Achieving health for all in Nigeria: what does it take?

The journey of a thousand miles begins with a single step. Globally, many countries have taken several steps forward towards achieving the lofty goal of universal health coverage (UHC) by 2030. Those who have succeeded in progressing towards UHC have done so by investing a larger proportion of their public revenue in their health sector and increasing the efficiency of how these funds are used.

But Nigeria’s progress towards this goal has unfolded at a rather slow pace. The country’s health financing landscape is characterised by suboptimal and grossly inefficient public spending on health, and high out-of-pocket expenditure for citizens as households currently cover the cost of 77.5% of the country’s total healthcare spending. In addition, the country’s health system performance remains characteristically poor, and resources are further strained by the COVID-19 pandemic and a rapidly shrinking economy which all have negatively impacted access, availability, and the delivery of essential healthcare services.

Achieving sustained progress to UHC in Nigeria costs money and will require significant efforts at federal, state, and local government level to increase resources available and ensure that they are used as efficiently and equitably as possible. Reflections from a recently hosted webinar on ‘Accelerating Nigeria’s progress to achieve universal health care’ by the UK-aid funded Lafiya programme, which aims to strengthen health systems in Nigeria, reveal five insights into how the government can address the barriers to UHC in the country.

1. Until Nigerians begin to demand better health services, political leaders will not invest adequately in health.

It is commonly agreed that if Nigeria wants to improve its health outcomes, public investments in health need to be seriously improved. One example is the Basic Health Care Provision Fund, which has been identified as one of the single most viable health financing policy thrusts in recent history. Accelerating its implementation will avert preventable maternal, child and new-born deaths in the coming years. To achieve this, there must be a clear and sustained funding commitment from the political class. But, “investing in health does not win elections in Nigeria”, as Ben Akabueze, DG Budget Office said in the discussion amid health seldom featuring as a prime priority among the electorates. Potential state governors are not commonly queried about their plans and policies for health. So, until Nigerians begin to place importance on health, minimal progress will be achieved.

2. Despite an increase in state-level health investments, there is still room for more

In recent years, several Nigerian states have surpassed the 15% benchmark for health budget allocation and even though many of them have been unable to maintain these allocation levels in subsequent years, this stands in stark contrast to the Federal Government’s health budget allocation which barely exceeds 7%. This underlines the various state governors’ commitment to UHC. However, as the core responsibility to provide primary health care services, which is a major pillar in achieving UHC, lies at the state level and must be adequately funded a 15% target is not enough to do so.

One key stakeholder necessary for optimising states’ progress towards UHC is the Nigeria Governors’ Forum (NGF). The NGF serves as the apex platform for state Governors to coordinate, peer learn and identify key areas of focus for them to prioritise in their respective states. It is understood from interactions with the secretariat that UHC is one of the Governor’s focus areas and that their broad strategy to achieve UHC is to strengthen Primary Health Care (PHC), successfully roll out state health insurance, and ensuring drug availability and an effective supply chain. While these are laudable goals, the Governors must also sufficiently invest in these areas for progress to be achieved.

3. The health sector needs to do a better job at demonstrating what it has achieved with the funds received before asking for more money

“We have been trying to ask the health sector to tie allocations to specific deliverables, but it is difficult to pin them down. All they want to talk about is more funding”, Ben Akabueze remarked during the webinar. It has become clear that a critical gap in the health sector is the low emphasis on sectoral accountability and showcasing productivity in spending. The country’s Medium-Term Sector Strategy, which outlines  priority health interventions towards UHC, should guide health budget allocations in the first instance. Historically, financial investments in health were not clearly linked to expected health outcomes. As the Director Department of Planning Research and Statistics, Federal Ministry of Health, Dr Ngozi Azodoh said: “Advocacy is about information and data; we must demonstrate that we have achieved the expected outcome. It is not enough to say that health is important. We are prepared to be held accountable“, thus expressing a willingness for the health sector to strengthen its accountability structures, which can enable it to make a better case for prioritising government investments in the sector.

4. Progress on UHC will lead to accelerated human capital development (HCD) gains

Increasing public investment in health is essential to achieving Nigeria’s HCD Vision by 2030. Failure to do so will negatively impact the country’s economy due to the strong linkage between health and economic growth .

The Federal Government has recognised this and set up the HCD Core Working Group (CWG), which plays a critical role in championing the vision of having a healthy, productive population by 2030 .

However, the execution of this vision mainly occurs at the state level. At least 26 states have developed HCD implementation plans and have appointed six champions – one per geo-political zone – to lead and facilitate the priority interventions as defined by the CWG, of which six are health related. Successfully implementing these interventions could put Nigeria on track to achieve its grand vision.

5. COVID-19 has shown us the importance of sustained health financing as the foundation of a resilient health sector