Public Health System
Ministry of Health (other Public Health Service providers)
The Ministry has several departments specializing in different aspects of health care. The Family Health department is concerned with creating awareness on Reproductive, Maternal Neonatal and Child Health, ensuring sound nutrition including infant and young child feeding, and care of the elderly and adolescents. The department of Public Health coordinates formulation, implementation and evaluation of public health policies and guidelines. It undertakes health promotion, surveillance, prevention and control of diseases.
Mission, roles and functions
Governance and organigram
National, Regional, District, Sub-district organization
Health Insurances present in the Country
Ministry of Health (other Public Health Service providers)
The Ministry has several departments specializing in different aspects of health care. The Family Health department is concerned with creating awareness on Reproductive, Maternal Neonatal and Child Health, ensuring sound nutrition including infant and young child feeding, and care of the elderly and adolescents. The department of Public Health coordinates formulation, implementation and evaluation of public health policies and guidelines. It undertakes health promotion, surveillance, prevention and control of diseases.
Mission, roles and functions
- Functions of the department of Planning Research And Statistics include developing plans and budgets and monitoring their implementation, serving as Secretariat to the National Council on Health, conducting research in collaboration with other departments and agencies, institutions and parastatals, conducting operational research and data collection, and performing various coordination functions.
- The department of Hospital Services supervises 53 Federal Tertiary Hospitals – Nigeria’s Teaching hospitals, Federal Medical Centres and National Eye Centers.The department processes appointment of Chief Medical Directors and Medical Directors, supervises oral health research, develops policies on nursing, coordinates training programmes for nurses and monitors the midwifery service scheme in collaboration with NPHCDA.
- The department of Food and Drugs Services formulates national policies, guidelines and strategies on food and drugs, and ensures ethical delivery of pharmaceutical services nationwide. The department sponsors the National Institute for Pharmaceutical Research and Development and the National Agency for Food and Drug Administration and Control, and acts as regulator through the Pharmacist Council of Nigeria, the Institute of Chartered Chemist of Nigeria and the Institute of Public Analyst of Nigeria.
Governance and organigram
- The federal government's role is mostly limited to coordinating the affairs of the university teaching hospitals, Federal Medical Centres (tertiary healthcare) while the state government manages the various general hospitals (secondary healthcare) and the local government focus on dispensaries (primary healthcare),[2] which are regulated by the federal government through the NPHCDA.
- The total expenditure on healthcare as % of GDP is 4.6, while the percentage of federal government expenditure on healthcare is about 1.5%.[3] A long run indicator of the ability of the country to provide food sustenance and avoid malnutrition is the rate of growth of per capita food production; from 1970–1990, the rate for Nigeria was 0.25%.[4] Though small, the positive rate of per capita may be due to Nigeria's importation of food products.
National, Regional, District, Sub-district organization
- A strict interpretation of the Constitution of Nigeria with regard to the sharing of responsibilities between the three tiers of government implies that it is the state governments that have principal responsibility for basic services such as primary health and primary education, with the extent of participation of Local Government Authorities (LGAs) in the execution of these responsibilities determined at the discretion of individual state governments. The constitutional existence of state-level discretion may lead to disparities across local governments or across states in the extent to which responsibility for primary health services is effectively decentralized. In the face of such constitutional ambiguity, the survey of LGAs and health facilities attempted to assess the actual extent of decentralization of services to local governments.
- The World bank made an inquiry to better understand the situation[1]. The overwhelming majority of LGA respondents indicated the LGA as the principal decision-maker for most of the areas of facility-level provision of primary health services. There was no systematic variation across local governments in the extent of decentralization of responsibility. The facility-level respondents similarly indicated the LGA as the principal decision-maker for most service provision decisions at the facility level, as compared to the other two tiers of government. The state and federal governments were indicated very infrequently as principal decision-makers for any area, and even then for only one or two areas of decision-making in any individual facility. This evidence for the health sector is a striking contrast to available evidence for service delivery in other sectors—such as primary education, water and sanitation—that are characterized by considerable overlap and confusion with regard to the sharing of responsibilities between the three tiers, often at the expense of undermining LGA responsibility and accountability.
- Community participation in primary health care service delivery has been institutionalized in Nigeria through the creation of Village Development Committees and District Development Committees. There are striking differences in the sharing of responsibilities between the LGA and community development committees in the two states of Lagos and Kogi studied here. In Lagos, more than 80%[2] of facility-level respondents indicated the LGA as principal decision-maker in most areas of service delivery at the facility level, while in Kogi, only about 50% indicated the LGA as principal decision-maker. The remaining facilities in Kogi listed either the community development committees or the facility head or both as the principal decision-makers. Community organizations are particularly active in Kogi in the areas of building maintenance, and acquiring drugs, medical supplies, and equipment for the facilities. There is comparatively little community engagement in setting charges for drugs, as was envisioned by the Bamako Initiative and almost negligible in disciplining staff, which is overwhelmingly indicated as the responsibility of local governments.
- Amongst government agencies the LGA is the main source of financing of primary health service delivery at the facility level. Staff salaries, facility building construction and maintenance, supply of drugs, equipment and other medical commodities, are all predominantly provided by local governments in Lagos state. However, in Kogi, community-based organizations and facility staff are frequently indicated by facility respondents as the main source of drugs (for 28% of facility respondents), medical supplies (31%), and building maintenance (57%)[3]. It is surprising to note that as many as 15% of facilities in Kogi indicate staff personal funds as the main source of facility resources, which if accurate probably implies that staff compensate themselves from facility revenues. In Lagos, for the majority of facilities (over 85%) resources were either provided by the LGA or indicated as not provided at all in the last twelve months. Staff salaries are almost exclusively provided by local governments in both states.
- Many health facilities reported shortages of basic health equipment. For instance, 95% did not have microscopes, 59%[4] did not have sterile gloves, 98% did not have a malaria smear, and 95% did not have a urine test strip. Lagos facilities were six times more likely to have a generator, but Kogi facilities were much more likely to have pharmaceutical products, such as chloroquine, paracetamol, antiobiotics, ORS sachets, and multivitamins. A likely explanation for this is that whereas in Lagos alternative suppliers are available, such as pharmacies, in Kogi the public clinics effectively function as pharmacies in which health staff sell privately acquired products. It is not clear whether this health staff are responding to shortages in public supply, or whether facility owned products are being expropriated. In Lagos, the public-private ownership correlations for these products are also negative but much smaller. Vaccines were far more likely to be available in Lagos facilities. That might suggest better public provision in Lagos but might also be an artifact of differing delivery schedules in the two states.
Health Insurances present in the Country
- Historically, health insurance in Nigeria can be applied to a few instances: free health care provided and financed for all citizens, health care provided by government through a special health insurance scheme for government employees and private firms entering contracts with private health care providers. However, there are few people who fall within the three instances.
- In May 1999, the government created the National Health Insurance Scheme, the scheme encompasses government employees, the organized private sector and the informal sector. Legislative wise, the scheme also covers children under five, permanently disabled persons and prison inmates. In 2004, the administration of Obasanjo further gave more legislative powers to the scheme with positive amendments to the original 1999 legislative act.[5]
- As a part of the effort to strengthen the national health system, a National Health Policy (NHP) was adopted in 2006. NHP seeks to establish a realistic health financing system that has the capability of meeting health system goals of improved health status of Nigerians; financial protection of citizen against cost of illness; fair financing of health services; and responsiveness to the citizens’ expectations. This plan includes the implementation of a re-designed National Health Insurance System (NHIS).
- The National Health Insurance Scheme (NHIS) is funded primarily by contributions from members based on income. For the Formal Sector Social Health Insurance Program contributions are premiums that make up 15% of an individual’s basic salary, with the employer contributing 10% while the employee pays 5% for coverage of themselves, their spouse, and up to 4 children. An employer may negotiate with an HMO for coverage of additional supplementary benefits and pay the extra contributions required. Participants in the Informal Sector Program are expected to make a monthly contribution based on the benefits package of their choice as well as other factors. The poor, elderly, veterans, and disabled are exempted from paying membership premiums.
- Since the implementation of National Health Insurance System, about 5 million Nigerians can readily access care through the NHIS. The NHIS benefits package is very comprehensive, covering virtually all the medical needs of enrollees- from consultation to drugs, consumables and major and minor surgeries. Studies have found that income and occupation impact usage of NHIS services; a large percentage—about 67%—of civil servants and professionals make use of NHIS services.Use of NHIS services is lower among low-income groups and young people, which is because the programs that target these populations still have not been introduced or fully incorporated into the NHIS system. Thus, while it appears that coverage has been extended greatly for the population, there are still about 46 million Nigerians, or 33%[6] of the population, with no access at all to organized modern health insurance.
Health training institutions (Academic, MoH, privates, others)
[1] Decentralized Delivery of Primary Health Services in Nigeria Survey Evidence from the States of Lagos and Kogi
[2] World Bank : survey of evidence from the state of Lagos
[3] World Bank
[4] World Bank
[5] Felicia Monye; 'An Appraisal of the National Health Insurance Scheme of Nigeria', Commonwealth Law Bulletin
[6] Nigeria: National Health Insurance System: http://programs.jointlearningnetwork.org/content/national-health-insurance-system
[7] World Health Organization
[8] USAID and Capacity
- Nigeria has one of the largest supplies of human resources for health (HRH) in Africa, comparable only to Egypt and South Africa. Figures provided by the Federal Ministry of Health of Nigeria indicate that, there are about 39,210 doctors and 124,629 nurses registered in the country as of 2006, which translates into 30 doctors and 100 nurses per 100,000 people. These figures are significantly higher than the sub-Saharan Africa average of 15 doctors and 72 nurses per 100,000 people (WHO, 2006Nigeria is one of 57 countries defined by the World Health Organization as having a critical shortage of health workers, or less than the threshold of 2.3 nurses[7], doctors, and midwives per 1,000 people needed to ensure minimal access to basic health services for all. Nigeria’s continued progress toward meeting its primary health care goals relies upon education[8], employment, distribution, and retention of a strong health workforce.
- Primary health care training institutions are responsible for training those health workers most likely to provide care at the community level—nurses, midwives, and community health extension workers—making education, as well as the equitable absorption and distribution of their graduates vital to population health. Assessments from the USAID and Capacity plus found that despite steady effort, training institutions face a number of challenges in their attempts to increase the number and quality of graduates. These include admission of unqualified or under-qualified students, which leads to high drop-out rates in the first semester; high student-teacher ratios; limited training and career development opportunities for faculty; infrastructure deficiencies; and insufficient learning equipment and materials, including textbooks. Many schools provisionally admit far more students than they are capable of enrolling, and then “weed out” unqualified students for several months, an adaptive response to low student qualifications which unfortunately results in crowded classes and increases the workload of already stressed faculty. For example, in 2009, 35,600 students enrolled in an accredited course, yet only 23,798 completed the course requirements, and 13,852 passed the national examinations on their first, second, or third try. Schools have developed creative responses to their challenges.
[1] Decentralized Delivery of Primary Health Services in Nigeria Survey Evidence from the States of Lagos and Kogi
[2] World Bank : survey of evidence from the state of Lagos
[3] World Bank
[4] World Bank
[5] Felicia Monye; 'An Appraisal of the National Health Insurance Scheme of Nigeria', Commonwealth Law Bulletin
[6] Nigeria: National Health Insurance System: http://programs.jointlearningnetwork.org/content/national-health-insurance-system
[7] World Health Organization
[8] USAID and Capacity
Three tiers system:
Nigeria is a federation with three tiers of government – federal, state, and local. While the federal government develops policies that are relevant across all three levels, responsibility for health service provision in the public sector reflects the three-tier structure. According to the Department of Health Planning, Research and Statistics of the Federal Ministry of Health (FMOH), there were over 20,000[1] registered health facilities in the public sector across these three tiers in Nigeria in 2007. The levels of care in the public sector are:
· Tertiary: Tertiary facilities form the highest level of health care in the country and include specialist and teaching hospitals and federal medical centers. These facilities have special expertise and fullfledged technological capacity that enable them to serve as referral centers for patients from the primary and secondary levels and act as resource centers for knowledge generation and diffusion. Each state has at least one tertiary facility. The responsibility for tertiary care and training falls under the mandate of the federal government.
· Secondary: Secondary care facilities include general hospitals, which provide general medical and laboratory services as well as specialized health services such as surgery, pediatrics, obstetrics and gynecology. General hospitals are typically staffed by medical officers (who are physicians), nurses, midwives, laboratory and pharmacy specialists, and community health officers (CHOs). The facilities serve as referral centers for primary health care facilities. Each district, local government area (LGA)[2], or zone is expected to have at least one secondary-level facility. State governments are responsible for this level of care.
· Primary: Facilities at this level form communities’ entry point into the health care system. They include health centers and clinics, dispensaries, and health posts which typically provide general preventive, curative, promotive, and pre-referral care. Primary facilities are typically staffed by nurses, CHOs, community health extension workers (CHEWs), junior CHEWs, and environmental health officers. It is the expectation and practice that LGAs finance and manage primary health care under the supervisory oversight of the state government.
[1] Nigerian Ministry of health
[2] USAID
Nigeria is a federation with three tiers of government – federal, state, and local. While the federal government develops policies that are relevant across all three levels, responsibility for health service provision in the public sector reflects the three-tier structure. According to the Department of Health Planning, Research and Statistics of the Federal Ministry of Health (FMOH), there were over 20,000[1] registered health facilities in the public sector across these three tiers in Nigeria in 2007. The levels of care in the public sector are:
· Tertiary: Tertiary facilities form the highest level of health care in the country and include specialist and teaching hospitals and federal medical centers. These facilities have special expertise and fullfledged technological capacity that enable them to serve as referral centers for patients from the primary and secondary levels and act as resource centers for knowledge generation and diffusion. Each state has at least one tertiary facility. The responsibility for tertiary care and training falls under the mandate of the federal government.
· Secondary: Secondary care facilities include general hospitals, which provide general medical and laboratory services as well as specialized health services such as surgery, pediatrics, obstetrics and gynecology. General hospitals are typically staffed by medical officers (who are physicians), nurses, midwives, laboratory and pharmacy specialists, and community health officers (CHOs). The facilities serve as referral centers for primary health care facilities. Each district, local government area (LGA)[2], or zone is expected to have at least one secondary-level facility. State governments are responsible for this level of care.
· Primary: Facilities at this level form communities’ entry point into the health care system. They include health centers and clinics, dispensaries, and health posts which typically provide general preventive, curative, promotive, and pre-referral care. Primary facilities are typically staffed by nurses, CHOs, community health extension workers (CHEWs), junior CHEWs, and environmental health officers. It is the expectation and practice that LGAs finance and manage primary health care under the supervisory oversight of the state government.
[1] Nigerian Ministry of health
[2] USAID