Nigeria’s private healthcare sector can help rehabilitate the country’s dysfunctional primary healthcare centres – as the Access to Finance Scheme developed by PharmAccess has shown.By Ibironke Dada, Uzodinma Osisiogu, and Njide Ndili
Primary healthcare is meant to be the initial entry point to care for individuals, families, and communities, but in Nigeria, this system has been in a dismal state for decades.
According to the Federal Ministry of Health, primary healthcare facilities constitute 84.6% of health facilities in Nigeria, but only a fraction are considered fully operational.
When citizens receive ineffective and subpar primary health care, they would rather visit secondary and tertiary facilities to the detriment of those who need specialized care.
Outsourcing defunct centres
In the Africa region of the World Health Organization (WHO), Nigeria had the highest proportion of care-seeking in the private health sector 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, 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 that is now receiving WHO support are examples of mobilizing private resources for improving public primary healthcare centres (PHCs).
A strong primary healthcare system is pivotal to attaining universal healthcare coverage. Recognizing the need for PHC reformation, PharmAccess developed the Access to Finance Scheme to revitalize public primary healthcare facilities that are defunct or functioning sub-optimally in rural or hard-to-reach areas. The scheme promotes PPPs whereby 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 to provide the loans at concessionary interest rates of 10.5% to private healthcare operators for the revitalization of the allocated primary healthcare facilities.
Take-off in Lagos and Delta states
Lagos and Delta states indicated interest in adopting and implementing this framework, however, only Delta state operationalized it in 2019. In Lagos state, 43 primary healthcare facilities were targeted, while in Delta state, six private healthcare providers took over 15 PHCs across 12 local governments areas.
The Delta State Contributory Health Commission empanelled all 15 PPP health facilities, which led to an appreciable increase in health insurance enrollment. In 2022, a fifth of Delta State’s population (1.2 million people) 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 utilization in the 15 PPP health facilities increased from over 8,000 in 2019 to over 30,000 in 2021, serving over 50,000 residents from about 50 communities.
Delta State Government (DeSG) 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.
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 recognize that universal healthcare (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 rarer than in developed countries. Therefore, implementing a PPP model in these contexts requires strong capacity and carefully navigating the following factors:
- Recognition of all stakeholders. Some community members initially resisted the implementation of the Access to Finance Scheme. Conducting a feasibility study about the local needs, risks, benefits, and resources of a specific state is therefore recommended. Involving local role-players with a good understanding of the political, economic, social, and cultural context is crucial.
- Initiate risk management. Taking the time to complete a detailed risk analysis and then appropriately allocating the management of these risks is another critical success factor. Risk management related to financial, operational, environmental, and political concerns must be assigned to the people most qualified to manage it.
- Ensure regulatory oversight. An effective and efficient regulatory system is essential for accrediting facilities, equipment, and services, among other functions. It guarantees that services rendered adhere to the necessary safety and quality requirements. Requiring healthcare facilities to implement the SafeCare quality standards will ensure the successful implementation of the Access to Finance Scheme.
In conclusion, Nigeria can only reach UHC by involving both the public and private sectors. A well-functioning primary healthcare 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.
Authored by Ibironke Dada, Uzodinma Osisiogu, and Njide Ndili from PharmAccess.With input from Prof Cheluchi Onyemelukwe, Olawale Bhadmus and Omigbile Olamide from Health Ethics and Law Consulting.