The health financing landscape in Nigeria is characterized by suboptimal government health investment and low level of citizen coverage by financial protection mechanisms. Evidence shows that without changing the aforementioned landscape, it is almost impossible to expand access to healthcare with equity and shared financial risk protection which are the hallmarks of UniversalHealth Coverage goals.
The recently conducted National Health Account shows that government health expenditure as a proportion of general government expenditure is 4%, while government health expenditure as a percentage of GDP is less than 1%. In the same vein, out-of-pocket expenditure as a share of total health expenditure is 73% and less than 5% of the population is covered by any form of prepayment mechanisms.
The Nigeria healthfinancing indices are a far cry from internationally recommended benchmarks of 15% GHE/GGE, at least 5% GHE/GDP, less than 30% OOPE/THE and a minimum of 90% coverage by financial protection mechanisms such as health insurance schemes.
Juxtaposing Nigeria healthfinancing indices with that of other lower middle-income countries and international benchmarks required to make significant progress towards UHC portrays a picture of an underperforming healthfinancing system .The suboptimal government health investment and highout of pocket expenditure no doubt contribute significantly to poor health indices in the country.
According to UN inter-agency group for child mortality, Nigeria is one of the five countries that accounted for 50 per cent of global child deaths in 2016, and the country was ranked among 10 worst countries in terms of wellbeing of mothers, going by a report from Save the Children in 2013.
The abysmal health outcome statistics mirror the poor coverage of essential health services and the socio-economic inequity in accessing basic care in the country. An access inequality chart from the World Health Organisation shows that women from high income group in the country are 10 times more likely to access skilled delivery service than women in the lowest income group, while children from the lowest income group are three times more likely to die before their fifth birthday than children from the highest income group.
The aforementioned scenario reflects dysfunctional state of health system governance and financing in the country. The policy makers in Nigeria are responding to the suboptimal healthfinancing indices by introducing a number of legal, institutional and policy frameworks aimed at improving government health spending, expanding coverage of financial protection mechanisms and ensuring efficient PHC service delivery.
Thus in 2014, a comprehensive health legal framework called National Health Act was signed into law at the twilight of the administration of the former President Goodluck Jonathan. Among other things, the National Health Act makes provision for basichealthcare Provision Fund (BHCPF), which is an earmarked fund aimed at improved government financing of both supply side and demand side of basichealth services. The BHCPF will be financed with not less than 1% Consolidated Revenue Fund (CRF) of the Federal Government of Nigeria and other sources.
As part of supply side reforms, the National Primary healthcare Development Agency (NPHCDA) has introduced a PHC management integration policy of PHC Under One Roof (PHCUOR). The pace of implementation of these laudable policy thrusts is however far from desirable; while PHCUOR and health insurance decentralization policy thrusts are at various stages of implementation in different states. The Federal Government is yet to allocate funding for BHCPF’s kickoff since the enabling law for the Fund was signed in 2014. The quest for kick-starting a major healthfinancing reform which could also spur the state governments to reposition their healthfinancing systems has therefore remained elusive since 2014. Thus, the dream of expanded health access with equity and shared financial risk protection still remains a dream.
As part of efforts geared towards advancing the cause of UHC in the country, Nigeria lawmakers have taken a giant step by establishing a Legislative Network for UHC which is a veritable tool for harnessing and aligning statutory functions of the legislators towards achieving UHC goal in Nigeria. The lawmakers have therefore committed themselves towards deploying their appropriation, legislation, oversight and accountability roles to the national UHC quest. Highly commendable is the recent resolution by the Senate to implement the National Health Act provisions, especially the basichealthcare Provision Fund (BHCPF) that earmarks not less than 1% of Consolidated Revenue Fund of the Federal Government to fund basic minimum package of care for all Nigerians. The additional funding for health by the Federal Government could serve as an impetus for the states to also contribute 1% of their state’s Consolidated Revenue Fund to their respective SSHIS.
While Federal Government’s investment in infrastructure and security is no doubt a step in the right direction, we should remind the political class that complementary investments in other important sectors are needed to achieve the much-desired dream of a prosperous and peaceful Nigeria.
The often cited reasons for suboptimal investment in some sectors such as low absorptive capacity of government agencies and fear of misappropriation of resources are genuine concerns. Healthsector stakeholders are not unaware that there are no fool-proof measures against inefficiency; the stakeholders are therefore committed to an interactive process of continuous improvement of BHCPF management processes to achieve the desired objective of improved health access with equity, financial risk protection and efficiency.
This should therefore create an impetus for sustained engagement of the policy makers with the political class to prioritize implementation of the BHCPF and put health on political front burner.
The build-up to the elections create a unique opportunity for citizens to table their needs before politicians and scrutinize contents of their political agenda to ensure conformity with the perceived or real needs of the citizens. There is therefore an urgent need to stimulate evidence-based political engagement by generating evidence and useful tools for political discourse on UniversalHealth Coverage prior to the 2019 election.
Stakeholders in the Healthsector should be prepared to promote issues-based electioneering ahead of the 2019 general elections. Healthsector activists should also effectively engage major political parties and aspirants to political offices to ensure that they understand prevailing health policies and obtain their commitments to implementing sound health policies upon winning elections.
Finally, Nigeria’s policy makers should be mindful of the strategic leadership position of the country in Africa and realize that Nigeria’s progress on UHC will provide impetus for other African countries to make progress. Nigeria has what it takes to be the centre of best practice and a model for best health system among equals. Showing unalloyed commitment towards UHC cannot be more auspicious than now.
*Dr Gafar Alawode, the Chief of Party, Health Finance and Governance Project, wrote through @gafaralawode
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