Legislative Oversight and Primary Health Care Financing

By Abubakar Jimoh

While adequate, accessible and affordable health care system is paramount to the survival of the citizens, Nigerian health care system is one of the worsts hit by inadequate budgetary allocation, delayed release, lack of judicious utilisation of the existing funds, and poor monitoring that discourage transparency and accountability at all levels. The Primary Health Care component bears the major challenges confronting adequate health care delivery in the country. Efforts to ensuring adequate and timely delivery of qualitative health care services at all levels led to the promulgation of the National Health Act in 2014.

The National Health Act 2014 is a comprehensive legal document containing several pro-poor provisions for primary health care which if effectively implemented, will resuscitate the dwindling health care resources, facilities and services at all levels, especially giving the 1% Consolidated Revenue Fund (CRF) from national budget. Appropriate legislative oversight has therefore, becomes imperative to ensure effective implementation of the pro-poor Act.

It is on this premise that House of Representatives’ Committees on Health and Appropriation in collaboration with Civil Society Legislative Advocacy Centre (CISLAC) organised a two-day retreat in Accra, Ghana, to provide a platform for the Committees to discuss and review current challenges and opportunities in financing Primary Health Care in Nigeria.

Significance of Primary Health Care

In his opening remarks, the Chairman House Committee on Appropriation, Hon. Mustapha Bala Dawaki coined the importance of Primary Healthcare when he said, “the importance of Healthcare Delivery Services most especially in the rural areas where majority of our citizens’ lives cannot be over emphasized, most especially in developing societies like Nigeria.”

The Chairman continues: “Primary Health Care centres which should be in every cranny of our society are today absent due to poor funding of the exercise since after its creation. This has accounted for the failing Health Services and the resurgence of diseases that have long been eradicated in many countries like the resurgence of Polio…”

Lack of political will in the implementation

Also, the Chairman House Committee on Health Services, Hon Chike John Okafor did not conceal the fact that Primary Health Care without doubt remains the most acceptable approach for attaining universal health coverage in a health system. “Therefore, when this approach is adequately financed and implemented, it will not only have the capacity of reducing ill-health and increase affordability of quality healthcare but will ultimately, better productivity and economic status of our country.

“The critical elements Primary Health Care deserve adequate financing and pull od resources for planning, development and implementation. This is mostly relied on strong political will of governments which prioritises the health sector in budget appropriations,” he said.

The Chairman observed lack of political will of governments, resulting in the dearth of funding of the Primary Health Care and continuous dilapidating services and delivery especially in the areas of maternal and new-born, immunisation and malnutrition.

He added: “Nigerian Government has been signatories to several conventions and declarations in the past and made progress towards achieving the commitments made in those signatories. One of the most significant declarations is the Abuja Declaration of 2001, where African Union Heads of States met and pledged 15% of National Budget allocation to the health sector. However, despite being ranked the largest economy in Africa and having overall increase in the allocation of budget to health over the years, Nigeria health budget still hover around 5 to 6 percent of the total annual budget.

“Consequently, Nigeria is yet to fulfil its commitment to the 15% Abuja Declaration. It is worthy to note that there other African Countries with much less resources who have met and even surpass the pledge made at the declaration, with evidence of better health and economic outcomes. Some of these countries are Rwanda with an 18% of its national budget to the health sector, Botswana and Niger with a 17.8%, Malawi with 17.1%, Zambia (16.4%) and Burkina Faso (15.8%).

“This shows that reaching the Abuja Declaration is a realistic goal and the most important approach to achieving this goal is to encourage a strong political will from the Federal Government and continue to push for the provision of the 1% of the Consolidated Revenue Fund (CRF). From projections by experts, the 1% CRF will amount to billions of Naira from the Federal Government alone.”

In order to address the lingering financial challenges in the health sector, Hon. Okafor recommended among other things: step-up campaign for private donations; encouraged inter-sectoral collaboration between health sector and other sectors to channel alternative resources to health; encouraged public-private partnership; and improved value for money in health spending.

Adopting ICT in the health care management

The Chairman House Committee on Health Institutions, Hon. Betty Apiafi, called for the amendment of the National Health Act to ensure flexibility in the implementation through participatory and inclusive process. She recommended the adoption of ICT-based approach in the Nigeria health care system management and delivery to attain cost-saving, adequate, accessible and appropriate health service delivery at all levels.

A country with poor health indices in Sub-Saharan Africa

The Honourable Minister of Health, Prof. Isaac Folorunso Adewole represented by … reiterated that Nigeria as a unique country in Africa deserves world class health system that provides good quality health care to improve health outcomes, reduce inequity in health access and outcomes.

He bemoaned the poor health indices attributed to Nigeria in Sub-Saharan Africa such as Maternal Mortality and Infant Mortality totalling 576 per 100,000 and 69 per 1,000 respectively comparing to those of other countries like Ghana, 319 and 43; Ethiopia, 353 and 41; Kenya, 510 and 36; and South Africa, 138 and 34.

These poor outcomes according to the Minister are largely driven by low coverage rates of key basic health services, adding that limited access to basic health services by lower quartile contributes to mortality rates.

Prof. Adewole identified as part of the impediments to effective performance of health care system in Nigeria: overlapping responsibilities across the different levels of government with each tier of government intervening transversely in primary, secondary and tertiary care; lack of inter-governmental accountability to enhance health systems performance; fragmentation of accountability systems; limited capacity to drive and execute policy ; poor budget process and planning; lack of demand for data and weak performance management systems; focus on inputs rather than results and outcomes; lack of pooled payment systems to support risk equalization and cross subsidisation; and high Out-of-Pocket expenditure, which increases citizens exposure to financial catastrophe.

Dreadful impacts of the inadequate financing

The Executive Director of CISLAC, Auwal Ibrahim Musa (Rafsanjani) noted that the retreat was timely as the nation moves towards another fiscal year, where critical inputs are expected into the nation’s budgetary process, especially by the executive and legislative arms of the government.

He said: “Health remains a major challenge in the development of Nigerian’s economy. This fact is buttressed by the study conducted by Civil Society Legislative Advocacy Centre (CISLAC) in 2013. The study shows that in Nigeria, one in 13 women dies during pregnancy or childbirth, and 12% of children die before reaching the age of five. The study observed that every 10 minutes one woman dies from conditions associated with childbirth.

“According to the study, only 39% births take place with assistance of medically trained personnel, coupled with the scarcity of skilled attendants, absence of personnel, among other factors impeding the effectiveness of health services in the country. In a situation where by nearly half of the population loses only plunges the economy and impedes development as every one person counts in any country’s development.

“Similarly, while it is confirmed that Child Spacing has direct impact on the health of the family and grossly the economy of a nation as a whole with tendency to mitigate maternal and child deaths in the country, yet, budgetary allocation to Child Spacing in the context of Nigeria Family Planning Blueprint and the Costed Implementation Plans is an endemic challenge at all levels.

The Executive Director bemoaned the announcement by the World Health Organisation (WHO) declaring Nigeria free in 2015 from the long-time dreadful polio epidemic which was recently reversed as two different cases of wild polio virus reportedly resurfaced in Borno state in the absence of adequate financing and timely release of fund by the government to sustain gains of halting polio in the country.

Existing legal and financial provisions

The CISLAC’s boss recalled that the National Health Act 2014, a comprehensive legal document, which implementation was supposed to have commenced since 2015 is yet to see the light of day even in the 2016 Appropriation Act. “Though financing health care system remains a major challenge across the world, but Nigeria is yet to demonstrate the ability to face this challenge so that the health system can benefit citizens at all levels”.

It is against this backdrop that the Health Minister noted that the National Health Act came to limelight as part of the efforts to address specific challenges confronting adequate health care delivery such as responsibility for health and eligibility for health services and establishment of National Health System; health establishments and Technologies; rights and obligations of users and health care personnel; National Health Research and Information System; Human Resources for Health; Control of use of blood, blood products, tissue and gametes in humans; and regulations and miscellaneous provisions

The Act according to him increases the fiscal space for health through the Basic Health Care Provision Fund, as established under Section 11 of the National Health Act will increase  the  fiscal  space  and  overall   financing  to  the  health  sector  to  assist  Nigeria achieve Universal Health Coverage (UHC); and enhance the principal  funding  vehicle   for  the  Basic  Minimum  Package  of  Health  Services   (BMPHS).

Deliberating on Provision Plan for Financing Basic Health Care, the Director-General, Budget Office of the Federation, Mr. Ben Akabueze noted that the overarching health sector goal for Nigeria, as for most nations, is Universal Health Coverage (UHC), which is achievable through provision of an estimated $86 per person in providing basic health services.

In his analysis, though the recommended public expenditure on health is 5% of a nation’s Gross Domestic Product (GDP), but Nigeria currently spends only about 1% of GDP. “Consequently, the burden of paying for healthcare in Nigeria is disproportionately borne by households, most of which have no health insurance.”

On the present economic downturn, which reduces ability of Nigerian households to fund out-of-pocket healthcare expenses, and hence generally excludes the poorest and most vulnerable from access to healthcare, the Director-General noted the importance of National Health Act (2014). The Act provides for the creation of the Basic Health Care Provision Fund (BHCPF) as part of efforts to improve public funding of healthcare. The Fund was established to finance various health programs, and specifically to improve access to quality Primary Health Care (PHC) across the country.

He explained that 50% of the fund will be transferred to the National Health Insurance Scheme (NHIS) to cover basic health care services; 45% will be disbursed to the National Primary Health Care Development Agency (NPHCDA) for essential drugs/vaccines/consumables, maintaining PHC facilities, equipment, transportation, and strengthening human resource capacity at primary healthcare facilities around the country; and final 5% will be used by the Federal Ministry of Health (FMOH) to respond to health emergencies and epidemics.

As stipulates by Section 11 of the National Health Act, the Fund will be largely sourced from a “Federal Government Annual Grant of not less than one percent of its Consolidated Revenue Fund.”

Based on the draft Medium Term Expenditure Framework and Fiscal Strategy Paper (MTEF&FSP) 2017-2019, the Budget Office’s boss mentioned that 1% of CRF translates to an average of N35bn per annum over the next 3 years, stating that additional sources of funding the BHCPF include grants by Development Partners and funds generated from innovative sources such as taxes on cigarettes and alcohol.

He is however bothered by implementation challenges such as the judicious utilisation of the funds to achieve the desired objectives; ability of the states to provide counterpart funds; widely differing map of status of primary healthcare across the states; ability of the most vulnerable to subscribe to the 0.5% National Health Insurance Scheme of Consolidated Revenue Fund; the existing administrative structure of fund between the State and Local Governments.

Declining budgetary allocation to health sector

Recalling the poor allocation to health sector in the 2016 national budget, the Executive Director, Budgit Nigeria, Mr. Seun Onigbinde lamented that health    as a critical sector received as low as N257bn (4.13%) when infrastructure, defence, education, police was allocated N467bn (7.7%), N429bn (7.07%), N406bn           (6.7%), and N300bn (4.95%).

Comparing data from various health allocations since 2013, he observed that the health budget peaked in 2013 at N280bn but despite the rise in  the budget size, health budget has declined from N257bn.

“Health allocation as share of National Budget has been declining and huge dip in 2016 (4.13%) from 5.78% in 2015. It is baffling to note that recurrent expenditure accounts for 88-95% of the budget since 2011. Federal Government has been spending so little on capital components of health budgets.

“Federal Government’s actually budgets N1, 438 annually for health per Nigerian.  With over 100m Nigerian without health insurance, the country grapples with weak infrastructure mostly at the primary health level.

“While the budget grew by 36% in 2016, health budget declined by 0.7%; 84% of the budget is still meant for personnel costs and    too little less than 14% spent  on capital expenditure. The Ministry of Health has 128 units            but 60% of the health  CAPITAL budget is allocated to the Federal Ministry of Health and National Primary Health Care Development Agency (NPHCDA),”the Budgit’s boss complained.

Understanding citizens’ rights to demand accountability  

In a paper titled “National Health Act & Provisions: How it will impact the Health Sector”, Dr. Muhammad Muhammad Saleh, a Technical Consultant on Health noted that the National Health Act is one single instrument required to unlock economy and the greatest transformation for the health sector in Nigeria.

He stated that the Act has established the Nigerian National Health System specifying all the key players and actors therein and their roles and responsibilities.

“An aggrieved person may lay a complaint about the manner in which he or she was treated at a health establishment and have the complaint investigated. Public officers are barred from medical checkup, investigation or treatment abroad at public expense, except in exceptional cases approved by a medical board and Minister or Commissioner of Health.

“The manipulation of genetic material (“cloning”) and the import/export of embryos are prohibited. Post mortems and autopsies can only be authorized by the following; spouse, child, parent, guardian, brother or sister – in that order,” the Consultant explained.

Dr. Saleh observed the Act as a very important development to change the status quo to guarantee the Right to Health for all citizens.

“Health services are classified as essential services and the Minister of Health is required to apply all reasonable measures to ensure return to normalcy after disruption within 14 days (i.e. Strikes). You can hold government accountable on their responsibilities to provide you with good health care service(s). All organizations, people and actions whose primary intent is to promote, restore and maintain health in Nigeria,” he noted.

Appropriate HIS to aid citizens’ decision

Similarly, Dr Jibril Muhammad Bashar, a Consultant at Health Policy and System Development recounted the prominence of the National Health Act when he added: “a comprehensive Health System that is promotive, protective, preventive, restorative and rehabilitative. Health System Based on Primary Healthcare reflecting the economic conditions, socio-cultural and political characteristics of the communities, addressing the main problems in the communities.”

Dr. Bashar An Integrated and Co-ordinated National Health Care System that is multi-sectoral, with community involvement, and collaboration with non-governmental organisations. He observed as key to effective health system management: planning, organisation, directing, staffing, coordinating, and budgeting.

In order to attain the national goal of achieving health for all Nigerians, he recommended appropriate Health Information System, which includes the availability of accurate, timely, reliable and relevant health information to inform public health action.

He added: “The planning, monitoring and evaluation of health services are hampered by the dearth of reliable data at all levels. A national health information system has been established, effort however, should be made to ensure data collected are accurate and timely and ownership should be institutionalised by Nigerian government. Efforts should be made to implement community based systems for the collection of vital health statistics of births and deaths.”

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