Road to Alma-Ata: Upscaling  Primary Health Care Financing for Universal Health Coverage -By Oreoluwa Olukorode

Introduction  

Primary Health Care (PHC) is the foundation of every health care system: it is the first point of contact for basic health care services, from health education, nutrition and food supply, water and sanitation, immunizations and prenatal checkups to communicable disease control, treatment of common medical problems, rehabilitation and the management of chronic conditions. 

Primary healthcare is also recognized as the “route to universal health coverage”. Without it, there will be no efficient and cost-effective access to the full range of health services people need, when and where they need them. 

Considering the importance of Primary healthcare, nations across the world have employed various methods of identifying gaps and generally improving their PHC system. In India, for example, recent health system reforms have invested in building more primary health centres, improving the availability of essential medicines and supplies, and staffing these facilities. Sudan is using community health dialogue to discuss health priorities and concerns with the aim of prioritizing and pushing for better health outcomes through primary healthcare.

As a signatory to the United Nations Charter and a member of the World Health Organization (WHO), Nigeria has also made efforts to provide primary healthcare to its citizens. The National Primary Health Care Development Agency (NPHCDA) was established in 1992 to mobilize resources for the strengthening of primary healthcare. In 2007, the National Programme on Immunisation (NPI) merged with the NPHCDA, and ever since remarkable progress has been made in the delivery of Primary healthcare services in a more comprehensive manner. Part of the achievements of this agency includes the ‘Saving One Million Lives’ Initiative; a project aimed at decreasing child and maternal mortality in the country. It also set up the Nigeria State Health Investment Project (NSHIP); which was designed to improve the delivery and uptake of maternal and child health interventions in about 8 Nigerian States. The National Emergency Routine Immunisation Coordination Centre (NERICC) was established with the vision of achieving at least 80% immunisation coverage in Nigeria by 2028, among other things. 

Despite these commendable achievements, present realities indicate that Nigeria is a distance away from providing universal health coverage through primary healthcare. Only about 20% of the PHC facilities across the country are fully operational. These facilities are faced with a shortage of skilled healthcare personnel, poor and neglected infrastructure, unavailability of medical equipment and medications, underutilisation by individuals and communities, and abandonment by the local government.

Without a doubt, these problems are tied to inadequate and inefficient methods of financing and a lack of a sound framework for the management and delivery of health services. 

Existing Methods of Financing Primary Healthcare in Nigeria

Nigeria’s Primary healthcare system is generally poorly funded and does not adequately meet the needs of its population. In October 2014, the Nigerian President signed into law the National Health Act (NHAct) to serve as a legal framework for the provision of healthcare services to all Nigerians. As part of this reform, the Basic Health Care Provision Fund (BHCPF) was established under section 11 to cover the routine daily operation cost of primary healthcare centres, and generally improve access to primary health care in Nigeria. However, the federal government did not allocate funds for its execution for four years. It took relentless interventions of various stakeholders to mount the necessary pressure that led to the first budget allocation to the BHCPF in 2018. 

The Basic Health Care Provision Fund is financed through:

1. An annual grant from the Federal Government of Nigeria of not less than 1% of the Consolidated Revenue Fund (CRF)
2. Grants from local and international donors 
3. Funds from internally generated revenue e.g taxes 
4. Private sector interventions

Further, to be eligible for this fund, states, and local governments are jointly required to contribute 25% of the total costs of their PHC projects as counterpart funding as a prerequisite for accessing funds from the BHCPF. 

Every year, 50% of the Fund is used to provide a basic Minimum Service of Package in PHC facilities through the National Health Insurance Scheme (NHIS); 45% is disbursed by the National Primary Health Care Development Agency (NPHCDA) out of which 25% is meant for providing essential drugs, 15% for maintaining PHC facilities, equipment and transportation, and 5% for strengthening human resource capacity. The final 5% is used for National Health Emergency and Epidemic Response by the Federal Ministry of Health (FMoH).

At the Federal level, the National Primary Health Care Development Agency (NPHCDA) is responsible for transferring the 45% meant for improving primary healthcare from the FMoH to the State Primary Health Care Development Boards (SPHCDB), who then disburses funds to Local Government Health Authorities (LGHAs). It is LGHAs that are responsible for funding PHC facilities and the facilities in turn are mandated to set up Health Facility Committees that monitor and keep records of how the funds are managed. 

Financing lies at the core of Nigeria’s primary healthcare delivery challenges. For PHC to be effective as an instrument for achieving Universal Health Coverage in Nigeria, it is important to improve the current financing mechanisms. 

The way forward:

• First, Nigeria already has a relatively high PHC density of about 18 primary healthcare centres per 100,000 people and the number of PHC centres in wards across the nation is more than the recommended level. However, most of these centres do not meet the minimum standards recommended by the National Primary Health Care Development Agency (NPHCDA). Foreign and local interventions aimed at improving health outcomes should be aligned with the national health priorities and must first be channeled at developing a functional and sustainable healthcare system, which involves revitalising the already existing PHC centres littered across the country. A 2011 study reports that 57% of total health sector assistance was for sexually transmitted diseases, whereas Nigeria’s burden of diseases associated with HIV/AIDS/TB was estimated to be less than 5%. Nigeria needs less disease-specific aid/grants and more focus on health systems strengthening that will, in the future, serve as the bedrock for the implementation and management of these disease-specific programmes. For this to work, there is a need to establish a stable relationship with major donors and set a sustained agreement on long-term funding cycles. 

• Second, domestic spending on Health has been low in Nigeria. The annual national budget should devote a minimum of 10% to the health sector and more importantly, funding for BHCPF should be increased to 2% of CRF instead of the present 1%. At the same time, each state should compulsorily provide 30% of the total funds expected from the BHCPF as a prerequisite for accessing it and a large fraction should be deployed to manage the day-to-day running of already existing PHC facilities. 

For the impact of these budgetary changes to be felt, it is also important to ensure accountability in the use of funds allocated through periodic evaluation of its utilisation at both federal, state, and local levels to prevent wastage, abuse, and misappropriation of funds.

• Third, economic projections and increasing debt burdens hint that domestic funding for primary health care in Nigeria might not increase soon. Therefore, there is an urgent need to explore other options for financing PHC. For instance, organised private sector bodies should be made to dedicate a particular percentage of profits made yearly to funding primary health care services in each local government area. Moreso, initiatives like Adopt-A-Private-Health-Facility Programme (ADHFP) should be encouraged among individual philanthropists and non-governmental organisations.

The tax generated from potentially harmful products like tobacco, sugar-sweetened beverages, and so on, should also be used as funds for primary healthcare in Nigeria. 

• Lastly, a recurrent challenge that needs to be looked into is the delayed approval and disbursement of funds allocated to primary healthcare centres by the Ministry of Finance, Budget, and National Planning. The Federal Ministry of Health should encourage timely preparation of the annual budget for the next fiscal year and commence all procurement processes early. In turn, the Ministry of Finance should prioritize the complete and timely release of the BHCPF at the beginning of the fiscal year. There is a need for accountability across the board to ensure efficient and transparent disbursement in the administration and expenditure of the BHCPF, from the federal level down to the PHC.

Conclusion

Despite the key role which primary healthcare can play in the attainment of universal health coverage, the fostering of an effective primary healthcare system remains difficult to achieve in Nigeria. To make primary healthcare function effectively, the people, the government and the healthcare workers have a role to play. The people must demand involvement in the planning, implementation, and evaluation of PHCs that affect them; the government must express, in practical terms, political will through adequate funding; and the healthcare workers can support through careful utilization of available resources and quality service delivery.