The Vulnerable Group Fund of the National Health Insurance Authority Act established by Section 25 of the Act has many sources of funding. The first is the resources accruing from the Basic Health Care Provision Fund which apparently has been activated before the enactment of the Act. The second source of funding is the health insurance levy which has not been fixed or imposed. It is not clear, given the prevalent economic situation, which sets of individuals, companies, or organizations that can afford to pay any extra levy. The third is the special intervention fund to be allocated by the government and appropriated to the Fund. However, there is a vote for “revolving pooled procurement and distribution of critical drugs for vulnerable groups”, in the sum of N5bn in the budget proposal.
But the VGF is not just for the procurement and distribution of critical drugs. Furthermore, there is a “contribution to vulnerable groups for catastrophic expenditure” for N5bn. It is not clear whether this vote is a contribution to the VGF anticipated in Section 25 of the NHIA Act. This needs to be clarified. Furthermore, part of the minimum core obligation of the state under national and international standards is to ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable and marginalised groups. Vulnerability and marginalisation based on poverty and lack of fiscal resources will be addressed by activating the VGF to cover all vulnerable and marginalised groups and ensure within the contemplation of S.3 (3) of the NHA, all Nigerians are entitled and actually enjoy the basic minimum package of health services.
The NHIA provides compulsory and universal health insurance coverage for all citizens and residents of Nigeria. The Authority has launched the operating manual. However, there is nothing in the budget proposal to give the Authority some nudge to start and sustain implementation so as to raise more pooled funds that will supplement treasury funding for the health sector. The Authority has a vote of N423,382,596 for six capital projects. Realising universal health coverage in Nigeria will be virtually impossible without pooled funds to address the challenges of catastrophic out-of-pocket health expenditure. Furthermore, the provision of funds to guarantee compulsory health insurance will activate Section 1 (1) (c) of the NHA to provide persons living in Nigeria with the best possible health services within the limits of available resources. Available resources include not just treasury funds but what can be mobilised from citizens through pooled health insurance funds.
In accordance with the recommendations of the Nigeria Health Care Financing Policy and Strategy: “Government shall earmark a percentage of the taxes on tobacco, alcohol, harmful environmental pollutants, and unhealthy foods as sin taxes to generate revenue for health.” Furthermore, the justification for the imposition of sugar and other sin taxes is related to promoting good and healthy lifestyles and reducing obesity and other non-communicable diseases such as type 2 diabetes, cardiovascular diseases, dental caries, liver disease, etc. However, while some of these taxes have been imposed, they are not dedicated to the health sector. They are left to the bottomless treasury pool where there is evidence of mismanagement. The minimum demand is that those taxes should be channelled to improve access to quality health care.
According to the Nigeria Family Planning 2030 Commitment: “By the end of 2030, Nigeria envisions a country where everyone including adolescents, young people, populations affected by crisis and other vulnerable populations are able to make informed choices, have equitable and affordable access to quality family planning and participate as equals in society’s development.” Nigeria promised to improve financing for family planning by leveraging both existing and additional innovative domestic mechanisms and to improve financing for family planning by allocating a minimum of one per cent annually of the National and State Health budgets.
The 2024 budget proposal provides N2bn for “counterpart contribution for family planning commodities” and another N200m for “increased access to comprehensive and quality family planning commodities.” However, these sums are not enough to meet Nigeria’s family planning commitments and amount to 0.15 per cent of the overall health budget. In accordance with the Nigerian Family Planning 2030 Commitment, one per cent of the 2024 health budget proposal will amount to N15.02bn. Therefore, the sum of N12.82bn is outstanding to meet the target.
The NHIA envisages equitable distribution of all health facilities, goods and services but there is nothing in the budget to address health issues in multi-dimensional poverty in terms of physical access to primary health care centres and other health facilities. Yes, the Ministry of Health has its plans but there seems to be an absence of health mainstreaming in all government policies which will ensure coordination by the Ministry of Health of all health investments in accordance with data from the Health Information Management System. There seems to be a staccato approach of constituency funds of legislators investing in PHCs and other MDAs investing in health facilities in a way and manner suggestive of duplications and lack of guidance from the coordinating Ministry of Health.
Furthermore, it is not clear whether the budget is tied to performance indicators, results and deliverables. It is not just sufficient to programme and spend public resources. It is imperative for the ministry to project what would for instance be the percentage reduction in our poor MNCH indicators, reduction in various disease burdens, etc., after public expenditure.
In summary, the recommendations include an increased allocation to health to at least 10 per cent of the overall vote; the increased provisions should be invested in the Vulnerable Group Fund, primary health care including MNCH, family planning, overhead votes, etc. Programme sin taxes to the health sector to beef up funding and use savings from inappropriate and frivolous expenditures to increase the health vote.
Decentralise capital votes to the implementing agencies. The capital vote should be disaggregated and only those for operations at the headquarters should be retained there and others should be sent to the responsible agencies. Provide details of all bulk capital votes without details to the Nigerian people; provide not less than 10 per cent of recurrent expenditure for overhead costs. The recurrent mix of personnel (97.3 per cent) and overheads (2.7 per cent) cannot facilitate functional health institutions that deliver effective services. Previous appropriations to the BHCPF which were not released should be added to the current year’s vote.
Concluded
