Despite several unmet expectations that adversely affected the country’s healthcare delivery system, there are some achievements in some key areas that may redefine the fortune of the ailing sector. In this special report, MOSES EMORINKEN writes on the implications of inadequate healthcare financing in the last eight years
Without sounding like a recurring echo or a broken record, Nigeria’s health sector is severely underfunded. The sector has not enjoyed the luxury of having enough funds to adequately cater for the healthcare needs of citizens. Many experts and stakeholders within the health space believe that with the way the sector has suffered neglect and struggled with prioritisation by governments, especially state governments, it is very difficult to say for sure if the health sector is truly on the concurrent list, or no list at all.
The result of the underfunding of health can be seen in the inadequate health facilities, inadequate remuneration and welfare packages for health workers, lack of or inadequate medicines and commodities, among others, which results in mass exodus of needed manpower, huge out-of-pocket expenses by individuals, and poor health indices like high child and maternal death rates, high prevalence of communicable and non-communicable diseases, low life expectancy, among others.
Also, because of the dearth of funds to provide qualitative healthcare services for an estimated 213 million people, according to the World Bank, many Nigerians have had to incur catastrophic costs in accessing healthcare services. The huge out-of-pocket expenditure has a significant financial burden for individuals and families, especially for those who have high healthcare needs. According to the World Health Organization (WHO), in Nigeria, out-of-pocket expenses for healthcare account for approximately 72 per cent of total healthcare expenditure. The implication of this is that a lot of healthcare expenditures are borne by individuals and their families, as opposed to being covered by health insurance or other types of public health financing.
Health sector budget
In 2001, African Union member states, including Nigeria, made a commitment to allocate at least 15 per cent of their annual budgets to improve their health systems and strengthen their response to HIV/AIDS, tuberculosis, and other related infectious diseases. This is in line with the World Health Organisation (WHO) long-standing policy position that countries should allocate 15 per cent of their national budget to healthcare.
Since then, while the federal government continues to express its willingness and commitment to increase the budgetary allocation to health, budgetary allocation has not reached 7 per cent; in fact, it vacillates between 3 and 5 per cent on the average. It is important to noted that from 2015 till now (during the Muhammadu Buhari administration), the budgetary allocations to health have increased: N237.08 billion in 2015; N250.06 billion in 2016; N304.19 billion in 2017; N356.45 billion in 2018; N372.70 billion in 2019; N441.01 billion in 2020; N549.83 billion in 2021; N711.28 billion in 2022; and N1.17 trillion in 2023. This year’s budget for health is that the health sector has received over one trillion naira. This represents 5.75 per cent of the total budget allocated to the health sector in 2023.
However, despite the increase of 5.75 per cent of the budgetary allocation to the health sector this year, Nigeria is yet to meet the 15 per cent commitment it made in 2001. While the health sector budget still needs a lot to be increased, it is encouraging to note that in eight years, the health sector budget has witnessed an increase of 323.68 per cent, according to a report by PACFaH@Scale, a coalition of civil society organizations under the development Research and Projects Centre (dRPC). According to the dRPC, the Federal Government budgetary allocation to the sector averaged 4.7 per cent in the last 20 years. The highest the country has ever assigned to the Ministry of Health was 6.1 per cent in 2012.
A proper analysis showed that between 2015 to 2023, the budget for the health sector increased from N278.31 billion to N1.17 trillion. PACFaH@Scale’s report further showed that the recurrent budget for health also increased from N237.31 billion in 2015 to N580.82 billion in 2023; while the capital expenditure increased from N22.68 billion in 2015 to N404.08 billion in 2023. However, stakeholders in the health community still advocate for the budgetary allocation to health to be increased to 15 per cent – as agreed African leaders many years ago. This, according to them, will take care of all health spending for infrastructure, welfare, commodities, strengthen the health systems and ensure that the country achieves universal health coverage (UHC) for all Nigerians.
However, the absence of timely release of funds and poor utilisation of such funds continues to slow down progress in the sector. Civil society organisations (CSOs) continue to advocate for accountability and transparency in the disbursement and utilization of released funds. It is important to state that aside from financing from the governments at the federal and state levels, private sector and international partners continue to contribute significantly to the health sector in Nigeria. Their investments span several billions of dollars. Some of the organisations include: The World Health Organization (WHO), United Nations Children’s Fund (UNICEF), Global Fund to Fight AIDS, Tuberculosis and Malaria, United States Agency for International Development (USAID), Bill and Melinda Gates Foundation, United Kingdom Department for International Development (DFID).
Basic Health Care Provision Fund (BHCPF)
The Basic Health Care Provision Fund (BHCPF) was established by the National Health Act of 2014. It was, however, launched in January 2019 by the Muhammadu Buhari administration. The fund, which was created to provide and finance essential health services that address the poor health indices at the Primary Health Care (PHC) centers, and provide qualitative healthcare services to the poor and vulnerable citizens, especially in rural areas, is a veritable tool in achieving UHC for all Nigerians – without leaving anyone behind.
Through the BHCPF, funds are made available to PHCs for the provision of a minimum package of services, including emergency care, maternal and child health services, preventive and curative treatments, and others. Also, free medical services are provided for pregnant women, children under the age of five, and people living with disabilities. The fund is also used to provide essential drugs and medical supplies, as well as upgrade primary healthcare facilities, recruit and train healthcare workers, with many other additional functions that are planned.
Funding for the BHCPF is derived from one per cent of the federal government’s Consolidated Revenue Fund, grants from development partners, and contributions from state governments. The funds are channeled to the National Health Insurance Authority (NHIA), NPHCDA and the National Emergency Medical Treatment (NEMT) gateway, which is expected to cater for emergency ambulance services. States are required by the National Health Act of 2014 to contribute a counterpart fund of 25 per cent to the BHCPF. However, speaking during the third quarterly Ministerial Oversight Committee Meeting of the BHCPF, the Minister of Health, Dr Osagie Ehanire, revealed that many states are yet to access the fund because they have not contributed their 25 per cent counterpart, which is a prerequisite by law.
Primary health care (PHC) financing
The PHC system is the first point of contact for people seeking health care services. Anchored on the “health for all” agenda, PHCs are designed to be community-centered and basic health services integrated. PHCs exist to ensure that healthcare services are available, accessible, affordable, and qualitative for all, regardless of social status or demographics. Some of the services provided include: immunization, maternal and child health care, family planning, treatment of common illnesses and diseases, and health education.
However, the PHC system across the country continues to perform sub-optimally because of a sundry of reasons, including outdated facilities, lack of or inadequate infrastructure, equipment, and personnel, as well as inadequate training, retraining and retaining of healthcare workers. While the primary, secondary and tertiary tiers of health are important, there needs to be a balance in key initiatives and financing for them. Many Nigerians seek care in secondary and tertiary health institutions, overburdening them, and neglecting the PHCs – no thanks to the sorry state of infrastructure, unavailability of critical health workers, lack of social and hygiene amenities, among others, of PHCs.
According to the National Primary Health Care Development Agency (NPHCDA), as of 2021, there are over 30,000 PHC centres spread across the 774 Local Government Areas (LGAs). Located in both rural and urban areas, PHCs have the capacity to provide about 70 per cent of all healthcare services in the country.
President Muhammadu Buhari, on January 10, 2017, promised to revitalize at least 10,000 PHCs in the country, starting with the flag-off of a PHC at Kuchingoro, Federal Capital Territory, Abuja. It is only about 4,000 PHC centers that have been revitalised so far, in terms of infrastructure, equipment and healthcare professionals. Experts insists that state governments need to invest more in employing more health workers and remunerating them because this falls within their purview and not the Federal Government. During this year’s World Health Day, Dr. Ehanire said, “We need local recruitment of health workers who are trained to work in those areas where they are already known and familiar with the environment. State governments and local governments need to prioritise employment and payment of rural health workers because health workers, including doctors at primary health care level, are actually on the payroll of state governments. They are not on the payroll of the Federal Government. It is the state governments who actually employ these workers at that level.
“Primary healthcare under one roof mechanism provides the platform for encouraging, requesting the employment of doctors, and also the nurses, midwives and rural health workers that will be moving from primary health care centers to visit the communities directly and interact with communities in their own homes, to help them with general basic education.”
Making health insurance available to all Nigerians
On May 19 last year, President Buhari signed the National Health Insurance Authority (NHIA) Bill into law. The new Act, according to President Buhari, will provide qualitative health insurance for 83 million poor and vulnerable Nigerians to be covered under the social health insurance. The NHIA Act contains provisions for the Vulnerable Group Fund (VGF), which shall be expended to provide subsidy for health insurance coverage of vulnerable persons as determined by the Council; and for the payment of health insurance premiums for the indigent.
The VGF will be funded through the Basic Health Care Provision Fund (BHCPF), health insurance levy, special intervention allocated by the government, money accrued to the Fund from investments, grants, donations, gifts and other voluntary contributions. The NHIA is one of the channels that receive 50 percent disbursement of the BHCPF, from the one per cent of the Consolidated Revenue Fund (CRF). While the creation of a special insurance fund for the indigent is a laudable initiative, identifying the indigent is a herculean task. However, to identify the poor, vulnerable and indigent persons, The Nation learnt that the NHIA will utilize the national social register resident at the Office of the Vice President of Nigeria.
According to the Director-General of the NHIA, Prof Mohammed Sambo, “The register is within the Ministry of Humanitarian Affairs. We plan to utilize the register. Since the programme will be implemented at the state level, we will ask the states to ensure that at the point of capturing people into the National Health Insurance Scheme, that data is validated. After validation, we intend to deploy the implementation of the Vulnerable Group Fund. The mechanism for the Vulnerable Group Fund will be exactly like the mechanism of the BHCPF. We will utilize state structures to deliver this through close monitoring and deploying of ICT.”
Contrary to speculations, the law does not impose a telecommunications tax on Nigerians as a funding source for the VGF. However, the NHIA boss continues to stress that his organisation will not relent in making moves for telecommunication tax, and that the tax from Sugar Sweetened Beverage (SSBs) should be channeled to the NHIA to cover the vulnerable in the population. “We will still go and pursue the telecommunication tax to ensure it is encapsulated in the financial act of the government, so that whatever proceeds that is approved from there can come to the NHIA,” he added.
The new NHIA Act has made insurance mandatory for all Nigerians. The voluntary nature of health insurance nationwide was the single most significant impediment to the attainment of universal health coverage before now. In fact, a number of studies have shown that, globally, it is difficult to achieve universal health coverage without making health insurance mandatory. While the NHIA continues to engage relevant stakeholders in order to get their support and buy-in for the seamless implementation of the Act, particularly making health insurance mandatory for all, it is important that the Authority does not tarry long to get it started, as the deadline for the attainment of universal health coverage is 2030 – less than seven years.
Stakeholders in the sector believe the NHIA has a lot of work to do to ensure that the informal sector is captured in its health insurance, because they make up the majority of the productive/earning class of the country. Since the NHIA (former NHIS) kick-started in 2005, the informal sector is yet to be covered. Aside from civil servants and organized private sector that are catered for to a reasonable extent, the informal sector, including traders running market stalls, hairdressers, waged labour, mechanics, tailors, etc., seems to have been left out of the party, one that will guarantee their health security and access to qualitative healthcare without breakneck cost.
Utilization of budgetary allocations for health sector
While stakeholders in the health space have consistently advocated for an increase in the budgetary allocation to health, hopefully to 15 per cent of the total national budget, a lot still needs to be done with respect to the utilization of the “inadequate” funds provided. Year in, year out, many health experts have urged the Federal Ministry of Health, under whose coordination the health budget is resident, to ensure that funds provided are expended judiciously before the next budget cycle.
However, finding by The Nation reveals that, even though the health sector receives inadequate funds to meet its needs, the Ministry of Health still returns money to the Federal coffers. Senator Ibrahim Oloriegbe, Chairman of Senate Committee on Health, has decried the lack of capacity of the Ministry of Health, under the Minister, Osagie Ehanire, to utilise funds provided by the Federal Government for the people of Nigeria.
Speaking during the official launch of a Primary Health Care report by One Campaign in 2022, Oloriegbe said: “It is sad to say that even the normal budget allocated to health, the health sector does not consume its money. Can you imagine that the health sector returned money back for not spending. It happened in 2022. In 2021, it almost happened; it didn’t happen because they just warehoused it, but what will it be spent on? It will be spent on what it is not meant for.
“In this 2022, as an oversight committee, the Minister said ‘no I can’t do that.’ We said – ‘we are crying that we don’t have enough, but the little given to us, we cannot spend it.’ Despite the fact that the budget implementation was extended up to May 31st, the Ministry of Health did not spend all its money. Whatever it is that is in this report, we have a long way to go. It is not only in getting the money but, how do we get the money to do what it is meant for?
“Citizens need to support the legislators when they take some actions that are legal against executives at the state level. Why you see things happening at the federal level is because the actual independence and interdependence that are supposed to happen are happening. Citizens need to ask that at the state level, there is more allocation to health, and to get the resources released and utilized appropriately. For the BHCPF, when the federal releases their money, there is always a requirement for the counterpart from the state; this counterpart is not released, that is why you don’t get the service done.”
The health sector needs a lot of investments, particularly domestic investments by state governments. Globally, there has been a progressive dwindle in the volume and frequency of donor funding by international partners. Hence, the government must ramp-up its political will and resolve to prioritize health. Reports have it that more than 70 per cent of funding for health comes from international donors, while less than 30 per cent comes in-country. This has to change for the country to be able to take ownership of its sundry health programmes and interventions.
It is, however, important to state that on August 26, 2020, Africa, and indeed Nigeria was declared polio-free (zero cases of the wild poliovirus) by the World Health Organisation (WHO). In the same vein, Nigeria is at the verge of achieving epidemic control for HIV/AIDS due to the tremendous growth in our programs over the last 7 years. According to the National Agency for the Control of AIDS (NACA), 1,619,133 out of the 1.9 million Nigerians living with HIV are now on treatment; that is, 98 per cent of persons living with HIV in the country are on treatment, with 95 per cent on viral suppression.
Also, investments in the country’s immunization programs have yielded fruits, especially with regards to COVID-19 vaccination. In Nigeria, according to the Nigeria Centre for Disease Control and Prevention (NCDC), since February 2020 to February 26, 2023, there have been 266,313 confirmed cases and 3,155 deaths. Worldwide, there have been 759,408,703 confirmed COVID-19 cases with 6,866,434 deaths. However, data from the National Primary Health Care Development Agency (NPHCDA) shows that, as of April 30, 2023, a total of 73,252,066 of the eligible population targeted for COVID-19 vaccination are fully vaccinated. This represents 63.2 per cent of the target population.
