Tracking effective utilisation of BHCPF to strengthen system

Nigeria’s dismal health landscape and the shortcomings of its health services are well documented and do not require lengthy explanation. It is indicative of the low esteem in which the country’s health indicators show that despite positive movement in some areas, health outcomes remain poor.

In the positive column, under-five mortality and infant mortality are declining, although 240,000 infants still die within 28 days of birth from preventable causes.

In other areas, however, progress on health has plateaued or even reversed. An alarmingly high number of women die during or soon after giving birth.

The maternal mortality ratio (MMR) of 576 deaths per 100,000 live births, recorded in the 2013 Nigeria Demographic and Health Survey, was even worse than the MMR of 545 in the 2008 survey. Although there was a slight drop in 2018, which persisted ten years after. The fertility rate remains high, and only 20 percent of women have access to a modern method of contraception. The defective health system is further exposed by the COVID-19 pandemic, which underscores the need to strengthen the health system.

Health budget
In finding the reason for these unacceptable health indices, looking at the funding for health and efficient utilisation of the lean resources can provide the answer.

In terms of funding for health, a closer examination of Nigeria’s health budget reveals that the vast proportion of the funding—86 percent—is taken by recurrent expenditure, mostly paying the salaries of health workers.

The low level of capital expenditure raises questions about the feasibility of some of the Federal Ministry of Health (FMoH’s) flagship projects, in particular the Primary Health Care (PHC) Revitalisation project, which seeks to rebuild or restore 10,000 primary health centers so that each political ward in the country has a functioning health facility.

Currently, 60 percent of capital expenditure is spent on the federal ministry itself. It should also be noted that there is a big disparity between the amount approved in the health budget and what is released. Between 2013 and 2015, an average of only 41 percent of the capital budget allocation for health was utilised. This leaves most of the spending for health to be from out pocket by an individual. What is more, is the efficient utilisation of the lean resources.

Effective utilisation of lean resources
While there is no doubt that Nigeria’s health system could be better resourced, the considerable amount of money that is already in the system is not utilized effectively. Compared with other African countries. The failure of resources to permeate the lowest reaches of the health service has given us an upturned pyramid structure that defines a properly functioning health system, where patients enter at the primary level and more serious cases are referred up. Instead, patients have lost faith in the PHC system and clog tertiary hospitals with easily treatable conditions, wasting the time of consultants. This explained our poor health indices as the base of the pyramid (PHC) where we can have more impact on most of the people are ineffective. The tertiary institution provides specialized care for very few. This might explain the table below for the South Western part of the country looking at the health indices and finances between 2011 and 2016.

Fig 2 shows that Lagos state invested more funds between 2011 and 2016 than Ondo. However, in terms of health indices, Ondo performed better with a reduction in infant mortality. The Ondo better performance was a result of strengthening the primary health care, which is with a more delivery-taking place in Primary Health Care (PHC) and reduction in the Secondary Health Care (SHC) facilities. The resulted in a drastic reduction in maternal mortality, which is related to infant mortality.

Basic Health Care Provision Fund
The FMoH has made PHC a priority and the National Health Act, passed in 2014, contains legislative efforts to channel more funding to this most neglected part of the health system. Under the act, not less than one percent of government revenue must be set aside for a Basic Health Care Provision Fund (BHCPF). The act defines exactly how the fund is to be apportioned: half must be used to provide a basic minimum package of health services to citizens through the National Health Insurance Scheme (NHIS); 45 percent must go toward PHC, equipment, facilities, and human resources, managed by the National Primary Health Care Development Agency (NPHCDA); and the remaining five percent must be spent on emergency medical treatment. The first tranche of the fund was released by the Federal to demonstrate their commitment about a year ago. Shows fund allocation to states for the NPHCDA gate and similar fund was released for the NHIS Gateway as well. However, this fund is yet to be utilized by the states of the federation. This will improve funding to the health sector. However, if not properly tracked will not achieve the desired result of a strengthened health system. The fund was meant to be utilised for the purpose and it is clear that there is no provision for the programme, which is a serious gap. There is a need to advocate for the state government to fill this gap.

Tracking of the Basic Health Care Provision Fund (BHCPF)
To ensure that the BHCPF achieve the desired goal of strengthening the health system and improve our health indices tracking is imperative.

The objective will be as follows:
1. Ensure the effective utilization of the fund as stated above.
2. Advocate for the programmatic provision by the state government
3. Track performance with the use of scorecards quarterly
4. Provide technical support to state on Health System Strengthening
5. Showcase performing state to encourage others through TV programs.
6. Annual award of excellence for performing state.

• Dr. Adeyanju is a former commissioner for health in Ondo State