Nigeria’s weak primary health system cannot cope with pandemics

By Ifedilichukwu Ekene Innocent, Advocacy, Campaign and Policy Manager, Survive programme

In a bid to strengthen the weak health system in Nigeria – especially at the primary health care (PHC) level – in 2014, the federal government of Nigeria finally signed into law the National Health Act. Persuading the government to take this step took about 10 years of tireless advocacy from Save the Children and other members of the Health Sector Reform Coalition.

National Health Act Guarantees Health Rights
The National Health Act provides a framework for the regulation, development and management of the national health system and for the first time sets PHC provision standards. It guarantees access, equity, quality, affordability and sustainability of health services especially at the PHC level.

The Act also created the Basic Health Care Provision Fund (BHCPF), which legally guarantees a minimum 1% of consolidated revenue specifically for strengthening PHC infrastructure and for the provision of a basic minimum package of services for all citizens, free at the point of use.

Primary Health Care Under One Roof
Primary Health Care Under One Roof is a policy that has been developed to reduce fragmentation of primary health services and to ensure that all services can be assessed at one point and are managed by one authority. The policy aims to drive efficiency and cost effectiveness, which can be passed on to users by improving the quality of services. Primary Health Care Under One Roof was approved in 2011 and was rolled out across at least 24 states in Nigeria to varying degrees. Only those states that have rolled out this policy, have established the State Health Insurance Scheme/Commission and are able to provide the 25% counterpart funding are eligible to draw on the BHCPF.

Resources from the BHCPF are meant to be used for the procurement of drugs, vaccines, equipment and essential consumables, but can also be used for the maintenance of facilitates, transport, development of human resources and emergency responses. BHCPF support should ensure that the basic minimum package of services remains free at the PHC level.

Chronic Under-Funding of Primary Health Care
Although the BHCPF was mandated in 2014, the funds were not appropriated in the budget until 2018. In that period, state and local government areas’ health allocations remained static. Federal government allocations for health have not improved much since 2016 when it was 0.5% of gross domestic product and just 5% of the national budget. This resulted in 75% of total health expenditure in 2016 being out of pocket, a situation that has only worsened since. Many Nigerians, especially those in rural communities, have been impoverished from the rising costs of health care – a clear indication that very little of the already small allocations for health is reaching the PHC level where the need is greatest.

Weak PHC Systems Harm the Poorest and Most Vulnerable Families the Most
As a result of weak PHC systems, child mortality rates in Nigeria are high: 132 children dying per 1,000 live births in 2018. Large numbers of children still die from preventable diseases: in 2018, 162,000 children died from pneumonia, making it the biggest killer of children.

The health situation in Nigeria is dire. Now the country also faces the threat of the COVID-19 pandemic. The first COVID-19 case was identified in Lagos on 27 February. Two months later, on 28 April, the number of confirmed cases had grown to 1,532. It keeps rising.

The increase in cases, according to the Nigerian Centre for Disease Control, is due to community transmission, which can be attributed to a lack of understanding on the importance of community social-distancing measures, mistrust in government services and the lack of access to safe water, sanitation and hygiene services. These challenges are compounded by inequalities in access to health services, including essential PHC by the poorest and most vulnerable families.

Urgent Need for Action
Along with our partners, we will continue to advocate for a 5% gross domestic product allocation for health, with an increase in allocations for PHC. There is an urgent need for all 36 states and the Federal Capital Territory to roll out the Primary Heath Care Under One Roof and Health Insurance Under One Roof policies, making them eligible to receive funds from the BHCPF. The federal government should release at least 1% of consolidated revenue in a regular and systematic fashion so that states can use this predictable funding to slowly strengthen primary health care plans and infrastructure and ensure free at point of use primary health care services.

For the moment though, BHCPF funds are crucial in setting up emergency response plans to ensure that the COVID-19 outbreak is contained and managed with as little damage as possible. Unless the federal government and all states act swiftly to put systems in place to ensure uninterrupted financial flows to the PHC level, Nigeria will not be able to cope with the COVID-19 crisis or any future pandemic.