HEALTH SECTOR REFORMS IN NIGERIA AND THE POTENTIAL FOR
POVERTY REDUCTION*
Introduction
Nigeria faces a number of development challenges, of which poverty holds a central
place. Indeed, the country is a land of paradox inasmuch as poverty is concerned. While
Nigeria is a leading oil-producing nation and highly endowed in terms of various natural
resources, the majority of her people are economically poor. As recent national data
shows, over one-third of Nigerians (35%) live in extreme poverty while 54% are
relatively poor. More than half of the Nigerian population live on less than a dollar a
day.1 In view of the extent and depth of poverty in the land, it should not be surprising
that the health status of the country is poor, with an average life expectancy of only 46.6
years2. According to the 2008 Human Development Report Nigeria is in the low human
development index category and ranks 154 out of 179 countries, behind some West
African countries with less economic potentials such as Ghana, Cameroon, and Senegal,
which are in the medium human development category2.
Poverty has a strong link and two-way relationship with health: poverty makes people
more vulnerable to ill-health, and ill-health tends to lead to poverty. Hence, as the
common saying, “Health is wealth”. Among others, the poor are more likely to
experience ill-health as a result of several factors, which include poor diet and poor living
conditions, and when they are ill they are less likely to access health care services
because of inability to pay. The poor in Nigeria are more likely to be found in the
relatively deprived rural areas and peri-urban slums, where high quality health services
are often lacking. On the other hand, ill health affects productivity, and therefore, reduces
income and also tends to wipe away savings and diminish ability to invest. Thus, ill
*
Dr. Adesegun Ola. Fatusi
Department of Community Health
Faculty of Clinical Sciences, College of Health Sciences,
Obafemi Awolowo University, Ile-Ife, Nigeria
adesegunfatusi@yahoo.co.uk
health and poverty reinforce one another, and compromise quality of life and longevity.
Indeed, the poor are more likely to die young. Poverty can indeed be described as the
leading global health challenge and “disease” in view of its ubiquitous effects on the
health status of individuals and communities in the world. According to the World Health
Organisation (WHO), “The world’s biggest killers and the greatest cause of ill-health and
suffering across the globe is extreme poverty. Poverty is the main reason why babies are
not vaccinated, why clean water and sanitation are not provided, why curative drugs and
other treatments are not available and why mothers die in childbirth3.
Thus, efforts to address poverty must necessarily consider health sector input, while
efforts to improve health must also be seen from its poverty reduction potential. The
Federal Government of Nigeria had launched the Health Sector Reform (HSR) as a major
initiative to improve the health and well-being of the citizens. This article discusses the
Nigerian health sector reform and its implications for poverty reduction.
.
Health Sector Reform: Rationale and Process
Reform means positive change. But health sector reform implies more than just any
improvement in health or health care. It is a process motivated by the need to address
fundamental deficiencies in health care systems that affect all health care services.
Health sector reform has been defined as “a sustained process of fundamental change in
policy and institutional arrangements, guided by government, designed to improve the
functioning and performance of the health sector, and ultimately the health status of the
population”4. A committee of the WHO African region defined it as “a sustained process
of fundamental change in policy, regulation, financing, provision of health services, reorganisation, management and institutional arrangements that is led by government and
designed to improve the performance of a health system to attain a better health status for
the population5. Drawing from the work of Berman, it can also simply be said to be a
“sustained and purposeful change to improve the efficiency, equity and effectiveness of
the health sector”6. “Sustained” in the sense that it is not a "one shot" temporary effort
that will not have enduring impacts; and, “purposeful” in the sense of having a rational,
planned basis - to improve health system performance in terms of well-defined outcomes.
HSR can also be described as “Strategic” in the sense of addressing significant,
fundamental dimensions of health systems.
In the case of Nigeria, the argument for HSR is based on the poor health status of the
population and the poor rating of the health system itself. Nigeria’s health system, for
example, was ranked 187 out of 191 countries by WHO in 2000. The infant mortality
ratea, the under-five mortality rateb and the maternal mortality ratioc are some of the
indicators that are often used to compare health status of populations. Nigeria’s figures on
each of the three indices are some of the worst in the world, even by the standard of
developing countries. Currently, a tenth of children born in Nigeria die under the age of
one year (Infant mortality rate of 100 per 1000 live births) and a fifth die before their fifth
birthday (under-five mortality rate of 201 per 1000 live births) 7. According to the most
recent estimates from United Nations agencies, over 50,000 mothers die from childbirthrelated events – the second highest annual national maternal deaths figure in the world.
Nigeria’s maternal mortality ratio is estimated to be between 800 and 1,000 maternal
deaths per 100,000 live births.
Furthermore, the leading causes of deaths among mothers and children in Nigeria are
largely preventable health problems or easily treatable ones. For children, these include
vaccine preventable diseases (polio, diphtheria, whooping cough, tetanus, and measles),
malaria, and diarrhea. The situation clearly suggests that the Nigerian health system
needs more than a cosmetic change - what it requires is a radical reform to improve its
performance8,9. In the words of Professor Adetokunbo Lucas, an eminent public health
physician, “The Nigerian health system is sick, very sick and in need of intensive care.”10
As a Federal Ministry of Health (FMOH) documents puts it, the Nigerian health “system
is so complex and has grown out of so many obtuse ‘needs’ that the best approach to
reform is to start afresh and plan the system de novo”.11
a
Infant mortality rate: Number of children that die under the age of 1 year per 1000 live
births.
b
Under-five mortality rate: Number of children that die under the age of 1 year per 1000
live births.
c
Maternal mortality ratio: The number of maternal deaths per 100 000 live births.
HSR is an inherently political process, and it is often implemented on a sector-wide level.
Initiatives to reform the health system has been attempted at various times in the history
of the health development of the country, with a view to substantially improve the system
to perform the three fundamental objectives of a health system, viz. Improve the health of
the population they serve, provide financial protection against the cost of ill-health, and
respond to people’s expectation12. A discussion of the various initiatives is beyond the
scope of the present paper, rather the focus is on the most recent effort – the HSR
initiated in 2004 during the second term of the President Olusegun Obasanjo, with
Professor Eyitabo Lambo as the Federal Minister of Health.
The HSR was one of the social sector reforms undertaken by the Obasanjo
administration, with the National Economic Empowerment Development Strategy
(NEEDS) providing the overall national development framework. The NEEDS, itself, has
four major goals: wealth creation, poverty reduction, employment generation and value
re-orientation. The development of the HSR implementation document entailed a
participatory and consultative approach with inputs from various stakeholders in the
health sector, including the National Council on Health. The mission statement regarding
the HSR was “to undertake a government-led comprehensive health sector aimed at
strengthening the national health system to enable it deliver effective, efficient,
qualitative and affordable health services and thereby improve the health status of
Nigerians as health sector’s contribution to breaking the vicious circle of ill-health,
poverty and under-development”. This suggests that the initiators and the drivers of the
reform process clearly recognized the inter-relationship between poverty and ill-health
and understand the potential of the HSR to contribute to poverty reduction in the country.
In fact, one of the underlying assumptions and cross-cutting principles for the HSR
programme is the belief “that ill-health is a major determinant of poverty. Thus,
addressing the health needs of all Nigerians is an important component of the country’s
poverty reduction strategy”.
The Contributions of the Health Sector Reform Process
While hard data is not available to assess the contributions of the HSR to poverty
reduction presently, a close scrutiny and an analysis of its provision and the
implementation process will provide insights into its potentials in this respect.
The HSR has the following strategic thrusts:

Improve the performance of the stewardship role of government

Strengthen the national health system and improve its management

Improve availability of health resources and their management

Improve the access (including physical and financial) 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.
Thus, these thrusts address the issues of payment, financing, organization, regulation, and
behavior - which are fundamental to health system performance. Within each of the
strategic thrusts for the reform programme, a number of priority health sector
performance issues have been identified for focused interventions, because of their
presumed sector-wide catalytic effects. These thrusts have been carefully selected and
priority actions outlined such that the implementations of relevant activities will logically
lead to improved health outcomes. The priority areas include the following: reduced
disease burden (with major focus on HIV/AIDS, tuberculosis, malaria and vaccinepreventable childhood diseases), reduction in child mortality and morbidity, improved
maternal health, and increased life expectancy (Figure 1) through improved health
behaviours and improved service provision. The selection of priority activities was made
on evidence-based platform, taking into consideration the contribution of each group of
health problem to the overall health status of Nigerian and the cost-effectiveness of
available interventions. Overall, the priority focus was on the diseases and health
problems that are responsible for most morbidities and mortalities among Nigerian
population groups. This is with the desire to positively impact the greatest number of
people within the shortest possible time. Such an approach has the potentials to positively
affect the landscape of health and wellness of the population such that they can be more
health to pursue their productive enterprises and earn improved incomes Also, the money
that would otherwise have been spent on ill-health and hospital bills can be used to
improve the nutrition and general living condition of individuals and households, as well
as improve savings and investment – all of which would contribute to poverty reduction.
The case of malaria as covered under the strategic thrust of “Reducing the disease burden
attributable to priority health problems provides a good illustration of how the reform
process could reduce poverty. Malaria is a leading cause of death among children and
also have negative impact on the outcome of pregnancy, including premature delivery
and delivery of low birth babies. Malaria also causes blood shortage (anaemia) in
pregnant women. In addition, malaria reduces productivity in all ages, thereby
contributing to decreased academic performance of school children and lower earning of
the adult. Under the reform process, and based on evidence of cost-effectiveness impact,
the strategy is to particularly address malaria through preventive measures such as
provision of insecticide-treated bed nets. Specific drugs are also to be provided to
pregnant women as part of routine antenatal care to prevent malaria. As Figure 2 depicts,
this, in turn, will result in improved delivery outcome and healthier babies. These
children will experience fewer episodes of malaria as they sleep under bed nets and the
family will therefore spend less on health problems (in terms of money and time). In turn,
there will be greater possibility of savings and investment, which will ultimately reduce
the potential for poverty. Other strategies such as education of mothers to treat simple
childhood health problems, recognize danger signs, and seek treatment early will also
complement the preventive strategies such that even if the child develop malaria, he or
she can be treated at the early stage to ensure early recovery. Overall these strategies will
lead to healthier adults, conceptually, with capacity for maximal productivity.
Some of the progress that have been made in the implementation of the HSR agenda
include increased coverage of preventive interventions such as insecticide-impregnated as
well as the provision of free artemisinin-based combination therapies to treat malaria in
children, and improved access to HIV testing facilities and anti-retroviral therapy. There
has also been an increase in the access to vaccines to protect children from major killer
diseases. The enactment of the National Health Insurance Services Act deserves special
mention. The scheme, though limited in coverage to workers in the formal sector at
present, has improved access to services. Increased resources have also been provided
towards the achievement of the health-related Millennium Development Goals, such as
those targeting child and maternal health, and the control of HIV/AIDS and malaria.
Efforts to improve quality through enforcement of consumers’ rights and improving
health behaviour through behaviour change interventions are also ongoing. While the
implementation of these and other activities may not translate directly to improved health
outcomes, they certainly have the potentials to contribute to improved health in Nigeria
substantially.
Conclusions
The on-going health sector reform has various provisions that could make for improved
health outcomes through improved health behaviour and improved quality of health
service delivery. These are expected to impact on poverty because of the strong linkage
between poverty and health. While the implementation rate of the HSR, though not
optimal, gives some reasons to cheer, it is important to note that the expected health
development outcomes will ultimately prove elusive except the carefully chosen priority
actions outlined in the HSR documents are pursued vigorously, relentlessly and
faithfully. The implementation strategy and rates need to be carefully monitored in this
wise. Thus, the HSR has the potential as a health system intervention to break the vicious
cycle of ill-health, poverty and under-development through improved health outcome and
translate it into a virtuous cycle of improved health status, prosperity and sustainable
development.
Figure 1d
Strategic Framework for Improving Health Outcomes through HSR
CONTEXT













NEEDS,
MDGs,
Health Systems Performance
Public Service Reform
PROCESS
Stakeholders’ Consultation
Consensus Building
STRATEGIC THRUSTS
Improving the stewardship role of Government
Strengthening the National Health System and its Management
Reducing Disease Burden
Improving availability of health services
Improving access to quality health services
Improving consumer awareness of their health rights and
obligation
Promoting effective public-private partnership
CHANGE IN HEALT H
PROGRAM AND SERVICES
 Improving Health Care
Financing
 Improved Human
Resources Management
 Improved Health Care
delivery,
 Improved procurement &
supply
 Improved access to health
information &
communication
d
CHANGES IN HEALTH SYSTEMS
PERFORMANCE
Improved access, equity, efficiency,
performance and sustainability of the health
system
CHANGES IN UTILISATION OF
SERVICES
 Improved health seeking behaviour
 Improved knowledge attitude and
practices
 Improved health promotion
activities
 Improved access to information
HEALTH OUTCOMES
 Reduced Disease
Burden (HIV/AIDS,
TB, MALARIA,
VPD)
 Reduction in Child
Mortality and
Morbidity
 Improved Maternal
Health
 Improved Life
Expectancy
Adopted from Lambo E. Health sector reform in Nigeria: The journey so far. Presentation at the National
Health Conference, Abuja, 28t - 29th 2006, pp.173-184
Figure 2
Potential Effect of Malaria Control on Poverty Reduction
Implementation of HRS measure against
malaria
Reduced malaria
related incidence
in children
Reduced Child
death
Reduced malaria
related incidence
Reduced spending
on illness
Reduced negative
maternal & Child
outcome
Healthier
Children…
Increased family
saving & investment
Healthy Adults
High level of
productivity &
Income
Improved economic wellbeing & reduced poverty
level
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