By Dayo Johnson – Akure
Dr Francis Akanbiemu is the Executive Secretary, Ondo State Primary Health Care Development Agency. In this interview, Akanbiemu speaks on the activities of the Nigeria State Health Investment Project, NSHIP, which will lapse in May after six years of operation in the state.
Now that the NSHIP program is ending, can we know the activities so far?
NSHIP has been working in Ondo since 2011 when they did the pilot at Ondo East local government area but, in 2014 or early 2015, it was extended to all the 18 local government areas of the state, and, since that time, NSHIP has been working to strengthen the health system of Ondo with focus on the primary health system.
Activities include antenatal care, safe delivery practices, in-patient care, family planning, immunisation and waste management. Surgical care is also part of the package though it is minor surgery. The system also assists secondary facilities to carry out major surgery because when you’re provided with funds, you can provide facilities and engage the staff.
Part of the NSHIP mandate is to ensure that you have human resources to strengthen the health system holistically. Before you spend money on any NSHIP project, however, you must prove that you are going to get result for what you’re going to be paid.
For instance, if you were attending to 10 patients before and you want to increase the number to 20, what you need to do is to have a good environment for patients to access you.
You need a business plan. There is usually a committee headed by each community leader and the mandate is to ensure full community involvement in the health system.
We also have what we call improvement in management system. Before NSHIP came, there was no meeting or information about income and expenditure; people just spent money.
But under the new dispensation, you must hold management meeting, there must be documentation, everything you want to do must be agreed. You now send the business plan to the NSHIP Coordinator who reviews the business plan.
Basically, NSHIP has changed the way we do things while wastage has reduced. Another critical aspect of the project is drug management. Drugs are made available to health facilities and it is the facilities that decide the drugs they want to buy.
ls there any sustainable plan after the expiration of NSHIP?
ln 2017, we started putting the work plan of NSHIP into the state annual budget. This is part of our sustainability plan, so that when the project winds up, government can now take over.
Some intervention might come also but I will not be able to say exactly what type of intervention that is coming, except the one being currently funded by the Federal Government which is known as Basic Health care Provision Fund.
This fund is meant to strengthen at least one health centre per political ward in every part of Nigeria. Ondo is close to accessing the fund which provides a window for sustainability apart from government effort to see the rise in the principles and practice of NSHIP. I am sure that by 2021, government will provide fund to sustain NSHIP.
Apart from this, government believes this is the best way to manage the health system. Though the annual budget of NSHIP is funded by the World Bank, as soon as the project winds up, government will take over.
NSHIP is a principle that helps to do things better, so it is that principle that government will fund and will not release funds when the funds will not produce results. If you are going to be paid, it will be based on results like how many patients you attended to or the number of deliveries. That is the model government is going to adopt for the sustainability of the project.
Do you envisage any problem in the payment of counterpart fund by the state government thereafter?
With the type of governor we have, who gives priority to health, he has already opened up discussion with us on what will happen after NSHIP.
But I want to let you know that government is not funding NSHIP but the health sector based on the gains recorded by NSHIP. What the World Bank actually came to do is to tell us that this is a better way to manage the health system and that’s why government signed that agreement. In 2018, the governor signed about N375m as counterpart fund to show the World Bank that we want this project to continue.
What is the specific impact of NSHIP in basic health centres across the state?
This project has improved the quality of care in health facilities and that of health care services utilization. It has also reduced out-of-pocket spending, removed catastrophic health expenditure and created employment.
And apart from the fact that NSHIP has improved monitoring and supervision of health facilities, it has also improved inter-agency and inter-stakeholder collaboration among the staff of the Ministry of Health, Hospitals Management Board and the Primary Health Care Development Board to work towards achieving a common goal.
NSHIP has autonomy and uses the autonomy to improve facilities. So there has been massive infrastructural upgrade apart from the direct intervention of the state governor on the health system of Ondo State.
You talked about likely federal government intervention in the health sector…
There is already an intervention going on now through what they call Basic Healthcare Provision Fund and under which each state pays N100 million counterpart fund.
Mr. Governor has paid since last year. There are processes that will make us access the fund and the processes are almost completed.
In late last year, the National Assembly called a meeting of Speakers of state assemblies, Commissioners for Health, Executive Secretaries.
I was part of that meeting. In that meeting, it was discovered that there were anomalies in the Basic Healthcare Provision Fund and they gave instruction that the project must stop until the anomalies are corrected.
They wrote to the Federal Ministry of Health that the manual that was developed was not in line with the National Health Act of 2014. That is why we are not accessing the fund yet.
They set up a committee to design another guideline. The committee has completed the assignment and waiting to present the guideline to stakeholders.
Once it is ratified, Ondo will get its own fund and it will be used in the same model of NSHIP.
Recently NSHIP was suspended. What happened and why was it brought back so quickly?
They asked Mr. Governor that if he wanted the project he had to pay N375 million and he paid immediately.
Will the health insurance scheme introduced by the state government be useful when the NSHIP winds up?
The health insurance scheme which Mr. Governor established for the good people of Ondo has commenced and government has started funding it.
Besides government funding, Basic Healthcare Provision Fund has two part way. The primary health is one part way while the insurance part way is another. The fund that is coming to the state is divided into two: Major part way and small part way. The small part way is the emergency medical treatment.
So, 50 per cent of that fund will be going to the insurance part way, 45 per cent to our part way while five percent will be for emergency.
That 50 percent, insurance will use it in collaboration with the fund Mr. Governor has already released to strengthen the health system.
The same model will be the NSHIP model. Pay for the services you have produced. You can see that the intervention is more of strengthening the PHC system and secondary is going to act as referral from the primary health care system. So, the insurance project is on course.
When the Basic Healthcare Fund is released to us, it will add to the fund already with the state insurance scheme and you will now have funding from two sides. We are funding the PHC, the insurance will also be funding.
We learnt that the Waste Management has just been introduced to NSHIP. Can you expatiate?
Waste management has been part of NSHIP but, of recent, NSHIP Project Coordinator decided to make it more robust with our agreement that waste is better managed, not just using the burnt and bury system.
We must use incinerator which is the standard practice worldwide. We agreed that we should handle waste in a more standard way especially with all kinds of diseases springing up everywhere as a result of poor hygiene.
Would you describe the NSHIP era in Ondo as a blessing?
NSHIP is a blessing to Ondo. In the past six years, it has been a success story. Our indicators have improved, our people have stopped dying like fowl and the health system is better generally.
This has been made possible because the present administration in Ondo has provided the enabling environment and has been supportive. One good thing about NSHIP which was piloted in Ondo is that it gives opportunity to every member of the community and representatives of health facilities to confront any challenge in the course of implementing the programme.
They are allowed to deploy their own strategies when it becomes imperative. The community has a say in what happens to their health.
The emphasis on community participation at the same time gives people the zeal to take full ownership of the project. Community leaders, religious leaders, traditional rulers, market women and other stakeholders gather to discuss the areas where they need NSHIP intervention in the health facilities in their environment.
This new idea has brought tremendous development to the 532 health facilities across Ondo.