"Of all forms of inequalities, injustice in healthcare is the most shocking and inhumane."-Martin Luther King Jr.
The healthcare sector in Nigeria has made little progress in providing adequate quality healthcare services and it remains a cause for concern for many Nigerians who continue to have access to inadequate healthcare services.
The Basic Health Care Provision Fund (BHCPF), as mandated by the National Health Act 2014, represented a critical step toward advancing the country's progress in achieving Universal Health Coverage (UHC). This fund was designed to guarantee fair and equal access to a fundamental set of healthcare services for vulnerable populations and, to establish fully operational primary healthcare facilities in every political ward, and functional secondary healthcare facilities in each state. In addition, it sought to improve emergency medical response services, reduce the financial burden of out-of-pocket healthcare expenses, and ultimately improve health outcomes.
BHCPF: A pathway for inclusive healthcare delivery
Operationalised in 2019, the BHCPF is funded through three main sources: an annual grant from the Federal Government of Nigeria, equivalent at present to at least 1% of the Consolidated Revenue Fund (CRF); contributions from international donor partners; and funds from various other sources, including the private sector. There have been calls to increase the allocation to at least 2% of the CRF.
Although the National Health Insurance Authority (NHIA) Act 2022 makes health insurance mandatory for all Nigerians, uptake remains low and there is insufficient awareness about the programme, especially within the informal sector. In 2021, the informal sector constituted over 65% of Nigeria's total employment, presenting a significant potential funding source, if effectively harnessed.
Dr. Sikiru Salawudeen, Director, Informal Sector, National Health Insurance Authority, acknowledged funding gaps as part of the challenges to achieving robust health insurance coverage. "The failure of state governments to engage with their obligations under the National Health Act Law by not providing counterpart funding and financial support to crucial agencies has hampered the operations of these agencies, many now resort to depending heavily on the BHCPF for their daily operations. These agencies utilise these funds for procuring goods and even for hiring personnel. But we are working with the Nigeria Governors Forum to raise more funds." He further stated that "The knowledge and awareness of the intervention is very important, our report for the last quarter shows a 17.5% enrolment nationally."
Securing additional funding to expand the enrolment base would be the most beneficial course of action for BHCPF. Dr. Okara Dogara, BHCPF Programme Coordinator and Technical Adviser to the Permanent Secretary of the Federal Ministry of Health, said: "We presently aim to enrol 1.9 million individuals, and we have already registered approximately 1.5 to 1.6 million. With additional funding, we can expand the enrolment to include more beneficiaries."
Making the most of the BHCPF
Integrating Nigeria's informal sectors is important to achieving comprehensive healthcare coverage and reducing out-of-pocket expenses. The 2022 Nigeria Lancet Nigeria Commission report advocated for a "one nation, one health" approach, emphasising the need for Nigeria to ensure a minimum standard of healthcare delivery for all citizens through strengthened public and private partnerships. This recommendation aligns with the 2020 Guideline for the Administration, Disbursement and Monitoring of the Basic Health Care Provision Fund, which outlines essential steps for achieving inclusive healthcare provision, especially for vulnerable populations.
Nigerians deserve a functional and high-quality healthcare system that is accessible and provides essential health services. This should be the government's paramount objective.
To actualise the goals of the BHCPF requires addressing challenges such as awareness creation, funding gaps, and sustained enrolment. The Vulnerable Group Fund (VGF), designed to cover the 83 million Nigerians unable to afford premiums, offers potential for the BHCPF expansion nationwide, but precise beneficiary identification is crucial. Recognising the vital role of community health committees in driving demand in rural areas, it is increasingly important to promote collaborative action plans for healthcare delivery, utilising these committees to expand the social safety net.
Governance and leadership are pivotal in establishing an optimal healthcare system. The recent review of the BHCPF by the ministerial oversight committee offered Nigeria an opportunity to improve its healthcare system and accelerate progress toward UHC. Therefore, political appointees responsible for interfacing with implementors of the BHCPF must stay well-informed to enhance insights and ensure effective implementation.
In a recent briefing, Professor Pate, the Coordinating Minister for Health and Social Welfare, outlined a revamped Basic Health Care Provision Programme (BHCPP) as a crucial component of achieving the Nigeria Health Sector Renewal Investment Programme (NHSRIP). This multi-sector effort will see funds pooled by all major stakeholders in health, including the government, in an effort to improve population health outcomes. This would also include a redesign of the BHCPF following stakeholder consultation. The BHCPF has not lived up to expectations, and advances in primary health care have yet to materialise. Furthermore, accountability and control were lacking, resulting in leakages in the systems and funds not being used as intended. Perhaps the new redesign of the BHCPF will enable greater accountability and efficiency of funds used.
To reposition the BHCPF to achieve its full objectives, the following should be considered:
- Accountability: Ensuring prudent implementation of the BHCPF is vital for improving national health outcomes and progressing toward UHC. Elected officials must prioritise upholding the accountability framework of the BHCPF initiative to maintain transparency, efficiency, and value for money.
- Funding: Public health activities occur at various government levels (federal, state, and local). Given the challenge of funding, even with the 1% CFR, the new administration should consider raising the CFR to 2% while mandating counterpart funding at all levels. However, innovative funding mechanisms such as pro health taxes should also be explored, especially for vulnerable groups.
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- Awareness Creation: State governments should actively engage with the local government and community members through community-based strategies and interventions targeted at identifying and tackling barriers to health insurance utilisation and access. This engagement is essential for fostering community support and ensuring that no one is left out of the BHCPF.
- Public-Private Partnership: Leveraging public-private partnerships (PPPs) is crucial for strengthening healthcare systems. The 2023 Future of Health Conference suggests using PPP models to enhance healthcare delivery by leveraging private investment, collaborating with non-profit partners, and accessing private sector technical expertise to improve services. These collaborations enable governments to pool resources and combine the technical expertise of both sectors to enhance population health.
- Quality Improvement: To enhance service quality, it is essential to build technical capacity for developing business plans and annual quality improvement plans, as recommended by the guidelines. This empowers facility officers to prioritise the facility's needs.
The BHCPF offers a significant opportunity to eradicate healthcare disparities and achieve universal health coverage by providing a Basic Minimum Package of Health Services (BMHPS) in line with Nigeria's core healthcare obligations, upholding constitutional rights to life and human dignity.
