http://resyst.lshtm.ac.uk@RESYSTresearch

An accountability framework for the

implementation of the Basic Health Care

Provision Fund (BHCPF) in Nigeria

Prof BSC UzochukwuHealth Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus

http://resyst.lshtm.ac.uk@RESYSTresearch

Webinar, 1pm BST, 19 April 2016

Session outline

• Background to the National Health Act (NHAct)

• Overview of the Basic Health Care Provision Fund (BHCPF) and its financing

• Research aim and methodology

• Accountability framework, recommendations to government and non-government actors

• Challenges to accountability and implementation

• Influencing policy and implementation process

Milestones in the development of NHAct

2004 Bill sent to National Assembly

2006 Public hearing and approval by the National

Economic Council

2007 Passed by House of Reps but not by the Senate

2008 Resurrected and reviewed by the National Assembly

2009 Passed by Senate and House of Rep

2011 Harmonized version, but Presidential assent not

given

2013 Public Hearing by Senate

2014 Assent by President (November 2014)

NHAct – key features

• Guarantees every citizen the right to a minimum package of health services

• Mandatory provision of emergency services

• Framework for identifying people eligible for free basic services - pregnant women, children under 5, senior citizens

• Establishes Basic Health Care Provision Fund (BHCPF)

Basic Health Care Provision Fund

Financing the BHCPF

• An annual grant from the Federal Government of not less 1% of the Consolidated Revenue Fund (total Federal Revenue before it is shared to all tiers of government)

• Additional sources of funding:• grants by international donors• funds generated from innovative sources (e.g. taxes on

cigarettes and alcohol). • 25% counterpart fund donations from States and Local

government areas

• For states to benefit from the funds, they are required to establish a state PHC development agency/board in addition to the 25% counterpart funding

Flows of funds through BHCPF

Implementing the BHCPF

Stakeholders

Federal government

Federal Ministry of Health, National Primary Health Care Development Agency, National Health Insurance Scheme, Federal Ministry of Finance

State government

State Ministry of Health, State Primary Health Care Board, State Ministry of Finance, Ministry of Local Government

Local government

Local Government Health Authorities

Health facilities Health workers , Health facility committees

External actors Development partners and donors , Civil Society Organisations, Community members

• Many stakeholders involved in implementing the Fund across all levels of government and externally

Research aim and methodology

Concerns about poor implementation of public policies and key reforms over the years, and of corruption in the health system, precipitated the study

Research questions:

• What are the expected roles of the different stakeholders who will be involved in implementing the BHCPF?

• What accountability mechanisms support the effective implementation of the Fund?

• What are the opportunities and challenges for implementing the BHCPF?

Research aim and methodology

• Conducted in Abuja (Nigeria Federal Capital) and Anambra State

• Research methods:

• Document reviews

• Interviews with key actors

• Stakeholder analysis

• The results of the enquiry were used to propose an accountability framework for the fund

Accountability framework

Specific strategies to strengthen accountability at each level of government including:

• mechanisms for strategic planning

• strong and transparent monitoring and supervision systems

• systematic reporting

Strategic planning

Monitoring and supervision

Systematic reporting

Recommendations

State government

1. Provide supportive supervision to LGHA through mentoring and training

2. Consider making the dispersal of funds to the LGHA conditional on results of previous disbursements

3. Employ qualified finance managers

4. Demonstrate transparency by:

• Separating BHCPF account from the State health account

• Making financial reports available to the public

Recommendations

Local government

1. Produce a plan for how the BHCPF will be disbursed to facilities

2. Employ qualified finance managers

3. Demonstrate transparency by separating BHCPF account from other sources of funding for PHC facilities

Recommendations

Health facilities

1. Produce a plan for how the BHCPF will be spent

2. Health Facility Committees should monitor how revenue is spent

3. Put in place systems for keeping records about how funds are managed

4. Use e-payment or banks to process consumer payments

Recommendations

Community members and other external actors

1. Community members, through Health Facility Committees, should be involved in decisions regarding how health facility revenue is spent

2. Development partners and CSOs should monitor the release of funds at each level of the health system

Challenges to accountability and implementation

• Delayed transfer of revenue

• Poor data and financial management

• Corruption

• Lack of preparedness/capacity of LGHA to manage the fund

Influencing the policy implementation process

• Feedback meeting with 2 state governments (Anambraand Enugu), federal MOH, development partners.

• HPRG researchers are members of a technical working group for the operationalisation of the NHAct

• Researchers involved in supporting plans for Universal Health Coverage at the Federal MOH

• Working with civil society organisations to advocate for implementation of the Act and maintain the government’s focus on Universal Health Coverage

Progress in Implementing Basic Health Care Provision Fund and Potential

Role of an Accountability Framework

Rt. Hon. Dr Daniel Ogbuabor

Chairman, House Committee on Health

Enugu State House of Assembly

Enugu, Nigeria

OUTLINE

•Progress of Implementation

• Primary Health Care Under One Roof (PHCUOR)

• State-supported NHIS

•Application of BHCPF Accountability Framework

•Conclusion

PROGRESS IN IMPLEMENTING BHCPF

• PHC UNDER ONE ROOF (PHCUOR)

PHCUOR Implementation Scorecard Report, November 2015

• Governance & ownership, Legislation, Minimum Service Package, Repositioning; Systems Development; Operational Guideline; Human Resources for Health; Funding Sources & Structure; and Office Set-up

• STATE-SUPPORTED NATIONAL HEALTH INSURANCE SCHEME (NHIS)

PHC UNDER ONE ROOF (PHCUOR)

GEOPOLITICAL ZONES PERFORMANCE

NORTH WEST - WELL-PERFORMING ZONE

JIGAWA – WELL PERFORMING STATE

SOUTHEAST – LESS PERFORMING ZONE

Enugu – Less Performing State

STATE-SUPPORTED NHIS

• Only 2 States – Lagos and Delta States

• Represents about 5%

• Template of legal framework exists for States to adapt

CHALLENGES

• Delayed Gazette process – 14 months after assent- No budget in 2016

• Delay in development of guidelines & manuals• Weak Technical Working Group (1/5 sub-committees met)

• States’ preparedness to manage fund is low• Weakness across 9 dimensions of PHCUOR

• Delay in transfer of funds• Poor data and financial management• Corruption

• Slow progress in establishing State-led Health Insurance Schemes

Potential Role ofAccountability Framework for BHCPF

Feeding into health policy

• Review of the Enugu health law is being undertaken to incorporate the establishment of the State PHCDB, and the State Health Insurance Fund

• The framework is useful as a tool to enable proper accountability and is being considered in the review

• As the chair of the House Committee on Health, I am responsible for facilitating and driving this process

REVENUE GENERATIONPOTENTIAL ROLES FEDERAL GOVERNMENT STATE GOVERNMENT LOCAL GOVERNMENT EXTERNAL ACTORS

Planning Inter-Ministerial Committee on Innovative Financing

1% CRF not in 2016 Budget

Counterpart funding of 25% in budget

Annual operational plan

Counterpart funding of 25% in budget

Annual operational plan

Inter-Ministerial Committee on Innovative Financing

Guidelines, Manuals & strategic plans

MTEF/ MTSS Medium-Term Dev. Plan Grants from partners

Monitoring and Supervision

Track revenue generation from all sources

Track budgetary provsion Track budgetary provision Track budgetary provision and other sources.

Reporting Public disclosure of BHCPF revenue

Public disclosure of financial information

Public disclosure of financial information

Public disclosure of financial information

BHCP FUND MANAGEMENTPOTENTIALROLES

FEDERAL GOVERNMENT STATE GOVERNMENT LOCALGOVERNMENT

HEALTH FACILITIES

EXTERNAL ACTORS

Planning Support establishment of SPHCDB

Guidelines, Manual & Plans

Establish SPHCDB

SSHDP include PHCUOR

Establish LG Health Authorities

Costed plan

Health Facility Committees (HFCs)Costed plan

Technical Assistance in establishing structures

Monitoring and Supervision

Dispersal of funds to States performance-based.

Oversight (PHCUOR)

External auditors

Dispersal of funds to SPHCB performance-based

Supportive supervision

Dispersal of funds performance-based

Supportive supervision

Monitor facilities,equipment, transport and HRH by HFCs

Publicexpenditure tracking

Reporting Online reporting Separate BHCPF Account

Online reporting (Operational Report, Financial Report, HRIS, Inventory Report, etc.)

Separate BHCPF Account

Quarterly LGHA Report

Quarterly Facility Report

PET report

PURCHASING MSP THROUGH NHISPOTENTIALROLES

FMOH STATE LOCALGOVERNMENT

HEALTH FACILITIES EXTERNAL ACTORS

Planning Supportestablishment of SHIS

Guidelines &Manuals

Establish SHIS

SHIS – SPHCB Inter-Agency Committee

LG Health Authorities

Costed plan

Accredited PHCs

Health Facility Committees

Costed plan

Technical Assistance in establishing structures

Monitoring and Supervision

Dispersal of funds from NHIS to SHIS performance-based.

External auditors

Dispersal of funds performance-based

Supportive supervision

Oversight

Dispersal of funds performance-based

Supportive supervision

Monitor service delivery and funds by HFCs

Publicexpenditure tracking (PET)

Reporting Online reporting Qualified Financial Managers

Separate BHCPF Account

Online reporting

Qualified Financial Managers

Separate BHCPF Account

e-payment for services

Book-keeping

BHCPF Account

PET report

Conclusion

Bureaucratic Accountability• Bureaucratic accountability

relationships exist among multiple public sector actors involved in BHCPF implementation

• Planning, M & S, and Reporting cut across revenue generation, PHC Fund Management, and Purchasing and ensures public accountability.

Social Accountability

• Potential involvement of community members, health facility committees, CSOs and health development partners in planning, M & S, and Reporting cut across revenue generation, PHC fund management and Purchasing.

References

• NPHCDA. (2015). Primary Health care under one roof implementation scorecard III report. NPHCDA, Abuja.

• Uzochukwu, B., Onwujekwe, O., & Mbachu, C. (2015). Implementing The basic health care provision fund in Nigeria: A framework for accountability and good governance. RESYST Policy Brief. HPRG, Enugu

Thank You