Nigeria has always been committed to the principles of universal health coverage and has adopted policy documents and legislation to that effect. However, indicators of Nigeria’s health outcomes and actual coverage of basic health services show underperformance, both in absolute terms and relative to other countries at similar levels of economic development.
Key drivers of underperformance include a health system unable to ensure universal coverage of primary health care services and weak accountability for results. The health sector has long been underfunded, and its structural and institutional frameworks have placed concurrent responsibilities on all three tiers of government (federal, state, and local) without any mechanism for intergovernmental accountability.
To rectify the lack of a legal framework necessary to drive a high-performing health system, in late 2014 the Federal Government of Nigeria signed into law the National Health Act. This Act provides a framework for action, encompassing the regulation, development, and management of a national health system, and it sets standards for rendering health services throughout the federation.
The Mission to Provide the National Health Act with Adequate Funding
The National Health Act specifies that all Nigerians shall be entitled to a Basic Minimum Package of Health Services (hereafter the Basic Minimum Package), a set of preventive, protective, promotive, curative, and rehabilitative health services or interventions. One of the key provisions in the Act is the Basic Health Care Provision Fund (BHCPF), which will serve as the principal funding vehicle for the Basic Minimum Package while at the same time serving to increase overall financing to the health sector. Its funding is derived from three tracks, namely: (1) an annual grant from the Government of Nigeria of not less than one percent of its Consolidated Revenue Fund; (2) grants by international donor partners; and (3) funds from any other source.
However, the BHCPF has remained unfunded since the law was signed in 2014, notwithstanding the fact that a diligent implementation of the Act could set Nigeria on the path toward universal health coverage. A turning point came in mid-2016, when Nigeria joined the GFF and the newly appointed minister of health proposed that US$20 million in grant resources from the GFF Trust Fund be used to pilot the BHCPF in three states. The Bill & Melinda Gates Foundation also committed US$2 million in grant resources to test the BHCPF’s early implementation and provided financing to the World Bank to undertake analytical work to strengthen the design. This influx of resources further strengthened the advocacy by various partners for the implementation of the BHCPF. The World Bank supported the leadership of the Ministry of Health in engaging with Nigeria’s Economic Management Team, and development partners in Nigeria supported an advocacy mission to the National Assembly. Civil society organizations and the media played a critical role in this advocacy campaign.
Nigeria’s parliamentarians responded by concluding that if external grant resources could support three states, the Government of Nigeria should be willing to commit its own resources as well. In this way, GFF resources proved to be an instrumental tool for a call to action. The outcome of these strategic investments and the associated analytical work and advocacy was that in May 2018, the Government of Nigeria decided to allocate the full one percent of its Consolidated Revenue Fund for the BHCPF in the FY2018 appropriation.
Strengthened Funding for Primary Healthcare
As Nigeria begins to implement the BHCPF, the fund is expected to mobilize close to 60 billion Nigerian naira (approximately US$150 million) in new money per year for primary health care strengthening and service delivery. While the resource envelope for the BHCPF would currently be inadequate to guarantee full coverage of the Basic Minimum Package to the entire population, the government’s proposed gradual expansion of the BHCPF is well within reach, especially as the economy recovers and the size of the resource envelope increases.
The BHCPF employs proven, results-based and decentralized approaches and thus represents not only more money but “smarter money,” enabling Nigeria to translate bold innovations in service delivery into improved health outcomes. The implementation uses two interrelated approaches to improve service delivery, not only in public but also in private facilities.
First, a fee-for-service payment approach to providers will initially spur the delivery of a highly prioritized package of 10 high-impact maternal and child health interventions, including family planning. A focus on serving rural areas will help address equity challenges, because health outcomes are significantly poorer—and worsening—in rural areas.
Second, an accreditation system will be used to prequalify both private and public health facilities, contributing to the setting and maintaining of minimum quality standards. Payments will be made on the basis of verified data after the services have been provided, while keeping services free to beneficiaries, thus increasing accountability while reducing barriers to accessing care. The BHCPF signals a new era in service delivery for primary health care services in Nigeria.
The Republic of Cameroon
Despite its lower-middle-income status, Cameroon was recently ranked 153rd out of the 188 countries tracked in the Human Development Index (HDI 2014) and, indeed, it is one of a group of countries whose HDI scores have declined in the past two decades. Contributing to this HDI deterioration is slow progress on key health outcomes.READ CASE STUDY
Democratic Republic of the Congo
In the Democratic Republic of Congo (DRC), the GFF was launched in April 2015. The government put in place a GFF platform that brought together the key government health stakeholders, other line ministries, civil society representatives, and development partners. The GFF platform took the lead in developing the country’s RMNCAH-N investment case, which prioritizes the interventions laid out in the National Strategic Development Plan 2016-2020. The Ministry of Health, with representatives from civil society organizations, focused on defining RMNCAH priorities; UNICEF conducted a health system bottleneck analysis; WHO provided support in costing the investment case; and the GFF Secretariat helped with the resource mapping exercise with the support of the government and several donors.READ CASE STUDY
United Republic of Tanzania
Between 2010 and 2015, Tanzania saw notable improvements in life expectancy (from 61.6 to 64.9 years), infant mortality rate (from 51 to 43 per 1,000 live births), under-five mortality rate (from 81 to 67 per 1,000 live births), and under-five stunting prevalence (from 42 to 34.4 percent). However, during this period the country’s maternal mortality rate increased from 454 to 556, and its total fertility rate remained stubbornly high at 5.2 (as of 2015). The increase in maternal mortality elevated maternal health to a national priority. To address this and other lingering challenges in RMNCAH-N, in 2015 Tanzania began implementing its RMNCAH-N investment case, known as One Plan II.READ CASE STUDY