Strategic health purchasing progress in sub-Saharan Africa and adjustments needed for health financing systems to become more resilient to pandemics

By: Obinna Onwujekwe, Nathaniel Otoo, Stella U. Matutina, Uchenna Ezenwaka, Augustine Kuwawenaruwa , Joël Arthur Kiendrébéogo

Strategic Purchasing Africa Resource Centre (SPARC) is a hub in sub-Saharan Africa that serves as a go-to source of information, support and capacity building for strategic purchasing to get better value for health spending to advance universal health coverage. Governance challenges which can be gross irregularities such as delays in provider payment, corrupt practices, and weak monitoring and accountability mechanisms, historical budgeting (not evidence-based), provider/purchase split and roles that are not clearly defined etc., affect the efficiency of health insurance schemes in Nigeria. In addition, some providers still dispense branded drugs and stockouts persist, coupled with an increasing rate of denial of referrals by HMOs. And finally, performance information is not linked to payment decisions, even as leakages also occur in the system, revealing lack of accountability, which also manifests in alleged misconduct among providers and HMOs. To address these many challenges affecting health insurance schemes in Nigeria, strategic purchasing is recommended.

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Marketplace aspect of Primary Health Centres in Nigeria and its implication for health care delivery

By: Aloysius Odii, Obinna Onwujekwe, Prince Agwu, Pamela Ogbozor, Tochukwu Orjiakor, Eleanor Hutchinson, Dina Babalanova

Healthcare facilities are routinely regarded as fundamentally an institution or establishments housing local medical services or practices. In that sense, the enduring human interactions and economic transactions in these spaces are often overlooked. Yet, this could pose challenge to healthcare delivery and the overall intent to meet health-related goals.

In this study, we narrate how health facilities operate as a marketplace and drew attention to its implication for healthcare delivery. Our description of the marketplace follows an economic anthropological perspective, which sees them as sites for complex social processes, instigators of cultural activity and realms for economic exchange.

The study was based on eight weeks of observations of six Primary Health Centres (PHCs) and two local government headquarters by four fieldworkers in Enugu State, Nigeria. The data was supplemented with semi-structured interviews with health workers, service users, and health managers. The data were analysed using NVivo and followed a narrative analytical approach.

The narrative showcased that health facilities are not just centres for health delivery but are hubs for economic activities, intertwined with social and cultural processes that in turn affect access to care. Besides pharmaceutical products, snacks, wears and drinks are sold by marketers and health workers on duty within the premises. Sometimes, this interferes with care when health workers are absent from duty to attend to their private business. Our narrative also demonstrated that access to pharmaceutical products as well as other medical services can be influenced by social relations and perceived ability to pay while services that are free can be offered for a fee. These activities were made possible by weak institutional structures that hardly communicate policies or regulate health workers’ activities.

The study concludes that besides serving as a centre for healthcare delivery, health facilities also sustain social and economic activities which sometimes interfere with service delivery. Health managers must manage informal structures within this space to improve health care delivery.

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Health system responses and capacities for COVID-19 in Nigeria: a scoping review

By: Uguru, N., Ojielo, N., Ogu, U., Onah, S., and Ude N

Prior to the index case in 2019, there was no official preparedness plan on the ground of inadequate public awareness of COVID-19 in Nigeria. Health system financing and infrastructural development were at a very low point. This study aimed to find out information and determine the capacity of the Nigerian health system’s responses to COVID-19 in the country.

A scoping review of media and official documents and journals, published from 1st December 2019 to 31st December 2020 was done. Other online news sources that have consistently reported health systems’ responses to COVID-19 in Nigeria, were also reviewed. The geographical scope of the articles were national and sub-national. The search was conducted in English and performed in PubMed, Google Scholar and Scopus.

Nigeria’s International Health Regulations (IHR) score at point of entry (PoE) 1 & 2 was 3 and 1 in 2019. Routine capacities established at points of entry were improved after the index case, however, effective public health response at points of entry, remained the same. After the index case, a presidential task force to organize response to the pandemic and oversee nationwide lockdown measures was inaugurated. However, this brought about poor access to food and income for millions of Nigerians. Non-health responses such as conditional cash transfers and welfare packages were haphazardly done and deemed not to have met the adequate economic response need.

By December 31st, 2020, Nigeria had 70 free laboratories from an initial 13 before the pandemic. Available testing platforms were G-expert, open PCR, Corbas and Abott, with a capacity to test 2500 samples a day, only half of this was achieved due to inadequate human resource supply. Equipment, infrastructure and supplies received a boost after the index case but were still considered inadequate, as there were 350 intensive care unit (ICU) beds prior to the index case, by 31st December there were 450 ventilated ICU beds. Local production and sourcing of materials were encouraged, though this remained below par at 14 mobile testing booths. Health worker infection rose as shortage of PPE’s was cited as a cause.

Nigeria’s health system response and capacity to handle COVID-19 is quite poor and grossly inadequate. There is a need to increase the number of health workforce in the country and institute adequate accountability mechanisms to ensure prudent and focused management of health funds.

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National Responses to COVID-19 in Nigeria: Data and Evidence to Support Health Preparedness and Responses

By: Obinna Onwujekwe and Chinyere Okeke

This presentation explores and compares responses in the two anglophone countries that together make up almost half the population of West Africa, Nigeria and Ghana. Drawing on desk reviews including media reports and policy documents as well as key informant interviews with key national and sub-national health sector decision-makers and implementers in the Covid 19 response timelines of interventions at central and local government level to address the pandemic, and observations as to how and why these interventions worked (or not), intended and unintended effects are presented. A qualitative exploration of whether the timelines of the waves from the epidemiological analysis and of the interventions show any similar patterns or not. Lessons from the analysis for the ongoing management of the present epidemic and any future pandemics are explored.

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A review of Nigeria’s health systems response to COVID-19: lessons for strengthening the health systems for improved service delivery

By: Chinyere Okeke, Chioma Onyedinma, Benjamin Uzochukwu, Obinna Onwujekwe

The COVID-19 pandemic has challenged the health systems of almost all the countries in the world. A strong health system is characterized by its ability to respond to emergencies while remaining resilient in delivering high-quality routine essential services promptly. This is not the case in most low- and middle-income countries, of which Nigeria is one of them, making them very vulnerable to COVID-19 pandemic. Prior to the pandemic, health systems had not received adequate attention. However, with this pandemic, the country’s leadership has made efforts to respond to reduce its spread. These efforts are worth documenting, as they will inform policymakers and other stakeholders in Nigeria to reflect on the ways to adapt and scale up the positive measures identified.

A scoping review of published and grey literature including journals, news/ media documents and official documents that were published from 1st December 2019 to 31st December 2020 was conducted. The reviewers read and extracted relevant data using FACTIVA in a uniform data extraction template. The template was structured in themes using the health system building blocks and service delivery subtheme that captured technical support and interventions targeted at health workers was used for the manual content analysis.

The identified interventions and strategies that have affected health service delivery were mostly technical support and interventions targeted at health workers. These included training of about 17,000 health workers, supervising and engaging more workers, upgrading laboratories and building new ones to improve screening and diagnosis, motivation of health workforce with incentives (financial and non-financial). There was influx of philanthropic gestures and improved data and information systems, supply of medicines, medical products and non-pharmaceutical preventive materials through local production. Overall, the presence of political will and government’s efforts in health systems response to COVID-19 facilitated these interventions.

The interventions of state and non-state actors have to some extent, strengthened the health systems for improved service delivery. However, more needs to be done towards sustaining these gains and towards making the health system strong and resilient to absorb the unprecedented shocks.

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A review of corruption and accountability issues in Nigeria’s COVID-19 response: Implications for health systems governance

By: Prince Agwu, Nma Ekenna, Uche Obi, Tochukwu Orjiakor, Aloysius Odii, Enyi Etiaba, Benjamin Uzochukwu, Obinna Onwujekwe

Flexible and urgent health spending during public health emergencies distorts procurement processes and potentially encourages corrupt practices in health systems. This can erode public confidence, resulting to poor compliance to health safety measures during public health crisis. Thus, anticorruption in health, and in pandemic responses is key. COVID-19 related articles (reports from various government bodies and CSOs) on resource mobilization, appropriation, public perceptions towards accountability and anticorruption, were reviewed. Findings were organised under three themes: i) mobilized resources for COVID-19, ii) evidence of corruption or anticorruption in spending them and iii) implications for health systems governance.

About N36.3b ($US93.5m) was raised through 295 donations to federal and state governments, to combat the virus. Additionally, Nigeria appropriated N10b ($27m) to epi-centres and the disease control agency in the country. Whilst information on available resources are freely available, that on expenditure has been opaque, which has generated heated concerns. Lack of evidence of optimal utilization of resources under the frames of accountability and anticorruption has aroused public concerns and trust in the actual existence of a pandemic. Diminished health worker motivation connects with industrial actions.

CSOs need to be actively engaged in driving government to show accountability, through partnering with multilateral organisations and donors to increase pressure on government to be accountable with resources mapped out for pandemic responses. Health workforce groups and Associations also need to actively engage government and demand accountability. Finally, conversations on corruption and accountability issues that affect health systems should be encouraged.

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Progress in the face of cuts: a qualitative Nigerian case study of maintaining progress towards universal health coverage after losing donor assistance

By: Uche Shalom Obi,  Osondu Ogbuoji,  Wenhui Mao,  Minahil Shahid,  Obinna Onwujekwe, Gavin Yamey

In the coming years, about a dozen middle-income countries are excepted to transition out of development assistance for health (DAH) based on their economic growth. This anticipated loss of external funds at a time when there is a need for accelerated progress towards universal health coverage (UHC) is a source of concern. Evaluating country readiness for transition towards country ownership of health programmes is a crucial step in making progress towards UHC. We used in-depth interviews to explore: (1) the preparedness of the Nigerian health system to transition out of DAH, (2) transition policies and strategies that are in place in Nigeria, (3) the road map for the implementation of these policies and (4) challenges and recommendations for making progress on such policies.

We applied Vogus and Graff’s expanded transition readiness framework within the Nigerian context to synthesize preparedness plans, gaps, challenges and stakeholders’ recommendations for sustaining the gains of donor-funded programmes and reaching UHC. Some steps have been taken to integrate and institutionalize service delivery processes toward sustainable immunization and responsive primary healthcare in line with UHC. There are ongoing discussions on integrating human immunodeficiency virus (HIV) services with other services and the possibility of covering HIV services under the National Health Insurance Scheme (NHIS). We identified more transition preparedness plans within immunization programme compared with HIV programme. However, we identified gaps in all the nine components of the framework that must be filled to be able to sustain gains and make significant progress towards country ownership and UHC. Nigeria needs to focus on building the overall health system by identifying systematic gaps instead of continuing to invest in parallel programmes. Programmes need to be consolidated within the overall health system, health financing priorities and policies. A comprehensive and functional structure will provide continuity even in the event of decreasing external funds or donor exits.

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