The recent eradication of wild polio virus from Nigeria says a lot about human resilience and the capacity to achieve much with little resources when there is genuine determination to succeed. It also shows how further the country could go in terms of attaining the universal health coverage, given the right funding.
Ending the dreaded disease has been quite a feat by the Federal Ministry of Health through the National Primary Health Care Development Agency (NPHCDA) which, working in synergy with other stakeholders like development partners, states and local government authorities, brought about several innovations and programmes to bear on the operations of the primary health care sub-sector. Programmes like the National Emergency Routine Immunization Coordination Centre (NERICC) and the Community Health Influencers, Promoters and Services (CHIPS) did not only contribute to the eventual victory over the virus but boosted health service delivery by ensuring that the underlying community-target approach yielded improved awareness and demand for Primary Health Care (PHC) services. Also, the related operational structures introduced by the Agency under the leadership of the Executive Director, Dr. Faisal Shuaib, are enduring legacies that could be deployed towards achieving similar success in the current fight against the coronavirus pandemic and future eventualities.
However, for the Agency to truly answer its name as the provider of strategic support for the development and delivery of quality primary health care, a lot more needs to be done. The entire primary health care system needs to be revamped, and this requires adequate and sustainable financing.
There are 32,000 primary healthcare facilities across the country serving over 200 million Nigerians. This is a far cry from the actual number needed to effectively attend to the population. Such shortfall constitutes a serious challenge. A recent report by the United Nations Children’s Fund (UNICEF) underscores the cumulative effects of the funding deficits. According to the report, Nigeria has overtaken India as the country with the highest death rate of children under the age of five. The country recorded an estimated average of 858,000 under-five deaths in 2019 against India’s 824,000 deaths out of the 5.2 million under-five deaths globally, with preventable or treatable infectious diseases such as malaria, pneumonia, diarrhoea, measles and HIV/AIDS accounting for more than 70% of the estimated deaths in Nigeria.
It is not just about reports and data, even the Honourable Minister of Health, Dr. Osagie Ehanire has been publicly highlighting the ugly situation and the efforts being made to overcome them. He recently admitted that Nigeria has the worst maternal mortality rate in the world. Speaking at a meeting with the Association of General and Private Medical Practitioners of Nigeria and Guild of Medical Directors, the minister disclosed that Nigeria currently has about 512 maternal mortality per 100,000.
However, as earlier hinted, this cannot be achieved without adequate and a more viable means of funding. Local and international donors have been doing their best over the years, but even with a steady and consistent income from the donors, an estimated N1 trillion is required to meet the funding gap over the next 10 years. The federal government has also been playing well its traditional role of public health funding, it however needs to do more by increasing its annual appropriation to the sub-sector. The current provision of about 1% of CFR to the Basic Health Care Provision Fund (BHCPF) to complement the funding of PHC by the states and Local Government Areas (LGAs) is grossly inadequate, considering the fact that currently an estimated 7,000 health facilities need to be either constructed or renovated to achieve the true concept of one functional Primary Health Care per ward based on the national standards for revitalization. The federal government needs to as a matter of urgency raise N500bn out of the current N1 trillion funding gap.
The amount may sound big, but for quality PHC delivery, huge capital investment is required. It should be noted that renovation of a health facility is not the same as revitalising it. While partial or full renovation means giving the facility a face-lift and could cost between N13 million and N26 million, a new construction could gulp as much as N52 million. And this is just the clinic building alone. When other aspects like the perimeter fence, solar power and bore-hole are added, the cost becomes quite massive. According to the Health Financing Team Analysis compiled by the NPHCDA and Partners, construction of just one primary health care centre costs as much as N82 million, excluding operational costs, equipment and human resource.
It is therefore worth reiterating the fact that coping with the enormous task of revitalizing PHCs calls for robust funding. And the onus is on the three tiers of government to play their roles accordingly. The federal government is largely responsible for teaching hospitals and medical education, state governments cares for state tertiary and secondary-care hospitals, and LGAs are directly in charge of PHCs. In fact, LGAs are expected to play a leading part in the establishment and running of PHC centres.
Unfortunately, the current structure in which revenue flows from the federal government to the states and LGAs as unconditional transfers and expenditure with decisions taken independently at each level is detrimental to the effective running of the PHCs. A system in which the federal government has no constitutional mandate to compel other tiers of government to spend in accordance with its priorities tend to cripple the expected result. For, even though the current revenue sharing regime stipulates that the LGAs get their financial allocation directly from the federal government, some governors have so reduced the local government councils to mere appendages of the states that much is left at their mercy, whims and caprices.
The consequence of this is that financial and political constraints at the state level often lead to uncertainty in the flow of funds to LGAs. With such constraint, coupled with the limited internal revenue generation capacity, the LGAs often just manage to pay staff salaries, leaving little resources for other aspects including health delivery services.
To solve these lingering problems, the federal government must, in addition to increased funding, find a way of ensuring steady flow of the resources to the right places. The health sector may need to borrow a leaf from the education sector. At the introduction of the universal basic education programme in 1999 as a reform programme aimed at providing greater access to quality basic education, the Universal Basic Education Commission was set up as an intervention mechanism to, among other things, ensure direct flow of funds to the education sub-sector at the grassroots.
The Primary Health Care Under One Roof (PHCUOR) programme is doing well in integrating all PHC service delivery under one authority of the State Primary Health Care Board, but in terms of controlling the finances to ensure equitable distribution, an alternative is required. It is either a unit with functions like the ones enumerated above are incorporated in the PHCUOR’s responsibilities or a separate body similar to the Universal Basic Education Commission is set up to carry out the tasks in concert with the states and local governments, ensuring proper funding and accountability.
Indeed, for the primary health care system to live up to expectations, the current under-resource and deficiencies in the system must be checked; government must not only fund the sub-sector adequately but ensure responsible spending of the fund available. If these measures are taken, it would enhance primary health care delivery in a way that would significantly improve maternal mortality rates over the next 10-year period, saving up to 110,540 lives – a 92% improvement on the current projected 9,561 lives that would be saved if PHC delivery remains the same.
Samuel Idoko is a social commentator based in Abuja. He could be reached on email@example.com.