Reproductive health policy reform in post-IMF Nigeria

¶ … public policy for reproductive health in Nigeria should not be without first recognizing the global issues that bear upon the country's public health system and the state of its people. Today the country continues to renew its effort in sustaining public health with vigorous plans and new programs that will be reviewed in this study. But any new proposal must also understand the depth of the country's problems and some of the reasons for it. This would help in the formulation of a proposal for public policy for reproductive health.

Nigeria reflects the devastation of health of the people of Sub-Sahara Africa. It is a reflection shared by the struggling health systems of most of the countries of that realm. Across the region these country's have poverty levels that result in some of the world's lowest life expectancy rates along with the world's highest maternal and child morality rates. Nigeria carries one of the lowest life expectancy rates, 44 years of age, of the Sub-Saharan countries.

The health systems of these countries are all evolving to coordinate as best they can as many resources that can be managed. Among these resources are a host of international public and private agencies, NGOs, and donors helping to improve the public health. These agencies include several from the UN including the EU, UNDP, WHO, and the World Bank. Among private donors who have had significant impact include the several funding agencies attributed to Bill Gates, Jimmy Carter, and Bill Clinton.

Literature Review

There are many good suggestions and strategies for improving Nigeria's public health system. But they should all be drawn within the reality of structural world policy issues in poverty. The citizens of Nigeria and all the African countries, along with other developing countries, have the most people in the world but share the smallest percent of its resources (O'Neil, 2009). There are any number of reasons for this inequality. But its existence makes only more poignant the challenge of public health in the developing countries. These countries are confined to developing appropriate programs and results while receiving only limited world resources.

Nigeria experienced wealth during the 1970s during its oil boom (Igbuzor 2006). Military dictatorships leading to weakened and ineffective governance ruined the country's prospects toward social advance and the eradication of poverty. In 1988 Nigeria entered the infamous Structural Adjustment Program foisted upon it by the International Monetary Fund and the World (Ogbimi 1998). This program resulted in "the virtual collapse of government health care services" in Sub-Saharan countries (Adinma et al. 2010). The economic program resulted in most federal income serving relief of external debt while seriously reducing spending on social and health policy programs and greatly exacerbating the wealth income gap.

After returning to civilian rule, in 2002 Nigeria finally left the IMF (Fotso et al. 2011, p. 8). While still facing debt from the 'Paris Club' consortium of foreign lenders, the country has more or less been in control of its own resources. Since moving from military rule in 1999 and despite the left over practices of institutionalized corruption from that experience, Nigeria has recently demonstrated good measure in a willingness to determinately pursue social, economic, and health policies under the civic government.

Federal Ministry of Health

The Federal Republic of Nigeria is drawn from a constitution which recognizes a federation consisting of a nationally elected central government, operating from the Federal Capital Abuja, and 36 state governments. The states distribute national funds to the councils of some 774 Local Government Areas and are, themselves, grouped and administered through six regional zones (Okonofua et al., p. 194). The county's 151 million citizens have over 250 ethnic tribes but has several groups comprising the majority. These include he Hausas and Fulani who populate the north. The Hausas are primarily Muslims. There are Yoruba majorities in the southwest while Ibos who populate the southeast. Christians are mainly in the south. Islam has recently taken over 50% of the country while Christianity populates 48%.

Nigeria's public health policy is formulated by the Federal Ministry of Health (FMOH) which places Public Health Care centers in service through State Ministries of Health (SMOH) who supply and coordinate LGA administration of local PHCs. One report describes the northern Nigeria PHC services as "virtually dysfunctional" (Doctor and Dahiru, 2010, p. 39).

The health system has a number of parastatals. The National Agency for Food and Drug Administration and Control (NAFDAC), National Primary Health Care Development Agency (NPHCDA), National Programme on Immunization (NPI), Nigerian Institute for Medical Research (NIMR) and National Action for Prevention and Control of AIDS (NAPCA) were created to deal with priority health issues.

Commitment

Shiffman and Okonofua (2006) argue for political and moral commitment to goals of 'safe motherhood' (the rallying cry for a UN initiative during the 1980s) (p. 126). They note that the country's adoption of democratic principles has led to the fostering and mobilization of advocacy social groups that had not been possible under the "predatory governance" of the military rule (p. 126). Nigeria now has several civic groups who are actively pushing for policies for safe motherhood. They include the Society of gynecology and Obstetrics of Nigeria (SOGON) which now holds annual conferences on relevant themes. The National Council of Women's Societies, besides lobbying for abortion law reform, promotes free maternal health care services. Safe abortion is publicly promoted by The Campaign against Unwanted Pregnancy and Ipas.

Other improvements noted by Shiffman and Okonofua include pronouncement of clear commitments from the Federal Ministry of Health in studies and documents concerning a national reproductive health policy. These efforts involved coordinated participation by the United Nations Population Fund (UNFPA) and the United Nations Children's Fund (UNICEF). The first budget committed to projects funding safe motherhood was obtained by the FMOH 2004. The government adopted WHO Millennium Development Goals (MDGs) toward reducing maternal mortality and improving child health in 2005.

However, in their 2006 study, Shiffman and Okonofua state that there was no top down push for effective coordination of the Safe Motherhood efforts. The state still only provided minimum funding to reduce maternal mortality. And significantly, "state and local governments pay virtually no attention to the issue" (p. 129).

Health Development Plan 2010-1015

The National Strategic Health Development Plan 2010-2015 concluded that Nigeria's health care system was "unable to provide basic, cost-effective services" at local government levels (p. 29). It found only a fifth of local clinics capable of providing sufficient obstetric services. Communication and the spread of information were limited, especially in the North West and North East zones (p.29).

The government report found most of the country's public health facilities, operated by the LGA councils had only limited equipment. This lack partly explained the high maternal mortality rates. Two-thirds of Nigerian woman do not deliver at these health facilities and their births are attended without medically skilled attendants (Okonofua and Shiffan, 2006). In an interview study published in 2010, Doctor and Dajori (2010) found that among 5,091 of 6,809 women respondees who had pregnancies, 89% of those women who had pregnancies over the last five years had been attended by non-skilled birth attendants.

The government's report faulted mismanagement and lack of transparency as the main culprits for the country's poor performance of health care delivery (p. 31). The government is currently formalizing the overseeing body, the National Primary Health Care Development Agency (NPHCDA), to oversee management and enforce transparency of finances from state to local transfer.

Financing Health Care

"[A]n estimated 150 million people globally suffer financial catastrophe each year and 100 million are pushed into poverty because of direct payments for health services" (WHO, 2010a, p. 9).

The World Health Organization in their 2010 World Health Report (WHR) made Health Systems Financing the primary topic. The subtopic was The Path to Universal Coverage. Recognizing the inequality of world health systems between developed and developing countries, the report emphasized several points toward improving health care in developed countries. First it must be recognized that 20% to 40% of all health care spending is wasted. Transparent systems must be established to distribute and spend funds efficiently. Second, direct payment systems comprise the greatest obstacle to progress. The most important point was drawn from the 2005 World Health Assembly resolution 58.33. A well-functioning health financing system is based on universal health coverage for all where everyone should have access to health services without financial burden (WHO).

WHO suggests that the form of direct payment, or cost sharing, for medical expenses, should be replaced with the prepayment approach, in which risks for all are pooled together and everyone is universally covered. All countries have poor people who cannot pay income taxes or insurance premiums. In Nigeria, these people make up the 'informal system' and are 70% of the population as contrasted to the 'formal system' (Onwujeke et al., 2010).

The overriding basis of a universal health care system is that it requires compulsory participation from all. It is a plan that spreads the burden of financial risk. Contributory schemes must be mandatory or else the rich will eventually opt out of the plan.

WHO also proposed that developing governments must prioritize health spending and raise levels of committed government funding to health care services (WHO, 2010a, p. 25). For developing countries, the WHO report suggests the state must use creative financing to provide subsidies to finance the poor who cannot pay. The governments must innovate other sources of domestic funding, such as taxes on pharmaceutical companies or even mobile phones. They could raise taxes on sin goods such as alcohol and cigarettes.

Also, the developing countries must improve their tax collecting/compliance efforts. For the third source of external donors, WHO reports that donor contributions from such as OECD countries are strongly affected by inflation and foreign exchange rates, along with regular delays in payments. These could be improved by better governance between countries (WHO, p. 32).

Economic systems would also have to be developed to lie more in consort with development opportunities for employment for all citizens so that they may be able to help subsidize health care plans.

Committed Goals

Representing a take charge attitude toward build sustaining health care systems, Nigeria proposed the Abuja Declaration which was adopted by African countries at a 24-27 April 2001 summit. The African leaders, in response to the AIDS epidemic committed themselves toward "allocating at least 15 per cent of our annual budget to the improvement of the health sector" (Abuja Declaration). For Nigeria, the intent is good, but the goal is realistically challenged, as it is among all developing nations. WHO reports Nigeria's total health expenditure from government expenditure rose to 6.5% in 2007, from 4.2% in 2000 (WHO, 2010b, p. 134). The figure tends to fluctuate depending on general economy and also the changing state of government.

The funding commitment goal, however possible, was followed by the several Millennium Declaration Goals (MDGs) drawn up by the United Nations and developing countries in September, 2000. The MDGs sought to concentrate efforts toward bringing up the quality of life of poor nations. The goals regarding reproductive health that were committed to by Nigeria and other developing countries were to reduce the child mortality rate by two-thirds in 2015, and to reduce by 75% the proportion of women dying in childbirth by 2015 (Igbuzor, 2006).

Toward A Good Policy

A good restructured public health system for Nigeria would include coordination of many parts, but all of them aimed for universal health coverage for all. A national insurance scheme which the country currently has, would also subsidize free coverage for those who cannot pay. This would include a large proportion of the country's informal system of workers.

Doctor and Dahiru (2010), in their study on obstetric service in three northern states, strongly suggest that child delivery should be free at the institutional level and that there should be an emergency transport system available for women in labor. They also underscore use of the media (radio) with informative educational sessions and efforts of formal education should be intensified.

Anambra passed a bill for free maternal health services in 2005. Islamic north region state Kano included a budget item for free maternal health services. State improvements have also been seen in Jigawa where obstetric centers and departments were upgraded with dedicated funds (Doctor and Dahiru, p.139).

The government formed the National Health Insurance Scheme (NHIS) in 1999 based on risk pooling and cost-sharing among individuals. The NHIS, launched in 2005, however, only covers the formal sector and currently has 1.2 million participants. As noted above, perhaps the most appropriate policies for covering such informal sectors should include goals of universal care where participation of all is compulsory. To work toward that goal, many observers, including the WHO, promote formats of tier layered community-based health insurance plans to cover informal sectors of the poor low employed.

Rwanda has three mutual insurance plans schemes (WHO, 2010a, p. 7). The one which reaches most of the people (80%), who are in rural or the informal work sectors, is the Assurances maladies communautaires. This plan is mainly for the poor who cannot afford premiums. These mutual insurance schemes derive 50% of funding from member premiums and the other half is sourced by government tax resources and donors. Rwanda has seen a notable decline in child mortality.

Adinma et al. (2010) identify community-based healthcare financing as "essentially household co-financing" (p. 2). Onwujekwe et al. (2010) make particular distinctions of CBHIs but importantly point out that the success of the models depend on involving the people, whom the plan intends to serve, in the planning and implementation. In a study of two CBHIs in Anambra state, Onwujekwe et al. (2009) found the plans short on enrollees and with no exemptions or subsidies requiring fees for registration. In an earlier study (2009a) the authors found that consumer awareness must be created to encouraged willingness to pay, especially among rural participants.

Other suggestions for public policy have to do with training and retention of staff. Harrison (2009) underscores the main disease is the "all-pervading chaos in our society" that produces weak governance structures and society dislocation (p. 19). The author emphasizes the shoring up of the education system and just as important, the proper recording and counting of population figures, including births, deaths, and cause of death.

In conclusion, the health public policy for Nigeria must include and coordinate a great number of parts. This study will develop more the concept of community-based health insurance as a form of universal care that could work as an appropriate model.