Author(s): Olanrewaju Tejuoso, Gafar Alawode, Elaine Baruwa
Date of Publication: 11 Apr 2018
A country health system that fulfills its responsibilities to citizens cannot function in isolation it needs good governance in terms of policy making, appropriations, oversight, and accountability mechanisms. That is, democratically elected governments/legislatures must pass informed policies and laws that govern the health system and allocate adequate resources to a ministry of health.
Failure of a health system in a democracy should have consequences through accountability mechanisms both within government, such as elections, and outside of government, through media coverage and other channels. However, these mechanisms do not function as desired in Nigeria. Thus, strengthening the legislature’s ability to make, implement, and monitor good health policy and developing its ongoing relationship with the Ministry of Health have the potential to strengthen the health system overall by moving legislators from audience to collaborators.
Recognizing the potential of an engaged legislature, in 2017 the Nigerian Senate Committee on Health joined with the United States Agency for International Development’s Health Finance and Governance Project, the World Bank, the Bill and Melinda Gates Foundation, and UKAid to mobilize Nigerian legislatures at the federal and state levels to identify ways in which legislators can use their statutory functions to achieve universal health coverage (UHC). The outcome was establishment of the Legislative Network for Universal Health Coverage (LNU).
At the LNU launch on July 24–25, 2017, legislators from nearly all of Nigeria’s states members of state health appropriations and health committees, house speakers, and government secretaries met to discuss their role in UHC. They determined that despite the legislatures’ governance responsibilities as outlined above, many legislators (1) were unfamiliar with the concept of UHC; (2) were unaware of the extent to which the chronic underfunding of health, primary health care (PHC) in particular, negatively affects their constituents; and (3) had never engaged with the federal and state ministries of health to clearly identify legislators’ responsibilities and enable them to perform in a way that would strengthen the health system. The LNU strategic committee immediately set out to develop a training curriculum to address each deficiency. The curriculum, designed with the Nigerian Institute of Legislative Studies, the Federal Ministry of Health, and the LNU steering committee, explains the basics of UHC and health financing, reviews the National Health Act, and uses an interactive case study approach with examples from several Nigerian states to demonstrate how legislators can use their policy making, appropriation, oversight, and accountability functions to move their states towards UHC.
Legislators’ work does not end once a law is passed: in 2014, civil society and donors took the lead in engaging legislators not the Ministry of Heath to pass the National Health Act. However, a year later, a new government was elected and the Act remained mostly unimplemented.
The Act is wide-ranging, describing substantial reforms of the public and private health sectors, but of key interest to Nigeria’s UHC objective is the earmarking of revenue from Nigeria’s Consolidated Revenue Fund for the Basic Health Care Provision Fund (BHCPF). The BHCPF is critical to ensuring equitable UHC because it will cover the care of vulnerable populations, including the indigent, pregnant women, and children under five. It will also be used to strengthen the PHC delivery system, including addressing the country’s maternal and child mortality rates. This is important for legislators: Nigeria is 64% rural, and its system has decentralized vital PHC services to the lowest and weakest tier of government and the majority of legislators represent communities with weak PHC facilities and very limited geographical and financial access to urban secondary facilities.
Training and advocacy through the LNU is transforming legislators’ views on appropriations and enabling them to hold all levels and branches of government, especially the executive, accountable to laws and the wishes of the populace. Only six months after the LNU’s training began, engagement and alignment through “legislative health agendas” is showing results. For example, the Lagos State commissioner for health said that he never used to be called by the chair of the appropriations committee. Now, state appropriations committees are calling on their state Ministry of Health to ask about ministry progress on UHC and the funding it requires. Prior to the LNU training, state ministries of health were not questioned about budget allocations, which were biased toward secondary-level facilities.
On the federal level, the budget bill the Nigerian Executive sent to the Nigerian Parliament in December 2017 did not include the 1% of the Consolidated Revenue Fund that is to go to the BHCPF. In line with its public statements at the launch of the LNU, the senate has put the provision into the budget and stated that they will not pass the budget without it. In response to pressure from state legislatures, the State Governors’ Forum has engaged the LNU and requested a presentation on the BHCPF so that the Forum can advocate to the Executive to leave the earmarked provision in the bill. The bill’s outcome is still undecided, but the success at engaging the Nigerian legislature on health and strengthening its relationship with state ministries of health has clearly demonstrated benefits.
Still, more needs to be achieved: over 70% of spending on health in Nigeria is on private providers and over 60% of all spending on health is out of pocket a great burden on most of the population. Yet the private sector remains underregulated and underutilized for the control of infectious diseases like tuberculosis, HIV, and AIDS and for the provision of effective interventions such as family planning/child spacing. The Ministry of Health, which traditionally has focused on the public health sector, views the private sector as beyond its control. But the legislature sees the private health sector as a potential driver of economic growth given its market size in terms of the number of providers, health maintenance organizations, pharmaceutical manufacturers, and other entities.
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