Last week, Nigeria's Supreme Court delivered a judgement granting financial autonomy to Local Government Areas (LGAs) in a suit filed by the Honourable Attorney-General of the Federation and Minister of Justice, Lateef Fagbemi. While this is predicted to drive grassroots development, primary healthcare is one area that will be impacted positively when local governments are financially empowered.
Beyond quality, accessibility is an important consideration while accessing healthcare. This is why primary healthcare is critical to any successful healthcare system because it is close to people. Up to 90 per cent of health services needed during someone's lifetime can be provided at the primary healthcare level. Primary healthcare is designed to be the foundation of every country's health system, focusing on preventive and curative services. Despite its crucial role and being part of public conversation for a long time, primary healthcare in Nigeria still faces several challenges that impact its effectiveness.
Primary healthcare, being closest to communities, is overseen by local government area councils. This is especially so because healthcare is on the concurrent legislative list, meaning the three tiers of government -- federal, state, and local -- all have roles to play in ensuring its full functionality. The 1999 constitution lists healthcare provision as one of the responsibilities of local governments. Healthcare at any level requires resources, however, when it is unavailable or inadequate, it becomes difficult to operate optimally. This has been the reality of most local government area councils for nearly two decades as they have become almost defunct, with state government receiving and disbursing funds on their behalf from the federal account. Now that this situation is about to change, these three areas will potentially be positively impacted when the judgment takes full effect.
What does this mean for maternal health?
Reaching a health facility and receiving adequate care are two of the three delays that contribute to maternal deaths. This can happen when local governments lack the human and financial resources needed to operate primary health centres (PHCs) effectively. There are examples where young midwives are trained to provide care for pregnant women in their communities, however, many of them are reluctant to work often due to the working conditions of the community facilities. With more resources at their disposal, local governments should be better able to improve the quality of care in health facilities and employ skilled healthcare workers. This reduces the need for women to visit secondary or tertiary facilities, unless there are complications. Should skilled healthcare workers at primary health centres identify any complications, an effective referral process should ensure that pregnant women are directed to secondary or tertiary health facilities. With additional funding, local governments will also be able to equip PHCs with necessary medical supplies and essential medication, such as uterotonics, to address cases of post-partum haemorrhage.
Health security and immunisation coverage
The issue of zero-dose children is a prevalent public health challenge caused by a range of factors. These children are vulnerable to deadly diseases because they have not received a single vaccine shot in their lives. Often, they are in communities that can be reached by local governments if they are working at their full potential. Unprotected children in communities increases the risk of disease outbreaks in communities. PHCs need the vaccines, adequate storage to preserve them and finances to reach every child in their catchment areas. Having financial autonomy will enable local government administrators to do this for their citizens without waiting for the state, which also has other competing priorities.
Well-resourced PHCs can help reduce zero-dose children and, in turn, improve local health security. However, when public health events occur, they can detect them quickly and escalate for investigation using already established protocols like the Surveillance, Outbreak Response Management and Analysis System (SORMAS).
Strengthened governance
Effective governance is one of the pillars of the Nigeria Health Sector Renewal Initiative, and the financial autonomy of local governments can help achieve this. By reducing layers of bureaucracy at the state level, LGAs should be able to prioritise healthcare initiatives based on local needs and provide oversight, minimising opportunities for corruption and mismanagement, a major challenge in Nigeria's health sector. In addition, accountability mechanism should enable communities to be more involved in monitoring how their funds are used, ensuring greater transparency and accountability. This enhanced governance framework can foster trust and confidence in the healthcare system, encouraging more people to seek care at local health facilities.
Not a walk in the park
Realising this vision is not going to be easy. There are already mixed reactions following the judgement. Several hurdles need to be overcome before Nigerians will start reaping the dividends of local government financial autonomy. First, state electoral commissions must conduct credible, free, and fair elections to elect local government chairmen. With Nigeria's history with elections, it's important to ensure the elections produce candidates that citizens will not question the legitimacy of their mandates. This is important because everything falls on good leadership.
Professor Obinna Onwujekwe, Coordinator of the Health Policy Research Group and Professor of Health Economics at the University of Nigeria, said the judgement giving financial autonomy to local governments will "have a positive impact with serious and results-oriented chairpersons".
Also, while LGA autonomy will promote transparency and accountability because community stakeholders and gatekeepers who are close to the local governments will be more involved, it is not guaranteed. Accountability will require intentional efforts and active citizen engagement to ensure fiscal openness and funds for the people, work for the people. Nigeria is part of global initiatives that seek to make governance more open, such as the International Budget Partnership and Open Government Partnership. However, can this be stepped down to the local government level?
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Technology should play a key role in promoting accountability as citizens can now easily ask questions to know how their funds are being used. But more of this needs to happen. The Community Health Watch initiative by Nigeria Health Watch promotes active citizenship by encouraging community members to share their healthcare experiences. BudgIT is also encouraging community members to Ask Questions. Realising that the judgement is only a first step, the Federal Government has capacity-building plans for local governments and traditional rulers.
While it may not be easy, it is not impossible. It requires purposeful leadership and an understanding of the importance of investing in primary healthcare. As Dr Suraya Dalil, Director of the Special Programme on Primary Health Care at the World Health Organisation, aptly puts it, "If we don't invest in health systems that are founded on the primary healthcare approach, then we have to spend more when the crisis comes."
