Réponses aux demandes d'information

Research Directorate, Immigration and Refugee Board of Canada

This Response replaces Response to Information Request NGA200342 of November 2020.

1. Overview

A July 2020 article by CNBC Africa, an African television network owned by Africa Business News and headquartered in Johannesburg (CNBC Africa n.d.), reports that there is a "lack of research on Nigeria's mental health demographics" (CNBC Africa 29 July 2020). In a telephone interview with the Research Directorate, the founder of the Mentally Aware Nigeria Initiative (MANI), an NGO "focused on raising awareness on mental health and illnesses as well as working to connect service users to mental health professionals" (Devex n.d.), noted that there is no recent mental health data (MANI 10 Oct. 2020). In a telephone interview with the Research Directorate, a research program director at the International Center for Research on Women (ICRW) [1] with experience working on mental health issues in Nigeria, speaking on their own behalf, similarly stated that there are no reliable statistics about mental illness in Nigeria, but added that mental illness is among the top five illnesses in the country (Research Program Director 7 Oct. 2022). A 2022 medical country information report on Nigeria by the EU Agency for Asylum (EUAA), citing email correspondence with a "[m]edical [d]octor and local consultant responsible for in-country data collection" for the report, also indicates that there is "limited reliable mental health prevalence data in Nigeria," because health care facilities do not "routinely" collect or report such data (EU Apr. 2022, 74).

Sources report that an estimated 20 to 30 percent of Nigerians suffer from "mental disorder[s]" (The Guardian 4 Dec. 2018; API and EpiAFRIC Jan. 2020, 5; The Eagle 14 Nov. 2018). An October 2019 Al Jazeera article indicates that, according to the WHO, around 50 million people, or one in four Nigerians, experience mental illness (Al Jazeera 2 Oct. 2019). Sources report that the "largest nationally representative study" on mental health in Nigeria, carried out by the WHO and published in 2004, found that one in eight Nigerians experienced a mental health condition during their lifetime (Africa Check 20 Nov. 2019; CNBC Africa 29 July 2020). For the year 2015, a WHO report estimates that approximately 7 million Nigerians suffered from depression (UN 2017, 17). According to the Research Program Director, mental illness is "very common" in Nigeria (Research Program Director 7 Oct. 2022). Sources report that studies have found that one in four people has a "diagnosable mental illness" (The Guardian 10 Oct. 2022) or "at least" 2 in 10 Nigerians have a form of mental illness (Research Program Director 7 Oct. 2022). In September 2022, the News Agency of Nigeria (NAN), an English-language news agency of the Nigerian federal government (NAN n.d.), citing the President of the Association of Psychiatrists in Nigeria (APN) [2], indicated that "more than 60 million Nigerians are suffering from mental illnesses" (NAN 11 Sept. 2022).

A study by Abiodun Adewuya et al., based on "a face to face household survey completed by 11,246 adult participants (age 18–75 years)" in Lagos State and published in 2018 in Comprehensive Psychiatry, a peer-reviewed journal (Elsevier n.d.a), reports the following results concerning prevalence, comorbidity and associated factors for depression and generalised anxiety:

The weighted current prevalence of symptoms of depression, generalised anxiety and combined depression/generalised anxiety were 5.5% … , 3.5% … and 1.2% … respectively. About 20.9% of all cases of depressive symptoms have co-morbidity with symptoms of generalised anxiety. Symptoms of depression and generalised anxiety had high co-morbidity with somatic symptoms, alcohol use problems and disability but not substance use disorders. Being female, not married (especially separated/divorced or widowed) and unemployment were significantly associated with presence of either symptoms of depression or generalised anxiety (Adewuya, et al. Feb. 2018, 61).

According to a country information report by Australia's Department of Foreign Affairs and Trade (DFAT), "[m]ental health has historically been neglected on Nigeria’s health and development policy agenda" (Australia 3 Dec. 2020, para. 2.24).

1.1 Impact of COVID-19 on Mental Health in Nigeria

According to Voice of America (VOA), a US-based international broadcaster that is funded by the US Congress (VOA n.d.), "Nigerian officials say social distancing and the coronavirus pandemic's impact on the economy have tripled the number of mental health cases" (VOA 18 May 2021). UNICEF also states that, according to an international survey conducted by UNICEF and Gallup, 1 in 6 survey participants aged 15–24 reported that "they often feel depressed, have little interest in doing things, or are worried, nervous or anxious" (UN 5 Oct. 2021). In an article on the psychological impact of COVID-19 in Nigeria published in [the peer-reviewed journal (Elsevier n.d.b)] Social Sciences & Humanities Open (SSHO), based on an online survey of 502 Nigerians conducted from March to April 2020, Abayomi Olaseni et al. note their finding that "Nigerians experienced psychological distress during [the] COVID-19 pandemic": 15 percent of respondents reported experiencing insomnia, 23 percent reported experiencing moderate to severe depression, 25 percent reported experiencing symptoms of "severe" post-traumatic stress disorder (PTSD), and 18.1 percent reported experiencing symptoms of clinical PTSD (Olaseni, et al. 26 Aug. 2020, 5).

Human Rights Watch (HRW) states that people who have "or are thought to have" mental health conditions "are chained and locked up in various facilities, including state-run rehabilitation centers and psychiatric hospitals, and traditional and faith-based rehabilitation centers" and are also "likely to get little or no necessary healthcare, despite being at extreme risk" of COVID-19 (HRW 30 Mar. 2020).

2. Availability of Mental Health Services

The US Department of State's Country Reports on Human Rights Practices for 2021 notes that "[m]ental health-care services were almost nonexistent" in Nigeria (US 12 Apr. 2022, 50). The founder of MANI noted that access to and quality of mental health care are "poor" (MANI 10 Oct. 2020). The same source indicated that people cannot access mental health services for early intervention (MANI 10 Oct. 2020).

A March 2018 Australian DFAT country information report on Nigeria states that

[t]he government reports approximately five psychiatric nurses per 100,000 population and very few clinical psychologists, social workers, neuro-physiotherapists, and occupational therapists. Psychotropic drugs are rarely available and health information systems do not incorporate mental and neurological health measures. (Australia 9 Mar. 2018, para. 2.20)

Other sources report that there are "not enough" (CNN 25 Sept. 2020) or "too few" (Nigeria Health Watch 15 Jan. 2020) mental health professionals in Nigeria (CNN 25 Sept. 2020; Nigeria Health Watch 15 Jan. 2020). The founder of MANI stated that mental health services in Nigeria are limited and that there are "few" psychiatrists and psychologists (MANI 10 Oct. 2020). The APN's website indicates that there are 250 psychiatrists and 200 psychiatry trainees who are members of the APN (APN n.d.b). A September 2019 article by the UK's Guardian newspaper notes that "[m]ental health professionals are rare in Nigeria" and reports that "there are an estimated 150 practicing psychologists" (The Guardian 25 Sept. 2019). An article by the Guardian, a newspaper in Nigeria, reports that according to the Medical Director of the Federal Neuro Psychiatric Hospital - Yaba in Lagos State, Nigeria has "'about 300'" psychiatrists "'to treat about 200 million people'" and the number of clinical psychologists "'is even lower. There is a scarcity of psychiatric nurses, social workers, and occupational therapists'" (The Guardian 10 Oct. 2022). Similarly, the Al Jazeera article indicates that there are fewer than 150 psychiatrists in Nigeria, and that the "WHO estimates that fewer than 10 percent of mentally ill Nigerians have access to the care they need" (Al Jazeera 2 Oct. 2019). According to the Christian Science Monitor, an international newspaper published by the First Church of Christ, Scientist (The Christian Science Monitor n.d.), "just 300 psychiatrists serve Nigeria’s 206 million citizens" (The Christian Science Monitor 10 May 2022). Nigeria's Guardian newspaper indicates that "about 75 per cent of those who need mental health care do not have access to it, as Nigeria has only 300 psychiatrists to treat about 200 million people" (The Guardian 10 Oct. 2022). A Nigerian government report on the second National Strategic Health Development Plan states that "[o]nly 20% of Nigerians with serious mental illnesses (SMI) have received treatment in the prior 12 months, showing the level of neglect for mental healthcare in the country" (Nigeria [5 Sept. 2018], 25).

Sources report that "only 3.3 percent (The Guardian 25 Sept. 2019; Nigeria [5 Sept. 2018], 25) or "[j]ust" 3.5 percent (The Christian Science Monitor 10 May 2022) of Nigeria's health budget is allocated to mental health (The Guardian 25 Sept. 2019; Nigeria [5 Sept. 2018], 25; The Christian Science Monitor 10 May 2022). The UK Guardian article adds that the limited budget "leaves the public system chronically understaffed" (The Guardian 25 Sept. 2019). The Research Program Director similarly stated that the mental health care system lacks financial resources, and the capacity of mental health care services is not enough to meet the needs of the population (Research Program Director 7 Oct. 2022). According to the Punch, a daily Nigerian newspaper, "[a]pproximately 80% of Nigerians with mental health needs cannot access care due to several … obstacles," the most "significant" of which are the "lack of funds, facilities, [and] mental health personnel" as well as "cultural and religious stigma" around mental health issues (The Punch 5 Jan. 2022). Similarly, according to the NAN, the President of the APN stated that among more than 60 million Nigerians who suffer from mental illnesses, "only about" 10 percent successfully accessed "appropriate care" (NAN 11 Sept. 2022).

Sources report that there are 8 federal neuropsychiatric hospitals in Nigeria (CNBC Africa 29 July 2020; Nigeria n.d.; Australia 3 Dec. 2020, para. 2.26). Similarly, the Research Program Director indicated that mental health services are provided "for the most part" by eight regional neuropsychiatric hospitals with the "main" one located in Lagos (Research Program Director 7 Oct. 2022). According to the Australian DFAT, the eight hospitals have a total of "around" 4,000 beds (Australia 3 Dec. 2020, para. 2.26). The same source states that there are 3 state-run hospitals located in Port Harcourt, Ondo, and Anambra (Australia 3 Dec. 2020, para. 2.26). Citing the Medical Director of the Federal Neuro Psychiatric Hospital - Yaba, Nigeria's Guardian reports that there are "only" nine federal psychiatric hospitals, including one in each of the six geopolitical zones (The Guardian 10 Oct. 2022).

An October 2020 BBC article observes that there are fewer than 15 state-run neuropsychiatric centres in Nigeria, which restricts access for many individuals, particularly in rural areas (BBC 3 Oct. 2020). In correspondence with the Research Directorate, the WHO Nigeria Country Office stated that "[i]npatient and outpatient mental health services including psychological and psychiatric services are available in Nigeria. However, access to comprehensive mental health services [is] more readily available in urban areas compared to rural areas" (UN 7 Oct. 2020). A resident psychiatrist at the Federal Neuropsychiatric Hospital in Lagos interviewed by CNN stated that "'we don't really have [mental health professionals] in rural areas. And if someone lives in such areas without mental health care, of course, they will find alternatives for care like traditional healers or churches'" (CNN 10 Oct. 2020). In a January 2019 interview with YaleNews, an assistant professor of psychiatry who, along with a group of researchers, started the Health Action for Psychiatric Problems in Nigeria Including Epilepsy and Substances (HAPPINESS Project), a project with the goal of increasing access to treatment for mental health conditions and epilepsy in underserved parts of the country, observed that in Imo State people need to travel four to six hours to see a psychiatrist and that many people requiring mental health services "'typically'" do not make the trip (Yale University 9 Jan. 2019).

A 2019 HRW report on the treatment of people with mental health conditions in Nigeria [3] states that "several" mental health professionals reported to HRW that "quality mental health services are available only to wealthier citizens who can afford it" (HRW 11 Nov. 2019). A WHO Mental Health Atlas profile on Nigeria indicates that people with mental health conditions "pay mostly or entirely out of pocket for services and medicines" (UN 2018).

The HRW report notes that, because of the limited access to and high cost of quality mental health care, people "often" seek advice from traditional or faith-based healers (HRW 11 Nov. 2019). The October 2020 BBC article observes that with fewer "than 300 psychiatrists in a country with a population of around 200 million, families often turn to traditional healing centres, and faith-based facilities, both Christian and Muslim" (BBC 3 Oct. 2020). According to the Australian DFAT report, "[t]here 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" (Australia 3 Dec. 2020, para. 2.24).

VOA indicates that in May 2021 Nigeria launched "a toll-free 24-hour helpline staffed by trained psychologists and counselors" in response to the impact of COVID-19 on mental health (VOA 18 May 2021). The same source states that it was "Nigeria's first toll-free line focused on mental health issues" and is "part of a joint effort between the government and a group of private counselors to address increasing mental health cases in the country" (VOA 18 May 2021). Business Day, a Nigerian newspaper, reports that in May 2021 the government of Nigeria launched the toll-free 112 mental health helpline "to provide nationwide free tele-counseling services to address the adverse and worsening psychological effects of the COVID-19 pandemic" (Business Day 11 May 2021).

3. Situation and Treatment of Persons with Mental Illness
3.1 Treatment by Society

Sources report that there is limited mental health awareness in Nigeria (CNN 25 Sept. 2020; API and EpiAFRIC Jan. 2020, 6; Ugochukwu, et al. Aug. 2020). According to sources, mental health issues are stigmatized in Nigeria (Australia 9 Mar. 2018, para. 2.21; UN 7 Oct. 2020, 6; MANI 10 Oct. 2020). However, the WHO representative noted that knowledge regarding mental health conditions is "increasing" and there are "several" ongoing anti-stigma campaigns (UN 7 Oct. 2020). The founder of MANI indicated that "mental illness is very stigmatized; it's improving a bit on the internet, but on the ground it is still bad" (MANI 10 Oct. 2020).

The BBC article states that even in regions with mental health facilities available, the stigma associated with mental health treatment prevents people from seeking treatment for family members (BBC 3 Oct. 2020). Similarly, the founder of MANI noted that people are "afraid to seek treatment" due to the stigma and that people will also travel to hospitals in other regions due to the stigma of visiting a local hospital (MANI 10 Oct. 2020). The same source stated that "[s]tigma and lack of education mean people do not access services" (MANI 10 Oct. 2020). According to the Christian Science Monitor, citing a consultant psychiatrist at the University of Maiduguri, "[t]he stigma surrounding mental health in Nigeria is sustained by a culture of silence and outdated portrayals in local media" (The Christian Science Monitor 10 May 2022).

The BBC article observes that "[i]n some communities, mental illness is seen as a taboo and the mentally ill are referred to as 'mad people', ex-communicated by their families, [and] forced to roam the streets in tattered clothes and eat from rubbish dumps" (BBC 3 Oct. 2020). The founder of MANI noted that, when people in Nigeria think about mental illness, they think about "madness," psychosis, and mania (MANI 10 Oct. 2020). According to a report on a 2019 national survey of 5,315 respondents on mental health in Nigeria conducted by the Africa Polling Institute (API) [4] and EpiAFRIC [5], those respondents who stated that "mental health disease" is incurable gave reasons for this belief that included the following: 31 percent indicated that "they see a lot of mad people around" and assume that there must be "no cure," 26 percent indicated they "believe it is due to possession by evil spirits," 17 percent indicated they "believe it is a curse from God," and 13 percent indicated they "believe it is a punishment for wrong doing" (API and EpiAFRIC Jan. 2020, 14, 25).

The API and EpiAFRIC report states that most respondents associated mental ill health much more with "overt signs" than "covert signs," noting that the majority of respondents believed that mental illness is "[w]hen someone starts running around naked" (70 percent of respondents) or "[w]hen someone starts talking to himself or herself" (63 percent of respondents) (API and EpiAFRIC Jan. 2020, 29, 18). The WHO representative indicated that there are varying levels of stigma with different mental health conditions (UN 7 Oct. 2020). The founder of MANI stated that psychotic conditions are more stigmatized because they are more visible, and that depression, PTSD, and other conditions are "more invisible," but that talking about these conditions is still stigmatized (MANI 10 Oct. 2020). Similarly, the Research Program Director stated even though mentalities are gradually evolving, mental illness is "generally" stigmatized in; however, "for the most part" the stigma is attached to "heavy" conditions such as schizophrenia and psychotic disorders while conditions such as depression and anxiety disorders are "more tolerated" (Research Program Director 7 Oct. 2022).

According to a consultant psychiatrist interviewed by the BBC, "'most'" people view mental illness as a "'spiritual problem'," and "'they seek help from spiritual leaders and traditional healers hoping to exorcise the evil spirit responsible'" (BBC 3 Oct. 2020). The Australian DFAT report indicates that "many families hid[e] conditions or blam[e] family members' mental illness on curses or witchcraft" (Australia 9 Mar. 2018, para. 2.21). The HRW report on the treatment of people with mental health conditions in Nigeria indicates that a "misunderstanding" of mental health conditions, including the "misperception that they are caused by evil spirits or supernatural forces, often prompt[s] relatives to take their loved ones to religious or traditional healing places" (HRW 11 Nov. 2019). According to the API and EpiAFRIC report, 84 percent of respondents felt that mental health issues were caused by "drug abuse," 54 percent of respondents felt that they were caused by "'[p]ossession by evil spirits'," and 23 percent felt that they were "a result of God's punishment" (API and EpiAFRIC Jan. 2020, 19).

The WHO representative stated that "[i]t is quite challenging for people with mental illness in Nigeria as they are subjected to discrimination, harassment, abuse, or violence" (UN 7 Oct. 2020). The founder of MANI indicated that people with mental health conditions, especially those who are homeless, are subject to harassment and violence (MANI 10 Oct. 2020). The head of a psychiatrists' union reported to BBC that the practice of mistreating and "'locking up'" mentally ill people is "'widespread'" across Nigeria (BBC 3 Oct. 2020).

The founder of MANI stated that family members or community members will keep people with mental health conditions inside, monitor them and hide them from the rest of the community to avoid the stigma and to protect them (MANI 10 Oct. 2020). The same source noted that family members also restrict the rights of people with mental health conditions by denying them their property rights and refusing to allow them to get married (MANI 10 Oct. 2020). The Research Program Director noted that "many" people living with mental illness are "mostly" rejected by their family members, friends and acquaintances and those who try to help them use the services of traditional ritualists or herbalists and religious healers as there are still strong beliefs that mental illness is associated with possession by evil spirits (Research Program Director 7 Oct. 2022). According to an article on community-based psychiatric care in Nigeria by Modupeoluwa Omotunde Soroye et al. published in the Journal of Multidisciplinary Healthcare, a peer-reviewed journal published by Dove Medical Press (Dove Medical Press n.d.), "in some quarters" in Nigeria it is "taboo" to discuss depression and schizophrenia and "[s]ome view people with schizophrenia as witches or demon[-]possessed" (Soroye, et al. 20 May 2021, 1146).

According to API and EpiAFRIC, if someone has a "mental health disease," 65 percent of respondents indicated that they would "quickly take the person to the hospital," 18 percent of respondents indicated that they would "take the person to a prayer house for deliverance," 8 percent of respondents indicated that they would "take the person to a traditional medicine healer," 4 percent of respondents indicated that they would "lock up the person," and 2 percent of respondents indicated that they would "beat the disease out of the person" (API and EpiAFRIC Jan. 2020, 21).

The founder of MANI indicated that the use of traditional medicine to treat mental health conditions is "very common" and that, for "most people," the first person they call when someone is mentally ill is a religious leader or a traditional healer (MANI 10 Oct. 2020). The same source noted that this treatment is harmful and that during the treatment, individuals "are usually tied up" and sometimes beaten to "try to beat the demons out of them," adding that "they are chained for years" (MANI 10 Oct. 2020). The Australian DFAT report states that "DFAT is aware of several cases in rural areas of individuals suffering from a mental illness being chained and/or caged in churches or dwellings" (Australia 9 Mar. 2018, para. 2.21). The HRW report on the treatment of people with mental health conditions observes that "[t]housands of people with mental health conditions across Nigeria are chained and locked up in various facilities where they face terrible abuse" (HRW 11 Nov. 2019). The same source notes that "[d]etention, chaining, and violent treatment are pervasive in many settings, including state hospitals, rehabilitation centers, traditional healing centers, and both Christian and Islamic faith-based facilities" (HRW 11 Nov. 2019). The same source reports that, at 27 of 28 facilities visited by HRW, "all residents had been unlawfully detained. They did not enter the facilities voluntarily and could not leave if they wished to do so" (HRW 11 Nov. 2019). The BBC article reports that "a 32-year-old man was chained up for at least seven years in his parents' garage in north-western Kano state" (BBC 3 Oct. 2020). The BBC article also notes that a 55-year-old man in Kano was found to have been locked up by his family for 30 years because of his mental illness (BBC 3 Oct. 2020). According to Reuters, there has been a "crackdown" by authorities on Islamic schools and rehabilitation centres (Reuters 5 Nov. 2019). The same source reports that in October 2019 President Buhari's office issued a statement that said "'[n]o responsible democratic government would tolerate the existence of the torture chambers and physical abuses of inmates in the name of rehabilitation of the victims'" (Reuters 5 Nov. 2019). CNN reports that "hundreds of people held under inhumane conditions" have been rescued in a "clampdown" on religious rehabilitation centres (CNN 10 Oct. 2020). Reuters notes that, as of November 2019, "nearly" 1,500 people had been "rescued from abusive institutions" (Reuters 5 Nov. 2019). However, an article co-authored by a senior researcher in the disability rights division of HRW and the founder of the Samuel Center for Social Connectedness notes that "[t]he government has also yet to acknowledge that chaining is happening in government-run facilities as well as traditional and other religious centers that are not Islamic" (Ćerimović and Samuel 7 Apr. 2020).

3.2 Treatment by Authorities

Information on the treatment of people with mental illness by authorities was scarce among the sources consulted by the Research Directorate within the time constraints of this Response.

The founder of MANI indicated that it is not common for people to call the police in cases of mental illness and that people generally try to manage it themselves or call someone they know to help (MANI 10 Oct. 2020). The same source noted that when the police are called because of an incident, it is common for them to use "more" force (MANI 10 Oct. 2020). Corroborating information could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

The HRW report indicates that "[i]n some cases" police arrest people with real or "perceived" mental health conditions and take them to government-operated rehabilitation centres (HRW 11 Nov. 2019). The same source reports that at these rehabilitation centres

many are shackled with iron chains, around one or both ankles, to heavy objects or to other detainees, in some cases for months or years. They cannot leave, are often confined in overcrowded, unhygienic conditions, and are sometimes forced to sleep, eat, and defecate within the same confined place. Many are physically and emotionally abused as well as forced to take treatments. (HRW 11 Nov. 2019)

The Research Program Director also noted that police agents sometimes arrest people with mental illness "without reasons" as many of them become homeless after being rejected by their families (Research Program Director 7 Oct. 2022). Corroborating information could not be found among the sources consulted by the Research Directorate within the time constraints of this Response.

The EUAA, citing the Second National Strategic Health Development Plan (NSHDP II) 2018-2022 by Nigeria's Federal Ministry of Health (FMOH), notes that challenges to accessing mental health care in Nigeria include

• "weak legislative support" for updating existing laws
• limited budget ("only" 3.3 percent of government health spending goes to mental health)
• "acute shortages of skilled human resources" to provide specialized care
• a "dearth of non-specialised skills" in "lower levels" of care that would allow the detection and management of mental health issues
• "failure" to integrate mental health into primary care provision
• a "lack of mental health programmes especially at lower levels of care" (EU Apr. 2022, 76).

US Country Reports 2021 indicates that, "[g]enerally," prisons made "few" efforts to offer mental health services or accommodations to prisoners with mental disabilities (US 12 Apr. 2022, 12).

4. State Protection
4.1 Legislation

The founder of MANI stated that there is no legislation to protect mentally ill people (MANI 10 Oct. 2020). Sources report that the 1958 Lunacy Act [or Law] is the basis of mental health law in Nigeria (Premium Times 23 Feb. 2020; CNBC Africa 29 July 2020). The WHO representative stated that "[t]he lack of a legal framework for protecting the human rights of people with mental illness is outdated as the Lunacy Act of 1958 subsists. The provisions of the Lunacy Act are not aligned with current international human rights standards" (UN 7 Oct. 2020). Sources report that, under the Lunacy Act, people with mental health conditions can be detained even without being provided medical treatment (HRW 11 Nov. 2019; CNN 10 Oct. 2020). According to sources, the government introduced a mental health bill in 2003, but it was withdrawn in 2009; it was then reintroduced in 2013 (Australia 9 Mar. 2018, para. 2.19; CNBC Africa 29 July 2020; Premium Times 23 Feb. 2020) but was not passed (CNBC Africa 29 July 2020; Premium Times 23 Feb. 2020). Sources report that a new mental health bill passed a second reading in October or November 2019 and that the Senate held a public hearing on the proposed legislation in February 2020 (CNBC Africa 29 July 2020; Premium Times 23 Feb. 2020). A November 2019 article by the Premium Times, a Nigerian online newspaper based in Abuja (Premium Times n.d.), indicates that the bill seeks to create a commission for mental health (Premium Times 20 Nov. 2019). The same source further reports that the lawmaker who introduced the bill stated that the bill aims to provide increased regulation of mental health and substance abuse services, and to protect persons with mental health issues (Premium Times 20 Nov. 2019). An article by Nigeria's Guardian newspaper reports that the president of the APN stated that the bill will protect the human rights of persons with mental illness, ensure they have access to effective and humane treatment, and require the government to provide funding for mental health (The Guardian 13 Jan. 2020). An October 2020 article by Vanguard, a Nigerian daily newspaper, reports that the Chairman of the Senate Committee on Health stated that the bill provides for the protection of the rights of people with mental illness, lays out different types and levels of management and treatment for mental health, establishes a committee to review the cases of people who require involuntary treatment, and addresses illegal forms of treatment (Vanguard 14 Oct. 2020). According to media sources, NGOs called in October 2022 for the bill to be passed (The Punch 18 Oct. 2022; The Nation 18 Oct. 2022), as it was waiting on the President's signature (The Nation 18 Oct. 2022).

Sources report that attempted suicide is a criminal offence and carries a penalty of up to one year in prison (The Guardian 25 Sept. 2019; MANI 10 Oct. 2020; Premium Times 29 Sept. 2019).

The information in the following paragraph was provided in a CNN article:

In 2015, Lagos State revised its law to advise hospital treatment for suicide attempt survivors; however, the law has not been changed at the national level. "There are frequent reports in local media of survivors being arrested and tried for attempting suicide." In 2017, a 25year-old man was arrested and detained for weeks for attempting suicide. The man said that he and other inmates were "'beaten'" and "'forced to take pills'." A health law expert stated that while jail sentences for attempting suicide are "rare," "it is the process of arresting and taking [suicide survivors] through a legal process that is particularly cruel" (CNN 31 Dec. 2018).

4.2 Recourse and Complaint Mechanisms

The WHO representative indicated that the Constitution of the Federal Republic of Nigeria and laws such as the National Health Act, 2014 apply to cases of abuse (UN 7 Oct. 2020). The founder of MANI noted that there is no legal recourse for people to complain because there is no legal framework [for mental illness] (MANI 10 Oct. 2020). The Research Program Director also indicated that there are no complaint mechanisms provided by the government in case of abuse, mistreatment, or violence against people with mental health conditions and there are no rules in terms of how officials and governmental agents should treat them (Research Program Director 7 Oct. 2022). The same source noted that individuals who suffer from "heavy conditions" such as schizophrenia do not know how to file a complaint (Research Program Director 7 Oct. 2022). However, the source noted that in cases of abuse or mistreatment it is possible for a relative to file a complaint on behalf of a person with a mental health condition if the latter is unable to do so, but the complaint will not receive any specific or special treatment as a result of the victim's mental illness (Research Program Director 7 Oct. 2022).

4.3 Examples of Non-Governmental Advocacy and Support Services

The Research Program Director indicated that there are "some" NGOs involved in helping people with mental health conditions that are having a "strong" impact on mental health care; MANI is one such NGO, providing support services and psychological counselling throughout the country (Research Program Director 7 Oct. 2022). The UK's Guardian states that MANI has a 24-hour mental health support service that allows people to seek support over WhatsApp or Twitter, an emergency response team of volunteer counsellors, and a 24-hour confidential suicide hotline (The Guardian 25 Sept. 2019). According to Soroye et al., "MANI has over 1500 youth volunteers across Nigeria who aim to destigmatize mental health"; the organization works to educate the public and allow youth to access mental health care without "fea[r] of discrimination" (Soroye, et al. 20 May 2021, 1146). An article on the situation in Nigeria during COVID-19 for people living with mental health conditions by Abdullahi Tunde Aborode et al. published in the International Journal of Health Planning and Management, a peer-reviewed journal (John Wiley & Sons, Inc. n.d.), also notes that MANI "provided free of cost online sessions to individuals at home with anxiety disorders" during the COVID-19 pandemic (Aborode, et al. 25 Nov. 2021, 1195). The Australian DFAT also reports the following about MANI and other NGOs involved in mental health services:

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. (Australia 3 Dec. 2020, para. 2.27)

The Borgen Project, a US-based non-profit organization that uses political advocacy to address global poverty (The Borgen Project n.d.), lists the following three NGOs as improving mental health in Nigeria alongside MANI: The Love, Peace and Mental Health Foundation (LPM), She Writes Woman, and the Neem Foundation (The Borgen Project 23 Sept. 2019).

LPM, an NGO based in Lagos (LPM n.d.a), provides support for people with mental illness, including low-cost therapy sessions, treatment, and free consultations (LPM n.d.b). According to the Borgen Project, LPM "carries out advocacy and awareness campaigns [for] youth in Nigeria" (The Borgen Project 23 Sept. 2019). Sources report that LPM also runs a monthly men's only mental health support group (LPM n.d.c; The Borgen Project 23 Sept. 2019). The Borgen Project adds that LPM also partners with "various psychologists and consultants to provide free therapy sessions during these meetings" (The Borgen Project 23 Sept. 2019).

She Writes Woman is a women-led organization that promotes mental health in Nigeria (She Writes Woman n.d.a). According to sources, the NGO operates a privately run mental health helpline (She Writes Woman n.d.b; The Borgen Project 23 Sept. 2019). The organization's website indicates that it hosts monthly women-only mental health support groups in the cities of Lagos, Abuja, Ibadan and Kaduna (She Writes Woman n.d.b). The Borgen Project similarly reports that She Writes Woman "curates" Safe Place, a support group for women in Nigeria to "meet, discuss mental health issues and get the help they need," noting that more that 800 women have benefitted from the service (The Borgen Project 23 Sept. 2019). Sources report that the organization also runs a walk-in clinic ["Safe Place Nigeria" (The Borgen Project 23 Sept. 2019)] that provides mental health care for young people (She Writes Woman n.d.b; The Borgen Project 23 Sept. 2019).

The Neem Foundation, an NGO "that is committed to improving the lives of those affected by the North-East insurgency in Nigeria" (Neem Foundation n.d.a), provides psychological support services in Borno State through its Counselling on Wheels program (Neem Foundation n.d.b; The Borgen Project 23 Sept. 2019). An August 2017 Reuters article reports that the Counselling on Wheels program uses tricycles to take psychologists and counsellors to remote communities to provide psychological and social services (Reuters 24 Aug. 2017). Sources report that the Neem Foundation also provides psychological support, including child-centred therapy and trauma care (The Borgen Project 23 Sept. 2019; Neem Foundation n.d.b), through its psychology centre in Borno State (Neem Foundation n.d.b).

An article by Michael O. Ezenwa published on the website of the American Psychological Association (APA) indicates that in response to the COVID-19 pandemic, the Nigerian Psychological Association (NPA) created a team to bring free "telepsychological services" to the public (Ezenwa 11 July 2021). Without providing further information, the source lists a number of other "programs" implemented by the NPA in response to the pandemic, including

• psychological assessment and mental health intervention for people experiencing health-related crises
• "[p]sychoeducation" to reduce community transmission of COVID-19
• psychosocial support counselling
• psychotherapy for "[h]ealthy [a]djustment"
• community counselling after COVID-19
• research into impact and "[t]reatment [e]fficacy"
• "[o]ngoing" free tele-psychological services for Nigerians
• counselling and psychotherapy for frontline health workers aimed at dispelling fear of contamination, improving self-esteem and providing "supportive therapy"
• psychological assessment for people in quarantine and isolation centres and for newly trained frontline health workers
• online self-care training for health workers
• psychoeducation to promote "[a]daptive [c]oping [b]ehaviours" in crisis situations (Ezenwa 11 July 2021).

5. Public Health Care Availability, Particularly in Abuja, Lagos, Ibadan, and Port Harcourt
5.1. Legislation Relating to the Availability of Health Care in Nigeria

The National Health Act, 2014 provides the following:

PART I–RESPONSIBILITY FOR HEALTH AND ELIGIBILITY FOR HEALTH SERVICES AND ESTABLISHMENT OF NATIONAL HEALTH SYSTEM

1.–

1. There is established for the Federation the National Health System, which shall define and provide a framework for standards and regulations of health services, without prejudice to extant professional regulatory laws and which shall–
   
   1. encompass public and private providers of health services ;
   2. promote a spirit of co-operation and shared responsibility among all providers of health services in the Federation and any part thereof ;
   3. provide for persons living in Nigeria the best possible health services within the limits of available resources ;
   4. set out the rights and obligations of health care providers, health workers, health establishments and users; and
   5. protect, promote and fulfil the rights of the people of Nigeria to have access to health care services.
2. The National Health System shall include–
   
   1. the Federal Ministry of Health ;
   2. the Ministry of Health in every State and the Federal Capital Territory Department responsible for Health ;
   3. parastatals under the federal and state ministries of health ;
   4. all local government health authorities ;
   5. the ward health committees ;
   6. the village health committees ;
   7. the private health care providers ;
   8. traditional health care providers ; and
   9. alternative healthcare providers.

…

11.–

1. There is established the Basic Health Care Provision Fund (in this Act referred to as "the Fund").
2. The Basic Health Care Provision Fund shall be financed from–
   
   1. Federal Government annual grant of no less than one per cent its Consolidated Revenue Fund.
   2. grants by international donor partners ; and
   3. funds from any other source.
3. Money from the Fund shall be used to finance the following–
   
   1. 50% of the Fund shall be used for the provision of basic minimum package of health services to citizens, in eligible primary or secondary health care facilities through the National Health Insurance Scheme (NHIS) ;
   2. 20 percent of the Fund shall be used to provide essential drugs, vaccines and consumables for eligible primary health care facilities ;
   3. 15 per cent of the Fund shall be used for the provision and maintenance of facilities, equipment and transport for eligible primary healthcare facilities ; and
   4. 10 per cent of the Fund shall be used for the development of human resources for primary health care ;
   5. 5 percent of the Fund shall be used for emergency medical treatment to be administered by a Committee appointed by the National Council on Health.
4. The National Primary Health Care Development Agency shall disburse the funds for subsection 3(b), (c) and (d) of this section through State and Federal Capital Territory Primary Health Care Boards for distribution to local Government and Area Council Health Authorities.
5. For any State or Local Government to qualify for a block grant pursuant to sub-section (1) of this section, such State or Local Government shall contribute–
   
   1. in the case of a State, not less than 25 per cent of the total cost of projects ; and
   2. in the case of a Local Government, not less than 25 per cent of the total cost of projects as their commitment in the execution of such projects.
6. The National Primary Health Care Development Agency shall not disburse money to any–
   
   1. Local Government Health Authority if it is not satisfied that the money earlier disbursed was applied in accordance with the provisions of this Act ;
   2. State or Local Government that fails to contribute its counterpart funding ; and
   3. States and Local Governments that fail to implement the national health policy, norms, standards and guidelines prescribed by the National Council on Health.
7. The National Primary Health Care Development Agency shall develop appropriate guidelines for the administration, disbursement and monitoring of the Fund with the approval of the Minister. (Nigeria 2014, bold and italics in original)

5.2 Availability of Public Health Care in Nigeria

According to the US Agency for International Development (USAID), "[h]ealth indicators in Nigeria are some of the worst in Africa" (US 13 June 2022). The Research Program Director stated that the public health care available in Nigeria is insufficient to cover the needs of the population since it is "poorly implemented" (Research Program Director 7 Oct. 2022). The Australian DFAT notes that health care provision is divided between the public and private sectors, "with the private sector providing around 60 per cent of health service delivery" (Australia 3 Dec. 2020, para. 2.20).

The Australian DFAT also notes that "Nigeria's health system faces significant challenges in meeting the needs of its population" (Australia 3 Dec. 2020, para. 2.21). A March 2022 article on health care in Nigeria by Ibrahim Abubakar et al. published by the Lancet, a peer-reviewed medical journal (The Lancet n.d.), notes that "[i]ndicators of health outcomes and coverage of basic health services in Nigeria show long-standing underperformance," "many state government struggle to mount the required funding to support their health systems" and the number of health workers "is relatively low" (Abubakar, et al. 15 Mar. 2022, 1173, 1177, 1178). According to the same source, "Nigeria continues to spend very little on health and health care compared with its peers in the region and around the world" (Abubakar, et al. 15 Mar. 2022, 1187). CNBC, citing data from the World Bank, similarly notes that "Nigeria's public spending on health care amounts to just 3.89% of its $495 billion GDP," whereas that figure is 5.17 percent in Kenya and 8.25 percent in South Africa (CNBC 4 Jan. 2021). HRW also notes that "Nigeria's healthcare system is plagued with chronic underfunding and limited infrastructure" (HRW 25 Mar. 2020).

Ibrahim Abubakar et al. note that corruption in Nigeria's health sector "impedes access to health care" (Abubakar, et al. 15 Mar. 2022, 1186). Similarly, a report on Nigeria generated by WHO as part of its Primary Health Care Systems (PRIMASYS) case studies notes that "[c]orruption in the health sector has made various health institutions ineffective," and the "scarce resources invested in the sector are wasted" (UN 2017, 28).

5.3 Public Health Care Availability in Abuja, Lagos, Ibadan, and Port Harcourt

Information on public health care availability in Abuja, Lagos, Ibadan, and Port Harcourt was scarce among the sources consulted by the Research Directorate within the time constraints of this Response. The Research Program Director noted that there is "not really" a difference between public health care availability in Abuja, located in the Federal Capital Territory (FCT), Lagos in Lagos State, Ibadan in Oyo State and Port Harcourt in Rivers State (Research Program Director 7 Oct. 2022).

This Response was prepared after researching publicly accessible information currently available to the Research Directorate within time constraints. This Response is not, and does not purport to be, conclusive as to the merit of any particular claim for refugee protection. Please find below the list of sources consulted in researching this Information Request.

Notes

[1] The International Center for Research on Women (ICRW) is a global research institute with offices located in Washington, DC; New Delhi, Nairobi, and Kampala, whose mission is to promote "gender equity, social inclusion and shared prosperity" (ICRW n.d.).

[2] The Association of Psychiatrists in Nigeria is an association of psychiatrists and "registered affiliates" from across Nigeria and the diaspora (APN n.d.a), which is "committed to holistic care for persons with mental illness and the promotion of positive mental health" (APN n.d.b).

[3] The report was based on visits to 28 mental health facilities in 8 states and the Federal Capital Territory from August 2018 to September 2019 and interviews with 124 people, including 49 victims of chaining (fastening of a person's ankle to a chain and attaching it to a heavy object, or using shackles around both ankles) and their families, employees of different facilities, mental health professionals, and government officials (HRW 11 Nov. 2019).

[4] The Africa Polling Institute (API) is a "non-partisan opinion research think-tank, which conducts opinion polls, surveys, social research and evaluation studies" to support public policy and advocacy in sub-Saharan Africa (API n.d.).

[5] EpiAFRIC is an African health consultancy group that "focuses on improving population health through expert research and data analysis, project design and evaluation, health communication, advocacy and training" (EpiAFRIC n.d.).

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Additional Sources Consulted

Oral sources: Assistant professor of psychiatry at a UK university who has researched mental health care in Nigeria; associate professor of psychiatry at a US university who researches mental health in Nigeria; Association of Psychiatrists in Nigeria; Centre for Mental Health Research and Initiative; Improved Sexual Health and Rights Advocacy Initiative; Improved Youth Health Initiative; International Center for Advocacy on Rights to Health; Lagos – Lagos State Ministry of Health; Mental Health Foundation Nigeria; Nigeria – Federal Ministry of Health; Nigeria Health Watch; Nigerian Medical Association; Nigerian psychologist and advocate for mental health; Oyo – Oyo State Ministry of Health; Women's Health and Equal Rights Initiative.

Internet sites, including: African Union; Amnesty International; Association for Child and Adolescent Psychiatry and Allied Professions in Nigeria; Austrian Red Cross – Austrian Centre for Country of Origin and Asylum Research and Documentation, ecoi.net; Bertelsmann Stiftung; Factiva; Fédération internationale pour les droits humains; Médecins sans frontières; Mental Health Innovation Network; Nigeria – National Population Commission, Nigerian Institute of Medical Research; UK – Home Office; UN – Office of the UN High Commissioner for Human Rights, Refworld; US – Congressional Research Service; The Washington Post; West African Health Organization; World Bank; Yale University – School of Medicine, The Happiness Project.