PRESENTATION AT ACHAP 7th BIENNIAL

CONFERENCE, NAIROBI, KENYA.

FEBRUARY 23RD -26TH 2015

DR DANIEL N. GOBGAB

CHAN NIGERIA

Estimated Population 173,615,000. (2013)

36 states + the Federal Capital Territory

774 Local Government Areas

9,572 Political Wards, the lowest unit of health services delivery

3 levels of Government – Federal, State and Local government Areas.

The states and local governments depend on fiscal federal allocation for over 85% of their expenditure

Economy heavily dependent on oil

Decentralization is a process of transitioning from a governance structure in which power is concentrated at the central or national level to one in which authority to make decisions and implement them is shifted to lower level government or agencies

Conventionally, there three types of decentralization– deconcentration, delegation and devolution.

Decentralization can be administrative (transfer of civil servants and public functions to the lower level), fiscal (devolution of decision-making powers), or a mixture of these

Devolution is the transfer of authority for

decision-making, finance, and management

to quasi-autonomous units of local

government with corporate status.

Devolution usually transfers responsibilities

for services to local government areas that

elect their own executive leaders and

councils, raise their own revenues, and have

independent authority to make investment

decisions.

Nigeria is practicing a mixture of all.

The federal Ministry of Health

The Ministry of Health in every State and the

Federal Capital territory Department for

Health

Parastatals under the Federal and State

Ministries of Health

All local government health authorities

The ward health committees

The village health committees

The private health care providers (for profit

and not for profit)

Traditional health care providers

Alternative health care providers

In the Nigeria Constitution, health is on the concurrent list. The provision of health services is a joint responsibility of the Federal, State and Local Governments.

Nigeria is one of the Countries in Africa which adopted a decentralized system of government post independence

The Federal Government's role is essentially coordinating the affairs of the University Teaching Hospitals, Federal Medical Centers (tertiary health care), Regulatory bodies, oversight of state health services and policy formulations among others

The State Government manages the various

General Hospitals(secondary health care);

The state also provides technical assistance

to the local government PHC services.

The Local Governments focus on Primary

Health Clinics (primary health care), which

are regulated by the federal government

through the National Primary Health Care

Development Agency (NPHCDA)

Primary Health Care is the fulcrum on which

health care delivery services are hinged.

Presidential summit Declaration on Universal

Health Coverage in Nigeria- 10th March 2014

On December 9, 2014, Nigerian President

signed into law the National Health Bill.

The new law is intended to provide a

framework for the regulation, development,

and management of a national health system in

Nigeria.

The National Health Act creates a Basic Health

Care Provision Fund to provide Nigerians with

access to basic health care services as a

strategy to universal health coverage.

Fifty percent of this fund will be allocated to the National Health Insurance Scheme to provide health coverage for pregnant women, children under the age of five, the elderly, and persons who are physically challenged.

The other half of the Fund will be used to provide essential vaccines and consumables for eligible primary healthcare centers (“PHC”), maintenance of facilities, equipment, transport for PHC facilities, and development of human resources for PHCs with a goal of extending primary healthcare to Nigerians living in hard to reach rural communities- (What FBOs are already doing)

The law also requires universal acceptance of accident and other emergency cases by all health facilities (public and private),

Provides for improved standards and quality of healthcare in health facilities, and prohibits the use of public funds by Nigerian public office holders and civil servants seeking medical treatment abroad.

While it remains to be seen whether the objectives of the National Health Act will be achieved, it is hoped that Nigeria will serve as a good example to other countries in Africa with respect to creating a sound health care sector

Health services has been taken to the grass root with community participation through ward and village health committees coordinated by LG health department

Funding for health at all levels is being done through annual budgets.

Decisions on health of communities is jointly done by standing ward and village health committees promoting ownership

Environmental health, water and sanitation are key components of health at the community level. ( re introduction of Environmental Health Officers)

Demand creation and community mobilization for service utilization are successfully done at the local level through community participation e.g. Polio eradication program.

Awareness creation and sensitization of the public on key public health issues through engaging all stakeholders e.g. Ebola virus disease control and reducing prevalence of HIV/AIDS

Joint monitoring of health service delivery between communities, CBOs and local council authorities is enhancing accountability.

Re introduction of training for community midwives to reduce MCH morbidity and mortality

Under 5 Mortality 189/1000 life

births in 2007

124/1000 life

births in 2012

Maternal Mortality 800/100,000 life

births in 2005

560/100,000 life

births in 2012

Life expectancy

both sexes

47 in 2007

(HIV/AIDS impact)

54 in 2012

The Lack of Political Will: Despite pronouncements to the

contrary, state governments do not want to devolve all

powers to the local level.

The Management Challenge: Many local governments have

limited financial and human resources and inadequate

governance capacity to fulfill the mandate thrust upon them.

This makes the states to micromanage affairs at the local

government level.

The Challenge of Unrequited Expectations:

‘Decentralization’ is not the panacea that it is touted to as it

is only limited to the “de concentration” of authority and

services to the local level, without the devolution of revenue-

generating and decision-making authority necessary for true

decentralization (there is an active debate ongoing now in

Nigeria about financial autonomy at the LGC)

Non Engagement of FBOs. The government recognizes the great contributions of FBOs,( up to 40% of health care deliver y services especially in hard to reach areas) yet there is no form of clearly defined partnership or MOU between the 2.

FBOs are not part of free services for children, pregnant mothers, the disabled, etc as specified in the National Health Act

Inequity in distribution. Decentralization reforms has also led to inequity of health care delivery (for example, undesirable local government disparities )

Low revenue base at lower levels. The states and local governments depend heavily on the central government for allocation of funds.

Resource mobilization through increased

revenue generation at state and local

governments levels to reduce dependence on

central allocation which has compromised

independence.

Strengthen the role of local governments in

improving public health management.

Close monitoring of the implementation of

the new National Health Act towards

realization of UHC for poor Nigerians

For the first time in many years, Nigeria has

come up with a National Health Act and as

the implementation has just begun, it is

expected that with greater clarity of roles

and responsibilities, the final decision on

local government financial autonomy if

implemented will enhance the achievement

of universal health coverage in the best

interest of the grass root people of Nigeria.