The decision by the federal government at the third THISDAY Healthcare Policy Dialogue to kick off implementation of the Basic Healthcare Provisions Fund was received with euphoria by Nigerians and its key development partners. But three months after, implementation is yet to commence. Martins Ifijeh writes
When the federal government, at the third THISDAY Healthcare Policy Dialogue in Abuja, made a commitment to speed up the implementation of the Basic Health Care Provisions Fund (BHCPF), many saw it as the beginning of new things to come in the health sector because of what it portends for poor Nigerians.
It was a renewed hope to get the National Health Act (NHA) working after it was passed four years ago. Stakeholders saw this as an opportunity to accelerate Universal Health Coverage (UCH); especially since N57.17 billion was already earmarked in the 2018 budget to finance the commitment.
But three months after Vice President Yemi Osinbajo made the commitment on behalf of the government at the THISDAY summit, Nigerians are yet to enjoy actual implementation, especially considering that 2018 is winding down next month.
However, with the declaration last week by the Executive Secretary of the National Primary Health Care Development Agency, (NPHCDA), Dr. Faisal Shuaib, that President Muhammadu Buhari will launch the BHCPF in few weeks, there seems to be renewed hope that the government has not forgotten about the plan. .
Faisal, had at a workshop in Kaduna said the design of the BHCPF through the provision of insurance and essential primary healthcare interventions will ensure that the poorest Nigerians access quality care without encountering financial hardship.
What BHCPF Means to Nigerians
The BHCPF is an additional fund outside the healthcare allocation in the national annual budget to address basic healthcare needs of Nigerians. In the 2018 budget, it was put at N57.17 billion for primary healthcare strengthening and service delivery. It mobilises additional resources from the government of Nigeria and development partners to improve the delivery of essential basic health services to Nigerians.
The BHCPF will pay for a modest benefit package of health services which currently comprises prenatal, delivery, and post-natal care, as well as Family Planning services for all mothers in rural areas of Nigeria and also cover the cost of high- impact child health interventions. It will also allow such services to be delivered by accredited private and public facilities that will be reimbursed for services delivered. In recognition that primary health centres (PHCs) hardly ever receive any operational costs to cover their expenses, publicly owned PHCs will be provided with operating budgets.
According to the mandated in the National Health Act, 50 per cent of the BHCPF is allocated to the National Health Insurance Scheme (NHIS) “gateway”, 45 per cent through the NPHCDA “gateway”, and five per cent is set aside to deal with emergencies under the Emergency Medical Treatment (EMT) gateway.
Under the NPHCDA gateway direct cash transfers are provided to public primary health facilities, while under the NHIS gateway accredited public and private facilities are paid for delivering Basic Minimum Package of Heath Services (BMPHS).
The design of the BHCPF provides an opportunity for channeling resources directly to public PHCs in the NPHCDA gateway, whilst the NHIS gateway provides an opportunity to incorporate the private sector through the accreditation of private providers in the NHIS gateway.
Nigeria Spends Too Little on Healthcare
It is no longer news that close to 80 per cent of Nigerians spend out-of-pocket on healthcare. This led to several advocacy efforts that brought stakeholders in the health sector together. In those days it was standard to hear any speech made by development partners or any health sector leader referencing the implementation of the BHCPF.
The management of THISDAY newspapers got heavily involved in the advocacy efforts and in the process invited the Nigerian-born Director of Health Nutrition and Population at the World Bank, Dr Olusoji Adeyi, to give a talk on the consequences of poor financing of the health sector in Nigeria at the First THISDAY Healthcare Policy Dialogue, held in Abuja.
Adeyi argued that Nigeria’s underperformance was one that should not be surprising due to the extremely low level of government spending on health.
He said at 22 per cent of public health spending, Nigeria ranks as one of the countries spending the least on health considering a 36 per cent average for low middle-income countries.
Adeyi further stressed that “although the country has made efforts to increase federal allocations to the health sector, with improved budgetary allocations from 2014 to 2017, health sector allocation in the total federal budget has decreased viz N264 billion (5.63 per cent) in 2014, N260 billion in 2015 (5.78 per cent), N257 billion in 2016 (4.23 per cent), and N340 billion in 2017 (4.15 per cent).”
He emphasised that the figures were nominal amounts such that when adjusted for inflation, the purchasing power of the health budget has declined even further. “The consequences on health outcomes are dire! There has been little or no progress in delivery of basic health services such as immunisation coverage, family planning, antenatal care, and skilled birth attendance, and worse still, these services are at levels lower than that of poorer neighboring countries,” he said.
Current Status of Implementation
The Minister of Health, Prof. Isaac Adewole announced that the BHCPF will commence with a start-up phase in three states of the federation -Abia, Niger, and Osun states. He indicated that the three states have rapidly put in place the necessary institutions to enable them benefit from the federal-funded BHCPF.
For states to participate in the BHCPF they need to have their SPHCDA and State Social Health Insurance Agencies set up. States will also need to make available the necessary financial investments necessary to run the program at the state level.
THISDAY gathered that the selected states have since made commitment with the cash transfer and signed a Memorandum of Understanding (MoU) with the FMOH outlining their rights and responsibilities for participating in the BHCPF. The minister of health has called on other states to quickly get ready for implementation in their states.
Speaking to THISDAY Senator Lanre Tejuoso said the implementation of BHCPF will not be business as usual, adding for it to make a difference it must promote transparency, participation of communities in decision making and better accountability for funds and results.
He was of the opinion that if the monies appropriated for the BHCPF wa not judiciously used, then the National Assembly will not be motivated to have a 100 per cent appropriation as it did in 2018 and will only budget for what the FMOH can account for.
Why is Implementation Slow?
On why implementation is slow, the Department of International Development Partnership to Engage, Reform and Learn (DFID-PERL) gives an insight. In its workshop on “Strategy Session on Social and Conventional Media Advocacy/Campaign for Implementation of BHCPF of the National Health Act”, a Health Communication Specialist, Dr Dale Ogunbayo blamed non-implementation as a battle for supremacy between the Federal Ministry of Health and heads of NHIS/NPHCDA for the unavailability of the money.
“The fund is yet to be released because of the weak political will of the government and the unspoken inter-agency rivalry between the federal ministry of health, NPHCDA, and NHIS”.
Speaking further he said: “This tussle is denying poor Nigerians the benefit of the implementation of the NHA and it will need to be resolved by strong political hand”. Ogunbayo said until President Buhari addresses the issue, problems relating to the implementation of the National Health Act will continue to arise in the health sector.
Development Partners Look Towards BHCPF Implementation
In the interim several development partners including the Global Financing Facility for Every Woman Every Child and the Bill & Melinda Gates Foundation have lined up behind the BHCPF.
In a press statement the GFF said it was investing 20 million dollars to improve and strengthen primary health care starting in three states in Nigeria, with the aim of reaching the poorest and most underserved throughout the country.
The GFF acknowledged the fact that the federal government was linking this investment financing to the BHCPF of the NHA. The GFF notes that the quantum of resources and prioritisation of services will contribute to sustainably financing the health and nutrition needs of women, children and adolescents.
Considering the importance this portends for the country’s health, there is therefore need for the federal government to speed up its implementation. The synergy between the NHIS, NPHCDA, FMOH and its finance counterpart will ensure release of the funds is given utmost priority.
Stakeholders are keen to argue that the BHCPF needs to be treated as a first line charge like other provisions backed by legislation, for instance, the UBE act in the education sector which is similar to the NHA. There is the need for key players outside the health sector; like the Minister of Finance, Hajia Zainab Usman, and in fact President Buhari to understand how this can change the country’s healthcare narrative if they make it one of their priorities.
As at the time of going to press, no release has been made to the BHCPF with just 34 days to the end of 2018.