Federal Ministry of Health
Essential Health Services:
The Nigeria Experience
By
Dr. Hassan Muhammad Lawal, mni, CON
Honourable Minister of Health
International Conference on Primary Health Care
and Health Systems for Achieving the MDG
April 28th -30th, 2008
Ouagadougou, Burkina Faso
Country Profile
Fig.1: Zones and States of Nigeria
Sokoto
Katsina
Jigawa
Zamfara
Borno
Kaduna
year
Bauchi
• Oil dependent economy
• Subsistent agriculture major
Gombe
Niger
Adamawa
Plateau
Kwara
FCT
Nasarawa
Oyo
KEY
Taraba
Osun
Benue
North West
Ondo
Ogun
Lagos
North East
Edo
Ebonyi
Delta
Bayelsa
occupation
Emergency Plan Focus States
Kogi
Ekiti
FCT, 6 geopolitical zones, 774
local government areas (LGAs)
• 140 million people, median age 17
Y obe
Kano
Kebbi
• Federation with 36 states plus
Imo
Rivers
Abia
Akwa
Ibom
Cross
River
North Central
South South
South West
South East
• Great diversity: wide regional
differences in socio-economic
and health status
• States & LGAs dependent on
Federation funds for health care
financing
Health
Services
• Both orthodox and traditional systems
•
•
Pluralistic orthodox health care services
•
LGAs have primary responsibility for PHC services
provision with supervision by the State Ministries of
Health & Coordination by Fed Govt.
National Health Policy provides for concurrency of
health at federal, States and local government areas
(LGAs) , but not backed by any law; health bill still
being processed
• Out of a total of 23, 640 health facilities registered in
Nigeria, 85% are PHCs.
Health
Services
• First attempt to Plan Health Services was the Basic
Health Services (BHS) scheme 1975 – 1983
- Focus on Prevention
- Expansion of Coverage with development of Health Care
Facilities
- Training of the existing over 40 cadres of Health Care
Providers including CHEWs, CHOs health Assistants etc
•
Re-orientation of Health Services towards PHC began
in 1986.
Nigeria’s PHC System before 1999
Democratic Dispensation
•
Although there was great achievements at inception
of PHC in mid 80s, it was not sustained
•
•
Weak governance system
•
Vertical PHC programs and massive decline in
immunization coverage
•
•
•
Inadequate funding and resource mobilization
System had limited access, inequity, low performance
limited, scale-up of effective interventions
No alternative Health Care financing strategy
Lack/inadequate involvement of private sector?
Communities and Development partners
Federal Govt. Response to the
Challenging Situation
•
Health Sector Reform Program initiated to address
System issues
•
Establishment of the MDGs office in the Presidency
to ensure HIGH LEVEL targeting of the Debt Relief
Funds to key sectors.
• Adoption of strategies for Revitalization of PHC
Health Sector Reform Program (2004 till date)
Seven Strategic thrusts are to:
- Improve performance of the stewardship role of government.
- Strengthen the national health system and improve its
-
-
management (including revitalization of PHC)
Improve availability of health resources and their
management.
Improve physical, financial, etc access to quality health
services.
Reduce the disease burden attributable to priority health
problems.
Promote effective public-private partnership in health.
Increase consumers’ awareness of their health rights and
health obligations.
The Debt Relief Funds in the Health
Sector-MDGs
•
The Debt Relief Funds were used to provide
significant additional funding to MDG- relevant
sectors since 2006.
•
The Health Sector has received:
- in 2006: N21. 28 Bn
- in 2007: N15 Bn
- In 2008: N16.90 Bn
Revitalization of PHC for essential
health care
•
Revision (2004) of the 1988 national health policy
with PHC still the bedrock
•
Decentralization of the National Primary Health Care
Development Agency established in 1992 with zonal
structures to ward level
• More recently, draft national health bill clearly
articulating the role of each level of government in
PHC and mechanism of Health care funding; still
awaiting passage by the National Assembly)
• Improving evidence-based decision making through
strengthening of the HMIS & IDSR
•
Strengthening Routine Immunization, National & SubNational Immunization Days
Revitalization of PHC for essential
health care - contd
•
Decentralization of PHC to LGA and more recently the
ward level; Establishment of the Ward Health System
- Aligns health district with the political ward
- Services and activities revolve round a health centre
- Community-management and financing of health services
strengthening
- Promotes local political commitment in PHC
•
Development of the Ward Minimum Health Care
Package (WMHCP) which includes:
Child Survival interventions, Maternal and New Born Care,
Control of priority diseases i.e. HIV/AIDS, Tuberculosis and
Malaria, Nutrition, Prevention of non communicable diseases,
Health promotion & education and community mobilization.
Revitalization of PHC for essential
health care cont.
•
Creation of health development committees in each
community to strengthen promote community
participation, ownership and co-management
•
Expansion of health services coverage through
infrastructural development: model PH Centers and
upgrading of health facilities
•
•
Services integration
Improving Financial access through health insurance
schemes and other community financing
mechanisms
Other enablers for improved functioning of
the PHC system for attainment of the MDGs
• Improved public-private partnership in service
delivery
•
Increased Infrastructural Development, construction
of 600 model PHC centers
• Nurses/midwives Corps
• Youth Corp Doctors PHC programme
• Increased resource mobilization for PHC services,
NHIS
•
•
Multi- sectoral approach to health, PPP
Launch of Health Promotion Policy
Status of Service Delivery
•
Childhood
Immunizations
• Malaria
• Tuberculosis
• HIV and AIDS
• Child health
• Maternal health
Child immunization
•
Strengthening of routine immunization ongoing
through static and outreach services
•
Integration of multiple antigens into polio
supplemental campaigns for increasing immunization
coverage; resulted in significant improvement in
immunization coverage:
- DPT 3 increased from 23.4% in 2003 to 77% in 2007
(administrative coverage data)
- Measles coverage more than 80% in 21 States and FCT
Malaria
•
Leading Cause of illness (60% out-patient)
consultation in facilities
•
•
Targets for Malaria control in line with AU targets
•
Access to ACT promoted through free distribution of
ACT to PHC facilities and efforts to grow plant incountry
- 16.9 million doses distributed in 2006 and 88,000 doses in
Treatment policy changed to Artemisinin-based
Combination Therapy in 2005
2007
•
Access to treatment expanded through promotion of
home-based care using trained community-based
Malaria con’td
•
Long lasting insecticide treated nets distributed free
to pregnant women and under-fives ; 15 million LLIN
distributed; 70 million required.
•
Distribution of insecticide-treated nets (ITNs) have
been scaled-up and coverage is now more than 15%,
up from less than 5% in 2004.
•
Integration of community-based distribution of
ivermectin and malarial control activities ongoing
• IRS successfully piloted in three States and scale-up
is to follow
HIV and AIDS
•
Focus on confronting socio-cultural and informational
barriers to HIV and AIDS; strengthening civil society
coalitions against AIDS and specific interventions
•
Increased general awareness of HIV/AIDS being
translated to behavioural change
•
About 300 VCT centres established across the
country
•
Number of persons on ART increased from 10,000 in
2002 to about 170, 000 in 265 sites compared to 25
sites in 2007
HIV and AIDS contd
•
PMTCT centres increased from 11 sites in 2002 to 300
sites in 2007
•
Services being cascaded to PHC levels
•
Number of local producers of ARV and ACT drugs
increased from zero (0) to eight (8) and five (5)
respectively
Interventions resulted in declining trend in HIV
sero-prevalence in Nigeria
Tuberculosis
•
Implementing DOTS Strategy from 1993 and Stop TB
strategy from 2006
•
Guidelines for community TB care developed in
2006/7
• By end of 2006
- 650 of the 774 LGAs implementing DOTS, increase in
coverage from 550 in 2005
- 694 microscopy centres in 550 LGAs
- 3329 treatment centres
- DOTS centres established in 200 private health facilities as
part of PPP
Tuberculosis cont’d
•
Community DOTS care being established in 12 States
and training of community volunteers ongoing (24000
trained)
• Interventions resulted in increase case detection of
33% (though short of target of 75%) and cure rate of
78%
Child Health
•
Large proportion of PHC services address child
health
•
IMCI adopted as strategy for child survival by National
Council on Health in 1997
• IMCI implemented in 24 of the 36 States and FCT
• Community IMCI also being rapidly scaled up
• Micronutrient interventions include:
- Universal iodization of salt - 99% of all salt iodised
- Vitamin A supplementation integrated with polio
supplemental immunization
•
Other strategies addressing child health include
Baby Friendly Initiative, RBM, Integrated Maternal,
Newborn and Child Health strategy
Maternal Health
•
Maternal health and child health traditionaly
addressed in PHC
•
Various policies and strategies over the years
addressing maternal health:
- Maternal health policy changed to Reproductive health policy
from 1996
- Vision 2010 and adoption of the Women and Children Health
Services by the National Council of Health in 2004 as the
strategy to achieve the goals of the vision
- Integrated maternal, newborn and child health ( IMNCH)
strategy from 2007
•
Maternal health indicators continue to remain poor in
spite of interventions ; MMR 800/100, 000
Challenges
•
•
The specification that PHC is under the LGAs
•
Structural problems of the three –tiered health system;
tiers have part autonomy by law
•
•
Non-passage of the National Health Bill into law
•
•
Clear definitions of modalities for integrated services
Lack of capacity of LGAs to manage PHC and deliver
services
Dearth of human resources now compounded by the brain
drain syndrome
Funding gaps
Challenges _ contd
•
Inadequacies in quality and quantity of manpower
(especially doctors and nurses) for PHC especially in rural
areas
•
Poor coordination; Fragmentation of programmes due to
multiplicity of implementing partners and development
partners
•
•
Inadequate HMIS & IDSR
•
Application of community participation in practice (prog
impl & Health care financing)
•
Lack of country-specific benchmarks for assessing
progress
Inadequate and Poor infrastructure/appropriate
technology
Conclusions
•
PHC remains the cornerstone of the Nigerian
Health System. The PHC concept as the
cornerstone has seen its highs and lows, but
is being repositioned to deliver its contract
with Nigerians and people living in Nigeria –
effective, efficient and equitable health
services through of the efforts of all
stakeholders.
Thank you