INTRODUCTION

The Nigerian Health System: The health system in Nigeria is “dysfunctional and grossly under funded with per capita expenditure of $9.44 on health” (World Bank, 2005a). Health status indicators are worse than the average for sub-Saharan Africa with infant mortality rate: 115/1,000; under-5 mortality rate: 205/1,000; and maternal mortality ratio: 948/100,000. Nigeria has the “world's second-lowest rate of immunization coverage and is the global centre of transmission of wild polio virus” (www.who.int). The Federal Ministry of Health estimates that “malaria causes the deaths of 300,000 children and 7,000 women each year and that Nigeria has the fourth-highest tuberculosis (TB) burden in the world, with 100,000 deaths each year and HIV prevalence of 5.8% (HERFON, 2006).

These indicators have adverse effects on socio-economic development and are all preventable diseases which can be controlled with a well organized health system and active community participation (FMOH, 2004a). Also, “fertility is high, birth intervals are short, and contraceptive prevalence is low. The population is growing at close to 3 percent per year”, which imposes an unsustainable burden on health care delivery services (www.usaid.gov). This rapid population growth in the country and failure to factor in population figures in the past has made planning unrealistic and led to the provision of inadequate facilities (FMOH, 2004b). The total expenditure on health is 5% of Gross Domestic Product (GDP) and the density per 1000 of nurses and doctors is 1.70 and 0.28 respectively (WHO, 2006). Some of these indicators may have informed the large number of GHPs, currently over 20, implementing or funding programmes in the country.

Nigeria has one of the worst health indices in the world and is classified among the WHO high-mortality developing countries as having high levels of mortality for children under five and for adult males aged 15 to 59 (www.who.int). As a low and medium income countries (LMIC) Nigeria faces huge struggles in overcoming the inequalities caused by globalisation. Structural challenges like international trade systems and mounting external debt with unfavourable renegotiation conditions for have had negative impacts on the economic growth (Hong, 2000). As a result, the country have less money to spend on essential basic services such as health care and it could be argued that GHPs funding has greater impacts on the health system.

 The Nigerian economy has been in crisis since the 1980s, the annual GDP growth rate from 1970-80 was 4.6 percent. From 1980-91, this rate declined to 1.9 percent, while the annual inflation rate climbed to 18 percent (World Bank, 2005b). The lack of consistent democratically elected governments responsive to population needs also affected the country's ability to pursue steady health development. This economic decline reduced the ability of the government to deliver health services and health expenditures reduced in real terms, in large part through wage freezes and the cessation of capital construction and equipment purchase (FMOH, 2004b; World Bank, 2005b). A further detrimental response to this decay has been the “imposition of user fees for curative services delivered in government facilities” (Uzochukwu & Onwujekwe, 2004).

Global Health Partnerships (GHPs): These initiatives or interactions (Richter, 2004a) have been defined as “partnerships and related initiatives whose benefits cut across more than one region of the world, and in which the partners reach explicit agreements on objectives; agree to establish a new (formal or informal) organization; generate new products or services; and contribute dedicated resources to the program” (World Bank, 2005c). Global PPPs were also defined as “a collaborative relationship which transcends national boundaries and brings together at least three parties, among them a corporation (and/or industry association) and inter-governmental organizations, so as to achieve a shared health creating goal …” (Buse and Walt 2000b).

The conceptual definition of GHPs can be summarised as; Global: to capture initiatives that extends across or transcends national borders; Health: the goal of the partnerships has to “concern the remedy of health problems especially those of significance for the poor” in LMICs; Partnerships: “a collaborative relationship among multiple organisations in which risks and benefits are shared in pursuit of a shared goal” (Buse 2004a). GHPs refer to “relatively institutionalised initiatives, established to address global health problems, in which public and for-profit private sector organisations have a voce in collective decision making” (Buse and Harmer, 2007). There are four basic types of GHPs; Financing: those who provide funds; Advocacy: those who advocate for increased international and national response; Research and Development: those involved in product discovery and development; and Technical assistance: those that provide drug donations, etc (Carlson, 2004b).

DISCUSSION

Data has been collected from various sources – websites, databases – national policy documents, journal articles, commentaries, expert opinion and empirical research. Grey literature was also included some from the ELDIS/IDS (Development database from the Institute of Development Studies, Sussex), the Department for International Development (DFID) Health Resource Centre. A combination of search strategies was employed; keyword searches, cited reference searches and online/hand searching The following empirical research were included; Studies of GHPs in developing countries; evaluating primary data collected via country case studies; measuring the  performance of health systems and written or translated into English. Studies that did not meet the above or that were not published or translated into English were excluded.

A total of 717 articles were retrieved by the search of scientific databases, while the grey literature databases yielded more (almost 100) of which about 50 were duplicates. The scanning of the titles excluded about 650 irrelevant papers, as they were not really about global health partnerships. Abstracts of the remaining papers and sometimes the full text were then analysed using the inclusion criteria. All those meeting this were selected and reviewed for quality and relevance. For each included study, information was collected on the case countries, health system indicators measured, measurement levels and conclusions.

The search uncovered 21 empirical papers of GHPs in developing countries evaluating primary data from case studies and measuring various components of health systems. Of these, 4 studies (Brugha et al. 2004; Carlson, 2004a; Drager et al. 2006; Shiffman, 2007) focused primarily at the national level for their data collection and evaluation while the rest undertook multilevel studies. This involved collecting and analysing in-depth data at all levels of a decentralised health system (National, regional, state and/or local). Some of the papers referred to the same research either reporting data at different times – baseline, interim and final – as is the case with the System-Wide Effects of the Fund (SWEF). The GAVI review was also analysed by various authors (Brugha, et al. 2002; Starling, et al. 2002; Heaton and Keith, 2002).

Analysis: It was clear from the selected studies that Nigeria could be labelled a failure based on a focus by GHPs on successful performance including their “narrow targets and limited vision” (Oxfam, 2006). In the following analysis, it is recognised that the Health Bill, which would strengthen PHC particularly by “creating a designated source of funding from earmarked taxes”, and more significantly establish the roles of all levels of government (World Bank, 2005b) is yet to be passed by the National Assembly. Also, the revised Health Policy and insurance scheme which sets out the financial contributions of governments in supporting PHC services to be accompanied by a role in program development, management and governance (Monye, 2006) is under implemented. Thus, financing remains a key challenge (Atim, 2006) and much of the new funds brought in by GHPs bypass the established mechanism (NEEDS) for managing external health sector assistance.

Policy: It was reported that GHP support to priority programmes had allowed some governments to put more emphasis on health system strengthening, with a specific focus on capacity development (Carlson et al, 2004). Also that GHPs have successfully raised the profile of certain diseases on the policy agendas of many countries by utilising public relations and branding (Ogden et al. 2003). This may be said to be true in Nigeria as most GHPs dedicate a percentage of their implementation to training. However, they have not been so successful in building capacity for policy development. Take maternal mortality, Nigeria contributes 10% to global maternal deaths and as many as 60,000 women die due to pregnancy-related complications each year (Roberts, 2003) and yet it remains a neglected issue in the country.

A network of Global Safe Motherhood Initiative exists and a policy window recently opened for the cause. However, this network has yet to capitalise on its potential power, and political priority remains low (Shiffman and Okonofua, 2006; Shiffman, 2007). Similarly, despite the presence of GAVI, GPEI and other relevant GHPs in the country, immunisation rates have continued to decrease and are less than 2% in some northern states (World Bank, 2005c). In fact in 2003, GPEI targets of reaching all children in the endemic areas were put off track by Muslim political leaders in the country who feared the vaccine had been contaminated with anti-fertility agents (Yahya, 2006).

Financing: Most GHPs are “issue-specific” and designed for quick-results and so find it difficult to align with implementing countries’ priorities, systems and procedures. Some are yet to fully embrace the Paris agenda switch from ‘project aid’ to ‘general budget,’ ‘sector budget,’ and ‘programme’ support through development strategies (HLF, 2005). The parallel systems used by most GHPs for financial management in-country are uncertain and some have suggested a vertically integrated model (Casper, 2004). However, over-reliance on vertical implementation may hamper efforts to improve harmonisation between GHPs and their involvement in basket funding as seen in Uganda (Brugha et al, 2002; Carlson, 2004).

In Nigeria, GFATM is the largest GHP, the value of the Nigerian grant over the period of five years is $180 million. In comparison, the 2004 allocation for health increased as a proportion of the total budget to 6.9%, but was still lower in monetary terms than 2003 expenditures (World Bank, 2005b). On the heels of this slide, GFATM suspended about $50 million in grants to Nigeria in 2006, because the country failed to meet targets on drug access and "transparency". This was due to the failure to install computerized accounting systems to trace disbursement of funding – a precondition for the grants and inconsistencies in data provided by the national AIDS agency (NACA), including the number of people taking antiretroviral therapy (ART) (www.vanguardngr.com). This incident may be seen as an example of the problem of corruption which is has a devastating impact on government ability to deliver on its obligations to support the health sector (Human Rights Watch, 2007).

Human Resources: In Nigeria, many top health personnel with exceptional skills and training have left their public posts to fill the vast majority of international NGO and GHPs positions in the country (HERFON, 2006). Around 6,400 or 18% of the total doctors registered in Nigeria are abroad. Some GHPs lack the necessary resources to carry out their programmes or to finance the “true costs of extensive consultation required for partnership” (Buse and Harmer, 2007). This sometimes leads to their programmes becoming a burden for health professionals in the country. For instance, a large number of health workers are used by GPEI to serve as supervisors and vaccinators during national and sub-national immunisation days and this takes a heavy toll on an already understaffed PHC system.

An extreme and controversial case was noted in Nigeria when GPEI employed young children to administer vaccines. According to Yahya (2006) “community members expressed considerable concern about the age and competence of vaccinators”. Respondents in several states expressed unease that girls between the ages of 9 and 14 were employed to administer vaccines to babies. “This was discouraging to many otherwise willing parents, who rejected the polio vaccines on the grounds that vaccination is a task for qualified health professionals.” To the parents, employing such girls for immunisation was impertinent on the part of the health authorities and degrading of a very important service.

Supply Systems: Procurement and distribution systems in Nigeria seem to meet GHPs requirements yet they “remain chaotic and lack updated pharmaceutical regulations” (Druce & Oduwole, 2005). GAVI funds 100% of all new vaccines in the country and between 2002 and 2007 has committed almost $100 million (www.gavialliance.org). They have only disbursed about a fifth of this, a pointer perhaps that concerns about the funding crisis of GHPs are not unfounded as the corporate private sector and bilateral donors have failed to meet expectations. GAVI depends to a large extent on the Gates Foundation for funding and in 2005, faced a 25% shortfall in commitments (Buse and Harmer, 2007).

Meanwhile, efforts aimed at local R&D of pharmaceutical raw materials are yet to yield the desired results due to low funding. The national policy continues to reflect a move toward cost recovery for curative health care and drugs at all three levels of the health system (FMOH, 2004a). Nigeria adopted a new Malaria Drug policy in 2005 (www.guardiannewsngr.com) and Artemisinin-based combination therapies (ACTs) were recommended for front line therapy. However, some economists are concerned about their cost-effectiveness and sustainability (Creese et al. 2002). Till date, there is continued pressure from local pharmaceutical manufacturers and not GHPs for government to provide a favourable environment for local manufacture of ACTs and insecticide-treated nets (ITNs).

Service Management: RBM in Nigeria, as in most LMICs, has focused on high coverage for three evidence-based strategies: prompt effective treatment of acute cases, use of ITNs and intermittent preventive treatment (IPT) in pregnancy (www.rbm.who.int). This social marketing of health care commodities, from mosquito nets to condoms by NGOs funded by GFATM, may have also increased the incidence of illegal payments, mostly to providers, in cash or kind (Lewis, 2006). Ogbuokiri (1995) concluded that “communities must be recognized as being at the heart of the health system not merely as recipients of health intervention strategies but as participants in the design, funding and management”.

GAELF cites Nigeria as one of its success stories in integrating drug distribution into existing national and local PHC strategies quickly and cost-effectively (www.filariasis.org). In a related vein, the Global Alliance for Improved Nutrition (GAIN) has recorded some progress in the area of food fortification in Nigeria (www.gainhealth.org). Other examples show that some GHPs have also succeeded in improving policy-making and institutional reforms at the national level (Smith et al, 2005). Nonetheless, some commentators would still recommend for better integration into the health system to “improve effectiveness and ensure impact and sustainability” (Druce and Harmer, 2004).

Information and Monitoring Systems: HMIS is very important in this regard since it is supposedly through effective M&E that GHPs can track their aims and relevant bodies can fully investigate their impacts. However, Nigeria is still lagging far behind of meeting international standards. This may be due to the decentralised system which may make it more difficult to monitor progress in policy/programme development and implementation due to an ineffective and fragmented M&E system. Most programmes implemented or funded by GHPs are based on demographic surveillance surveys carried out several years ago.

In a study influenced by a new government /multilateral program with the target of achieving a 25% reduction in HIV prevalence in the population, it was found that despite increased spending on HIV/AIDS from GHPs (particularly GFATM), little success had been recorded. The study focused on factors opposing successful HIV/AIDS programmes in Nigeria and concluded that one of the major hindrances in Nigeria has been lack of accurate information. The study found a near absence of database for HIV/AIDS programmes and lack of basic facilities to monitor, evaluate and analyze the impact of these programmes. The study therefore posits that HMIS play various roles in ensuring the success of various government and GHPs programmes and that organizational behaviours and activities will change whenever M&E becomes an intrinsic part of the health care services. (Aremo et al. 2003).

Conclusions: There are several GHPs in Nigeria who run programmes through the appropriate national disease control programmes (FMOH, 2004a). Others impose a less immediate burden on government programmes; however, this more hands-off approach means an even greater dependence on a working system (Carlson 2004a). GHPs are apparently highly reliant on a functioning health system and where there are national programmes with poor reach, there is a direct impact on the effectiveness of GHPs funding (Caines & Lush, 2004). From available literature, it is clear that early achievements of extending delivery of specific health interventions such as childhood immunisation cannot be sustained unless they become an integral part of national health systems.

GHPs sometimes overlook how the health system is situated within the political economy of a particular country. For example, in Nigeria, states have considerable autonomy and resources well above the annual budgets of many countries in the sub-region – however, it is only few GHPs that operate at state level with almost all massing at the federal level. One challenge is to get GHPs to move away from vertical programming to addressing systemic issues which may mean using resources targeted at focal diseases for other health strategies in the system. The symbiotic relationship between GHPs and health systems has led most authors to state that the GHPs should include health system strengthening as part of the support they give to implementing countries and a realistic way forward must be to invest in an integrated financing strategy (Caines et al, 2005)..

The Stop TB Strategy aims to "contribute to health system strengthening" and encourages national TB programmes and partners to be pro-active in harmonizing efforts to improve the functions within national health systems (www.stoptb.org). However, GHPs often pursue their objectives without considering the impacts and in seeking rapid results; they often do not make use of recipient health systems especially weak ones in most LMICs (Caines, 2005). Some GHPs do not make “significant efforts to approach poverty related health problems with a focus on equity and integration” especially in difficult countries like Sierra Leone (Carlson, 2004) or Nigeria (Hargreaves, 2002). Poverty is at the root of inadequate health care however, there was little evidence that GHPs supported major investments to improve institutional settings and structures in Nigeria, and the effect has frequently been that their activities strained the unstable local health system and diverted human and other resources from their normal channels.

With countries that had introduced a system-wide approach (SWAP), similar to Nigeria’s NEEDS, financing GHPs sometimes put their resources into the common budget with other donors in order to harmonise with existing national priorities. They also provide support for ensuring M&E systems produce the information needed; GFATM- and GAVI-related coordination committees improved participation of a wider group of stakeholders concerned with GFATM diseases and with immunisation. However, this has to be framed within issues of availability, acceptability, quality and accessibility of health services; as well as participation and sense of ownership, especially by vulnerable groups and communities in order to be deemed effective overall. This study posits that GHPs may play a strengthening role in providing funding and technical assistance to country disease programmes but also in some cases they are a burden due mostly to the under-resourced health system.

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