Policies, Partnerships and Projects: Lessons in Healthcare Reforms From Kaduna State by Ibrahim Jato

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“Our programs are structured to ensure that a pregnant woman does not die due to her inability to access quality services during pregnancy and childbirth, that a child is not lost from preventable diseases that communities are not overburdened with endemic diseases, and that community linkages are harnessed and promoted.” – Nasir El-Rufai, Governor of Kaduna State.
 
 
With less than 100,000 qualified medical doctors to a population of about 180 million, oil-rich Nigeria has one of the worst doctor to patients ration in the world. This explains, in part, why Nigeria is among the seven countries with the lowest life expectancy in the world, averaging just 54 years. For perspective, countries like South Sudan and Afghanistan, ravaged by war in recent years, have higher life expectancy rates than Nigeria.
 
 
Nigeria also has the 7th largest infant mortality rate in the world, as well as one of the highest maternal mortality rates. If the statistics are disheartening, the reality is even more depressing. A typical 70 percent of health budget is spent in urban areas where about 30 percent of the population resides. Thus, there is a conspicuous absence of health facilities in many rural communities across the country. Where any exists, the absence of a qualified health professional or lack of drugs and other essential medical supplies hamper service delivery.
 
 
With a population of 6.4 million, Kaduna is the third most populous state in Nigeria and the situation of public health system there is hardly any deviation in from the trend observed in the country. As at 2013, only 40 percent of the over 1,000 primary health centres in Kaduna were functioning. A general lack of political commitment to health development coupled with poor funding, corruption has led gross inequity in the distribution of health facilities and personnel.
 
 
Today however, that trend has been completely reversed. A change in political leadership in the state eighteen months ago ushered in a new regime under renowned technocrat and Harvard alumni, Nasir El-Rufai. In a clear departure from the old, and rather retrogressive, style of administration, El-Rufai’s healthcare reforms in Kaduna is built on a foundation of solid policies. In an environment where the construction of a handful of hospitals counts as major achievements, El-Rufai has ditched mediocrity for excellence by instituting remarkable reforms with wide-reaching impact in Kaduna’s health sector.
 
 
Just three months into El-Rufai’s administration, the Primary Health Care Under One Roof Bill was signed into law. Essentially, the law permits the state to operate its primary healthcare activities on the same platform. The law also enables the transfer of workers in primary healthcare centres from local councils to the state civil service.
 
 
It is not uncommon for governments to bridge social welfare gaps by introducing subsidies. Unfortunately, however, subsidies schemes are often fraught with corruption and gross mismanagement. Kaduna State has managed to subsidize healthcare in such an efficient manner that other states in Nigeria should certainly learn from. For example, patients pay as little as N20,000 for dialysis treatments that cost as high as N200,000. This was achieved by supplying eight dialysis machines to four hospitals.
 
 
The sum of N180 million was committed to routine immunization through the State Primary Healthcare Development Agency to ensure no child eligible for immunization in Kaduna is missed. Also, the Joint United Nations Programme on HIV/AIDS selected Kaduna as the best performing state in Nigeria. Kaduna State won the prize because its hospitals counselled and tested 84,000 pregnant women for HIV during the period and referred everyone that tested positive to a treatment facility.
 
 
The decision in April to transfer all doctors, nurses, drugs and equipment at the Government House Clinic in Kaduna (used by the Governor and other top officials) to Dantsoho Hospital in Tudun Wada (used by the public), effectively eradicated the culture of privilege in Kaduna’s public health system. Policies like this make Kaduna the pacesetter in healthcare reforms in Nigeria and worthy example for not just other states but also the federal government to emulate. Kaduna’s people-centric and cost saving government house clinic policy contrasts sharply against the federal government’s decision to allocate 2 billion for capital projects as the State House Clinic in Abuja, an amount which far exceeds the combined allocations for capital projects in all teaching hospitals in the country.
 
 
To reduce maternal and infant mortality rate in Kaduna State, the El-Rufai administration re-engaged 800 retired nurses and midwives after a gap analysis revealed huge personnel shortage. This move has boost service delivery at primary health centres across the state and made quality and affordable healthcare accessible to people at the grassroots.
 
 
In Kaduna State, pregnant women, children under five years and the elderly have access to free health services at state-owned facilities. To widen the net of coverage and ensure all residents of the state have access to healthcare without incurring out-of-pocket expenditure, the El-Rufai administration approved the establishment of a Contributory Health Scheme. Under the scheme, a pool of funds contributed by residents will be supplemented with funds from the state coffers and the federal government through the National Health Insurance Scheme.
 
Thus, the financial barriers to healthcare that often exclude the poor and vulnerable will be removed. The corruption that often trails bills payment and out-of-pocket expenditure by patients at government hospitals will also be completely eradicated. This contributory model of universal healthcare coverage has proven to be successful in more advanced economies and is also being considered by Lagos State.
 
In what could be considered a leap towards stronger primary healthcare services in rural communities in Kaduna State, the government signed a strategic partnership with UK Department for International Development and the Bill & Melinda Gates Foundation. The four-year partnership will no doubt transform the primary healthcare system in Kaduna State and advance ongoing efforts in polio eradication, routine immunisation, family planning and maternal and child health services.
 
The biggest ever refit of public healthcare infrastructure in Kaduna State is the recent partnership agreement signed with global corporate giant, General Electric. Under the agreement, 278 healthcare facilities in Kaduna State will be equipped and units of relevant medical technology including ultrasound, heart monitors, neonatal incubators and anaesthesia machines will be made available to medical professionals. into the hands of our health workers.
 
The partnership, which includes a training package for the healthcare professionals and a three-year equipment maintenance agreement, is poised to deliver a comprehensive solution to the healthcare challenges in the state, including maternal and infant mortality, communicable illnesses and the problems caused by the growth of chronic conditions like diabetes, heart disease and cancer.
 
Governments at state and federal levels in Nigeria often focus on projects as a vehicle for healthcare delivery. As such, emphasis is placed solely on building hospitals, even when such are not properly equipped and capacity gaps are not bridged. This explains why major health indices in Nigeria remain poor despite billions budgeted annually for health, in addition to donations from international organisations.
 
The Kaduna State approach of blending sound policies with strategic partnerships to birth meaningful projects is on course to deliver at least one refitted hospital in each of the 255 wards in the state. This is in addition to 23 well equipped and staffed general hospitals. With all these in place, all residents of Kaduna are assured of comprehensive and affordable healthcare coverage for the years ahead.
 
This innovative approach should no doubt be a model for other states desirous of accelerated development in healthcare services.
 
Ibrahim Jato is a public finance expert based in Kaduna.

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