In public diabetes clinics across Nigeria, patients can reliably collect metformin—the first-line oral medication for type 2 diabetes—at little or no cost. Yet the same clinics cannot offer a simple retinal examination that could prevent blindness. This disconnect between drug access and preventive screening is a stark illustration of how noncommunicable disease programmes in low- and middle-income countries remain skewed toward treatment rather than early detection.

Metformin Is Stocked, but Retinal Screening Is Not

At the Lagos University Teaching Hospital diabetes clinic, metformin is almost always in stock. The drug is inexpensive, produced by several local manufacturers, and included in Nigeria's essential medicines list. Patients with a diagnosis of type 2 diabetes can receive a three-month supply after a brief consultation. For many, this is a lifeline: metformin reduces blood glucose and, over time, lowers the risk of complications.

But those same patients are rarely offered an annual retinal screening. Diabetic retinopathy—damage to the blood vessels in the retina caused by chronic high blood sugar—is the leading cause of blindness among working-age adults in Nigeria. The condition is asymptomatic in its early stages, when laser treatment is most effective. By the time patients notice vision loss, the damage is often irreversible.

“We diagnose many patients only when they already have advanced retinopathy,” said Dr. Amina Suleiman, an endocrinologist at Aminu Kano Teaching Hospital in Kano State. “They come in with blurry vision or floaters, and by then we can only offer palliation.” In a study published in 2024 in the Nigerian Journal of Clinical Practice, nearly 30% of patients attending a public diabetes clinic in Lagos had some degree of retinopathy at the time of diagnosis.

The policy gap is clear: the government's diabetes programme budgets for medication procurement but does not allocate funds for screening equipment or training. The result is a system that treats a chronic disease while leaving a major complication unaddressed.

A Familiar Pattern in Noncommunicable Disease Programmes

Nigeria is not alone in this pattern. Across sub-Saharan Africa, noncommunicable disease (NCD) programmes have historically focused on acute care and medication supply, often driven by donor priorities. The Global Fund and PEPFAR, for instance, have poured billions into HIV, tuberculosis, and malaria, but NCDs receive a fraction of that investment. A 2023 analysis by the World Health Organization found that only about 2% of global health aid goes to NCDs, despite their accounting for more than 70% of deaths worldwide.

Retinal screening equipment is expensive. A fundus camera, which captures images of the retina, costs roughly ₦3–5 million (about US$4,000–6,500). For a clinic with an annual operating budget of ₦20–30 million, that is a prohibitive one-time expense. Even when cameras are donated, maintenance and consumables—such as mydriatic drops and printer paper—are often not budgeted for.

“The machines sit in storage because no one trained the staff to use them, or the camera breaks and there's no repair budget,” said Dr. Chidi Okafor, a public health researcher at the University of Ibadan. Similar gaps have been documented in Malawi and Bangladesh, where diabetes clinics stock metformin and insulin but lack retinal cameras, and where rates of diabetic retinopathy remain high.

The shortage of trained ophthalmologists compounds the problem. Nigeria has roughly one ophthalmologist per 400,000 people, with most concentrated in the southern cities. In northern states like Yobe and Borno, the ratio is closer to one per million. Without screening, early retinopathy goes undetected, and patients progress to advanced stages requiring vitrectomy or laser therapy—procedures that are themselves scarce and expensive.

Why Retinal Screening Matters for Diabetes Outcomes

The rationale for annual retinal screening is grounded in strong evidence. The United Kingdom Prospective Diabetes Study (UKPDS), a landmark trial that followed more than 5,000 patients with type 2 diabetes for a decade, showed that intensive glucose control reduced the risk of retinopathy progression by about 25%. More importantly, screening programmes that detect retinopathy early and refer for laser photocoagulation can reduce the risk of blindness by roughly 50%, according to the Cochrane Review of screening interventions.

Laser treatment is effective, but only if applied before the disease reaches the proliferative stage, where new, fragile blood vessels grow on the retina and can bleed into the vitreous humour. Once vision is lost from macular oedema or vitreous haemorrhage, recovery is limited. In Nigeria, where access to vitrectomy is rare, prevention through screening is the only realistic strategy.

The cost-effectiveness of screening is also well established. A 2022 modelling study in The Lancet Global Health estimated that a national screening programme in Nigeria, using teleophthalmology to extend reach, would cost about US$4–5 per person screened and prevent an estimated 30% of blindness cases over five years. That is comparable to the cost of treating a single advanced retinopathy case, which can exceed US$1,000 when surgery and follow-up are included.

Yet without a dedicated budget, screening remains a theoretical benefit. Patients who can afford it pay out of pocket for a private retinal exam—typically ₦5,000–10,000—but that is beyond the reach of many who rely on public clinics. The result is a two-tier system where wealthier patients preserve their vision while poorer patients go blind from a preventable condition.

The Funding Pipeline Skips Preventive Infrastructure

Why does the funding pipeline skip preventive infrastructure? Part of the answer lies in donor priorities. The Global Fund, PEPFAR, and the World Bank's IDA loans have historically focused on infectious diseases, where treatment metrics are straightforward and results are visible within a few years. NCD prevention, by contrast, requires long-term investment in equipment, training, and data systems that may not show returns for a decade.

Domestic health budgets in Nigeria are stretched thin. The national health budget for 2025 was about ₦1.3 trillion (roughly US$1.7 billion), of which less than 5% was allocated to NCDs. Most of that goes to salaries and recurrent costs, leaving little for capital investments like retinal cameras. The National Health Insurance Authority (NHIA) covers diabetes medications for enrolled members, but its benefits package does not include annual retinal screening.

Private health insurance uptake in Nigeria remains below 5% of the population, and even those with insurance often find that retinal screening is excluded or subject to high co-pays. The result is that screening is effectively unavailable for the vast majority of the 5–7 million Nigerians estimated to have diabetes—a number that is projected to double by 2045.

The situation mirrors that of other NCDs. A similar pattern was described in a recent article on this site about Kenyan heart failure patients who receive loop diuretics but not ejection fraction measurement, and in the story of South African clinics that dispense metformin while eye exams go unbooked. The common thread is a system that prioritises treatment over diagnosis and prevention.

Grassroots Efforts to Bridge the Gap

In the absence of government funding, several grassroots initiatives have emerged to fill the screening gap. The nonprofit organisation Diabetes Without Borders has trained community health workers in six northern states to perform basic fundoscopy using portable, battery-operated retinal cameras. These workers screen patients at primary health centres and refer those with abnormalities to a central teleophthalmology hub in Kano, where specialists review images remotely.

A mobile van pilot in Kano State, funded by the World Diabetes Foundation, screened roughly 12,000 patients in 2025. The van visited rural markets and schools, offering free retinal exams. Of those screened, about 15% had signs of retinopathy, and 3% required urgent laser treatment. The cost per screened patient was around ₦3,500–5,000 (US$4–6), including staff time and consumables.

Teleophthalmology platforms are also gaining traction. The Nigerian Telemedicine Network, a partnership between the Federal Ministry of Health and several private telecom companies, has linked 20 rural clinics to ophthalmologists in Abuja and Lagos. Images taken by nurses are uploaded to a cloud-based system and reviewed within 48 hours. Early results from a 2024 pilot in Oyo State showed that the platform increased screening rates from near zero to about 40% of registered diabetes patients within six months.

These efforts demonstrate that screening is feasible even in resource-limited settings. But they remain small-scale and donor-dependent. Scaling them to cover the entire country would require a level of political will and financial commitment that has not yet materialised.

What a Comprehensive Diabetes Package Would Cost

What would it take to make retinal screening universally available in Nigeria's public diabetes clinics? A rough estimate: equipping 500 clinics—roughly one per local government area—with a portable retinal camera, a laptop, and training would cost about ₦2 billion (US$2.5 million) as a one-time investment. Annual recurrent costs for consumables, data transmission, and specialist review would add roughly ₦4–5 per capita for the estimated 6 million diagnosed diabetes patients—around ₦24–30 million per year.

That sum is modest compared to the cost of treating preventable blindness. A single vitrectomy for advanced diabetic retinopathy at a private hospital in Lagos can cost ₦500,000–1 million (US$600–1,200). By preventing even a few hundred cases of blindness each year, the screening programme would pay for itself within a few years.

Modelling by the International Agency for the Prevention of Blindness suggests that a national screening programme in Nigeria could reduce diabetes-related blindness by roughly 30% within five years, assuming 70% coverage and timely referral. The number needed to screen to prevent one case of blindness is estimated at around 200–300, which compares favourably to other preventive interventions like mammography for breast cancer.

Yet the budget allocation is not forthcoming. The Ministry of Health's 2026 budget proposal, reviewed by local media, includes a line item for diabetes medication procurement but no dedicated funding for screening. Advocacy groups have called for the inclusion of retinal screening in the NHIA benefits package, but legislative action has been slow.

Policy Levers That Could Shift the Balance

Several policy levers could shift the balance. The most straightforward is to include annual retinal screening in the NHIA's essential benefits package for diabetes patients. This would require an actuarial analysis of costs, but the premium increase would likely be small—perhaps ₦200–300 per enrollee per year—and could be offset by savings from reduced blindness-related disability.

Another option is to earmark a portion of existing health taxes for screening. Nigeria's sugar-sweetened beverage levy, introduced in 2022 at ₦10 per litre, generates roughly ₦50 billion annually. Allocating even 5% of that revenue—₦2.5 billion—to a dedicated retinal screening fund would be enough to equip and operate a national programme. Legislation to that effect has been proposed in the National Assembly but has not advanced.

Bulk procurement of retinal cameras through the National Primary Health Care Development Agency could reduce unit costs by 20–30%. Several manufacturers have expressed willingness to offer discounts for large orders, especially if paired with a maintenance contract. The World Health Organization's prequalification programme for medical devices could also help ensure quality and affordability.

Integrating retinal screening with existing community health outreach—such as HIV/TB home visits or immunisation campaigns—could reduce per-patient costs by sharing logistics and personnel. In Malawi, a pilot programme that added diabetic retinopathy screening to HIV clinic visits achieved screening rates of over 80% among eligible patients at a marginal cost of less than US$2 per person.

None of these options are silver bullets. The political economy of health budgeting in Nigeria is complex, and competing priorities—from maternal mortality to infectious disease outbreaks—will always demand attention. But the cost of inaction is measured in preventable blindness, lost productivity, and diminished quality of life for hundreds of thousands of Nigerians.

As Dr. Suleiman put it, “We have the drugs. We have the knowledge. What we lack is the will to invest in prevention.” Until that will translates into budget lines and procurement orders, public diabetes clinics will continue to dispense metformin while retinal screening goes unfunded—and patients will continue to lose their sight unnecessarily.

Counterarguments and Practical Constraints

Some health officials argue that the focus on medication is rational given limited resources. Metformin prevents a range of complications beyond retinopathy—including cardiovascular disease and kidney failure—and its benefits are well-proven for the majority of patients. Screening, they contend, is only one component of comprehensive diabetes care, and in a setting where even basic glucose monitoring is inconsistent, prioritising retinal exams may seem premature. For instance, many clinics lack reliable glucometers or HbA1c testing, meaning patients' glycaemic control is poorly tracked. Without that data, identifying high-risk individuals for retinopathy becomes less efficient.

Additionally, the logistics of screening are non-trivial. Dilating pupils for a retinal exam temporarily blurs vision, which can be disruptive for patients who need to work or drive. In rural areas, patients may travel several hours to a clinic, and adding a screening that requires waiting for dilation and image review could deter attendance. Some programmes have addressed this by using non-mydriatic cameras that do not require dilation, but these are more expensive and still require training.

There is also the risk of false positives leading to unnecessary referrals and anxiety. In settings where ophthalmologists are scarce, a screening programme that generates many referrals could overwhelm the few specialists available. A 2023 study from northern Nigeria found that among patients referred for suspected retinopathy, only about half actually had clinically significant disease, highlighting the need for quality assurance in screening.

These constraints do not invalidate the case for screening, but they underscore the importance of careful implementation. A phased approach—starting with high-risk groups such as patients with long-standing diabetes or poor glycaemic control—might be more feasible than universal screening. Such targeting could reduce costs and improve the yield of referrals, making the programme more palatable to budget planners.

The Human Cost of Inaction

Behind the statistics are individual stories. A 45-year-old market trader in Kano, diagnosed with diabetes five years ago, began noticing blurred vision in early 2025. She visited her local clinic, where she received metformin but no eye exam. By the time she saw an ophthalmologist three months later, she had proliferative retinopathy with vitreous haemorrhage. Laser treatment was attempted but incomplete due to the extent of damage. She is now unable to read price tags or navigate her stall, and her income has dropped by more than half. Her children have taken over the business part-time.

Cases like hers are not rare. A 2024 survey in three northern states found that among diabetes patients who reported vision problems, the average time from symptom onset to ophthalmology consultation was over four months. During that window, treatable retinopathy often becomes irreversible. The survey also found that fewer than 10% of diabetes patients had ever had a retinal exam, despite most having had diabetes for more than five years.

The economic ripple effects are substantial. A study published in the Nigerian Medical Journal estimated that diabetes-related blindness costs the Nigerian economy roughly ₦50 billion annually in lost productivity and caregiver expenses. That figure does not include the intangible costs of reduced quality of life and social isolation. Investing in screening, even at the scale of ₦2–3 billion per year, would likely yield net savings within a decade.

As Dr. Okafor noted, “We are spending money on the downstream consequences of not screening. If we redirected even a fraction of that to prevention, we would see better outcomes and lower costs.” The challenge is that health budgets are siloed: the ophthalmology department bears the cost of treating blindness, while the diabetes programme controls screening funds. Without integrated budgeting, the incentive to invest upstream is weak.

Despite these barriers, there are signs of progress. The Federal Ministry of Health's National Eye Health Strategic Plan for 2024–2030 includes a goal to screen 50% of diabetes patients for retinopathy by 2028. Whether that goal will be backed by funding remains to be seen. Advocacy groups continue to push for legislative action, and several state governments have expressed interest in pilot programmes. The coming years will test whether Nigeria can translate policy aspirations into real-world screening coverage.

This article is for informational purposes only and does not constitute professional medical advice. Individuals with diabetes should consult their healthcare provider about appropriate screening and treatment options.