Historically, access to healthcare in Nigeria has been a significant challenge, with out-of-pocket (OOP) expenditure accounting for approximately 70% of healthcare financing -- among the highest rates globally. To alleviate this financial burden, the Federal Government of Nigeria established the Basic Health Care Provision Fund (BHCPF) under the National Health Act, aimed at ensuring sustainable financing for primary healthcare across Nigeria.
The BHCPF aims to improve access to essential healthcare services across the country by ensuring that primary and secondary healthcare services are readily available and affordable, particularly for vulnerable populations. Despite its implementation in 2019, the impact of BHCPF remains under-explored, particularly regarding its effectiveness in achieving its objectives for reducing OOP expenditures and increasing life expectancy.
Implementation of the BHCPF in Kano State
By providing a Basic Minimum Package of Health Services (BMPHS), the fund targets a significant reduction in OOP healthcare expenditure, aiming to ensure that at least one primary healthcare center (PHC) per political ward is fully functional, and seeks to increase life expectancy in the country. The BHCPF approach involves direct funding to the healthcare facilities. To reach beneficiaries, the funds are channeled through three main avenues: the National Health Insurance Scheme, National Emergency Medical Treatment, and the National Primary Health Care Development Agency (NPHCDA). Funds from the NPHCDA cover essential medications, vaccines, and consumables. The funds are also to be used for the maintenance of primary healthcare facilities, equipment, and transport, as well as supporting human resource initiatives for primary health care.
The operationalisation of the BHCPF in Kano State is through three gateways that bring together the Kano State Primary Health Care Management Board (KSPHCMB), the Kano State Contributory Health Management Agency (KSCHMA), and the State Emergency Medical Treatment Committee to ensure equitable access to healthcare in the state. Together, these organisations work together to ensure the effective distribution of funds, the engagement of healthcare workers, and the provision of essential health services to the most vulnerable populations.
The BHCPF in Kano State receives funding from various sources, including the KSPHCMB and KSCHMA through relevant national health agencies. "...the funds for these services are sent directly from KSCHMA, they send these funds directly to the basic health care account, for the facilities to be well taken care of and equally from the Board." BHCPF Programme Manager, Nurudeen Sheriff said.
Setting a benchmark
In Kano State, the implementation of the Basic Healthcare Provision Fund (BHCPF) is about more than simply disbursing funds -- it is also about accountability and continuous improvement. These include stringent retirement processes for funds, the development of quality improvement plans, and regular supervision and audits. According to the BHCPF Programme Manager, Nurudeen Sheriff, these practices have not only improved service delivery, but have also set a benchmark for other states in Nigeria to follow.
According to Sheriff, three main strategies distinguished BHCPF implementation in Kano State.
- Timely Retirement Process: Kano State has a strict timeline for the retirement of funds. Health facilities that fail to adhere to the set timelines results in the loss of subsequent disbursements. This practice ensures that funds are utilised promptly and effectively.
- Quality Improvement Plans: Each healthcare facility in Kano develops a comprehensive Annual Quality Improvement Plan. This plan covers all the thematic areas, from infrastructure to community engagement, with detailed quarterly business plans outlining activities and estimated costs. Each health facility has a mentor that guides them in the development of the plan. Following the development of the plan, it is submitted to the Local Government where it will be signed by the PHC coordinator before it is submitted to the state for watermarked verification. This meticulous planning ensures that funds are spent wisely and in line with predefined quality standards.
- Supervision: Supervision is rigorous in Kano State to ensure that the plans are being implemented effectively. Any deviations from the plan prompts corrective actions, including potential refunds to state accounts if expenditures are not justified.
Surpassing expectations
Despite the set targets being ambitious, such as achieving 70% PHC functionality within five years -- Kano State has exceeded expectations, achieving these milestones ahead of schedule. In 2021, Kano State initiated its BHCPF programme with 381 healthcare facilities and currently Kano State has 484 fully functional PHCs.
Since its inception, the state has astutely utilised BHCPF funds to improve healthcare facilities, hire essential staff like midwives, and provide life-saving drugs and equipment. According to Sheriff, as of May 2024, the State had enrolled 162,165 persons to receive essential healthcare services in the facilities.
"Since the programme started there have been significant changes aside from directly sending funds to some facilities, the programme has engaged 135 midwives" Sheriff noted.
He added that since the implementation of the BHCPF, "we have recorded a reduction in maternal mortality rate, and the Penta-3 coverage of the state has increased because people can access immunisation services for free. Apart from this, if you go to our facilities, they are judiciously utilising these funds in terms of infrastructure, the building of the facilities, and the equipment, we didn't have a sphygmomanometer (to measure high blood pressure) but now they have a lot of equipment and lifesaving drugs."
The BHCPF has contributed to reducing the financial burden, thereby reducing OOP health expenditure in the Kano State. The real success of BHCPF can be seen in the lives it has touched. Beneficiaries of the programme, particularly vulnerable groups like women, children, and people with disabilities, shared stories of improved health and well-being.
**Halima Tijani, a mother of two, shared that the programme has been a lifesaver for her family. Halima's child had diarrhoea and malaria, accessing care at the BHCPF facility ensured that her child did not die from the disease. "If it wasn't for this programme, my children might not be alive today." Halima shared.
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Overcoming challenges
Despite these successes, the implementation of BHCPF has not been without challenges. Delays in fund disbursement, data inaccuracies, and bureaucratic hurdles have affected the programme's efficiency. For example, Kano State has yet to receive disbursements from the national level for the first two quarters of 2024, posing significant challenges to maintaining the momentum. In addition, due to bureaucratic hurdles, the work plan prepared for implementation of activities in 2023 was approved in August 2023 toward the beginning of the last quarter of the year. Similarly, the work plan for 2024 is yet to be approved as of May 2024. Such delays lead to delays in programme implementation and significantly affect the success of the programme.
The BHCPF represents a critical step towards achieving Universal Health Coverage (UHC) in Nigeria. While challenges remain, the successes in Kano State demonstrate the programme's potential to transform healthcare delivery. Strengthening the BHCPF in other states, using Kano State's approach, is crucial for nationwide health improvement. By implementing timely retirement process, quality improvement plans, and rigorous supervision, other states can learn from Kano's successes. This will enhance healthcare access, reduce OOP expenditures, and move Nigeria closer to achieving Universal Health Coverage.
**Not her real name.
