JUSTICE NWAFOR writes on the inability of states in Nigeria to fund healthcare adequately and how it affects epidemic preparedness..
IN Nigeria, the different levels of the healthcare system are frequently seen as being interconnected. This is largely because the federal government occasionally assumes the responsibility of the states and local governments in an effort to strengthen the system and increase access to services. The country’s healthcare system is actually divided into three levels: tertiary, secondary, and primary, and the federal, state, and local levels of government are mandated to provide for each of them, respectively.
However, in recent years, the Federal Government has received more attention than the states which have received less.
Isaac Adewole, a former minister of health, provided some clarifications regarding the function of state and local governments in the country’s healthcare intervention in a 2018 interview with Premium Times. He claimed that local governments, not the Federal Government, are in charge of providing primary healthcare.
According to Mr Adewole, the Federal Government’s involvement in the provision of healthcare is largely restricted to managing federal medical centres and university teaching hospitals (tertiary healthcare), while state governments oversee general hospitals (secondary healthcare) and local governments concentrate on primary healthcare, in accordance with rules set by the Federal Government through the National Primary Health Care Development Agency (NPHCDA).
“PHC is not under us, it’s under local governments. We made PHC a focus because we just had to take care of it. But normally, PHC is not the responsibility of the federal government,” Mr Adewole said.
The local government system in Nigeria is essentially dormant. State governors have frequently been accused of tampering with the system and preventing it from operating as it ought to. In most states, local government chairmen are chosen by governors instead of through elections. This has significantly impacted everything connected to the local government system, including the primary healthcare system, and has contributed to its docility.
According to experts, since the states have taken control of the system, they ought to do the same for everything connected to it, including the primary healthcare centres (PHCs).
The primacy of PHCs in epidemic preparedness
In 1978, leaders from across the world met in Alma-Ata, Kazakhstan, and affirmed the primary place of PHCs. The conference also agreed that “it forms an integral part of the country’s health system. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process.”
This and a number of other statements were documented to form what has become known as the Alma-Ata Declaration.
Forty years later, in 2018, in Astana, Kazakhstan, global leaders met again and reaffirmed what was declared earlier. In clear terms, the conference stated that “strengthening primary health care is the most inclusive, effective, and efficient approach to enhancing people’s physical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals”. This became part of the document that has become known as the Astana Declaration.
Despite the great intentions of the declarations, primary health care still wallows in neglect and endures inadequate funding, especially in Nigeria where its management lies with the local government system which has performed badly in recent years.
Dr Claire Standley, an assistant research professor and expert in public health responses and emergency preparedness at the Centre for Global Health Science and Security at Georgetown University, told the Nigerian Tribune that Nigeria could undoubtedly increase access to high-quality healthcare delivery, prepare for epidemics, and move closer to achieving the goals of universal health coverage by revitalizing the community approach to addressing healthcare needs, which is at the core of primary healthcare.
“Strengthening the foundation of the health system would help Nigeria achieve to some extent the goals of universal health coverage and ensure that people have access to the basic services they require to help them live healthily and have fulfilling lives”, Dr Claire said.
Thomas Frieden and other researchers from the Infectious Diseases Institute at Makerere University in Kampala, Uganda, the International Health Policy Programme at Amphur Muang in Nonthaburi, Thailand, and Resolve to Save Lives in New York, the United States, examined how primary healthcare facilities can be ready for and assist in epidemic outbreak response in April 2023.
They found that progress toward primary health care that is equipped to handle epidemics is likely to be incremental based on explicit agreement on a core set of services, improved use of funds, and accountability, supplemented with funding for core staffing and infrastructure, and carefully considered incentives for health improvement.
“Epidemic-ready primary healthcare infrastructure that is able to help prevent and withstand the next pandemic will require substantial financial and structural reforms and sustained political and financial commitment,” the study said.
Impacts of states’ poor healthcare funding on epidemic preparedness
States have a great role to play in epidemic preparedness. Dr Francis Faduyile is the former president of the Nigeria Medical Association (NMA). He told the Nigerian Tribune that the states should have the primary responsibility of preparing the healthcare sector for epidemic response and other health emergencies, adding that when they fall short in this duty, the system becomes fragile and unable to fulfill its primary function. When states do not adequately fund the system and prepare for epidemics, they will eventually spend more money, lose personnel, cause pain to the populace, and weaken the entire healthcare system, according to Dr Faduyile.
“To prepare for outbreaks and emergencies, you must have the officers in place; you must have protocols and periodic training during which people are trained to know what to do and what is expected of them. All these are necessary for the appropriate response that is needed from the health workers at the state level if we have an epidemic outbreak.
“How many states can boast of having the requisite equipment to detect some of these emerging or re-emerging diseases that are causing epidemics? When Covid-19 came, we barely had anything. It was a far cry from what was expected.
“It is better to get the necessary things in place and prepare for epidemic outbreaks before they come, because when the outbreaks come, there will be no time to prepare and get ready again. The states need to put all the measures in place. Preparation for emerging and re-emerging diseases is very important. Human beings are exposed to things that could lead to disease outbreaks every day,” he said.
Dr Ugochukwu Golibe, a public health expert, echoes the sentiment of Dr Faduyile. He told the Nigerian Tribune that the consequences of states not funding health adequately don’t just affect the affected states; they also have an internal impact on the states that appear to be doing well. People move in large numbers between the states of the country, and when one state struggles, it tends to have an effect on the others, he said. “Therefore, the campaign for states to allocate enough funding for healthcare should concern everybody.”
Having enough hospitals to serve the population in remote communities is another aspect of readiness. Even though some PHCs are in a terrible state, there are still not enough of them.
Nigeria had 39,914 operational hospitals and clinics as of March 2022, including private and public hospitals at the primary, secondary, and tertiary levels of care, according to the Nigeria Health Facility Registry (NHFR).
Lagos has 2333 facilities, Katsina 1943, Benu 1837, Niger 1565, Oyo 1490, Kaduna 1419, Plateau 1470, Kano 1476, Nasarawa 1337, Cross River 1280, Kogi 1235, and Bauchi 1212. Osun 1070, Edo 1042, Ogun 1197, Abia 1196, Anambra 1166, and Imo 1197.
Experts say these numbers are inadequate to care for Nigerians, given that the population is continually growing.
Need to release budgeted sums
According to experts, the emphasis should not only be on mentioning a specific amount for healthcare but also on making sure that such allocations are actually made available. This is concerning given that, despite the fact that some states allocate a small amount to healthcare and fail to dedicate a budget line for epidemic preparedness, they fail to release all of the budgeted amounts in the budget year.
In 2021, Oyo State, in the southwest of Nigeria, budgeted N13.7 billion (13,757,004,841.39) for health. Not all of the money was released even though it was less than the 15% that was supposed to go to the sector in accordance with the Abuja declaration. According to the budget performance report released by the state government, N9.8 billion (9,802,170,014.51), which is 71.3 percent of the budgeted amount, was released.
A breakdown of the sector’s budget showed that of the N10.6 billion (10,692,004,841.39) designated for ‘Hospital Services’ budget line, N8.2 billion (8,208,175,267.06), which is 76.8 percent, was released. For the ‘Public Health’ budget line, N1.5 billion (1,593,994,747.45), which is 55 percent of the budgeted 2.9 billion (2,900,000,000.00), was released.
The Nigerian Tribune found that the 2021 healthcare budget performed better than the overall budget, which performed at about 60 per cent. The supplementary budget brought the annual budget from N268,770,964,860.01 to N318,770,964,860.01.
Some experts argue that a 70 percent and above release is a huge success, but Dr Golibe asserts that for progress to be made, states have to allocate enough and release the entirety of the proposed sum.
Dr Faduyile advises that despite the difficulty of financing health care, doing so is a wise investment.
“I advise the states to pump more money into health and make the PHCs functional because they are close to the populace. When they are functional, we can talk about being ready for epidemic outbreaks or health emergencies,” he said.
State governments should take more responsibility and increase healthcare funding.