'2024 health budget too meagre to guarantee nation's good health' – Guardian Nigeria
Pessimism has greeted the Federal Government proposed N1.33 trillion for healthcare in the 2024 fiscal spending. Stakeholders insist that the budget is not sufficient for Nigeria to implement the National Health Insurance Authority (NHIA) Act, achieve Universal Health Coverage (UHC) by 2030, meet the health-related Sustainable Development Goals (SDGs), tackle emerging epidemics and pandemics etc. CHUKWUMA MUANYA writes on the implications of budgeting less than 15 per cent of Nigeria’s yearly budget for health.
When the African Union (AU) met in Abuja, in April 2001, and agreed to set aside at least 15 per cent of their yearly budget to improve the health sector and achieve Universal Health Coverage (UHC), expectations were expectedly high.
The Abuja Declaration by African leaders, was also adopted by the World Health Organisation (WHO). But 22 years after that declaration, Nigeria is still in the woods as far as health indices are concerned.
Presently, Nigeria has one of the worst health indices in the world, especially on maternal and child health. The WHO ranks the country 187 out of 191 member nations.
The ranking, which puts Nigeria ahead of war-torn countries like the Democratic Republic of the Congo, Central African Republic, and Myanmar, etc., takes into consideration, factors including performance indicators like overall level of health, distribution of health in populations, responsiveness, and distribution of finance.
Increasing the yearly allocation to the health sector in the national budget to 15 per cent, from an average of five per cent since 2000, has been one of the major recommendations made on how to improve health.
Unfortunately, despite the abundance of promises and assurances, and an extra N151 billion from the 2023 figure, the Federal Government has, for the umpteenth time, failed to meet the 15 per cent recommended allocation to healthcare in the 2024 proposed budget.
A breakdown of the 2024 Appropriation Bill shows that the health sector got N1.33 trillion which is five per cent of the 2024 Budget of N27.5 trillion, which is less than 5.75 per cent of what was budgeted in 2023.
The sum of N1.07 trillion is provisioned for the Federal Ministry of Health and Social Welfare (FMoHSW) and its agencies (Recurrent and Capital expenditure). While N137.21 billion is set aside for Global Vaccine Alliance (Gavi)/immunisation funds, including counterpart funding for donor support programmes.
Also, the sum of N125.74 billion will be transferred to the Basic Healthcare Provision Fund (BHCPF), which is one per cent of the Consolidated Revenue Fund (CRF). Presidential Committee on Health Sector Reform got N500, 000, 000.
A further breakdown of N1228,100,390,765 Appropriation Bill shows that N771,558,140,429 is for personnel, N21,756,304,848 for overhead, and N434,785,945,488 for capital expenses.
This indicates that more than two-thirds, that is 65 per cent of the budget would be devoted for paying salaries, and a paltry one-third of the budget would be for capital projects.
A further analysis of the budget shows that the 2024 budget of N1.33 trillion may achieve “far less than” the 2023 budget of N1.179 due to inflation and forex devaluation.
Also, the gains of the BHCPF increasing by almost 300 per cent from N47.64 billion in the 2023 budget, to N125.74 billion in the 2024 must have been swallowed up by inflation and forex devaluation.
Comparing the 2023 budget with previous ones shows an increase from 4.7 per cent in 2022 to 5.75 per cent in 2023 of the national budget for health; the health budget increased by 339.19 per cent from N278.31 billion in 2015 to N1.179 trillion in 2023; BHCPF reduced by 13.61 per cent from N55.15 billion in 2018 to N47.64 billion in 2023 budget, and scaling up of family planning (FP) services from zero budget in 2022 to N20 million in 2023 to procure commodities through counterpart funding.
Indeed, for the first time in the history of health funding in Nigeria, over N1 trillion was allocated to the sector in the 2023 budget.A further analysis of the 2023 showed that N1.179 trillion was allocated to the health sector out of the total of N20.5 trillion for the 2023 fiscal year.
The health sector also got N81.47 billion under the service-wide vote. This includes N69.57 billion for GAVI/immunisation; N7.4 billion for counterpart funding, including global fund, health refund to GAVI, and N4.4 billion for military retirees under the National Health Insurance Scheme (NHIS).
The 2023 budget showed a significant increase from the N826.9 billion allocated to the health sector in 2022 and the N547 billion allocated in 2021.
Despite alternative funding from the service-wide vote (contingency budget) and Nigeria’s BHCPF, budgetary allocation to the health sector never surpassed seven per cent. Even its peak of 6.2 per cent in 2012 was far less than the 15 per cent commitment in the Abuja Declaration.
Stakeholders are bemused that despite several promises by President Bola Ahmed Tinubu, to increase budgetary allocation, he has indeed reneged. He had, in July 2023, two months after his inauguration, promised to raise the budget from five/six per cent to 10 per cent.
Tinubu said that his administration would be increasing yearly budgetary allocation to the health sector to 10 per cent by 2024, promising to further raise it if utilised accountably.
Critics say the major implications of budgeting just five per cent of the 2024 proposed budget for health are that healthcare would continue to be unaffordable to the majority of the population, and Nigerians would continue to pay out-of-pocket for medical services, while the president and other political office holders would continue to engage in medical tourism.
Additionally, Nigeria-trained doctors, nurses, pharmacists, and other health workers would continue to leave for greener pastures where better working conditions and improved remuneration are assured.
Beyond the very poor release, as well as gross underutilisation of funds, the critics called for a timely publication of a health budget implementation report for accountability, while also urging the National Assembly to carefully scrutinise proposed estimates to avoid duplication and wastage of scarce resources.
The N2.18 trillion 2023 supplementary budget passed in October, which did not include any vote for the health reflected the government’s poor treatment of the sector.
And this misplaced priority is to the dismay of the Nigerian Association of Resident Doctors (NARD) and other stakeholders. President of NARD, Dr. Dele Abdullahi, described the budgetary allocation to health in the 2024 Appropriation Bill as a mockery of the state of emergency declared in the sector by the Minister of Health and Social Welfare, Prof. Muhammad Ali Pate, at the just concluded National Council of Health (NCH) in Ekiti, Ekiti State. Abdullahi said it calls to query, the commitment of the Federal Government to ensuring adequate healthcare within the system.
“Our stand will always be 15 per cent as it was declared in Abuja in 2001, by the African Union, then we can evaluate the efficiency of how these funds are put into use, and if we will need more, a healthy workforce is an efficient workforce, and adequate healthcare services is a basic right of every Nigerian,” he said.
Abdullahi added: “I think that ship has sailed as the National Council on Health already made that recommendation based on realities on the ground, which was why when I saw the budget proposal for health standing at a mere five per cent of the current budget, I was confused about what they are proposing.
“It is not about the arbitrary digits of the amount that the five per cent translates to, but this amount has to be compared with previous amounts using economic indices at different times. Though the money may be more, the economic reality and price of goods are also more, so, in reality, the healthcare system has fewer funds to work within a country that says the healthcare is failing.”
A public health physician and former Chief Medical Director (CMD), of Lagos University Teaching Hospital (LUTH) Idi-Araba, Prof. Akin Osibogun, said a main challenge to the delivery of quality health services in Nigeria is not the percentage of budgetary allocation to health, but remains the level of financing and the inefficient use of resources.
Osibogun said total health expenditure per capita in Nigeria is a meagre $97 compared to roughly $4,000 in Europe, and $8,500 in the United States, adding that the general analysis of global data shows that the more a country spends on health per capita, the better the health outcomes.
“Our fund pooling mechanisms are currently weak and inadequate. Up to 70 per cent of our current total health expenditure is from Out-of-Pocket (OOP). In general, from global data, the more prominent OOP is in a country’s health financing mechanism, the poorer the health outcome.
“Thirdly, even with our low level of health expenditure, we are inefficient spenders with our health outcomes being worse than those of a country like Senegal spending less than half of what we are spending,” Osibogun said.
The Guardian investigation revealed that poor budgetary allocation to key bodies charged with the regulation of medical and drug affairs in the country such as NAFDAC has made them toothless bulldogs, and compounded the problems of fake and counterfeit medicines.
Meanwhile, contrary to the content of the proposed Appropriation Bill 2024 for health, President Tinubu, at the recent unveiling of Nigeria’s Health Sector Renewal Investment Initiative, and the signing of the Health Renewal Compact by Federal, state governments, and Development Partners in Abuja, said his administration is prioritising and improving Nigeria’s health sector through massive investments, and the allocation of increased funds to the sector in the proposed 2024 budget.
The event was part of activities marking Universal Health Coverage (UHC) Day, observed yearly on December 12. To address the high cost of healthcare, President Tinubu said the BHCPF will be redesigned to enhance access to essential healthcare services as outlined in the National Health Act (2014).
He added that the BHCPF, comprising at least one per cent of the Consolidated Revenue Fund, is expected to receive at least $2.5 billion in pooled and non-pooled financing from 2024 to 2026 to improve the primary health system nationwide.
Minister Pate outlined plans to double the number of fully functional Primary Healthcare Centres (PHCs) from 8,809 to 17,618 by 2027 across all 36 states and the Federal Capital Territory (FCT), adding that these PHCs will be linked to a comprehensive emergency care system.
Meanwhile, estimates show that Nigeria needs at least N1.8 trillion yearly to achieve UHC (put 200 million people on minimum health insurance package).
A breakdown shows that if a premium of N750 is paid for every enrollee Nigerian monthly, it will be N9,000 for one year, and for 200 million people, the amount would be N1.8 trillion.
But the figure is more than the N1.33 trillion proposed for capital and recurrent health expenditure in the 2024 budget. Critics say although it will cost Nigeria N1.8 trillion yearly to put 200 million on health insurance (achieve UHC), the country will save trillions of naira that it would have spent on managing chronic diseases such as diabetes, stroke, kidney damage, and cancers.
According to the 2023 UHC Global Monitoring Report, achieving UHC by 2030 is crucial for fulfilling the promise of the 2030 Agenda for Sustainable Development and realising the fundamental human right to health. The verdict is that the 2024 budget is grossly inadequate to improve the health of Nigerians despite promises by the Federal Government.
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