HEALTH SYSTEMS STRENGTHENING IN ACTION: CREATING SUSTAINABLE GOVERNMENT COMMITMENT IN KWARA STATE, NIGERIA

Background

Ten years after the President’s Emergency Plan For AIDS Relief (PEPFAR) program began in Nigeria, domestic financial resources continue to be substantially supplemented by external funding, which accounts for about 75% of total spending on HIV and AIDS. Public and out-of-pocket spending only amounts to 25%. As of 2010, state governments contributed less than 0.3% of total government funding for HIV in Nigeria, with the federal government accounting for 99.7% of public spending on HIV and AIDS.

In 2010, the Government of Nigeria (GoN) and the United States Government (USG) signed a Partnership Framework on HIV/AIDS detailing a five-year strategic plan to develop and implement a sustainable national response to HIV and AIDS.1 As part of this agreement, the

ABOUT PRO-ACT

The Prevention and Organizational Systems - AIDS Care and Treatment (Pro-ACT) project is a seven-year project (2009-2016) funded by the United States Agency for International Development (USAID) and implemented by Management Sciences for Health (MSH) in five Nigerian states: Niger, Kwara, Kebbi, Sokoto, and Zamfara. Pro-ACT strengthens the capacity of Nigeria’s public, private, and community sectors for sustainable HIV/AIDS and TB prevention, control, care and treatment integrated within the health system.

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OCTOBER 2016

NIGERIA PREVENTION AND ORGANIZATIONAL SYSTEMS - AIDS CARE AND TREATMENT PROJECT

2 n HEALTH SYSTEMS STRENGTHENING IN ACTION: CREATING SUSTAINABLE COMMITMENT

GoN was expected to incrementally increase funding for the country’s HIV and AIDS response and reach a funding level of 50% by 2015. The most recent National AIDS Spending Assessment (NASA 2012) put central level government spending at 21.3%.2 The assessment report does not, however, disaggregate government spending by central, state, and local government levels.

In April 2014, PEPFAR reviewed its implementation policy and announced that support to Nigeria would focus on:

n Meeting the most critical needs of the national response, and

n Implementing a gradual transition of less critical programmatic investments to the GoN.

The implementation strategy focused on streamlining and standardizing a PEPFAR package of services and programs, and engaging with the GoN for the sustainability of certain laboratory services and opportunistic infection treatment. The major changes in the PEPFAR Nigeria strategy included ceasing support for services such as hematology and clinical chemistry lab investigations and drugs for treatment of opportunistic infections. In the non-priority states, PEPFAR discontinued support for HIV prevention activities, targeting key populations and demand creation activities instead. Implementing Partners were required to transition support for these activities to state governments who now had to fund these activities on their own.

The Pro-ACT project, funded by the United States Agency for International Development (USAID) and implemented by Management Sciences for Health (MSH), provided technical support to the state governments to facilitate this transition. Though similar interventions were implemented in all five of the project states, Kwara was the first state to show signs of commitment and action towards owning and taking up responsibility for some of the transitioned HIV services.

In Kwara, state government HIV/AIDS spending was consistently low as a result of not having the financial and management framework necessary to facilitate funding of the transitioned services. To significantly increase domestic HIV/AIDS funding, strategic support by the Pro-ACT project in collaboration with the government of Kwara State was provided to:

n Strengthen the budgetary process to reflect the needs of the transitioned services

n Develop the State Strategic Plan

n Develop the annual unified HIV/AIDS Costed Operational Plan

n Engage with key stakeholders at the State Ministries of Health; Budget and Economic Planning; and Kwara State Agency for the Control of HIV/AIDS (KWASACA) for budget release and implementation.

As a result of this support, Kwara State became the first state in Nigeria to allocate and approve funding for transitioned PEPFAR-supported HIV and AIDS services.

Approach

From its inception, the Pro-ACT project has channeled its efforts towards the gradual transitioning of PEPFAR investments and achievements to the GoN. To achieve this, the project implemented two strategic approaches:

1. Influencing policy to improve financing for HIV and AIDS, increase resources (such as consumables, laboratory reagents, and medicines), and improve access and coverage for HIV and AIDS service delivery.

2. Strengthening existing structures for efficient management of resources and stewardship for HIV and AIDS service delivery.

The transition process included the following assessments and activities that enabled the Kwara State government to take ownership of the HIV and AIDS activities:

Organizational capacity assessment (OCA)

An OCA was carried out in Kwara using the National Harmonized Organizational Capacity Assessment Tool (NHOCAT) to identify management and technical strengths and weaknesses of the key HIV and AIDS institutions. Major findings included weaknesses in resource mobilization, accountability, governance, and leadership. The project prioritized technical assistance to strengthen the leadership and management capacities of health managers, including resource mapping and resource mobilization, strategic implementation planning, and the MSH Leadership Development Program (LDP).

Transition capacity assessment (TCA)

Using the AIDSTAR-One PEPFAR HIV/AIDS treatment transition capacity assessment tool, the project measured the readiness of Kwara to take over the management, care, and treatment of HIV/AIDS. The aggregate score for the state was 37%, indicating basic capacity at implementing minimum standards and systems. The major findings included strong partnerships developed and fostered by the state government. Weaknesses included human resources, operating systems, policies, infrastructure and resources, management systems, and fiscal management.

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These variables had an average score of 27% implying inadequate capacity to take over management, and HIV/AIDS care and treatment services. To improve the systems, Pro-ACT supported the state to establish a state HIV and AIDS management team (SMT), and technical working groups (TWG) on treatment care and logistics management.

Sustainability plan

The project developed a strategic transition plan that highlighted current PEPFAR support, including technical assistance and supplies with specific activities that would transition to the state institutions and communities in an incremental manner.

Mapping of stakeholders

To gain a better understanding of the inner workings of the state’s budgetary process and to identify key stakeholders in the state that influence resource mobilization, Pro-ACT conducted a mapping of stakeholders. The team identified influential health and non-health actors, including representatives from the Ministry of Health, HIV and AIDS Agency, Legislative, Budget & Economic Planning, and the Ministry of Finance. The mapping was used to assist the state TWG with designing resource mobilization and advocacy strategies for generating domestic resources and advocating for HIV/AIDS funding in the state budget.

Costing and forecasting transition needs

Pro-ACT, using a state-adapted forecasting and quantification tool, estimated that to support these

services, Kwara State would require about N256 million (US$1.6 million) to meet its Expected Funding Commitment for 2015, based on the actual number of clients and cost per service. Justification notes, advocacy briefs, and investment cases were also developed to support advocacy efforts for building political will and support for HIV and AIDS services budgetary allocations.

Engagement with political stakeholders

High level meetings were conducted with commissioners and permanent secretaries from ministries, departments, and agencies from all states to inform them of PEPFAR’s new policy direction, acknowledge the need to budget for the cost of transitioned HIV and AIDS services, and commit to promoting ownership and sustainability of HIV and AIDS services.

Engagement with technical stakeholders

Mutual engagement and advocacy meetings were held with multi-agency stakeholders including key technical officers from the State Ministry of Health, State AIDS Control Agency, Ministry of Budget and Economic Planning, State House of Assembly, and State Executive council. These meetings helped various actors to understand the justification for supporting the transitioned HIV and AIDS services through policy and budgetary changes.

Strengthening governance structures

Pro-ACT supported the state to establish multi-sectoral coordination platforms, guided by the national response, to improve management efficiency and accountability. Civil

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Society Organizations (CSOs) and networks of people living with HIV (PLHIV) were also represented in these coordination platforms and engaged in advocacy efforts.

Results The combination of stakeholder engagement, technical support, and targeted advocacy resulted in:

n The passage and executive approval of N277 million (US$1.7 million) to specifically cover transitioned PEPFAR services in the 2015 Kwara State budget, in addition to N381 million (US$2.3 million) to scale up HIV and AIDS prevention, treatment, and care services across the state in 2015, a significant increase over the N50 million (US$300,000) budgeted in 2014. This was the first state in Nigeria to allocate and approve funding for transitioned PEPFAR-supported HIV and AIDS services. In 2016, the Kwara government budgeted N204 million (US$1.2 million) for supporting the transitioned PEPFAR services. The decrease in the budget allocation from 2015 to 2016 was in light of the overall decline in projected government revenue arising from falling oil prices.

n The creation of multi-agency collaboration platforms for more inclusive, open, and comprehensive budgeting and stewardship of HIV and AIDS services. The multi- agency platforms include the State Ministry of Health, State AIDS and STI Control Program (SASCP), State Agency for the Control of HIV/AIDS (SACA), Implementing Partners, Networks, CSOs, other line ministries such as Education, Women Affairs, Youth and Sports, Budget and Planning, Ministry of Finance and Private sector. The platforms meet quarterly and have developed a Road Map on sustaining the HIV response in the State.

n Increased capacity of CSOs and PLHIV networks to advocate for stronger state accountability, enhanced through the LDP with an emphasis on voice and power for making change. Following the LDP training, Civil Society For HIV/AIDS in Nigeria (CISHAN) and the Network of People Living with HIV and AIDS in

Nigeria (NEPWHAN) Kwara State Chapter were empowered to participate and contribute to different HIV/AIDS coordination fora on issues affecting the State ownership of the HIV/AIDS response. On the 2015 World HIV/AIDS Day, NEPWHAN and CISHAN disseminated a press release on Government Funding of HIV/AIDS in Kwara State, which contributed to the inclusion of an HIV/AIDS budget line in the State Budget.

ConclusionPro-ACT’s support in Kwara State resulted in a dramatic increase in state government funding for HIV/AIDS services, increasing from 1 million naira ($600) in 2009 to 50 million naira ($300,000) by 2014. Anecdotal evidence suggests that the following factors may also have contributed to this success:

n The political will and interest of the State government;

n Pro-ACT’s positive relations and shared trust with the state, built over time;

n The highly developed capacity of the CSOs and PLHIV support groups; and

n The timing of the intervention, which began before the conclusion of the state budgeting process.

For this process to be replicated and scaled up, further study of the key enablers and sucess factors in Kwara State is needed. n

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PEPFAR’s support has assisted the people, and Kwara State has benefitted immensely. We should have been taking up our responsibilities. It is time to begin. - Hon. Monde Aliyu Umar, Chairman of the Health Committee, Kwara State House

of Assembly_________________________________________________________________

References 1. Partnership Framework on HIV/AIDS, 2010-2015: A Memorandum of Understanding between the Government of Nigeria and the Unites States Government to Fight HIV/AIDS in Nigeria. August 25, 2010. (http://www.pepfar.gov/documents/organization/148812.pdf) 2. Federal Government of Nigeria National AIDS Spending Assessment (NASA) for the Period: 2011-2012 (http://files.unaids.org/en/media/unaids/contentassets/documents/data-and-analysis/tools/nasa/20141017/nigeria_2011-2012_en.pdf)

Additional information can be obtained from: Med Makumbi, Project Director, Pro-ACT Project, mmakumbi@msh.org

Management Sciences for Health, Abuja, Nigeria, www.msh.org

This publication is made possible with the generous support of the United States President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under Associate Award No. AID-620-A-00-09-00013-00. The contents are the responsibility of the Pro-ACT Project and do not

necessarily reflect the views of USAID or the United States Government.