By Eze Onyekpere
This discourse reviews key health governance issues that need to be addressed by political parties and their candidates as their commitment to the realization of the highest attainable state of physical and mental health by all Nigerians. These governance issues need to be addressed as critical steps towards the goal of universal health coverage (UHC).
The National Health Policy 2016 (NHP) states that the 1999 Constitution “does not lay emphasis on health and fails to state the roles and responsibilities of the 3-tiers of Government in health systems management and delivery. The National Health Act 2014 (NHA) is the first legislative framework for the health system. The country has several sub-sectoral policies and plans including the reproductive health policy, national Human Resources for Health (HRH) policy and plan, national health promotion policy, health financing policy, amongst others”. In 2014, the Constitution Amendment exercise provided for maternal and child health as justiciable Fundamental Rights in Chapter 4 of the Constitution. However, the amendment did not scale through after approval by 24 states of the Federation because the President refused to give assent to the Bill due to legislative executive feud which had nothing to do with the amendment. The Constitution is the grundnorm and ranks highest in the hierarchy of laws. As such, it needs definitive statements on the right to health. What would the party and its candidates do to strengthen legal and policy frameworks governing the health sector?The NHA makes detailed provisions for the governance of the National Health System, starting with the National Council on Health at the highest level. There are various national coordination platforms and different thematic technical groups and task teams. There is however poor coordination and harmonization of these groups, leading to duplication of functions and waste of scarce resources. The NHP further states that there is ineffective coordination among the three levels of government and between the private and public sectors. NHA makes provisions for the Basic Health Care Provision Fund to be accessed by states through three windows. States are required to provide counterpart funding but many states are not providing these counterpart funds; therefore they have not accessed their share of the funds which are mainly dedicated to primary health care and the protection of the vulnerable. What would the party do to entrench effective coordination and oversight and ensure that states provide their counterpart funds for the BHCPF?
The Legislature is the arm of government charged with making laws for the peace, order and good government of the Federation and the States while the Executive executes laws and policies. In presidential democracies, there is an inbuilt tension in the relationship between the Executive and the Legislature, with obvious checks and balances. The general position is the Executive originates and prepares budgets while the Legislature approves and exercises oversight over the management and use of public resources. Good working relationship between the Executive and Legislature is imperative for improved allocations to health, value for money and improvements on health delivery. Collaboration between the Executive and Legislature is imperative in ensuring good health care for the population. How would the party manage Executive Legislative relationships to generate a good partnership for health?
Benchmarking is the practice of evaluating something by comparing it with a standard. States and components of the National Health System can be peer-reviewed; be evaluated against best, fit for purpose and good practices with a view to peer learning and learning from the best in class. Will the party consider this a good practice and how would the party implement this? Nigeria in 2005, during the implementation of the National Economic Empowerment and Development Strategy of the Obasanjo administration, undertook a benchmarking exercise for State Economic Empowerment and Development Strategies. The benchmarking was divided into various components. The report encouraged states to improve their public finance management system, reduce poverty, enhance policy formulation and implementation, etc. This can be replicated in the health sector. Benchmarking exercises can be tied to a challenge fund, an incentive to encourage the best performers and some form of naming and shaming of laggards who have failed to take steps to improve the health system of their states and agencies. Benchmarking should be collaborative between the government, donors and civil society. In two benchmarking exercises undertaken by Centre for Social Justice at the federal level, notably, the Fiscal Responsibility Index and the Budget Inequality Index, the Ministry of Health performed poorly among the benchmarked Ministries. This shows a weak capacity to deliver on its vision, mission and overall national health goals. Accountability and transparency are two sides of the same coin and they are qualities of a functional, efficient, and effective health system. They build confidence in the system and guarantee that all partners have the opportunity to contribute to the development of the sector. Extant government civil society collaboration is perfunctory. Civil society is considered a meddlesome interloper by the government, and as such, there is hardly a meaningful engagement between the government and civil society. The NHP states that there is a lack of transparency in the budgetary process. Large parts of health capital budgets at the federal level are stated in lump sums without disaggregation. How will the party guarantee accountability and transparency in the health sector?
Instituting a comprehensive accountability framework that promotes effective monitoring and evaluation of health sector performance, system audit, feedback system, due process in procurement and independent verification is imperative for the improvement of healthcare delivery. What will the party do to improve monitoring and evaluation in the health sector? Experts have posited that: “Monitoring and Evaluation (M&E) is a process that helps improve performance and achieve results. Its goal is to improve current and future management of outputs, outcomes and impact. It is mainly used to assess the performance of projects, institutions and programmes. It establishes links between the past, present and future action”. Health M&E is “about collecting, storing, analyzing and finally transforming data into strategic information so it can be used to make informed decisions for programme management and improvement, policy formulation, and advocacy. Although, this is not a comprehensive list of health governance issues, it can be a good starting point for political parties and candidates to state their positions on them.
Onyekpere writes from Lagos