Resilient and Sustainable Systems for Health Project Brings Health Care to All in Nigeria

Nigeria, like many other low- and middle-income countries, suffers from systemic weaknesses which cripple its health care system and leave many without adequate access to health services or care. With support from the Global Fund, the MSH-led Nigeria Resilient and Sustainable Systems for Health (RSSH) project is working with Nigeria’s Center for Disease Control, the Department of Health Planning Research and Statistics (DHPRS) at the Federal Ministry of Health, and the National Product Supply Chain Management Program to strengthen and expand the capacity of its national and state-level health systems. One way that RSSH is supporting Nigeria in providing quality health care, especially for those most in need, is through its state-level interventions around public financial management, the state health insurance scheme, and organizational and labor market assessments.

Providing vulnerable populations with access to social health insurance

Because of their inability to pay, vulnerable populations in Nigeria are unable to access health care services. Although the federal government of Nigeria introduced universal health coverage (UHC) in 2005, the absence of reliable data on vulnerable populations makes the successful implementation of social health insurance a challenge. In Kaduna State the situation was the same; the state was committed to paying the insurance premium for vulnerable persons but, without data, could not correctly identify those who fall into that category. Employing a mix of geographical mapping, community-based targeting, and the use of the poverty probability index (PPI), RSSH identified 27,571 vulnerable individuals living in 4,837 households across three local government areas. The project helped the state design a protocol for identifying vulnerable populations, recruiting and training data enumerators, conducting field surveys, conducting data cleaning and analysis, and designing a vulnerable population database. The resulting database, which has been validated and received by the state, will now support Kaduna State in effectively targeting residents who fall under the vulnerable category with social health insurance coverage.   

Prioritizing financial planning for health outcomes

Limited budgetary allocations and investments in health make it urgent for the Nigerian government to address the challenge of poor financial planning, which has contributed to the poor health outcomes experienced in Oyo State. Working with the state government, RSSH set up a health planning cell to serve as the “engine room” for budget development. Members, including those drawn from the DHPRS and the Department of Finance and Accounts, have the mandate to improve accountability and monitoring of the state’s health budgetary process. To achieve its goal, the group conducts quarterly reviews of the state’s annual operations plan (designed to identify and prioritize intervention projects and develop costed work plans and a performance monitoring system) and provides reports to the DHPRS. The planning cell also advises key health departments on how best to prioritize implementation of key projects whenever there are shortfalls or delays in released budgets from the state government. Through this collaboration with the state government, RSSH highlights the critical need of aligning health priorities and developing health budgets that can sustain needed resource allocations to address health sector needs. “The health sector planning cell is where issues pertinent to Oyo State’s health sector budget are formulated,” explains the Permanent Secretary of the State Ministry of Health, Dr. I.O Ayoola. “Activities, interventions, and projects are prioritized…so the state can achieve its best health outcomes.”

Developing an organizational structure to meet health coverage for all

Since its establishment in 2018, the Imo State Health Insurance Agency (IMSHIA) in Nigeria has struggled to meet its mandate to provide health insurance to all state citizens and reduce out-of-pocket payment in accessing health care. Lack of clarity on authority and reporting, clear administrative structure, and poorly defined job profiles were identified as major challenges for the IMSHIA. To better support IMSHIA to provide quality health care, RSSH looked to improve its institutional architecture. To strengthen the governance structure of the agency, RSSH began with a benchmark study of established schemes. Using a methodical comparison of other states, the national health insurance schemes within Nigeria, and other African countries with similar contexts and track records of success, best practices were examined. Working hand-in-hand with state actors, the RSSH project led the development of a top-level and detailed organizational structure aimed at streamlining administrative processes and guaranteeing efficiencies. Job profiles based on globally accepted standards and structured to address state-specific needs were created and helped to reduce ambiguity about roles and minimum requirements. Process manuals for all key functions within the agency were also developed, providing processes and procedures to be employed in managing daily operations.