A transformation has been taking place in Northern Nigeria. Perhaps few have noticed its creeping successes; fewer mothers’ lives lost and more children living to see their sixth birthday. After all, few people know when they are part of the statistic most likely to die and even less when they become part of a decreasing trend in mortality.
The process of change began in the 1990s and has taken two decades to manifest as effective primary health care service delivery. A strong primary health care system is a prerequisite to deliver comprehensive maternal, newborn, child and routine immunisation services. For me, involved in several UK Department for International Development’s funded projects two decades ago, such as the Bamako Initiative and the Benue Health Fund, it became clear that the extreme weakness of health services provided by Local Government Authorities , was further compounded by the very serious impediments to reforming them.
In Nigeria, Local Government Areas are responsible for delivering almost all primary health care services from the public sector and so it was clear that the core problems were issues of governance. These included: fragmentation of responsibility for staff, financing and service delivery; inadequate financing of health services, especially for primary health care, as well as very weak financial management; the lack of Local Government Area accountability for delivering services, or for their funding, let alone any accountability to the people they were meant to serve or recognition of their essential role in community involvement citizen voice and wider cross sector engagement; and very weak support and supervision from state level to Local Government Areas and Local Government Areas to facilities as well as from federal to state level.
In 2001, the Department for International Development recognised that the governance and management of primary health care by Local Government Areas was perhaps the most significant, intractable problem facing Nigeria’s health services. It therefore decided to help a number of states and the Federal Government to tackle this problem. The Department for International Development launched a large six year, multi-faceted change management health programme in four states (later six).
In doing this, the Department for International Development and some key Nigerian stakeholders recognised that numerous attempts to fix Local Government Area health services over the previous decade had achieved very little. Broad and substantive transformation was therefore required of health sector governance, management and service delivery – hence the name of this new programme: the “Partnership for Transforming Health Systems 1” (PATHS1).
It was the PATHS1 reform initiative that introduced the integrated district health system in Enugu and also the Gunduma health system in Jigawa, both of which are very far-reaching changes to the governance and organisation of health services in each state. More recently this has been taken forward by the PRRINN-MNCH Programme as “Primary Health Care Under One Roof” (PHCUOR) in Yobe, Zamfara as well as Jigawa States. The National Primary Health Care Development Agency is now championing Primary Health Care Under One Roof as a national initiative.
In 2011 it was adopted as Nigerian policy by the country’s National Council on Health. The Executive Director of the National Primary Health Care Development Agency said there are many challenges to running a health system in a federal government, “The way around it is for all the authorities responsible for basic services from federal to local government levels to agree and bring their authorities ‘under one roof’”. He said primary health care under one roof would enhance coordination, collaboration, effectiveness and efficiency; eliminate constraints, fragmentation and managerial uncertainty, wastage of resources and create an enabling environment for implementation of the Health Act¹.
Primary Health Care Under One Roof is modelled on the World Health Organisation’s guidelines for integrated district-based service delivery and includes the following major changes in health sector governance:
- State legislation establishing integrated structures, financing and staffing and management of Primary Health Care – in Jigawa ‘s case replacing the Local Governement Areas’ role in health with “Gundumas”.
- Significantly increased budget allocations and releases of funds for Primary Health Care, plus the establishment of much more effective financial management and reporting systems.
- Single lines of accountability (particularly in Jigawa), integrated support and supervision from state level right down to facilities and stronger links between health services and the communities they serve.
- Extensive systems improvement in policy, planning, management, organisation and capacity within the health sector.
These changes provided the indispensable foundation on which effective Primary Health Care service delivery is now being built. One outcome has been the spectacular increase in immunisation coverage which Jigawa (2.2% to 32.7% seen between 2009 and 2013 under the PRRINN-MNCH programme²) as well as Enugu and Ekiti have achieved, signalling an overall improvement in the delivery and uptake of health services.
Another is that government is now getting increasing recognition from the public for providing better health care, which has increased political interest and commitment for the reform process. The changes have included significant reform and improvements to the functioning of state-level structures as well as extensive and wide ranging changes at lower levels. The process of achieving this change has involved extensive engagement with and buy-in by a wide variety of stakeholders at every level in the health services.
Finally, the big question: what were the essential ingredients in achieving these substantive health sector reforms? Together with my colleagues at Health Partners International, implementers in these donor-assisted programmes, we identified ten key ingredients. However we also believe these key ingredients are potentially very pertinent to the work and roles of the National Primary Health Care Development Agency and the Federal and State Ministries of Health.
- Very careful attention to engagement with stakeholders at many levels affected by reforms, who must lead and implement the reform process. This engagement is at the heart of governance reforms, but it is not automatic nor simple to execute. It requires understanding the political economy in each state, very careful planning and methods of engagement, as well as constant attention.
- Multi-faceted health system change initiatives. Too often interventions address a small corner of the health system so their results tend to be short-lived, because different elements of the system are integrally inter-connected and inter-dependent so narrow changes are difficult to sustain. PATHS and PRRINN-MNCH have had the ability to work widely across the health system, addressing issues of governance, finance, institutional management, demand and accountability, service delivery, etc, – frequently at the same time. Comprehensive reforms such as these require large-scale interventions, “flexible” resources (as compared to rigid aid or usually inflexible government funding) and continuity over a significant period – preferably 10 to 15 years.
- Capacity to respond flexibly to local conditions and grasp opportunities when they come up for addressing core elements of health system functionality, while still maintaining consistency and persistence.
- A sectoral approach to governance reform. Our experience suggests the struggle for reform may be easier within a sector such as health, rather than across the whole of government. We have found that key players have been prepared to give ground on a limited portion of their finance, staff, structure, systems, etc., in the expectation of fairly tangible, popular benefits (e.g. better health care or education services). Changes of this nature right across government would pose a far greater challenge to entrenched interests – although there are a few indications that change in one sector can start to spread to others.
- A “systems approach” to developing organisational and institutional management. It has proved extremely important to get basic systems up and running for financial management, support and supervision, patient care management, logistics, drug supplies and so on. These are indispensable and their effect in improving health service delivery is direct and extensive.
- Linking up governance reforms with systems strengthening. This link is seldom made and there are usually different people working on improving management systems to those working on governance issues. All the critical issues in managing health services (e.g. budget allocations and disbursement, staff management, drug procurement and capital investment) have massive governance implications and requirements as well. These need to be understood and then strategies adopted to improve systems in the context of the prevailing governance milieu and where necessary with support for governance reforms.
- Strengthening management capacity, especially through a work-based, problem-based, mentoring approach (not enough of this has yet been done in Nigeria).
- Attention to coverage and scale-up from the beginning. Time and again pilot projects targeting a few Local Government Areas have not proved feasible to expand more widely. The Department for International Development’s whole-state approach from 2001 onwards has been vital for realistic, real change and replicability.
- Appropriate technical support. Health managers battling on their own can’t find the time, energy and resources to carry forward major reforms or to identify and assess the best options to pursue. Access to capable, supportive assistance and shared experience from similar situations can therefore be very valuable. Getting the right type of technical support is difficult however, because often it is inappropriate for local conditions, amateurish and unskilled, undermining of local initiative, self-serving and self-perpetuating. Donor projects have been the main source of such support, but it is a more appropriate role for Federal agencies, such as the FMOH or NPHCDA, if they had the resources and willingness to change their functions radically, focusing on a supportive role to the states with plenty of time in the field.
- Hard sustained work. Many people believe that they can come in, spend some time, wave the wand and all things will miraculously improve. This is delusional. Our experience is that you need senior, experienced support over a long time to make a difference. Stakeholders on the ground won’t trust you, let alone listen to you, until you have served some time, paid careful attention to those directly facing the problems every day, understood the complexity of the issues, etc, etc. Turning systems around needs the kind of sustained input that often is not allowed for. It is also important to realise that important systemic changes will suffer setbacks. There are good reasons why the existing system works the way it does and we want to change this. Thus, while on the surface it makes sense to improve and make a better functioning, more efficient health delivery system, this is not necessarily what the power-brokers want (although they would never admit this).
So transformation inevitably requires a sustained approach, continuity with very careful strategizing, some inevitable setbacks and above all persistence over a long period of time.