February 2016 nigeriahealthwatch; There have been enormous health challenges in Nigeria, with health indicators showing that Nigeria is one of the worst places on earth to be born. One major underlying challenge is that the health sector has been chronically underfunded for many years.
The Nigerian Government has signed several conventions and declarations in the past but too little is being done to meet the commitments made. The most significant of these declarations is the Abuja declaration of 2001, where African countries committed 15% of national budgets to the health sector. Despite recently being ranked as the largest economy in Africa, Nigeria has not kept to the Abuja declaration; it has not come close.
Other African countries with much less resources have reached and surpassed this allocation, with tangible benefits in their health outcomes and arguably economic outcomes. Notably, Rwanda allocates 18% of its national budget to the health sector. In both Botswana and Niger 17.8% of the budget is reserved to fund the health sector. Other examples include Malawi (17.1%), Zambia (16.4%) and Burkina Faso (15.8%)
On the other hand, Nigeria’s budgetary allocation to Health since 2012, has been, at best, a mere 6%. In November 2015, President Buhari submitted his Medium Term Expenditure and Fiscal Strategy paper to the National Assembly.
It emphasized a social inclusion strategy that would “protect the poor and most vulnerable… providing qualitative and affordable healthcare and improving overall living standards of Nigerians.” The Sustainable Development Goals also provide a framework for designing government programmes that align with globally agreed development outcomes.
Despite these two guiding frameworks, the 2016 budget proposal by the Federal Government seems to move the health sector away from the aspirations of the National Health Act passed in 2014. The intent of the new law was to correct the lopsidedness in the funding of the primary health care system in Nigeria and aimed at providing the bridging funds needed to create a resilient health system. The current proposed health budget does not allow for this impetus to take place.
What is the government planning to spend in 2016?
For 2016, the Federal Government has proposed an overall budget of N6.08 trillion. Of this total, N2.65 trillion is for non-debt recurrent expenditure while N1.85 trillion is for capital expenditure for the year. Here is a breakdown of the 2016 Budget Outlay.
How does health factor into the proposed budget?
In the 2016 budget proposal the Federal Ministry of Health and its agencies received just over N221 billion for recurrent expenditure which is 8.4% of non-debt overall recurrent expenditure. Under capital expenditure 35.7 billion was allocated for health projects in 2016, a mere 2.2% of aggregate capital allocations.
When you put these numbers together, the total, just over N257 billion, equals 5.6% of the total non-debt federal allocations for 2016. However, it is only 4.23% of the total budget proposal, again falling short of the commitments made under the Abuja Declaration of 2001.
For the various health budget lines and projects domiciled outside the Federal Ministry of Health and its agencies, a total of N24.76 billion has been identified.
This includes the budget lines for the National Agency for the Control of AIDS (NACA), the State House Medical Center, the National Assembly Clinic, NHIS contributions for military retirees, payment of outstanding salary arrears for health professionals, and a host of projects in different ministries and agencies of government where medical supplies or construction of health facilities are part of their budgets. The total allocation to health programmes in the 2016 budget proposal comes to N282.14 billion, which is only 4.64% of the overall budget.
A significant amount of resources has been allocated to social welfare programmes which do not have details in the 2016 budget proposal. From these programmes, it is expected that provisions will be made for primary health infrastructure across the country, especially in relation to constituency projects. There is no specific breakdown showing what these amounts allocated for special programmes and interventions of the Federal Government will be used for. Until these details are made known, we cannot make any conclusive analysis of the allocations for the health sector.
How does the current proposed health budget compare to that of 2015?
The structure of the 2016 Federal Budget proposal for health did not follow the pattern of the 2015 appropriation. Several components that were defined in the 2015 budget as MDG-targeted interventions for specific challenges, particularly in Maternal and Child Health, are not clearly provided for in the 2016 proposal.
This may be connected with the expiration of the MDGs. However, since there are provisions for SDG-related interventions and other special intervention programmes that are not clearly defined in the proposed budget, we cannot determine what programmes will target the major challenges in the health sector, especially related to maternal and child health.
From this side by side comparison of the 2015 vs 2016 health budgets, it is obvious that there is an overall increase in health-related allocations but a decline in the provisions for the Federal Ministry of Health and its agencies driven by the reduction in recurrent expenditure.
While there is a noticeable increase in the proposed counterpart funding for HIV /AIDS including the Global Fund, there was no provision for a counterpart Fund for the Polio Eradication Programme & Routine Immunization and other vaccines which have almost N16 billion allocated in the 2016 budget.
Allocations to NPHCDA have also increased, from N12.14bn to N17.8bn while allocations to hospitals and medical institutions decreased from N226.5bn to N215.6bn. All these have to be understood in the context of an inflation rate of about 10%. Also it is globally recognised that inflation in the health sector is generally higher that the average inflation rate, so in effect we are facing a significant reduction in government spending on the health sector.
What does this mean for the funding of the 2014 National Health Act?
The National Health Act creates a Basic Healthcare Provision Fund (BHPF) to provide Nigerians with access to basic health care services. Fifty percent of this fund is to be allocated to the National Health Insurance Scheme (NHIS) to provide health coverage for pregnant women, children under the age of five, the elderly, and persons who are physically challenged.
The other half of the Fund is to be used to provide essential vaccines and consumables for eligible primary healthcare centers (“PHC”), maintenance of facilities, equipment, and transport for PHC facilities, and development of human resources for PHCs with a goal of extending primary healthcare to Nigerians living in hard-to-reach rural communities. The Fund is to be derived from 1% of Nigeria’s Consolidated Revenue Fund, donor contributions as well as contributions from state and local governments.
From the projected consolidated revenue for 2016 as shown in the MTEF, 1% of CRF would amount to about N35 billion from the Federal Government alone.
If this sum was provided for as new funding to the health sector for the purpose it was intended for in the National Act, it will push the budget for 2016 to just over N300 billion, without counterpart funding from the states. That in itself would create impetus for primary health care and universal health coverage for Nigerians. In relation to the Abuja commitment, this mandatory annual provision alone can push Nigeria closer to the target of 15%.
Unfortunately, there is no evidence that the 2016 budget proposal has made the statutory provision for health as documented in the National Health Act of 2014. The Government of Nigeria appears to have disregarded its own policies in the budget proposal. If at this point the government is not concerned about funding the National Health Act, what does this mean for implementation of the Act, for provision of basic health care services for the most vulnerable amongst us?
Is health really a priority for this government?
While there is a slight increase in the overall provision for funding health programmes in the federal budget proposal (not accounting for inflation), the funding gap is still very wide and grossly inadequate to achieve the health objectives of the SDGs especially at the primary health care level.
The proposal is silent on funding for priority health challenges such as maternal and child health, and there is no evidence that the government plans to increase funding for vaccination, HIV/AIDS, Malaria and TB programmes, which are currently almost completely dependent on donor funding.
After the euphoria of the final passage of the National Health Act into law in 2014, it is most disappointing, from all analysis, that the 2016 budget proposal has not taken into consideration the funding of such an important policy, probably one of the best pieces of legislation to come out of Nigeria since Independence. It begs the question; does our government really care about the health of our pregnant women, who are dying every day? Does it want the best for our children, our elderly, those living with disabilities, those affected by AIDS, by NTDs?
The Nigerian government has the law in place to begin to truly alleviate the deep underlying health issues that plague everyday Nigerians. It has the law, but does it have the will to do what the law provides for? Does it have the will to do what is right?