Nigeria is rated as Africa’s most populous black nation. It was amalgamated into a single nation in the year 1914 by the British who have been its colonial masters till the 1st of October 1960 when it gained its independence. Nigeria became a republic in the year 1963. It is the 8th most populous nation in the world with over 350 different ethnic groups that speak more than 250 languages. The diversity in Nigeria extends to geography and climate of the country. Nigeria has high lands in the eastern and north central areas, lowlands in the coastal areas, and desert areas in the north east. Regarding the climate, there are dry to arid regions in the north with less than 600 mm of rain, as well as tropical rainforest to mangrove regions in the coastal areas where the rainfall can exceed 2650 mm.
By population alone, Nigeria is Africa’s largest country, and the south-east is the most densely populated. A third of Nigeria’s population lives in urban areas. The country has a very young population age profile with about 45% of the country being under 15. Economists have predicted Nigeria to become the 5th largest economy in the world by 2050. After independence the economy of Nigeria was largely agriculture based, with the nation being among the biggest exporters of cocoa, palm oil and groundnuts. This was a trend that continued until the nation began exporting crude oil in commercial quantities upon its discovery. Today Nigeria is the 8th largest exporter of crude oil, and the income for the economy until the last year or two has been almost exclusively oil based.
The World Health Organization (WHO) in 2006 estimated Nigeria’s expenditure on health at $50 per capita, which represented 4.1% of the GDP. The UNICEF estimates put Nigeria spending on health at 1% of the central government spending between 1998 and 2010. The nation’s health budget made allowance for a lump sum of $26.6 billion to be set aside for health expenditure for the years 2010 – 2015, of which 49% would be spent on health service delivery and 42% spent on human resource capacity build up (United Nations Population Fund, 2011). In any country, there are several indices by which the health sector is evaluated. The World Health Organization designed a framework, by which the health system of any country can be evaluated. The organization has the aim to provide services that will improve the health of the population they serve (Adesanya et al., 2012).
These indices are described as building blocks of the health sector that provide a firm basis, upon which to evaluate the health services delivery on an institutional level. These indices are particularly significant because they enhance the possibility of getting a more robust picture of the health situation in any country, as they provide a vital cross cutting component. The leadership/governance and health information systems figures deliver information as well as a platform for the evaluation of overall policy and regulation of all the health system blocks. The vital inputs to the health system include the health workforce and financing. The final group of indices, namely the service delivery and access to medical technologies and products are the empirical index of the health system output, i.e. what is available to the populace in the particular health sector being reviewed (World Health Organization, 2010b).
Based on these criteria provided, this paper will examine the Nigerian health sector to see areas, where it is falling short of international standards and explore the possible options to improve the health sector. The latest information from the WHO showed that Nigeria has life expectancy of 54 years, while the African average of 56 years, a maternal mortality rate of 840 per 100,000 live births, while the African average is 494 per 100,000 live births, and a per capita income of $1239 (World Health Organization, 2010b).
The strength of the health sector or it effectiveness in delivering the set goals is a direct function governance that it is provided with, and the Nigeria health sector is no exception. In the case of Nigeria, the health sector suffered significantly due to the nation’s prolonged period of military rule, and the emphasis that particular government put on health sector expenditure. Between the years 1985-1993, the per capita expenditure in the health sector stalled at $1 per head as the internationally recommended minimum is $34 per head.
Unsurprisingly, as a result the Nigerian health sector performed abysmally when compared to its African neighbors, in the year 2005 the Nigerian government allocated a paltry 5.6% compared to the 11% allocated by the Ugandan government. The result of this pattern of low investment in the health sector is that the Nigerian health sector was ranked 39 places behind Uganda in the 2000 world health report. A comparison of both economies will reveal the reasons behind low Nigerian performance. Nigeria’s health sector spending has consistently been below the Millennium Development Goals (MDG) set for it.
The health care system in Nigeria has suffered several downfalls in recent years. Despite its strategic position in Africa, the country is greatly underserved in terms of health care service delivery. There is the problem of inadequate health facilities, medical equipment and personnel, especially in the rural areas. Also, the fluctuation in government funding, political interference, inadequate human resources, poor management and absence of coordination between the local governments and the state government limits the effectiveness of the efforts of the federal government (World Health Organization, n.d.).
Nevertheless, there is the need to understand the organizational and management structure of the health care system in Nigeria. In principle, the system is decentralized into a three-tier structure, which has roles to play at the federal, state and local government levels. The three tiers to some extent are involved in all the major health system functions, such as stewardship, service-provisioning and financing. Specifically, the federal ministry of health is responsible for the creation of policies, and technically supporting the overall system. More so, the state ministries of health are responsible for regulating and supporting the primary health care services. Lastly, the local governments are responsible for the primary health care whereby health services are organized through wards (World Health Organization, n.d).
In recent years moves have been initiated to resuscitate the seemingly moribund health sector. The government has reconstituted many institutional bodies, which are empowered to ensure that health professionals maintain high standards. An example of these institutional bodies is the Medical and Dental Council Malpractices Tribunal. However, under the health sector reform program, the government aims at dealing with the organizational, financial and systemic challenges facing the health system (World Health Organization, n.d). This program is structured along seven fundamental strategic thrusts which are defined by World Health Organization (n.d.):
Additionally, according to the National Health Bill and Institutional Reforms within the FMOH, the National Bill has been drafted to provide a framework for the development and management of the Nigerian health system. This is aimed at establishing minimum standards for the delivery of health care services across the country. In addition to defining clear roles for the three tiers of government, the Bill provides for the creation of a Primary Health Care Development Fund and how the financial resources are to be utilized (World Health Organization, n.d). The Bill proposes a direct funding line for the primary health care. It will be channeled through the state primary health care boards to be distributed to local government health authorities based on annual performance reports and budgets.
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According to the National Primary Health Care Development Fund (NPHCD), health care systems will be funded from the revenue raised from taxes on tobacco, alcohol, road traffic insurance schemes, value-added tax and other tax systems at the national level. The state and the local governments will also have defined responsibilities to contribute to this fundraising program. The funds will be used to finance the provisioning of a basic minimum package of health care services for the primary health care facilities including:
i. The purchase of essential drugs that will be used for primary health care;
ii. The payment of salaries for primary health care workers in local governments;
iii. The provision and maintenance of equipment, facilities and transportation for primary health care (World Health Organization, n.d.).
More so, the Health Sector Reform Program will aim at reducing the distance travelled by consumers of health care services to health care delivery points. The consumers not only bear the cost of health services, but also cover for the transportation cost to come to health care facilities. However, in addition to the finances that affect the health system in Nigeria, there are three other critical elements that determine access to health care services, which are:
i. The distance to health care facilities;
ii. The type and severity of the illness;
iii. The perceived quality of the health care service.
To counter the financial challenges of customers in Nigeria, the NPHCD is building and equipping more primary health care centers across the country in order to provide quality health care service to consumers. Moreover, in addition to other ancillary activities that are aimed at achieving the health-related MDGs in the country, this project is being funded by the Debt Relief Fund.
The health service delivery system is aimed at providing health service through various hospitals and clinics, which are owned by the federal, state or local governments. At the same time the local governments are responsible for the management of primary health care services that include primary health care centers, comprehensive health centers, health clinics and health posts (World Health Organization, n.d.). There should be at least three doctors in these centers that will provide some secondary clinical services and primary health care services. There should be a comprehensive health care center in each local government area, and at least a basic obstetric and neonatal care center with qualified personnel.
There is the need for a health care service delivery monitoring system that will be used to evaluate the effectiveness of the delivery on a regular basis. Thus, a health care service delivery monitoring system has to rely on multiple sources of data that will be analyzed for the purpose of improving the decision making (World Health Organization, 2010a). The data collected from routine health facilities provision needs to be supplemented with the information collected form health facility assessment. In addition, this system is established at the district level with support from the national or regional provincial departments. Due to decentralization, provinces are usually responsible for monitoring and evaluation of the health care system services, with little investment to assist them in achieving their goal (World Health Organization, 2010a).
In general, the number of primary health care facilities should indicate the reasonable availability of health services with less regional disparity compared to the case of hospitals. In 2000, FMOH revealed that almost 7000 private and 13,000 public primary health care facilities existed. However, the ratio of the population to the primary health care facilities is higher in the northeast, southeast and the northwest, but the disparities are not marked. Moreover, there are relatively less public primary health care facilities in the south compared to the north.
It was revealed that there was an estimate of 54 specialists in tertiary Nigerian hospitals as of 2000 with a facility ratio of 2.1 million. There were 855 secondary facilities that belonged to the public sector, which had better than standard population to facility ratio of about 135,000. Also, there are a number of privately owned hospitals that can bring the total number of secondary health care facilities to 3,002 (World Health Organization, n.d). In addition, there are 72% of private hospitals that make up the total number of secondary health care centers in the country (World Health Organization, n.d). However, for a better health care service delivery more facilities should be established and better delivery models should be established.
The national health insurance scheme, which was first mooted in 1978, is the governments answer to financing health care. The potential of this scheme to improve access to the poor sector of the country depends on how fast it generates a sizeable number of contributors. As a form of the remuneration package, health care consumers who are formally employed may not pay for health care services or it might be at a subsidized rate for them. However, most of the poor citizens have to make-out-of-pocket payment at the points of health care service delivery. The health insurance scheme will support both tertiary and secondary payment systems (Wakabi, 2013).
Although the donor support for the health sector has increased with the advent of democracy in the last five years, it still represents a tiny contribution when compared to some other countries. Such financial challenges are further complicated by the limited information available on the state and local government’s health care budget. In addition, even though the federal, state and local governments retain overall responsibility to fund health services, there are agencies which fund programs at the different levels (World Health Organization, n.d.). Also, there are hospital management boards that are owned by the state and federal governments that manage and fund secondary and tertiary facilities respectively.
In conclusion, there are several indices, by which the health sector of every country is being evaluated. The World Health Organization provided a framework, by which the health system of any country can be evaluated. The framework is based on 6 indices for health system evaluation, and these indices are service delivery, health workforce, health information systems, access to essential medicines, financing, leadership and governance. They are described as the building blocks of the health sector that provide a firm basis, upon which to evaluate the health services delivery on an institutional level. They are essentially significant in enhancing the possibility of getting a more robust picture of the health situation in any country, as they provide a vital cross cutting component. However, the leadership/governance and health information systems figures provide information as well as a platform for evaluation of the policies and regulations of all the health system blocks.
Based on these criteria provided, the Nigerian health sector was examined to see areas where it is falling short of international standards and explore the available options to improve the health sector. However, the effectiveness in delivering its set goals to a large extent is a direct function of governance that it is provided with, as in the case of the Nigeria health sector. The health area suffered significantly due to the nation’s prolonged period of military rule and the emphasis that particular government put on health sector expenditure. Despite its strategic position in Africa, the country is greatly underserved in terms of delivering health care service to consumers.
There is the problem of inadequate health facilities such as the health centers, medical equipment and personnel, especially in the rural areas. Also, the fluctuation in government funding, political interference, inadequate human resources, poor management and absence of coordination between the local and the state governments limits the effectiveness of the federal government’s the efforts (World Health Organization, n.d.). In recent years, however, the moves have been initiated to resuscitate the seemingly moribund health sector. The government has reconstituted many professional bodies, which are empowered to ensure that health professionals maintain high standards.
Based on the National Primary Health Care Development Fund (NPHCD), health care systems will be funded from the revenue raised from taxes on tobacco, alcohol, road traffic insurance schemes, value-added tax and other tax collections at the federal level. However, the NPHCD is building and equipping more primary health care centers across the country in order to provide quality health care service to consumers. The national health insurance scheme, which was first mooted in 1978, is the government’s answer to financing health care. It is planned that the scheme will support both tertiary and secondary payment systems.
More so, the Health Sector Reform Program will aim at reducing the distance travelled by health consumers to health care delivery points. Health care service consumers usually do not only bear the cost of health services, but also cover the transportation cost to health care facilities. The health service delivery system is aimed at providing health service through various hospitals and clinics, which are owned by the federal, state or local governments. Nevertheless, there is the need for a health care service delivery monitoring system that will be used to constantly evaluate the effectiveness of the health care services. In order to meet its objective, a health care service delivery monitoring system has to rely on multiple sources of data that will be analyzed for decision-making.
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