Nigeria has repeatedly been lauded for the detailed prevention strategy and considerable resources it pumped into its polio campaign. It is also praised for managing to contain the Ebola virus within three months of the outbreak in 2014.
But the resilience and responsiveness of Nigeria’s health system at the primary care level has been questioned in recent times. Aside from these feats the country’s health system, which deals with about 178 million people, perennially under-performs.
Nigeria has been unable to curb the ongoing outbreak of Lassa Fever, which has killed at least 63 people in three months across several states. This is a higher death toll than Ebola.
Primary health care – as the first point of call – has been neglected and under-utilised. It is evident that there has been an undue focus on more specialised tertiary health care. For Nigeria to have a successful system, its health sector needs to be repositioned to focus on primary health.
Nigeria’s newly appointed health minister, Isaac Adewole, inherits a health system with legislation that stipulates that primary health care should be a focus of policy.
But to make primary health care a viable reality, Adewole would need to get three things right:
its financing;
human resources; and
providing a quality service.
A renewed focus on primary health care
The Nigerian Health Act, now just over a year old, is the first of its kind in the country and guarantees health for all.
In line with the act, Adewole seems to have identified primary health care as a focus area. He intends to strengthen existing primary health care facilities, rather than build new ones. He plans to renovate and equip at least 10,000 primary healthcare facilities in the country. These would then offer basic care and relieve the burden on tertiary and secondary health facilities across the country.
They will be part of the strengthened hub and spoke model of referral system. This system has worked well with HIV/AIDS programs in Nigeria.
He also intends to strengthen accountability in the health sector and the partnerships between the federal and state ministries of health and state primary healthcare agencies. These will result in patient-centred health care being delivered in the primary healthcare system.
Improved funding is a good start
Nigerian President Muhammadu Buhari is set to establish a Basic Health Care Provision Fund to improve funding for programs that provide primary healthcare services in the country.
The 2016 budget for health is lower than previous years. In his budget speech to the National Assembly, Buhari announced a proposed recurrent budget of NGN 221.7 billion for the health sector, with an overall health budget of N257.3 billion. This compares to education, which received NGN 369.6 billion.
The capital budget for health has in fact been increased for 2016. But the increase still doesn’t mean that Nigeria has met the commitment it made when signing the Abuja Declaration in 2001. This committed it, along with other signatories, to spending 15% of their budget on health care.
One of Adewole’s first challenges will be to find funding to implement the act. To date implementation of the National Health Act has been slow as the Federal Ministry of Health has largely depended on financial support from development partners.
The act comes as Nigeria asks the World Bank and the African Development Bank for US$3.5 billion in emergency loans to fund its state deficit of US$15 billion. Should the bailout occur, it is not expected to have a direct bearing on health funding.
Adewole will face his biggest challenge in getting funding from local government areas. To access the funds states must establish functional primary healthcare agencies or boards and contribute counterpart funding.
Traditionally, local government areas, which have the statutory function of providing primary healthcare funding, have been unable to provide quality primary healthcare services. This has been because of poor capacity and lack of funds.
Adewole would have to revisit this obligation and a constitutional review would become imperative.
One solution would be for him to set up performance-based financing schemes, rewarding those who provide results. Currently, the pilot phase of the Nigeria State Health Investment Program has been financed by the World Bank in three states. The scheme has had varying results but has been successful in some respects. Adewole could scale this up.
Getting the manpower on board
Another critical issue is to provide quality services. The health workforce needs to be adequately primed to deliver these services.
There have been unending labour crises and inter-professional rivalry within the health sector. These have disrupted the health sector unduly. This has had an impact on patients and users.
And according to a recent impact evaluation conducted by RAND Health, some of the human resources used in health interventions at the primary healthcare level appear not to have produced significant result.
Health workers need to be reoriented to put the welfare of the patients ahead of their parochial interests.
Adewole would need to establish and institutionalise clinical governance and quality improvement frameworks. These are provided for in the act, which guarantees patients and healthcare users the right to health.
The right blueprint
Since his appointment Adewole has held several stakeholder consultations and engagements with both state and non-state actors.
Adewole now needs to develop a new national strategic health development plan to realise the vision of reforming the health sector and appoint a crack team to translate his vision into practical steps with clear deliverables and timelines.
This plan must include a blueprint for achieving universal health coverage for all Nigerians, as we step into the new era of sustainable development goals.