Ibironke Dada, Uzodinma Osisiogu, and Njide Ndili (Guest Writers)
Nigeria’s private healthcare sector can help rehabilitate the country’s dysfunctional primary healthcare centres (PHCs) — as the Access to Finance Scheme developed by PharmAccess has shown.
PHCs are meant to be the initial entry point of care for individuals, families, and communities. However, in Nigeria, this system has been in a dismal state for decades.
According to the Federal Ministry of Health and Social Welfare, PHC facilities constitute 84.6% of health facilities in Nigeria, but only a fraction are considered fully operational. When people receive poor primary health care, they go to secondary and tertiary facilities. This increases the volume of outpatient services provided at this level and can disproportionately affect those who need specialised care.
Outsourcing defunct centres
According to the World Health Organization (WHO), Nigeria had the highest proportion of care-seeking in the private health sector in Africa at 52%. Given the sector’s large market share, it can support innovative and resilient healthcare delivery models that meet Nigerians’ health needs.
Over the years, the Government has facilitated public-private partnerships (PPPs) to improve healthcare infrastructure and service delivery in tertiary hospitals. Philanthropic/hybrid models, including initiatives such as the Adopt-A-Healthcare-Facility-Programme which is now receiving WHO support, are examples of mobilising private resources for improving public PHCs.
A strong PHC system is essential for attaining universal healthcare coverage (UHC). Recognising the need for PHC reformation, PharmAccess developed the Access to Finance Scheme to revitalise public primary healthcare facilities that are defunct or functioning sub-optimally in rural or hard-to-reach areas. The scheme promotes PPPs where private operators can access loans from the matching fund framework developed by the Medical Credit Fund and Delta State Contributory Health Commission. In this arrangement, the Bank of Industry was the finance institution that provided loans at concessionary interest rates of 10.5% to private healthcare operators to revitalise the allocated PHC facilities.
Take-off in Lagos and Delta states
Lagos and Delta states indicated interest in adopting and implementing this framework. However, only Delta state operationalised it in 2019. In Lagos State, 43 PHCs were targeted, while in Delta state, six private healthcare providers took over 15 PHCs across 12 Local Governments Areas (LGAs).
In 2022, the Delta State Contributory Health Commission empanelled all 15 PPP health facilities, which led to an appreciable increase in health insurance enrolment. About 1.2 million people, a fifth of Delta State’s population, were enrolled in the State Contributory Health Scheme, the highest number in Nigeria.
The Access to Finance scheme demonstrated a capacity to generate significant returns on investments in the medium to long term. Patient utilisation in the 15 PPP health facilities increased from 8,000 in 2019 to over 30,000 in 2021, serving over 50,000 residents from about 50 communities.
Through this initiative, the Delta State Government had cost savings of about N211 million due to private investment in 2019. Additionally, the program is expected to yield a return on investment (ROI) of over 300% by 2026, a rare achievement for government-run PHCs.
Successes noted
Key achievements include a notable reduction in maternal and under-five deaths. Participating facilities reported an under-five mortality rate of 0.7 per 1,000 live births compared to the state’s rate of 53 per 1,000, and no maternal deaths were recorded in three years. This success highlights the importance of effective public-private partnerships in improving maternal health outcomes. In terms of job creation, about 243 healthcare jobs were created by 2021, contributing to health workforce retention in rural communities.
Factors that lead to these achievements include:
● Strong political will and leadership.
● A well-functioning health insurance scheme to drive demand and ensure the flow of funds.
● The adoption of a quality improvement system such as the SafeCare methodology developed by PharmAccess.
● The involvement of key stakeholders from the Ministry of Health, health agencies and the local government.
Plan collaboration carefully
Stakeholders recognise that achieving UHC cannot be accomplished without involving the private sector. However, successful collaborations between the public and the private sectors in lower and middle-income countries are not as common as in developed countries. Therefore, implementing a PPP model in these contexts requires strong capacity and careful navigation of the following factors:
● Recognition of all stakeholders. Some community members initially resisted the implementation of the Access to Finance Scheme. It is therefore recommended that a feasibility study about the local needs, risks, benefits, and resources of a specific state should be conducted. Involving local role-players with a good understanding of the political, economic, social, and cultural context is crucial.
● Initiate risk management. Another critical success factor is completing a detailed risk analysis and then appropriately allocating the management of these risks. Risk management related to financial, operational, environmental, and political concerns must be assigned to the people most qualified to manage it.
● Ensure regulatory oversight. A robust and efficient regulatory system is crucial for accrediting facilities, equipment, and services, among other responsibilities. It ensures that the services provided meet the necessary safety and quality standards. By requiring healthcare facilities to adopt the SafeCare quality standards, we can effectively support the successful rollout of the Access to Finance Scheme.
In conclusion, Nigeria can only achieve UHC by involving the public and private sectors. A well-functioning PHC system is essential to this. Challenges abound, but studying and learning from initiatives such as the Access to Finance scheme will lead to quicker progress in achieving high-quality primary health care — and ultimately, UHC.
Additional reporting by Prof Cheluchi Onyemelukwe, Olawale Bhadmus, and Omigbile Olamide from Health Ethics and Law Consulting