Written by Yewande Kofoworola Ogundeji

In the ‘not so new’ era of Universal Health Coverage (UHC), several health financing experts and policy makers from several LMICs often gather to discuss and explore the role of health financing in UHC, where one of the main concerns center around ‘prioritizing health care’ in terms of the government’s financial commitment.

Indeed, inadequate government spending on health care in most countries in Sub-Saharan Africa (Nigeria included) is a historic and widely documented key challenge in health financing. This led to the adoption of the 15% benchmark of total annual country budget towards the health sector, also known as ‘The Abuja Declaration (2001)’.

It is not enough to allocate 15% of the annual budget to health, what is equally important is good budget performance (whether most or all of it is released/disbursed and/or spent), allocative efficiency (what it is spent on), and accountability (transparent spending, with resource tracking mechanisms in place).

Fifteen years after the Abuja declaration, Nigeria is still lagging in terms of the 15% allocation of its annual budget to health, with less than 6% allocated to health in the 2016 budget. Experts and policy makers have suggested mobilizing additional resources for health through increased allocation and/or earmarked taxes for health. This left me pondering over the question – how can the government be convinced to allocate (budget and release) additional resources for health and/or a whole 15% of the annual budget – given that there are other seemingly important sectors competing for the same scarce resources (e.g. defense, education, finance, and agriculture to name a few out of over 33 sectors) in a fiscally constrained country such as Nigeria.

Speaking with a former Minister of Health on health care financing on UHC in Nigeria to explore answers to my question. He said to me, “In order to achieve UHC in Nigeria, the government has to increase spending on health care i.e. they must be willing to earmark additional resources for health. To ensure this, the Ministry of Finance is very important and we (health ministries and agencies) must learn to speak the language of the Ministry of Finance due to other competing demands”.

In an ideal world, allocation of resources between competing sectors often requires tough decisions and trade-offs. Evidence to inform these decisions is critical in advocating for additional resources to health. The most frequently used argument in the international community is the positive correlation between government spending on health and economic development (which mirrors the well-known saying ‘health is wealth’).

I suppose the major issue that may come to mind in a country like Nigeria is that convincing evidence to demonstrate that increased government investments in health is related to improved economic development does not exist. Surprisingly, this is not the case! There are a number of published studies in this area in the Nigerian context.

So, why then do we not have additional resources for health if the evidence base to support this exists? A number of things come to mind:

(1) The evidence in literature is not concise, comprehensible, or easily accessible to high level policy makers, or

(2) There are inadequate ‘champions’ to advocate for additional investments in health using available evidence, or

(3) Providing evidence that ‘health is wealth’ is not enough, which is the more likely reason

What else can we do to ensure increased government spending on health in a way that will strengthen the already existing evidence? An insight from another health financing expert at a workshop focused on improving health financing in Nigeria mirrored my thoughts. “We must make stronger macro-economic arguments for health in Nigeria to make a stronger case for more money for health.” The only missing connection is what constitutes ‘stronger’.

Perhaps a way to further strengthen advocacy for additional resources for health is to demonstrate capacity for efficient and transparent spending. Health financing research indicates that in order to secure more money for health, it is vital for health ministries/agencies/parastatals to demonstrate that there would be ‘more health for the money’ – allocations for health care must be efficiently (making cost-effective decisions) and transparently disbursed and expended (with resources tracking mechanisms in place). For example, Mexico successfully used accountability and resource tracking mechanisms to identify and stop funding leakages of health resources, which was redistributed efficiently to address the persistently high rate of childbirth-related death and disability. Similarly, other LMICs such as India and Ethiopia have successfully used National Health Accounts (mapping the flow of health sector funds) to successfully advocate for additional investments in health. Unfortunately, accountability and resource tracking (particularly for health care funding) mechanisms are weak in Nigeria. However, a few donors and implementing partners are working to build capacity on resource tracking and accountability for health resources at various levels in Nigeria and producing National Health Accounts, which is a step in the right direction.

In summary, two factors appear to be important in advocating for additional resources for health in a fiscally constrained country such as Nigeria:

1. Provide convincing evidence to Ministry of Finance on the role of health in economic development (returns on investments in health), and
2. Develop and adopt robust resource tracking tools to ensure accountability and transparency for public resources on health care. This is particularly important because evidence has shown that increase in public health expenditure may not always bring about the desired output due to inefficiency in spending and resource leakages.