Nigeria: New Legislative Drive to Revitalize Primary Health Care

By Abubakar Jimoh

  • Health financing system is characterized by low investment by Government – Rt. Hon. Dogara
  • Nigeria does not need to wait for economic development to invest substantially in health – Hon. Okafor
  • PHC is the most acceptable approach to deliver effective, accessible acceptable health care – CISLAC
  • PHC receives little funding with highest disease burden – Religious group
  • Current delivery of care system will continue to fail, except for radical reforms – CSIG
  • Majority of Nigerians live in rural areas where many diseases are prevalent – NSP
  • Healthy population paramount to the development of a thriving economy – Coalition

On 7th and 8th September, 2016, the House of Representatives Committees on Appropriation and Health in partnership Civil Society Legislative Advocacy Centre (CISLAC) organised a two-day Retreat for House of Representatives on financing Primary Health Care in Nigeria. The Retreat which was held in Accra, the capital city of Ghana aimed at providing a platform for relevant Committees in the House of Representatives to discuss and review current challenges and opportunities in financing Primary Health Care in Nigeria.  The retreat drew about 60 participants from House of Representatives, Ministries of Health, Budget and Planning, civil society, and development partners. 

In response to calls and commitments from the Retreat, on 20th October, 2016, the House Chairman Committee on Health Services, Hon. Chike John Okafor, during a plenary session, moved a motion on the “Urgent Need for Revitalization and Adequate Funding of the Primary Health Care System”. The House mandated the Committee to convene a public hearing to identify, harmonize and streamline additional sources of funding from stakeholders and report back to the House within four weeks for further legislative action. It also urged the Federal Government to declare a state of emergency in the Primary Healthcare Sector in Nigeria.

It is on this backdrop that the Committee recently organized a two-day Public Hearing to provide interface between the House and relevant stakeholders to identify and proffer innovative, practical and measurable strategies of financing health sector and revitalizing the Primary Health Care in Nigeria for the promotion of the good health and overall wellbeing of the citizens.

Inadequate financing, major impediment to PHC

Speaking at the public hearing, Speaker of the House, Rt. Hon. Yakubu Dogara admitted that health care financing remains “one of the greatest problems hindering access to health care services”. “In Nigeria today, the government is using different methods to address public health financing. Unfortunately, the health financing system is still characterized by low investment by Government, extensive out of pocket payments (OOPP), limited insurance funding and low donor funding,” he explained.

The Speaker spoke on the need to revitalize the Primary Health Care centers across the country, as they are the first port of call to majority of Nigerians living in rural areas; and eliminate the barriers to access health care delivery through prepayments and subsequent pooling of funds in preference to direct out of pocket payments.

NASS as a transformation agent

Hon. Okafor noted that the National Assembly has a crucial role to play in catalyzing the transformation of the health sector in Nigeria, stating that Primary Health Care, no doubt, remains the most acceptable approach for achieving a universal health coverage in our healthcare system as over 80% of Nigerians live in the grassroots and Primary Health Care centres are the closest health institutions accessible to them.

He said: “Currently, there are 774 Local Government Areas (LGAs) with 9,572 political wards in Nigeria. At least, each of the LGAs has one Primary Health Care Centre that is not fully functional. Most of these PHC centres lack drug supplies, basic health infrastructures, and cannot boast of good number of medical personnel. In fact, patients accessing these PHC centres can hardly afford the cost of transportation or cost of subsidized drugs in these centres due to the economic hardship of most the rural dwellers.

The Committee Chair reiterated the impact of non-functional primary health care in death of 192, 284, 143, 688, 212, 557 people from malaria, diarrhea diseases, and neonatal and maternal disorders in 2015, respectively.

As the attainment of Universal Health Coverage in Nigeria hinges on full functionality of the Primary Health Care system, he said it was imperative that current bottleneck hindering the provision of efficient Primary Health Care in Nigeria were identified and removed in a holistic, inclusive and strategic manner. “A competent skilled and healthy workforce is critical to policy and plan formulation, regulation and service delivery… Consequently, Nigeria does not need to wait for the economy to develop before investing substantially in health and human capital development.

“The national Government must commit to improving minimum health services by committing to a timetable to reach the 15% Abuja Declaration on Health budget target and must immediately implement the National Health Act. This should start by funding the Basic Health Care Provision Fund (BHCPF) with no less than 1% of the Consolidated Revenue Fund – or about 38.6 billion Naira – in 2017 budget. By providing a minimum package of health services to all citizens by creating primary health care facilities, this fund will save thousands of lives.

“Delivering this funding could have a significant impact and put the country on a path to better health once and for all. Evidence suggests that a 10% increase in total health expenditure per capita leads to a 21% decrease in under-5 mortality rates and a 22% decrease in infant mortality rates,”Okafor added.

Poor funding for highest populated PHC

In its submission at the public hearing, Civil Society Integrity Group noted that the current models of coordination and delivery of care in the country will continue to fail the Nigerian people, except systems-based radical reforms and re-organisations of the processes are implemented.  It explained that though with 22% fund provision, Primary Health Care accounts for highest disease burden and highest population coverage. The group urged the Committee to reverse fund allocation to health care to reflect more resources to the Primary Health Care.

Similarly, Knights of St. John International called for reversed funding pyramid in favour of Primary Health Care where the highest burden of diseases lies, and established standards of service quality and regulation of practices.

Lack of political will to implement 1% CRF Provision

The National Immunization Financing Task Team recalled in 2015, a report by the United Nations Children’s Fund (UNICEF) estimates that about 750, 000 children in Nigeria dies annually before their 5th birthday and 28% of the deaths were caused by diseases that are vaccine-preventable diseases, which result in paralysis (wild polio virus) and financial burden.

According to the Team, although Nigeria pays fully for the traditional vaccines, Gavi supports government of Nigeria heavily on new financing. Nigeria however, became illegible for continued Gavi support thus, the gradual transition of Gavi support will commence in 2017 and last till 2021. During the transition period and thereafter, Nigeria will need to mobilise more financial resources to fill the funding gaps.

It explained that data from National Primary Health Care Development Agency shows that we need to appropriate about $140 million for routine immunization vaccine for 2017-18 in the 2017 Appropriation Act to ensure timely availability of vaccines. This unprecedented increase, in the words of the Team, results from the introduction of new vaccines, the increasing infant population, and the transition out of Gavi support. Unfortunately, these changes are occurring in a dynamic context – historically inadequate budget for immunization, economic recession and lack of political will to implement the 15% Abuja Declaration or not less than 1% Consolidated Revenue Fund (CRF) for Basic Heath Care Development Fund as stipulated in the National Health Act 2014.

The Team recommended strategic actions by key policy makers and stakeholders to ensure sustainable immunization financing in Nigeria; enhanced working relationship between the House and Senate to ensure adequate budgetary allocation for vaccine and immunization in 2017 budget. It also, urged the House to ensure budgetary allocation of not less than 1% CRF to finance the Basic Health Care Fund in the 2017 budget

Monitoring, review and evaluation

The Wellbeing Foundation Africa in its submission recommended adoption of weekly review of national and states data on the current state of maternal health through a common dashboard supported by the Nigeria Bureau of Statistics, the National Population Commission, and the National Primary Healthcare Development Agency to provide holistic legislative support towards adequate financing for Primary Health Care in the country.

PHC revitalization, long overdue

Nigeria Society of Physiotherapy submitted that the need to revitalize primary health care system in Nigeria is long overdue, as majority of Nigerians live in rural areas where many diseases are prevalent. Many of these diseases leave Nigerians with permanent disabilities that may require lifelong rehabilitation.

The group recommended prioritized attention towards the rehabilitation of Primary Health Care; promotion of healthy lifestyle; flexible, responsive and innovative approach to developing services that are reflective of local needs, environment and available resources.

Life-or-death consequences

Civil Society Organizations in Health Sector Reform Coalition (HSRC) noted that investments in health contribute to a healthy population, and a healthy population is paramount to the development of a thriving and modern economy.

“If Nigeria increased life expectancy by just one year, it would translate to approximately $19.2 billion in additional economic output; in 2015 this would have yielded a 279% return to the economy. Moreover, every dollar invested in vaccine programs can yield at least 16 more dollars in economic returns.

Failure to invest in health forfeits the potential economic benefits for Nigeria and has life-or-death consequences,” it warned.

The Coalition recommended implementation of the National Health Act, which set aside not less than 1% of Consolidated Revenue Fund to the Basic Health Care Provisions Funds;  increased allocation to the health sector at all levels of Government to reach the 15% percent Abuja Declaration benchmark of African Heads of State in 2001; increased efficiency and effectiveness of the health sector spending through greater value for money strategies; full and timely release of capital budget of health sector starting from 2017 financial year; encouraged public-private partnership to enhance adequate fund provision for Primary Health Care.

Ghana Retreat and renewed legislative health agenda

In a communiqué signed by Chair, Committee on Health Services, Hon Chike John Okafor; Chair, Committee on Health Institutions Hon (Mrs) Betty Apiafi; Chair, Committee on Appropriation, Hon Mustapha Bala Dawaki; and the Executive Director, CISLAC, Auwal Ibrahim Musa (Rafsanjani), at the end of the Retreat in Ghana, it was observed that “while adequate, accessible and affordable health care system is paramount to the survival of the citizens, Nigerian health care system is one of the worst 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.

“Although Primary Health Care (PHC) remains the most acceptable approach to deliver effective, accessible and acceptable health and services at all levels, effective implementation of PHC objectives has been hampered by lingering inadequate budgetary allocation.

“Delayed domestication and implementation of the international, continental and regional conventions and protocols on health as well as the 2014 National Health Act, inadequate budgetary allocation to health sector, poor monitoring and lack of judicious utilisation of the existing funds has hampered accountability, and effective provision and distribution of basic health package across the country.

“Revenue Deficit amounting to N2.2trillion in the 2016 Appropriation Act, and the existing lowest revenue-to-GDP ratio pose inherent challenge to the adequate financing for health care system in Nigeria, including the allocation of statutory 1% Consolidated Revenue Fund as provides in the 2014 National Health Act.

“Delayed incorporation of Information Communication and Technology into health care management and delivery in the country impedes adequate tracking and monitoring and timely achievement of Primary Health Care objectives.

“Over-concentration of skilled health workers in the urban areas at the expense of the rural areas health impedes effective health delivery and access to adequate primary healthcare at the grassroots. Improved access, quality and equity in the health sector are enabled by adequate investment, infrastructure, appropriate oversight and effective institutional governance.

“Lack of political will by some State and Local Governments to fulfill counterpart commitments on health care financing is a great impediment to adequate primary health care in Nigeria.”

The communiqué observed that Nigeria has hitherto not independently funded or produced its own vaccine as a result of inadequate funding for health and untapped capacity or technical know-how for the local production of vaccine; and adequate revenue generation in Nigeria to financing critical sector like health is hindered by unchecked illicit financial flows, loopholes in tax collection and administration at all levels.

The Retreat recommended integrating Primary Health Care under one roof to improve coordination, effective management, functional and quality healthcare system, especially at local levels; 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; provision of adequate technology and innovation to generate, analyse and communicate health data disaggregated by gender, age, geographical location, health status amongst others; improved incentive and reward system aimed at encouraging and motivating health workers, especially in the rural areas to reduce rural-urban migration of skilled health workers.

Participants recommended flexibility in the implementation of the National Health Act 2014 through participatory and inclusive procedures to recognise the various local context and peculiarities impacting on the effective implementation of the Act by the State Governments; creation of enabling institutional, legal and policy environment to ensure  increased public-private investment in Primary Health Care in order to promote health care technology and innovation and accessible and affordable health care delivery at all level.

On financing for Primary Health Care, the Retreat recommended adequate Primary Health Care financing in Nigeria through enhanced political actions for resource mobilisation and full-fledged implementation of the National Health Act 2014 with prioritised attention to the 1% provision of Consolidated Revenue Fund from the national budget; improved budgeting system through performance-based approach to prioritising and addressing endemic challenges confronting the implementation of the National Health Act 2014 and adequate Primary Health Care financing in Nigeria; establishment of a Ministerial Fund Disbursement Committee to ensure appropriate tracking, monitoring and effective management of the 1% statutory allocation to health, to address inherent problems of counterpart funding to the State Governments; development of sustainable self-funded and legislative-backed immunisation plan through the creation of an Immunisation Trust Fund (ITF), a public-private vehicle to fund procurement of vaccines and drive critical research and acquisition of appropriate technologies to encourage local production of immunisation vaccine, with the goal of reducing and eliminating reliance on importation; innovative financing of Primary Health Care delivery through various sources within short, medium and long-term such as economic diversification, use of % of existing taxes and additional taxes on Cigarettes and alcohol; investment in preventive healthcare services and infrastructure, including the reactivation of DDT as an immediate means to eradicating malarial at all levels; local and State governments ought to revive Primary health by making adequate budgetary provisions so the Federal government can face its responsibility of tertiary health care.

The Retreat further recommended strengthening of legislative oversight in Primary Health Care financing through legislative-executive collaboration and creation of synergies to promote transparency and accountability in the management of funds for Primary Health Care system; and proactively creation of an enabling environment to ensure effective and sustainable Primary Health care and childhood immunization financing in Nigeria.

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