Monumental socio-economic devastation caused by the ongoing COVID-19 pandemic brings to the fore the need to further engender and prioritize health security policy and funding globally and locally. The Nigeria Health Security landscape has witnessed considerable transformations in the last couple of years with significant investment in epidemic prevention, detection and treatment by the National Centre for Disease Control. However, the ongoing COVID-19 pandemic has stretched the country’s health security infrastructure and exposed its suboptimal capacity to cope in the face of ravaging pandemic.
While a wide range of stakeholders are working relentlessly to stem the tide of the COVID-19 pandemic, minimize the ensuing economic hardship through various palliative measures and restore normalcy to the health sector, it’s extremely important to leverage the prevailing situation to make an enduring case for building a more resilient health system including health security system.
Based on the foregoing, the Preventing Epidemic (PE) project being implemented by the Legislative Advocacy Initiative for Sustainable Development (LISDEL) with funding from the Global Health Advocacy Incubator (GHAI) organized a roundtable forum of key stakeholders in the executive and legislative arms of government, as well as donors, development partners, Civil Society Organizations and the media to foster policy dialogue towards strengthening health security policy and institutional frameworks and financing in Nigeria on 27th August, 2020.
Health systems strengthening for UHC and health security are two sides of the same coin
In order to achieve universal health coverage (UHC), health security which is a fundamental responsibility of the government, needs to be prioritized and included in the annual health budget. The drastic drop in provision of essential health services such as immunization, antenatal care, family planning and outpatient care experienced during the COVID-19 pandemic points out the need to align health security and health system pillars, from ‘leadership and governance’ to ‘service delivery’. It also reveals the need for revitalization of primary healthcare centers all over the country. Achieving UHC and health security will also require improving financial risk protection through implementation of compulsory State Social Health Insurance and Contributory Schemes. Also, the roles of critical non-health sectors (such as agriculture, transport, environment, communication etc.) in promoting health security should be leveraged to achieve progress in strengthening the health system.
Furthermore, the critical role of expenditure tracking and costing in planning and advocacy to make an investment case for health security funding cannot be overemphasized. Therefore, health security components should be included in the 2020 National Health Accounts to ensure proper health security expenditure monitoring. Also, an appropriate costing methodology for health security should be adopted to inform health security policy and planning.
Importance of Basic Healthcare Provision Fund in transforming health security landscape in Nigeria
It is evident that most countries are at higher risk of epidemics as a result of growing interactions of man, animals and the environment. Consequently, the Nigeria Centre for Disease Control (NCDC) was established with the mandate to protect Nigerians from the impact of communicable diseases through evidence-based prevention, integrated disease surveillance and response activities. The agency is funded through annual appropriation from the federal government, including 2.5% of the Basic Health Care Provision Fund (BHCPF). Appropriation for BHCPF commenced in 2018, and N361.59 million has been released to NCDC till date. This additional funding has enabled NCDC to implement activities such as: (a) strengthening of emergency outbreak response through the establishment of Outbreak Response Fund and Indigent Patient Treatment Support, as well as supporting stockpile of outbreak response commodities; (b) establishment of National Incident Coordination Centre, State Public Health Emergency Operation Centers (PH EOCs), State Infectious Diseases Treatment Centers and sustaining National Reference laboratory and State PH labs; and (c) digitalization of surveillance and outbreak response through roll out of Surveillance Outbreak Response Management and Alert System (SORMAS) and capacity building of health workers in states. However, the revision of the BHCPF operational guidelines has excluded the provision for allocation of 2.5% of BHCPF to NCDC, thereby impeding the agency’s ability to sustain some of the aforementioned interventions.
Recommendations towards ensuring the NCDC’s ability to continue to make substantial progress in epidemic preparedness and response include: (a) increased budgetary allocation; (b) re-introduction of the 2.5% allocation from BHCPF for public health emergencies; and (c) formulation of legislations that will further empower NCDC in its health functions.
Harnessing and aligning statutory functions of lawmakers towards advancing health security financing
The lawmakers play the critical role of formulating laws, appropriating funds and overseeing the implementation of laws. In recognition of health security policy and financing as a very important agenda, the Nigerian lawmakers are partnering with various stakeholders to provide a legal framework that will ensure consistent financing for improving health security in Nigeria. They are also working out innovative strategies to finance health security from domestic sources.
Acknowledging the importance of adequately funding NCDC, the lawmakers have decided to use their oversight functions in empowering the NCDC to benefit from the BHCPF through a revision of the National Health Act; to ensure that the nation’s health security is given the required attention. More so, there is a need for capacity building of lawmakers in order to better utilize their statutory functions to improve health security financing, and enable them make a case for increased appropriation for epidemic preparedness and response.
The role of policy-makers in advancing health security financing
As the body responsible for the formulation and implementation of health policies in Nigeria, the Federal Ministry of Health (FMoH) is engaging stakeholders in the health sector, critical non-health sectors and the states to improve their ability to prepare for and respond to health emergencies.
To achieve a more resilient health system, it will be necessary for the FMoH to review health security policy and coordination of health security institutional framework. Also, it is important for the FMoH to work out creative techniques for working in a post-COVID economy to be able to achieve success despite the constrained macro-fiscal space.
Policy gaps to be addressed to reposition the health security landscape
Each of the three tiers of government has responsibilities towards the health sector; however, the responsibilities for health security seem to be skewed towards the federal government as a result of policy and financing gaps existing in the States and Local Government Areas. Therefore, more efforts need to be deployed into strengthening the capacity of the state and local governments to take ownership and responsibility for health security, by providing structures needed for emergency services and financing interventions for prevention, as well as early detection and management of outbreaks in communities.
The NCDC has been engaging with state governments and encouraging them to provide a dedicated budget line for emergency preparedness and response to enable them to fund the structures that have been established; such as national guideline for meningitis, cholera and other infectious diseases which will be implemented by the state epidemiologists and their teams, the public health Emergency Operation Centres (EOCs) as well as training and capacity building.
In addition, enrollment into state health insurance schemes should be hastened through the implementation of BHCPF and other funding sources in order to address the existing health policy and financing gaps.
Accountability mechanisms for optimal efficiency
As all parties responsible for health security execute their functions, it is important to hold them accountable on the performance of their roles. It is also imperative to ensure accountability and efficiency in spending. While budgeting, the proportions of funds allocated to overhead, personnel and capital expenditure need to be balanced for efficient utilization of existing resources. Also, as the states are being encouraged to contribute their quota to implementation of state health insurance, they should also be encouraged to set up monitoring and accountability mechanisms to ensure that the contributed funds are used to achieve health for all, including health security. Also, the lawmakers should be held accountable for the provision for raising health budgetary allocation by 5% in the Legislative Health Agenda (LHA); which is expected to be followed by advocacy for progressive increase to the 15% Abuja declaration benchmark.
A health security accountability framework has been developed to raise the accountability bar for health security at both national and sub-national levels through improved transparency, answerability and evidence-based decision making on health security financing. The framework will measure performance of the various stakeholders (legislature, executive arm of government, the media and CSOs) based on selected health security financing indicators and targets, and document the roles and expected responses of different stakeholders to the trend of the health security financing indicators.
In spite of the several steps that Nigeria has taken to improve its capacity to prevent and respond to major outbreaks, the country’s public health infrastructure is still fraught with identifiable gaps ranging from insufficient legal frameworks for epidemic preparedness and response, poorly funded health systems for epidemic response, low level of awareness on epidemic preparedness among the political elite, to the absence of an institutionalized multi-sectoral collaboration for epidemic response and gross inefficiencies across board. Meanwhile, it is difficult to realize the goal of achieving UHC in the absence of a resilient health system; therefore, health security should feature prominently in all interventions aimed at strengthening the health systems.
Achieving improved health security requires all stakeholders’ involvement, from provision of sound legal, institutional and policy framework for health security, and adequate investment in epidemic preparedness and response, to commitment of subnational governments to health security policy implementation and financing. Also, making significant progress towards health security with Nigeria’s unfavourable macro-fiscal situation, which is worsened by the COVID-19 pandemic calls for innovation on mobilization of additional resources and efficient spending of the meagre public resources. In addition, the accountability bar for health security needs to be raised by holding government accountable for providing legal, institutional and policy frameworks for health security, spending efficiently and fulfilling their policy and spending commitments.
Finally, there is a need to take advantage of the ongoing COVID-19 crisis to achieve an enduring health security financing transition in Nigeria. The exposure of the lapses in the health systems as well as level of preparedness and ability to respond to epidemics, occasioned by the crisis provides a strong evidence to make a case for increased and sustainable investment in health security.