10 April 2019

The 2019 general elections have come and gone. The political leadership of this country is in the process of setting an agenda for the next four years. This is a unique opportunity to raise the profile of the health sector among the political elite and push it to the top of government’s agenda at all levels.

Why do stakeholders in the health sector need to seize the opportunity to influence agenda setting at the outset? It is a well known fact that health sector has not received its deserved attention from the political class as health rarely features among key policy thrusts of government at the highest level. This manifests partly as a suboptimal level of government funding of the health sector. Government spending on health accounts for less than 1 per cent of the Gross Domestic Product in Nigeria. This level of spending on health is one of the lowest in world. It is, therefore, not surprising that Nigeria has one of the poorest health indices, which reflects limited access to basic health services by the teeming population of the country.

Effective social policy stands on a tripod of which one leg is political, another one is ethical (social value, especially equity) and the third one is technical. Erroneously, social policy, including health policy, is often heavy on technical approach while limited attention is paid to political and ethical legs of the social policy tripod. The results often manifest in policy documents gathering dust on the book shelves and well-articulated policy thrusts often don’t receive necessary political backing because they are not part of government’s agenda at the highest level.

We have, therefore, learnt lessons on how to do things differently. The recent mileage gained on Basic Health Care Provision Fund implementation came about because the key stakeholders were able to mobilise the lawmakers and ensure that health financing forms part of their agenda under the auspices of the Legislative Network for Universal Health Coverage. For the first time since the National Health Act, which includes BHCPF, came to be in 2014, the BHCPF found its way into the 2018 budget even when the executive arm of the government did not include it in the budget estimate submitted to the National Assembly. Another important lesson we have learnt is that the few states that increased their health allocation to 15 per cent Abuja Declaration benchmark were the states that were effectively engaged by stakeholders when their respective governments were in the process of setting their agenda. So, health became a priority of the likes of Jigawa and Bauchi states because the political class was effectively engaged at the point when governance agenda was still fluid.

Nigeria’s health policy landscape is not lacking potent policy instruments that can change the narrative of abysmal health system performance and flip the fortune into a narrative of improved health indices, which could make the country healthier and set good examples for other countries to emulate. Take, for example, the potential revolutionary policy of health insurance decentralisation, which could expand health insurance coverage to the teeming population of the country, thereby expanding access to health with financial protection and equity. Despite considerable progress made on the decentralisation process, the overall aggregate tends to mask the very poor performance of some states that are yet to develop their legal framework for the State Social Health Insurance Scheme. Although the BHCPF appeared in the ruling party’s manifesto and it was identified as one of the items that form the focus for the party’s ‘next level’ agenda, this is a very important opportunity to hold the APCA accountable for the campaign promise and to mount a healthy pressure to ensure that adequate funding is provided for the implementation of the BHCPF.

Beyond spending more on health, policy thrusts around improved efficiency of spending and enhanced quality of health care should be high on the governance agenda. Many of the states in the country spend more than 80 per cent of their health budget on human resource for health and several literatures have revealed that this could be the greatest source of inefficiency in the health sector. The governor of a certain state in the North-West recently warned that ghost workers constitute almost half of the state’s health workforce. The situation could be true, albeit at different degrees in other states.

Apart from a ghost workforce, absenteeism, low productivity and distribution that is skewed in favour of the urban at the expense of rural areas, where the burden of disease could be worse, are part of the problems that contribute to inefficiency in health sector spending. The existing effort geared towards enhancing transparency and accountability in health workforce management should be brought to the notice of the political class.

Some donor agencies piloted the Human Resource Information System with the aim of making relevant HRH information available for decision making. The effort has since lost momentum as projects that piloted the laudable initiatives have closed out. It is extremely important to mobilise necessary support to rejuvenate such initiatives to enhance value for the money. One of the bane of the civil service in this part of the world that hampers productivity of health workers is lack of effective performance management system that link reward to performance. Again, there were promising efforts in the past towards introducing a seasoned performance management system in the health sector, which is worth revisiting.

Another important source of inefficiency in the health sector stems from the drug and commodity management system. The entire commodity management value chain requires adequate attention as many challenges arise from the lack of an adequate system to ensure competitive pricing of commodities, quality assurance, suitable storage facilities at both storage central medical store and health facilities. Some states, through donor support, have been able to institute successful Drug Revolving Fund, which ensures the availability of essential drugs at affordable prices. This was made possible through the establishment of a semi-autonomous State Drug Management Agencies saddled with the responsibility of policy design and implementation on issues that affect the entire commodity value chain.

Some factors that contribute to the inefficiency of the health system stem from Public Financial Management arrangements that are beyond the control of the health sector. As a case in point, the budget structure in almost all the states in the country is input-based, whereas the rest of the world is moving to programme- based budgeting that ties spending to outcome in specific programme areas, therefore making resource tracking and accountability for resource use to be easier.

This arrangement also makes it easier for lawmakers to link appropriation to health outcomes during their oversight and accountability functions. While some states are making progress on International Public Sector Accounting System, which is helping to change their budget classification system, more progress is needed to ensure that they use programme codes for budget formulation, execution and monitoring.

While there could be other important areas to bring to the notice of the political class, what is more important is for the actors in the health space to explore every opportunity to bring some of these policy thrust and issues to the political front burner.

  • Dr. Gafar Alawode is the Programme Director, DGI Consult, Abuja

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