When Legislators, Civil Society United For Improved Health Care

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Daramola Okafor

The House of Representatives committees on appropriation and health, in partnership with Civil Society Legislative Advocacy Centre, a non-governmental organisation, recently, organised a two-day retreat in Accra, Ghana, for their members on financing primary health care. Funke Olaode reports

While adequate, accessible and affordable health care system is paramount to the wellbeing of the citizens, the Nigerian health care system is said to be among the worst in the world. Hit by inadequate budgetary allocation, delayed release of funds, imprudent utilisation of existing funds, poor monitoring, and lack of transparency and accountability at all levels, the country’s healthcare system has been troubled for a long time. But how can these impediments to efficient medical care be removed? This was the main question that stakeholders tried to find answers to at a two-day retreat recently organised by the Civil Society Legislative Advocacy Centre.

CISLAC is a non-governmental organisation dedicated to strengthening the link between civil society and the legislature through advocacy and capacity building for civil society groups and policy makers on legislative processes and governance issues.

Between September 7 and 8, members of the House of Representatives committees on appropriation and health converged on Holiday Inn in Accra, Ghana, for a two-day retreat aimed at providing a platform for the legislators to discuss and review current challenges and opportunities in financing primary health care in Nigeria. The retreat drew about 60 participants from the House of Representatives, the Federal Ministry of Health, Ministry of Budget and Planning, civil society and development partners. It featured presentations from experts and representatives of the Minister of Budget and National Planning and the health minister.

Major Challenge
In his opening address, the executive director of CISLAC, Auwal Musa Rafsanjani, said the retreat would not have come at a better time than now, when Nigeria is moving towards another fiscal year, where critical inputs are expected into the country’s budgetary process, especially by the executive and legislature.

Rafsanjani said all hands must be on deck to ensure a better health care system, stressing that health remains a major challenge in the development of the economy. This fact, he said, was buttressed by a study conducted by CISLAC in 2013. The study shows that in Nigeria, one in 13 women dies during pregnancy or childbirth, and 12 per cent of children die before reaching the age of five. The study observes that every 10 minutes one woman dies from conditions associated with childbirth.

According to the study, only 39 per cent births take place with the 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. This situation adversely affects the economy and impedes development, generally. The above factors are largely attributed to poor budgetary allocation to the health sector.

Rafsanjani stated that child spacing had direct impact on the health of the family and the economy of a nation as a whole, with tendency to mitigate maternal and child deaths in the country. He said budgetary allocation to child spacing services in the context of the Nigeria family planning blueprint and implementation plans was an endemic challenge at all levels.

Challenge of Donor Dependence
The executive director of CISLAC regretted the recent reversal of the announcement by the World Health Organisation last year declaring Nigeria free from the long dreaded polio epidemic owing to the discovery of two different cases of the wild polio virus in Borno State. He attributed this to inadequate financing and timely release of funds by the government to sustain the gains made in the fight against polio in the country.

It is noteworthy that health care financing in Nigeria has hitherto been donor-dependent, which poses a fresh challenge to sustainability. Cases in point are nutrition funded by UNICEF; routine immunisation funded by Global Alliance for Vaccine Initiative, GAVI, Bill Gates and Aliko Dangote; HIV/AIDS funded by Global Fund, etc. However, with the rebasing of the Nigerian economy, there has been a paradigm shift from donor-driven funding to advocacy for ownership of the health sector by Nigerian government.

National Health Bill
Rafsanjani commended the legislators for the bold step it took in 2014 to revive to long embattled National Health Bill and advocated for its passage into law by the National Assembly.

The National Health Act 2014, he emphasised, 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 given the one per cent Consolidated Revenue Fund from the national budget. However, the Act which implementation was supposed to have commenced since 2015, is yet to see the light of day even in the 2016 Appropriation Act.

The CISLAC boss hoped that with quality representations from the National Assembly, the Federal Ministries of Health, and Budget and Planning, at the retreat, it would be a result oriented deliberation, which would be applied in developing holistic strategies for adequate and sustainable health care financing. He advocated proper legislative and policy directions in fund mobilisation, allocation, and utilisation for health care systems at all levels.

In his paper, titled, “Financing the Basic Health Care Provision Plan,” the director-general, Budget Office of the Federation, Mr. Ben Akabueze, noted that the overarching health sector goal for Nigeria, as for most nations, was Universal Health Coverage. And to achieve this goal, government in Nigeria needs to be spending about $86 per person in providing basic health services. But actual expenditure is under 50 per cent of this amount.

Akabueze stated, “The recommended public expenditure on health is five per cent of a nation’s Gross Domestic Product; Nigeria currently spends only about 1% of GDP (note however total government revenues less than 10 per cent of GDP).”

On how the Basic Health Care Provision Fund could be appropriated, Akabueze said 50 per cent of the fund would be transferred to the National Health Insurance Scheme to cover basic health care services, 45 per cent 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; while the the final 5 per cent would be used by the Federal Ministry of Health to respond to health emergencies and epidemics.

On the implementation issues on the BHCPF, Akabueze said it had been observed that it was one thing to appropriate the funds and another to actually use them to achieve the desired objectives. He assured that the BHCPF, which will probably be treated as a statutory transfer in the budget, will still be classified as part of aggregate funds allocated to the health sector; just as health is classified as a priority sector.

Throwing more light on how National Health Act and how the provisions will impact the health sector, Dr. Muhammad Muhammad Saleh said the National Health Bill was assented to by the president on October 31, 2014, but the major challenge observed in the NHS prior to the act was the lack of clarity on the responsibilities of the different tiers of the health system in the provision of health care services.

The act, he said, presents a lot of economic benefits to Nigerians by saving more disposable income through reduction in huge health expenditure, especially for the vulnerable groups.
In 2008 life expectancy for male and female in Nigeria was 48 years and 50 years, respectively, according to the NDHS. The participants observed that if the NSHDP was fully implemented, it would have improved the life expectancy to 55 years in 2011, 63 in 2013 and 70 years in 2015.

To curtail this health care disaster, the participants noted that health workforce, including individuals working in the private and public sectors, must be adequately equipped with the relevant skill mix, distribution based on need and well-motivated to deliver services.

Recommendation
After the deliberations, the following observations and recommendations were made through a communiqué jointly signed by the chairman, House Committee on Appropriation, Hon. Mustapha Bala Dawaki; chairman, Committee on Health Institutions, Hon. (Mrs.) Betty Apiafi; chairman, Committee on Health Services, Hon. Chike John Okafor; and executive director, CISLAC, Rafsanjani. It was observed that although primary health care remained the most acceptable approach to deliver effective, accessible and acceptable health services at all levels, effective implementation of PHC objectives had been hampered by lingering inadequate budgetary allocation.

Other problems are delayed domestication and implementation of 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, which has hampered accountability, and effective provision and distribution of basic health package across the country.

Revenue deficit amounting to N2.2 trillion in the 2016 Appropriation Act and the existing lowest revenue-to-GDP ratio pose inherent challenges to adequate financing for health care system in Nigeria, including the allocation of statutory one per cent Consolidated Revenue Fund as provided in the 2014 National Health Act, the communiqué noted.

It said government should improve 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. 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 levels was also recommended.

It said there should be 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 one per cent 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.

Other recommendations include establishment of a Ministerial Fund Disbursement Committee to ensure appropriate tracking, monitoring and effective management of the 1% statutory allocation to health and address inherent problems of counterpart funding to the state governments; strengthening 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 the primary health care system.