This is a guest post by Tarry Asoka

First published on the Carenet Website. Here

Nigeria is a federal country of 36 States – federating units, which have considerable economic and political autonomy. It has been noted that on a year by year basis, some of the States in Nigeria have resources well above the annual budgets of many countries in the sub-Saharan Africa (SSA).  Yet, health indicators of Nigeria although with some geographical variation are one of the worst in the sub-region.

Whereas the 1979 Constitution placed Health on the concurrent list of responsibilities with the exception of a few services made exclusive to the federal it also still assigned specific responsibilities to States and Local Government Areas (LGAs). The 1999 Constitution however was virtually silent on this. Each level of government is largely autonomous politically and in terms of financing and managing health services under its responsibility. The Commissioner of Health is only answerable to the State Governor who is the Chief executive Officer of the State.

In principle, State governments are responsible for secondary hospital care and supporting LGAs to provide primary health care – state planning, operational support, coordination, monitoring and training. State hospitals are under-utilised due to so many reasons that are systemic – weak referral mechanisms, the unmotivated and under-qualified staff, the payments required of patients when seeking care, the lack of functioning equipment, medical supplies and drugs. This is due as much to the lack of management systems (e.g. preventive maintenance systems for buildings and equipment, drug supply system) as to lack of resources.

However, despite all these problems many State governments are doing good things but not doing them right; and they are also not doing the right things that can re-vitalise their health systems. States behave in this manner due to a number of reasons. They derive their powers from the constitution, giving them legitimacy to exercise control over resources allocated to them – how to use them and in what ever manner they deem fit. The Federal Ministry of Health (FMoH) has little or no influence over health service delivery in the States because rather than providing oversight the FMoH micro-manages the nation’s health system. The States also have to respond to the needs and demands of their immediate environment. But most profoundly, the States do no have the capacity to absorb the huge resources allocated to them – to plan and implement healthprogrammes for their people.

To reverse these negative trends and improve the health status of Nigerians, three actions are suggested.

  1. Efforts should be concentrated at working at the State level by engaging State governments. 
  2. The role of FMoH should be redefined to become a ‘resource’ for the States rather than executing health programmes. 
  3. Finally, a ‘change movement for better healthcare’ needs to be fired up, possibly through ‘political action’.

For details of what is happening in one state; click here Nasarawa.

Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (, which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.

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