As a young resident doctor working in a busy paediatric centre in Nigeria, over half of the patients I saw were brought in too late and we couldn't do a lot to save them. These children had malaria, pneumonia, diarrhoea—ailments that were not only preventable, but treatable, making their deaths unnecessary and devastating.

It was a defining moment in my life and career.

Rather than stay in the clinic to attend to the children who were lucky enough to be brought in on time, I decided to find out why the other children weren’t.

Many parents had the same answer—they had no money and couldn’t afford to come earlier. There was clearly something wrong with the way we finance healthcare and children were dying as a result. I left Nigeria for the UK to study health economics, and returned with as many questions as insights.

The answer became clear one afternoon when I was speaking to a pregnant woman in a rural primary healthcare centre and a five-year-old boy was rushed in, convulsing. Had this been the busy, metropolitan hospital I worked in previously, I’d have had everything I needed to save him. But here, there were no anticonvulsants—none of the essential equipment I needed to do my job.

The reality is that even if the financial barriers for people to come in for care are removed, they still might get to the facility and find nothing there to help them. Driven by the experience of this boy’s death, I started working with government to put in place community-based health insurance schemes, essential drug systems, and referral systems, and building up primary healthcare.

It was everything I wanted to do, both from the demand side to remove financial barriers and the supply side for high-quality services. It was addressing all of the issues that drove me out of the clinic, particularly equity in health. To me, equity is when a poor woman with no education and no job living in a rural village in Nigeria can get the quality healthcare she needs whenever she needs it.

Doing this work with Palladium and the Health Policy Plus (HP+) project is one of the highlights of my life.

Sitting on a Shelf

HP+ closed last month, and I find myself reflecting on the work we did over the past seven years. In some cases, we encountered important policies that, while in place, simply weren’t being implemented as they should be. One of these was Nigeria’s Basic Health Care Provision Fund (BHCPF) – a program with a benefits package that covers many health needs, including maternal and child health.

The BHCPF is funded from one percent of a consolidated revenue fund of Nigeria. The first time it was released, it was about 55 billion Nigerian naira (US$127M). 45% of this goes to primary healthcare facilities for infrastructure, human resources, drug supplies, and equipment so that facilities are ready to provide services.

50% is to be used on the demand side, through health insurance to remove financial barriers for people to get care—especially poor and vulnerable people. This insurance pathway goes through each state’s health insurance scheme.

Together, these two funding streams ensure that people don’t have to worry about paying for their healthcare and that facilities are funded and equipped. That’s how the BHCPF was structured when the National Health Act passed in 2014.

But the policy wasn’t being implemented.

In 2018, HP+, in collaboration with other partners, advocated to Parliament, which agreed to appropriate the intended funds for the first time. Still, nothing happened.

HP+ began working to ensure that the states were actually ready to access these funds and meet the criteria in place in order to get them. Our approach was to provide support to three Nigerian states and the Federal Capital Territory to prepare them to meet all the criteria. We supported states to assess their facilities to identify where they didn’t meet the criteria, to develop quality improvement plans, business plans, and set up accounts with the Central Bank and commercial banks to accept the funds.

We developed capacities across all levels to manage the funds and successfully advocated for the setup of local government health authorities to oversee operations. As a result, the three states and Federal Capital Territory that HP+ supported were the first states in Nigeria to qualify for the funding.

And that is how this policy that for years had been on paper, sitting on a shelf, was implemented for the first time.

A Holistic Approach

Our work extended even beyond the states we supported. We provided technical, institutional, and relational capacity strengthening at the national level to bring together all agencies involved to develop a training manual and operational materials so that everyone would be trained on how to implement the BHCPF policy—from the national and state levels to the local government, community service organisations, health workers, and community development committees. And critically, to ensure social accountability and sustainability, we empowered communities to ensure citizens voices were heard and involved in the implementation.

We monitored how facilities were using the money and the effect was incredible. It snowballed within communities as people rallied to come and do their part to improve facilities, repair leaking roofs, and restore water and electricity. There was an outpouring of excitement and support from the town hall union, some of them even helping to set up hospital beds. The funds enabled facilities to purchase equipment and drugs. It was amazing to see people coming in to receive healthcare, which, at many of these facilities, wasn’t possible before.

This was just one of the ways that HP+ policy implementation used a holistic approach to ensure that there are structures in government and agencies that need to work together to enable policy to come alive. All the BHCPF modules and the training manuals have been scaled up and are now used by other organisations supporting other states to bring them into compliance to receive funds and implement effectively, years beyond our support.

The long-awaited implementation of this national policy is truly a result of HP+’s work.

During an event marking the closing of HP+, a director from the National Primary Healthcare Development Agency said the model of partner support should be the gold standard for all who wanted to support government. A director from the Ministry of Health added that HP+ had trained more than 3,000 people, including national teams, state teams, the trainers of trainers, and civil society organisations. Following that the health ministries multiplied this and trained over 50,000 people, who are now training their own people across the 36 states.

Within the first two months, approximately 300,000 people had enrolled in the insurance program and were accessing care in the three states HP+ supported. Although data is not yet available on how the policy has affected maternal and newborn survival rates, we are already seeing output data that the number of women who come to the health centres have greatly increased.

Real Change

I think that when there is real change in the lives of people, then you know that policies enabling that change are good. Where I feel the most satisfaction is when funds reach the facilities and you see people enrolling in insurance, women receiving care, and babies being delivered with skilled attendants present and going home healthier.

And then I close my eyes and imagine that what is now happening in a primary healthcare facility in Osun State was happening in every rural community in Nigeria, and how amazing that could be. That’s where the magic is; where we can see that our work is making peoples’ lives better in the spirt of equity, that all lives are worth saving.

Read 'What was Health Policy Plus and why Does it Matter?' or learn more about Health Policy Plus.