Federal Ministry of Health

1. Federal Ministry of Health Essential Health Services: The Nigeria Experience By Dr. Hassan Muhammad Lawal, mni, CON Honourable Minister of Health International Conference on Primary Health Care and Health Systems for Achieving the MDG April 28th -30th, 2008 Ouagadougou, Burkina Faso

2. Country Profile • Federation with 36 states plus FCT, 6 geopolitical zones, 774 local government areas (LGAs) • 140 million people, median age 17 year • Oil dependent economy • Subsistent agriculture major occupation • Great diversity: wide regional differences in socio-economic and health status • States & LGAs dependent on Federation funds for health care financing

3. Health Services • Both orthodox and traditional systems • Pluralistic orthodox health care services • National Health Policy provides for concurrency of health at federal, States and local government areas (LGAs) , but not backed by any law; health bill still being processed • LGAs have primary responsibility for PHC services provision with supervision by the State Ministries of Health & Coordination by Fed Govt. • Out of a total of 23, 640 health facilities registered in Nigeria, 85% are PHCs.

4. Health Services First attempt to Plan Health Services was the Basic Health Services (BHS) scheme 1975 – 1983 Focus on Prevention Expansion of Coverage with development of Health Care Facilities Training of the existing over 40 cadres of Health Care Providers including CHEWs, CHOs health Assistants etc Re-orientation of Health Services towards PHC began in 1986.

5. Nigeria’s PHC System before 1999 Democratic Dispensation • Although there was great achievements at inception of PHC in mid 80s, it was not sustained • Weak governance system • System had limited access, inequity, low performance limited, scale-up of effective interventions • Vertical PHC programs and massive decline in immunization coverage • Inadequate funding and resource mobilization • No alternative Health Care financing strategy • Lack/inadequate involvement of private sector? Communities and Development partners

6. Federal Govt. Response to the Challenging Situation Health Sector Reform Program initiated to address System issues Establishment of the MDGs office in the Presidency to ensure HIGH LEVEL targeting of the Debt Relief Funds to key sectors. Adoption of strategies for Revitalization of PHC

7. Health Sector Reform Program (2004 till date) Seven Strategic thrusts are to: • Improve performance of the stewardship role of government. • Strengthen the national health system and improve its management (including revitalization of PHC) • Improve availability of health resources and their management. • Improve physical, financial, etc access to quality health services. • Reduce the disease burden attributable to priority health problems. • Promote effective public-private partnership in health. • Increase consumers’ awareness of their health rights and health obligations.

8. The Debt Relief Funds in the Health Sector-MDGs • The Debt Relief Funds were used to provide significant additional funding to MDG- relevant sectors since 2006. • The Health Sector has received: • in 2006: N21. 28 Bn • in 2007: N15 Bn • In 2008: N16.90 Bn

9. Revitalization of PHC for essential health care Revision (2004) of the 1988 national health policy with PHC still the bedrock Decentralization of the National Primary Health Care Development Agency established in 1992 with zonal structures to ward level More recently, draft national health bill clearly articulating the role of each level of government in PHC and mechanism of Health care funding; still awaiting passage by the National Assembly) Improving evidence-based decision making through strengthening of the HMIS & IDSR Strengthening Routine Immunization, National & Sub-National Immunization Days Merging of NPI with the NPHCDA

10. Revitalization of PHC for essential health care - contd • Decentralization of PHC to LGA and more recently the ward level; Establishment of the Ward Health System • Aligns health district with the political ward • Services and activities revolve round a health centre • Community-management and financing of health services strengthening • Promotes local political commitment in PHC • Development of the Ward Minimum Health Care Package (WMHCP) which includes: Child Survival interventions, Maternal and New Born Care, Control of priority diseases i.e. HIV/AIDS, Tuberculosis and Malaria, Nutrition, Prevention of non communicable diseases, Health promotion & education and community mobilization.

11. Revitalization of PHC for essential health care cont. • Creation of health development committees in each community to strengthen promote community participation, ownership and co-management • Expansion of health services coverage through infrastructural development: model PH Centers and upgrading of health facilities • Services integration • Improving Financial access through health insurance schemes and other community financing mechanisms

12. Other enablers for improved functioning of the PHC system for attainment of the MDGs • Improved public-private partnership in service delivery • Increased Infrastructural Development, construction of 600 model PHC centers • Nurses/midwives Corps • Youth Corp Doctors PHC programme • Increased resource mobilization for PHC services, NHIS • Multi- sectoral approach to health, PPP • Launch of Health Promotion Policy

13. Status of Service Delivery • Childhood Immunizations • Malaria • Tuberculosis • HIV and AIDS • Child health • Maternal health

14. Child immunization • Strengthening of routine immunization ongoing through static and outreach services • Integration of multiple antigens into polio supplemental campaigns for increasing immunization coverage; resulted in significant improvement in immunization coverage: • DPT 3 increased from 23.4% in 2003 to 77% in 2007 (administrative coverage data) • Measles coverage more than 80% in 21 States and FCT

15. Malaria • Leading Cause of illness (60% out-patient) consultation in facilities • Targets for Malaria control in line with AU targets • Treatment policy changed to Artemisinin-based Combination Therapy in 2005 • Access to ACT promoted through free distribution of ACT to PHC facilities and efforts to grow plant in-country • 16.9 million doses distributed in 2006 and 88,000 doses in 2007 • Access to treatment expanded through promotion of home-based care using trained community-based distributors

16. Malaria con’td • Long lasting insecticide treated nets distributed free to pregnant women and under-fives ; 15 million LLIN distributed; 70 million required. • Distribution of insecticide-treated nets (ITNs) have been scaled-up and coverage is now more than 15%, up from less than 5% in 2004. • Integration of community-based distribution of ivermectin and malarial control activities ongoing • IRS successfully piloted in three States and scale-up is to follow

17. HIV and AIDS • Focus on confronting socio-cultural and informational barriers to HIV and AIDS; strengthening civil society coalitions against AIDS and specific interventions • Increased general awareness of HIV/AIDS being translated to behavioural change • About 300 VCT centres established across the country • Number of persons on ART increased from 10,000 in 2002 to about 170, 000 in 265 sites compared to 25 sites in 2007

18. HIV and AIDS contd • PMTCT centres increased from 11 sites in 2002 to 300 sites in 2007 • Services being cascaded to PHC levels • Number of local producers of ARV and ACT drugs increased from zero (0) to eight (8) and five (5) respectively

19. Interventions resulted in declining trend in HIV sero-prevalence in Nigeria

20. Tuberculosis • Implementing DOTS Strategy from 1993 and Stop TB strategy from 2006 • Guidelines for community TB care developed in 2006/7 • By end of 2006 • 650 of the 774 LGAs implementing DOTS, increase in coverage from 550 in 2005 • 694 microscopy centres in 550 LGAs • 3329 treatment centres • DOTS centres established in 200 private health facilities as part of PPP

21. Tuberculosis cont’d • Community DOTS care being established in 12 States and training of community volunteers ongoing (24000 trained) • Interventions resulted in increase case detection of 33% (though short of target of 75%) and cure rate of 78%

22. Child Health • Large proportion of PHC services address child health • IMCI adopted as strategy for child survival by National Council on Health in 1997 • IMCI implemented in 24 of the 36 States and FCT • Community IMCI also being rapidly scaled up • Micronutrient interventions include: • Universal iodization of salt - 99% of all salt iodised • Vitamin A supplementation integrated with polio supplemental immunization • Other strategies addressing child health include Baby Friendly Initiative, RBM, Integrated Maternal, Newborn and Child Health strategy(IMNCH)

23. Maternal Health • Maternal health and child health traditionaly addressed in PHC • Various policies and strategies over the years addressing maternal health: • Maternal health policy changed to Reproductive health policy from 1996 • Vision 2010 and adoption of the Women and Children Health Services by the National Council of Health in 2004 as the strategy to achieve the goals of the vision • Integrated maternal, newborn and child health ( IMNCH) strategy from 2007 • Maternal health indicators continue to remain poor in spite of interventions ; MMR 800/100, 000

24. Challenges • The specification that PHC is under the LGAs • Lack of capacity of LGAs to manage PHC and deliver services • Structural problems of the three –tiered health system; tiers have part autonomy by law • Non-passage of the National Health Bill into law • Dearth of human resources now compounded by the brain drain syndrome • Clear definitions of modalities for integrated services • Funding gaps

25. Challenges _ contd Inadequacies in quality and quantity of manpower (especially doctors and nurses) for PHCespecially in rural areas Poor coordination; Fragmentation of programmes due to multiplicity of implementing partners and development partners Inadequate HMIS & IDSR Inadequate and Poor infrastructure/appropriate technology Application of community participation in practice (prog impl & Health care financing) Lack of country-specific benchmarks for assessing progress Sustainability issues

26. Conclusions • PHC remains the cornerstone of the Nigerian Health System. The PHC concept as the cornerstone has seen its highs and lows, but is being repositioned to deliver its contract with Nigerians and people living in Nigeria – effective, efficient and equitable health services through of the efforts of all stakeholders.

27. Thank you