Even though the low proposed budgetary allocation for health in the Nigerian government’s 2019 proposed budget that was recently presented to the National Assembly by President Muhammadu Buhari for approval is quite worrisome, stakeholders and industry watchers were not surprised considering age-long trends.
But things are quickly changing. The gap in health funding used to be bridged by donor fund but this is gradually running out. In this interview, physician and health economist Dr Biodun Awosusi tells healthnews.ng that Nigeria needs to be more proactive in its health spending – and should set its priorities right.
Various health initiatives in Nigeria are heavily reliant on foreign donors. What are the good and bad sides of this development?
Although external financing is 8% of total health expenditure in Nigeria, it represents a significant chunk of financing for polio elimination efforts, childhood vaccine programs; malaria, TB, HIV and AIDS control; and increasingly reproductive, maternal and child health programs. Foreign donors’ priorities are largely influenced by domestic politics, are unpredictable and not completely aligned with the national policies and plans.While these external financing sources have been crucial in the last two decades, Nigeria may no longer be eligible for grants from the Global Fund, GAVI as well as grants and concessional loans from development finance institutions especially the World Bank by 2030.
Nigeria prides itself as the Giant of Africa but foreign governments and donors are in tight control of its peoples’ health. What do you think is responsible for this?
Nigeria is actually in control of its health sector except for key programs like polio elimination, vaccines, malaria, HIV & TB where the country is heavily dependent on donors. External financing is less than 10% of total health expenditure. Three-quarter of health sector funding is out-of-pocket.
What is the best global practice for financing the health sector?
Adequate public financing that guarantees access to high quality healthcare with financial protection is the best global practice. This implies spending at devoting at least 15% of the national budget to health or US$86 per capita. In the last two decades, Nigeria has consistently spent poorly on health partly because of poor revenues and misplaced priorities with a lacklustre attitude towards human capital development. Nigeria spends approximately US$11 per capita less than the African average.
What needs to change in Nigeria to address the issue at hand?
In Nigeria, we need to spend more on health and use available resources more efficiently. African countries like Rwanda, Ethiopia and Botswana have made significant progress in their health systems because they invested heavily in the health of their people. Nigeria’s revenue as a share of GDP is 6% and will increase to 7% by 2022. Nearly 80% of that revenue is spent to service loans. The opportunity to increase health sector funding is low: so we must use what we have very well.
What models would you recommend for Nigeria?
Government must spend more on health (at least US$86 per caita OR 15% of total budget OR 5% of GDP) and judiciously use what we have well without waste focusing primarily on primary healthcare. Health insurance should be made compulsory and the National Health Insurance Scheme strengthened to improve health insurance coverage in the informal sector in partnership with the state governments. The National Basic Healthcare Provision Fund offers a great opportunity for the much needed increase in public financing for universal primary care coverage. Government must continue to implement the National Health Act and citizens should demand transparency and accountability. Additional recommendations are available in this Lancet article.
What has been the impact of little local financing in the achievement of various set health goals in Nigeria?
Nigeria’s health indices are poor: maternal mortality at 576 deaths per 100,000 live births is one of the highest in the world: it is three times the global average. One in eight children die before they reach their fift birthday. This is not unconnected with the poor health sector funding.With more funding, we can improve health indices.
Who do you think should be held responsible?
Every citizen is responsible but the central and state government leaders bear the greatest blame. It takes political will to devote signficant funding to the health sector, develop evidence-based policies and implement them in the best interest of citizens. Active citizens
What are the interests of the various foreign donors that are financing key health projects in Nigeria?
The interest is to partner with government to improve health systems and achieve better health outcomes
How soon do you think Nigeria can achieve total sovereignty in its health sector?
The priority for Nigeria is basically to increase public financing for health as economy grows and public revenue rises. It is inevitable because Nigeria will transition from a number of external financing within the next two decades: Global Polio Eradication Initiative funding for Nigeria will drop by 40% in 2019; US Government funding support for HIV and TB may be cut while Nigeria will need to increase its immunization financing to US$265million by 2028.
What issues do you think require most urgent local funding in Nigeria?
Primary healthcare
What is your personal view of health financing in Nigeria in comparison with other parts of Africa and across the world?
Nigeria spends poorly on health compared to low income countries like Rwanda, Botswana and Ethiopia who spend considerably more and have results to show for it. In Rwanda, there is a nationwide compulsory health insurance scheme. Ethiopia has an innovative Health Extension Program which makes primary healthcare services available in rural areas. We can learn from them to spend adequately on health at current income status. But the opportunity to spend more on health is limited by the poor macro-economic environment in Nigeria. We therefore need to find innovative ways to improve efficiency within the health system leveraging emergies technologies.
Dr. Awosusi currently works as health economist at Health Systems and Development Enterprises.
