…not all 36 states are captured in the Basic Health Care Provision Fund (B)HCPF and a good number of the “gateway states” are yet to fulfill all the requirements to make the BHCPF function optimally. Some states have not conducted the facility baseline assessment, for example, while fewer states have conducted the necessary capacity building trainings required.
In African folklore, the story is told of how the Gorilla bungled the golden opportunity to be like humans by having her body hair shaven and tail removed. She lost the opportunity to a premature celebration, the story concludes. The moral of the story is that premature celebration runs the risk of arresting progress and truncating development. A case study published by Princeton University, Innovations for Successful Societies (November 2019) appears to capture the celebratory excitement and jubilation that greeted the much-awaited inclusion of the 1 per cent Consolidated Revenue Fund for Basic Health Care Provision Fund in the 2018 Budget, as enshrined in the National Health Act (2014). It took three years of persistent advocacy by civic actors to eventually secure the implementation of the Act. The Princeton case study notes that “…in 2018 the Nigerian legislature passed an appropriation bill that for the first time included 1 per cent allocation for the fund – significantly boosting the resources available to improve the quality and accessibility of primary health care services across the country” (emphasis added). Judging by the avoidable delay and inexplicable non-implementation of the provisions of the NHA 2014 for three consecutive fiscal years, perhaps it is possible to understand why some observers and analysts might justify rolling out the drums. However, the commendable landmark inclusion of the 1 per cent CRF for the BHCPF in the 2018 budget and subsequent releases of the fund is one thing, significantly boosting resources to enhance quality and expand access to primary health care services across Nigeria is another. The dream of universal health coverage, where the Out of Programme Experience (OOPE) is significantly reduced with broad population coverage and wide service coverage, is still a slog shot away, despite the progress in the implementation of the BHCPF.
A Brief Hindsight
The struggle for the implementation of the National Health Act 2014, specifically its Section 11, which provides for the establishment of the Basic Health Care Provision Fund (BHCPF) to be funded from, among others, a federal government annual grant of not less than one per cent of its Consolidated Revenue Fund (CRF), rests within the faultlines of the legislative-executive relations. Unlike typical legislative-executive relations with manifest rancour, this was subterranean. Successive budget proposals by the executive did not make provision for the BHCPF, to the dissatisfaction of the legislature. It was obvious that while the National Assembly appeared receptive and indeed supportive of the inclusion of the BHCPF in the budget, the executive was rather cautious in fulfilling the commitment.
The benign legislative-executive divergence played out at a UNFPA event in 2017, when in his speech, the then chairman of the Senate Committee on Health, Senator Olanrewaju Tejuoso, who became the icon of the campaign for BHCPF, brought up the issue of a 1 per cent for the BHCPF and beckoned on the then minister of state for Budget and National Planning, Hajia Zainab Shamsuna Ahmed (now minister of Finance, Budget and National Planning) to provide information on the status of the BHCPF. The minister was visibly uncomfortable when she said, “I have been ambushed!” She provided a detailed explanation on why it was not immediately feasible to include the 1 per cent CRF for BHCPF in the budget. At that point, it was clear that unless there was another legislative ambush, actualising the BHCPF was not going to happen immediately. How was the executive reluctance eventually overcome? This is a story for another day. For now, let us try to examine why it took so long to get the BHCPF into the budget.
The dire economic situation constricted the fiscal space, leaving no room for manoeuvre. Rather than bringing on board a new budget line which the BHCPF required, the budgets of 2015, 2016 and 2017 were devoted to economic recovery.
Why the Delay?
Various theories have been advanced to explain the delay in actualising the BHCPF. Some analysts hold the view that the seed for the delay was sown at the point of assenting to the National Health Act in 2014 when the administration of President Goodluck Jonathan was winding down. Entering into a commitment on the twilight of his tenure was seen as deliberately placing the burden of implementation on the incoming government. Hence, the new administration of President Muhammadu Buhari didn’t want to be compelled to assume responsibility for a commitment it was not a party to creating immediately after mounting the saddle.
The second theory, which amplifies the first, concerns the economic recession that kicked in just after the Buhari administration entered office. The dire economic situation constricted the fiscal space, leaving no room for manoeuvre. Rather than bringing on board a new budget line which the BHCPF required, the budgets of 2015, 2016 and 2017 were devoted to economic recovery.
The third explanatory perspective is set against the traditional tension between the ‘hard’ and ‘soft’ sectors. It is customary that the inception of a new administration is faced with tough choices between deploying available resources to ‘hard’ immediately recognisable infrastructural projects like roads and bridges or less visible ‘soft’ sectors like health. Often, the tension is resolved in favour of the former, because the immediate political capital that is derived from the visibility that attends roads construction, for example, is incomparable with the seemingly intangible long term dividends of investing in health. The priority sectors in the Economic Recovery and Growth Plan reflects this reality. If the first, second and third theoretical perspectives are put together, it is possible to understand why the inclusion of a 1 per cent of the CRF for the BHCPF in the budget was not an immediate priority for three years after the National Health Act was assented to in 2014.
…the excitement over the allocation and disbursement of the BHCPF has overshadowed an important question: If the CRF is N10.33 trillion, as shown in 2018 budget, will 1 per cent of that sum give us N44.50 billion?
The Current Situation and the Risk of A Gorilla Debacle
What is the current situation with the BHCPF and why is it necessary not to celebrate too early? One, the first tranche happened just some months back and the second tranche more recently. As at this moment, it is not certain if these resources have percolated to the facility level.
Two, the one per cent Consolidated Revenue Fund (CRF) earmarked for the BHCPF amounts to about N40 billion (about USD$100 million). It is a drop in the ocean of the investment required to get the healthcare system to the stage of “significant” improvement in access and quality as inferred to in the Princeton case study.
Three, and here is the major problem, not all 36 states are captured in the BHCPF and a good number of the “gateway states” are yet to fulfil all the requirements to make the BHCPF function optimally. Some states have not conducted the facility baseline assessment, for example, while fewer states have conducted the necessary capacity building training required. Indeed, the National Advocates for Heath (NA4H) performance scorecard reveals that only Abia, Ebonyi, FCT and Osun State have met all the prerequisites for the BHCPF implementation.
Finally, this is just by the way, the excitement over the allocation and disbursement of the BHCPF has overshadowed an important question: If the CRF is N10.33 trillion, as shown in 2018 budget, will 1 per cent of that sum give us N44.50 billion?
Aremu Fatai Ayinde is with the Department of Political Science, University of Ilorin, Nigeria.