This Technical Brief discusses the work that was done in Jigawa, Enugu and Ekiti to develop integrated and decentralised health systems. Efforts to improve Nigerian health services are being undermined by a variety of institutional weaknesses. Health services remain fragmented among multiple health providers (local government, state, federal, faith-based and private for profit organisations). Overlap in service provision between private and public sectors has resulted in wasteful duplication. The public sector faces shortages of staff, equipment and supplies and health facilities are in need of rehabilitation. Many programmes are organised along vertical lines resulting in poor integration and limited co-ordination between them. There is no organised referral system in place. Multiple management structures co-exist and roles and responsibilities remain unclear and are often duplicated within and between the three tiers of government. There is only limited supervision and staff morale is low. The quality of services is often poor and communities have little confidence in these. As a result, utilisation is poor.
PATHS supported a number of states to address these difficulties, with emphasis on the development of an integrated health system as one of the cornerstones of the reform strategy. The programme supported the evolution of three models:
- The essential healthcare package model of Ekiti – a service-driven model that started with the delivery of an essential healthcare package as the entry point
- The District Health System of Enugu – an institutional restructuring and management strengthening model that had support from the state Governor
- The Gunduma Health System of Jigawa – a similar model to Enugu but where state-health managers were re-orientated to become change agents for the district health system model. These three states can be said to be fairly representative of the health needs and health services in Nigeria
Key lessons learned from this process:
- The basic model of the WHO District Health System (based on the key principles of improving integration, decentralisation, coordination, access and effective health services) can be adapted to suit state-specific situations in Nigeria.
- Though health service problems are similar in all states of Nigeria, there is no one-size-fits all model of an integrated health system for a country with such diversity and with a federal form of government that provides for local initiative to deal with local problems.
- Exposure to successful examples early in the process of health sector reform is essential for building a critical mass of converts to carry the process of change forward, for convincing opponents and the undecided of its feasibility, and for reassuring those who are willing to commit to change.
- Though managerial and administrative initiative can result in clear progress towards achieving the goals of a decentralised health system, formal legislation to back its existence provides an essential environment for sustained implementation of reform efforts by local managers.