The setting was cosy, but the goal was clear: the participants who attended the Nigeria Health Watch policy dialogue on Universal Health Coverage (UHC) last week were specifically handpicked to dissect the National Health Act, particularly the Basic Health Care Provision Fund (BHCPF) and draw out its direct and indirect ties to UHC in Nigeria. The policy dialogue was sponsored by Christian Aid UK-Nigeria.
The group of participants which ranged from state health legislators to representatives of faith bodies had discussions on five specific objectives:
- What does the National Health Act say about the Basic Health Care Provision Fund?
- How can we get communities to hold government accountable towards achieving UHC?
- How can we get religious and traditional leaders involved in the push towards achieving UHC?
- What do legislators need to do and how can we get them to do it?
- How can the Executive show political will for UHC?
The National Health Act and the Basic Health Care Provision Fund
There has been increasing demand for the Executive arm of the Nigerian government to include the 1% Consolidated Revenue Fund (CRF) in the 2018 budget. The call has come from advocacy groups and even members of the Federal legislature, for government to take this critical first step towards implementing the National Health Act, which has remained on paper since 2014 when it was signed by former President Goodluck Jonathan.
The policy dialogue sought to take a critical look at the BHCPF, really understand what it provides for Nigerians, and discuss why it seems to be such a stumbling block for political office holders supposed to implement it. Four participants at the event gave one-minute pitches to President Buhari, giving reasons why he should ensure that the 1% CRF is be provided for in the 2018 Budget.
Participants at the dialogue unanimously agreed that according to the Health Act, the BHCPF is not comprised only of the 1% Consolidated Revenue Fund by the Federal Government. There is more to the BHCPF than 1% CRF. The Act states that the BHCPF is to consist of 1% CRF, grants from donors and partners and funds from any other sources.
The debate arose as to why so much emphasis was placed on the 1% CRF, without as much discussion into counterpart funding from donors and any other source of funds.
Dr. Adaeze Oreh, a Family physician, noted that donor-contributions have been downplayed because donors have already played a large part in the development of Nigeria’s health space. Dr. Oluwole Odutolu, Senior Health Specialist at the World Bank, also pointed out that the global community has already pledged $20million into the pilot of the Basic Health Care Provision Fund in Abia, Niger and Osun States. The Nigerian Government is yet to put in its own funds.
Mr. Emmanuel Eze, Executive Secretary of the Anambra State Health Insurance Agency, one of the speakers at the dialogue, highlighted that his state’s scheme had expanded beyond the formal sector and recognised the role of primary health centres as a first line of care. “The Anambra State Health Insurance Scheme is not limited to the formal sector. We have gotten support from major informal organisations with payment mechanisms for their members,” he said, adding, “Primary healthcare centres in Anambra State are being upgraded to ensure quality healthcare delivery.” This is important because many Nigerians tend to go directly to secondary and even tertiary health centres when in need of care for basic health issues. These issues should ideally be taken care of at the primary health centre level, but many primary health centres across the country are not functional.
Dr. Ifeanyi Nsofor, Director Policy and Advocacy at Nigeria Health Watch, the moderator of the UHC policy dialogue, left participants mulling over this question. “If President Buhari decides to implement the National Health Act today, are donors ready to pool in all their funds to the BHCPF? How do we ensure accountability and transparency in management of the Fund?” So far, donors have been relatively silent about the BHCPF, maybe taking a cue from the government’s own lackadaisical attitude towards implementing it, so the question remains as to whether they would embrace the law once the government decides to take action.
Vivianne Ihekweazu, Head of Strategy and Business Development at Nigeria Health Watch, presented an overview of UHC implementation in other African countries. She pointed out that other countries have gone ahead of Nigeria in meeting the Abuja Declaration which stipulates that 15% of a country’s annual budget should be used to improve the health sector. Rwanda has met the 15% requirement, while South Africa is currently allocating 13.5% of its budget to health. In comparison, Nigeria will be allocating a mere 3.9% of its annual budget to health in 2018.
How can we get communities to hold government accountable towards achieving UHC?
Celestina Obiekea of Connected Development (CODE), said that lack of trust in the system is a huge challenge for Nigerians when it comes to the discussion on Universal Health Coverage. She pointed out that people need to be carried along by government in such a manner that they fully understand what the solutions being proposed are and what they mean for them as Nigerians. When communities do not understand the system and their rights within it, then accountability suffers because they do not know what to hold their government accountable for.
“Peer-to-peer learning has often been the most effective way to drive any movement and the push for Universal Health Coverage through effective health insurance and primary health care systems should not be any different”, she said. The Nigerian government must also be deliberate about getting people involved in the policies and structures of health systems that affect them. Increased sensitization and communication will only increase the drive for transparency and accountability in government.
Accountability should also be driven by the understanding that affordable, accessible and quality healthcare is a right, not a privilege. Dr Ejemai Eboreime, Health Systems and Policy Specialist at the National Primary Health Care Development Agency (NPHCDA) said, “There is a ‘social contract’ between the Government and Nigerians that stipulates that every Nigerian should have access to affordable and quality healthcare at all times.”
Hon. Joseph Onah, Chairman, Benue State House Committee on Health, who was one of the speakers at the event, echoed this opinion. He gave a summary of the proposed health insurance bill in Benue State and emphasized the need for a public hearing before the bill is passed: “We hope that in the next 30 days, Benue state will pass the health insurance bill into law but there is an urgent need to hold a public hearing on the Benue Health Insurance Bill,” he said.
How can we get religious and traditional leaders involved in the push towards achieving UHC?
Prof. Tanimola Akande, Chairman, ECWA Health Insurance Committee, speaking on the role religious bodies must play to complement government’s efforts for UHC, presented the case study of the Evangelical Church Winning All (ECWA) Health Insurance Committee, which was set up to provide advise to the Church on provision of health insurance coverage for the 6 million plus members of ECWA church. The ECWA Health insurance when approved, will first cover the 11,000 staff of ECWA Church.
Lack of trust has already been identified as a key issue that health insurance schemes face in building up the enrollee pool. Prof. Akande stated that religious bodies might be exempt from this challenge as people are more likely to trust religious institutions than the government. He called for religious bodies to play a more active role in bridging the access gap to health services to help raise the number of Nigerians that receive health coverage. He noted that peer-to-peer learning from the religious sector is very important and religious groups with the right information can mobilise members into various health coverage schemes, with the ultimate goal of reducing out-of-pocket expenditure for health services.
The policy dialogue rounded with participants proffering solutions and next steps to the issues raised. They raised the following points:
- There is the need to move from advocacy to activism in the demand for Universal Health Coverage.
- We must develop linkages for accountability, we need performance indicators that we would hold our leaders accountable to.
- If Nigeria is to make significant changes in the health sector this year, the government must ensure the release of the Basic Health Care Provision Fund (BHCPF).
- Beyond political will, we need societal will. We must get out of societal lethargy and sensitise the population about what UHC is and why it is important.
- Other stakeholders must rise, and the health system should be a workable partnership between the public and private.
- On state health insurance systems, states must know that each state is structured differently, what works for one state might not work for the other. Each state must own its process and localise it.
- We need to begin to demand for more than just 1% Consolidated Revenue Fund (CRF) for health in Nigeria. It is our right!
Increasing knowledge of health as every Nigerian’s right will ramp up societal will which in turn will force political will at all levels of our country’s polity. But it starts with all of us getting involved, asking the right questions and refusing to back down until health is prioritised in Nigeria.
How are you pushing for UHC in Nigeria? What role can your religious and traditional leaders play in the journey towards UHC in Nigeria? How are you holding your state government accountable for the provision of affordable and quality healthcare? Join the conversation and share your thoughts on social media using the hashtag #Health4AllNaija.