Nigeria

Nigeria has always been committed to the principles of universal health coverage and has adopted policy documents and legislation to that effect. However, indicators of Nigeria’s health outcomes and actual coverage of basic health services show underperformance, both in absolute terms and relative to other countries at similar levels of economic development.

Key drivers of underperformance include a health system unable to ensure universal coverage of primary health care services and weak accountability for results. The health sector has long been underfunded, and its structural and institutional frameworks have placed concurrent responsibilities on all three tiers of government (federal, state, and local) without any mechanism for intergovernmental accountability.

To rectify the lack of a legal framework necessary to drive a high-performing health system, in late 2014 the Federal Government of Nigeria signed into law the National Health Act. This Act provides a framework for action, encompassing the regulation, development, and management of a national health system, and it sets standards for rendering health services throughout the federation.

The Mission to Provide the National Health Act with Adequate Funding

The National Health Act specifies that all Nigerians shall be entitled to a Basic Minimum Package of Health Services (hereafter the Basic Minimum Package), a set of preventive, protective, promotive, curative, and rehabilitative health services or interventions. One of the key provisions in the Act is the Basic Health Care Provision Fund (BHCPF), which will serve as the principal funding vehicle for the Basic Minimum Package while at the same time serving to increase overall financing to the health sector. Its funding is derived from three tracks, namely: (1) an annual grant from the Government of Nigeria of not less than one percent of its Consolidated Revenue Fund; (2) grants by international donor partners; and (3) funds from any other source.

However, the BHCPF has remained unfunded since the law was signed in 2014, notwithstanding the fact that a diligent implementation of the Act could set Nigeria on the path toward universal health coverage. A turning point came in mid-2016, when Nigeria joined the GFF and the newly appointed minister of health proposed that US$20 million in grant resources from the GFF Trust Fund be used to pilot the BHCPF in three states. The Bill & Melinda Gates Foundation also committed US$2 million in grant resources to test the BHCPF’s early implementation and provided financing to the World Bank to undertake analytical work to strengthen the design. This influx of resources further strengthened the advocacy by various partners for the implementation of the BHCPF. The World Bank supported the leadership of the Ministry of Health in engaging with Nigeria’s Economic Management Team, and development partners in Nigeria supported an advocacy mission to the National Assembly. Civil society organizations and the media played a critical role in this advocacy campaign.

Nigeria’s parliamentarians responded by concluding that if external grant resources could support three states, the Government of Nigeria should be willing to commit its own resources as well. In this way, GFF resources proved to be an instrumental tool for a call to action. The outcome of these strategic investments and the associated analytical work and advocacy was that in May 2018, the Government of Nigeria decided to allocate the full one percent of its Consolidated Revenue Fund for the BHCPF in the FY2018 appropriation.

Performance-based Financing

The BHCPF employs proven, results-based and decentralized approaches and thus represents not only more money but “smarter money,” enabling Nigeria to translate bold innovations in service delivery into improved health outcomes. The implementation uses two interrelated approaches to improve service delivery, not only in public but also in private facilities.

First, a fee-for-service payment approach to providers will initially spur the delivery of a highly prioritized package of 10 high-impact maternal and child health interventions, including family planning. A focus on serving rural areas will help address equity challenges, because health outcomes are significantly poorer—and worsening—in rural areas.

Second, an accreditation system will be used to prequalify both private and public health facilities, contributing to the setting and maintaining of minimum quality standards. Payments will be made on the basis of verified data after the services have been provided, while keeping services free to beneficiaries, thus increasing accountability while reducing barriers to accessing care. The BHCPF signals a new era in service delivery for primary health care services in Nigeria.