Transforming Nigeria’s Health Sector: The SWAp Advantage By Chinedu Moghalu

At the beginning of efforts to reimagine Nigeria’s health sector for improved quality outcomes in September last year, the Government and its partners chose to confront the longstanding challenges with a fresh and innovative approach. Despite significant funding over the years, the health sector had not seen a commensurate improvement in impact and success. The technical capacities of stakeholders had not been efficiently harnessed, leading to the need for a tool that would enhance coherence and complementarity in health interventions.

The Health Sector Strategic Blueprint (HSSB) for 2023-2027, developed in conjunction with the Nigeria Health Sector Renewal Investment Initiative (NHSRII), received approval from the President on December 12, 2023, after it was endorsed by the National Council on Health (NCH) a few weeks earlier.

A Sector-Wide Approach

To end the legacy of poor performance that had bedeviled the health sector for so many years, the President approved the adoption of a Sector-Wide Approach (SWAp) as the guiding framework for these initiatives. The blueprint, along with the accompanying Health Sector Renewal Compact, aims to scale up health outcomes through the unified efforts of the President, the 36 State Governors, and Donor Partners, highlighting a whole-of-government and whole-of-society commitment to health sector reform. SWAp now serves as a vital tool for delivering the HSSB and NHSRII by fostering collaboration and coherence, thereby eliminating the fragmentation that has long hindered progress. At the core of SWAp are the principles of “One Plan, One Budget, One Report, and One Conversation,” ensuring that all efforts are aligned and directed towards common goals of saving lives, reducing physical and financial pains, and producing health for all Nigerians.

Enhanced Resource Coordination and Efficiency

Fragmentation and disjointed efforts have long plagued Nigeria’s health sector, leading to inefficiencies and poor outcomes. Disparate initiatives and overlapping programs have often resulted in mismanagement and resource wastage. By adopting SWAp, the Government seeks to unify federal, state, and development partners’ programs under a single, coherent framework aligned with national health priorities. This alignment reduces redundancy and optimizes resource allocation, as seen in countries like Ghana and Tanzania. For instance, Ghana’s adoption of SWAp led to a 30% increase in immunization coverage and a 15% reduction in child mortality rates. In Tanzania, the approach contributed to a 40% decrease in maternal mortality over a decade. Resource allocation inefficiencies have frequently led to service delivery gaps. The SWAp framework mandates a transparent and accountable budgeting process that aligns financial flows with national health priorities as stipulated in the National Health Act 2014. This approach ensures that resources are systematically directed towards critical areas, enhancing efficiency and equity. Ethiopia’s experience with SWAp demonstrates how strategic resource allocation can lead to more equitable healthcare access and improved health outcomes, evidenced by a 50% increase in primary healthcare utilization and a 20% reduction in stunting rates among children.

Strengthened Governance and Accountability

Good governance, transparency, and accountability are vital for a successful health system. Leveraging SWAp, the Government has established robust mechanisms for monitoring and evaluation, ensuring progress is tracked against key performance indicators through Joint Annual Reviews (JAR) and regular quarterly performance dialogues. This transparency fosters a culture of accountability, builds trust among stakeholders and the public, and reinforces the credibility of the health system.

Empowerment of State-Level Health Systems

The transformation of Nigeria’s health sector heavily depends on the active participation and leadership of state governments. Towards this, the Ministry recently inaugurated a Quarterly Performance Dialogue (QPD) between the Coordinating Minister of Health and Social Welfare and State Commissioners of Health. The primary objective of this initiative is to establish regular progressive engagements among key health sector stakeholders, evaluate progress against set indicators, facilitate cross-state problem-solving, and amplify state perspectives, challenges, and successes. This initiative is vital for ensuring continuous improvement and addressing the unique needs of each state in Nigeria’s diverse health landscape. The QPD is tied to the more comprehensive Annual Operational Plans (AOPs), which align state health priorities with national goals, ensuring a coherent approach to health sector development. Decentralized decision-making has proven to strengthen state-level health systems, fostering local ownership and accountability. South Africa’s experience with decentralized health governance shows that empowering local authorities leads to more responsive and effective healthcare delivery, contributing to a 25% increase in access to healthcare services in rural areas.

Universal Health Coverage and Long-Term Success

Achieving Universal Health Coverage (UHC) is a key goal for Nigeria’s health sector. President Bola Tinubu has emphasized that providing quality healthcare for all Nigerians is central to his administration’s success. By aligning programs through SWAp and using the Basic Primary Healthcare Provision Fund (BHCPF) as an entry point, the Government and its partners want to double revitalized PHCs across the country to ~ 17,000 functional upgraded PHC facilities, expand health insurance coverage, enhance financial protection for vulnerable populations, and improve the quality of primary healthcare services. Coordinated efforts utilizing SWAp can facilitate the scaling up of essential health services such as immunization and reproductive, maternal, newborn, children, and adolescent health and nutrition. Rwanda’s progress towards UHC through similar strategies provides a valuable model for Nigeria, with the country achieving over 90% health insurance coverage and a significant reduction in out-of-pocket health expenditures. Long-term success is a critical concern for Nigeria’s health sector. By working together through SWAp, the Government and its partners can promote long-term success by strengthening health systems, enhancing data collection and usage, and fostering innovation in healthcare delivery. Institutionalizing best practices and establishing resilient health infrastructure ensures the health sector can withstand future challenges. India’s efforts to build a sustainable health system through continuous improvement and innovation offer important lessons for Nigeria. India has seen a 37% reduction in maternal mortality and a 45% increase in institutional deliveries over the past decade, demonstrating the impact of strategic health system strengthening. Zambia has similarly seen a 50% increase in the coverage of essential health services and a 25% reduction in under-five mortality rates over the past decade, highlighting the effectiveness of SWAp.

Ownership, Visibility, and Communication

A fundamental aspect of SWAp is ensuring ownership, visibility, and effective communication within the health sector. National authorities must lead in setting priorities, managing resources, and driving the agenda. Ownership is crucial for long-term success and ensuring health programs align with local needs and contexts. Towards making all processes and outcomes transparent to stakeholders and fostering trust and collaboration among partners, SWAp is beneficial for enhancing visibility and promoting accountability of health initiatives across the spectrum. Effective communication is essential to ensure that all stakeholders are informed, engaged, and able to contribute to the health sector’s goals. Regular updates, transparent reporting, and open dialogues are necessary to maintain momentum and address any challenges promptly. Moreover, recognizing and crediting agencies for their contributions and funding enhances visibility and satisfaction among donors and partners, ensuring continued support. Bangladesh and Zambia have demonstrated that local ownership, visibility, and robust communication are key to the success of their health sector reforms. In Bangladesh, the implementation of SWAp led to a 60% increase in institutional deliveries and significant improvements in maternal and child health indicators.

Leadership Commitment and Vision

President Tinubu underscored the importance of prioritizing health in Nigeria’s policy agenda at the launch of the NHSRII and the Compact on December 12, 2023. “Health is back on the front burner of Nigeria’s policy in line with the Renewed Hope Agenda,” he declared, highlighting the administration’s commitment to transforming the health sector and ensuring that all Nigerians have access to quality healthcare. Equally, the Hon. Coordinating Minister of Health and Social Welfare, Muhammad Ali Pate, emphasized the critical role of adopting a sector-wide approach in achieving these goals. “The Sector-Wide Approach is not just a policy initiative; it is a strategic tool for building a truthful, resilient and effective health system in Nigeria. By fostering coordination, transparency, and accountability, we can ensure that our health interventions are impactful and sustainable,” he noted. By enabling the country to drive its health agenda, SWAp ensures national ownership and leadership in health initiatives. This model has been effectively utilized in countries like Zambia and Bangladesh, showcasing how a unified approach can harmonize efforts and enhance health outcomes. In Zambia, SWAp implementation resulted in a 50% increase in the coverage of essential health services and improved health outcomes across various indicators.

A Model for Other Ministries and Agencies

Other ministries, departments, and agencies of government would indeed fare better using the SWAp framework if the Renewed Hope Agenda is to be wholly achieved, and sustainably, too. By adopting this approach, the MDAs can align their efforts, reduce fragmentation, and improve the efficiency and effectiveness of their programs. This could help ensure that national priorities are met through coordinated and transparent processes, leading to better outcomes across all sectors.

Conclusion: The Future of Nigeria’s Health Sector

The success of the NHSRII hinges on the effective implementation of the SWAp and the Health Sector Renewal Compact. By enhancing coordination, improving resource allocation, strengthening governance, empowering states, promoting UHC, and building long-term success, the Government and its partners can lay the foundation for a health system that delivers improved quality outcomes for all Nigerians. The future of Nigeria’s health sector, and indeed its overall development, relies on the unwavering commitment, strong leadership, and active collaboration of all stakeholders. The NHSRII promises to deliver a comprehensive and coordinated transformation of the health sector, and the sector-wide approach provides a clear path towards a healthier and more prosperous nation.

Chinedu Moghalu is the Senior Special Adviser to the Hon CMHSW on Strategic Communication, Stakeholder Engagement and Advocacy.