We are in May. Later this month we will mark one year into the tenure of the Buhari administration, a quarter of its four-year mandate. Also in May, we anticipate the kick-off of the Minister’s promised “one newly functional” primary health centre per day.
The appointment of Professor Isaac Adewole as Minister of Health was met with quiet optimism across the health sector. Professor Adewole’s first few public statements were mostly on the effects of medical tourism, a tragic phenomenon, but one that is largely inconsequential to the vast majority of Nigerians who cannot afford it.
However, he soon changed his focus to primary health care. He was initially widely reported to have stated an intention to build 10,000 new PHCs. He, however, has since corrected this to a new phrase in the Nigerian health sector, an intention to “make functional” 10,000 PHCs in two years; 5,000 in 2016 and another 5,000 in 2017. He promised that one “newly functional” PHC will be delivered, at the rate of one per day over 110 days starting from May 1, 2016. Based on the assumption that one PHC will serve a population of an average of 10,000 people, the Honourable Minister concludes that by the end of 2017, he will have provided “Universal Health Coverage” to 100 million Nigerians.
Obviously inspired by the achievements of Professor Ransom Kuti who, although remembered as the most successful Minister of Health in Nigeria, served under a military government, we are happy that Professor Adewole has put primary health care front and centre of his agenda.
This is a great vision. We completely agree with the need to strengthen Primary Health Care as the approach to delivering healthcare in Nigeria. Our responsibility as citizens is to support the Minister in the realisation of his vision for the health sector.
However, in order to enable our roles as good citizens and enable accountability for the Minister’s promises, his promises need further definition. What exactly is being promised? The two most important phrases used by the Minister are; 1. “universal health coverage”, and 2. “make functional”. In order to enable us fulfil our mission of seeking increased accountability we need to reach a consensus on what these two phrases mean, as they are not as simple as they may initially appear to be.
First, let’s explore “Universal Health Coverage”. To be clear “Universal Health Coverage” is not the same as “Universal (primary) Health Coverage”. The most widely acceptable definition of Universal Health Coverage by WHO says; “all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”. This describes what is available in places like the United Kingdom, the Unified Health System (Sistema Único de Saúde), covering 75% of Brazil’s population, or as was achieved in Mexico in 2012.
For all intents and purposes, this is not what the Honourable Minister appears to be referring to. Rather, the best interpretation of what the Honourable Minister is promising has to be the latter; universal primary health coverage. Now let’s try to define what that means.
Universal primary health coverage can only be defined as the delivery of a basic minimum care package that is negotiated and agreed in a particular context. I.e. each country has to define the level of services that it wants to deliver at the “primary care level”. In Nigeria, the best possible definition of the services provided at the PHC level has been defined by the National Primary Health Care Development Agency as the Basic Minimum Package. Study it – because it is by understanding its contents that we can fulfil our obligations as citizens of holding our government accountable for its delivery.
This brings us to the second term used: “make functional”. From what we gather from the Minister’s’ statements, there is an intention for the Federal Government to directly fund and manage the 10,000 facilities. This is a radical departure from the status quo. He promises that these centres will run a 24-hour service, which will be free at the point of care. The plan is that these centres will be powered by solar-generated power and will also have an “industrial” borehole to provide water to the clinic. With regard to funding, as there is no provision for this in the 2015 budget (that we have seen) and no indication of external funding, we have come to the conclusion that the funding for this can only come from the premiums for Federal Civil servants in the Nigeria Health Insurance Scheme that have accumulated over the years because people covered are not claiming for secondary care (hospitals are paid capitation for primary care). But even this is unlikely to be sufficient to fund the plans for more than a year.
While we are excited about this focus, we note that there is one small snag. In the complex federal government structure in Nigeria, the delivery of functionality in primary health care is actually the responsibility of the second and third tiers of government; states and local government areas. This mandate was further strengthened recently by the National Health Act: in section 2 of the new Act, it lists all the services to be provided by the Federal Ministry of Health, and this does not include Primary Health Care. It also legislates for the establishment of a Basic Health Care Provision fund, to be managed by NPHCDA and disbursed only through State Primary Health Care Boards.
Over the past few years, NPHCDA and most States have been working hard to consolidate local and state government resources required for primary health care “under one roof” i.e. into one agency at the State level. This means that agencies responsible for paying salaries, employing staff, procuring medicines, and consumables as well as all other aspects of “functionality” are managed at the State level actually and outside of the direct influence of the Federal Ministry of Health. States like Lagos, Ondo, Jigawa, and Kano have already made significant in-roads into developing their primary health care delivery mechanisms.
The Federal Government itself has over the past few years, been supporting the states to increase their capacity to deliver “functionality” through several initiatives. These include the Saving One-Million Lives initiative, now funded by the $500M World Bank credit, which is using an innovative incentives regimen to increase the functionality of primary health care through states. Another initiative to improve functionality is the introduction of performance-based financing, supported by the World Bank in some states, which the Executive Director of the NPHCDA is quoted as calling a “game-changer” for healthcare in Nigeria. On the financing side, after many years of resistance, the National Health Insurance Scheme has recently accepted the establishment of State Health Insurance Schemes, managed by the states themselves.
Creating functionality is about creating systems that work. Systems cannot be created over-night. We can build, refurbish, staff, equip primary health care centres, but making them sustainably functional is a complex task that cannot be managed from Abuja. The role of the federal government should be that of a catalyst, guide, instigator, but not to deliver primary health care directly.
To be absolutely clear, we completely agree with the core vision of the Minister, of reviving primary health care. However, we recognise the reality that we are in a Federal Republic with legislated functions of the federal level of government, versus the states and local governments. For the past three years, we have all been pushing for the implementation of “Primary Health Care Under One Roof” to ensure a unified state level structure that is able and responsible for coordinating the management of PHC services at state level.
We know that not every state is doing well with primary health care, and there is a feeling of frustration. But this is not the time to by-pass the states. There are no examples of services in Nigeria that have been successfully and sustainably delivered at the local level by the Federal Government. While primary health care is extremely important, and while we acknowledge the frustration of the lack of prioritisation of primary health care by some states, it is still their responsibility; a responsibility that we as citizens must hold them accountable to.
We ask the Minister of Health to keep primary care under one roof, in the states, and let us work with you to hold them accountable.