How countries can make progress towards UHC after transitioning out of DAH: Lessons from Nigeria

By Shalom Obi, Osondu Ogbuoji, Wenhui Mao, Minahil Shahid, Gavin Yamey, and Obinna Onwujekwe
 
In the coming years, about a dozen middle-income countries are expected to transition out of development assistance for health (DAH). This is so because the eligibility criteria set by most multilateral donors are based on income per capita or rise in GDP. However,  an increase in income per capita does not necessarily mean a reduction in disease burden. For example, despite an increase in GDP, Nigeria still stands out as very unprepared for the upcoming transition, based on poor health indices, very low domestic financing for health, and poor government commitment to health.
 
Nigeria is vulnerable to setbacks, in event of health-focused donors exiting its health funding space because the country struggles with a low per capita income, debt burden, weak capacity to efficiently use public resources, limited and less effective health systems, and weak governance and public institutions. More so, considering the low government funding for health (see Figure 1 below), the impending financial gap will most likely shift to out-of-pocket spending which constitutes 75.2% of total health expenditure. This will be catastrophic and may drive more of the vulnerable population below the poverty line. The decline in donor funding has already been reflected in suboptimal service delivery and health service users are now having to pay for previously free-of-charge services. 
Figure 1: Trend of Domestic General Government Health Expenditure (GGHE-D) Global Health Expenditure Database
 
The more currently appropriated funds for health are not subject to high-level accountability, the effects on the vulnerable may likely to be grave, further drawing the country away from achieving UHC. With changes in DAH and impending transitions, there is an urgent need for sustainable solutions, as stakeholders must begin to think about how to fund healthcare when external funds decrease or end.
 
For evidence-driven transitioning, away from DAH, stakeholders may wish to refer to a qualitative research that used Vogus and Graff’s expanded framework for evaluating the readiness of Nigeria’s transition. Unfortunately, the illustrated gaps (see Figure 2) identified in the study show that Nigeria is not currently prepared to sustain donor-funded programs and make progress if/when donors leave.

Figure 2: Gaps – using Vogus and Graff’s expanded framework for evaluating country readiness for transition of donor-funded health programs to domestic ownership (Vogus and Graff, 2015)
 
The above framework shows clearly that Nigerian health system is mostly unprepared to transition out of DAH and make progress towards UHC. This is predominantly due to policy implementation gaps, unaccountability and corruption, and a lack of initial transition plans at the onset of health programs.
 
Policy implication
To overcome the challenges and bottlenecks that hinder policy implementation and close these gaps,
  • Policymakers should consider the feasibility, sustainability, and accountability of policy implementation during the policy process. They should ensure that there are feasible road maps for apt implementation of pro-UHC policies.
  • Secondly, crucial steps must be taken to ensure that transition plans are factored into program planning from the onset, and not as an addendum. A well-grounded health plan that puts transition in perspective is needed to foster sustainability and progress towards UHC at the time of transition.
  • Nigeria must also endeavor to make political commitment to health – at least improve from current 5% of annual budget allocated to the health sector, while racing toward the 15% commitment as promised in the Abuja declaration of 2001. This will enable the country to integrate healthcare programs and build the overall health system to transition smoothly out of various donor programs, whilst making progress towards UHC. Meeting this commitment has become even more critical given the effects of COVID-19 pandemic.
 
Lessons for upcoming transitioning countries
Upcoming cohort of transitioning countries should have a robust transitioning plan in place to sustain gains of donor funds and make progress toward UHC. Transition plans should not be an afterthought, but a well-incorporated aspect of health programs’ plans. Therefore, donors and recipient countries should ensure that transition plans are built into health programs at the planning stage. Furthermore, it is not enough for upcoming transitioning countries to have pro-UHC policies, they should also have roadmaps for implementation, with broad stakeholder involvement. It is also crucial for such countries to give careful consideration to increasing their fiscal space for domestic funding for health, integration of health programs, and building the overall health system. This will engender sustainability and ensure progress towards UHC at the time of transition. Donors and recipient countries should endeavor to have inbuilt transition plans to give direction to program implementation and enable institutionalization of service delivery processes for continuity.
 
Conclusively, to manage transitions from DAH and make progress towards UHC, the Nigerian government needs to identify and address implementation gaps, as well as systematic gaps in using domestic resources for financing critical health services. Policymakers should identify clear road maps for the implementation of the existing pro-UHC policies. Furthermore, funds should be redirected to building the overall system—consolidating and coordinating programs and linking them into the overall health system, health financing priorities, and policies. Instead of continuing to invest in parallel programs, a comprehensive and functional structure for continuity, one that will be robust enough to withstand decreasing external funds or donor exits, should be developed at the national and sub-national levels as a matter of urgency.
 
Shalom Obi is a Research Fellow at the Health Policy Research Group, University of Nigeria, with focus on health policy research and community health systems.
Obinna Onwujekwe is a Professor of Health Economics, Systems and Policies at the University of Nigeria Enugu Campus. He is the Chief Editor of the African Journal of Health Economics, and the Coordinator of the Health Policy Research Group, University of Nigeria. He also coordinates the African Health Observatory Platform (AHOP) for Health Systems, Nigeria Center.
Acknowledgement: We thank Dr Godstime Eigbiremolen for the review of the blog

Nexus of Science and Evidence-based Decision Making in strengthening the health system in Nigeria: Public lecture of Prof Obinna Onwujekwe at the Nigeria Academy of Science

On May 12, 2022 Prof Obinna Onwujekwe gave a public lecture at the induction of fellows into the Nigeria Academy of Science. The lecture was titled, “Nexus of Science and Evidence-based Decision Making Towards a Responsive and Strong Nigerian Health System”. Prof Obinna gave practical examples of getting research into policy and practice, stating that it is an ideal every scientist should aspire to, and it is the key driver of the Health Policy Research Group, University of Nigeria. Emphasis was laid on utilizing non-academic means to communicate research, such as blogs, policy briefs, podcasts, filming, etc., as they attain wider reach and appeal more to policymakers and the wider public than the technically written scientific publications. He went ahead to discuss stakeholders’ identification, engagement, relationship building, and the real-life value that is brought to research by the Outcome Mapping strategy. The public lecture was received well by fellows and other attendees, as they were challenged to ensure that they move quality studies away from the papers and shelves into policies and programmes that will benefit society.

 

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Prof Obinna making his delivery

 

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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Policy Dialogue between African Health Observatory and stakeholders in Nigeria’s Health Financing

Central to the achievement of Universal Health Coverage (UHC) is to improve service coverage, financial access, and financial protection for health service users. Concerned about Nigeria’s slow pace toward UHC, the Nigerian National Centre (NC) of the African Health Observatory Platform (AHOP) organized a policy dialogue (PD) that brought together key members of the National Healthcare Financing (HCF) and equity Technical Working Group (TWG) (HCF-TWG) and FMOH to discuss the current policy issues on health financing (interest on health financing governance and domestic resource mobilization (DRM)), with a focus on UHC. The dialogue was to brainstorm about the future directions in terms of strategic activities or actions that will be taken to make a change in the context of strengthening the Nigerian health system and achieving UHC. The dialogue explored how to specifically enhance efforts towards achieving UHC in Nigeria through domestic funding lenses and improved health financing governance.

The participant for the dialogue comprised 17 people drawn from the NC (HPRG) and the National HCF-TWG: FMoH (5), International/Development partners (4), National Health Insurance Scheme (NHIS) (2), NC (5), and Academia (1).

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Photo representation of participants