Report No. 34177-NG Nigeria Health, Nutrition, and Population Country Status Report (In Two Volumes) Volume I: Executive Summary November 2005 Africa Region Human Development The Federal Ministry of Health The World Bank Group Nigeria Document of the World Bank Summary and Conclusions Acknowledgements This Country Status Report (CSR) is ajoint product of the Federal Ministry of Health in Nigeria and the World Bank. The Marginal Budgeting for Bottlenecks section was undertaken in close collaboration with UNICEF. The Nigeria MOH team was headed by H.E. Professor Eyitayo Lambo (Minister o f Health), and was composed by Dr. Shehu Sule (Director o f Department o f Health Planning and Research), Dr.Tolu Fakeye (Head Division o f InternationalHealth, Dept. o f Health Planning and Research), Dr. M. Lecky (previous, Head Division o f International Health, Dept. o f Health Planning and Research), Dr. N. Azodoh (Dept. o f Health Planning and Research) and also included staff from the various MOH departments and agencies, as well as representatives from the private sector and universities. From the World Bank side, Christine Lao Peiia and Maria Eugenia Bonilla-Chacin coordinated the over-all CSR work. The World Bank CSR team i s composed o f Patrick Mullen, Anne Okigbo, Feng Zhao, Ulrika Enemark, and Edit Velenyi. Invaluable comments and suggestions were received from peer reviewers: Agnes Soucat, Chnstopher Walker, and Maureen Lewis as well as members o f the Nigeria country and the World Bank Human Development teams including Galina Sotirova, Eva Jarawan, O k Pannenborg, Alexander Preker, Stephan Legros, Keith Hinchliffe, Jane Miller, and Victoria Kwakwa. Important inputs were received from Genevieve Begkoyian, Rudolph Knippenberg, James Patterson, Ephraim Kebede and Fagbemi Omoniyi. Abiodun Elifuoye and Therese Tshimanga provided very good logistical and document processing support. Laura Frigenti and Hafez Ghanemprovided over-all guidance. This report has beenpresentedand has benefitedfrom comments and suggestions in(1) a two-day CSR workshop organized in Nigeria in June 2005 which was attended by key MOH, federal health parastatal organizations, and donor agencies including DFID, WHO, UNICEF, CIDA, EU, and UNFPA; (2) a second two-day CSR workshop organized inNigeria inNovember 2005 which was attended by the FMOH, federal health parastatal organizations, and CIDA; and (3) discussions with the Minister and his Management Team in June 2005. Site visits and discussions 'were also conducted during the preparation o f this report in Abuja, Lagos, Jos, and Nasarawa. 1 Summaly and Conclusions Table of Contents Summary and Conclusions ........................................................................................................... 5 Context ........................................................................................................................................ 5 Health Outcomes ......................................................................................................................... Health Care Utilization............................................................................................................... - 7 6 MillenniumDevelopment Goals (MDGs)................................................................................... 9 Household and Community Determinants of Health Outcomes and Service Utilization ..........10 Health System............................................................................................................................ 15 Health Services and Programs................................................................................................... 20 Health Service Availability and Utilization by Type of Provider ............................................. 24 Role of the Private Sector .......................................................................................................... 30 Health Care Financing and Requirements ................................................................................. 31 Main Challenges and Policy Options ........................................................................................ 39 Health Policy ............................................................................................................................. 37 Sources.......................................................................................................................................... 45 3 Summary and Conclusions ListofTables andFigures Tables Table 1. Under-five mortality and chronic malnutrition across regions. Nigeria. 2003 ................................ . 12 21 Table 3. Health service utilization by type o f provider, Nigeria, 2003 (% o f children with cough or fever in Table 2 Child health service availability, Nigeria, 2001 ("A o f facilities) (n=674) ....................................... the previous two weeks who received care) (n= 1,295)................................................................ 24 Table 4.Health service utilization by type o f provider, Nigeria, 2004 (`A o f children and adults illor injured Table 5. Health service utilization by geopolitical zone and type o f provider, Nigeria, 2004 (% o f children inthe previous two weeks who receivedcare) (n=7,028) ........................................................... 24 Table 6. Federal government health expenditures, Nigeria, 1998-2003 (incurrent and constant 2003 prices) and adults illor injured inthe previous two weeks who received care) (n= 7,028) ..................... 25 31 Table 7.Estimates for total health expenditure inNigeria, circa 2003-2004 ................................................ ....................................................................................................................................................... 35 Table 8 Estimated cost and impact o f MBB policy scenarios ..................................................................... . 36 Figures Figure 1. Measles immunization coverage by GDP per capita (SSA countries with GDP per capita less than 8 Figure 2. Progress towards meeting the MillenniumDevelopmentGoals. Nigeria. 1990-2003 ..................... US$ 500).......................................................................................................................................... 9 Figure 3 Change in probability o f receiving care associated with education level (compared to women with no education). Nigeria. 2003 ................................................................................................. 10 Figure 4. Infant and under-five mortality in urban and rural areas, Nigeria, 1993-2003 (mortality per 1,000 11 Figure 5. Regional differences inhealth service utilization, Nigeria, 2003 ................................................. live births)...................................................................................................................................... 13 Figure 6. Women's reported barriers to accessing health care, Nigeria, 2003 (??o f women) ..................... Figure 7. Socio-economic disparities health outcomes andbasic service utilization, Nigeria, 2003 ...........13 14 Figure 8. Women's reportedbarriers to accessing health care. Nigeria. 2003 (% o f women) ..................... 15 Figure 9 Government fundingflows to the health system inNigeria........................................................... . 16 Figure 10 .Doctors and nursesimidwives per 100.000 population by GNI per capita. 2001 (countries with GNIper capita under US$l.500) ................................................................................................... 18 Figure 11. Health service utilizationby type o f provider and consumption quintile (% o f illor injured inthe 26 Figure 12. PHC services per 100.000 population. Nigeria. 2001 .................................................................. previous two weeks who received treatment). Nigeria. 2004 ........................................................ 26 Figure 13 Regionalpatterns o f utilization by type o f provider. Nigeria. 2003 (% o f children with cough or . Figure 14 Availability o f pharmacistsipatent medicine vendors. Nigeria. 1999 (%households living within .fever who were treated) ................................................................................................................. 28 Figure 15. Utilization o f pharmacyipatent medicine dealer for treatment o f child illness. Nigeria. 2004 (% 5 km) ............................................................................................................................................. 29 30 Figure 16 .oFederal f children with illness inprevious two weeks who received treatment) ...................................... government health expenditures. Nigeria. 2001-2002 ................................................... 32 Figure 17. Per capita domestic public sector health spending and GDP per capita. 2002 (countries with Figure 18.GDP per capita less thanUS$ 1.000) ............................................................................................ 33 Total health spending and under-5 mortality. 2002-03 (countries with under-5 mortality over 40 per 1.000)....................................................................................................................................... 36 4 Summary and Conclusions SUMMARY AND CONCLUSIONS 1, TheHealth, Nutrition, and Population Country Status Report (CSR)for Nigeria aims to contribute to the evidence base of the Government'spoverty reduction strategy and health system reform efforts at the same time as informing the Bank's policy dialogue with the Government. The major theme o f the CSR i s the analysis o f the health situation o f the poor and how the health system i s performing interms o f meeting the needs o f the poor. The report benefits from recent high-quality and representative household surveys, as well as administrative data on health services and financing. Although such administrative data are sometimes dated and incomplete, they are supplemented by a variety o f surveys and studies o f different aspects o f the health system and financing. The report has six chapters: i)Health Outcomes; ii)HouseholdBehavior and Community Factors Affecting Health; iii)Health System and Policy; iv) The Role of the Private Sector inHealth Care Provision; v) Health Care Financing; and vi) Extra Resources Needed to Achieve the Health-RelatedMillennium Development Goals (MDGs). This section presents a summary o f the main text as well as conclusions and a discussion o f policy implications. CONTEXT 2. Nigeria is a large and diverse country and under itsfederal system, responsibilityfor health services is divided between levels of government. The population o fNigeria, estimated at around 130 million, i s the largest inAfrica and i s very diverse. This complexity i s mirrored by widely varying patterns o fhealth outcomes and health services. Administratively, the country i s organized as a federation with a federal government, 36 states and the Federal Capital Territory (FCT), and 774 local government areas (LGAs). States are often grouped into six "geopolitical zones" for analytical purposes, althoughthese have no administrative existence (see Figure 14 for an example). Along with overall policy, the federal government i s responsible for tertiary-level health services, state governments are responsible for secondary services and local governments are responsible for primary services. At the same time, a number o f programs and parastatal agencies, usually based at the federal level with state counterpart organizations, work on PHC services. Although national policies provide a certain measure o f standardization, each level o f government i s largely autonomous interms o f financing and managing health services under its responsibility. I 3. Theeconomy has grown in recent years, but the democratic government continues to confront a legacy of mismanagement and corruption. Windfall oil revenues along with prudent government macroeconomic and fiscal policies have contributed to significant growth inthe economy since 2003, keepingpace with and exceeding population growth. Real GDP growth i s projectedat 7.4% in 2005. The long years o f military rule weakened, politicized, and corrupted government bureaucracies. After taking office in 1999, the democratic government has taken several steps to address these systemic issues, including anti-corruption campaigns and civil service reform. Improvements in governance and management o f the health system will depend to a great extent on these overall reforms. 4. Poverty is widespread and inequalities are large. Despite recent economic growth, most Nigerians remain very poor. In2005, projected GDP per capita i s US$ 582 (IMF, 2005a), while non-oil GDP per capita, an indicator for the resources directly available to households, i s projectedto be US$224. The 2004 Nigeria Living Standards Survey (NLSS) indicates that income i s highly unequally distributed, with large urban-rural and regional disparities. (Federal Office of Statistics, 2004) These data show that inbroad terms, poverty i s highest inthe northern zones and lowest inthe south, with the North-Central zone situated inbetween. 5 Summary and Conclusions HEALTH OUTCOMES 5. There have been slight improvements in thepastfew years, but child mortality remains high, as one million under-five children die in Nigeria annually. The 2003 Nigeria Demographic and Health Survey (NDHS) provides the most reliable and representative estimates for child health indicators. The survey found that duringthe 1999-2003 period, under-five mortality was estimated at 201 per 1,000 live birthsand infant mortality was 100 per 1,000.' These rates are higher than what would be expected given Nigeria's GDP per capita, and because o f the country's population size, translate into human suffering on a large scale. Nevertheless, after stagnating duringthe 1990s,* childmortality rates seem to have startedto decrease inthe past few years. 6. Similarly, the nutritional status of Nigerian children ispoor, showing little improvement compared to 1990. The 2003 NDHS found that 38% o funder-five children suffer from chronic malnutrition (stunting) and 9% from acute malnutrition (wasting), rates which are consistent with other poor countries in Sub-Saharan Africa. Estimated chronic malnutrition has decreased from almost 42% in 1990, but the prevalence o f wasting has remainedthe same. There i s some evidence that suggests that malnutrition increased duringthe 1990s, but has significantly declined since 2000. The proportion o f children aged 6-35 months that were chronically malnourished increased from 44% in 1990 to 50% in 1999 (NDHS 1990, 1999). In2003, however, the proportion had declined to 42%. 7. High child mortality and malnutrition are concentrated in the north of the county. The issue i s discussed further below, but it must be emphasized at the outset that national averages mask significant regional disparities. Under-five mortality inthe North West and NorthEast regions exceeds 260 per 1,000, while it i s less than 180per 1,000 inthe rest o f the country. Child mortality inthe north is, therefore, among the worst observed anywhere, while rates inthe rest o f the country are comparable to other sub-Saharan African countries such as Kenya, Tanzania, and Ethiopia. 8. The main causes of child mortality are communicable diseases,particularly malaria, which can be easilyprevented or treated. The pattern o f child morbidity inNigeria i s similar to other poor countries inthat, in addition to neonatal causes, most child deaths are due to diarrhea, pneumonia, and malaria, often in association with malnutrition. It i s estimated that malaria causes around one-third o f child mortality, equivalent to about 300,000 deaths among under-five children annually. 9. Fertility remains high, as on average, each woman will have overfive children. The 2003 NDHS estimated the total fertility rate (TFR) at 5.7.3 Although this has decreased from 6 in 1990, it i s still higher than the estimated average for Sub-Saharan Afnca. Highfertility has wide societal and economic effects, such as limitingwomen's labor force participation, and straining household and community resources. 10. Maternal mortality is similarly high; an estimated 37,000 women die in childbirth annually in Nigeria. Highfertility increases women's risko f death during childbirth. Other factors IUnder-fivemortality (540) i sthe risk of deathduring the first five years of life, while infant mortality (,qo)is the risk of deathduring the first year of life. * Datafrom the 2003 NDHS indicatethat under-fivemortality during the period 1994-98was 236 per 1,000, little changed fromthe rate of 234 estimatedfor 1989-93. The total fertility rate i s the number of childrenawoman would have over her lifetime if she experiencedthe age- specific fertility rates observedby the survey. 6 Summary and Conclusions contributing to maternal mortality are poor maternal nutrition and care, particularly emergency obstetric care (EOC). It i s estimated that the maternal mortality ratio inNigeria i s around 800 per 100,000 live births, a similar order o f magnitude relative to other poor countries, and implying around 37,000 maternal deaths per yeara4 11. Many women have low nutritional status and micronutrient deficiency. The 2003 NDHS estimatedthat 15% o f adult Nigerian women have a low body mass index (BMI) indicating malnutrition. Only countries with lower income per capita - such as Ethiopia, Eritrea, Madagascar, Chad, and Niger - have a higher proportion o f women with such a l o w BMI. A 2003 nutrition survey found that 10% o f pregnant women were deficient invitamin A, 20% suffered from iron deficiency and 4% had severe iodine deficiency. 12. Adult HIVprevalence is estimated at S%, so that Nigeria has the third highest number of infectedpeople in the world -an estimated 3.5 million. A 2003 national sentinel survey found that adult HIVprevalence was 5%. This i s partially encouraging, since it i s an apparent decrease from the 2001 estimate o f 5.8%, but the data are not sufficient to conclude that the epidemic has stabilized. Estimatedprevalence in 1992 was 1.8%. State-level estimates from the 2003 survey do not show any broadregional pattern. 13. Nigeria has thefourth highest number of tuberculosis (TB) cases in the world, while other infectious diseases,such as meningitis, also represent a considerable health burden. Estimated annual TB incidence i s 293 new casesper 100,000 persons; estimated prevalence (both new and old cases) o f 546 per 100,000 implies that over 700,000 people have TB inthe country. Nigeria experiences periodic epidemics o fmeningitis and suffers from numerous other endemic communicable diseases. 14. Although communicable diseases are major causes of mortality and morbidity in the country, there are reasons to believe that non-communicable diseases (NCDs) represent an increasing share of Nigerians 'burden of disease. MajorNCDs inNigeria include: hypertension, diabetes mellitus, coronary heart disease, sickle cell disease, cancers, G6PD deficiency anemia, mental health, road traffic injuries and violence, oral health, blindness, rheumatic heart disease, stroke, osteoporosis. 15, As at 2001, Nigeria ranked second on the weighted scale of countries with very high road trafJic crashes. (WHO Nigeria publication on Road safety 2004). Similarly, according to data from the Federal Road Safety Commission (FRSC), over 7,000 Nigerians die every year from road traffic crashes, while over 26,000 injuries are recorded. HEALTH UTILIZATION CARE 16. Immunization rates in Nigeria are extremely poor and have declined signijkantly in the last decade. The 2003 NDHSfound that only 13% o f one-year-old childrenhadreceived all recommended immunizations, compared to 27% in 1990. Coverage o fmeasles immunization in 2003 was 36%, compared to 46% in 1990. Immunization coverage inNigeria i s among the lowest in Sub-Saharan Africa (and the world), comparable to war-affected countries such as Sierra Leone (Figure 1). Order-of-magnitude comparisons of maternal mortality ratios are necessary due to their wide confidence intervals. In the Nigeria case, becausethe necessary data are not available, the estimate is from a model (AbouZahr and Wardlaw, 2001). 7 Summary and Conclusions Figure 1, Measles immunization coverage by GDP per capita (SSA countrieswith GDP per capita less than US$ 500) I 100, 90 - 0 c 0 p 80 - W 0 7 0 - 0 0 6 0 - f 0 5 0 - 0 0 40 -Sierra E - - E 30 \Nigeria YI 20 - Central African Republic 10 - 0 1 8 Summary and Conclusions symptoms. With regardto TB, there has been progress in increasing DOTS' coverage, but case detection i s still very low, at an estimated 18% o f all cases. 22. Between a quarter and halfof sick children and adults do not receive care. The 2003 NDHS found that 57% o f children with diarrhea and 21% o f children with cough or fever inthe previous two weeks didnot receive care. Similarly, the 2004 NLSS found that 44% o f children and adults who had an illness or injuryin the previous two weeks did not receive care. 23, Half of women report severeproblems in accessing health care, with cost and distance the mostfrequent barriers. The 2003 NDHS asked women about the biggest problems they have in accessing health care when they need it and 47% specified one or more barrierU6The most often reported problems were the cost of treatment (30% o fwomen) and distance or lack o f transport (24%). MILLENNIUM DEVELOPMENTGOALS(MDGs) 24, I n general, the 1990s were a lost decadefor Nigeria, so that achieving the MDGs in the next tenyears represents a considerable challenge. The health-related MillenniumDevelopment Goals (MDGs) are to, between 1990 and 2015, halve poverty and hunger, cut under-five mortality bytwo-thirds, reducematernalmortality by three-quarters, and halt and begin to reverse the incidence o f HIV/AIDS, malaria, TB, and other major diseases. Figure 2. Progress towards meeting the Millennium DevelopmentGoals, Nigeria, 1990-2003 MDG No. 2: Halve the proportion of people who suffer from hunger (under 5 MDG No.4: Reduce by 213 the under chronic malnutrition) five mortality lo 0 i -- I 1980 1990 2000 2010 2020 1989-1993 1994-1998 1999-2003 2015 MDG No.5: Increase the proportion of birth MDG No.7: Halve the proportion of attended by skilled personnel people without access to safe water (% using surface water as source) 100 50 80 40 60 30 40 20 20 0 lo0 ~ 1980 1990 2000 2010 2020 1990 1999 2003 2015 Sources: NDHS 1990, 1999,2003. Note: The unbroken line shows the trends in some of the MDGs indicators while the dashed line the path necessary to meet the goals by the year 2015. 'Directly-observedtreatment, short-course Respondentscould list morethan one problem. 9 Summary and Conclusions 25. Thereseems to have been someprogress in thepastfew years on child malnutrition and mortality, but maternal care has not improved. Although the prevalence o f acute malnutrition has not changed since 1990, chronic malnutrition among children has decreased slightly compared to 1990 (Figure 2). As seen inthe Figure there has also been a slight reduction in under-five mortality, particularly inrecent years, even though it remains at a very highlevel. In contrast, coverage o f skilled delivery care has stagnated and even slightly decreased inrecent years. Finally, although the proportion o fpeople who must rely on surface water as their source for drinkingwater has been cut inhalf since 1990, many have moved to other potentially unsafe sources so that only 42% o fhouseholds had a safe source in2003. 26. The evidence is mixed onprogress in combating HIV/AIDS, TBand malaria. Knowledge o f HIV/AIDS has increased, a small but significant proportion o f adults have benefited from VCT, and sentinel surveys provide some evidence that the HIV/AIDS epidemic i s not rapidly expanding. On the other hand, a significant proportiondoes not know o f key preventive measures and many continue to practice risky behaviors. With regardto malaria, ITNcoverage i s close to zero and treatment i s not provided inmany cases. With regard to TB, DOTS treatment centers have expanded, but case detection remains very low. HOUSEHOLDCOMMUNITYDETERMINANTSHEALTH AND OF OUTCOMES AND SERVICE UTILIZATION 27. Health outcomes depend on a variety of household and community-level determinants, translated into health status in various ways, including through access to and utilization of quality health services. Among the more important household and community characteristics shown inmany contexts, including Nigeria, to be associated with both health outcomes and health service utilization are maternal education and household socio-economic status. Urbardrural and regional differences inhealth status and health service utilization are also evident and may reflect differences ina range o f factors, including economic conditions and health service availability. The various factors associated with health outcomes and service utilization are analyzed separately inthe following chapters. This section summarizes those findings. Figure 3. Change in probabilityof receivingcare associatedwith educationlevel (comparedto women with no education), Nigeria, 2003 0 25 0 20 0 15 0 10 0 05 0 00 primary higher ~9 More than 2 antenatal visits .Assisted delivery 0Birthinhealthfacility The estimates are the change in probabilityof receivingcare associatedwith primary and higher education compared to women with no education after controllingfor a variety of other factors. Authors' estimates from 2003 NDHS data. 10 Summary and Conclusions Education 28. Maternal education has been observed in many contexts to be closely associated with improved health outcomes and Nigeria is no different. Education canbenefit mothers and their children ina number o f ways, increasing their knowledge o f healthpractices, ability to integrate health education messages, and willingness and confidence to receive quality health services from the health system. Regression analysis o f 2003 NDHSdata indeed shows that the risk o f child mortality significantly decreases as maternal education increases, even after controlling for householdeconomic status and other factors. Risko f mortality for children o f women with primary education i s 20% lower than children o fwomen with no education, while the risk for children o f women with secondary or higher education i s 40% lower. Similar reductions inthe risko fchild chronic malnutrition are evident. 29, Health gains due to maternal education arepartly through healthy behaviors and increased utilization of health services. Regression analysis o fthe 2003 NDHS data found that infants o f mothers with educationare more likely to be exclusively breastfed. Similarly, such models, always controlling for household wealth and other factors, show that children o f better educated mothers are more likely to be immunized, to receive Vitamin A supplementation, and to be taken for medical treatment when ill.Education also has evident benefits for women themselves, increasing their likelihood of using modem contraception, and o freceiving antenatal and delivery care from a medical provider (Figure 3). Urban-Rural Differences 30. Health outcomes are worse in rural areas than in urban areas. Consistent with experience everywhere inthe world, important health outcome indicators such as child mortality and malnutrition are lower inrural areas than inurban areas inNigeria. The 2003 NDHS found, for example, that under-five mortality was an extremely highrate o f 243 per 1,000 inrural areas, compared to 153 per 1,000 inurban areas (Figure 4). Similarly, 43% o f under-five children in rural areas are chronically malnourished(stunted), compared to 29% inurban areas. 31. Similarly, health service utilization is lower in rural areas. One o f the factors behind urban- rural differences inhealthoutcomes i s differences inutilization o f health services. For example, in2003, 7% ofone-year-old children inrural areashadall the recommendedvaccinations, compared to 25% inurban areas. Inrural areas, 51% o f pregnant women receive antenatal care, compared to 83% inurban areas; 27% o f deliveries are attended by qualified personnel inrural areas, compared to 59% inurban areas. Figure 4. Infantand under-five mortalityin urban and rural areas, Nigeria, 1993-2003(mortality per 1,000 live births) 250 urban rural 200 150 121 100 50 0 Under five Infant Source is 2003 NDHS. 11 Summary and Conclusions 32. Rural residents are less likely to receive care while cost andphysical accessibility of health sewices are higher barriers to care thanfor urban residents. The 2003 NDHS found that while 40% of childrenwith cough or fever inthe previous two weeks receivedmedical care inurban areas, the proportion was only 28% inrural areas. More women inrural areas (58%) than in urban areas (26%) reportedone or more major problems with accessing health care, with cost (38% inrural areas and 17% inurban areas) and distance or transport (32% inrural areas and 9% inurbanareas) representingthe mainbarriers, 33. Urban areas may havefared better than rural areas over thepast decade, but the available evidence on trends is mixed. Improvement inchild malnutrition may have been somewhat greater inurbanareas, withprevalence ofstuntingdecreasingfi-om 35% in 1990to 29% in2003. This compares to rural areas where it was 46% in 1990 and 43% in2003. Immunization coverage decreased everywhere, but less so inurban areas. In 1990 53% o f one-year-old children inurban areas were fully vaccinated, while in2003, the proportion was 25%. Inrural areas, 23% were fully vaccinatedin 1990, compared to only 7% in2003, representing a decline o f aroundtwo- thirds. However, differences intrends inantenatal anddelivery care are not evident. In 1990 in urban areas, 61% o f deliveries were attended by a health professional and this hardly changed by 2003, when the proportion was 59%. Similarly, inrural areas, the proportion was 26% in 1990 and 27% in2003. RegionalDisparities 34. Regional differences in health outcomes mirrorpatterns ofpoverty, with the northern regions experiencing much higher child mortality and malnutrition than the south. The 2003 NDHS found that under-five mortality rates inthe North East andNorthWest zones are more than double the rates inthe South West and South East (Table 1). Similarly, chronic malnutrition in the north i s higher than inthe south, as more than half o f under-five children inthe North West are stunted. As i s the case with poverty rates, the North Central zone i s situated inbetween, with under-five mortality and malnutrition rates higher than inthe south but lower than inthe North West and North East. Similarly, the South South zone stands somewhat apart from the rest of the south, particularly with regardto child mortality.' It should be noted, however, that regional patterns inHIV infection are not so clear, as the 2003 sentinel survey found widely varying results for states within the same regions. Table 1, Under-five mortality and chronic malnutritionacross regions, Nigeria, 2003 under-5 chronic mortality malnutrition (per 1,000) (% under-5s) North Central 165 31 North East 260 37 North West 269 53 South East 103 23 South South 176 16 South West 113 23 Source is 2003 NDHS. 'The ~ South South zone evades easy generalization as health indicators seemto reflect complex patterns. For example, child mortality is high but chronic malnutrition i s low. Very highinfant mortality is concentrated inrural areas. Possible explanations could include pollution or particularly poor health care services inrural areas. 12 Summary and Conclusions North- North- North- South- South- South. West East Central South East West Source is 2003 NDHS. 35. Regionalpatterns in health service utilization are similar to those of health outcomes. Figure 5 illustrates regional differences infull immunization among one-year-old children, treatment o f acute respiratory infection (ARI)or fever among under-five children, and delivery care by qualified personnel. It shows that utilization of these basic services i s lowest inthe NorthWest and North East zones and highest inthe South East and South West zones. Utilization inthe North Central and South South zones i s situated inbetween (except for AlWfever treatment inthe North Central zone, which i s higher than inthe south). Regression models find that inmany cases, regional differences persist after accounting for differences ina variety o f factors, including household socio-economic status and even indicators o f availability o f health services. Figure 6. Women's reported barriersto accessing healthcare, Nigeria,2003 (YOof women) 50 50 45 45 40 40 need to get permission 35 35 30 30 $ 25 25 20 20 15 15 10 10 5 5 0 0 Source is 2003 NDHS. 13 Summary and Conclusions 36. I n general cost and distance are major barriers to health service utilization across the country, but culturalfactors influencing care-seeking are more important in the north. The 2003 NDHS found that the highest proportions o f women (over 50%) who report one or more major problems with accessinghealth care live inthe North East, NorthWest, and South South. In contrast, only 16% o fwomen inthe South West reported such problems. However, Figure 6 indicates that cost and distance are major barriers to care inmost o f the country, although the South West continues to stand out with much lower proportionsreporting such problems. Barriers to care related to cultural factors, inparticular women's concern that that there will be no female health provider and women's need to get permissionfrom their husband inorder to seek care are cited as major problemsmostly inthe North West, NorthEast, and South South. Socio-economic Disparities 37. Thepoor suffer from greater mortality and malnutrition. Poverty has been shown to go together with illhealth and low health service utilization inmany contexts. The urban-rural and regional differences described above reflect, to a large extent, patterns o fpoverty inthe country. Under-five mortality among the poorest fifth o f the populationi s estimated at 257 per 1,000, compared to 79 among the highest quintile (Figure 7). Similarly, 49% o funder-five children in the poorest quintile suffer from chronic malnutrition, compared to 18% inthe highest quintile, and 22% o f the poorest women have a low body mass index (BMI), compared to 9% in the highest quintile. 38. Afactor contributing to the worse health situation of thepoor is their lower utilization of basic health services. For example, children inthe highest wealth group are ten times more likely to be fully immunized than the poorest children and the most well-off women are almost seven times more likely to have a qualified delivery attendant. Similarly, 19% o f children with cough or fever inthe poorest quintile receive medical treatment, compared to 54% among the highest quintile (Figure 7). The 2004 N L S S found that only around 40% o f people inthe lowest quintile with an illness or injuryreceivedcare, compared to around 70% inthe highestquintile. Figure 7. Socio-economic disparities health outcomes and basic service utilization, Nigeria, 2003 0childchronicmalnutrition w oren malnutrition -0- under-5 mrtaiity -4- quallfieddelivery care 2508 7 60 50 .-!A 200gb 50 - 40 p z E 150 40 30 LD c 30 100 20 a 20 10 50 10 0 0 0 lowest 2 3 4 highest lowest 2 3 4 highest quintiie auintile Source is 2003 NDHS. 14 Summary and Conclusions Figure 8. Women's reported barriersto accessing healthcare, Nigeria, 2003 (% of women) 1 60 do not know where to go E need to get permission 50 distance Ecost 40 $ 30 20 10 0 lowest 2 3 4 highest quintile Source is 2003 NDHS. 39. Cost and distance are the major barriers to carefor thepoor, while knowledge and cultural factors are also more important among thepoor. Figure 8 indicates that cost i s the most important reported barrier to care for women o f all socio-economic levels, butmuch more so for the poorest. The cost o f health services i s an important problem for almost half o f the poorest women, compared to 13% among the highest quintile. Although distance i s also an often- reportedbarrier for women in all quintiles, its importance increases (inrelation to cost) as women get poorer. Finally, lack o fknowledge o f where to obtain health services i s a far more important factor for the poorest, as are cultural factors such as the need to obtain permission before seeking treatment. HEALTH SYSTEM Health SystemOrganization 40. TheNigerian health system is decentralized under afederal structure. The federal level i s responsible for overall policy as well as tertiary services, the state level i s responsible for secondary services, and local governments are responsible for primary services. 41. Thesehealth responsibilities are tied tofundingflows, leading topoor coordination and integration of the referral system. Figure 9 illustrates how the government health system i s funded. The lion's share o f government resources comes from oil revenues to the Federation Account, which i s shared between levels o f government according to an allocation formula. However, these resources are not sectorally earmarked and states and LGAs are not requiredto provide budget and expenditure reports to the federal government. This considerably limitsthe effective influence that the Federal Ministryo f Health (FMOH) may have over primary and secondary health services, and that the state Ministries o f Health (SMOHs) may have over PHC services. This, combined with poor coordination between levels o f government, has led to limited integration o fthe referral system, impeding the connectionbetween primary and first referral services. 15 Summary and Conclusions Figure 9. Government funding flows to the health system in Nigeria Federation Account tertiary health services parastatalsand - vertical programs State Governments Local Government Authorities primaryhealth services 42. Parastatal agencies and verticalprograms, particularly at thefederal level, also intervene across the different levels of services. Federal and state parastatal agencies have been created to implement programs and manage services across the different levels. Inthe late 198Os, Hospital Management Boards (HMBs)were created at the federal and state levels to manage government tertiary and secondary level facilities respectively. Federal parastatals created inthe early 1990s included the National Agency for Food and Drug Administration and Control (NAFDAC), National Primary Health Care Development Agency (NPHCDA),National Programme for Immunization (NPI), and the Population Activities FundAgency (PAFA). By 1999 at the federal level, there were 16programs, at least 11agencies and departments, and 14 different policies or strategies to address particular issues. More recent organizations are the National Action Committee on AIDS (NACA) and the National Health Insurance Scheme (NHIS). The structural impetus behind these federal initiatives was to address problems, particularly at the PHC level, through direct provision o fresources and implementation programs. However, the effectiveness of these agencies and programs has been lessened by fluctuating funding levels, problems with management and political interference, and poor coordination with state and local governments. Governance,Accountability and Management 43, Like other sectors, the health system is recoveringfrom aperiod ofpoor governance and corruption. The long decades o f military rule weakened, politicized, and encouraged rent- seeking in government bureaucracies, and the health system was no exception. Governance and accountability i s particularly weak at the local level. This i s partly due to capacity constraints at this level, exacerbated bythe proliferation o fLGAs,which has spread capacity even more thinly. In1988, whenresponsibility for PHC services was assignedto the local level, there were only 158 LGAs, compared to 774 in2005. But capacity limitations are not the only issues; there are also significant problems with commitment, governance, and accountability at the local government level which i s reflected inthe insufficient release o f funds to basic health services. For example, an assessment inBenue state suggests that salaries are met but there is little funding made available for other non-salary recurrent costs (PATHS, 2003). There i s also some evidence that even wages are not being paid in some areas; for example, a 2003 World Bank study found that 42% o f staff inKogi state reportednot receiving any salary for at least 6 months during the previous year. 16 Summary and Conclusions 44. Thereare generalproblems withplanning, budgeting, andfinancial management at all levels of government. At every level, from the FMOHto PHC facilities, lack o f control and uncertainty about funding undermine rational planning and budgeting. For example, within the FMOH, individual department heads do not control personnel budgets. At the same time, plans and budgets may be approved, but managers lack confidence that funds will actually be released, especially for non-wage expenditures. Strategic planning i s largely not done, and allocation o f resources (infrastructure, equipment, and staff) i s done in an ad hoc fashion driven by political considerations. Although budgets are drawn, they do not correlate with expenditures and there are no financial performance reviews. Financial management i s focused primarily on salaries and i s weakest at the local government level. CommunityRole 45. A number of assessments havefound that a variety of community-based organizations (CBOs) are active in Nigerian communities, including traditional and kinshipinstitutions, community associations, occupational associations, women's groups, ethnic associations, faith- based groups, women's groups, and more institutionalizednon-governmental organizations (NGOs). Community involvement at the local levelhas longbeenrecognizedas important, buti s difficult to achieve. Measures can be taken for greater community involvement ingovernance o f the health system. Such initiatives could be seen as bottom-up components o f a comprehensive strategy which also involves more top-down reforms at the federal and state levels. The 1988 National Health Policy emphasized the community's role in strengthening PHC services, and its implementation included the creation o f PHC Management and Technical Committees at the LGA level, District (Ward) Development Committees, andVillage DevelopmentCommittees. It seems that although these committees have been put inplace inmost cases, many are not adequately functional. For instance, a 2001 survey of 202 LGAs in two states in each of the six geopolitical zones found that 89% had a PHCManagement Committee. However, only 27% o f such committees had met inthe previous three months. 46. The largepresence of community-based organizations (CBOs) in Nigerian communities provides a basisfor enhancing community involvement in health service administration, while experiences in some locations canprovide examples and lessons. However, efforts to strengthen the role o f civil society organizations inhealth system governance will face a number o f limitations. First,the numbers o f civil society organizations are not evenly distributed. A World Bank (1996) study found that the poorest communities and regions o f the country also tend to have fewer and weaker CBOs. Second, in general, CBOs have significant capacity constraints, often characterized by a "missing middle," between their membership and a limitednumber o f capable leaders. Third, CBOs arejust as vulnerable as other structures inNigerian society to factionalism, patronage, and corruption. HumanResources 47. A large number of doctors and nurses are being trained in the country. The number o f doctors inNigeria is in line with other countries o f similar income per capita while the number o f nurses exceeds what would be expected'(Figure lo). There are about 24 doctors and 126 nurses/midwives per 100,000 people. Nevertheless, a large number o f Nigerian doctors and a growing number of nurses are not worlung inthe country and the desire to migrate abroad i s common among doctors for financial and career development reasons. 17 Summary and Conclusions Figure I O . Doctors and nurses/midwivesper 100,000population by GNI per capita, 2001 (countrieswith GNI per capita under US$1.500) 1000.0 doctors per 100,000 nurses/rnidwivesDer 100.000 0 0 0 . 0 - 0" 0 0 O . gg-% 100.0 P *+ 0 0 0 0 1 .S 0 0 8 0 0 5:: 0 0 sr_o QUJ 0 0 8 0 0 . 10.0 0 `0 0 1.o 0 500 1000 1500 0 500 1000 1500 GNI per capita 2001 ($US) GNI per capita 2001 ($US) Note: Countries of the former Soviet Unionand former Yugoslavia are excluded. Data sources are World Development Indicators,Joint Learning Initiative (2004) and NPC and UNICEF (2001). 48. I n general remuneration and working conditions attract skilled health personnel to urban areas and theprivate sector. Most doctors and nurses work inhigher level facilities. Available data also indicate that about 74% o f doctors practicing inNigeria work inthe private sector [National Association o f Resident Doctors, cited by Dare et al. (2003)l. Interms o f regional distribution, while there are no significant differences inthe number o f nurses per capita across regions, there are more doctors per capita inthe south and more public sector PHC personnel per capita inthe north. 49. Most doctors are male and most nurses and midwives arefemale, and the majority of community health workers arefemale. A 2003 survey o f healthpersonnel infive states (Ondo and Lagos inthe South West, Cross River inthe South South, Kano inthe NorthWest, and Plateau inthe North Center) found that over 80% o f doctors are male and over 70% o fnurses and 90% of midwives are female. About 66% o f community health workers are female, which may improve cultural accessibility o f services. Most records clerks are female. 50. Human resource management in thepublic sector requires improvement. Federaland state ministries o f health and local health departments have little control over salary levels, yet the wage bill accounts for most o f their budget. Rigid civil service rules inhibit effective personnel management and lead to undesirable results. Moreover, the lack o f support (supplies and equipment) undermines performance and poor remuneration leads public sector workers to supplement their incomes. Traditional birthattendants and village health workers have been trained ina significant proportion o f communities, but most do not receive regular support from the health system. DrugSupply 5 1, Drug supply is inadequate in public sectorfacilities, particularly PHC services. When resources are available to local governments, salaries are the first priority so that there i s often little left for other recurrent costs, particularly drugs, leadingto "out o f stock syndrome" inmany PHC facilities. A 2001 survey o f 674 facilities in202 LGAs found that 46% had less than half o f the essential drugs list available. Secondary and tertiary facilities tend to have more regular drug supply, likely related to the better overall fundingavailable at the federal and state levels. 18 Summary and Conclusions 52. Drug revolvingfunds have been established widely, especially in the Northern regions, and sometimes with external support. However, these funds have not been effective inensuring reliable supply. The 2001 survey o f facilities in202 LGAs found that around 40% o f facilities had a drugrevolving fund inplace, and that inmost regions, this proportion was over 60%, reaching 75-85% inthe north. The lowest proportion(27%) was inthe South West, where presumably private sector drug supply i s ample, particularly inLagos. However, the drug revolving funds do not seem to have ensuredregular supply, as over halfo f facilities experienced a stock-out inthe previous three months. Problems experienced by drugrevolving funds include requirements by state and local governments that drugsale proceeds be centralized, which loosens accountability and control, so that funds are often used for purposes other than to replenish drug supply. Evenwhen retained by the facility, funds are often used to meet other costs, inparticular, staff remuneration. More successful experiences are those where local governance and accountability have been strengthenedoverall, particularly with community involvement. 53. There has been a strong private sector response to the shortcomings o f the public system's drug supply. This has been facilitatedby the regulatory environment, which officially registers both qualified pharmacists and patent medicine dealers. The latter are not permitted to fill prescriptions, but inpractice this i s hardly enforced. Informal and itinerant drughawkers also sell drugs, often obtaining their supplies from patent medicine dealers. Much supplyis imported, but there are also around 200 manufacturers inthe country. 54. There areproblems with rational use ofpharmaceuticals. A large number of patients receive medical advice from potentially unqualified drug sellers, raising concerns about inappropriateuse of drugs. Problems have also been observed with the rational use o f drugs prescribedinpublic sector facilities. 55. Thereare concerns about drug quality, but little empirical evidence is available. It has been estimated that up to 40% o f drugs incirculation inNigeria are fake. However, this term tends to be applied to drugs which have not been registered by the National Agency for Food and Drug Administration and Control (NAFDAC), and for which there i s no evidence about quality one way or another. However, the large number o f unqualified drug sellers also raises concerns on the quality o f the drugs they sell. 56. Thepharmaceutical regulatoy framework is inplace and NAFDAC i s the implementing agency, having registered a total o f 4,363 medicines, including 83 traditional medicines which have been proved safe. A National DrugPolicy was adopted in 1990. An Essential Drugs List was first published in 1986 with 204 drugs; it now contains 484. This inclusive list i s one reason why the 2002 FMOHassessment found that 90% o freviewedprescriptionswere for drugs on the list. However, a 2001 facility survey found that the l i s t itself was available inonly 47% o f facilities. Equipment and Support Services 57. Most healthfacilities in all regions arepoorly equipped, but equipment availability increases with the level of care. A 2001 health facility survey found that only around 25% of health facilities hadmore than halfo f the minimumpackage o f equipment, while 40% had less than a quarter o f the set o f equipment. Only 30-40% o f PHC centers, comprehensive PHC centers and secondary hospitals had more than half o f the defined set o f equipment. Similarly, a survey of public sector primary and secondary health care facilities showed that only 66% o f PHC facilities and 80% o f the hospitals had basic obstetric care instruments. 19 Summary and Conclusions 58. Lack of adequatefunding for PHCservices at the local level has undermined repair and maintenance, as well as capital investment, inservices such as ambulances, laboratories, electricity, cold chain, water supply, and environmental sanitation. Similarly, blood supply and screening i s largely ad hoc, but a number o f centralized transfusion centers are being established. 59. TheNational Health Management Information System was established in 1990,but reporting ispoor and incomplete and there are a number ofparallel systems. Reportingrequirements are complex and unclear, and facility record-keeping i s incomplete. A 1994 survey o f PHC services found no less than 34 different reporting formats for different vertical programs. A considerable challenge i s that inmost cases, private health service providers are not included inreporting systems, missinga large proportion o f the relevant data. 60. Nigeria is not alone in its d$jculties in operating a reliable health management information system in a context of decentralization, and large household surveys canprovide a solution in terms of reliable data. Insuch situations, facility and householdsurveys can often provide reliable sources of data on a number o f issues, and this report relies heavily on a number o f such studies. The 2001NPHCDA facility survey provides data not available elsewhere, and a repeat study would be very useful. The government's experience with population-representative household surveys has improved dramatically inthe past few years, as a Nigeria Demographic and Health Survey (NDHS) and a Nigeria Living Standards Survey (NLSS) were completed in 2004. A census will provide essential demographic data. HEALTH SERVICES AND PROGRAMS 61. Standard servicepackages have not been ofjcially adopted in Nigeria although related policy work has been done on this by the FMOH. However, it i s generally understoodthat PHC services comprise basic preventive and curative interventions. Secondary services include delivery care and management o f delivery complications, care for complicated and severe malaria, and surgical services such as obstetric, orthopedic and radiological. Most secondary facilities also provide a range o f PHC services, such as antenatal care. The tertiary level should be focused on medical training and specialized services, including management o f cancer, radiological investigation, renal dialysis and advanced surgical care. Immunization 62. Theperformance of immunization services in Nigeria has risen andfallen based on domestic and international interest andfunding. To increase immunization coverage the Expanded Program on Immunization (EPI) was established in 1979; however, poor funding and vaccine supply, insufficient community mobilization, and over-reliance onhigh-cost mobile campaigns kept vaccine coverage low. These problems have continued to hamper routine immunization in the country. Vaccine coverage peaked in 1990 and then quickly deteriorated due to cuts indonor fundingthat were not compensatedby government support. 63. I n the mid-I990s, thepoor state of immunization services again received attention, so that the National Program on Immunization (NPI) was created as a parastatal agency and available funding increased. At inception, NPI identified the following challenges to the immunization program: lack o fpolicy, weak PHC system, lack o fpolitical will at lower levels o f government, lack o f management structures, inadequate cold chain and logistics, weak maintenance o f infrastructure, and overdependence on donor agencies. Despite all efforts, immunization coverage remainedlow and only 13% o f children were fully immunized in2003. Poor coordination, lack o f community mobilization, inadequate health staff training, deficiencies inthe 20 Summary and Conclusions cold chain, particularly at the LGA level, and more importantly, vaccine shortages, still remain major challenges. 64. Despite recent setbacks, thepolio eradication campaign has been well-supported and has successfully expanded its coverage, but its highprofile has introduced distortions. Because o f Nigeria's importance as a reservoir o f the disease, the polio eradication campaign has received considerable international and domestic support inrecent years. Success inexpanding coverage was recently interrupted by controversy over vaccine quality in some northern states. The political obstacles have now been resolved, and mass campaigns are being implemented. However, the mass mobile campaigns are costly, bothinterms o f funds and interms o f diverting human resources from routine activities. All this said, the polio eradication campaign also provides a window o f opportunity to improve routine immunization as it could also: improve the cold chain, logistic and the vaccine management system; increase the political commitment to immunization; and increase awareness and community participation. 65. Thereis currently a renewedfocus on improving immunization services, with thefederal government retaining a leadership role. The NPIi s currently implementing a five-year strategic plan, including a five-year cold chain investment plan. After several years o f vaccine shortages, government funding has improved and vaccine procurement has been handledby UNICEF, Cold chain and distribution, particularly at the LGA level, continue to pose problems, although these have been addressed to some extent by increases ininvestment and private sector involvement. GAVIis also supportingthese efforts. In2005, the NPIreportedthat the number o f LGAswith higher than 60% coverage o f DPT3, an indicator for routine immunization coverage, has increased. ChildHealthandNutritionServices 66. Health facilities routinely provide many o f the interventionsthat address child illness. A 2001PHC facility survey found, however, that "general outpatient services," are available in 70- 80% o f facilities (Table 2). Because this i s a basic service o f PHC facilities, the rest o f the facilities were presumably not functional. However data are limited on service composition and quality. Table 2, Child health service availability,Nigeria,2001 (% of facilities) (n=674) North North North South South Eo; Nigeria Central East West East South service is offered general outpatientservices a i a4 a3 a i 77 78 a i Immunization 79 67 75 72 a0 a2 76 growth monitoring 55 44 38 41 59 71 51 school healthservices 28 21 15 22 19 37 23 service is offered daily general outpatientservices a0 a0 a0 75 71 73 77 Immunization 12 12 13 a 11 13 12 growth monitoring 16 7 6 6 10 16 10 school healthservices a 3 5 3 4 10 5 Source is Adeniyi et a/.(2001). 21 Summary and Conclusions 67. Growing recognition that child malnutrition is one of the underlying causes of child morbidity and mortality led to the creation in 1990 of the National Committee on Food and Nutrition and a National Nutrition Policy in 2002. Surveys have found that growth monitoring reaches about halfthe population, but i s considerably less available inrural areas and the northern regions. There has been progress inparticular areas such as breastfeeding promotion andmicronutrient supplementation. The 2003 NDHS foundthat 97.2% o fhouseholds now use iodizedsalt. Vitamin A supplementation has also achieved a boost throughvaccination campaigns. Population, Reproductiveand Maternal Health Services 68. Building on groundwork in the 1980sand early 1990s,policy development onpopulation and reproductive health has advanced in recent years. In2001 the FMOHtook the lead with a new National Reproductive Health Policy and Strategy. The policy and strategy encompass safe motherhood, inparticular antenatal and delivery care, family planning, adolescent reproductive health, prevention and treatment o f sexually transmitted infections (STIs) and HIV/AIDS, and address harmful practices and reproductiverights. 69. Family planning services arefairly available, but social, cultural, and economicfactors keep utilization low. The 1999NDHS indicatedthat moderncontraceptives were available within 5 km to 70-80% o f households inurban areas and to over 50% o fhouseholds inrural areas, even among the poorest quintiles. However, utilization remains low (8.9% o f adult women in 2003), suggesting that preferences are more important than access o f services. At the same time, the 2003 DHS also estimates an unmet need for contraception o f about 17 % suggesting the need to address supply issues incertain areas. 70. Antenatal care is a basic element of the PHC strategy, and the service is available in about 66%of healthfacilities. However, the quality of antenatal care couldbe improved, particularly in rural areas. The 2003 NDHS collected data on the content o f antenatal care which provide indicators for service quality. About 80% o f the women who receive antenatal care reported having their weight and bloodpressure measured, only around 66% had urine or blood samples taken, while just over 50% were informed o f signs for pregnancy complications. Quality i s considerably lower inrural areas. 71. Qualified delivery care is available to most urban households and to about two thirds of rural households, but much less available to thepoor in rural areas. Utilization, however, seems to be somewhat less than availability, likely due to cost and, perhaps, cultural factors, The 2003 NDHS found that only 36% o f deliveries are assisted by qualified personnel- 59% inurban areas and 27% inrural areas. 72. Referral carefor delivery complications - a key determinant of maternal mortality - is least available to thepoor in rural areas. The 1999 NDHS found that inurban areas, the mean reported distance to such services i s 6.4 km, while inrural areas it i s 16.9 km. However, for households inthe poorest quintile inrural areas, the mean distance i s over 26 km, comparedto 12 kmfor households inthe highest quintile. 73. Coverage of basic emergency obstetric care (EOC) is insuflcient in most regions, particularly in the North; however, coverage of comprehensive emergency obstetric care is deemed acceptable. Basic EOC involves managed deliveries, particularly administration of drugs and assisted delivery, while comprehensive EOC includes the ability to provide caesarean- sections, A 2003 study o fpublic and private health facilities in 12 states estimated that only Lagos meets the populationtarget for basic EOC coverage. Incontrast, all surveyed states meet 22 Summary and Conclusions the target coverage for comprehensive emergency obstetric care o f one facility per 500,000 people. HIV/AIDS, Malaria andTuberculosis 74. Thepolicy and institutionalframework for combating HIV/AIDS has been developed. A National AIDS Control Programwas established under the FMOHin 1986 and in2000, political commitment by the President led to the creation o f a multi-sectoral National Action Committee on HIV/AIDS (NACA). State action committees have also been established. A National Policy on HIV/AIDS was adopted in2003, with components including preventiono f disease transmission, law and ethics, care and support for those affectedby the epidemic, information and communication, and institutional development. 75. Preventive interventions have reportedly expanded but more effort is needed to reach the poor in rural areas. In 1999 only 17% of women inurban areas and 7% inrural areas knew o f condoms as a preventive measure, while in2003, these proportions had increased to 60% and 40% respectively. Anti-retroviral treatment i s available to a small number o f patients, but scaling- up faces considerable challenges due to funding, drug supply problems, and capacity constraints. Likewise, prevention o f mother-to-child transmission has been introduced but faces similar challenges to scaling up. 76. A surveillance system is inplace and a recentprevalence survey provides important data. Sentinel surveillance o f antenatal care clients has been established and in2004, the government completed a national prevalence survey which provides crucial data for assessing the status of the epidemic and informing strategies and programs. 77. With regard to malaria, Nigeria has adopted the Roll Back Malaria strategy but coverage of key preventive and curative interventions remains low. The elements o fNigeria's strategy are: i)casemanagement; ii)prevention; iii)information,education,andcommunicationand community mobilization; iv) partnerships; v) operational research; and vi) monitoring and evaluation. Improving case management will depend on progress inPHC services, although Nigeria also intends to adopt a home-based treatment strategy usingartemisin combination therapy (ACT). With regardto prevention, intermittent prevent treatment (IPT) o fpregnant women and insecticide-treated nets (ITNs) are the main strategies. However meeting service coverage targets will require significant efforts. For instance, the 2003 NDHS found that only 34% of febrile children receive anti-malaria treatment, 1% of pregnant women receive IPT, and only 1%of pregnant women and children sleep under an ITN. Implementation of the strategy in some states i s supported by the Global Fund. 78. I n 2002, a strategicplanfor tuberculosis (TB) control was adopted,focusing on expansion of coverage of directly-observed treatment (short-course) (DOTS). The National Tuberculosis and Leprosy Control Program, established in 1991under the FMOH, i s taking the lead, with counterparts ineach o f the states. Since then there has been progress inincreasingDOTS coverage. However, case detection remains very l o w at 18% in2003, far from the global goal of 70%. This i s partly due to the weakness o fpublic sector PHC services. Nevertheless, the DOTS treatment success rate i s reportedto be 79%, close to the global goal o f 85%. Government financial support has been limited so TB control i s dependent on international donors. 23 Summay and Conclusions HEALTH SERVICEAVAILABILITYAND UTILIZATIONBY TYPEOF PROVIDER Hospitals 79. On average, Nigeria seems to have an adequate number of tertiay and seconday hospitals. The federal government operates a number of tertiary and specialized hospitals and there i s a federal hospital inmost states, although the level o f services available inmany i s characterized as more at the secondary level. There are approximately 54 tertiary and specialized hospitals, implyingapopulation to facility ratio of around 2.1 million. Generalhecondary hospitals are the responsibility of state governments, and should have several physicians and at least 20 nurses. There were reportedto be 855 public sector secondary facilities inthe country in 2000, for a population to facility ratio o f around 135,000. Inaddition, there are a large number o f privately- operated facilities, bringingthe reportedtotal to 3,002 secondary facilities inthe country. Table 3. Health service utilizationby type of provider,Nigeria,2003 (% of childrenwith cough or fever in the previoustwo weeks who received care) (n = 1,295) urban rural overall public hospital 21 11 14 public PHC provider 10 16 15 private hospital or clinic 12 a 9 other private medical provider 1 2 2 pharmacy/patentmedicine dealer 47 4a 47 Other a 14 13 Total 100 100 100 Source is 2003 NDHS. Table 4. Healthservice utilizationby type of provider, Nigeria,2004 (% of children and adults ill or injured in the previous two weeks who receivedcare) (n = 7,028) urban rural overall Hospital 51 32 40 Public 37 23 29 for-profit 13 a 10 non-profit 1 1 1 PHCprovider 28 45 38 Public 11 25 19 for-profit 16 l a 17 non-profit 2 2 2 pharrnacy/patent medicine vendor 8 I O 9 Other 13 13 13 Total 100 100 100 Authors' estimates from 2004 NLSS data. 24 Summary and Conclusions 80. Among medicalproviders, utilization is divided equally between hospitals and PHCservices. The 2003 N D H S found that, of children with cough or fever who were treated, similar proportions (around 15%) went to a public hospital or a PHCprovider (Table 3). Similarly, considering public and private providers together, the 2004 N L S S found that, among people o f all ages who visited a healthprovider, 40% went to a hospital and 38% went to a PHC service (Table 4)* 81. Rural residents are less likely to use hospitals and more likely to use PHCservices. Among children with cough or fever who receivedtreatment, 11%inrural areas went to a public sector hospital, compared to 21% inurban areas (Table 3). Among patients of all ages, the 2004 NLSS found that 32% inrural areas went to a hospital, compared to 51%inurban areas. (Table 4). Table 5. Health Service utilizationby geOpOlitiCalzone and type of provider,Nigeria,2004 (YOof children and adults ill or injured in the previous two weeks who received care) (n = 7,028) pharmacy/ hospital PHC patent medicine other total vendor South South 31 36 14 20 100 South East 37 35 11 16 100 South West 52 34 6 8 100 North Central 36 42 9 14 100 North East 35 47 6 12 100 NorthWest 46 37 9 8 100 Nigeria 40 38 9 13 100 Authors' estimates from 2004 NLSS data. 82. Thereare considerable regional differences in hospital service availability, but this is only partly reflected in utilizationpatterns. Ratios o fpopulationper secondary facility are over 150,000 inthe NorthWest and North East zones, but under 50,000 inthe North Central and southern zones. This disparity i s largely due to the much greater numbers o f private sector secondary facilities operating inthe south, and to a lesser extent inthe center o f the country. Availability i s somewhat reflected inutilization, as the 2004 NLSS found that, inthe South West zone, which contains Lagos, over 50% o f people who received care went to a hospital. However, hospital utilization i s also highinthe NorthWest zone, where there are many fewer hospitals, (Table 5) 83. Thepoor are less likely to use hospitals. Figure 11presents estimates from the 2004 NLSS showing that utilization of hospitals increases as household economic status rises, so that by the highest quintile,more people use hospitals than PHC providers. Primary Health Care Services 84. The ward (district) referral system isfunctioning in around two-thirds of districts. An important component o f the "classic" PHC strategy, adopted by a number o f countries in the 1980s and early 1990s,i s the integration o fprimary and first-referral services under a single administrative structure incatchment areas (often called districts) o f around 100,000 or 200,000 people. InNigeria, the division o f responsibilities between local governments, responsible for primary healthcare, and state governments, responsible for secondary-level services, i s a structural barrier to full implementation o f the district strategy. Nevertheless, the ward system has been implemented inthe country, involving collaborative arrangements between states and local governments as well as between individual secondary (first-referral) hospitals and PHC 25 Summary and Conclusions facilities. A 2001 survey of PHC services in202 LGAs collectedinformation on referral in400 wards which provides indications o f how well the "district" model i s functioning. It found that 58% o f wards had a referral facility. Two-way referral was functioning in 44% o f wards, while only 11% had transport available for referral. Figure 11, Health service utilizationby type of provider and consumption quintile (% of ill or injured in the previoustwo weeks who received treatment),Nigeria,2004 70 - all types of providers 70 - mdical providers only 60 - 60 - 50 - hospital 50 - public 40 - 40 - PHCprovider 30 - 30 - 20 - other 20 - 10 - lo 1 04 0 poorest 2 3 4 highest poorest 2 3 4 highest quintile auintiie Authors' estimates from 2004 NLSS data. 85. Comprehensive primary health care centers shouldhave a doctor and offer both PHC and a limitednumber of secondary clinical care services. Inprinciple, there should be one comprehensive primary health care center per LGA, serving a population o f 50,000-100,000. Within LGAs, there shouldbe at least one primary health care center per ward, covering a population o f 10,000-20,000. These facilities should be staffed by a clinical officer (medical assistant) and a nurse or midwife, and offering basic preventive and curative services. At the community or village level, health clinics or posts should be staffed by community health extension workers (CHEWS) and support birthattendants and other community health workers. Figure 12.PHC services per 100,000 population,Nigeria,2001 health postslclinicsldispensaries health centers 8 25 7 20 6 5 15 4 10 3 2 5 1 0 0 Authors'calculations from data inAdeniyi et a/.(2001). 26 Summary and Conclusions 86. Overall, the number of PHCfacilities suggests reasonable availability, but higher-level PHC services are concentrated in the south while there are more lower-level services and community health workers in the north. According to FMOHdata, in2000 there were over 13,000 public sector PHC facilities and almost 7,000 private PHC facilities, for a total o f about 20,000. The overall population to facility ratio o f around 5,500 suggests reasonable availability o f PHC services. Data from the 1999 NDHS indicate that 71% o fhouseholds are within 5 kmo f a PHC facility. However, Figure 12describes data from a 2001 facility survey which shows that the North East and North West have greater numbers o f lower-level PHC facilities -health posts, clinics, and dispensaries - than the rest o f the country. At the same time the southern regions have a greater concentration o f higher-levelPHC services -health centers. 87. Rural residents andpeople in theNorth Central and North East regions are more likely to use PHC services. The 2003 NDHS found that among children with cough or fever who received treatment, 45% inrural areas went to a PHC provider, compared to 28% inurban areas (Table 3). The 2004 NLSS found similar proportions among children and adults who were treated for illness inthe previoustwo weeks (Table 4). This survey also foundthat residents ofthe NorthCentral and NorthEast zones were somewhat more likely to go to PHC services (around 45% o f treated patients) than residents o f other zones (around 35% o f treated patients). (Table 5) 88. Thepoor are more likely to use PHC services. Figure 11, illustrating data from the 2004 NLSS, clearly shows that use o f PHC services increases as households are poorer. Inthe highest quintile, 37% o f people who were treated went to a PHC service, while the proportion inthe lowest quintile i s 58%. Private Medical Providers 89. Private sector medicalproviders accountfor a signijkantproportion of available services and about one third of utilization of formal medicalproviders. A 2001 facility survey estimated that about 66% of hospitals and comprehensive health centers, and about 15% o f primary services, were operated by the private sector. The 2003 NDHS found that among children with cough or fever who received treatment, 11%went to a private medical provider, comparedto 29% who went to a public sector hospital or PHCprovider (Table 3). The 2004 NLSS found that among illchildren and adults who receivedtreatment inthe last two weeks, 27% went to a private for-profit medical provider, and 3% went to a private non-profit provider, compared to 48% who went to a public sector facility. Ingeneral terms, both surveys found that (excluding consideration of pharmaciedpatent medicine dealers and other non-formal providers) private providers are consulted one-third o f the time and public medical services are consulted about two- thirds o fthe time. 90. Urban residents are slightly more likely to useprivate sector medical services. The 2003 NDHS found that inurban areas, 13% o f children with cough or fever who received treatment went to a private medicalprovider, compared to 10% inrural areas (Table 3). Similarly, the 2004 NLSS found that the proportion o fpeople who received treatment who useda private sector medical service was 32% urban areas and 29% inrural areas (Table 4). 91. Higher-level private medical services are more available in the south, and this is reJected in utilizationpatterns. Overall inNigeria, private providers account for 72% of secondary facilities. They account for 5% inthe NorthEast and 24% inthe NorthWest, compared to over 90% inthe South East and over 80% inthe South South and South West. Similarly, private comprehensive health centers account for a significant proportion o f the total inthe South West zone, but are almost absent inthe northern regions (Figure 12). With regard to both hospitals and PHC facilities, utilization o f private sector services i s higher inthe souththan inthe north. The 2003 NDHS, for example, found that for the treatment o f cough or fever among children, utilization o f 27 Summary and Conclusions private medicalproviders was higher than public providers inthe South East and South West while the reverse was the case inthe north (Figure 13). The 2004 NLSS found similar patterns: inthe South East, 50% ofchildren and adults who were treatedfor illness inthe previoustwo weeks went to a private medical provider, compared to 22% who went to a public service, while inthe NorthWest, the proportionswere 5% and 68% respectively. Figure 13. Regional patternsof utilization by type of provider, Nigeria, 2003 (% of childrenwith cough or fever who were treated) 80 70 60 50 40 30 20 10 0 public mdical provider private mdical provider pharmcylpatent mdicine dealer Source is 2003 NDHS. 92. Private non-profit medical providers mostlyprovide higher level services, are most available in the South East region, and overall accountfor a smallproportion of service utilization. A 2001 facility survey found that 5% o f comprehensive health centers and secondary hospitals were operated by non-profit organizations, which are often religious groups. They are most available inthe SouthEast, accounting for 11%ofsuch services. Overall, the non-profit sector represents a small proportion of total utilization: the 2004 NLSS found that only 3% o f people who received treatment inthe previous two weeks went to a private non-profit provider (Table 4). 93. The better-off are more likely to useprivate sector medical services, but every income group usespublic services more thanprivate ones. Consistent with urbadrural and regional patterns o f poverty and health service utilization, people inthe higher quintiles are more likely to use private sector medical services. Figure 11provides data on treatment o f illchildren and adults; it shows that utilization of private medical providers rises with income. Inthe poorest quintile, among ill people who were treated, 23% went to a private medical provider and this increased to 38% inthe highest quintile. Although use o f public sector medical services decreases with economic status, it still exceed utilization o fprivate services (excluding non-formal providers) inevery quintile. Patentmedicinevendors 94. Patent medicine vendors, a legally-recognized category of drug seller, arefar more numerous than registeredpharmacies and are signijkantproviders of "informal I'care. They are widely available, particularly in the south, and in urban areas in allparts of the country. As with other private sector health services, registered pharmacies are concentrated inthe south. Inthe SouthWest zone, for example, there i s one pharmacy for every 50,000 people, but inthe North East, there i s one for every 280,000 people. Patent medicine vendors are also more available in the south, but the regional disparities are not as great. The 1999 NDHS foundthat overall, 60% of households live within 5 kmo f a patent medicine vendor. These providers are most available 28 Summary and Conclusions children with cough or fever who were treated, 59% inthe poorest quintile went to a pharmacy or patent medicine dealer, compared to 35% among the most well-off (Figure 15). Figure 15. Utilization of pharmacy/patentmedicinedealer for treatment of child illness, Nigeria, 2004 (% of children with illness in previous two weeks who receivedtreatment) :::; Y 70% 1 40% 30% cough or fever 20% - diarrhea 10% - 0% 7 quintile Authors' estimates from 2003 NDHS data. Traditional healers 98. Survey data indicate that somepeople go to traditional healersfor treatment. The 2003 NDHS found that only around 3.5% o f illchildren who were treated were taken to a spiritual or traditional healer. Similarly, the 2004 NLSS found that less than 1% o f illchildren and adults who were treated went to a spiritualist, traditional birthattendant or traditional healer. There was little difference observed betweenurban andrural areas. Both surveys found that a further 10% o f utilization was accounted for by treatment by family members or other unspecified caregivers. ROLEOFTHE PRIVATESECTOR 99. Theprivate health care sector is a major component of the health care delivery system in Nigeria. As noted above, the private sector operates about 66% o fhigher level medical services and around 15% o f PHC services. Similarly, about 33% o f utilization o f formal medical services are accounted for by the private sector. There i s significant use o f non-formal private services, particularly patent medicine vendors -with surveys finding utilization to be 50% (of those treated) incases o f child illness and around 10% for general illness among older children and adults. Private health care providers are heterogeneous, ranging from patent medicine vendors, dental and medical clinics, to tertiary hospitals. Most o f these are registered by the government, butthere are also unregisteredclinics, drug shops andnumerous drughawkers. 100. Although the majority ofprivate sector healthfacilities arefor-proJit; many are not-for proJit, mostlyfaith-based. For example, the ChristianHealthAssociation inNigeriahas about 400 registeredmember institutions; these institutions provide services through about 3,500 health facilities which are mostly concentrated inthe South o f the country. Data discussed above indicate that non-profit services account for about 5% o f total comprehensive health centers and secondary hospitals, and for about 3% o f total utilization. There are also a few employer-based providers. The private for-profit facilities tend to be small practices and tend to focus on the provision o f curative services; in contrast the mission sector operates larger facilities that offer bothpreventive and curative interventions. 101. Thepharmaceutical retail sector is composed of registered pharmacies, patent medicine vendors and through illegal drug hawkers. In2003, there were 2,75 1registered pharmacies, but 30 Summary and Conclusions there were an estimated 36,000 or more patent medicine vendors inthe country. Inaddition, there are an unknown number o f informal drug sellers. None o fthese retailers are allowed to prescribe drugs but inpractice many do. This combined with little knowledge and training, especially among patent medicine vendors and drughawkers, has resultedinirrational prescription of drugs. 102. The health authorities have recognized the importance of theprivate sector and are promotingpublic-private partnerships in health. However, many challenges remain. First, although the regulatory system i s inplace, enforcement i s weak due to funding problems. Second, coordination between the public and private sector i s weak reflected inthe absence o f an efficient and thought through referral system between the sectors. Third, the system for monitoring the activities o f the private sector i s not functioning; very few private practitioners report their activities to the public sector. HEALTH FINANCING REQUIREMENTS CARE AND 103. Estimating total health expenditure in Nigeriapresents considerable challenges. The division o fresponsibilities for health across the different levels o f government makes it difficult to compile data on expenditure as the states and LGAs are not required to report budgets and expenditures to the federal level. Additionally, available data sources often contradict each other. The following analysis i s based on the limited available data. Public Sector HealthSpending 104. Federal government health spending has increased significantly in recent years. In2003, the federal government accounted for 49% total government spending, states accounted for 37%, and local governments accounted for 14%. Inline with growth inGDP and total government spending, federal government health expenditures have increased inreal terms, by about 100% duringthe period 1998-2003 (Table 6).' The 2004 budget allocation for healthincreasedas a proportion o f the total budget to 6.9%, but was slightly lower monetary terms than reported expenditures in2003. The 2004 healthbudget was Naira 35,300 million, equivalent to US$265 million or US$ 2.10 per capita." Table 6. Federal government health expenditures, Nigeria, 1998-2003(in current and constant 2003 prices) 1998 1999 2000 2001 2002 2003 Naira million at current prices 11,984 16,180 18,182 44,652 63,171 39,686 US$ million at parallel exchange rate 141 176 150 333 454 288 Annual growth in federal health 25 (15) 122 36 (37) expenditures in current $US Growth in federal health expenditures 104 in current $US 1998-2003(%) % federal government health 3.3 4.5 2.7 2.8 3.7 3.2 expenditures/total federal expenditures Federalhealth expenditures at 19,718 24,969 26,236 54,255 67,999 39,686 constant 2003 prices (naira million) Real annual growth rate in federal 27 5 107 25 (42) health expenditures (%) Real growth in federal health 101 expenditures 1998-2003(%) Authors' calculationsfrom Central Bank of Nigeria (CBN) reported data. The three sources of data on federal health spending available to the authors provide similar estimates except for the year 2002, for which two ofthe sources report a total of aroundUS$250 million andthe third, the CBN figures reported inTable 6,reportsUS$454million. loDataon actual expenditures in 2004 are not available to the authors. 31 Summary and Conclusions 105. Mostfederal health spending goes to teaching and specialized hospitals andfederal medical centers -and most goes to salaries. Data on the allocation o f funds released for health bythe federal government in2001 and 2002 are presentedinFigure 16. In2002,77% of federal health expenditures went to federal hospitals - 58% to teaching and specialized hospitals and 19% to the federal medical centers instate capitals. This i s somewhat o f an increase from 2001, when the proportion was 65%, with most o f the difference coming from federal parastatal agencies (such as the National Primary Health Care Development Agency and the National Immunization Programme), whose proportion dropped from 28% in2001 to 14%in2002. In 2001 and 2002, between 66% and 75% o f federal health expenditures were devoted to personnel costs, while around 5% covered other recurrent costs (suggesting that most drug costs are borne bypatients). About a quarter o fthe total was on capitalexpenditures. Figure 16. Federal government health expenditures,Nigeria, 2001-2002 100% - 90% - 20% 80% - 2001 2002 Authors' estimates from data from Office of the Accountant General. 106. Comprehensive data on state government health spending are not available but it is estimated to be of a similar order of magnitude asfederal health spending and on average lower in the north than in otherparts of the country. As noted above, total state government spending accounted for 37% of total government spending in2003. Estimates o f state government spending on health are based on data from samples o f states and in2002 range from a lower bound o f about US$150 million to an upper bound of about US$ 330 million, a similar order o f magnitude to average annual federal health spending inrecent years. Data from 13 states indicate that spending across state governments seem to be lowest inthe northernregions and highest in the North Central and South South zones. Like federal spending, state health spendingi s likely concentrated on the main area o f state responsibility, secondary hospitals, and i s also likely mostly on personnel, although data on this are not available. 107. Thereare no comprehensive data on health spending by the 774 local government areas (LGAs), responsiblefor primary health care services, but it is likely less than eitherfederal or state health spending. Total local government spending accounted for 14% o ftotal government spending inNigeria in2003. Data on the sectoral allocation o f local government expenditures are not available, and estimates o f local government health spending are based on available information from small samples. An estimatedrange for LGA health spending in2002 i s from US$ 35 to 145 million, likely less than either federal or state health spending. There i s evidence that like other levels o f government, most health spending by local governments i s on personnel. A 2002 study o f 30 LGAs inLagos and Kogi states found that inLagos, 65% o f local government health spending was on personnel, while the proportion inKogi was 78%. (Khemani, 2004). 32 Summary and Conclusions 108. There is a general impression that inprevious years LGAs did not receive sufficient funding to meet their responsibilities, but their overall revenue situation has improved recently with increased FederationAccount transfers. In 1998, reportedlocal government expenditures were US$ 520 million but by 2003 this had increasedto US$2,5 10 million. This large increase inoverall availableresources would suggest a correspondingimprovementinlocal government financing o f primary health care services. Nevertheless there continues to be concerns raised regarding governance and the commitment o f LGAs to basic services. For example, a study o f LGAsinLagos andKogi states found that non-payment o f salaries was not correlatedwith the level o f available resources, suggesting diversion o f funds. (Khemani, 2004) 109. International supportfor the health sector is growing and canpotentially have substantial impact on specific health issues. At an estimated US$ 1per capita annually in2002, international donor assistance to the sector i s equivalent to at least one third o f total federal government health spending, and to similar proportions or more o f state or local health spending. Donor-supported programs are therefore relatively large inrelation to any one level o f government, particularly considering growing commitments inrecent years, and can be influential because they are focused for the most part on specific health issues (such as HIV/AIDS, malaria, family planning or immunization). Figure 17. Per capita domestic public sector health spending and GDP per capita, 2002 (countries with GDP per capita less than US$ 1,000) 60 e e e e 0 0 200 400 600 800 1000 GDP per capita (US$) Authors' calculations from WHO 2005 and World Development Indicators 2005. 110. Plausible estimatesfor government health spending are somewhat at odds with the prevailing impression of very low publicfunding for health sewices but consistent with Nigeria's economic growth andper capita GDP. Basedon available data, a plausible estimate o f total annual domestic government health spending i s around US$ 8 per capita. This level may be counter to prevailing impressions o f low public spending on health, but Figure 17 indicates that it i s consistent with Nigeria's GDP per capita. Private Sector andHouseholdHealth Spending 111. Health spending by privatefor-profit and non-profit organizations is not negligible. Given the importance o fprivate non-profit providers insome parts o f the country, particularly hospitals runby religious organizations, spending on health by non-profit organizations i s likely not negligible. Moreover some large for-profit firms and government parastatal companies, particularly inLagos and other large cities, directly provide or finance health services for employees and their families. 33 Summary and Conclusions 112. Private health insurance has been limited, but is reported to be growing, while there have been some experiments with community health insurance and apublic health insuranceprogram is being initiatedfor government employees. In2001, it was reported that only four private health insurance companies were operating inthe country (Alubo, 2001). However, private insurance has apparently been growing inthe past few years ina more stable economic and political climate. A number of experiments in community-based health insurance have been implemented inNigeria, includingsavings schemesthrough existingcommunity-based organizations suchas women's associations, faith-based organizations, and craft and trade groups. The National Health Insurance Scheme (NHIS) intends to establish healthinsurance partly financed by public sector employee contributions. 113. Recent household survey data indicate that out-of-pocket spending on health services in Nigeria exceeds US$20per capita, representing around 9% of total household expenditures, The 2004 Nigeria Living Standards Survey (NLSS) collected data on householdhealth expenditures from a representative sample o f 19,159 households. The estimate from these data of average per capita out-of-pocket spending on healthi s aroundUS$22.50. The survey data indicate that this out-of-pocket spending on health services accounts for 8.7% o f total household expenditures. This health spending includes ezpenditure on outpatient care, transportation to health care facilities, and medications." 114. This is one of the largest shares of health expenditure out of total household expenditure in developing countriesfor which data are available. For instance, incounties such as Vietnam, Brazil, and Albania, householdhealth expenditure represents 7% or less o f total household expenditure. InEthiopia, expenditure on healthrepresents only about 1% o f total expenditure. In Nigeria, the large burden o f out-of-pocket health expenditure i s due to highutilization o f private providers, cost recovery by public facilities with no clear exemptions and waivers, and limited availability o f health insurance mechanisms. 115. The better-offhouseholds, on average, spend a larger share of their total expenditure on health care than thepoorest households. Consistent with this is that health spending as a proportion of total household spending is highest in the South East and lowest in the North West. Itis not surprisingthat the better-off spendmore onhealth; as discussedpreviously, the better-off have higher utilizationrates than the poorest and they are also more likely to use private providers. On average, a household belonging to the poorest fifth o f the population spends about U S $ 4 per capita annually on health care; incontrast, a householdamong the richest fifth spends about US$70 per capita annually. Households inthe South East spend the most on health (about 11%) relative to total expenditure; while households inthe NorthWest spendthe least (about 7%). 116. Expenditure on drugs represents the largest share of household health spending and is a greater burdenfor thepoorest. Around 70% o ftotal health spending i s on medications, a proportion which i s significantly higher for the poorest quintile (around 80%) than for the highest quintile (around 60%). 117. Many patients, including thepoorest,payfor high-impact child and maternal health interventions. The 2004 NLSS found that 34% of parents paid for their child's most recent vaccination, 55% o f mothers paid for post-natal care, and 81% paid for antenatal care - all services which are supposed to be officially free o f charge due to their public health impact. Moreover there are no significant differences across householdexpenditure quintiles, indicating that exemption mechanisms are not successfully distinguishingthe poor from the non-poor. l1The estimatesare preliminary and exclude data onhousehold expenditures for hospitalization. 34 Summary and Conclusions 118. Many households couldfall intopoverty orfurther into it as a consequence of catastrophic health expenditures. The survey found that as many as 12% o fhouseholds spend about a fourth o f their total resources on health care and as many as 4% o f households spend half of their resources on health care- a proportion indicating catastrophic health expenditure. Total Health Spending 119. I n terms of total health spending and sources offunds, it is likely that Nigeria spends more than is commonly thought. Fromthe available data, an estimated lower bound for total annual health spending circa 2002-03 i s around US$29.50 per capita and an upper boundi s around US$ 33.00 per capita. Table 7 presents the authors' estimates from various sources o f data. This level o fhealth spending represents between 6.5 and 7.4% o f GDP. Comparedto other countries, this level o f spending i s somewhat higher than would be expected given Nigeria's GDP per capita. It seems that with recent economic growth and greater political stability, health spending inNigeria is higher than generally perceived. Table 7. Estimates for total health expenditure in Nigeria,circa 2003-2004 US$ Naira (million) (million) US$ per capita Federal 39,686 288 2.34' State 58,033 421 3.42* Local 41,568 301 2.453 total domestic 139,287 1,009 8.22 international donors 20,850 150 I.224 total public 160,137 1,159 9.44 private organizations 3,982 30 0.245 private insurance 13,836 104 0.835 private out-of-pocket 377,046 2,835 22.556 total private sector 394,864 2,969 23.61 Total 555,001 4,128 33.06 'CBN 6.3% (from 2002 budget data from 13 states) of CBN reported total state expenditures in 2003. 12% (from 1999-2000 data on LGA budgets in Lagos and Kogi states) of CBN reported total LGA expenditures in 2003 assumed increase from Soyibo et a/.(2004) estimate of US$ 125 million in 2002. Universityof lbadan NHA estimate for 2002 (Soyibo et a/.,2004). Authors' estimate from 2004 NLSS data. 120. However, Nigeria's health outcomes are not commensurate with its health expenditure. Figure 18 provides a roughillustrationo f what Nigeria i s buyingwith its comparatively high level of total health spending. Although under-five mortality has declined since the 1990s, the 2003 NDHS estimate o f 201 per 1,000 i s much higher than would be expected given Nigeria's level of health spending. Possible reasons for this? Available data indicate that most health spending does not go to primary health care and preventive services which provide the most cost- effective means o f improving populationhealth status. Around two-thirds of public spending (i.e. most federal and state government spending) i s allocated to hospitals. Similarly, because the better-off spendmore and because they tend to go to higher-level hospitals and private providers, it is likely that most private spendingis not allocated to PHC andpreventive services. 35 Summary and Conclusions Figure 18. Total health spending and under-5 mortality, 2002-03 (countrieswith under-5 mortality over 40 per 1,000) 0 0 0 250 - 0 0 - * -0 0 4 0 50 100 150 200 total health spending 2002 (US$) Requirementsto Achieve the MDGs 121. Using the Marginal Budgetingfor Bottlenecks tool (MBB), simulations were made on the extra resources needed to achieve the health-related MDGs in Nigeria. These simulations estimated the cost o f the inputsrequired to increase the coverage o f effective interventions that improve maternal and child health as well as some interventions to prevent and treat malaria, TB and HIV/AIDS . Table 8. Estimated cost and impact of MBB policy scenarios reduction reduction extra cost total extra cost Scenario under-5 in maternal in capita per (us$per capita per (US$ per mortality mortality year) Year) 1, Improving immunizationmanagement and governance 7% 0% 0.19 0.19 2. Strengthening population based outreach services 14% 2% 1.36 1.55 3. Addressing community-basedinterventions 54% 7% 2.83 4.38 4. Providing basic clinical services 66% 30% 2.26 6.64 5. Providing comprehensive referral care (CEOC) 68% 53% 3.52 10.16 6. Treatment of HIV/AIDSand managementof resistant and 68% 53% 5.72 15.88 complicated TB and HIV/AIDS Authors' estimates. ~ 122. Thesesimulations estimated that on average an extra US$16perpersonperyear are needed to achieve signiJicant progress in reaching the health-relatedMDGs in Nigeria. This i s the cost o f implementing five possible sets o fpolicies and interventions to gradually eliminate bottlenecks inthe health sector and thus accelerate progress to meet the goals. These estimates do not include the cost o f interventions outside the health sector that are also needed to achieve the healthMDGs(e.g. education, poverty reduction, and others). 36 Summary and Conclusions 123. Basic preventive, community-based and clinical interventions can have a signijkant impact on child and maternal mortalityfor an extra US$I Oper capita annually, while another US$bper capita will improve treatmentfor HIVMIDS and TB. Table 8 shows the impact and cost estimates associated with different packages o f policies and interventions. The first scenario improves immunization management and governance, with an estimated marginal cost o f US$ 0.19, When interventionsthat strengthenthe capacity for population-based outreach services are added to the first scenario, the total cost increases to US$1.55. The third scenario increases the coverage o f community based interventions such as the promotion o f exclusive breastfeeding and ITNusage, increasingthe total marginal cost to US$4.38per personper year. The first three scenarios are mostly aimed at improving child survival. The fourth scenario provides basic clinical services and the fifth provides comprehensive referral care. Along with the first three policy packages, the fourth and fifth scenarios could significantly reduce child and maternal mortality at a total extra cost o f around US$10per capita per year. The last scenario focuses on treatment o f HIV/AIDS and the management of resistant and complicatedTB. Adding this last scenario to the previous ones increases the extra resources needed to US$ 16per personper year. HEALTH POLICY Background 124. Thepublic sector health system expandeddramatically in the 1970s and 80s, applying the PHC "district model. At independence in 1960, health services inNigeria were largely I' focused on curative care and centered inurban areas. Inthe 1960s and 70s, government considerably expanded the health care system. Duringthe early 1980s, the Basic Health Services Scheme (BHSS), inline with the 1978Alma Ata Declaration, envisionedorganizing PHC services based on a "district" model, by which one comprehensive health center, four health centers, and 20 clinics would serve a catchment population o f 150,000. 125. The 1988National Health Policyfurther emphasizedprimay health care, andput in place the structures and division of responsibilities which characterize the system today. The policy and subsequent directives defined the responsibilities o f the federal, state, and local levels o f governments, and created the various state and federal programs and parastatal agencies focused on specific aspects o f the sector. 126. Progress was achieved in the creation of the new institutional structures,particularly relating to the decentralization of responsibility for PHC to the LGAs. Inthe 1980sand early 199Os, the strategy to improve primary health care involved training PHC workers, infrastructure investment, and setting up a district and village governance structure. Resources and technical assistance were to be provided to the LGAsby states and the federal government, which established the National Primary Health Care Development Agency (NPHCDA) in 1992 for this purpose. As noted inprevious sections, following this effort, district and village committees are inplace anddrugrevolving funds are operating inmany areas. Similarly, investmentin infrastructure, equipment, and training was considerable (World Bank, 1991). 127. However, institutional changes and investments were to a large extent notfollowed-up with sustained support, as the three levels of government, as well as external donors, reduced funding for health services during the militay dictatorship of the 1990s. Political interference, increasedcorruption, and general deterioration o f public sector governance also severely affected the health system. Development o f the system became characterized by one-off investments, in infrastructure or drugs, determined by political criteria, and with little or n o provision for sustainability. Ingeneral, institutions, such as the various coordination committees at different 37 Summary and Conclusions levels, became non-functional, service availability and quality was reduced, and utilization declined. Current Health Sector Strategy 128. Thegovernment democratically-elected in 1999started the dfficult process of reversing the deterioration of the health system, includingpolicy development and increasing spending on health. Its 2004 Poverty Reduction Strategy Paper (PRSP), called the National Economic Empowerment and Development Strategy (NEEDS), includes a "Social Charter," focusing on human development, including a significant component on the health sector. The overall goal i s to improve the health status o f Nigerians through strengthening primary health care services and undertaking health sector reforms. Within the fiamework o f the NEEDS,the health sector policies and programs adopted or plannedby the government can be grouped into four main strategic thrusts. i> Thefederal government's draft Health Act, currently before the National Assembly, could strengthen directfederal support to PHC services, essentially reviving the strategy of the early 1990s. Ifeffectively implemented, the Act would strengthen the role of a federal parastatalagency, the National Primary HealthCare Development Agency (NPHCDA),particularly by establishing a designated source o f funding. This fundwould be constituted from earmarked taxes on alcohol andtobacco, and more importantly from contributions from the federal, state and local governments. ii) Anumberof disease-specificor "vertical"programsarebeingstrengthened, particularly through the support of thefederal government and international partners, which should improve coverage of high-impact interventions. HIV/AIDS, malaria, and TB programs, for example, are centrally-based, often with state-level counterparts, and receive support from the federal government and international partners. Inaddition, the federal government plans to support an MDGprogram ina number o f states addressing, inparticular, child and maternal mortality. Under the draft Health Act, responsibility for immunization i s expressly retainedby the federal government. iii) Theroleof stategovernmentsinsupportingLGAsandPHCservicesmaybe strengthened. The draft HealthAct contains language which strengthens the role o f state governments inPHC services, while the National PHC Fundcreated by the draft Act will necessarily strengthen the state role insofar as state financial contributions are accompanied by a role inprogram development, management and governance. At the same time, a number o f states have developedpoverty reductionstrategies (SEEDS) which affirm a commitment to improve basic health services and combat HIVIAIDS inparticular. iv) Thefederal government is establishing a national health insurance scheme. The federal government intends to establish national health insurance, starting with public employees and with the intention o f expanding in subsequent years to private formal sector employees. This represents a technical challenge, but accountability and trust issues are paramount as employees are asked to turn over a part o f their salaries to the pool. The scheme holds the potential o f improving the use o f the large private householdexpenditures on health as well as reducing financial risks to individual households. Inits first stage, the scheme will largely benefit the already better-off who have formal employment. Insubsequent phases, support to community-based insurance schemes i s envisioned for the benefit o fnon-formal sector and agricultural workers. The scheme plans to include a subsidy program that aims at protecting 38 Summary and Conclusions some vulnerable groups such as inmates, permanently disabled people, pregnant women, children under five, and pensioners. MAINCHALLENGESANDPOLICYOPTIONS 129. A number o fimportant challenges andpotentialpolicyimplications emerge fromthe analysis inthis report. Indiscussing these it i s useful to distinguishthe "what" from the "how." That is, the "what" takes into account the country's health problems and the technical interventionsrequired to address them. The "how" considers the institutional mechanisms and means, particularly financial, that could be applied to delivering the necessary technical interventions. HealthSituation andNeedfor High-ImpactInterventions 130. The overall health situation in Nigeria, as measured by child and maternal mortality and nutritionfor example, is poor in both absolute terms and in relation to other countries of similar economic level. Despite some improvements inrecent years, childmortality and malnutrition are as highas inthe poorest countries inthe world. Because o fNigeria's size, poor health indicators translate into human suffering on a massive scale. Every year, around 1million under-five children die and 40,000 women die inchildbirth inthe country. Over 8 million under-five children are chronically malnourishedand 4.5 millionadult women are malnourished. At least 3.5 millionpeople are estimated to be infected with HIV, and over 700,000 have TB, while malaria continues unchecked as the number one cause o f child mortality and a major cause o f adult illness and mortality. 131. Utilization of basic health services is similarly very low, worse than in many other countries of similar economic level. For example, coverage o froutine immunization, one o fthe cheapest and easiest basic health interventions, i s particularly problematic, as only 13% o f one- year-old children are fully immunized. Similarly, coverage o f skilled delivery care, important for the preventiono f maternal mortality, i s low, at around 36%. 132. Public andprivate spending on health care in Nigeria is higher thanpreviously thought and very inefficient in terms of health outcomes. Government health spending has increased in recent years along with overall growth inGDP and total government expenditures. At the same time, a recent household survey found that private out-of-pocket health spending i s very large. Total health spending, estimated to be inthe order o fUS$ 33 per capita annually, i s higher than in other countries o f similar income per capita, but seems to purchase worse results. For example, under-five mortality inNigeria i s significantly higher than would be expected given this level o f health spending. 133. Effective interventions to improve health outcomes are well-understood and wide coverage could be achieved at reasonable cost. Considerable effort has been devoted internationally to specifying and costing the most effective preventive and curative health interventions which address the largest proportion o f the burden o f disease indeveloping countries, particularly inSub-Saharan Africa. High-impact interventionsto reduce child and maternal mortality are summarized inError!Referencesource not found. inChapter 6. Examples o f high-impact preventive interventions include routine immunization, micro-nutrient supplementation and antenatal care. Examples o fhigh-impact curative interventions include oral rehydration therapy (ORT), malaria and pneumonia treatment, and emergency obstetric care (EOC). Simulations, described inChapter 6, and summarizedinTable 8 above, indicate that extra annual spending o f US$10 per capita i s all that would be neededto significantly reduce child and maternal mortality (while another US$6 would provide effective HIV/AIDS and TB 39 Summary and Conclusions treatment). It is likely that this extra amount or part o f it can be obtained from minimizing efficiencies inthe health sector. 134. Improvedallocation and efficiency o f current health spending, as well as increasedpublic expenditure ina context o f economic growth and increasing oil revenues, are certainly feasible. W e know the "what:" the healthproblems are well-defined, the requiredhealth interventions are well-known and their cost has been estimated. The challenge i s to work on the "how" financing, implementation and delivery mechanisms and strategies. Federalismand the HealthSector 135, Thepublic sector health system operates within afederal structure where responsibilities andfundingflows are divided between the three levels of government. The level o f government with the least capacity andresources -the LGAs-are responsible for primary health care (PHC) services -the level o f care which can have the greatest effect on the healthproblems with the largest burden on the population. The federal and state governments, with more capacity and resources, are responsible for hospital services. The basic institutional challenge for the system i s how to coordinate the three levels o f government, notjust to improve referral o fpatients between primary and secondary services, but to increase support to LGAs and PHC services from higher levels o f government. 136. Centrally-financed "vertica1"programs are one option to channel greaterfederal resources into PHCservices, but experience in Nigeria has been decidedly mixed. The government should consider greater decentralization of day-to-day management while strengthening thefederal role in technical assistanceand capacity building of lower levels of government. Consistent and extremely low coverage o f routine immunization underlinesthe problems with under-resourced, centrally-financed and managed programs targeting specific diseases. Other programs, targeting HIV/AIDS, malaria and TB inparticular, have only recently seen substantial resources, so it may be too soon to assess their effectiveness. The government i s also considering a "MDG Program" to address selected health issues intargeted states. These initiatives have state-level programs and offices, but the extent o f decentralizationo f management and control i s unclear. 137. Onthe one hand, it is clear that federal resources are necessary and welcome inorder to support high-impact interventions addressing particular diseases and conditions. On the other hand, a strong role for state and local governments i s neededto achieve horizontal integration with PHC services, manage day-to-day implementation, and appropriately address local contexts. At the same time, there is wide variation inthe capacities o f state and local governments, with those with the greatest needs possessing the lowest capacity (such as inrural areas, inthe northern regions, and the South South). An option for the federal government to consider i s to continue to provide financing - ideally, at increasing levels -but to withdraw from implementation and day-to-day management, providing technical assistance and capacity building to state and local governments that require it. Such a strategy would also require significantly improved coordination across the federal, state, and local levels. 138, Another optionfor gettingfederal resources into PHCservices is to revive thefederal developmentprogram, improving coordination and local responsiveness. As noted above, the draft HealthAct would revive the National PHC Development Agency (NPHCDA). Experience withthis federal development program inthe 1980s and 1990si s mixed. Onthe one hand, as described inthis report, progress was made inestablishing local and community-level PHC governance structures, training PHC and community health workers, and generally establishing the basic structure of the PHC delivery system. On the other hand, as i s often the case with such development programs, there was too much focus on investment ininfrastructure and equipment 40 Summary and Conclusions and not enough on systems to ensure their maintenance and continued functioning. At the same time, it i s evident that there was often insufficient input fi-om local governments and communities, so that for example, health centers were built that may not have been needed or wanted or inplaces where they are not used. Moreover private health services were insufficiently taken into account and involved. Like with central disease-specific programs, while federal financing for development o f PHC services i s certainly necessary and welcome, the federal government should take inaccount the lessons o f the past and consider focusing on financing and technical assistance while decentralizing implementation and management to the state and local levels. 139. The role of the states in supporting high-impact interventions and PHCservices needs to be strengthened. Ingeneral, a number o f states have committed to improving health outcomes in their poverty reduction strategies (SEEDS) and this can only be done by improving public and private PHC services, the responsibility o f local governments. Improving state government coordination with and support to local governments i s necessary both due to the weakness o f local governments and also because it i s required inorder to establish an effective PHC system. That is, the classic "district" health system model o f a secondary hospital anchoring a network of PHC services ina defined catchment area requires close state and local government coordination due to the division o f responsibilities for secondary and primary services. Enugustate, for example, i s working on reviving this model. 140. There is an overall need to work on defining federalism in the health sector. Disease- specific programs, and even the federal PHC development program, are discrete initiatives which do not address the overall relationship and responsibilities between the federal government and the states inthe health sector. As noted several times, the federal government (and to a lesser extent) state governments, command the fiscal resources needed to improve primary health services, but responsibility for these services lies with local governments. Inother federal countries, this situation i s addressed by negotiation and tradeoffs. For example, inCanada, federal fundingi s made available to the provinces inreturn for commitments to meet national standards inhealth service provision. An overall deal or performance-based contract arrived at in Nigeria would likely look similar - federal financing, technical assistance and capacity support in return for state commitments to certain standards or targets, with the establishment o f some mechanism for monitoring these commitments. Of course, given the number and widely differing contexts o f the states, targets and strategies could vary widely, with states learning from each other's experiences. 141. The draft Health Act potentially contains a mechanism where such negotiations and tradeoffs could take place. The proposed National PHC Development Fund, althoughreceiving some sin tax revenue, will be largely dependent on pooled contributions from the federal, state and local governments. Because "deduction at source" from Federation Account transfers to state and local governments has been disallowed, the federal government cannot unilaterally determine the extent and use o f state and local government contributions. This will therefore be the subject o f negotiationbetween levels o f government, where federal, state, and local roles and types of cooperation on developing PHC services can be defined. For this to occur, or for other mechanisms to be put inplace, work at the political level to define federalism inthe health sector i s also needed and could be done by the existing federal-state coordination body - the National Health Council. As noted above, agreement between the federal and state governments i s not sufficient - closer cooperation between state and local governments i s also required inorder to effectively translate increasedresources into improved PHC services. 41 Summaiy and Conclusions ImprovingPublic Sector Services 142. A major aim of changes in the overall governance andfinancing structure discussed above should be to improve the quality ofpublic sector PHC services. This will require improvements in infrastructure and equipment, in the incentives, remuneration, allocation, and training of health human resources, in drugprocurement and distribution, and in support systems. Possible strategies that could be adopted to improve the quality o f public sector health services include: improving health facility supervision and certification, increasingthe accountability o f service providers through improving consumer awareness usingdifferent information channels such as village meetings and media, as well as usingmechanisms as community report cards; strengthening professional associations to increase self-regulation mechanisms; and increasing the availability o f female health workers, particularly inthe north. Workingwiththe PrivateSector 143. A strongprivate sector hasfilled some of the gaps caused by the weakness ofpublic sector PHCservices. To generalize, the better-offand residents o fthe southern regions use private sector medical providers (i.e. private clinics and hospitals), while the poor inall regions and particularly residents o f the northern zones turn to private informal providers, particularly patent medicine vendors. 144. Although government acknowledges the importance of `)ublic-private partnership, it is I' onlyjust starting to effectively define what this means. For example, evidence presented inthis report suggests that the large use o f private medicalproviders inthe south and o f patent medicine vendors by the poor i s not particularly efficient inachieving good health outcomes, given the poor health indicators inNigeria (even inthe south inabsolute terms). Some work on public- private partnership i s being done by the government such as the malaria strategy envisions a large role for patent medicine vendors inmaking effective treatment available to households. 145. The main challenges are to improve the quality ofprivate medical providers, address the issues raised by widespread utilization ofpatent medicine vendors, make use of theprivate sector to improvepublicly-financed services, and generally integrateformal and non-formal private providers into the health system. One challenge i s to increase the role o fprivate-sectormedical services, particularly inthe delivery o f high-impact interventions. This i s especially difficult in the case o f preventive interventions, such as immunization or family planning, which are highly- subsidized or free to the user and generally deliveredby public sector facilities. It needs to be worth their while to deliver such services, requiring the development o f financing and reimbursement mechanisms, such as voucher systems. A second general challenge i s related to quality, underscored by the highutilization o fpatent medicine vendors, particularly incases o f common children's illness. Strategies need to be developed to improve the quality o f treatment delivered by these providers, requiring a mix o f training programs, education and awareness- raising o f clients, and voucher systems or other mechanisms to encourage provider accountability to users inthe delivery o f high-impact interventions. A third challenge i s to effectively make use of the private sector to support or deliver publicly-financed services. Contractual arrangements with for- andnon-profit organizations can be a cost-effective strategy for improving services which are customarily deliveredby public facilities, perhaps starting with less complicated social marketing activities and then gradually movingto clinical care services, depending on the local context, Finally, a general challenge i s to better integrate formal and non-formal private providers into the health system. This could involve including representatives o f the private sector in governance structures and enhancing their capacity to participate, improving supervision and regulation, and ensuring the integration o fprivate providers ininformation systems. 42 Summary and Conclusions Supporting CommunitiesandHouseholds 146. Communities and households can be directly supported and empowered to improve their own health through education, improvement in hygienic behavior, and utilization of high-impact preventive interventions. Community outreach activities, such as health education andpromotion of home-based treatment, are largely absent everywhere inthe country, although there are still trained village health workers inplace from efforts to train them inthe early 1990s. Information and education campaigns can improve basic household hygienic behaviors, such as hand- washing, breastfeeding and nutritional practices, which have a proven impact on health outcomes. Moreover a number o f high-impact preventive interventions, such as use o f insecticide-treated nets and family planning, depend on community and household knowledge and behavior - as well as on the availability and affordability o f the necessary material inputs. 147. I n addition, a number of high-impact curative interventions can be delivered by communities and households themselves. Home-based care o f diarrheal disease such as ORT use i s the prototype curative intervention that can be deliveredby households themselves. Community and householdprovision o f malaria and pneumonia treatment should also be considered, particularly incontexts o fweak and poorly utilizedhealth services. One-off training and communication campaigns are not sufficient, as sustainable support networks, particularly for the provision o f drugs and other inputs,are required. This suggests that development o f the PHC system and community-basedstrategies (supported by the PHC system) should go hand inhand. ReducingFinancialBarriersandRisks 148. Cost of care is a major barrier to utilization,particularly for thepoor, while out-of- pocket paymentsfor health services are very high,further impoverishing many households. Both public and private sector health providers charge for services, so that cost i s an important consideration inthe decision to seek care. Surveys indicate that up to half o f people who require care do not receive it due to cost, distance, and other factors. The N L S S also shows that private out-of-pocket payments for health services are very high- over US$20 per capital annually, and three times higher than government health expenditures. A large proportion o f the poorest households are at risk o f catastrophic health expenditures which could cause further impoverishment. 149. Although theplanned health insurance scheme will help some households, strategies to reduce the barriers to utilization,financial burdens and risks experienced by thepoorest households need to be developed. The plannednational healthinsurance scheme will initially benefit better-offhouseholds working inthe formal public and private sectors. Although support to community healthinsurance schemes i s envisioned, experience in other countries has shown that such programs are usually small-scale and difficult to sustain. As experience in Sub-Saharan Africa has shown ingeneral, there are no easy answers to health care financing issues. Both supply and demand side strategies needto be considered and tried. Onthe supply side, improving support to and quality o fbasic PHC services, includingraising health personnel wages and subsidizing drugs, should go some way to reducing financial barriers to utilization and formal and informal user fees. Exemption and waiver mechanisms for the poorest could also be improved, althoughtheir transaction costs tend to generally exceed their benefits unless they are well- managed. On the demand side, strategies that could be considered could include voucher systems" and/or conditional cash transfers (for immunization, for example). l2Voucher systems work best inplaceswhere there is a sufficient number o fhealthprovidersto choose f'rom. 43 Summary and Conclusions AddressingDisparities 150. Regional and socio-economic disparities are exceptionally large in Nigeria, andfor the mostpart coincide, aspoverty is higher in the north than in the south. Poor health outcomes and low utilization o fbasic services are concentrated inthe north o fthe country although the South- South zone also has a number of unfavorable indicators. Under-five mortality rates inthe North West and NorthEast are among the highest observed anywhere, while rates inthe southern regions are more consistent with other Sub-Saharan Afi-ican countries o f similar GDP per capita. Similarly, utilization o f basic services i s much lower among the poor and inthe north of the country. For example, children inthe highest wealth quintile are 10times more likely to be fully immunized than the poorest children, just as children inthe SouthWest and South East are 5 to 10times more likely to be fully immunizedthan children inthe NorthWest andNorth East. 151. Public sector PHC services are used more by thepoor than by the better-ox but most public capacity and resourcesflow into hospitals, used more by the better-off thanby thepoor. These socio-economic differences inutilization have regional dimensions, as higher-level public sector health services are more available inthe south and lower-level PHC facilities are more available inthe north. Interms o f availability o f higher-level services, the South South zone i s similarly deprived as the northernregions. 152. There is a clear need to target support to the North. This report has described regional differences inhealth outcomes and health service availability and utilization which should inform policy and programs. First,it i s clear that support, both financial and capacity-building, needs to be targeted to the northern regions of the country, where healthindicators are at levels comparable to the very poorest parts of the world. Essentially, this should mean support to the provision o f high-impact interventions which address the main causes o f child and maternal mortality. 153. Achieving better availability and utilization of high-impact interventions for poorer populations in the north and elsewhere will require a mix of strategies. Addressing the issues discussed above, relating to central disease-specific programs, development o f PHC services, federalism and hnding flows, should ultimately aim at channelingresources to high-impact services for the poor. More specific implementation strategies, also discussed above, will include improving the quality and affordability o f public and private services, improvinghousehold knowledge and practices, and directly supporting households. 154. Programs and reforms should be appropriate to the regional context. For example, reforms such as health insurance and improved accreditation o fprivate providers may be appropriate to parts of the southern region, where poverty i s lower and private medical providers account for a significant proportion of utilization. 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