Nigeria’s health indicators can only be compared with countries either in war or just coming out of a war situation. Whether it is in maternal and child mortality and morbidity, life expectancy, doctor- patients ratio, hospital beds to the population, access to basic health services, out-of-pocket expenditure, the indicators are nowhere near the financial and human resources available to Nigeria. From available statistics, the country has not even started taking remedial steps to resolve the health contradictions. What is wrong or what has gone wrong?
This discourse intends to analyse the challenges facing the health sector especially from the financing and financial resource angle. It is pertinent to recall that worldwide, health is considered a basic human right with key functional parameters including availability of services, accessibility (including physical, economic, information and non- discrimination components of accessibility). The third parameter is acceptability while the fourth centres on quality. In light of the indivisibility, interrelatedness and interconnectedness of all human rights and fundamental freedoms, the right to health is inextricably linked to the right to life because the easiest way to deprive people of their life is to deprive them of health supporting conditions to the point of abrogation. To ensure a health system that meets these functional parameters, adequate public and private resources need to be mobilised.
In terms of public resources, Nigeria made a commitment to allocate not less than 15 per cent of its annual budget to the health sector. However, this commitment is more honoured in breach despite the fact that the commitment was made with other African countries in Abuja, our federal capital. Available evidence indicates that public funding at the federal and state levels has been poor. It was 5.78 per cent, 4.13 per cent, 4.14 per cent of the overall votes in 2015, 2016 and 2017 budgets respectively at the federal level. The proposal for 2018 is a paltry 3.95 per cent of the overall votes. If the actual health figures are converted into the US dollar, it will be $1.367bn in 2015; $1.269bn in 2016; $1.011bn in 2017 and $1.116bn proposed for 2018. Thus, the federal financing has been an undulating landscape that fails to match the forward ever commitment which admits of no retrogressive steps. Why is the funding in 2015 higher than 2016, 2017 and even the proposal for 2018. Only the government can provide the answer. But clearly, it is a violation of Nigeria’s commitments under various regional and international charters especially the International Covenant on Economic, Social and Cultural Rights and the African Charter on Human and Peoples Rights.
The enactment of the National Health Act in 2014 brought a ray of hope that at last, the federal, state and local governments were ready to take steps to start the proper funding of the health sector. This hope revolved around Section 11 of the Act which makes provisions for the Basic Health Care Provision Fund, being a fund to be funded by not less than one per cent of the Consolidated Revenue Fund, grants from donors and funds from any other source. Since 2014, the Federal Government failed, refused and neglected to make budgetary provisions for the Fund. Civil society organisations have initiated all manner of advocacy to convince the Federal Government to implement the law including a suit filed by the Nigeria Medical Association and the Centre for Social Justice seeking the order of mandamus against the President for the implementation of the law. The Federal Government at the taxpayers’ expense is vigorously defending the suit in terms of seeking to justify its breach of the Act’s provisions.
However, the National Assembly seems more inclined to ensure the setting up of the Fund and the Senate President, Bukola Saraki, at a recent meeting of the Nigeria Medical Association indicated the National Assembly’s resolve to make provision for the Fund in the 2018 appropriation bill which they will soon enact. As soon as this announcement was made, the executive arm of government which is in court defending its failure quickly used its “@Asorock” Twitter handle to state that: “@AsoRock <https://twitter.com/AsoRock> is committed to spending 1% of its Budget on Healthcare, in line with the National Health Act. The policy decision reflects the @MBuhari <https://twitter.com/MBuhari> administration’s resolve to improve healthcare delivery in Nigeria. We also welcome @NGRSenate <https://twitter.com/NGRSenate>’s endorsement of the Decision.” What manner of resolve is this? Why should governance become an opportunity to turn the truth on its head, to deceive and to mislead? The executive arm of government was resisting the setting up of the Fund to the extent that donors came together to pilot the Fund to show its feasibility. Yet, the administration said it showed a “resolve”!
A very interesting dynamic of the Fund is about its management and administration. Section 11 (7) of the Act states unequivocally: “The National Primary Health Care Development Agency shall develop appropriate guidelines for the administration, disbursement and monitoring of the Fund with the approval of the Minister”. It also makes provisions for percentages that will be used by designated statutory agencies to fund different components of health care. Counterpart funding is expected from states and local governments up to 25 per cent of the cost of projects as their commitment to their execution. Available information indicates that authorities at the Ministry of Health may not be too happy with the provisions of the law to the extent that the NPHCDA has not been allowed to perform its duty of developing the guidelines. It appears that up till date, there is no guideline, signed off by all relevant stakeholders available for the implementation of the Fund.
Nigeria is a country governed by duly enacted laws and policies. The health sector is part of the Nigerian society and should be governed by laws. The establishment, management and disbursement of funds accruing to the Fund should be done in accordance with the due process of law. The law binds everyone, from the highest authority being the President, to the Minister of Health and anyone who considers themselves higher than the authority of law clearly presents themselves as an outlaw and has no reason to continue in a position of public service. All stakeholders including the civil society must be carried along in the process of implementing the Fund so that Nigerians will be in a position to exercise oversight, as the ultimate sovereigns, over the allocation, disbursement, management, utilisation and reporting on the Fund. This will involve full publicity around fund releases, projects and activities that will be funded by the releases including the specific location of the services and projects, reporting time schedule and availability of the reports to the public in printed and electronic copies.
Nigeria is under obligation to take steps to the maximum of available resources for the progressive realisation of the right to health. More resources are expected to be made available to healthcare as the budget increases. Backward steps, as witnessed by the government’s refusal to implement a duly passed law, without compensatory mechanisms especially for the poor, constitute a gross violation of the health obligation. The Federal Government can no longer be allowed to sanction murder by refusing to fund health care, despite clear statutory provisions. Let us implement the Basic Health Care Provision Fund, as provided in the National Health Act now!
