The Primary Health Care (PHC) sector in Nigeria has suffered from chronic underinvestment since the 1980s, when primary health care was decentralized and handed over to local governments. Local PHC facilities have suffered from outdated procurement processes and delays in budget flows, which slow down repairs and investment in services. There has also been weak oversight and little opportunity for citizens to participate in decision-making about resourcing these facilities. Although many Nigerians rely on their local PHC facility for care, only 20% of the 30,000 facilities across the country are in working order.
With our support, Community Empowerment Network (COMEN) built the skills and coalition to get the Anambra state government to increase its 2020 budget health allocations by 6.4%. Their 2021 budget also centralized and increased allocations to the State Primary Healthcare Development Agency from 26.4 million in 2020 to 757.6 million naira. State officials also disbursed their 20% share (the federal government matches with the other 80%) of the Basic Health Care Provision Fund (BHCPF)1 to 175 PHC facilities for the first time. Anambra is now the leading state in Nigeria in accessing the BHCPF.
COMEN is a large organization that helps 181 communities— over 6 million residents— to identify and prioritize development needs. SPARK’s strategy is to seek out groups that are already organizing and mobilizing around a service delivery issue. COMEN had been trying to influence community development priorities in Anambra state for a few years and in 2015 had managed to get community demands reflected in the budget but tangible changes in services were slow to materialize. We felt that by applying more rigorous budget analysis and advocacy tactics, COMEN could make further inroads in building the community’s influence over resource decisions.
Anambra has a poor track record of primary health care service delivery, as is the prevalent norm across Nigeria. Providers lack the capacity to provide basic care and clean water and basic sanitation to residents. PHC facilities are poorly staffed, have ageing infrastructure and equipment and lack supplies of essential drugs. We focused on what the community said was their top priority—access to clean water and sanitation— as our “entry point” to drive broader conversations around the need to invest in PHC facilities.
In 2015, Anambra’s State Government launched a program to rehabilitate 63 out of 326 PHC facilities annually. However, COMEN’s budget tracking with IBP revealed that PHC facilities had not received any funding from the federal health budget, state health budget or local government budgets in the 2020 and 2021 fiscal years. This underinvestment was not due to lack of revenue but poor budget execution (see graph 1). The state government succeeded in mobilizing and collecting 99.51% of its targeted revenue between 2015 and 2019. The problem was that these revenues were not allocated and spent effectively by the government to make good on its promises.
Path to COMEN’s results
We and our technical partners—Justice, Development and Peace Caritas, Nnewi (JDPC) and the African Centre for Leadership, Strategy and Development (Centre LSD)—helped COMEN to build budget analysis skills and forge relationships with local officials to demand that Anambra’s government adequately prioritize the PHC sector.
Joining of technical and political power
COMEN’s political influence as a well-organized network was already significant. What they lacked were budget and advocacy skills to address the bottlenecks that were keeping revenues from reaching their intended purpose. It was important for them to understand and map the actors, roles, institutions and contexts that influence budget decisions in the primary health care sector. COMEN had to be able to answer this question: If governments consistently made allocations for the PHC program, then why were the facilities in such a poor state?
We helped COMEN make the connection between public budgets and service delivery by understanding how resources flow to PHC facilities and how such resources are used to deliver services across facilities. Unpacking this process allowed us to identify what was keeping repairs and other services from being met. We leveraged our convening power to help COMEN build relationships with local and state officials that had a say in how PHC facilities were resourced. By understanding the political economy, and how to navigate it, COMEN was able to design more purposeful and focused campaigns.
Strengthening formal budget spaces
Many of Nigeria’s rural areas have town unions that convene community members and local officials to address needs and improve services. They do not, however, exist in all communities and, for the most part, have failed to help communities achieve the improvements they seek. Many communities had grown apathetic about the value of engaging with government because they were not seeing tangible results. They were organized but struggled to have the power and voice to seek change.
We had to counter this apathy and help communities understand how they could turn things around. We worked with COMEN to host participatory workshops through the town union structure. We educated residents about how to interpret and monitor budgets that matter most to them. With their newfound skills, these residents were able to speak up about their needs and to speak out against the failures of budget implementation. As a result, town unions transformed from spaces of tired apathy to ones of hope and action.
Generating and leveraging data to make demands
To gather data on the state of the PHC sector, COMEN visited and inspected 21 facilities late in 2019, with a specific focus on water and sanitation. They interviewed frontline workers and held discussions with community members to form an all-round view of what was needed both by patients and workers. We supported COMEN to research, analyze, package and use these facility assessments, and budget information, to drive change. By arming themselves with facts about the conditions of facilities and budget implications – facts which the government did not have – COMEN grew its reputation as a knowledgeable, credible and legitimate partner for local and state government. These new dynamics renewed hope in COMEN and community members after years of being ignored.
We also realized that data was not enough—we had to help COMEN navigate and transform relationships with officials and community leaders who had to take this data to drive constructive action. When COMEN initially tried to engage frontline service providers at PHC facilities they found resistance and they ultimately realized this was due to pressure providers were receiving from the Anambra State Primary Health Care Development Agency (ASPHCDA) to not share data. These efforts also strained the relationship between communities and frontline health workers who felt victimized.
COMEN worked to build trust and form coalitions with local actors, including traditional leaders, religious formations and civil society organizations—like the Idikacho Women in Governance (I-WIG) and the Anambra State Associations of Town Unions (ASATU)—who helped amplify community reach. They also forged ties with local officials like Ward Development Committees (WDCs), Water Sanitation and Hygiene Committees (WASHCOM), officers in charge of PHC facilities and local government health departments who helped them analyse service gaps across facilities and recommend strategies to improve them.
I am proud of leading members to advocate for Primary Health Care Centers, championing and defending civil society space and the formation of a partner network. Our partnership with the Justice Development and Peace Caritas helped us influence and improve Primary Health Care Center’s service delivery and provide the evidence needed for the #FixmyPHC campaign, which directly led to governments increasing money spent in Primary Health Care Centers.
– Ubagu Martha Amuche
A member of COMEN in the Ojoto community.
Formal and informal engagement and participation
We saw an opportunity to leverage the PHC assessments, and the inroads we had made through the town union structure to impact change. The Anambra State Government had created a Community Charters of Demands Desk within its Ministry of Economic Planning, Budget and Development, for communities to submit Charters of Demands on services and other community development priorities. This channel had not been utilized effectively because communities had lacked the skills to draft effective Charters. With support from us and our technical partners, COMEN worked with 12 focus communities to submit Community Charters of Demands. They also encouraged other communities to do so through the Anambra State Associations of Town Unions. In total, 57 communities submitted Community Charters of Demands for the 2020 fiscal year.
Communities should come together in their townhall meetings to prioritize what they would like to have in the annual budget, so it can be pushed to make sure that what they want is accommodated financially.
Mr. Arthur Iweanya
Director, Ministry of Economic Planning, Budget and Development Partners
Through the new alliances built and with clear community demands in hand, COMEN reached key government offices such as the ASPHCDA, the Anambra State Government Commissioner for Health, the Senior Special Assistant, the COVID response task force and the Ministry of Budget and Economic Planning. These officials could influence budget systems at PHC facilities and effectively monitor their service delivery. Increasingly, local officials are more willing to provide valuable information about PHC facilities. Through dialogue, frontline health workers also now understand the crucial role they play in strengthening the performance and accountability of local health care systems. As a result, they have applied pressure on ASPHCDA to improve health workers’ conditions.
COMEN’s engagement with relevant government institutions has given them access to decision-making spaces previously closed to them. COMEN are now part of annual budget bilateral forums in Anambra, where the executive presents budget proposals to civil society for feedback before they submit them to the legislature for appropriation.
Working with oversight institutions
At the height of the pandemic, COMEN tried to link their state campaign to a national health budget cut campaign. They sent position papers to National Assembly health committee members and Anambra state legislators. They participated in donor-led advocacy, such as an event organized by the UK Department for International Development. Though no concrete outcomes emerged, these efforts helped connect COMEN’s coalition to the national health budget debate. COMEN’s work with oversight institutions has been mostly reactive and represents an area for further investment.
Amplifying COMEN’s voice
COMEN and partners embarked on two media campaigns to garner public and political attention. The first of the media campaigns was a 3-week series of radio and TV phone-in programs, featuring a representative from the ASPHCDA. These programs raised awareness about preventing the spread of COVID-19 and tied in the poor conditions of PHC facilities across Anambra leveraging the facility assessments. By putting government “on the spot,” COMEN and partners made a strong case to prioritize PHC facilities during the pandemic. This campaign was effective because the Anambra State Governor wanted to be seen to be a “champion of good health” during the pandemic.
COMEN’s main successes to date
As a result of COMEN’s budget advocacy and coalition-building, the Anambra State Government revised the 2020 health budget upwards from 4.7 billion to 5 billion naira (an increase of 6.4%) and reiterated its commitment to implement the program to rehabilitate PHC facilities and improve health services.
Anambra state officials also heeded COMEN’s and our recommendation to strategically centralize all allocations for PHC facilities to the agency that is best suited to manage the funds. In its draft 2021 budget, state officials moved all monies for repairing the facilities under the ASPHCDA, increasing its allocation from 26.4 million to 757.6 million naira. Because the funds are under the direct supervision of the agency responsible for repairing facilities, there are less opportunities for delayed funds, political patronage and waste to sidetrack these monies from being spent on what they were allocated for.
Finally, the state government yielded to pressure from COMEN and partners to disburse the BHCPF to PHC facilities. 175 out of 326 facilities in Anambra have successfully accessed the first disbursement tranche. 17 are from the campaign’s 21 focus facilities serving an estimated 91,000 people. Out of those 17, 15 have commenced renovation work, such as fixing taps and water systems. Because of our partnership, this is the first time the Anambra State Government has met the criteria for accessing the BHCPF and provided its 20% share of the Fund (the federal state provides the other 80%). Anambra State is now the leading state in Nigeria accessing the BHCPF.
By building mutual understanding and trust with health officials and budget decision-makers, we are finally seeing much-needed repairs to PHC facilities in Anambra. Beyond the immediate improvements, COMEN and the communities’ skills and government relationships have been permanently transformed. These transformations will prove invaluable going forward. They also provide lessons learned we are applying to scale up results beyond Anambra to Oyo state in 2021.
In 2021, COMEN and their civil society networks will monitor the implementation of the BHCPF and the 2020 Anambra state revised health budget allocations to the PHC sub-sector. They will collate this information to address budget implementation bottlenecks. They will also monitor the conditions of the PHC facilities every quarter through a community scorecard to document service improvements. This information will be used to engage relevant government actors at national and subnational level, who, in turn, will commit to keep improving PHC service delivery.