Nigeria has made considerable gains in HIV control though it still carries the third highest burden of the disease globally. More than three million people in the country are living with HIV. In 2013 the national HIV prevalence was 3.6%; prevalence was slightly higher in rural than in urban areas.
Decentralising health care has been mooted as a mechanism to achieve universal coverage of HIV treatment services. Effectively decentralising the HIV and AIDS treatment services should result in less bureaucracy, a separation of functions and better matching of services to local preferences.
HIV and AIDS treatment in Nigeria is largely centralised in tertiary health facilities. These are mostly located in the urban city centres. As a result there are both geographic and socio-economic inequities to access.
Part of the government’s efforts to strengthen primary health care facilities is to decentralise services. But getting this implemented is fraught with difficulties.
Our study looked at how politics and institutional factors influenced policymakers, politicians, HIV programme managers and health facility managers on the decentralisation question.
We studied health facilities offering antiretroviral treatment services in urban and rural areas in three states. Adamawa is in the north east, Abia’s in the south east and Cross River is in the country’s south-south region. All are at different points of decentralising their HIV treatment services.
We found that from a political perspective, there was a concern that people would lose their power. They were worried that they would no longer be able to employ staff or monitor services.
From a practical perspective, health care workers were more concerned that the state facilities would not have the capacity to manage or roll out antiretroviral services. And the states that had started to decentralise antiretorviral services did not have facilities in rural areas. This limited access.
Decentralisation of antiretroviral services in Nigeria could be made effective if these issues were addressed.
How the system works
HIV treatment is Nigeria is complicated by the fact that government agencies make policies, but donors provide most of the funding for prevention and treatment services.
An added complexity is that policies and guidelines for HIV treatment are formulated by government agencies, particularly the Ministry of Health. At the national level the National Agency for Control of AIDS coordinates HIV and AIDS activities. The state AIDS agencies and the local government AIDS agencies coordinate activities at their respective levels.
Implementation decisions are made at all three levels of government. But local governments form the weakest link in the treatment chain because they have the fewest resources. Their hands are tied because they are almost totally dependent on the state governments.
Donors work closely with implementing partners to provide the necessary HIV/AIDS prevention and treatment services. National and state agencies also play a crucial role as implementing partners. They provide advice to the funders on where, when and how resources will be needed. And they support the states in programme planning, resource allocation and capacity building for service providers and implementation.
Those for and against
At the time of the study Cross River state had functional HIV control units at its local government health departments. HIV control units oversee programmes in the local government but are located at the State Ministry of Health. HIV/AIDS treatment services were being provided at primary care facilities. Abia and Adamawa states had their HIV control units at the State Ministry of Health. Abia state had plans to start providing treatment services at primary care facilities. Adamawa state had no plans to decentralise treatment.
Both political and institutional factors influence where officials stand on the decentralisation question.
Political factors include the local and global agenda for health, political tenure and party affiliations. Institutional factors include the consolidation of decision-making power and concerns about careers.
Some health workers said they supported reform because it would ease their workload, improve access for clients, decongest facilities, improve the quality of care and reduce bureaucratic processes in getting services.
Some national and state level role players said they supported decentralisation because it would:
clarify roles and responsibilities at the different levels of implementation;
preserve control over staff employment and deployment;
provide clearer mechanisms for local accountability, and
ensure continuous oversight and monitoring of local activities by state and central role players.
The cons of decentralisation
Notwithstanding the high level of support for decentralisation there were some concerns.
Some participants were worried about the capacity. Would local level facilities be able to manage and account for resources that would come to the primary health care level? They were also concerned about the poor state of primary health care facilities.
Health workers appeared more concerned about technical issues. In particular they were worried that changes could hinder the way they perform their work. This included the capacity of the state or local governments to manage the resources and build and improve staff capacity. Decentralisation, they suggested, should be limited to providing services at primary health care facilities and some decision making. But all financial issues should be left to central control.
Some argued that HIV-infected people may not support decentralisation because of stigmatisation. They would fear being identified when they received treatment. Others were of the view that government officials sidelined by the reform may express their disinterest by an outright withdrawal of support.
Answers to the challenges
To address concerns around staff welfare, government should ensure that primary care facilities have adequate staff capacity to take on any additional roles. Alternatively, there should be incentives for those taking on additional roles.
And efforts should be made to strengthen the capacity of roleplayers at the local level to manage and implement HIV control activities. States and implementing partners should also provide support for those implementing the system at primary care level.
Finally, careful attention should be given to inter-agency cooperation. Competition for control of resources and agendas also needs to be managed carefully.