PATHS2: Transforming the Nigerian Health System

The focus of the Partnership for Transforming Health Systems 2 (PATHS2) evolved during its eight years, from governance, to service delivery, to private sector partnerships.

But PATHS2’s central goal did not change: Improving the planning, financing, and delivery of sustainable, replicable, pro-poor health services for common health problems. The project has much to show for its efforts, in particular improving child health and reducing maternal mortality.

PATHS2 was led by Abt Global and funded by UKaid from the Department for International Development. Abt’s partners included MannionDaniels, the Axios Foundation, and Options. The project worked in five states beginning in 2008: Enugu, Jigawa, Kaduna, Kano, and Lagos.

The project concluded in the northern states of Jigawa, Kaduna, and Kano in January 2014, but continued in the southern states of Enugu and Lagos through July 2016, principally working through public-private partnerships (PPPs) to strengthen service delivery.

Thousands of Lives Saved
“PATHS2 brought fundamental change to Nigeria’s health care system,” said Diana R. Silimperi, M.D., division vice president for International Health at Abt Global. “The project engaged people at all levels of the government, in communities, and in the health system and prepared them to take stewardship roles in the system.”

“The project also strengthened citizens’ and civil societies’ ability to hold local health authorities and service providers accountable for quality, affordable care,” Silimperi said.

PATHS2’s long list of achievements includes:

• Helping save more than 140,000 lives in Northern Nigeria by supporting a robust and resilient health system with improved access to and availability of quality maternal, newborn, and child health services;
• Increasing deliveries by skilled birth attendants from 13 percent in 2009 to 48 percent in 2015;
• The proportion of PATHS2 supported public health facilities with a defined list of essential drug supplies in stock at time of the visit grew from 4 percent in 2009 to 87.5 percent in 2016; and
• Increasing the percentage of the public who can spot significant, pregnancy-related health problems from 4 percent in 2012 to 26 percent in 2016.

Properly Funding Nigeria’s Health System
“Perhaps the most significant achievement facilitated by PATHS2 was the December 2015 enactment of the National Health Act, which had been debated for more than a decade,” Silimperi said.

The law ensures steady funding for health services by requiring one percent of the country’s consolidated revenue fund to be dedicated to health care.

Half of the funding is for health coverage for pregnant women, children under five, the elderly, and the physically challenged. The other half is for primary healthcare services, including buying supplies – such as vaccines – plus for facility maintenance, equipment, transport for primary health care facilities (PHCs), and development of human resources for PHCs.

Also, PATHS2 aided the development of a number of health care policies, plans, and systems to ensure that the best-possible services are delivered by the best-trained and supported staff. These include the first-ever National Strategic Development Plan and subsequent plans for the five states supported by PATHS2, which lead the 31 other states to follow suit. The plans set goals and measure progress against these goals.

Working with Informal and Private Sector Health Providers
PATHS2 worked to ensure that informal health providers in Nigeria – including traditional birth attendants and patent medicine vendors – were officially recognized and integrated into the country’s health system. PATHS2 also integrated the private sector into the health system in part by facilitating the creation of lifesaving referrals via emergency transportation agreements, also called Emergency Transport Schemes.

But nurses, doctors, and other health providers cannot do their jobs without adequate medical supplies. So PATHS2 strengthened the drug supply system in all five supported states, leading to functional drug revolving funds in 535 health facilities, including faith-based organizations. These revolving funds guarantee a supply of high-quality, affordable drugs direct from manufacturers. After an initial capital investment, the fund uses the proceeds collected from drug sales to replenish drug stocks. This eliminates frequent excessive markups from intermediary distributors.

Felicia Ademoye, a client of the Igbogbo Primary Health Centre in Ikorodu, Lagos State, said that the drug revolving funds increased her visits to the facility. “Now they have most of the drugs here,” she said. “This encourages me to patronize the facility because the drugs are cheap and of high quality.”

Driving Change through Community Events, Empowerment
“One of the most important lessons of the project is the power of community partnerships and outreach to bring change,” Silimperi said.

PATHS2, for example, established 1,098 community groups to actively influence the types and quality of services delivered in both public and private health facilities.

The project also:

• Trained traditional leaders and male gatekeepers to be advocates for maternal, newborn, and child health  issues;
• Conducted more than 3,500 health care outreach events by trained health workers; and
• Trained more than 18,000 community volunteers to recognize the danger signs of a difficult pregnancy, which produced faster referrals for emergency care and saved lives. 

“From my knowledge of the maternal danger signs I would say that I have been taking a very big risk with my life. I know better now. No woman should risk her life or that of her baby,” said Mrs. Gift Ede of Igbo-Etiti, Enugu State.

Read more about PATHS2:

• An Effective Partnership for Health Systems Strengthening: The PATHS2 Legacy in Northern Nigeria
• Nigeria: Working to Improve Health, Governance, and Food Security
• PATHS2 Shares Health Systems Innovations and Experiences in Nigeria through Knowledge Fair

Read about Abt’s related work:

• Evaluating International Programs: Answering the Toughest Questions
• Evaluating the Power of Pull Mechanisms to Improve Global Food Security
• SHOPS Celebrates Five Years of Progress in Family Planning, HIV and AIDS, and Maternal and Child Health