Where do you go when you need medication? Treatment for a minor injury? Vaccination for your child? Education about preventing or managing disease? In Nigeria, the answer should be your primary health care (PHC) facility. PHCs are required to provide these services and more, including clean water and basic sanitation. But the truth is many can only manage to provide a subset. Due to a lack of skilled health workers and adequate supplies, these PHCs leave communities underserved and vulnerable to disease.
Indeed, while Nigeria’s PHC system has made great strides over the years—with a shift from narrow disease-specific vertical programs to a horizontal health system focus of the new “Primary Health Care Under One Roof” reform—there remain many challenges in the health sector, mostly concentrated at the primary health care level. Rather than enumerating these, it is perhaps better to focus on one root problem and a remedy - financing and basket funds, respectively. Initially implemented in Zamfara State to improve routine immunization, the successful basket fund model has since expanded to other states, with the goal of further enhancing overall PHC service delivery.
While working as the Director of Primary Health Care in Yobe State, and later as the National Programme Manager of the Partnership for Reviving Routine Immunization in Northern Nigeria- Maternal Newborn and Child Health (PRRINN-MNCH), I learned that financing lies at the core of Nigeria’s PHC delivery challenges. It is difficult to access the necessary funds to finance basic needs in the health sector. At the state level, federal and state allocations are occasionally misapplied, resulting in incomplete disbursement of local budgets. On the local level, budgets are not earmarked, leading to delays in the release (or at times non-release) of PHC funds—often hinging upon the political will and administrative priorities of those in power.
Dr. Ahmad Abdulwahab in a group photograph with LGA Chairmen of Zamfara State, the Honorable Commissioners of the State Ministry of Health and State Ministry for Local Governments and senior officials of the PRRINN-MNCH program after a meeting on the Basket fund.
A basket fund is a promising mechanism of addressing many of these financing problems. In 2009, Zamfara State with PRRINN-MNCH established the first basket fund in the country to improve routine immunization program and delivery. A basket fund pools resources from state, local, and federal governments as well as from donors and even the private sector. These resources are then directly disbursed to responsible officers for specific PHC activities such as immunization outreach and vaccine distribution to health facilities. Zamfara’s basket fund consists of government contributions (80%) and support from developmental partners (20%) for improving routine immunization.
Over the past five years, the Zamfara basket fund has been tremendously useful in addressing the issue of financial resources. By creating a strong set of checks and balances, the basket fund has increased accountability and transparency in how, when, and where the funds are disbursed. It has helped guarantee funding for basic PHC services and also ensure coordination so that duplication of resources does not exist. As a result of the basket fund, the number of political wards with regular disbursements to finance routine immunization rose from 14% to 100%. Similarly, the DPT3 immunization coverage significantly increased in these political wards over a period of six months.
Due to this success, Zamfara’s basket fund has now expanded to finance maternal health (in particular, the Midwives Service Scheme that mobilizes midwives to rural areas), polio supplemental immunization campaign, and nutrition programs and activities. In the near future, we hope to see the basket fund encompass all PHC services.
Many states with the support of partners are now replicating the Zamfara basket fund model in hopes of achieving similar success. For example, in 2013, Kano State established a basket fund, with an agreement to gradually reduce the significant contribution of international donors until 2016, when the basket should be completely funded by the government. Even the National Primary Health Care Development Agency (NPHCDA) has recognized the efficacy of basket funding and has incorporated it into the National Routine Immunization Strategic Plan as one of the interventions that the federal government recommends all states to implement.
However, basket funds are not without their own challenges. Namely, political will is critical. The Kano basket fund was established quickly with the strong endorsement of the Deputy Governor, but achieving such commitment has been slow in other states. Additionally, coordination and alignment of priorities among partners and the government is essential, and a liaison is often needed to spearhead this process.
Dr. Abdulwahab photographed along with the Zamfara State Public Health Officials and IVAC members.
On a scale of 1-10, I would rate Nigeria’s overall PHC system at three or four. This is an improvement from scores in the negative that it would have garnered several years ago when there was little effort in strengthening health systems. There is now greater awareness among policymakers and partners that primary health care is fundamental to improving the health of the nation.
I believe the basket fund is a high impact, easy, and replicable model that can help Nigeria achieve its goals of increased accountability, effective service delivery, and improved health outcomes. IVAC’s White Paper on Basket Funds provides a timely and useful resource for states wishing to establish and implement basket funds. If basket funds continue to grow beyond specific program priorities, they will cover all PHC services. This would be the ultimate realization of our vision of “primary health care under one roof.” Because of basket funds, the issue of lack of funding for basic PHC services may become an issue of the past.
Support from states and partners during this process will be essential for the success of basket funds. To reach its full potential and move the needle on PHC in the country, there must be strong political will and clear leadership. The time has come for Nigerian officials and partners to work together to usher in a new era in which the financing, resource allocation, and implementation of primary health care activities are designed in a way that is streamlined and accountable, and serves the true functions they were intended for. That is the vision many of us working in the PHC field have for this country.
Dr. Ahmad Abdulwahab, [MBBS, MPH], is a Nigerian medical doctor and public health/health systems specialist with over 18 years of experience in the Nigerian health sector. He has worked with both Government and International organizations at state and national levels. He was at a time the Director of PHC and Disease Control in the Yobe State Ministry of Health and served as the National Programme Manager for the 7-year 65 million pounds DFID/Norwegian Government funded Partnership for Reviving Routine Immunization in Northern Nigeria - Maternal Newborn and Child Health (PRRINN-MNCH) programme. He has also provided technical services to several International agencies such WHO, UNICEF, USAID, Netherland Leprosy Relief and Global Fund and has shared his extensive experience and knowledge of public health, policy development and health systems reform, through presentations at several national and international fora.