Using data and measurement tools effectively to expand health coverage in Nigeria
Although Nigeria has established several mechanisms for attaining universal health coverage, including a Basic Health Care Provision Fund (BHCPF), progress toward achieving this health goal has been limited. The support by Results for Development (R4D) to the gateways implementing the BHCPF is aimed at addressing some of these limitations. The support to harness data and develop monitoring tools is particularly important for the BHCPF implementing agencies to effectively assess and improve access to quality health care services, especially for poor and vulnerable Nigerians.
Attaining universal health coverage (UHC) is at the heart of the health objectives of every country across the world. However, attaining UHC has remained elusive in many countries.
In Nigeria, poor health financing remains a major driver of the country’s poor health indicators. The majority of Nigerians depend on private spending to access health services, which makes out-of-pocket payments the country’s highest contributor (about 70%) to total health expenditure. With as many as 4 out of 10 Nigerians living below the national poverty line, this expenditure is burdensome, unsustainable and a hindrance to attaining universal health coverage. Quality health care in Nigeria is also hampered by other issues, including low health insurance coverage, subpar facilities, and inadequate human resources.
To address these issues, the federal government began implementing the Basic Health Care Provision Fund (BHCPF) — a financing mechanism to improve access to primary health care, especially for the poor — in 2019. While the implementation of BHCPF has, to some extent, increased the number of Nigerians that can access and afford health services, there are still many opportunities to improve the effectiveness of this program.
The paucity of data for evidence-based decision-making and the lack of automated data management systems for quick, seamless, and collaborative decision-making is one of the biggest challenges. With over 9,000 health facilities expected to be enlisted nationwide and several different government agencies involved in the rollout, managing data manually has become problematic and unsustainable.
To support the Nigerian government in addressing these challenges, Results for Development and our partner Sydani worked alongside the National Health Insurance Authority (NHIA) and the National Primary Health Care Development Agency (NPHCDA) to:
- Review the implementation of BHCPF and identify the root causes of challenges.
- Prioritize interventions/activities.
- Strengthen key capacities within the agencies.
- Co-develop and deploy tools, systems, and resources.
Key lessons from working with the NHIA
To effectively provide insurance coverage and improve access to health facilities and services, the NHIA must be able to effectively monitor the progress of BHCPF implementation at the state and facility levels. This important consideration informed R4D’s and Sydani’s interventions in supporting the NHIA to develop tools for improving data collection and analysis and tracking and monitoring systems.
- When there are multiple agencies/funds, theories of changes must be aligned. To establish an effective monitoring and mvaluation (M&E) system for the NHIA, R4D and Sydani supported the agency to revise its theory of change to align with the overarching BHCPF theory of change. We helped facilitate a process with the M&E Division that involved engaging stakeholders and reviewing key documents to define goals and outcomes. We also supported the NHIA to refresh its 10-year strategic plan by delineating clear priorities and responsibilities for the various departments.
- M&E frameworks must be based on how things actually operate. Critical to ensuring the effectiveness of an M&E system was the development of the M&E framework based on guidelines provided in the BHCPF operational manual. The M&E framework has provided the NHIA a basis for measuring progress against stated objectives and for identifying challenges in the delivery process that must be resolved.
- Data must be accessible for informed decision-making. The third component of support was the development of a dashboard to ensure that information is accessible for decision-making, indicators are efficiently tracked, and data is stored centrally to ease data collation, cleaning, and analysis. The Excel-based dashboard disaggregates information by state and geopolitical zones based on functions. It helps the NHIA monitor the implementation of activities and allows the NHIA to provide more targeted support to states.
After establishing M&E systems (theory of change, M&E framework, indicators, and dashboards), R4D and Syndani supported the NHIA to operationalize them. This included ensuring effective capacity building and transfer for the M&E unit to carry out its functions and sustain the use of the M&E system, and advancing processes for routine data collection, collation, analysis and reporting. Focal persons in the planning cells were mapped, specific individuals responsible for BHCPF implementation were identified and a baseline capacity building needs assessment conducted for unit members. Additionally, a data management plan was developed that highlights how BHCPF data will be managed and utilized.
Increasing access to health
Besides providing insurance coverage and reducing out-of-pocket expenses, access to health is also defined in terms of population coverage, range of services provided, timeliness, and availability of workforce. The agency, NPHCDA, concentrates efforts on these aspects of health services by ensuring that every ward in Nigeria has a functioning Primary Health Centre to provide basic health care to the population it serves. It also provides direct financial investments to fund the upgrades of critical primary care infrastructure, improve the availability of skilled health staff, medicines and health commodities at the Primary Health Centres.
To achieve these objectives, R4D and Sydani supported the agency’s Program Implementation Unit (PIU) in: conducting operational expenditure (OpEx) research to define the optimal resources needed to fund each PHC in Nigeria, developing a robust M&E framework, and strengthening partner coordination.
Going forward, sustaining the current momentum and change will contribute significantly to operationalizing the BHCPF across states and in health facilities. This will lead to better access to health services and result in better health outcomes, especially for the poor and vulnerable — a significant step toward attaining universal health coverage in Nigeria.
