Dear HIFA Colleagues,
Just like governments (elected politicians and civil servants) and the private sector, members of the civil society are likely to look out for themselves as individuals unless grounded in intimate communities. Within the health sector space, except for certain community-based groups such as service-user and carer groups for given health disorders and similar patient associations, this condition is not likely to be met in most cases.
So, how has the attempt to replace small groups of people who know one another with the imagined communities of civil society that try to provide voice and act on behalf of the whole populations really work?
The case [1] of Health Reform Foundation of Nigeria (HERFON), an indigenous non-governmental organisation (NGO) that over a ten-year period led a broad coalition of stakeholders to get a national health bill signed into law as an Act in 2014, which provides a comprehensive legal framework for the coordination, administration, financing, and governance of health care in Nigeria; is worth examining.
HERFON arrived in the early 2000s at a time the Nigerian health system was performing very poorly despite enormous resource in-put and potential to make a difference. For example. maternal mortality levels were among the highest in the world while life expectancy was below the African average. Even as the private sector provided a large proportion of healthcare services, the government did little to make access to healthcare affordable. Consequently, household out-of-pocket expenditure was over 70% of health spending. Complicated by the governance structure as a ‘federal country’ whereby the federal government and the 36 state-governments derive their authority from the constitution; patronage politics tend to undermine accountability for health services in Nigeria. And the health system was also highly fragmented with different agents/actors responsible for aspects of the same service and several duplications of national coordination platforms. Though statutorily the Federal government provides State governments with health policy direction and funding, these subnational bodies have autonomy over how funds are allocated and how health services are provided. As such coordination of public healthcare provision across the country faces political obstacles within and between all tiers of government.
No doubt, this sort of context in which civil society organisations are needed to intervene to bring about policy reforms that can lead to better health for all Nigerians is not only complex but also challenging. In addition, it was realised that in such a situation; individuals and organisations on their own are unlikely to be able to drive meaningful long-term change. In tackling the fundamental constraints to change, an approach is required that identifies and supports coalitions of interest across civil society, government, legislators, the private sector, and media. Such coalitions could then be supported to work on issues that engage a range of stakeholders and that have the potential to lead to institutional change - an ‘issue-based approach’ that drives chaange.
Building on the solid foundation of a Change Agents Programme (CAP) that brought together professionals from different professional backgrounds with a collective interest for change in the health delivery apparatus to act as ‘Change Agents’; HERFON reinforced its basic tenet that sustainable change must come from within and be institutionalised but this will not happen without catalysts of change. Taking advantage of this pool of resources, and with the support of the UK Department for International Development (DFID) [now Foreign, Commonwealth and Development Office � FCDO] that also developed CAP along with Nigeria’s Federal Ministry of Health (FMoH) to reform the health sector; HERFON set out to define reform agendas and advocate for policy changes independent of government and donors.
In undertaking health sector reform and policy development, HERFON adopted the PACE approach (partnership, advocacy, capacity building and evidence generation) as the framework that guided its work to ensure that skilled and well positioned change agents are actively and effectively developing and defining agendas for health systems reforms. This period also coincided with the time the FMoH embarked on a health reform programme (from 2004), aimed not only at resolving the conflicts of roles and responsibilities among the tiers of government, but also advancing a shared vision for a national health service with all actors. The drafting of a National Health Bill and its passage into law was one such reform.
Drawing upon a large and diverse membership base from well-connected individuals across several sectors including those within and outside government, HERFON engaged both the National Assembly and the Federal Ministry of Health to drive the passage of the Health Bill through the legislature. Beyond taking an overt campaigning role, the organisation fostered a partnership of stakeholders including other civil society organisations, developed their capacity to carry out advocacy initiative in relation to the Health Bill, and undertook operational research to generate evidence to support its advocacy endeavours using Maternal, Newborn, and Child Health (MNCH) services as a focus. Interestingly, though the drafting and processing of the 1st version of the National Health Bill in 2004 was well received but it soon generated a lot of interest from several quarters and concerns about some of its provisions were raised by several entities including Health Professional Associations, religious bodies, and others. This led to several revisions of the bill, which caused long delays in the legislative process. Between 2005 and 2010 six versions of the bill were drafted, and eventually it was passed by the National Assembly (the Senate and the Federal House of Representatives) in 2011 but failed to receive Presidential assent presumably due to a few unresolved contentious issues in the Bill.
Given this impasse and with the passage of the Health Bill becoming a ‘wicked problem’ where the answers are incomplete, contradictory, and set against changing requirements [2], it necessitated a change of tactics whereby rather than individual organisations acting on their own, a specific coalition of civil society organisations targeted at getting the Bill passed was formed to help navigate the politically volatile environment and manage the diversity of interests. With HERFON as Secretariat, the Health Sector Reform Coalition (HSRC) as it was named became the platform through which concerted efforts were expected to be directed towards sustained advocacy to get the Bill passed and signed into law. It encompassed a diverse and multi-disciplinary range of stakeholders including indigenous health delivery civil society organisations, professional bodies (legal, health sector), International non-governmental organisations (INGOs) and the media. While organising a coalition of this nature to achieve a common goal was a daunting task with individual members still having their respective agendas, the HSRC managed to hold the collective by ‘force of purpose’ to deliver its outcome.
Following a landscape analysis of the Health Bill, it became clear to the coalition that enacting a national health law in a country as complex and diverse as Nigeria is more of a political process than a technical one3. Therefore, extensive political analysis and dialogue among various interest groups are required on an on-going basis to support the process. This insight along with consistency of efforts by HSRC members paved the way for a more targeted advocacy, lobbying, consensus building, reconciling differences among various groups, stimulating responsiveness and ownership of the process and the product by all concerned, including the public. And despite diverse interests that were still dissatisfied, in particular the Federal Ministry of Finance that was not behind the financial commitments of the Bill, the sitting President was persuaded through a combination of high-level domestic and international political pressure to sign the Act in the twilights of his administration in 2014.
Considering the convoluted course, the Bill took to become an Act, a note of caution was given by some observers including the author that it may require the same level of sustained advocacy (if not more) to get the National Health Act implemented.
Almost 8 years down the line, progress has been very slow and there have been several obstacles at the Federal government level including on-gong tussles about funding for the Act, how these should be managed and by whom. Limited political prominence of health sector reforms in the States remains the main difficulty in promoting the Act at the level where service delivery happens. It was noted that in domesticating the Act in their domains, States are only creating an appearance of change by setting up structures (Agencies) as demanded by the Act without addressing fundamental issues - the functions these Agencies are meant to carry ouut in order to deliver improved health outcomes. As the Act is legally binding for Federal level institutions and sets out guidance for changes at State and Local Government levels, the absence of any additional financing, appears to be of little interest to stakeholders in implementing these provisions at the subnational levels.
Thus, echoing the call for continuous civil society participation in health policy especially in the UHC era, key observers note: “There is not strong opposition to health reform, rather a lack of enthusiasm to act and the bottlenecks that remain will need renewed and concerted effort to be overcome” [4].
1. Roques, A.; Asoka, T. Assignment Report: Health Reform Foundation of Nigeria (HERFON) Annual Review 2011. HDRC, UK (2011) 94 pp. https://assets.publishing.service.gov.uk/media/57a08ae3ed915d3cfd0009ce/... (accessed 18/05/2022)
2. O’Brien, G. et al. (2008) Climate adaptation from a poverty perspective. In: Kok M. T. J. & Metz, B. (eds.) Development Policy as a way to Manage Climate Change Risks. London: Earthscan Routledge
3. Asoka, T. (2013) Much Ado about a National Health Bill: why the President may not sign the bill again. Africa Health (Nigeria Edition). 36 (1): 2 - 5. https://www.dropbox.com/s/8vae9j2frhdcnnt/AH-Nigeria%20Nov%20%202013.pdf... (accessed 18/09/2022)
4. Tulloch, O. Cummings, C. Ogunbayo, D. and Oreh, C. (2017) A Case Study of the Implementation of the 2014 Nigeria Health Act - what can we learn for public policy rreform? Abuja: Partnerships to Engage Reforms and Learn (PERL) - Learning, Evidencing, and Advocacy Pillar (LEAP) http://www.perlnigeria.net/storage/casestudies/June2018/ajcSQsA69fLeSgvz... (accessed 18/05/2022)
Best, Tarry
HIFA profile: Tarry Asoka is a consultant in health and development based in Nigeria. Besides assisting clients to meet their corporate objectives, Tarry is keen on searching for and implementing innovative solutions that address critical challenges that confront the world in health and development. He has experience with civil society participation in health policy processes in Anglophone West Africa (Ghana, Liberia, Nigeria, Sierra Leone, and The Gambia). In Nigeria, he has provided mentoring support and help to channel resources to the lead CSO (Health Reform Foundation of Nigeria – HERFON) both as UK DFID (now FCDO) Health Adviseer over a 5-year period and later as an Independent Consultant. Tarry is a member of the HIFA working group on SUPPORT-SYSTEMS. https://www.hifa.org/support/members/tarry
https://www.hifa.org/projects/new-support-systems-how-can-decision-makin...
tarry AT carenet.info
