIS needing an anti-cancer medication that is included in the NHIS drug list, there is a 10% co-payment by the patient. However, if the anti-cancer medication is not included in the NHIS drug list, there is no general rule but usually a negotiation between the healthcare provider and HMOs [Health Maintenance Organisations] takes place to decide how much of the cost can be covered… Inpatient and outpatient consultation fees are supported by NHIS if the patient is covered…’^{[footnote 112]}

5.1.11 The MedCOI response of June 2020 also provided details of cancer medicines, including prostate cancer and cost of treatments in Nigerian Naira (See section Costs and currency for note on prices cited). The table gives the generic and brand name for drugs listed, along with dosage, form (injection or tablet for example), number of units per container, price per box in Nigerian Naira, the place (pharmacy or hospital) the drug can be obtained and whether that drug cost can be either reimbursed, supplied via a special program (NHIS) or is free:

Generic name	Brand name	Dosage	Form	Number of units in the container	Price per box in NGN	Place (Pharmacy, hospital,…)	Reimbursement/special program/free
Degarelix acetate	Firmagon®	120 mb	injection	2 vials	255,5000	Hmedix pharmacy and stores. Suite 06, Habiba Plaza, Osun Crescent, off IBB Way, Maitama, Abuja	Not included in the current NHIS Drug List, and not covered by NHIS. In these circumstances there are no specific rules, but there is usually a negotiation between the healthcare provider and HMO.
Abiraterone acetate	Atrezer®	250 mg	tablet	120	286,055	Alpha Pharmacy, Lagos	Not included in the current NHIS Drug List, and not covered by NHIS. In these circumstances there are no specific rules, but there is usually a negotiation between the healthcare provider and HMO.

	Public outpatient treatment price in NGN	Public inpatient treatment price in NGN	Private outpatient treatment price in NGN	Private inpatient treatment price in NGN	Reimbursement/special program/free/comments
Oncologist	1000/first consultation 500/other consultations	30,000/week	10,000 first consultation 7,000/other consultations	40,000/day	Costs of outpatient consultation in public facilities are covered by NHIS. Outpatient consultations are also covered in private hospitals registered with NHIS.
Urologist	1000/first consultation 500/other consultations	30,000/week	10,000 first consultation 7,000/other consultations	40,000/day	Costs of outpatient consultation in public facilities are covered by NHIS. Outpatient consultations are also covered in private hospitals registered with NHIS.

	Public outpatient/inpatient treatment price in NGN	Private outpatient/inpatient treatment price in NGN	Reimbursement/special program/free/comments
PSA test (prostate Specific Antigen)	4,500	6,000	Covered by NHIS.

^{[footnote 113]}

5.1.12 A MedCOI response from October 2020 stated: ‘There are oncologists, surgeons and general practitioners in most tertiary centres including: National Hospital, Abuja, Lagos University Teaching Hospital, University of Calabar Teaching Hospital, University of Port Harcourt Teaching Hospital, Ahmadu Bello University, Zaria, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria.’^{[footnote 114]}

5.1.13 A Journal of Public Health in Africa paper from December 2020 noted:

‘Oncology care in Nigeria is constrained, and has limited capacity. In total, Nigeria has 9 designated comprehensive cancer care centers, 8 public and 1 private… In 2018, it was estimated that there were 26 oncologists… [however] the resource-constrained health care system, lack of cancer awareness, poverty, shortage of well-trained health care personnel and inadequate research infrastructure all contribute to adverse cancer outcomes. Furthermore, for many patients, healthcare practitioners are a last resort in addressing health concerns, contributing to late-stage diagnosis and poor cancer outcomes.’ ^{[footnote 115]}

5.1.14 A paper published on the medical journal website British Medical Journal Open, authored by Sharma A, Alatise OI, O’Connell K, et al, on ‘Healthcare utilisation, cancer screening and potential barriers to accessing cancer care in rural South West Nigeria: a cross-sectional study’, citing various sources stated:

‘In Nigeria, cancer incidence and mortality are increasing, and women have a higher cancer incidence than men… The most common forms of cancer in Nigeria are breast and cervical, with these accounting for over 50% of cancer deaths… Regionally, the need to improve access to cancer services for early detection has been recognised, with a focus on these cancers. In 2018, Nigeria launched the “National Cancer Control Plan 2018–2022’” with the goal to make screening services available for all Nigerians and at least “greater than 50% screening of all eligible populations by 2022”… Despite this, the current state of cancer screening activities and barriers to care in this region [South West Nigeria] (esp. rural areas) is not well defined or documented. This gap limits our ability to define actionable steps towards improving access and achieving the established screening goal. National programmes for screening breast and cervical cancers are lacking. Typically, screening interactions occur at primary healthcare facilities or community health clinics—often for women when they are being seen during pregnancy or for other related health issues such as immunisations. Screening services for cervical and breast cancers have been implemented sporadically by both government and non-government organisations but predominantly in urban areas. The overwhelming majority of individuals in the region are symptomatic when they present with disease…’^{[footnote 116]}

5.1.15 The World Health Organisation (WHO) in a cancer country profile for Nigeria provided the following statistics for the most common cancer cases:^{[footnote 117]}

Most common cancer cases (2018)

Type of cancer	Incidence	Mortality
Breast	22.7%	16.4%
Cervix uteri	12.9%	14.8%
Colorectum	5.8%	5.8%
Leukaemia	2.3%	3.2%
Liver	4.4%	7.3%
Non-Hodgkin lymphoma	4.6%	5.3%
Ovary	2.4%	2.9%
Prostate	11.3%	8.3%
Stomach	2.1%	3.0%
Brain, CNS	2.1%	2.7%

5.1.16 See Annex A for list of available medications, including those used to treat different cancers.

5.2 Breast cancer

5.2.1 The MedCOI CFS 2017 provided some costs in Nigerian Naira on the most common breast cancer medicines and treatments . The table provides a list of Chemotherapy, Hormonotherapy and Immunotherapy medications, the number of units per container and the price in Nigerian Naira. See section Costs and currency for note on prices cited:

Chemotherapy

Medication	Number of units in the container	Price in NGN
Adriamycin	Vial 50 mg	4,500
Paclitaxel	Vial 100 mg	15,000
Paclitaxel	Vial 150 mg	27,000
5FU	Vial 500 mg	700
Cyclophosphamide	Vial 500 mg	700
Carboplatin	Vial 450 mg	45,000
Methotrexate	Vial 250 mg	500
Epirubicin	Vial 50 mg	12,000

Hormonotherapy

Medication	Number of units in the container	Price in NGN
Goserelin	Vial 3.6 mg	30,000
Goserelin	Vial 10.8 mg	80,000
Anastrozole	28 tablets of 1 mg/tablets	25,000
Tamoxifen	30 tablets of 20 mg/tablets	2,500

Immunotherapy

Medication	Number of units in the container	Price in NGN
Transtuzumab	Vial 440 mg	710,000
Transtuzumab	Vial 150 mg	280,000

^{[footnote 118]}

5.3 Prostate cancer

5.3.1 A MedCOI response from June 2020 stated:

‘Prostate cancer is the third leading cause of cancer death in Nigeria and the leading cause of cancer deaths among Nigerian men. 1 in 4 black men will be diagnosed with prostate cancer in their lifetime and a man of African descent is 70% more likely to develop prostate cancer than men of other ethnicities. Current data suggest that at least 15 Nigerian men die every day due to prostate cancer, resulting in about 5,806 deaths yearly with 13,078 new cases… Men on Blue is a health intervention project that does awareness initiatives and organises free prostate specific antigen (PSA) screenings… According to MedCOI contact person…, although this project has done PSA screenings on a number of men and guides patients with suspicious results to the appropriate treatment facilities, they do not provide direct financial support for the treatment of prostate cancer… According to MedCOI contact person…, there are two other NGOs supporting patients with prostate cancer:

• the Prostate Disease Research Foundation and the
• Thomas John Prostate Foundation…

‘According to their publicly available information, these foundations also mostly focus on awareness raising and providing free PSA tests.’ ^{[footnote 119]}

5.3.2 A MedCOI response from June 2020 stated:

‘PSA test (Prostate Specific Antigen) and diagnostic imaging by Doppler ultrasound/ sonography can be done in most secondary and tertiary centres. CT scan is available in a few of the tertiary centres and some private establishments and diagnostic centres such as Lifebridge Diagnostic Centre and Medicaid Centre both in Abuja. Diagnostic imaging by scintigraphy (nuclear medicine) is however only available in very few centres including University College Hospital, Ibadan, Lagos University Teaching Hospital and National Hospital Abuja, though the machines may sometimes be unavailable for use when they are faulty.’^{[footnote 120]}

6. Cardiovascular diseases

Section 6 updated: 30 November 2021

6.1.1 An Africa Check article from 2017 noted that there were ‘332 cardiologists currently registered in Nigeria, the ratio works out to 1 cardiologist for 581,000 people.’ ^{[footnote 121]}

A 2019 Nimed Health article listed 15 hospitals or units that performed heart surgery in Nigeria (apparently a mix of public and private)^{[footnote 122]}.

6.1.2 A MedCOI source indicated in September 2019 that ‘pacemaker placement and maintenance is only done in specialist centers.’^{[footnote 123]}

6.1.3 A MedCOI response from November 2019 stated: ‘Holter monitor/ ambulatory ECG device (cardiology) are available in some private medical centres with cardiologists.’^{[footnote 124]}

6.1.4 A MedCOI response of February 2019 noted: ‘Electrical cardioversion can be done in some tertiary hospitals and specialist centres.’^{[footnote 125]}

6.1.5 A MedCOI response from March 2020 stated: ‘Concerning the partial availability of treatment cardiac surgery: heart valve surgery: Heart valve surgery can be done at some private hospitals such as Alliance Hospital, Abuja and Nizamiye Hospital [Abuja]. Experts are brought in from abroad at various times to perform the surgery in collaboration with local doctors.’^{[footnote 126]}

6.1.6 A MedCOI response from May 2020 stated that heart valve cardiac surgery is partly available in the private facility Nizamiye Hospital in Abuja but that the EMBLEM MRI [implantable cardioverter ] defibrillator placement and maintenance are not available^{[footnote 127]}.

6.1.7 The same report also stated: ‘There are very few cardiac surgeons but arrangements are sometimes made by some hospitals to bring in such specialists periodically as visiting medical teams from abroad who come to work together with Nigerian surgeons in some establishments such as University College Hospital Ibadan (Public facility), Garki Hospital, Abuja (Public/Private facility) and Nzamiye Hospital Abuja (Private facility). ICD [Implantable cardioverter-defibrillator] placement and vascular surgery are also being done at these institutions.’ ^{[footnote 128]}.

6.1.8 A MedCOI response from June 2020 stated:

‘There are cardiologists and physical therapists in most tertiary institutions including: National Hospital, Abuja, National Cardiothoracic Centre at University of Nigeria Teaching Hospital, Enugu, Ahmadu Bello University, Zaria, University College hospital, Ibadan, and University of Ilorin Teaching Hospital, Ilorin, with a few of them in private practice around the country such as Reddington Hospital Lagos and First Cardiology Consultants Hospital 20A, Thompson Avenue, Ikoyi, Lagos. ECG and diagnostic imaging by means of ultrasound of the heart (= echocardiography) can be done in these centres.

‘There are cardiac surgeons and vascular surgery in very few centres. Placement of ICD (Implantable Cardioverter Defibrillator) by Cardiologist can be carried out at National Cardiothoracic Centre at University of Nigeria Teaching Hospital, Enugu; Foxglove Multispecialist Hospital Abuja and Nizamiye Hospital, Sector S. Cadastral zone, Life Camp, Abuja.’^{[footnote 129]}

6.1.9 Information obtained from the same MedCOI response (based on assessments by local MedCOI contacts) indicated the availability of in and outpatient treatment by cardiologists from public facilities; the placement of ICD’s [implanted cardioverter defibrillator] and diagnostic imaging via electro cardio gram^{[footnote 130]}.

6.1.10 The same MedCOI response confirmed that an ‘ICD (implanted cardioverter defibrillator)…specifically model: Medtronic Evera MRI S DR… can be imported and made available in Nigeria. There are Medtronic representatives in Nigeria who claim they can import it and cardiologists are available that can implant and monitor at Nizamiye Hospital and Foxglove Multispecialist Hospital Abuja.’^{[footnote 131]}

6.1.11 A MedCOI response from June 2020 stated: ‘Vascular surgeons are few in Nigeria but are available at some tertiary centres.’^{[footnote 132]}

6.1.12 A Nigerian Journal of Cardiology paper from June 2020 noted:

‘…treatments once considered advanced now becoming the standard of care with the establishment of emergency medical systems, coronary care units, and widespread use of new diagnostic and therapeutic technologies such as echocardiography, cardiac catheterization, percutaneous coronary intervention (PCI), bypass surgery, and implantation of pacemakers and defibrillators.

‘Advances in drug development had also yielded major benefits on both acute and chronic outcomes. The widespread use of an “old” drug, aspirin, had by this period been shown to reduce the risk of dying of acute or secondary coronary events. Low-cost pharmacologic treatment for hypertension and the development of highly effective cholesterol-lowering drugs such as statins had also begun to make forays into both primary and secondary prevention, by reducing CVD deaths.

‘Efforts to improve the acute management of myocardial infarction led to the application of lifesaving interventions that include the use of beta-adrenergic blocking agents (beta-blockers), PCI, thrombolytics, statins, and angiotensin- converting enzyme inhibitors.

‘…The economic state of Nigeria has definitely impacted on the pattern of CVDs [cardiovascular diseases] in Nigeria. Health is not cheap. Neither is cardiovascular health. The new developments in cardiovascular health – investigative modalities, medications, interventions available, and other treatment options – all come at a price: A costly price for most Nigerians.

‘…The economic situation of the Nigerian populace means many Nigerians are unable to access nor afford cardiovascular and other health-care services.

‘…Nongovernment organizations…some religious bodies, and many volunteer agencies such as the VOOM Foundation and Save a Heart Foundation have been of immense help in helping Nigerians access cardiovascular and other healthcare either free of charge or at highly subsidized rates.

‘There is increasing involvement of willing foreign partners and collaborators as well as Nigerian cardiovascular physicians and surgeons in diaspora in ameliorating the burden of CVDs through grants, periodic outreach missions, donation of both equipment, and consumables.’ ^{[footnote 133]}

6.1.13 A MedCOI country contact in a response from July 2020 stated:

‘… there are no national programmes run by the government that financially support people with cardiovascular diseases… However… the following NGOs provide financial support to patients with cardiovascular diseases..:

• Kanu Heart Foundation…
• Spiritan Self Awareness Initiative…
• Cardiostart International…
• Hospitals for Humanity (HfH)…’^{[footnote 134]}

6.1.14 A MedCOI country contact also stated in the same response:

‘…the NHIS provides coverage for drugs for cardiovascular problems as usual but with 10% co-payment by the NHIS enrollee’ and “if a patient with cardiovascular disease is registered with NHIS, [the] initial consultation and follow-up consultations are covered by [the] NHIS as usual.”…

‘However…, the insertion of a implanted cardioverter defibrillator (ICD) is not covered by the NHIS, which means that the patient will have to pay out of pocket for this procedure, including the cost of the ICD itself and also the fee for the surgical procedure. If the patient is then able to pay for this treatment, the ICD can be imported into the country, so the device will become available, and there is also medical expertise to implant the ICD into the patient.’ ^{[footnote 135]}

6.1.15 With regard the cost of cardiovascular medicines and treatment the same MedCOI report provided the following three tables with prices in Nigerian Naira (see section Costs and currency for note on prices cited):

The first table^{[footnote 136]}, gives the generic and brand name for drugs listed, along with dosage, form (injection or tablet for example), number of units per container, price per box in Nigerian Naira, the place (pharmacy or hospital) the drug can be obtained and whether that drug cost can be either reimbursed, supplied via a special program, or is free:

Generic name	Brand name	Dosage	Form	Number of units in the container	Price per box in NGN	Place (Pharmacy, hospital,…)	Reimbursement/special program/free
Verapamil	Teva	40 mg	tablet	14	350	Bakan Gizo Pharmacy, Abuja	Covered by the NHIS, but requires a 10% co-payment by the patient.
Verapamil	Teva	80 mg	tablet	14	520	Bakan Gizo Pharmacy, Abuja	Covered by the NHIS, but requires a 10% co-payment by the patient.

The second table^{[footnote 137]}, provides information on the healthcare professional who provides treatment, such as cardiologist / physical therapist, the cost of public outpatient and inpatient treatment as well as the costs of private outpatient and inpatient treatment and whether that treatment cost can be either reimbursed, supplied via a special program or is free.

	Public outpatient treatment price in NGN	Public inpatient treatment price in NGN	Private outpatient treatment price in NGN	Private inpatient treatment price in NGN	Reimbursement/special program/free/comments
Cardiologist	1,000/first visit 500/other visits	See below*	10,000/first visit 7,000/other visits	See below*	Fully covered by the NHIS in public facilities and in private facilities registered with NHIS.
Cardiac surgeon	1,000/first visit 500/other visits	See below*	10,000/first visit 7,000/other visits	See below*	Fully covered by the NHIS in public facilities and in private facilities registered with NHIS.
Physical therapist	500/first visit 250/other visits		2,500/first visit 2,00/second visit		Fully covered by the NHIS in public facilities and in private facilities registered with NHIS.

The third table^{[footnote 138]}, gives a description of available treatment – such as the placement of ICD (Implantable Cardioverter Defibrillator), the cost of public treatment and cost of private treatment in Nigerian Naira, and whether that treatment cost can be either reimbursed, supplied via a special program or is free:

	Public treatment price in NGN	Private treatment price in NGN	Reimbursement/special program/free/comments
Placement of ICD (Implantable Cardioverter Defibrillator)	1,500,000	3,100,000	Not covered by the NHIS
Follow up of ICD by a cardiologist	2,500	20,000	Not covered by the NHIS
Diagnostic imaging: ECG (electro cardio gram; cardiology)	4,000	5,000	Fully covered by the NHIS in public facilities and in private facilities registered with NHIS.
Diagnostic imaging by means of ultrasound of the heart (= echocardiography = echocardiogram = TTE)	5,000	30,000	Fully covered by the NHIS in public facilities and in private facilities registered with NHIS.

*’…the costs of inpatient treatment by a cardiologist or cardiac surgeon are difficult to ascertain or provide a specific amount as it depends on the individual patient, severity of the clinical condition and the overall duration of the hospital admission… Patients not enrolled with NHIS have to pay the costs associated with inpatient treatment by a specialist (cardiologist/cardiac surgeon) out of the pocket.’ ^{[footnote 139]}

6.1.16 See Annex A for list of available medications, including those used to treat cardiovascular diseases.

7. Dental treatment and conditions

Section 7 updated: 30 November 2021

7.1.1 An Africa Check article from 2017 noted:

‘…[fewer] than 5,000 registered dentists are serving Nigeria’s teeming population. …Nigeria’s health minister claimed more than 80% of the population do not have access to oral health care services.

…Even when a public health institution is functional, its services are not free. Fees differ from state to state and local government to local government.

…“People only see their dentists when something is terribly wrong. The economic [cost] of a mere toothache could be great,” the head of the Nigeria Dental Association… told Africa Check.’ ^{[footnote 140]}

7.1.2 A MedCOI response from August 2019 indicated that inpatient and outpatient treatment and surgery for dental problems was available at the time of research^{[footnote 141]}.

7.1.3 See Annex A for full list of medications including those used for dental treatment and conditions.

8. Ear, nose and throat conditions

Section 8 updated: 30 November 2021

8.1.1 A MedCOI response from January 2019 stated: ‘There are pulmonologists, paediatric pulmonologists and ENT specialists in most tertiary centres including: Lagos University Teaching Hospital, National Cardiothoracic Centre at University of Nigeria Teaching Hospital, Enugu, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin.’^{[footnote 142]}

9. Diabetes

Section 9 updated: 30 November 2021

9.1.1 The MedCOI country contact noted in the CFS 2017 that ‘There is no specific Institution designated to treat diabetes in Nigeria… available human resources and infrastructures are grossly insufficient for the country… [However] treatment is possible in public hospitals.’ ^{[footnote 143]}

9.1.2 The same MedCOI country contact noted:

‘There is no specific programme that gives patients access to diabetes care at a reduced cost. The International Diabetes Federation (IDF), in collaboration with specialists, provides free insulin and monitoring/treatment devices for children with type 1 diabetes. This aid is subject to availability and local logistic issues.

‘… treatment for diabetes is not accessible in all the regions of the country. Asides from big urban areas, the skills/expertise and structured multidisciplinary care needed for the care of this complex disease is hardly ever sufficiently available. Remote regions in the country may not have access to all the drugs. Several medications especially insulin (which requires storage in low temperatures) may not be available.’ ^{[footnote 144]}

9.1.3 A Daily Trust, a Nigerian newspaper, article from 2019 noted:

‘[A patient] who has suffered from diabetes for over 20 years, said diabetes management is almost beyond the reach of many Nigerians.

‘”Apart from drugs, you need a healthy lifestyle - nutritious food (with less carbohydrate), physical activities, etc. Many people with diabetes also have other conditions such as hypertension which must also be adequately managed. For me, I have to buy insulin (N2,500) [£4.56^{[footnote 145]}] twice a month in addition to oral drugs…”

‘…”It is very expensive to manage the disease as most of the medications are being imported. It is not affordable to an average Nigerian living with the condition. Affordability and availability of the medications are major issues that need to be looked into by authorities in easing the suffering of people living with diabetes,” [a professor] said.’ ^{[footnote 146]}

9.1.4 A Diabetes Africa article from 2020 quoted a Nigerian hospital consultant:

‘”I am one of fewer than 200 endocrinologists in Nigeria. Using the rather conservative prevalence figure above, that’s one endocrinologist for 60,000 Nigerians living with diabetes.”

‘…there is no systematic screening and recording of people with diabetes.

‘…other healthcare professionals can provide diabetes education and care, provided they have received adequate training, but many challenges remain in addition to the lack of specialists: low public health spending, inadequate facilities, maldistribution of clinicians. Between scheduled check-ups, patients often still require medical advice and monitoring and this is almost impossible in rural areas.’ ^{[footnote 147]}

9.1.5 A MedCOI response from June 2020 stated with regard the availability of insulin:

‘The medications insulin ultra long acting degludec and acarbose are available but with supply issues with unknown duration. The time for resupply is unknown because the supply is determined by demand. Medications are in general not normally kept in stock unless pharmacists get regular prescriptions from doctors, and that’s the reason why stocking depends on demand. Nevertheless, insulin ultra long acting degludec and acarbose can be both sourced and made available to patients (and these have been stocked in the past).’ ^{[footnote 148]}

9.1.6 Ugwu, E., Young, E. & Nkpozi, M in a study published in July 2020 and aimed at evaluating diabetes care knowledge and practice among primary care physicians (PCPs) in Southeastern part of Nigeria stated:

‘Due to the perennial shortage of diabetes specialists, primary care physicians (PCPs) constitute the largest diabetes care manpower in Nigeria…

‘A total of 64 PCPs with mean duration of practice of 17.3 ± 11.6 years completed the study. 65.6% were in private practice and 50% attended to between 11 and 20 persons living with diabetes (PLWD) weekly. Majority (78.1%) had not participated in any diabetes training since graduation from medical school and 79.9% were not aware of any diabetes clinical practice guideline.

‘The PCPs had adequate knowledge of classical symptoms of diabetes. However, they had very poor knowledge of glycemic thresholds for diagnosis of diabetes…

‘We observed serious gaps in diabetes care practice such that only 18.8% of the respondents performed foot examination on newly diagnosed PLWD while 28.1 and 39.1% provided counseling on foot care and hypoglycemia respectively… Majority (57.8%) rated their confidence in prescribing insulin as “low” and only 23.4% had ever prescribed outpatient insulin for type 2 diabetes in their practice…’^{[footnote 149]}

9.1.7 The same study concluded that: ‘Diabetes care knowledge and practice were poor among PCPs in Southeast Nigeria. There is an urgent need to improve their capacity to provide diabetes care through periodic training.’^{[footnote 150]}

9.1.8 See Annex A for list of available medications including a range of insulin.

10. Epilepsy and neurological conditions

Section 10 updated: 30 November 2021

10.1.1 Human resources and infrastructures for the country’s needs are insufficient, according to the MedCOI country contact. The MedCOI country contact estimated the number of neurologists at 60 ^{[footnote 151]}.

10.1.2 MedCOI in an response from November 2019 indicates that antiepileptic and epilepsy drugs are available in public and private pharmacy facilities in Nigeria^{[footnote 152]}.

10.1.3 See Annex A for list of available medications used to treat neurological conditions.

11. Eye conditions and diseases

Section 11 updated: 30 November 2021

11.1.1 The Fondation L’Occitane website noted that in 2016 there were 16 paediatric ophthalmologists in Nigeria^{[footnote 153]}.

11.1.2 A PM News Nigeria article from 2019 noted:

‘A Consultant Ophthalmologist…called on government at all levels to establish Vision Care Centres in rural areas to bring sub-specialist care to the unreached areas.

‘…there is no presence of Ophthalmologists and Optometrists in rural areas, as the majority are skewed to urban centres.

‘Ophthalmologist population ratio is 1:350,000…’ ^{[footnote 154]}

11.1.3 A 2020 Punch article noted that ‘The Chief Executive Officer, Eleta Eye Institute, Ibadan…has lamented the shortage of ophthalmologists in Nigeria, saying it will take the 700 ophthalmologists in the country about 77 years to give Nigerians quality eye care.’ ^{[footnote 155]}

11.1.4 A MedCOI response from June 2020 stated ‘There are general practitioners, cardiologists and ophthalmologists who can perform intravitreal injections with medication in most tertiary centres including: University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, and in the National Hospital, Abuja.’ ^{[footnote 156]}

11.1.5 A 2019 article in the Nigerian journal for Ophthalmology by Monsudi KF, Ademola-Popoola DS, Ayodapo AO stated:

‘There are inadequate human resources for eye care in Africa compared to other parts of the world,… The few eye care service providers in Africa are maldistributed….They are more in the urban areas, leaving most of the rural population uncared. The experience is not different in Nigeria, as most of the human resources for eye care are mainly concentrated in the cities, the western and the oil-rich southern parts of the country… Family Physicians, who are doctors of first contact, have difficulty in referring patients who need specialist eye care services because of the challenge of dearth of eye specialist near their vicinity of practice. For the achievement of universal eye health coverage, emphasis needs to be on developing the human resources sector through effective planning.

‘Nigeria has approximately 700 ophthalmologists for about 188 million people.. However, WHO recommends one ophthalmologist for 50,000 people in developing countries… Of accredited medical schools in Nigeria, 27 are accredited to train resident doctors in ophthalmology. Each center intake for residency training varies and this is usually determined by government policy and the hospital management, which recruit based on vacancy and availability of human and material resources for training…

‘Over the years, Nigeria ophthalmologists and NPMCN [National Postgraduate Medical College of Nigeria] have tried to increase eye care service to Nigeria population. However, about 80% of the population in the rural area still find it difficult to assess this service because of financial constraint and lack of eye care professional in their domain…’^{[footnote 157]}

11.1.6 See Annex A for list of available medications and for eye conditions in particular.

12. Gastroenterology

Section 12 updated: 30 November 2021

12.1.1 An Africa Health Sciences 2016 paper noted that ‘in Nigeria there are just 60 registered gastroenterologists…’ ^{[footnote 158]}

12.1.2 A MedCOI response from March 2020 stated:

‘There are gastroenterologists… gastrointestinal surgeons, internists,… and haematologists in most tertiary centres including: Lagos University Teaching Hospital, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria.

‘Diagnostic imaging by means of a oesophago- gastro-duodenoscopy is available in some of the mentioned tertiary centres.

‘Fecal calprotectin; stool test for intestinal inflammation/ disease activity is not done in any of the hospitals.’^{[footnote 159]}

12.1.3 See Annex A for list of available medications, including those used to treat gastroenterological conditions.

13. Gynaecology

Section 13 updated:30 November 2021

13.1.1 The website of ‘The Society of Gynaecology and Obstetrics of Nigeria’ (SOGON) noted that it is the ‘umbrella professional organization of Gynaecologists and Obstetricians in Nigeria.’ ^{[footnote 160]}

13.1.2 A MedCOI response from July 2019 stated:

‘There are… gynaecologists… in most tertiary centres including: University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos State University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Wuse District Hospital, Abuja with a few of them in private practice around the country such as Reddington Hospital and St Nicholas Hospital in Lagos.’^{[footnote 161]}

13.1.3 A Nimed Health article from August 2020 noted that ‘in Nigeria a gynaecologist is also a specialist in obstetrics… they are therefore called Obstetrician and Gynaecologist (OB/GYN)… Nigeria has a total number of 968 Obstetricians and Gynaecologists of which 846 were male…122 female.’ ^{[footnote 162]}

13.1.4 See Annex A for list of available medications including those used to treat gynaecological conditions.

14. HIV/AIDS

Section 14 updated: 30 November 2021

14.1.1 Nigeria has a National AIDS and sexually transmitted infections (STIs) Control Programme (NASCP). The National Agency for the Control of AIDS (NACA) ^{[footnote 163]} has been mandated to support the NASCP^{[footnote 164]}. According to the MedCOI country contact in the CFS 2017, the programme activity includes both free screening and treatment. The programme also covers treatment of the disease, including the treatment of opportunistic infection^{[footnote 165]}.

14.1.2 The MedCOI country contact in the CFS 2017 noted that free HIV treatment may be available in all public facilities as well as in designated private facilities^{[footnote 166]}. The MedCOI contact also stated that there is no other eligibility criterion to have access to the services other than the clinical eligibility criteria and that free treatment is accessible to all people living with HIV/AIDS ^{[footnote 167]}.

14.1.3 A Nigeria Public Health website article from 2019 noted:

‘Since 2006, the Nigerian government has provided free antiretroviral treatment at designated facilities in the country. But this has not been enough to eliminate the high and sometimes inequitable economic burden of HIV/AIDS on households…The country continues to fall short of the recommended number of HIV testing and counselling sites compounded low levels of access to antiretroviral treatment…

‘There are more than 30 antiretrovial medications in six drug classes, each class of drug attacks HIV in a different way. Generally, drugs from two (or sometimes three) classes are combined to ensure a powerful attack on HIV… ‘…the Network of People Living with HIV/AIDS has called on governments to ensure that Antiretroviral Therapy (ART) is completely free, accessible and without user fee. However, despite these calls, [a] monthly fee to access these drugs continues unabated in several states.’^{[footnote 168]}

14.1.4 The same public health article estimated:

• HIV treatment costs US$18,300 per year (£13,714^{[footnote 169]})
• HIV and Hepatitis C combined treatment costs at least US$29,000 (£21,732^{[footnote 170]}) per 48 weeks
• HIV drugs are free to patients who register at HIV treatment centres which are located in all Nigerian states
• Non registered persons can purchase HIV drugs from pharmacies and hospitals.^{[footnote 171]}

14.1.5 The same Nigeria Public Health website provided a ‘Complete List of Free HIV Treatment Centers in Nigeria’. as well as an article listing the states with the highest HIV rates in Nigeria^{[footnote 172]}

14.1.6 Nigeria UNAIDS data pages noted:

• People living with HIV - 1,700,000
• People living with HIV who know their status - 1,600,000 (90%)
• People living with HIV who are on ART- 1,500,000 (86%)
• Coverage of adults and children receiving ART – 86%
• Number of adults and children receiving ART - 1 492 151^{[footnote 173]}

14.1.7 The Journal of Public Health and Epidemiology noted in a 2020 paper about healthcare and treatment in Nigeria that ‘…HIV [treatment is] mostly delivered through tertiary and secondary healthcare facilities around the country… there is a need to increase the number of specialised healthcare facilities and trained medical personnel around the country to deal with infectious disease.’ ^{[footnote 174]}

14.1.8 Avert ‘a UK-based, internationally focused charity, using digital communications to build health literacy on HIV and sexual health’ noted on their website which was updated in August 2020 with last full review in 2018: ‘Low levels of access to antiretroviral treatment remains an issue for people living with HIV, meaning that there are still many AIDS-related deaths in Nigeria…

‘Nigeria is a long way off meeting the global target of enrolling 90% of people diagnosed with HIV on antiretroviral treatment (ART). Just 33% of all people living with HIV were receiving treatment in 2017. Among children this is even lower, with just 26% on ART… Of the people on HIV treatment, only 24% had achieved viral suppression in 2016…

‘Poor treatment coverage and adherence means that the number of AIDS- related deaths in the country has remained high with 150,000 deaths in 2017…

‘Although Nigeria adopted a “test and treat” policy in 2015, which means that anyone with a positive diagnosis is eligible for treatment, this is far from a reality. Nevertheless, efforts have been made to scale-up treatment access, and 212,000 more people were enrolled on antiretroviral treatment between 2016 and March 2017…

‘Yet weaknesses in the health system exist and create a barrier to many people accessing or staying on treatment. Even when ART can be accessed, drug supplies are known to run out and cause stockouts… In an attempt to address this, the National Strategic Framework for the HIV response has made strengthening supply chains and improving logistics around treatment a priority…

‘The UNAIDS catch-up plan for Nigeria, also identifies removing “user-fees” as being a key next step in expanding treatment coverage… Although accessing the antiretroviral drugs themselves is free, often patients will be asked to pay for other services, for example running other tests. Studies have shown that these fees and high costs of travel to clinics can be a barrier to many people accessing care…

‘Nigeria aims to triple treatment coverage in the next three years, ensuring that 90% of the population living with HIV are on treatment by 2021… To do this they will also need to address stigma and discrimination around the virus, and have committed to work to foster an enabling environment for people living with HIV to come forwards…

‘Nigeria was also selected as a key focus country for the World Health Organization’s drug resistance strategy in 2017… Results from 2008, the most recent data available, showed that in some clinics levels of drug resistance mutations had reached 2.1% among new patients and 50% among those who had been exposed to ARVs before…’^{[footnote 175]}

14.1.9 A Premium Times article from March 2021 stated:

‘About 11.2 per cent of People Living With HIV (PLWHIV) in Nigeria still incur huge out-of-pocket costs for treatment, a new report has shown.

‘The report titled “Community-Led Monitoring (CLM) initiative on COVID-19 and HIV in Nigeria” shows that 212,800 PLWHIV in the country make significant out of pocket expenses to access treatment.

‘The report indicates that distance of treatment centres and out of pocket expenses are major barriers to HIV service accessibility.

‘“20.2 per cent of PLHIV do not have treatment centres close to where they live.”

‘Other barriers include side effects of HIV treatment, drug breaks, lack of confidentiality at site level, user fees for processing payments, stigmatization and discrimination amongst others.

‘Data for the report were collected between September and December 2020 by the Network of People Living with HIV/AIDS in Nigeria (NEPWHAN) with support from the National Agency for the Control of AIDS (NACA) and the UNAIDS.’ ^{[footnote 176]}

14.1.10 A MedCOI response from August 2020 noted that:

‘There are infectionologists, internists and HIV specialists in most tertiary centres and state HIV centres including: National Hospital, Abuja, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos State University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, and Wuse District Hospital, Abuja.

‘The laboratory tests including CD 4 count are done in most of these establishments and viral load and resistance test for antiretroviral drugs in a few of them as well as some private laboratories e.g. Synlab in Lagos and Abuja.’^{[footnote 177]}

14.1.11 A Nigeria Public Health website published an article in November 2020 listing the states with the highest HIV rates in Nigeria^{[footnote 178]}.

The same Public Health website also published an article from May 2021 and noted: ‘Antiretroviral drugs in Nigeria are free but HIV testing in most places is not free’^{[footnote 179]}

14.1.12 A Punch article from June 2021 noted:

‘The President Muhammadu Buhari… has said that the Federal Government, with the support of the United Nations, Global Fund and Civil Society Organisations, has enrolled almost 1.5 million Nigerians on life- saving HIV treatment.

‘He said this at a United Nations General Assembly High-Level Meeting on HIV/AIDS to review the progress on the commitment to end the deadly , response in countries.

‘…Buhari assured those in attendance that Nigeria had made good its commitment at the High-Level Meeting Side Event at the 72nd Session of the UNGA in September 2017, to commence placing 50,000 Nigerians living with HIV on treatment annually, using national resources.’ ^{[footnote 180]}

14.1.13 A Boyd, AT, Jahun, I, Dirlikov, E et al in a September 2021 research publication ‘Expanding access to HIV services during the COVID-19 pandemic—Nigeria’, 2020 stated:

‘To accelerate progress toward the UNAIDS 90-90-90 targets [Targets are that by 2020 - 90% of people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression^{[footnote 181]}], US Centers for Disease Control and Prevention Nigeria country office (CDC Nigeria) initiated an Antiretroviral Treatment (ART) Surge in 2019 to identify and link 340,000 people living with HIV/AIDS (PLHIV) to ART…..

‘During February–September 2020, the reported number of PLHIV [persons living with HIV] initiating ART per month increased from 11,407 to 25,560, with the proportion found in the community increasing from 59 to 75%. The percentage of newly-identified PLHIV initiating ART with a 3-month ART starter pack increased from 60 to 98%. The percentage of on-time ART refill pick-ups increased from 89 to 100%. The percentage of PLHIV established in care receiving at least 3-month MMD increased from 77 to 93%. Among PLHIV initiating ART, 6-month retention increased from 74 to 92%.’ ^{[footnote 182]}

14.1.14 MedCOI reported that the following antiretrovirals (ARV) drugs, used in the treatment of HIV/AIDS, are available in Nigeria:

Antiretrovirals:

• Atripla^{[footnote 183]}
• Abacavir^{[footnote 184]}
• Atazanavir^{[footnote 185]}
• Dolutegravir^{[footnote 186]}
• Descovy^{[footnote 187] [footnote 188]}
• Darunavir^{[footnote 189]}
• Efavirenz^{[footnote 190]}
• Elvitegravir^{[footnote 191]} (supply problems @ August 2020)
• Emtricitabine^{[footnote 192] [footnote 193]}
• Epzicom® Kivexa® (combination of abacavir and lamivudine) ^{[footnote 194]}
• Eviplera® (combination of emtricitabine / rilpivirine / tenofovir disoproxil) – available but with supply problems)^{[footnote 195]}
• Lamivudine^{[footnote 196]}
• Maraviroc^{[footnote 197]}
• Nevirapine^{[footnote 198]}
• Raltegravir^{[footnote 199]}
• Ritonavir^{[footnote 200]}
• Rilpivirine (available but with supply problems)^{[footnote 201]}
• Truvada® (combination of tenofovir disoproxil/ emtricitabine) ^{[footnote 202]}
• Triumeq® (combination of abacavir/dolutegravir/lamivudine)^{[footnote 203]}
• Tenofovir disoproxil^{[footnote 204]}

14.1.15 Genvoya^{[footnote 205]} and Tenofovir alafenamide^{[footnote 206]} are not available, and Biktarvy^{[footnote 207]} was not available as at October 2020.

14.1.16 As of January 2020, Raltegravir was experiencing supply problems but MedCOI reported in January 2020 that Raltegravir is available at Dozie and Dozie Pharmacy, a private facility in Abuja. Resupply in out of stock pharmacies takes approximately 3 weeks^{[footnote 208]}.

14.1.17 See Annex A for list of available medications including those used in the treatment of HIV/AIDS.

15. Liver disease

Section 15 updated: 30 November 2021

15.1.1 The Society for Gastroenterology and Hepatology In Nigeria website noted: ‘SOGHIN is a national association of medical professionals involved in the diagnosis, treatment and prevention of diseases of the Gastrointestinal Tract (GIT) and the Liver… SOGHIN members are present in all Federal teaching hospital[s], many Federal Medical centers, State teaching and general hospitals and private hospitals from every region of Nigeria… There are over 300 Members including specialists like Gastroenterologists, Hepatologists, Haematologists…’ ^{[footnote 209]}

15.1.2 A MedCOI response from August 2020 stated that outpatient and inpatient treatment by heptologists is available in Nigeria^{[footnote 210]}.

15.2 Cirrhosis

15.2.1 A MedCOI response answered questions related to complications of cirrhosis:

Questions

• a) ‘Is there the possibility to perform periodical paracentesis to reduce the volume of ascites? ‘if yes; is there the possibility to test the ascites liquid to diagnose for bacterial peritonitis (a frequent complication in case of ascites due to liver impairment)?
• b) ‘Are these therapeutic approaches possible for esophageal varices: variceal ligation (banding) and sclerotherapy ?
• c) ‘Is there the possibility to check blood level of ammonia ( to check for hepatic encephalopathy )?

Answers

• a) ‘Draining of ascites is yes. The fluid can for example also be analysed at the laboratories of Lagos State University hospital, Lagos University hospital, Havana specialist hospitals, Eko hospitals and other private and public hospitals in Lagos state.
• b) ‘Yes there is capacity to deal with esophageal varices using banding or sclerotherapy through endoscopy. This is available for example at Eko hospitals and Havana hospitals as mentioned above.
• c) ‘Yes there are laboratories that can do ammonia level; for example at; Me cure healthcare limited (Me Cure House, Apapa-Oshodi Express Way, Papa Ajao, Lagos) and Synlab laboratories (9 Egbeyemi Street, Ilupeju, Lagos).’^{[footnote 211]}

15.2.2 See Annex A for list of available medications including treatments for cirrhosis.

15.3 Hepatitis

15.3.1 A MedCOI response from February 2019 noted that: ‘[Hepatitis B Virus] HBV antibody [tests] in case of Hepatitis B can be done in most of these centres [secondary and tertiary centres], but DNA testing for Hepatitis B can only be done in very few private centres such as DNA Lab and Pathcare.’ ^{[footnote 212]}

15.3.2 The MedCOI response country contact in the CFS 2017 noted that

‘Nigeria does not have a specialized institution for the treatment of hepatitis, but there are specialized subunits in internal medicine departments of the tertiary healthcare centres … there is not a programme for a partial or total coverage of hepatitis treatment. Also, the country does not have a policy to improve access to healthcare and /or reduce the cost of treatment and/or medication… treatment is available geographically, as most tertiary healthcare centres across the country provide treatment for hepatitis.

However, this contact specifies that it is mainly possible in urban areas and not economically accessible.’ ^{[footnote 213]}

15.3.3 A Hepatitis Foundation blog article from 2020 noted:

‘[The] Clinton Health Access Initiative (CHAI) to date is leading in providing access to affordable treatment for Hepatitis C patients in Lafiya, Nasarawa state, through its partnership with the government. The program provides affordable HCV (Hepatitis C virus) RNA [ribonucleic acid tests] and generic DAAs [direct-acting antivirals]… CHAI through its access program has succeeded in negotiating costs of HCV diagnostics in some health centres across Nigeria, such as Lagos, Abuja, and Kwara, where patients can access affordable HCV RNA tests.

‘Similarly, Taraba State Government in partnership with Roche Products is providing a Pegasys [peginterferon alfa-2b] based HBV [Hepatitis B virus] treatment program for Tarabans. The Yakubu Gowon Centre in partnership with Taraba state government is also providing affordable diagnostics and treatment on HCV for patients at its treatment locations in Takum local council of Taraba state. The centre recently donated some doses of DAAs for patients.

‘Birth-dose HBV vaccination: Nigeria has a coverage rate of about 51% birth- dose HBV vaccination rate in the country… there are no HBV vaccination programs for at-risk populations such as Men who Have Sex With Men, health care workers, People Who Inject Drugs, Incarcerated Populations. There are no government-funded harm reduction projects for People Who Inject Drugs in Nigeria.

‘Over 80% of activities of civil society and patient groups in Nigeria are on- demand creation, awareness and testing and linkage to care for patients. In June 2019, Centre for Initiative and Development (CFID) and other civil society organizations in Nigeria received a donation of 120 doses of DAAs at the African Hepatitis Summit in Kampala, Uganda through the African Regional Board Member.’ ^{[footnote 214]}

15.3.4 See Annex A for list of available medications including treatments for hepatitis.

16. Kidney disease and failure

Section 16 updated: 30 November 2021

16.1.1 A MedCOI response from July 2019 stated:

‘There are haematologists… in most tertiary centres including: National Hospital, Abuja, Lagos University Teaching Hospital, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria with a few of them in private practice around the country such as Reddington Hospital and St Nicholas Hospital in Lagos.

‘Acute and chronic haemodialysis, peritoneal dialysis and surgical placement of shunt for hemodialysis are available in many of these centres. The investigations can be done in most hospitals. Kidney transplant has been carried out at Garki Hospital Abuja (Public/Private venture), St Nicholas Hospital in Lagos (Private) and Obafemi Awolowo University Teaching Hospital Complex, Ife (OAUTHC ) and Zenith Medical and Kidney Centre Abuja, in partnership with Fortis Hospital Banglore, India has conducted some successful Kidney Transplants in Nigeria.’^{[footnote 215]}

16.1.2 A MedCOI response from July 2020 stated:

‘There are nephrologists, urologists and internists working in the facilities like mentioned above [National Hospital – Abuja, Zenith Medical and Kidney Centre – Abuja, and in tertiary centres like in Lagos University Teaching Hospital and Lagos state University Teaching Hospital. And further these specialists are also working in private facilities such as Reddington Hospital and St Nicholas Hospital in Lagos.

‘Garki Hospital Abuja (Public/Private venture), St Nicholas Hospital in Lagos (Private) Obafemi Awolowo University Teaching Hospital Complex, Ife (Public) and Zenith Medical and Kidney Centre Abuja ( like mentioned above), in partnership with Fortis Hospital Banglore, India have conducted successful kidney transplants in Nigeria. Pre- and aftercare are available in these centres.’^{[footnote 216]}

16.1.3 The same MedCOI response also confirmed that nightly hemodialysis is available in hospitals, but is not available at home^{[footnote 217]}. Hemodialysis treatment is available at University of Benin Teaching Hospital, Onitsha General Hospital, Holy Rosary Specialist hospital and Iyi Enu Hospital in Onitsha and also the Central Hospital Sapele Rd, Oka, Benin City^{[footnote 218]}, University College Hospital, Ibadan^{[footnote 219]}, National Hospital – Abuja^{[footnote 220]} and Lagos University Teaching Hospital^{[footnote 221]}.

16.1.4 A MedCOI response from October 2020 stated with regard patients who had undergone kidney transplants: ‘Blood is tested for the concentration of tacrolimus and mycophenolic acid in order to monitor the dosage of immunosuppressants’^{[footnote 222]} and confirmed that laboratories are able to test for blood concentration of the medicines mycophenolic acid and tacrolimus in the private facilities of

• 1) Synlab , 9 Egbeyemi Street, Ilupeju, Lagos and;
• 2) Afriglobal Medicare, 8 Mobolaji Bank Anthony Way, By Unity Bustop, Ikeja, Lagos^{[footnote 223]}.

16.1.5 With regard costs of the laboratory tests to assess blood levels of tacrolimus and mycophenolic acid, a November 2020 MedCOI response stated:

‘… such costs are not covered by the NHIS and there are no government/public hospital laboratories that perform such labtests. Some public facilities like the Lagos state university teaching hospital (LASUTH) have public private partnership (PPP) with some labs to undertake non- routine tests like these ones. One […] such private laboratories in partnership with LASUTH is Afriglobal healthcare, and the specific cost for measuring tacrolimus blood levels at Afriglobal healthcare is about NGN 18,600 [around £33^{[footnote 224]}]. The Lagos University Teaching Hospital has also a PPP with Synlab Nigeria who have equipment to measure both tacrolimus and mycophenolic acidlevels at an estimated cost of NGN 20,500 [around£37^{[footnote 225]}] for each test.’ ^{[footnote 226]}

16.1.6 A MedCOI response from November 2020 gave the following information with regard the cost of renal medication and treatment with £1 = 560 Nigerian Naira @ 11 October 2021^{[footnote 227]}. See section Costs and currency for note on prices cited:

The first table^{[footnote 228]} provides information on the medical specialist who provides treatment, the cost of public outpatient and inpatient treatment as well as the costs of private outpatient and inpatient treatment and whether that treatment cost can be either reimbursed, supplied via a special program or is free

	Public outpatient treatment price in NGN	Public inpatient treatment price in NGN	Private outpatient treatment price in NGN	Private inpatient treatment price in NGN	Reimbursement/special program/free/comments
Medical specialist
Nephrologist	1,000/first consultation 500/follow-up consultations	Depends on the case complexity and duration of the admission*	20,000/first consultation 10,00/follow-up consultations	Depends on the case complexity and duration of the admission	The treatment by a nephrologist for general renal problems is covered by the NHIS; however, kidney transplant-related treatments are not covered by the NHIS

The second table^{[footnote 229]} gives the generic and brand name for drugs listed, along with dosage, form (injection or tablet for example), number of units per container, price per box in Nigerian Naira, the place (pharmacy or hospital) the drug can be obtained and whether that drug cost can be either reimbursed, supplied via a special program or is free:

Generic name	Brand name	Dosage	Form	Number of units in the container	Price per box in NGN	Place (Pharmacy, hospital,…)	Reimbursement/free
mycophenolic acid as mycophenolate socium	Myfortic	360 mg	Tablet	10 tablets	17,000	Alpha Pharmacy	Not covered by NHIS
tacrolimus	Prograf 1 mg	1 mg	Tablet	50 tablets	22,100	Alpha Pharmacy	Not covered by NHIS
tacrolimus	Vingraf 2 mg	2 mg	Tablet	60 tablets	51,000	Alpha Pharmacy	Not covered by NHIS

16.1.7 A MedCOI response of November 2020 noted: ‘… the costs for inpatient treatment by a nephrologist is difficult to ascertain as it depends on each individual patient. Some may need longer admissions if there [sic] are unwell while some may not stay long if they improve quickly. For example, in Lagos state university teaching hospital, where kidney transplants are infrequent, the transplant cost is NGN 5million [around £8,900^{[footnote 230]}] and covers the costs of surgery, post-transplant care and drugs post-transplant for up to 6 months.’^{[footnote 231]}

16.1.8 Further, according to the November 2020 MedCOI response ‘… the overall cost per month concerning the treatments… for such a post-renal transplant patient is roughly NGN 400,000/month [£714^{[footnote 232]}]. The NHIS does not support such treatments.’ ^{[footnote 233]}

16.1.9 Further details of laboratory tests, diagnostic imaging, research and transplantation related treatments alongside the cost of public treatment and private treatment in Nigerian Naira as well as whether that treatment cost can be either reimbursed or is free can be seen in the table provided by MedCOI below^{[footnote 234]}.

	Public treatment price in NGN	Private treatment price in NGN	Reimbursement/free/comments
Laboratory research
laboratory research: urine test for proteinuria	1,000	1,800	Covered by the NHIS
laboratory research of renal/kidney function (creatinin, ureum, proteinuria, sodium, potassium levels)	2,600	5,500	Covered by the NHIS
Diagnostic imaging
x-ray radiography	1,500	3,200	Covered by the NHIS
ultrasound	3,500	7,200	Covered by the NHIS
ECG (electro cardio gram)	4,000	5,500	Covered by the NHIS
Diagnostic research
diagnostic research, in the form of renal biopsy	4,500	48,400	Covered by the NHIS
Transplantation-related treatments
transplantation of kidney including all pre-and aftercare	5,000,000	8,500,000 (this price does not include drugs)	Not covered by the NHIS
transplantation aftercare: treatment of graft rejection	The cost is calculated on a case by case basis	The cost is calculated on a case by case basis	Not covered by the NHIS

16.1.10 See Annex A for list of available medications including those used to treat kidney disease and failure.

17. Malaria

Section 17 updated: 30 November 2021

17.1.1 A 2017 article in the Infectious Diseases of Poverty (IDoP) Journal noted that ‘In Nigeria, artemether-lumefantrine and artesunate-amodiaquine, in that order, were adopted as first-line treatments of uncomplicated P. falciparum malaria in 2005.’ ^{[footnote 235]}

17.1.2 The USAid Malaria Initiative 2017 Nigeria Plan noted provision in the country for insecticide treated mosquito nets, quinine, ACT, Artemether-lumefantrine, Artesunate-amodiaquine, Injectable artesunate and Sulfadoxine- pyrimethamine^{[footnote 236]}.

17.1.3 The MedCOI response country contact in the CFS 2017 noted that: ‘[drug] prices for endemic diseases ‘such as malaria are within a reasonable band all over the country. Though the government and markets forces regulate the cost of drugs, keeping the prices within a reasonable band everywhere in the country. However, there are some with a very wide margin.’^{[footnote 237]}

17.1.4 The National Malaria Elimination Programme goal is to ‘To reduce malaria burden to pre-elimination levels and bring malaria-related mortality to zero.’^{[footnote 238]}

18. Palliative care

Section 18 updated: 30 November 2021

18.1.1 The Journal of Emergency and Internal Medicine noted in a 2017 paper:

‘Palliative Care is still at a developmental stage… in 2007 Dr. Anne Merriman facilitated the inauguration of the Hospice and Palliative Care Association of Nigeria (HPCAN) together with the national association founding fathers. The African Palliative Care Association (APCA)…[Dr Merriman] provided the seed grants to [start] the Association. Since then palliative care services have been scaled-up in at least 5 out of the 6 geopolitical zones in Nigeria. The HPCAN had liaised with the Federal Ministry of Health severally and in 2008 submitted a proposal for the establishment of Palliative care Units in all the tertiary health institutions in Nigeria and today we have about 15 of such Centers scattered across the nation.

‘…The estimated palliative care needs in Nigeria is well over 4.6 million saddled with severe dearth of manpower.

‘…Morphine 80% is most commonly used analgesics used in palliative care services in Nigeria and is widely available in the country. Although most health care workers with inadequate training in pain management…feel more comfortable with Tramadol and Pentazocine.’ ^{[footnote 239]}

18.1.2 A MedCOI response from June 2020 indicates that terminal and palliative care is available at the public facility - National Hospital, Central Business District, Abuja^{[footnote 240]} and University College Hospital, UCH Road, Ibadan^{[footnote 241]}.

18.1.3 See Annex A for list of available medications used in palliative care including a range of painkillers.

19. Sickle cell disease

Section 19 updated: 30 November 2021

19.1.1 There is a National Sickle Cell Centre (NSCC) run by the Sickle Cell Foundation Nigeria (SCFN) located in Lagos State. NSCC is dedicated to SCD and has modern laboratories, a specialist library, an emergency care unit, clinical services among other sickle cell intervention initiatives^{[footnote 242]}.

19.1.2 A MedCOI response from June 2019 stated: ‘Stem cell transplantation has been done successfully on 7 Sickle cell patients in Benin [State] with 3 done between 2011 and 2013 at University of Benin Teaching Hospital while 4 were done at Cellteck Medical Centre, Benin from December 2017 to 2018. There are very few that have been done between 2011 and 2018 and none this year. The hospitals have been having some setbacks in infrastructure to enable them do more.’^{[footnote 243]}

19.1.3 A MedCOI response from January 2020 noted in respect of haematology and clinical treatment of sickle cell: ‘There are haematologists in most tertiary centres in Nigeria including National Hospital, Abuja, Lagos University Teaching Hospital, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria.’^{[footnote 244]}

19.1.4 A MedCOI response from November 2020 noted that: ‘Clinical treatment in case of sickle cell crises and blood transfusion can be done at most secondary and tertiary centres.’^{[footnote 245]}

19.1.5 See Annex A for list of available medications.

20. Tuberculosis (TB)

Section 20 updated: 30 November 2021

20.1.1 The MedCOI country contact noted that ‘Nigeria has a National Tuberculosis and Leprosy Control Programme (NTBLCP)… there is no serious human resources shortage, but the country lacks basic infrastructure, especially diagnostic materials, reagents and equipment.’ ^{[footnote 246]}

20.1.2 Copenhagen Consensus, described on its website as a think tank that researches solutions and advises policy makers and philanthropists that works with governments, NGOs and multilateral organizations on projects around the world^{[footnote 247]}, noted in an undated entry:

‘Diagnosing active TB is quite complex, since many symptoms are similar to those for other common diseases. Nigeria has one of the lowest detection rates in the world, with only 16% of cases being notified to the National TB and Leprosy Control Programme (NTLCP). A lack of capacity in the primary health care system means that hospitals are often the only places to treat the disease effectively.

‘Poor rates of diagnosis and lack of access to effective treatment creates significant costs and hardship for TB sufferers and their families. Even for straightforward cases which are cured, the cost to households, mainly from lost income, is around 120,000 Naira [£219^{[footnote 248]}], which can be catastrophic for poor families. An average delay of around three months from onset of symptoms to receiving treatment also allows further transmission of the diseases.’^{[footnote 249]}

20.1.3 The MedCOI country contact in the CFS 2017 noted that ‘[d]iagnosis, anti- TB drugs, medical consultation, laboratory exams and tests are available for free in all TB treatment centres over the country… treatment and anti-TB drugs are accessible in the majority of the country’s regions. However, geography is a factor limiting access to treatment for those who live in the far rural areas where there are no healthcare facilities.’ ^{[footnote 250]}

A MedCOI response of January 2018 noted that in and outpatient treatment by pulmonologists was avail from public facilities^{[footnote 251]}.

20.1.4 The National Tuberculosis and Leprosy Control Programme (NTBLCP) annual report 2019 stated with regard coverage of TB services in Nigeria:

‘There was an 31% increase in number of health facilities providing TB treatment services from 9,625 in 2018 to 12,606 in 2019… The proportion of health facilities providing TB services increase from 28% (with 35,000 health facilities as denominator) in 2018 to 31% (with 40,562 health facilities as denominator) in 2019.

‘However, only 31% of the health facilities in the country are providing TB treatment services. The low TB treatment coverage with TB services is one of the factors accounting for the high number of missing TB cases in the country’^{[footnote 252]}

20.1.5 The same report stated with regard public facilities:

‘The number of Public facilities providing TB treatment services increased from 8,174 in 2018 to 9,024 in 2019. Majority (72%) of the health facilities providing TB services in Nigeria are in the public , while 28% (3,582) of the facilities providing TB services are in the private. The public health facilities coverage with TB services in 2019 is 30%, this is expected to increase to 47% in 2020 based on the additional 5,117 public health facilities expected to be engaged for provision of TB services in 2020…’ ^{[footnote 253]}

20.1.6 With regard private facilities the NTBLCP report stated: ‘‘The private health facilities engaged for provision of TB treatment TB services increased by 147% from 1,451 in 2018 to 3,582 in 2019.’ ^{[footnote 254]}

20.1.7 See Annex A for list of available medications including those used to treat TB.

21. Thyroid diseases

Section 21 updated: 30 November 2021

21.1.1 A MedCOI response from May 2019 stated with regard parathyroidectomy stated: ‘Transplantation by parathyroid autotransplantation including pre and after care is not available but parathyroid surgery can be carried out in many tertiary centres.’^{[footnote 255]}

21.1.2 See Annex A for list of available medications including those used to treat thyroid diseases.

22. Mental healthcare

Section 22 updated: 30 November 2021

22.1 Overview

22.1.1 The DFAT report of December 2020 noted:

‘Mental health has historically been neglected on Nigeria’s health and development policy agenda. The WHO estimates one in four Nigerians suffer from mental illness, but fewer than 10 per cent of mentally ill Nigerians have access to the care they need. According to the WHO, the absence of treatment is fuelled by poor funding, stigma and poor knowledge of the disease. There is a strong societal belief that mental illness is caused by evil spirits or supernatural forces. Many Nigerians suffering from mental illness seek treatment from traditional or faith-based healers rather than mental health professionals.

‘Despite long-running attempts to repeal and replace it, the colonial-era Regional Lunacy Law (1958) remains in place. Critics of the law argue it is outdated and inconsistent with current realities, it perceives all mental health issues as “madness”, and its provisions violate the fundamental human rights of persons with mental health and psychosocial disabilities. Mental health advocates have sought to replace the law with a Nigerian Mental Health Bill that would protect the rights of persons with mental disorders, ensure equal access to treatment and care, discourage stigma and discrimination, and set standards for psychiatric practice in Nigeria. The Bill was initially introduced to the National Assembly in 2003, withdrawn in 2009 and re-introduced in 2013. The Bill remains at the consultation stage.

‘The national policy on mental health services delivery was initially formulated in 1991 and last updated in 2013.’^{[footnote 256]}

22.1.2 The HRW 2021 world report observed: ‘Thousands of people with mental health conditions remain chained and locked up in various facilities, including state hospitals, rehabilitation centers, traditional healing centers, and both Christian and Islamic faith-based facilities. In February [2020], the Senate Committee on Health held a public hearing on a draft mental health bill.’^{[footnote 257]}

22.1.3 The US State Department human rights report covering 2020 observed

‘Some national-level policies such as the National Health Policy of 2016 provide for health-care access for persons with disabilities. By year’s end 10 states had adopted the national disability law including Kano, Jigawa, Anambra, Kogi, Ondo, Lagos, Ekiti, Plateau, Kwara, and Bauchi… Persons with disabilities faced social stigma, exploitation, and discrimination, and relatives often regarded them as a source of shame… Mental health-care services were almost nonexistent.’^{[footnote 258]}

22.2 Availability of facilities and treatment

22.2.1 The MedCOI country contact in the CFS 2017 noted that ‘There are 8 neuropsychiatry hospitals throughout the country. Each of the accredited medical schools and the attached teaching hospitals has a psychiatry department. There are also six state-owned mental hospitals financed and managed by various state governments.’ ^{[footnote 259]} The MedCOI CFS 2017 also noted ‘the treatment of mental illness is possible in public hospitals. There is no form of mental illness for which treatment is not available in Nigeria. Human resources are not sufficient for the country’s needs.’^{[footnote 260]}

22.2.2 The online publication Punch noted that a consultant psychiatrist at the University of Ilorin Teaching Hospital stated that ‘there are less than 300 psychiatrists to Nigeria’s estimated 180 million people.’^{[footnote 261]}

22.2.3 Treatment facilities are mainly located in the urban and in some semi-urban areas^{[footnote 262] [footnote 263]}.

22.2.4 The MedCOI CFS 2017 noted the availability of:

• in and outpatient treatment by psychiatrists and psychologists from public facilities
• psychiatric counselling and medication assistance by psychiatric nurse from public facilities
• psychiatric treatment in the form of sheltered housing, assisted living and care at home by psychiatric nurse from private facilities^{[footnote 264]}

22.2.5 The DFAT report of December 2020 noted

‘There are eight federal neuropsychiatric hospitals in Nigeria (totalling around 4,000 beds), as well as three state-run hospitals in Port Harcourt, Ondo and Anambra. The WHO last estimated (in 2006) that, for every 100,000 persons, Nigeria had around 0.4 mental health beds, 4 psychiatric nurses, 0.09 psychiatrists and 0.02 psychologists and social workers. These ratios are unlikely to have significantly improved, with many Nigerian-trained health professionals migrating to western countries, particularly the UK and Canada.

22.2.6 ‘A number of NGOs work to provide mental health services nationwide. Mentally Aware Nigeria Initiative (MANI) is Nigeria’s largest NGO focused on raising mental health awareness and connecting service users to mental health professionals. Since its creation in 2015, MANI has established a national suicide hotline, counselling services (both in-person and via social media) and legal support for people arrested or prosecuted for attempting suicide, which is a criminal offence in Nigeria. The International Committee of the Red Cross (ICRC) and Nigerian Red Cross are active in northeast Nigeria, particularly around Maiduguri in Borno state. They visit homes and shelters to raise awareness about mental health issues and conduct three-month counselling sessions for victims of violence and displacement. Other NGOs are also active in the northeast to provide mental healthcare support for victims of the Boko Haram insurgency… DFAT assesses Nigeria has a limited capacity to provide formal mental health services to its citizens. Community and family structures and religious institutions may, in some cases, help cover this gap.’^{[footnote 265]}

22.2.7 A MedCOI response from April 2020 stated: ‘Cognitive behavioural therapy for the management of PTSD is available in most psychiatric hospitals.’^{[footnote 266]}

22.2.8 MedCOI noted in July 2019 that ‘Sheltered housing over a long period is only available privately e.g. at the Synapse Magnolia [in] Lagos State. There is also one community residential facility available in Lagos and it is run by a religious mission for rehabilitation of patients with drug problems.’^{[footnote 267]}

22.2.9 A MedCOI response from August 2019 noted: ‘Psychiatric care is also available [in addition to Amino Kano University Teaching Hospital] at Dawanau psychiatric hospital, Dawanau, Kano and Kano State Psychiatric Hospital, Dala, Kano.’^{[footnote 268]}

22.2.10 A MedCOI response from November 2020 stated with regard a patient with PTSD and psychotic traits: ‘There are psychiatrists, psychologists, psychiatric nurses and management of psychiatric crisis intervention. [I]in case of suicide attempt [treatment] is also available at the Federal Neuro-Psychiatric Centre Kaduna and Enugu as well as some state Psychiatric Hospitals: State Government Psychiatric Hospital, Psychiatric Unit Yola Specialist Hospital, Yola, Psychiatric Hospital Eket, Akwa Ibom, Neuro Psychiatric Hospital, Nawfia, Awka, Psychiatric Unit, General Hospital, Makurdi, Psychiatric Hospital, Maiduguri, Neuro Psychiatric Hospital, Aro, Abeokuta, Department of Psychiatry, Jos University Teaching Hospital, Jos, Psychiatric Hospital Rumuigbo, Port Harcourt, Psychiatric department, National Hospital, Abuja and a few others. ‘Assisted living / care at home by psychiatric nurse and home care are only provided by private centres such as Synapse Centres in Lagos and Abuja.’^{[footnote 269]}

22.2.11 MedCOI reported in various responses dated February 2019 to November 2020 that the following anti-depressants were available in Lagos and Abuja:

• Amitriptyline^{[footnote 270]}
• Citalopram^{[footnote 271]}
• Clomipramine^{[footnote 272]}
• Duloxetine^{[footnote 273]}
• Escitalopram^{[footnote 274]}
• Fluoxetine^{[footnote 275]}
• Fluvoxamine^{[footnote 276]}
• Imipramine^{[footnote 277]}
• Mirtazapine^{[footnote 278]}
• Nortriptyline^{[footnote 279]}
• Paroxetine^{[footnote 280]}
• Sertraline^{[footnote 281]}
• Trazodone^{[footnote 282]}
• Venlafaxine^{[footnote 283]}

22.2.12 MedCOI reported in responses dated from February 2019 to November 2020 that the following antipsychotics were available in pharmacies in Lagos, Abuja and Kano:

• Amitriptyline (Lagos) ^{[footnote 284]}
• Amisulpride^{[footnote 285]} (Lagos)
• Aripiprazole^{[footnote 286]} (Abuja)
• Clozapine^{[footnote 287]} (Abuja)
• Fluphenazine^{[footnote 288]} (Abuja)
• Flupentixol^{[footnote 289]} (Lagos)
• Haloperidol^{[footnote 290]} (Abuja and Lagos) ^{[footnote 291]}
• Olanzapine^{[footnote 292]} (Lagos)
• Penfluridol^{[footnote 293]} (Abuja)
• Paliperidone palmitate depot injection^{[footnote 294]} (Lagos)
• Perphenazine^{[footnote 295]} (Kano)
• Pipamperone^{[footnote 296]} (Abuja)
• Quetiapine^{[footnote 297]} (Lagos),
• Risperidone^{[footnote 298]} (Lagos)
• Zuclopenthixol^{[footnote 299]} (Abuja)

22.2.13 MedCOI reported in various responses dated between May 2019 and July 2020 that the following anxiety (anxiolytics) and sedative medications are available in pharmacies in Abuja, Lagos and Kano:

• Alprazolam^{[footnote 300]} (Lagos),
• Chlordiazepoxide^{[footnote 301]} (Lagos),
• Diazepam^{[footnote 302]} (Lagos),
• Flurazepam^{[footnote 303]} (Abuja),
• Lorazepam^{[footnote 304]} (Lagos),
• Loprazolam mesilate^{[footnote 305]} (Abuja),
• Lormetazepam^{[footnote 306]} (Abuja),
• Nitrazepam^{[footnote 307]} (Kano),
• Oxazepam^{[footnote 308]} (Lagos),
• Temezepam^{[footnote 309]} (Abuja),
• Zopiclone^{[footnote 310]} (Lagos),
• Zolpidem ^{[footnote 311]} (Lagos),

22.2.14 MedCOI reported in a response of April 2020 that the following medications used to treat addiction are available in pharmacies in Lagos:

• Naltrexone hydrochloride and Disulfiram^{[footnote 312]}.

22.3 Child development and mental health

22.3.1 A MedCOI response from April 2020 stated:

‘There are pediatric psychiatrists, pediatric psychologists and pediatric neurologists in a few of the Teaching hospitals in Lagos, including the Federal Neuro -Psychiatric Centre 8 Harvey Road, Yaba , Lagos. Besides in general many adult psychiatrists treat also pediatric psychiatric cases. The Child and Adolescent Mental Health Service Centre (CAMHSC) of the Federal Neuropsychiatric Hospital, Yaba , Lagos and University College Hospital department of psychiatry have child psychiatrists and child psychologists.

‘Speech therapists are available ; however overall there are very few speech therapists in Nigeria. ‘There are no clinical geneticists in Lagos, but there are professionals trained in genetic counseling in many secondary and tertiary institutions, including Lagos University Teaching Hospital, Idi-Araba Lagos, and Lagos State University Teaching Hospital, Ikeja Lagos.

‘Pediatric day care and schooling are available in private establishments only.’^{[footnote 313]}

22.3.2 MedCOI responses answered a question related to communication methods:

Question

‘Is specific support with alternative communication methods (AAC) available for such a child [diagnosed to have extra chromosome (called trisomy-X or 47,XXX) ] and for example by a speech therapist? [ AAC = Augmentative and Alternative Communication = encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language].

Answers

• a) ‘Yes there is. Patrick Speech and Languages Center is a facility that offers these services widely. Address: Remi Fani Kayode Street, Ikeja G.R.A, Lagos’^{[footnote 314]}
• b) ‘Yes this is available at God’s Care School For Special Needs, 10 Onuorah Street, Umuayom Village, Awka’^{[footnote 315]}

22.3.3 A MedCOI contact in a response from September 2020 gave the following information with regard NGOs or national programmes supporting children with development disorders:

‘…there are no national programmes specifically providing financial support to children with developmental disorders. However, some national tertiary health centres offer partial coverage, and usually any child can access such services in these centres. In addition, some state governments are able to offer partial coverage for children; for example, the Lagos state government offers partial health coverage to all children aged between 0-12 years, including those with development disorders…. Nevertheless, there are NGOs, as well as state governments supporting these children in terms of providing educational opportunities and specialized services such as speech therapy, occupational therapy and child psychologist services… For example, the Lagos state government has a department for disability affairs– Lagos State Office for Disability Affairs (LASODA) – which carries out different functions, including offering disability services, issuance of directives and guidelines for education, and promoting social development, special schools, vocational and rehabilitation centers.’^{[footnote 316]}

22.3.4 The same report also stated according to a MedCOI contact:

‘… the Lagos state government also owns schools for disabled children and supports NGOs that offer these services… For example, the Lagos state government owns the Modupe Cole Memorial Child care and Treatment Home/School,… a school that started as a private NGO but has been acquired by the Lagos government, and currently provides special services free of charge….

‘[T]here are also private–public sector partnerships in Lagos such as the children development center Africa (CDCA) in Lagos. In this partnership, the Lagos state government supplied the building to CDCA while the facility itself is run by a private organisation. In this facility, services are not free but they are instead based on a sliding scale, which means that a poor family will pay less for services in comparison to a rich family…

‘There is another NGO in Lagos named Patrick Speech and Languages Centre that provides a range of services, including speech and language therapy, behaviour modification therapy, occupational therapy, and vocational training… Although there is a fee to be paid by the patient, this NGO offers partial scholarships for their services…

‘…across Nigeria there are other NGOs supporting children with developmental disorders mentioned below, and despite the fact that they require the payment of a fee by the patient, they can also waive part of their service fees…:

• ‘Royal School of Educational Therapy (RSE-T) Foundation (Abuja)…
• ‘Comprehensive Autism and related Disabilities Education and Training (C.A.D.E.T.) Academy (Abuja)…
• ‘Centre for Children with Special Needs (Abuja)… Open Doors Special Education Centre (Jos, Plateau State)…
• ‘Anthos House (Lekki, Lagos)…
• ‘OTANA Integrated Centre (Port Harcourt)…
• ‘OLG Health Foundation and Autism Centre (Abuja)…
• ‘Start-Rite School Lagos (Ikeja, Lagos)…
• ‘Centre for Autism and Developmental Disabilities – CADD (Delta state)…
• ‘Hope House Initiative (Abuja)…
• ‘Benola (Lekki)…
• ‘Disability Empowerment Solution (Ibadan)…
• ‘Zammar Institute…’ ^{[footnote 317]}

22.3.5 See Annex A for list of available medications.

Annex A: List of available medication according to MedCOI

The list of drugs below has been compiled from MedCOI responses produced between February 2019 and December 2020 and researched by medical practitioners working in Nigeria. The information is limited to the availability of the medication, usually at a particular clinic/health institute, and does not provide information on accessibility. That a particular medication was identified as being available at one facility does not mean that it was only available at that clinic/health centre.

A

Abacavir^{[footnote 318]}, Abiraterone acetate^{[footnote 319]}, Acarbose^{[footnote 320]}, Acenocoumarol^{[footnote 321]}, Acrivastine (available but has supply problems)^{[footnote 322]}, Adrenaline^{[footnote 323]} (injections), Alemtuzumab^{[footnote 324]}, Alendronate sodium (alendronic acid) ^{[footnote 325]}, Alfacalcidol^{[footnote 326]}, Alprazolam^{[footnote 327]}, Alginic acid^{[footnote 328]}, Amiodarone^{[footnote 329]}, Amisulpride^{[footnote 330]}, Amitriptyline^{[footnote 331]}, Amlodipine^{[footnote 332]}, Amlodipine + olmesartan (medoxomil) combination^{[footnote 333]}, Amoxicillin^{[footnote 334]}, Amoxicillin + clavulanic acid (combination) ^{[footnote 335]}, Anastrozole^{[footnote 336]}, Antenolol^{[footnote 337]}, Apixaban^{[footnote 338]}, Atazanavir^{[footnote 339]}, Atorvastatin^{[footnote 340]}, Atenolol^{[footnote 341]}, Aripiprazole^{[footnote 342]}, Ascorbic acid^{[footnote 343]}, Atripla^{[footnote 344]}, Avanafil^{[footnote 345]}, Azathioprine^{[footnote 346]}.

B

Baclofen^{[footnote 347]}, Barnidipine^{[footnote 348]}, Beclometasone^{[footnote 349]}, Beclometasone inhaler^{[footnote 350]}, Beclometasone + formoterol (combination) ^{[footnote 351]}, Beclometasone nasal spray^{[footnote 352]}, Benzylpenicillin sodium^{[footnote 353]}, Betaxolol^{[footnote 354]}, Betamethasone^{[footnote 355]}, Bevacizumab^{[footnote 356]}, Biktarvy® (bictegravir+emtricitabine+tenofovir alafenamide)^{[footnote 357]}, Biperidene^{[footnote 358]}, Bisoprolol^{[footnote 359]}, Botulinum toxin type a and type b^{[footnote 360]}, Brinzolamide^{[footnote 361]}, Budesonide^{[footnote 362]}, Budesonide + salmeterol (combination) ^{[footnote 363]}, Bumetanide^{[footnote 364]}, Buprenorphine^{[footnote 365]}, Buserelin acetate^{[footnote 366]}.

C

Calcitriol^{[footnote 367]}, Calcium^{[footnote 368]}, Calcium carbonate^{[footnote 369]}, Calcium carbonate + colecalciferol^{[footnote 370]}, Calciumcarbonate + magnesiumcarbonate^{[footnote 371]}, Calcium gluconate^{[footnote 372]}, Calcium polystyrene sulphonate^{[footnote 373]} (available but with some supply problems), Calcium + vitamin D (combination, such as Calcimagon D3®)^{[footnote 374]}, Canagliflozin^{[footnote 375]}, Candesartan^{[footnote 376]}, Carbasalate calcium^{[footnote 377]}, Carbamazepine^{[footnote 378]}, Carbomer eye drops^{[footnote 379]}, Captopril^{[footnote 380]}, Carvedilol^{[footnote 381]}, Cefepime^{[footnote 382]}, Ceftazidime pentahydrate^{[footnote 383]}, Ceftriaxone^{[footnote 384]}, Cetirizine^{[footnote 385]}, Celecoxib^{[footnote 386]}, Cholecalciferol^{[footnote 387]}, Chlortalidone^{[footnote 388]}, Chlordiazepoxide^{[footnote 389]}, Cimetidine^{[footnote 390]} Cinnarizine^{[footnote 391]}, Citalopram^{[footnote 392]}, Clarithromycin^{[footnote 393]}, Clindamycin^{[footnote 394]}, Clomipramine^{[footnote 395]}, Clonazepam^{[footnote 396]}, Clotrimazole^{[footnote 397]}, Clopidogrel^{[footnote 398]}, Clorazepate^{[footnote 399]}, Clemastine^{[footnote 400]}, Clopidogrel^{[footnote 401]}, Clozapine^{[footnote 402]} , Clobetasone^{[footnote 403]}, Cromoglicic acid^{[footnote 404]} Cyclizine^{[footnote 405]}.

D

Dabigatran^{[footnote 406]}, Dalteparin^{[footnote 407]}, Dapagliflozin^{[footnote 408]}, Darbepoetin alfa^{[footnote 409]}, Denosumab^{[footnote 410]}, Deferiprone^{[footnote 411]}, Deferasirox^{[footnote 412]}, Deferoxamine^{[footnote 413]}, Degarelix acetate^{[footnote 414]}, Descovy® (combination of emtricitabine + tenofovir alafenamide) ^{[footnote 415]}, Desloratadine^{[footnote 416]}, Desmopressin^{[footnote 417]}, Dextran / hypromellose eyedrops^{[footnote 418]}, Dexamethasone^{[footnote 419]}, Dexamethasone sodium phosphate^{[footnote 420]}, Diazepam^{[footnote 421]}, Diclofenac^{[footnote 422]}, Digoxin^{[footnote 423]}, Dihydrotachysterol^{[footnote 424]}, Diphtheria, tetanus, pertussis (acellular) hib vaccine and poliomyelitis (inactivated) (vaccine)^{[footnote 425]}, Disulfiram^{[footnote 426]}, Diltiazem^{[footnote 427]}, Docetaxel^{[footnote 428]}, Dolutegravir^{[footnote 429]}, Dorzolamide^{[footnote 430]}, Doxazosin^{[footnote 431]}, Doxycycline^{[footnote 432]}, Duloxetine^{[footnote 433]}, Dydrogesterone^{[footnote 434]}.

E

Edoxaban^{[footnote 435]}, Efavirenz^{[footnote 436]}, Elvitegravir^{[footnote 437]}, Empagliflozin^{[footnote 438]}, Emtricitabine^{[footnote 439]}, Enalapril^{[footnote 440]}, Enoxaparin^{[footnote 441]}, Epinephrine^{[footnote 442]} (adrenalin), Eplerenone^{[footnote 443]}, Epoetin alfa^{[footnote 444]}, Epoetin beta^{[footnote 445]}, Epoetin theta^{[footnote 446]}, Epoetin zeta^{[footnote 447]}, Epzicom® Kivexa® (combination of abacavir and lamivudine) ^{[footnote 448]}, Ergocalciferol^{[footnote 449]}, Erythropoietin^{[footnote 450]}, Escitalopram^{[footnote 451]}, Estradiol^{[footnote 452]}, Estradiol + dydrogesteron (eg Femoston®)^{[footnote 453]}, Esomeprazole^{[footnote 454]}, Estradiol + levonorgestrel (@Wellnara) ^{[footnote 455]}, Estradiol + norethisterone^{[footnote 456]}, Estradiol + norgestrel (available but with supply problems) ^{[footnote 457]}, Ethinylestradiol + levonorgestrel (Microgynon®. Stediril®)^{[footnote 458]}, Etoricoxib^{[footnote 459]}, Eviplera® (combination of emtricitabine / rilpivirine / tenofovir disoproxil) – available but with supply problems) ^{[footnote 460]}, Exemestane^{[footnote 461]}, Exenatide^{[footnote 462]}.

F

Famotidine^{[footnote 463]}, Felodipine^{[footnote 464]}, Fentanyl^{[footnote 465]}, Ferric carboxymaltose ( intravenous iron )^{[footnote 466]}, Ferrioxidesaccharate (ferric saccharate- intravenous iron) - Venofer®^{[footnote 467]}, Ferrous fumarate^{[footnote 468]}, Ferrous gluconate^{[footnote 469]}, Ferrous citrate or iron(II) citrate^{[footnote 470]}, Fexofenadine hydrochloride^{[footnote 471]}, Flupentixol^{[footnote 472]}, Flupentixol decanoate depot injection^{[footnote 473]}, Fluphenazine^{[footnote 474]}, Flurazepam^{[footnote 475]}, Flecainide acetate^{[footnote 476]}, Fluticasone^{[footnote 477]}, Fluticasone furoate^{[footnote 478]}, Fluticasone (propionate) ^{[footnote 479]}, Fluvoxamine^{[footnote 480]}, Flumetasone^{[footnote 481]}, Fluticasone ointment^{[footnote 482]}, Fluoxetine^{[footnote 483]}, Fluorouracil^{[footnote 484]}, Fluorometholone^{[footnote 485]}, Fluvastatin^{[footnote 486]}, Formoterol^{[footnote 487]}, Fosinopril^{[footnote 488]}, Filgrastim^{[footnote 489]}, Folic acid^{[footnote 490]}, Furosemide^{[footnote 491]}, Fusidic acid^{[footnote 492]}.

G

Gabapentin^{[footnote 493]}, Glibenclamide^{[footnote 494]}, Gliclazide^{[footnote 495]}, Glimepiride^{[footnote 496]}, Glycopyrronium bromide^{[footnote 497]}, Goserelin^{[footnote 498]}, Granisetron^{[footnote 499]}.

H

Haloperidol^{[footnote 500]}, Haloperidol decanoate depot injection^{[footnote 501]}, Hepatitis b vaccine^{[footnote 502]}, Hydrochlorothiazide^{[footnote 503]}, Hydrocortisone^{[footnote 504]}, Hydrocortisone butyrate^{[footnote 505]}, Hypromellose eyedrops^{[footnote 506]}, Hydroxycarbamide^{[footnote 507]}, Hydroxychloroquine ( Plaquenyl ®)^{[footnote 508]}.

I

Ibandronic acid, Ibuprofen^{[footnote 509]}, Ibutilide^{[footnote 510]}, Imipramine^{[footnote 511]}, Indapamide^{[footnote 512]}, Influenza vaccine^{[footnote 513]}, Ipratropium^{[footnote 514]}, Ipratropium + fenoterol (combination)^{[footnote 515]}, ipratropium bromide monohydrate^{[footnote 516]}, Irbesartan^{[footnote 517]}, Iron(III) isomaltoside 1000 (intravenous iron - Diafer®/Monofer®)^{[footnote 518]} (available but supply problems), Isosorbide dinitrate^{[footnote 519]}, Isosorbide mononitrateI^{[footnote 520]},

Insulin

• Insulin: ultra longacting[42hr] ; insulin degludec^{[footnote 521]}
• Insulin, premixed: aspart (rapid acting) and aspart protamine (intermediate acting) like ® NovomixI^{[footnote 522]}
• Insulin, premixed: combination of lispro (rapid acting) and insulin lispro protamine( intermediate acting)^{[footnote 523]}
• Insulin: intermediate acting [12-24hr]; insulin NPH / isophane like ® Insulatard^{[footnote 524]}
• Insulin: rapid acting[2-5hr]; insulin lispro^{[footnote 525]}
• Insulin: long acting[24hr]; insulin glargine like ®Lantus^{[footnote 526]}
• Insulin: long acting[24hr]; insulin detemir^{[footnote 527]}
• Insulin: rapid acting[2-5hr]; insulin aspart like ®Novorapid Ipratropium^{[footnote 528]}
• Insulin: rapid acting[2-5hr]; insulin glulisine^{[footnote 529]}

K

Ketamine^{[footnote 530]}, Ketoconazole^{[footnote 531]}

L

Lacidipine^{[footnote 532]}, Lactulose^{[footnote 533]}, Lamotrigine^{[footnote 534]}, Lamivudine^{[footnote 535]}, Lansoprazole^{[footnote 536]}, Latanoprost^{[footnote 537]}, Lercanidipine^{[footnote 538]}, Leuprorelin acetate^{[footnote 539]}, Lenograstim^{[footnote 540]} (supply problems), Levothyroxine (= L- thyroxine); synthetic version of thyroxine/ T4^{[footnote 541]}, Levonorgestrel^{[footnote 542]}, Levocetirizine^{[footnote 543]}, Levetiracetam^{[footnote 544]}, Lidocaine^{[footnote 545]}, Lidocaine + prilocaine (combination) ^{[footnote 546]}, Lipegfilgrastim^{[footnote 547]} (supply problems), Linagliptin^{[footnote 548]}, Liothyronine sodium^{[footnote 549]}, Liraglutide^{[footnote 550]}, Lisinopril^{[footnote 551]}, Loprazolam mesilate^{[footnote 552]} (Not registered in Nigeria, but can be imported by Dozie Pharmacy), Loratadine^{[footnote 553]}, Lorazepam^{[footnote 554]}, Loratadine^{[footnote 555]}, Losartan^{[footnote 556]}, Lormetazepam^{[footnote 557]}.

M

Macrogol^{[footnote 558]}, Macrogol + electrolytes ( eg; potassium chloride, sodium chloride, sodium hydrogencarbonate)^{[footnote 559]}, Magnesium alginate^{[footnote 560]},Magnesium hydroxide^{[footnote 561]}, Measles vaccine^{[footnote 562]}, Mefenamic acid^{[footnote 563]}, Mesilate^{[footnote 564]}, Mesalazine^{[footnote 565]}, Metformin^{[footnote 566]}, Metformin+sitagliptin(combination) ^{[footnote 567]}, Methadone^{[footnote 568]}, Methotrexate^{[footnote 569]}, Methoxy polyethylene glycol-epoetin beta^{[footnote 570]}, Metoclopramide^{[footnote 571]}, Metoprolol^{[footnote 572]}, Metronidazole^{[footnote 573]}, Miconazole^{[footnote 574]}, Midazolam^{[footnote 575]} (supply problems), Mirtazapine^{[footnote 576]}, Mometasone nasal spray^{[footnote 577]}, Montelukast sodium^{[footnote 578]}, Morphine^{[footnote 579]}, Multi vitamins^{[footnote 580]}, Mumps vaccine^{[footnote 581]}, Mupirocin^{[footnote 582]}, Mycophenolic acid as mycophenolate sodium^{[footnote 583]}.

N

Naloxone^{[footnote 584]}, Naltrexone hydrochloride^{[footnote 585]}, Naproxen^{[footnote 586]}, Nebivolol^{[footnote 587]}, Nicardipine^{[footnote 588]},Nifedipine^{[footnote 589]}, Nitrendipine^{[footnote 590]}, Nortriptyline^{[footnote 591]}, Nitrazepam^{[footnote 592]}, Nitroglycerin (= trinitrine = glyceryl trinitrate) ^{[footnote 593]}, Nortriptyline^{[footnote 594]}.

O

Octreotide^{[footnote 595]}, Olanzapine^{[footnote 596]}, Olanzapine pamoate depot injection^{[footnote 597]}, Omeprazole^{[footnote 598]}, Olmesartan^{[footnote 599]}, Olsalazine^{[footnote 600]}, Ondansetron^{[footnote 601]}, Oxaliplatin^{[footnote 602]}, Oxazepam^{[footnote 603]}, Oxycodone^{[footnote 604]}, Oxycodone + naloxone^{[footnote 605]}.

P

Palivizumab^{[footnote 606]}, Palonosetron hydrochloride^{[footnote 607]}, Pantoprazole^{[footnote 608]}, Paroxetine^{[footnote 609]}, Pegfilgrastim^{[footnote 610]} (supply problems), Penicillin^{[footnote 611]}, Penfluridol^{[footnote 612]}, Perphenazine^{[footnote 613]}, Perindopril^{[footnote 614]}, Phenobarbital^{[footnote 615]}, Phenprocoumon^{[footnote 616]}, Phenoxymethylpenicillin^{[footnote 617]}, Pipamperone^{[footnote 618]}, Pneumococcal vaccine^{[footnote 619]}, Polyvidone eye drops^{[footnote 620]}, Potassium citrate^{[footnote 621]}, Propranolol^{[footnote 622]}, Promethazine^{[footnote 623]}, Prasugrel^{[footnote 624]}, Pravastatin^{[footnote 625]}, Prednisolone^{[footnote 626]}, Prednisolone eye drops^{[footnote 627]}, Prednisone^{[footnote 628]}, Pregabalin^{[footnote 629]}, Promethazine^{[footnote 630]}.

Q

Quetiapine^{[footnote 631]}, Quinapril hydrochloride^{[footnote 632]}.

R

Rabeprazole sodium^{[footnote 633]}, Ramipril^{[footnote 634]}, Ranitidine^{[footnote 635]}, Raltegravir^{[footnote 636]}, Rilpivirine (available but with supply problems)^{[footnote 637]}, Risperidone^{[footnote 638]}, Risedronate sodium^{[footnote 639]}, Ritonavir^{[footnote 640]}, Rivaroxaban^{[footnote 641]}, Rosuvastatin^{[footnote 642]}.

S

Sacubitril + valsartan ( combination, Entresto® )^{[footnote 643]}, Salbutamol^{[footnote 644]}, Salbutamol (drops) for nebulizer^{[footnote 645]}, Salmeterol^{[footnote 646]}, Salmeterol + fluticasone (propionate) ^{[footnote 647]}, Saxagliptin hydrochloride^{[footnote 648]}, Sertraline^{[footnote 649]}, Sildenafil^{[footnote 650]}, Simvastatin^{[footnote 651]}, Sodium chloride^{[footnote 652]}, Sodium (natrium) polystyrene sulphonate^{[footnote 653]}, Sotalol^{[footnote 654]}, Spironolactone^{[footnote 655]}, Sitagliptin^{[footnote 656]}, Sulfadiazine^{[footnote 657]}, Sulfasalazine^{[footnote 658]}.

T

Tacrolimus^{[footnote 659]}, Tadalafil^{[footnote 660]}, Tamoxifen^{[footnote 661]}, Tamsulosin^{[footnote 662]},Telmisartan^{[footnote 663]}, Tenofovir disoproxil^{[footnote 664]}, Temezepam^{[footnote 665]}, Tetracycline^{[footnote 666]}, Terazosin^{[footnote 667]},Ticagrelor^{[footnote 668]}, Timolol^{[footnote 669]}, Tiotropium (available but some supply problems) ^{[footnote 670]}, Topiramate^{[footnote 671]}, Tolbutamide^{[footnote 672]}, Tramadol^{[footnote 673]}, Traconazole^{[footnote 674]}, Trazodone^{[footnote 675]},Triamcinolone acetonide^{[footnote 676]}, Trimethoprim^{[footnote 677]}, Trimethoprim AND sulfamethoxazole ( Cotrimoxazole) ^{[footnote 678]}, Triptorelin^{[footnote 679]}, Triumeq® (combination of abacavir/dolutegravir/lamivudine)^{[footnote 680]}, Truvada® (combination of tenofovir disoproxil/ emtricitabine) ^{[footnote 681]}.

U

Urapidil (available but some supply problems)^{[footnote 682]}.

V

Valproic acid or valproate OR Depakine®^{[footnote 683]}, Vardenafil^{[footnote 684]}, Vitamin D^{[footnote 685]}, Vitamin B1 (thiamine) ^{[footnote 686]}, Valsartan^{[footnote 687]}, Venlafaxine^{[footnote 688]}, Verapamil^{[footnote 689]}, Vildagliptin^{[footnote 690]}, Vilanterol + fluticasone furoate (combination)^{[footnote 691]}.

Z

Zafirlukast^{[footnote 692]}, Zolpidem ^{[footnote 693]}, Zolpidem^{[footnote 694]}, Zoledronic acid^{[footnote 695]}, Zopiclone^{[footnote 696]}, Zuclopenthixol^{[footnote 697]}, Zuclopenthixol decanoate depot injection^{[footnote 698]}.

In addition to the drugs above, MedCOI noted in responses of various dates that the following medications which are either not registered with the National Agency for Food and Drug Administration and Control or are not available locally but can be obtained by ‘parallel import’ (that is can be imported from overseas):

• ‘Dihydrotachysterol, darbepoetin alfa and fusidic acid are not registered by NAFDAC but are available as parallel import at Dozie pharmacy.’ ^{[footnote 699]}
• ‘Denosumab, quinapril hydrochloride, barnidipine and leuprorelin acetate have no NAFDAC ( National Agency for Food and Drug Administration and Control) registration number, but can be brought in by Dozie pharmacy by parallel import because they have prior NAFDAC approval.’^{[footnote 700]}.
• ’Palivizumab and tiotropium are not stocked routinely, but if a patient needs it, it can be imported into the country; the time for importing/ re- supply is unknown.’ ^{[footnote 701]}
• Urapidil and acrivastine can be brought in by parallel import and have a time of resupply of 3 weeks…The availability of acebutolol [a betablocker] has been discontinued and is unavailable.’ ^{[footnote 702]}
• ‘Ibandronic acid, buserelin and goserelin are available by parallel import as they are not registered’. ^{[footnote 703]}
• ‘Edoxaban is not registered but is available at Dozie pharmacy. Sacubitril + valsartan combination is registered and is available only under the brand Uperio®. The combination calcium carbonate + magnesium carbonate is available as over-the-counter supplements in some private pharmacy stores.’ ^{[footnote 704]}

Terms of Reference

A ‘Terms of Reference’ (ToR) is a broad outline of what the CPIN seeks to cover. They form the basis for the country information section. The Home Office’s Country Policy and Information Team uses some standardised ToRs, depending on the subject, and these are then adapted depending on the country concerned.

For this particular CPIN, the following topics were identified prior to drafting as relevant and on which research was undertaken:

Healthcare system

Overview of structure including patient access to:

• Public – free or subsidised at point of entry
• Private - pay at point of entry
• Health insurance system – private, public and community based insurance systems, cost and contributions
• Non-government organisation (NGO) provision and assistance
• Costs – for the above to:
  • consult a general practitioner
  • consult a specialist and receive treatment
  • contribute to an insurance scheme

Infrastructure and staffing

• Number, location and type of medical facility (and specialism) – primary, secondary and tertiary
• Number and location in absolute and as per head of population of nurses and doctors, including specialists
• Provide links to medical, dental and other healthcare practitioners, and hospitals. US and UK mission websites usually identify local healthcare providers. Some countries’ medical and dental professional or government bodies list practitioners and hospitals.

Pharmaceutical sector

• Availability of therapeutic drugs
• Accessibility of therapeutic drugs, cost and other factors affecting access

Specific diseases/conditions (providing information as set out for cancer below) including:

Cancer

• Prevalence and types
• National programme for control and treatment
• Available treatment: facilities, personnel and location
• Accessibility: cost of treatment and other factors affecting access, such as location of particular treatment centres
• Support in obtaining treatment from state, private or civil society sectors

Cardiovascular diseases

Dental disease and conditions

Diabetes

Geriatric care

Gynaecology

Hepatitis

HIV/AIDS

Mental health

Musculoskeletal conditions

Neurological diseases

Paediatric diseases

Palliative care

Renal disease and failure

Sickle cell disease

Tuberculosis

Annex of main drugs - an alphabetical list of commonly requested drugs, indicating availability and cost

Bibliography

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Changes from last version of this note

Updated country of origin information

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3. XE Currency converter, 25 November 2021. ↩

4. IMF, ‘Nigeria’ (Country data), no date. ↩

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113. MedCOI, Response to information request, BDA 7259, 3 June 2020. ↩

114. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

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160. ‘The Society of Gynaecology and Obstetrics of Nigeria’ (SOGON), ‘SOGON’, undated. ↩

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179. Nigeria Public Health, ‘How much does HIV test cost in Nigeria?’, 2 May 2021. ↩

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193. MedCOI, Response to information request, BMA 13749, 9 July 2020. ↩

194. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

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199. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

200. MedCOI, Response to information request, BMA 13749, 9 July 2020. ↩

201. MedCOI, Response to information request, BMA 11966, 22 September 2019. ↩

202. MedCOI, Response to information request, BMA 12594, 22 July 2019. ↩

203. MedCOI, Response to information request, BMA 12216, 20 March 2019. ↩

204. MedCOI, Response to information request, BMA 13820, 6 August 2020. ↩

205. MedCOI, Response to information request, BMA 13912, 27 August 2020. ↩

206. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

207. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

208. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

209. Society for Gastroenterology and Hepatology In Nigeria SOGHIN, ‘SOGHIN’, undated. ↩

210. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

211. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

212. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

213. Project MedCOI, Country Fact Sheet – Nigeria, June 2017. ↩

214. Hepatitis Foundation, ‘The Journey to Hepatitis Elimination in Nigeria’, 15 January 2020. ↩

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217. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

218. MedCOI, Response to information request, BMA 11523, 6 September 2019. ↩

219. MedCOI, Response to information request, BMA 12400, 24 May 2019. ↩

220. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

221. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

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223. MedCOI, Response to information request, BMA 14098, 15 October 2020. ↩

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225. XE Currency converter, 11 October 2021. ↩

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229. MedCOI, Response to information request, BDA 7369, 9 November 2020. ↩

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300. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

301. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

302. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

303. MedCOI, Response to information request, BMA 12363, 15 May 2019. ↩

304. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

305. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

306. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

307. MedCOI, Response to information request, BMA 12726, 27 August 2019. ↩

308. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

309. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

310. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

311. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

312. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

313. MedCOI, Response to information request, BMA 13491, 20 April 2020. ↩

314. MedCOI, Response to information request, BMA 13849, 30 July 2020. ↩

315. MedCOI, Response to information request, BMA 13845, 31 July 2020. ↩

316. MedCOI, Response to information request, BDA 7333, 18 September 2020. ↩

317. MedCOI, Response to information request, BDA 7333, 18 September 2020. ↩

318. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

319. MedCOI, Response to information request, BMA 13445, 26 March 2020. ↩

320. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

321. MedCOI, Response to information request, BMA 12906, 7 November 2019. ↩

322. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

323. MedCOI, Response to information request, BMA 12768, 4 September 2019. ↩

324. MedCOI, Response to information request, BMA 12473, 20 June 2019. ↩

325. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

326. MedCOI, Response to information request, BMA 13854, 1 August 2020. ↩

327. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

328. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

329. MedCOI, Response to information request, BMA 12791, 25 September 2019. ↩

330. MedCOI, Response to information request, BMA 12767, 6 September 2019. ↩

331. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

332. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

333. MedCOI, Response to information request, BMA 14127, 3 November 2020. ↩

334. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

335. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

336. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

337. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

338. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

339. MedCOI, Response to information request, BMA 13749, 9 July 2020. ↩

340. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

341. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

342. MedCOI, Response to information request, BMA 13508, 14 April 2020. ↩

343. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

344. MedCOI, Response to information request, BMA 13820, 6 August 2020. ↩

345. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

346. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

347. MedCOI, Response to information request, BMA 12926, 13 November 2019. ↩

348. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

349. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

350. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

351. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

352. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

353. MedCOI, Response to information request, BMA 12109, 5 March 2019. ↩

354. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

355. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

356. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

357. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

358. MedCOI, Response to information request, BMA 12767, 6 September 2019. ↩

359. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

360. MedCOI, Response to information request, BMA 12926, 13 November 2019. ↩

361. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

362. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

363. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

364. MedCOI, Response to information request, BMA 11523, 6 September 2019. ↩

365. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

366. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

367. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

368. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

369. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

370. MedCOI, Response to information request, BMA 12722, 6 September 2019. ↩

371. MedCOI, Response to information request, BMA 13622, 25 May 2020. ↩

372. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

373. MedCOI, Response to information request, BMA 13712, 12 June 2020. ↩

374. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

375. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

376. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

377. MedCOI, Response to information request, BMA 13082 17 December 2019. ↩

378. MedCOI, Response to information request, BMA 13508, 14 April 2020. ↩

379. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

380. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

381. MedCOI, Response to information request, BMA 12791, 25 September 2019. ↩

382. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

383. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

384. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

385. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

386. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

387. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

388. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

389. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

390. MedCOI, Response to information request, BMA 12722, 6 September 2019. ↩

391. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

392. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

393. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

394. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

395. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

396. MedCOI, Response to information request, BMA 12926, 13 November 2019. ↩

397. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

398. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

399. MedCOI, Response to information request, BMA 12095, 11 March 2019. ↩

400. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

401. MedCOI, Response to information request, BMA 13508, 14 April 2020. ↩

402. MedCOI, Response to information request, BMA 13432, 26 March 2020. ↩

403. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

404. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

405. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

406. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

407. MedCOI, Response to information request, BMA 13854, 1 August 2020. ↩

408. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

409. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

410. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

411. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

412. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

413. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

414. MedCOI, Response to information request, BMA 13445, 26 March 2020. ↩

415. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

416. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

417. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

418. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

419. MedCOI, Response to information request, BMA12083, 19 April 2019. ↩

420. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

421. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

422. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

423. MedCOI, Response to information request, BMA 12852, 17 October 2019. ↩

424. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

425. MedCOI, Response to information request, BMA 12109, 5 March 2019. ↩

426. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

427. MedCOI, Response to information request, BMA 13508, 14 April 2020. ↩

428. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

429. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

430. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

431. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

432. MedCOI, Response to information request, BMA 13176, 6 January 2020. ↩

433. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

434. MedCOI, Response to information request, BMA 12722, 6 September 2019. ↩

435. MedCOI, Response to information request, BMA 13622, 25 May 2020. ↩

436. MedCOI, Response to information request, BMA 13820, 6 August 2020. ↩

437. MedCOI, Response to information request, BMA 13912, 27 August 2020. ↩

438. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

439. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

440. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

441. MedCOI, Response to information request, BMA 13854, 1 August 2020. ↩

442. MedCOI, Response to information request, BMA 12768, 4 September 2019. ↩

443. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

444. MedCOI, Response to information request, BMA 12586, 12 July 2019. ↩

445. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

446. MedCOI, Response to information request, BMA 13712, 12 June 2020. ↩

447. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

448. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

449. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

450. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

451. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

452. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

453. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

454. MedCOI, Response to information request, BMA 12906, 7 November 2019. ↩

455. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

456. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

457. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

458. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

459. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

460. MedCOI, Response to information request, BMA 11966, 22 September 2019. ↩

461. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

462. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

463. MedCOI, Response to information request, BMA 12722, 6 September 2019. ↩

464. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

465. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

466. MedCOI, Response to information request, BMA 13712, 12 June 2020. ↩

467. MedCOI, Response to information request, BMA 13712, 12 June 2020. ↩

468. MedCOI, Response to information request, BMA 12594, 22 July 2019. ↩

469. MedCOI, Response to information request, BMA 12594, 22 July 2019. ↩

470. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

471. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

472. MedCOI, Response to information request, BMA 12767, 19 July 2019. ↩

473. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

474. MedCOI, Response to information request, BMA 13432, 26 March 2020. ↩

475. MedCOI, Response to information request, BMA 12363, 15 May 2019. ↩

476. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

477. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

478. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

479. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

480. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

481. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

482. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

483. MedCOI, Response to information request, BMA 12726, 27 August 2019. ↩

484. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

485. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

486. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

487. MedCOI, Response to information request, BMA12608, 1 August 2019. ↩

488. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

489. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

490. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

491. MedCOI, Response to information request, BMA 12796, 27 September 2019. ↩

492. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

493. MedCOI, Response to information request, BMA 13190, 21 January 2020. ↩

494. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

495. MedCOI, Response to information request, BMA 12796, 27 September 2019. ↩

496. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

497. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

498. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

499. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

500. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

501. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

502. MedCOI, Response to information request, BMA 12109, 5 March 2019. ↩

503. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

504. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

505. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

506. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

507. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

508. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

509. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

510. MedCOI, Response to information request, BMA 12791, 25 September 2019. ↩

511. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

512. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

513. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

514. MedCOI, Response to information request, BMA 12608, 1 August 2019. ↩

515. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

516. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

517. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

518. MedCOI, Response to information request, BMA 13712, 12 June 2020. ↩

519. MedCOI, Response to information request, BMA 13082, 17 December 2019. ↩

520. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

521. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

522. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

523. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

524. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

525. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

526. MedCOI, Response to information request, BMA 13210, 5 February 2020. ↩

527. MedCOI, Response to information request, BMA 13210, 5 February 2020. ↩

528. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

529. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

530. MedCOI, Response to information request, BMA 13176, 6 January 2020. ↩

531. MedCOI, Response to information request, BMA 13190, 21 January 2020. ↩

532. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

533. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

534. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

535. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

536. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

537. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

538. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

539. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

540. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

541. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

542. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

543. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

544. MedCOI, Response to information request, BMA 12304, 29 April 2019. ↩

545. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

546. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

547. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

548. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

549. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

550. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

551. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

552. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

553. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

554. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

555. MedCOI, Response to information request, BMA 12336, 9 May 2019. ↩

556. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

557. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

558. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

559. MedCOI, Response to information request, BMA 12906, 7 November 2019. ↩

560. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

561. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

562. MedCOI, Response to information request, BMA 12109, 5 March 2019. ↩

563. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

564. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

565. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

566. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

567. MedCOI, Response to information request, BMA 13387, 9 March 2020. ↩

568. MedCOI, Response to information request, BMA 13176, 6 January 2020. ↩

569. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

570. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

571. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

572. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

573. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

574. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

575. MedCOI, Response to information request, BMA 12926, 13 November 2019. ↩

576. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

577. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

578. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

579. MedCOI, Response to information request, BMA 13569, 8 May 2020. ↩

580. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

581. MedCOI, Response to information request, BMA 12109, 5 March 2019. ↩

582. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

583. MedCOI, Response to information request, BMA 14098, 15 October 2020. ↩

584. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

585. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

586. MedCOI, Response to information request, BMA 12906, 7 November 2019. ↩

587. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

588. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

589. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

590. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

591. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

592. MedCOI, Response to information request, BMA 12363, 15 May 2019. ↩

593. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

594. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

595. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

596. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

597. MedCOI, Response to information request, BMA 12095, 11 March 2019. ↩

598. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

599. MedCOI, Response to information request, BMA 14127, 3 November 2020. ↩

600. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

601. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

602. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

603. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

604. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

605. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

606. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

607. MedCOI, Response to information request, BMA 12083, 19 April 2019. ↩

608. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

609. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

610. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

611. MedCOI, Response to information request, BMA 13176, 6 January 2020. ↩

612. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

613. MedCOI, Response to information request, BMA 12726, 27 August 2019. ↩

614. MedCOI, Response to information request, BMA 13192, 27 August 2020. ↩

615. MedCOI, Response to information request, BMA 12926, 13 November 2019. ↩

616. MedCOI, Response to information request, BMA 13210, 5 February 2020. ↩

617. MedCOI, Response to information request, BMA 12109, 5 March 2019. ↩

618. MedCOI, Response to information request, BMA 12726, 27 August 2019. ↩

619. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

620. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

621. MedCOI, Response to information request, BMA 12852, 17 October 2019. ↩

622. MedCOI, Response to information request, BMA 13851, 6 August 2020. ↩

623. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

624. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

625. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

626. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

627. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

628. MedCOI, Response to information request, BMA 14006, 15 September 2020. ↩

629. MedCOI, Response to information request, BMA 12230, 2 April 2019. ↩

630. MedCOI, Response to information request, BMA 14079, 6 October 2020. ↩

631. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

632. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

633. MedCOI, Response to information request, BMA 12722, 6 September 2019. ↩

634. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

635. MedCOI, Response to information request, BMA 12722, 6 September 2019. ↩

636. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

637. MedCOI, Response to information request, BMA 11966, 22 September 2019. ↩

638. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

639. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

640. MedCOI, Response to information request, BMA 13749, 9 July 2020. ↩

641. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

642. MedCOI, Response to information request, BMA 13082, 17 December 2019. ↩

643. MedCOI, Response to information request, BMA 13622, 25 May 2020. ↩

644. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

645. MedCOI, Response to information request, BMA 13298, 24 February 2020. ↩

646. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

647. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

648. MedCOI, Response to information request, BMA 13591, 9 June 2020. ↩

649. MedCOI, Response to information request, BMA 13736, 3 July 2020. ↩

650. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

651. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

652. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

653. MedCOI, Response to information request, BMA 13712, 12 June 2020. ↩

654. MedCOI, Response to information request, BMA 12036, 8 February 2019. ↩

655. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

656. MedCOI, Response to information request, BMA 13387, 9 March 2020. ↩

657. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

658. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

659. MedCOI, Response to information request, BMA 14098, 15 October 2020. ↩

660. MedCOI, Response to information request, BMA 12608, August 2019. ↩

661. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

662. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

663. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

664. MedCOI, Response to information request, BMA 13820, 6 August 2020. ↩

665. MedCOI, Response to information request, BMA 13508, 14 April 2020. ↩

666. MedCOI, Response to information request, BMA 13176, 6 January 2020. ↩

667. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

668. MedCOI, Response to information request, BMA 13508, 14 April 2020. ↩

669. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

670. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

671. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

672. MedCOI, Response to information request, BMA 12796, 27 September 2019. ↩

673. MedCOI, Response to information request, BMA 13190, 21 January 2020. ↩

674. MedCOI, Response to information request, BMA 13190, 21 January 2020. ↩

675. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

676. MedCOI, Response to information request, BMA 13163, 13 January 2020. ↩

677. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

678. MedCOI, Response to information request, BMA 13625, 27 May 2020. ↩

679. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

680. MedCOI, Response to information request, BMA 12216, 20 March 2019. ↩

681. MedCOI, Response to information request, BMA 12594, 22 July 2019. ↩

682. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

683. MedCOI, Response to information request, BMA 12926, 13 November 2019. ↩

684. MedCOI, Response to information request, BMA 14230, 2 December 2020. ↩

685. MedCOI, Response to information request, BMA 13920, 21 August 2020. ↩

686. MedCOI, Response to information request, BMA 13519, 22 April 2020. ↩

687. MedCOI, Response to information request, BMA 13668, 10 June 2020. ↩

688. MedCOI, Response to information request, BMA 12726, 27 August 2019. ↩

689. MedCOI, Response to information request, BMA 13718, 25 June 2020. ↩

690. MedCOI, Response to information request, BMA 13387, 9 March 2020. ↩

691. MedCOI, Response to information request, BMA 12592, 23 July 2019. ↩

692. MedCOI, Response to information request, BMA 13966, 26 August 2020. ↩

693. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

694. MedCOI, Response to information request, BMA 12363, 15 May 2019. ↩

695. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

696. MedCOI, Response to information request, BMA 13691, 17 June 2020. ↩

697. MedCOI, Response to information request, BMA 14229, 27 November 2020. ↩

698. MedCOI, Response to information request, BMA 13421, 24 March 2020. ↩

699. MedCOI, Response to information request, BMA 13579, 12 May 2020. ↩

700. MedCOI, Response to information request, BMA 14092, 16 October 2020. ↩

701. MedCOI, Response to information request, BMA 13883, 20 August 2020. ↩

702. MedCOI, Response to information request, BMA 13779, 21 July 2020. ↩

703. MedCOI, Response to information request, BMA 13702, 24 June 2020. ↩

704. MedCOI, Response to information request, BMA 13622, 25 May 2020. ↩