Nigeria has a population of 173 million people governed across 36 states and 774 local government areas. Health services are decentralized across three levels of government - federal, state, and local. The new National Health Act aims to improve healthcare access and quality through a basic healthcare provision fund and universal health coverage. Key challenges to decentralization include a lack of political will, limited local capacity and resources, and inequities in service distribution across areas.

1. PRESENTATION AT ACHAP 7th BIENNIAL
CONFERENCE, NAIROBI, KENYA.
FEBRUARY 23RD -26TH 2015
DR DANIEL N. GOBGAB
CHAN NIGERIA

2.  Estimated Population 173,615,000. (2013)
 36 states + the Federal Capital Territory
 774 Local Government Areas
 9,572 Political Wards, the lowest unit of
health services delivery
 3 levels of Government – Federal, State and
Local government Areas.
 The states and local governments depend on
fiscal federal allocation for over 85% of their
expenditure
 Economy heavily dependent on oil

3.  Decentralization is a process of transitioning
from a governance structure in which power is
concentrated at the central or national level to
one in which authority to make decisions and
implement them is shifted to lower level
government or agencies
 Conventionally, there three types of
decentralization– deconcentration, delegation
and devolution.
 Decentralization can be administrative (transfer
of civil servants and public functions to the
lower level), fiscal (devolution of decision-
making powers), or a mixture of these

4.  Devolution is the transfer of authority for
decision-making, finance, and management
to quasi-autonomous units of local
government with corporate status.
Devolution usually transfers responsibilities
for services to local government areas that
elect their own executive leaders and
councils, raise their own revenues, and have
independent authority to make investment
decisions.
 Nigeria is practicing a mixture of all.

5.  The federal Ministry of Health
 The Ministry of Health in every State and the
Federal Capital territory Department for
Health
 Parastatals under the Federal and State
Ministries of Health
 All local government health authorities

6.  The ward health committees
 The village health committees
 The private health care providers (for profit
and not for profit)
 Traditional health care providers
 Alternative health care providers

7.  In the Nigeria Constitution, health is on the
concurrent list. The provision of health
services is a joint responsibility of the
Federal, State and Local Governments.
 Nigeria is one of the Countries in Africa which
adopted a decentralized system of
government post independence
 The Federal Government's role is essentially
coordinating the affairs of the University
Teaching Hospitals, Federal Medical Centers
(tertiary health care), Regulatory bodies,
oversight of state health services and policy
formulations among others

8.  The State Government manages the various
General Hospitals(secondary health care);
The state also provides technical assistance
to the local government PHC services.
 The Local Governments focus on Primary
Health Clinics (primary health care), which
are regulated by the federal government
through the National Primary Health Care
Development Agency (NPHCDA)
 Primary Health Care is the fulcrum on which
health care delivery services are hinged.

9.  Presidential summit Declaration on Universal
Health Coverage in Nigeria- 10th March 2014
 On December 9, 2014, Nigerian President
signed into law the National Health Bill.
 The new law is intended to provide a
framework for the regulation, development,
and management of a national health system in
Nigeria.
 The National Health Act creates a Basic Health
Care Provision Fund to provide Nigerians with
access to basic health care services as a
strategy to universal health coverage.

10.  Fifty percent of this fund will be allocated to the
National Health Insurance Scheme to provide
health coverage for pregnant women, children
under the age of five, the elderly, and persons
who are physically challenged.
 The other half of the Fund will be used to
provide essential vaccines and consumables for
eligible primary healthcare centers (“PHC”),
maintenance of facilities, equipment, transport
for PHC facilities, and development of human
resources for PHCs with a goal of extending
primary healthcare to Nigerians living in hard to
reach rural communities- (What FBOs are already
doing)

11.  The law also requires universal acceptance of
accident and other emergency cases by all
health facilities (public and private),
 Provides for improved standards and quality of
healthcare in health facilities, and prohibits the
use of public funds by Nigerian public office
holders and civil servants seeking medical
treatment abroad.
 While it remains to be seen whether the
objectives of the National Health Act will be
achieved, it is hoped that Nigeria will serve as
a good example to other countries in Africa with
respect to creating a sound health care sector

12.  Health services has been taken to the grass root
with community participation through ward and
village health committees coordinated by LG
health department
 Funding for health at all levels is being done
through annual budgets.
 Decisions on health of communities is jointly
done by standing ward and village health
committees promoting ownership
 Environmental health, water and sanitation are
key components of health at the community
level. ( re introduction of Environmental Health
Officers)

13.  Demand creation and community mobilization
for service utilization are successfully done at
the local level through community participation
e.g. Polio eradication program.
 Awareness creation and sensitization of the
public on key public health issues through
engaging all stakeholders e.g. Ebola virus disease
control and reducing prevalence of HIV/AIDS
 Joint monitoring of health service delivery
between communities, CBOs and local council
authorities is enhancing accountability.
 Re introduction of training for community
midwives to reduce MCH morbidity and mortality

14. Under 5 Mortality 189/1000 life
births in 2007
124/1000 life
births in 2012
Maternal Mortality 800/100,000 life
births in 2005
560/100,000 life
births in 2012
Life expectancy
both sexes
47 in 2007
(HIV/AIDS impact)
54 in 2012

15.  The Lack of Political Will: Despite pronouncements to the
contrary, state governments do not want to devolve all
powers to the local level.
 The Management Challenge: Many local governments have
limited financial and human resources and inadequate
governance capacity to fulfill the mandate thrust upon them.
This makes the states to micromanage affairs at the local
government level.
 The Challenge of Unrequited Expectations:
‘Decentralization’ is not the panacea that it is touted to as it
is only limited to the “de concentration” of authority and
services to the local level, without the devolution of revenue-
generating and decision-making authority necessary for true
decentralization (there is an active debate ongoing now in
Nigeria about financial autonomy at the LGC)

16.  Non Engagement of FBOs. The government
recognizes the great contributions of FBOs,( up to
40% of health care deliver y services especially in
hard to reach areas) yet there is no form of clearly
defined partnership or MOU between the 2.
 FBOs are not part of free services for children,
pregnant mothers, the disabled, etc as specified in
the National Health Act
 Inequity in distribution. Decentralization reforms
has also led to inequity of health care delivery (for
example, undesirable local government disparities )
 Low revenue base at lower levels. The states and
local governments depend heavily on the central
government for allocation of funds.

17.  Resource mobilization through increased
revenue generation at state and local
governments levels to reduce dependence on
central allocation which has compromised
independence.
 Strengthen the role of local governments in
improving public health management.
 Close monitoring of the implementation of
the new National Health Act towards
realization of UHC for poor Nigerians

18.  For the first time in many years, Nigeria has
come up with a National Health Act and as
the implementation has just begun, it is
expected that with greater clarity of roles
and responsibilities, the final decision on
local government financial autonomy if
implemented will enhance the achievement
of universal health coverage in the best
interest of the grass root people of Nigeria.