Op-Ed: Why we need to implement the Basic Health Care Provision Fund (BHCPF) now!
By Dr. Gafar Alawode
The health financing landscape in Nigeria is characterized by suboptimal government health investment, high out of pocket expenditure 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 health care with equity and shared financial risk protection which are the hallmarks of Universal Health Coverage goals.
The recently conducted National Health Account shows that government health expenditure as a proportion of general government expenditure (GHE/THE) is 4%, while government health expenditure as a percentage of GDP (GHE/GDP) is less than 1%. In the same vein, out of pocket expenditure as a share of total health expenditure (OOPE/THE) is 73% and less than 5% of the population is covered by any form of prepayment mechanisms. The Nigeria health financing 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 health financing 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 health financing system.
The suboptimal government health investment and high out 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 percent 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 WHO shows that women from high income group in the country are ten 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 health financing 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 admisntration of the former President Goodluck Jonathan. Among other things, the National Health Act makes a provision for Basic Health Care Provision Fund (BHCPF), which is an earmarked fund aimed at improved government financing of both supply side and demand side of basic health services. The BHCPF will be financed with not less than 1% Consolidated Revenue Fund (CRF) of the Federal Government of Nigeria and other sources.
In addition, as part of efforts geared towards expanding health insurance coverage in the country, the National Health Insurance Scheme (NHIS) has decentralized health insurance scheme to the state government to usher in the so-called State Social Health Insurance Scheme (SSHIS) as NHIS could not get maximum support of the states on its centralized national schemes. As part of supply side reforms, The National Primary Health Care Development Agency (NPHCDA) has introduced a PHC management integration policy of PHC Under One Roof (PHCUOR). This policy thrust is a response to hitherto fragmented PHC management which is inefficient and less accountable. The government has also put PHC revitalization at the front burner of its UHC agenda.
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 kick off since the enabling law for the Fund was signed in 2014. The quest for kick starting a major health financing reform which could also spur the State Governments to reposition their health financing 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 Basic Health Care 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 the National Assembly has demonstrated readiness to implement the BHCPF, it is not clear if the health financing policy thrust has resonated with the executive arm of the government. Apparently, convincing the executive arm of the government to commit money to the BHCPF is an important hurdle to scale on the journey towards successful implementation of BHCPF. The forgoing raises a fundamental question of level of political prioritization of health in Nigeria, and to what extent the government considers health expenditure as a veritable investment that can spur economic development. As health competes with several other important sectors, it is crucial to justify increased spending on health and change the narrative from health as expenditure to one where health spending is seen as an investment yielding economic returns. The Lancet commission on health investment revealed that almost a quarter of recent economic growths in low- and middle-income countries are attributable to value of additional life-years (VLYs). In other climes where health of the citizens is taken more seriously, health care delivery is more than a service; it is highly political. Hence, health policy, health access and perception of quality of health care could decide the electoral fortunes of an individual politician and their political affiliations
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. Evidence abounds on how health investments contribute to economic growth through improved productivity, poverty reduction and job creation.
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. However, stakeholders in the health sector have worked relentlessly to put in place robust operational and regulatory frameworks that will galvanize effective and efficient management of the BHCPF. Health sector stakeholders are not unaware that there are no fool-proof measures against inefficiency; the stakeholders are therefore committed to an iterative process of continuous improvement of BHCPF management processes to achieve the desired objective of improved health access with equity, financial risk protection and efficiency.
The foregoing 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. Political engagement and citizen participation play a vital role in successful health reform. Lessons learned from health reform efforts from other Middle-Income Countries such as Mexico, Thailand, Ghana and Costa Rica suggest that strong political will and recognition by all and sundry that health is a human right are the critical success factors for health reform — this entrenches the notion that access to health care should be based on need and not ability to pay or any other social considerations.
General elections create a strategic interface between politicians and citizens. 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 Universal Health Coverage prior to the 2019 election. Stakeholders in the health sector should be prepared to promote issues-based electioneering ahead of the 2019 general elections. Health sector 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.
Pre-election engagements of flag bearers of political parties have worked in the past; prior to previous governorship elections, Civil Society Organizations (CSOs) were able to engage some gubernatorial candidates on key health issues, secured their commitments on improved health funding and after elections, the elected Governors consistently allocated more than 15% of their respective state’s budgets to health. We should do more of these ahead of 2019.
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 is the Chief of Party, Health Finance and Governance Project
- He can be reached on Twitter @gafaralawode