Health

THE CONTEXT

If you live in Nigeria, here’s a challenge for you: stop and ask a random stranger if they or someone they know has had an unpleasant (or even a near-death) experience with the Nigerian health system. It does not matter which state you live in, or what road or street you happen to be on: the overwhelming response will most likely be yes. And you need not travel far to find stories of Nigeria’s poor healthcare: the numbers tell some of the stories.

Statistics show how hard it is to survive childbirth in Nigeria: the country has the second highest rate of maternal deaths in the world.[i] Put differently, one Nigerian woman dies every 13 minutes from preventable causes related to pregnancy or childbirth.[ii] This represents approximately 109 deaths a day, or 40,000 deaths each year.[iii] Once a child is born in Nigeria, it is difficult for him or her to survive childhood: for every 1,000 live births, 104 children under the age of five die.[iv] To make up for this loss, parents typically have many children. When a Nigerian makes it to adulthood, it is difficult for them to live long: the average life expectancy is just 53 years.[v] Only two other countries have lower life expectancies – Sierra Leone and the Central Africa Republic.[vi]

The difference between life and death for the average Nigerian often boils down to a simple factor – money. Out-of-pocket expenditures represent over 70% of individual health spending, while government spending accounts for about 16% and donor spending for about 8%.[vii] The lack of public financing means that the private sector (including pharmacies and patent medicine vendors) provides more basic healthcare services than public clinics, and for these services poor people pay punitive costs. Geography also influences access to healthcare and health outcomes: for nearly all health indicators, the South of Nigeria is better off than the North. For example, one-third of 15–19-year-old girls in Northern Nigeria have delivered a child without the help of a health professional, a traditional birth attendant or even a friend or relative.

As a country, Nigeria has one of the worst healthcare systems in Africa and also globally. When the World Health Organization (WHO) ranked health systems around the world in 2015, it placed it 187th out of 191 countries.[viii] As a result of the weak healthcare system, those who can afford to travel outside the country for treatment often do: some reports estimate that Nigerians spend up to $1.2 billion on medical tourism annually.[ix]

Nigeria’s health system in comparison with those of other African countries provides room for both humility and hope. On the one hand, the country’s status as the ‘Giant of Africa’ is questionable when its health spending and indicators are compared with data from other countries on the continent. On the other, the progress that other African countries have made on health shows that Nigeria has the potential to do better – under the right leadership.

THE CHALLENGES

In 1978, WHO recognised primary health care as the key to achieving ‘Health for All’, using a grassroots approach. Primary health care is the first level of contact with the health system for individuals, families and communities in a national health system. Primary Health Centres (PHCs) were made central to Nigeria’s health system in 1985. Implementation of this scheme began with models in 52 local government areas (LGAs) in 1985 – a significant milestone in Nigeria’s health sector.[x] During this period, the PHC system became a model for other African countries.

Today, however, only 20% of the 30,000 PHC facilities across Nigeria are functional.[xi] Most of those that are not shut down are run down, lacking the capacity to provide basic healthcare services. Those PHCs that are operational are plagued by a variety of issues, including poor staffing, inadequate equipment, poor distribution of health workers, poor infrastructure and inadequate supplies of medicines.[xii] With the nerve centre of the health system in disrepair, poor health indicators are inevitable. In 2017 the Minister of Health, Professor Isaac Adewole, noted that 80% of health problems in Nigeria could be solved at the PHC level if the system were to be revitalised.[xiii]

Parallel to the weak primary health care system are challenges of inconsistent political leadership and poor health financing. For example, between 2000 and 2015 government expenditure on health averaged just 3.6% of general government expenditure.[xiv]

THE SOLUTIONS

A stronger, healthier Nigeria will be a Nigeria where universal health coverage (UHC) is a reality. That is, a Nigeria where both rich and poor can access health services, where citizens do not have to travel abroad for quality health services and where they are not exposed to financial hardship when they access the health services they need. By improving the health of individuals and of the general population, UHC can contribute to poverty reduction.

There is strong evidence that bolstering primary health care is a key first step towards UHC.[xv]

The World Bank estimates that 90% of all health needs can be met at the primary health care level.[xvi] Adopting and sustaining a UHC system is as much a political process as a technical one, however. Nigeria does not just need improved health financing to make UHC a reality – it needs committed and sustained political leadership. Working towards the goal of achieving UHC, ONE urges presidential and gubernatorial candidates and the government elected in 2019 to take the following steps:

Implement the National Health Act of 2014

A decade in the making, the National Health Act (NHA) was passed in 2014 to address and eventually reverse Nigeria’s extremely poor health outcomes. The NHA clarifies citizens’ rights to health services, provides a policy and financial framework for the delivery of a basic minimum package of health services through the existing primary health care system and presents a plan for UHC. Central to implementation of the NHA is the Basic Healthcare Provision Fund (BHCPF, also known as Huwe), which is intended to be funded annually through a statutory allocation of not less than 1% of Nigeria’s Consolidated Revenue Fund (CRF) (i.e. total revenue). In 2015 the Ministry of Health noted that, if effectively implemented, the NHA would be capable of cumulatively saving the lives of over 3 million mothers, newborns and children under the age of five by 2022.[xvii] So far, however, this 1% revenue allocation has not been included in the federal budget. Since 2016, ONE has joined with other voices in the health sector to campaign for the 1% provision under the #MakeNaijaStronger campaign.

Developments in 2018 have been encouraging: the National Assembly and the Federal Government have committed to implementing the NHA and have allocated ₦55.1 billion to the BHCPF.[xviii] ONE encourages election candidates to articulate their commitment to operationalising the BHCPF and to set out plans for effective implementation of the fund.

The incoming administration should also ensure that BHCPF funding is earmarked as a statutory allocation in 2019 and beyond. Statutory allocations are always prioritised and they are not usually affected by a shortage of funds. Not committing to designate the BHCPF as statutory means that if there is any shortfall of funds within a budgetary year, it will suffer severe cuts. The incoming Federal Government should also support state and local governments to access the fund (currently, to be eligible for BHCPF funding, states and LGAs are expected to contribute 25% counterpart funding towards PHC projects).[xix] State governments and the Federal Government must contribute to financing health in order to make it accessible to all.

Finally, the NHA mandates the government to allocate “not less than 1%” of its consolidated revenue to basic healthcare. 1% is the floor – not the ceiling. Studies have shown that if 1% of the CRF were allocated to the BHCPF, and this funding were used only to cover pregnant women in each state, it would still be insufficient to ensure the universal financial protection of a basic minimum package for all pregnant women, even using 100% of the BHCPF.[xx] ONE urges the 2019 administration to work towards allocating more than 1% as the statutory allocation for basic healthcare in Nigeria.

Investments in the health of citizens are investments in the economy. For example, a study published by WHO, the World Bank, USAID and others in 2011 noted that increasing life expectancy by just one year can increase a country’s gross domestic product (GDP) by 4%.[xxi] Healthy and productive citizens are the most essential component of Nigeria’s Economic Recovery and Growth Plan.

Ensure Transparency and Accountability in the Health Sector

Nigeria needs more money for health, but also more health for the money. Given the realities of corruption, increased and improved investments in health without accompanying transparency and accountability are akin to pouring water into a leaky bucket. Under the #MakeNaijaStronger campaign, ONE has also been advocating for open contracting in the health sector.

At the international Anti-Corruption Summit in London in May 2016, Nigeria’s Federal Government committed to implementing transparency in public procurement in the health sector.[xxii] In early 2017, the government launched a beta version of its open contracting portal for all sectors. The revised procurement portal, NOCOPO, is now operational (as of 30 June 2018) with eight pilot government agencies, including the Federal Ministry of Health and the National Primary Health Care Development Agency.[xxiii]

The government elected in 2019 should ensure the continuity of this project by: 1) ensuring that timely procurement data is made publicly available in an open, digital, machine-readable format and is updated at regular and transparent intervals and 2) sensitising and building the capacity of civil society and citizens to monitor procurement data on the portal.

If properly implemented, the operationalisation of the BHCPF, coupled with measures ensuring transparency and accountability, could spark much-needed change in the Nigerian health sector.

 

[i] World Health Organization (WHO) (2015). ‘Trends in Maternal Mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division’, p.54. https://www.unfpa.org/sites/default/files/pub-pdf/9789241565141_eng.pdf (last accessed 9 August 2018)

[ii] African Population and Health Research Center (2017). ‘Maternal Health in Nigeria: Facts and Figures’, p.1. http://aphrc.org/wp-content/uploads/2017/06/APHRC-Maternal-Health-in-Nigeria-%E2%80%93-Facts-and-Figures.pdf (last accessed 9 August 2018)

[iii] Ibid.

[iv] World Bank. ‘Mortality rate, under-5 (per 1,000 live births)’. https://data.worldbank.org/indicator/SH.DYN.MORT?locations=NG&view=chart (last accessed 9 August 2018)

[v] World Bank. ‘Life expectancy at birth, total (years)’. https://data.worldbank.org/indicator/SP.DYN.LE00.IN (last accessed 9 August 2018)

[vi] Ibid.

[vii] Institute for Health Metrics and Evaluation (IMHE). ‘Financing Global Health: Viz Hub’. https://vizhub.healthdata.org/fgh/ (last accessed 15 August 2018)

[viii] A. Tandon et al. (2015). ‘Measuring Overall Health System Performance for 191 Countries’. GPE Discussion Paper Series No.30, p.21. WHO. http://www.who.int/healthinfo/paper30.pdf (last accessed 13 August 2018)

[ix] A. Oluyemi et al. (2017). ‘Medical Tourism in Nigeria: Challenges and Remedies to Health Care System Development’. University of Illorin. https://www.ajol.info/index.php/ijdmr/article/download/172290/161689; and N.-R. Ukwuoma (2017). ‘Medical tourism costs Nigeria over N400bn annually – Minister’. Nigerian Tribune, 8 May 2017. https://www.tribuneonlineng.com/88716/ (both last accessed 13 August 2018)

[x] B.S. Aregbeshola and S.M. Khan (2017). ‘Primary Health Care in Nigeria: 24 Years after Olikoye Ransome-Kuti’s Leadership’. US National Library of Medicine National Institutes of Health/Frontiers in Public Health, Vol. 5, 48. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346888/ (last accessed 13 August  2018)

[xi] Ibid. See also L. Jannamike (2018). ‘Buharicare: FG targets affordable healthcare for 8m Nigerians under new policy – Minister’. Vanguard. https://www.vanguardngr.com/2018/01/buharicare-fg-targets-affordable-healthcare-8m-nigerians-new-policy-minister/; and Information Nigeria (2016). ‘36 States and the FCT to Share $1.5M FG Fund For Primary Healthcare’. http://www.informationng.com/2016/07/36-states-and-the-fct-to-share-1-5m-fg-fund-for-primary-healthcare.html (last accessed 8 August 2018)

[xii] J.M. Chinawa (2015). ‘Factors militating against effective implementation of primary health care (PHC) system in Nigeria’. Annals of Tropical Medicine and Public Health, Vol. 5. Issue 1, 5-9. http://www.atmph.org/article.asp?issn=1755-6783;year=2015;volume=8;issue=1;spage=5;epage=9;aulast=Chinawa (last accessed 8 August 2018)

[xiii] M. Ifijeh (2017). ‘Nigeria: Adewole – 80% of Health Issues Can Be Solved At PHC’. This Day, 14 December 2017. https://allafrica.com/stories/201712140508.html (last accessed 13 August 2018)

[xiv] WHO (2018). ‘Global Health Expenditure Database’. http://apps.who.int/nha/database/Select/Indicators/en; and ONE’s internal calculations.

[xv] IHME (2016). ‘Financing Global Health 2016’. http://www.healthdata.org/sites/default/files/files/policy_report/2017/IHME_FGH_2016_Technical-Report.pdf (last accessed 23 August 2018)

[xvi] G. Doherty and R. Govender (2004). ‘The Cost-Effectiveness of Primary Care Services in Developing Countries: A Review of the International Literature’, Working Paper No. 37, Disease Control Priorities Project, World Bank, WHO and Fogarty International Centre of the US National institutes of Health. https://www.researchgate.net/publication/242783643_The_Cost-Effectiveness_of_Primary_Care_ Services_in_Developing_Countries_A_Review_of_the_International_ Literature (last accessed 23 August 2018)

[xvii] Federal Ministry of Health (2015). ‘One Year Anniversary of the National Health Act 2014: Press Statement of the Permanent Secretary’. http://www.health.gov.ng/index.php/about-us/9-uncategorised/228-one-year-anniversary-of-the-national-health-act-2014 (last accessed 23 August 2018)

[xviii] Budget Office of the Federal Republic of Nigeria (2018). ‘Appropriation Bill 2018’, p.100. http://www.budgetoffice.gov.ng/index.php/2018-appropriation-act?task=document.viewdoc&id=680 (last accessed 14 August 2018)

[xix] National Assembly of Nigeria. ‘National Health Act, 2014: Explanatory Memorandum’, p.15. https://nass.gov.ng/document/download/7990

[xx] O. Onwujekwe et al. (2016). ‘Financial Feasibility of Using the Basic Health Care Provision Fund to Provide a Basic Minimum Maternal and Child Health Benefit Package in Nigeria’, p.1. Health Policy Research Group Nigeria, Policy Brief No.1, August 2016.

[xxi] Harmonization for Health in Africa (2011). ‘Investing in Health for Africa: The case for strengthening systems for better health outcomes’. http://www.who.int/pmnch/topics/economics/20110414_investinginhealth_africa/en/ (last accessed 13 August 2018)

[xxii] See Transparency International (2016). ‘43 Countries, 600 Commitments: Was the London Anti-Corruption Summit A Success?’ https://www.transparency.org/news/feature/43_countries_600_commitments_was_the_london_anti_corruption_summit_a_succes; and Ventures Africa (2016). ‘President Buhari’s Speech At the Anti-Corruption Summit, London’. http://venturesafrica.com/president-buharis-speech-at-the-anti-corruption-summit-in-london/ (last accessed 13 August 2018)

[xxiii] Nigeria Bureau of Public Procurement (BPP) website. http://nocopo.bpp.gov.ng/ (last accessed 29 August 2018)