Mobilizing Domestic Resources for TB: What Have We Learned?

By Esther Okunola

Program Officer, DGI Consult

Background

Tuberculosis (TB) is the world’s most lethal infectious disease and the second highest cause of mortality, despite being treatable and preventable. Nigeria has the second greatest TB burden in Africa, accounting for up to two-thirds of all TB cases worldwide. In Nigeria, approximately 440,000 people are infected with TB each year, with 155,000 people dying from the disease; a number that has remained nearly constant for the past two decades.¹

Domestic funding for TB in Nigeria accounts for less than 10% of the annual TB budget, a stark contrast to what is obtainable in countries with similar income groups such as India where the government contributes about 75% of the TB budget. In 2020, there was a 70% funding deficit for the TB budget in Nigeria, with 23% of funding coming from donors and only 7% from the government (figure 1). The persistently high TB burden in Nigeria is principally attributable to the large financing gap for TB control programs at the national and state levels.²

Figure 1: Gaps in TB Financing in Nigeria, 2020

Source: Global Tuberculosis (TB) Report, 2020. World Health Organization (WHO)

Promoting sustainable financing mechanisms through DRM and the integration of TB into national and state social health insurance schemes are the key strategies highlighted in the National TB Strategic Plan 2015 – 2020 for expanding access to TB prevention, diagnosis, and treatment in Nigeria. The strategic plan targets multiple financing schemes which includes increasing public sector spending, scaling up private sector funding, financing TB services through national/state health insurance, and improving efficiencies by spending across funding mechanisms.³

DGI Consult’s Approach to Domestic Resource Mobilization (DRM) for TB: The Oyo, Ogun, and Lagos State Experience

DGI Consult through the DRM stream of the USAID-funded TB LON 3 project seeks to improve investment in health and TB particularly, by deploying interventions for mobilizing domestic funding for TB in Oyo, Ogun, and Lagos States, using a two-pronged approach, i.e., budget advocacy for sustainable TB financing, and the integration of TB services into the State Social Health Insurance Schemes (SSHIS).

Budget Advocacy for TB Financing

To build a compelling case for government investment for TB, a Public Finance Management (PFM) assessment was conducted in the 3 states to understand the trend of health and specifically TB budget performance, and identify the PFM obstacles that militate against optimal funding. Unavailability of TB budget line in Oyo state and lack of release of allocated funds for TB in Ogun and Lagos states were identified as obstacles that impeded TB financing.

DGI Consult supported Ogun state to establish a multi-sectoral Health Financing Technical Working Group (HFTWG) and strengthened the existing HFTWG in Oyo and Lagos states to advocate for improved funding for health, particularly TB through series of problem-focused and action-oriented meetings. In Lagos state, for instance, the interface between the health and finance MDAs was strengthened to foster effective communication and resolve the bottlenecks that impede the timely and complete releases of allocated funds for the TB program.

Technical support was provided to the State TB and Leprosy Control Program (STBLCP) in Oyo State to request for the creation of a budget line for TB, to generate a sustainable funding source for TB. Similarly, technical assistance was provided to the STBLCP across the states to identify TB funding priorities, then prepare and submit a high-quality funds requisition memo. Thereafter, tenacious stakeholder engagements and high-level advocacy to the approving authorities in the health and budget MDAs were carried out to facilitate approvals.

Integration of TB services into the State Social Health Insurance Schemes (SSHIS)

The journey of integration of TB services into SSHIS in the states was initiated with engagement of stakeholders to conduct an SSHIS institutional gap assessment. This helped to identify gaps, track the progress that had been made, and ascertain the readiness for integration of TB services into the SSHIS benefits package. Due to the high cost of TB management and the limited funds available in the SSHIS pool in the states, the integration of TB services requires a phased approach. Therefore, the health insurance operators and STBLCP were guided on milestones to be covered to successfully incorporate TB services into the SSHIS benefits package, through the creation of TB integration roadmap in the three states (figure 2). Also, to ascertain that this initiative achieves progress across the three dimensions of coverage (patients, services, and cost), a TB coverage trajectory was developed (figure 3).

Figure 2: TB Integration Roadmap

Figure 3: TB Coverage Trajectory

An important milestone of the TB integration roadmap is to establish the financial feasibility of TB integration. The SSHIS in the 3 states was supported to conduct an actuarial analysis to establish the financial feasibility of integrating TB services into their benefits package. This provided the estimated premium required to bridge the TB coverage gap, determined the minimum enrollee population required to provide full TB coverage, and analyzed the cost implication of TB case management. The SSHIS were also supported to expand their coverage through informal sector engagements since the most of TB patients belong to this group.

Results

Establishing stronger communication between the health and finance MDAs led to swift approvals and disbursement of funds for the STBLCP. This is evidenced by the cumulative release of NGN38million for the STBLCP in Lagos state in 2021 as against the lower/zero releases in previous years (figure 4). Similarly, the release of NGN59.9million and NGN7.5million has been approved by the Executive Governor of Oyo and Ogun state respectively for the STBLCP.

Figure 4: Trend of budgetary releases to TB in Lagos State 2016 – 2021

Source: Lagos State Ministry of Health

Effective high-level advocacy has led to the creation of program-based TB budget line in Oyo state and significant increase in TB budget allocation in 2022 budget across the states.
The results of the Actuarial Analysis conducted across the 3 states shows an amazing level of financial feasibility for integration of specific TB services into SSHIS benefit package even at low level of Health Insurance penetration (figure 5).

Active engagement of the informal sector has led to increase in SSHIS informal sector enrollment by 2,598 and 1,600 individuals in Oyo and Lagos State respectively. This is expected to increase health insurance coverage to a substantial number of TB patients.

Figure 5: Additional premium for TB service integration at OYSHIA penetration levels

Source: Oyo State Actuarial Analysis Report, 2021

Challenges

Some of the challenges encountered in the budget advocacy for TB financing and the integration of TB services into SSHIS benefits package include the following:

Overall sub-optimal budget execution in the health sector
The bureaucratic processes of fund approval and releases in the states
Poor coordination of TB partners’ activities in the states which contributes to delayed approval of fund requisition memo due to perceived duplication
Lack of (or inadequate) release of Equity Fund for subsidization of the vulnerable population, which includes many TB patients
Slow progress in population coverage expansion by the SSHIS
Difficulty in procuring TB drugs by providers.

Lessons Learnt

Strengthening the communication nexus between health and finance actors through multi-sectoral engagement and capacity building helps to improve budget performance
Sustained evidence-based advocacy and continuous engagement with high-level policymakers is essential to enhance government responsiveness towards DRM for TB
Integration of TB to the SSHIS benefit package is amazingly feasible financially even at a low level of health insurance penetration

Conclusion

Improved DRM through a multi-sectoral approach, effective communication between the health and finance MDAs, and sustained evidence-based advocacy are needed to achieve sustainable financing for TB and other priority disease programs, as well as improved overall budget performance at subnational levels. This can be attained by concerted efforts of relevant stakeholders to shift the trajectory of TB financing from high dependency on external funding to increasing domestic funding for TB and strengthening TB integration into health insurance.

Recommendation

The following are recommended to further promote DRM for TB in Nigeria:

Sustained advocacy for the timely and complete releases of the earmarked Equity Funds to the SSHIS by the State Governments is needed to improve TB patients’ access to subsidized healthcare services, increase their access to other government social protection programs and further facilitate the integration of TB services into the SSHIS.
Evidenced-based budget advocacy combined with the integration of TB services into state health insurance schemes should be scaled up and adopted as strategic actions to address TB funding gaps in Nigeria.
Dependence on dwindling donor funding by the STBLCP should be reduced and production of high-quality fund requisition memos for the allocated TB funds should be intensified, with rigorous follow-up until the funds are released.
Successful integration of TB into SHIS requires effective dialogue with NTBLCP and other relevant stakeholders to chart a course on ensuring access to TB commodities for providers under the SSHIS.
With the evidence of the financial feasibility of TB integration into SSHIS, the SSHIS TB coverage trajectory should be reviewed to identify and agree on services that could be integrated now, in the near future and at the advanced stage of health insurance penetration.
Development partners should provide necessary technical assistance to the health insurance operators to ensure a seamless delivery of TB services under the health insurance scheme.

References

2020 Global TB Report
Nigeria’s TB profile. 2021. World Health Organization (WHO) Country TB profiles. Available at: https://worldhealthorg.shinyapps.io/tb_profiles/?_inputs_&entity_type=%22country%22&lan=%22EN%22&iso2=%22NG%22
The National Strategic Plan for Tuberculosis Control 2015 – 2020. NTBLCP, Federal Ministry of Health.

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