Using Multisectoral Action to Advance Nigeria’s Universal Health Coverage Agenda: What Have We Learned?
By: Frances Ilika
The countries of the world have set a goal of having universal health coverage for all by 2030. This goal is a tall order for the wealthiest of countries and a dream for many lower and lower-middle income countries. Nigeria, for example, has a health system that is poorly funded because many don’t consider universal health coverage a politically useful investment.
To make progress toward the goal, Nigeria and all countries need to employ mechanisms that work for their contexts while applying best practices. Multisectoral actions have served Nigeria well in removing obstacles to universal health coverage funding and making health sector a political priority; Nigeria has enacted some great policies to address health system financing challenges. However, the country has had little success in implementing these policies. Funding these policies requires working outside silos and using a multisectoral approach. Policymakers must reach beyond the health sector to collaborate with their finance and budget ministries, as well as parliamentarians and other politicians.
In many meetings and conferences, I hear a lot of talk about multisectoral actions as a missing piece of the universal health coverage puzzle. Most people talk about it from a theoretical perspective, without any concrete lessons to share for broader application. Fortunately, Nigeria has been able to harness multisectoral actions and is making progress on its universal health coverage efforts. In this blog, I want to share some of Nigeria’s experiences with prominent universal health coverage reforms and how they have drawn on multisectoral actions. The story of Nigeria’s progress with universal health coverage focuses on how key policy inputs were implemented in a collaborative manner and the magic that made it work.
The Basic Health Care Provision Fund (BHCPF) provides conditional downstream funding. The BHCPF is a transfer of funds from the national government to state governments — which also make a contribution — all the way to health facilities. The fund supports a basic minimum package of health services for all Nigerians, as well as basic infrastructure, human resources, medicines, and commodities for improved availability and quality of services. The funds equal 1 percent of the consolidated revenue at the national level, but accessing BHCFP requires action at the national, state, local government, and community level. Before the BHCPF, there were few connections and conversations among health actors at the various levels, but that has changed.
Because the funds are administered by the state, the most important element for success is the formation of the state-level multisectoral technical working groups. They are composed of representatives of government ministries of health and finance, parliamentarians, civil society organizations, traditional chiefs, private sector entities, media, and other influential actors. The technical working groups used strategic evidence-based advocacy and targeted incentives to obtain political recognition and support from politicians, as well as recognition from finance ministries that investments in health contribute to poverty reduction and job creation. With support from decisionmakers, counterpart state funds were released. In addition, advocates obtained the political approvals needed for setting up state-level agencies, another requirement to qualify for and access national BHCPF funds.
Civil society organizations played an important role. They motivated community members to complement government funds by using local resources to purchase hospital equipment and restore electricity and running water.
Different actors coordinated their efforts to achieve successful results in three state (Abia, Ebonyi, and Osun) as well as the Federal Capital Territory. These four jurisdictions were the first to see funds transferred directly to facilities and used to improve access and quality of care. A key reason for successful implementation was that the different actors all started with comprehensive, consistent information about how to move forward. With support from the United States Agency for International Development through the Health Policy Plus project, the states and the Federal Capital Territory developed successful multisectoral platforms and interagency interaction. The jurisdictions helped develop training manuals distributed to national, state, local, and health facility staff and including ward development committee heads made up of community representatives.
Implementation of Health Insurance at the Sub-National Level. In 2015, to improve financial protection from hardship, Nigeria’s National Council on Health decentralized health insurance implementation to states. To implement this change, states first need to enact a law that established a health insurance agency, made funds available, and provided legal backing for the agency’s activities. In addition, multisectoral health financing technical working groups were established in the states. Membership represented the relevant ministries (health, finance, justice, budget, women’s affairs, information), as well as parliamentarians (responsible for the legislation), and civil society organizations and the private sector entities (involved in implementing the insurance schemes). These technical working group members completed training together, which provided the opportunity for dialogue and improved transparency. Taking advantage of an expedited process for passing the enabling legislation and establishing the agencies, the state finance ministries appropriated and released funds. The civil society organizations played a large role in advocating for the release of funds and in gaining community acceptance of the schemes. Seeing the benefits of establishing the multisectoral technical working groups to drive the legislation and implementation of the state health insurance schemes, these states have become models for how to translate policy into results and actions.
Improving Universal Financing of Vertical Programs. Beyond primary health care is the need for more specialized care — and the accompanying funding needed to support those services. At a meeting to discuss domestic financing for tuberculosis, a director from the Ministry of Finance appeared disinterested — even bored. To try to understand why he was not engaged, I asked him what things mattered to him. He told me that he is challenged with other issues — creating jobs, economic empowerment, and poverty reduction — and that he will be evaluated on those at the end of the year. So we took a step back and I explained how advancing universal health coverage could help him reach his goals. Universal access to healthcare will help people become healthier so they can be more productive; with better health care, fewer households will fall into poverty due to catastrophic expenditures on health; and with a strong health sector, Nigeria can also achieve greater economic growth. To our surprise, the director understood our points and became a champion of universal health coverage and has provided tips to on how to get more funds appropriated and released for tuberculosis and HIV.
Key Lessons for the Future: From these experiences, we learn some key lessons about how multisectoral actions can make a difference in achieving universal health coverage.
First, a multisectoral action, even if focused on health outcomes, needs to have broader, mutual gains to get sustained traction. Related to that is that if people outside health show up at our meetings, then we need to show up at theirs. Understanding the political economy is vital. Identifying and understanding the needs of the different actors will help keep them engaged and retain their interest.
Second, driving a multisectoral collaboration requires a vibrant platform. The technical working group examples presented here included actors from key sectors driven by the health ministries. But could they be based in a ministry with more political mileage? Certainly, there would be trade-offs related to the agenda, but understanding the context is important in understanding where to position the multisectoral collaboration. Factors that came into play in Nigeria included the presence of an external independent party such as HP+ to support the process, the availability of clear evidence to make the case for universal health coverage, and clear incentives and mutual benefits in the language used to frame the engagement of the different actors.
Third, we need to stay focused on increasing the total amount of funding for health — not on reducing one program’s funding so another can become larger. As we popularly say, the bigger the pie, the larger the cut. As these goals of the finance ministries are benefited by better health, so, too, is the role of the health sector in advancing the goals of the finance and other sectors. We must focus on identifying mutual benefits, identifying incentives for the sectors to be involved and focus on mutual gains. This approach has the ability to garner more political commitment, technical insight, and improved financing of the health sector while making the health sector a key player. All these elements are critical to mobilizing the needed funds for advancing universal health coverage and making sure that no one is left behind.
Frances Ilika is the Nigeria Country Director for Health Policy Plus and would like to acknowledge Jay Gribble, Deputy Director for Family Planning and Reproductive Health, for his contributions to this blog.
