With one of the poorest health indices in the world, Nigeria accounts for a large percentage of the infant and maternal mortality rates globally. Every year, the country records about 800 maternal deaths in every 100,000 live births (equivalent to 58,000 mothers dying per year on account of pregnancy or childbirth) , 67 infant deaths per 1000 live births , and 132 under-five deaths per 1000 live births (meaning that one in eight Nigerian children never reach the age of 5). These poor health indices are fueled majorly by low government expenditure on health . Nigeria has one of the lowest levels of government spending on health in the world, which is mostly allocated to secondary and tertiary care, resulting in poorly funded Primary health Care Centers (PHC). In 2017, the health budget of all the 36 states was a little over N332 billion, which was about 4.9% of total budget size , a far cry from the Abuja declaration of April 2001, where the African Union countries pledged to allocate at least 15% of their annual budgets to improve the health sector.
To address this shortfall in health care funding and ensure the provision of basic health care to all Nigerians, the National Health Act 2014 (NHAct 2014) provides the Basic Healthcare Provision Fund (BHCPF) as a statutory fund constituting one per cent of the Federal Government Consolidated Revenue Fund (CRF). The BHCPF is designed to increase public spending in health and reduce out of pocket expenditure by consolidating funds from government sources, donors, and partners for a results-based and decentralized facility financing approach. The BHCPF is expected to reach over 100 million Nigerians in rural and hard to reach areas, especially women and children under-five. To implement this provision of the National Health Act, the Federal Government in 2018 earmarked N51.15Bn (1% of its CRF) along with contributions of a $20 million grant by the Global Financing Facility through the World Bank and $2 million from the Bill and Melinda Gates Foundation to fund the BHCPF.
The BHCPF uses two approaches to ensure the provision of basic health care to all Nigerians. The first approach through the National Primary Health Care Development Agency (NPHCDA) is to improve service delivery in at least one Primary Health Care Center (PHC) per ward in Nigeria. A quarterly payment is to be made to accredited public PHC facilities to meet their operating expenses and improve their capacity to deliver quality health services. The second approach through the National Health Insurance Scheme (NHIS) is to purchase and ensure the provision of a Basic Minimum Package of Health Services (BMPHS) by the accredited PHCs. The BMPHS is a package of high impact interventions which covers the entire spectrum of care (preventive, promotive, curative, and rehabilitative) to be delivered at health facilities. Payment for the provision of these services is to be made to accredited PHCs as capitation.
To guide the implementation of the BHCPF, an operation manual was signed by the implementing entities (FMOH, NHIS, and NPHCDA) in December 2018 with the Federal Government releasing N27.55 Billion from the earmarked N51.15 Billion in January 2019. So far, the NPHCDA has disbursed funds for Decentralized Facility Financing (DFF) and PHC human resource development to 15 States (Abia, Niger, Osun, Kwara, Plateau, Ebonyi, Delta, Edo, Anambra, Benue, Nasarawa, Kaduna, Kano, Bayelsa, Adamawa) and the FCT while the NHIS has disbursed funds for the provision of the BMPHS to 16 states (Edo, Katsina, Yobe, Delta, Lagos, Adamawa, Imo, Kaduna, Bauchi, Bayelsa, Ebonyi, Oyo, Plateau, Abia, Niger, Osun) and FCT. Additionally, following concerns raised by the National Assembly on the non-alignment of the BHCPF operational manual with the stipulations of the NHAct 2014, the Honourable Minister of Health on 5th August 2020 approved a revised BHCPF guideline to replace the operational manual in implementation of the BHCPF.
Despite the progress recorded in implementation so far, the BHCPF has not been without its own challenges, from poor alignment between the three implementing entities – FMoH, NPHCDA and NHIS, poor allocation and release of funds, to under-utilization of funds disbursed. More importantly, it is not yet clear how the country will meet the estimated ₦2.3 trillion annual target (at a minimum of ₦12,000 per person) required to provide the BMPHS to all Nigerians as stipulated in the NHAct.
To ensure that the BHCPF meets its objectives, there is need for proper coordination and alignment amongst the implementing entities who should also proactively advocate for improved allocation and release of funds, states should be more resourceful in utilizing the funds disbursed, there should be more objective approaches for ensuring the reach and coverage of the BHCPF within the limited funds, the country will benefit from innovative and sustainable health financing strategies to realize the required target for adequately funding the BHCPF.
Effective implementation of the BHCPF will improve availability of funds to address weaknesses in the health system, including shortages in human resources for health, stock-outs of drugs and medical supplies, poor quality and/or inadequacy of medical equipment, inadequate power or water supply, and this will ultimately renew confidence in the system and improve demand for essential health services. The BHCPF is an initiative that will move Nigeria a step closer to achieving Universal Health Coverage for all.
Written by Muhammad Awwal Abdullahi who can be reached on firstname.lastname@example.org
Reviewed by Folake Oni