Center for Social Justice, Author at Centre for Social Justice

Budgeting and the Demand for Evidence, By Eze Onyekpere …the need to go back to evidence based budgeting has crystallised. It is not about the health sector alone but the sector best illustrates the insanity of abandoning evidence as the defining context for budgeting. The muddle through approach has not worked before and it will not work now. The 2018 federal budget continues in the trajectory of previous budgets. It is a long list of programmes and projects, not necessarily tied to any order through systematic coherence, which leads to predetermined sectoral outcomes. It is a continuation of the norm based on the “muddle through” approach to budgeting. This discourse seeks to analyse the defining challenges inherent in the muddle through budgeting approach, using a key sectoral perspective. There are critical challenges with budgeting in Nigeria and these resonate more in the overall health sector, primary health care and maternal, new born and child health (MNCH) subsectors. The first is that there is hardly a good link between laws, plans, policies and budgets. The second is the idea of failing to learn from practice and refusing to draw the right lessons from previous experience. The third is about working without taking cognisance of available evidence or refusing to collect, collate and analyse evidence to inform budgetary action. The foregoing leads to a budgeting process which repeats the same mistakes, year after year, and insists on the continued mistakes (which have now crystallised as “normal practice”). On the other hand, both the crafters and implementers of the budget expect results different from previous results every year. A new result in such a situation of refusing to change and continued refusal to be led by evidence is an outright factual and legal impossibility! On the first challenge, it is admitted that the Constitution of the Federal Republic of Nigeria 1999 (as amended), as the grundnorm, did not make specific provisions on the right to health or the governance of the health sector, except in its Schedule Four, which elaborates the functions of a local government established under S.7 of the Constitution. In paragraph (2) (c) of Schedule Four, it is stated that: “The functions of a Local Government Council shall include participation of such Council in the Government of a State as respects the following matters – the provision and maintenance of health services.” However, other laws and policies and actual practice have identified the roles of different stakeholders and tiers of government. Extant practice, which is recognised in the National Health Act 2014 and the National Health Policy of 2016, is that the federal government, through the Federal Ministry of Health, is more of a policy maker and runs tertiary and specialised health institutions. The state governments run secondary health care, as well and tertiary hospitals, mostly attached to state owned universities as teaching hospitals. Local governments, on the other hand, are charged with primary health care (and most MNCH services are delivered at the PHC level), even though the States seem to cover the field through their dominance, usurpation and management of local government finances and affairs. The natural expectation is that since most of the PHCs in the states do not meet up to the prescribed standards, the bulk of federal funding should have gone to bringing them up to speed, instead of starting new PHCs afresh. This is what adherence to laws, plans and policies demand. The expectation is that in consideration of the fact that the budget is a law, the National Assembly should stick to the foregoing division of labour in the enactment of federal budgets. However, the federal budget is suffused with votes, especially constituency projects focused on PHC, thereby dabbling into the role of local governments and States. Thus, federal health budgets are distracted from addressing the priorities identified in national plans and policies. The Federal Government of Nigeria (FGN) can only pay for the capital components of PHCs and thereafter hand them over to state and local governments to run through their continued incurring of recurrent expenditures and overheads. Without agreements or Memoranda of Understanding between federal, state and local governments on the construction and management of the PHCs, many federally constructed PHCs have not been put to use. Yes, the buildings are standing and sometimes taken over by weeds and rodents, but no service is delivered to the people. Thus, money has been spent but no value is added and no benefit derived. The National Primary Health Care Development Agency has set approved minimum standards for PHCs in Nigeria. The standards are in health infrastructure, human resources for health and service provision. The human resources include a midwife or nurse midwife, two community health workers, two junior community health workers, four support staff/health attendants and two security personnel. The infrastructure demands include a detached building with at least five rooms, walls and roof that are in good condition, with functional doors and netted windows, and seperate but functional male and female toilet facilities with water supply within the premises. It must have a sanitary waste collection system, connected to the national grid and other regular alternative supplies of power, with staff accommodation provided within the premises – two bedroom apartments. Appropriate medical equipment and furnishing are also to be in place. The services to be rendered include MNCH, family planning, health education and promotion, curative care for malaria, oral health, etc. The natural expectation is that since most of the PHCs in the states do not meet up to the prescribed standards, the bulk of federal funding should have gone to bringing them up to speed, instead of starting new PHCs afresh. This is what adherence to laws, plans and policies demand. In some instances, in one year and in one state, as many as 20 brand new PHCs are to be paid for by the federal budget. The implication is that the state and local governments are expected, after construction, to hire new personnel to run the PHCs and this expectation comes to play without prior consultation with the state and local governments by the legislator representing the constituency or the Federal Ministry of Health. In essence, the state or local government is expected to provide millions of naira every month without a prior provision in its budget. In the challenge of failing to learn from practice and refusing to draw the right lessons from previous experience, the foregoing arrangements entrenched in PHC constituency projects did not work yesterday, it will not work today and will not work tomorrow. But who cares? Who is listening? Again, there are too many projects inserted into the budget which cannot be accommodated under available funds. The available resources are therefore spread too thin and in such a manner that they will not produce good results. This sets the stage for abandoned and poorly constructed projects, while value for money is compromised and budgetary resources are wasted. Communities are hardly involved in project selection and, at the planning stage, leading to little or no involvement and absence of community ownership. Such projects without community participation are bound to fail. Pray, who identified the PHC as a community priority? In the challenge of failing to learn from practice and refusing to draw the right lessons from previous experience, the foregoing arrangements entrenched in PHC constituency projects did not work yesterday, it will not work today and will not work tomorrow. But who cares? Who is listening? It is like a state of automatism – we must continue repeating the failure and wasting the resources! foraminifera This leads to the third challenge: On which evidence is the decision about locating these PHCs made? The minimum expectation is that the Health Management Information System in a State should have the data on the location of public and private health institutions, the number of persons and communities they serve in terms of their proximity, the actual numbers that visit and uptake of available health services, the kind of care rendered and services demanded by community members, etc. Also, there should be information of prevalent ill-health and health conditions which is founded on epidemiological analysis. Based on these and other considerations, the decision about building new PHCs will be made as this will be based on evidence. The location will not be subject to political considerations with its requisite arbitrariness. In the final analysis, the need to go back to evidence based budgeting has crystallised. It is not about the health sector alone but the sector best illustrates the insanity of abandoning evidence as the defining context for budgeting. The muddle through approach has not worked before and it will not work now. Evidence based budgeting holds the key to the improvement of the budgeting process and the realization of expected outcomes. Eze Onyekpere is the lead director at Centre for Social Justice.

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