Health workers attend to patients in Nigeria. Photo by: KC Nwakalor / USAID / CC BY

Nigeria has failed in its Abuja Declaration commitment to ensure 15% of its annual budgetary allocation goes toward health, according to a nonprofit coalition known as the Partnership for Advocacy in Child and Family Health at Scale, or PACFaH@Scale. This is a project anchored by the nonprofit development Research and Projects Centre, a local group dedicated to capacity building for the expansion of social capital and accountability in Nigeria.

Twenty years ago, heads of state and government for African Union countries came together at a summit to address the challenges posed by HIV/AIDS, tuberculosis, malaria, and other diseases plaguing the region. On April 27, 2001, several commitments — including Nigeria’s 15% budget pledge — were made to bolster resources and improve health care across Africa.

A new report by the nonprofits of PACFaH@Scale has analyzed the country’s Federal Ministry of Health and its agencies' budgets between 2001 and 2021. Its findings show that Nigeria neglected to follow through on its promise, oftentimes barely reaching a third of the pledged target.

In the visualization below, interact with the health budget data by year and explore additional health budget lines under the service-wide vote (contingency budget), as well as the differences between capital and recurrent allocations.

“These past years, Nigeria has not earned as much as it used to earn from the oil revenues. There are competing demands for limited resources. However, whatever the revenue, health should be a priority,” said Hajiya Halima Jibril, national president and project director at the Federation of Muslim Women Associations of Nigeria, a partner of the PACFaH@Scale project.

According to the report, the average budget allocation to the sector was about 4.7% across two decades.

               

Nigeria health budget from 2001 to 2021.

Here is a summary of key takeaways from the report, as well as a selection of views from the leaders of nonprofit partners and champions of the project:

1. Consistently low funding commitments

Despite alternative funding from the servicewide vote (contingency budget) and Nigeria’s Basic Health Care Provision Fund, budgetary allocation to the health sector never surpassed 7%. Even its peak of 6.2% in 2012 is far less than the 15% commitment in the Abuja Declaration. Amid the ongoing COVID-19 pandemic, the country’s allocation to health for the 2021 fiscal year is 4.5%.

Dr. Minnie I. Oseji, national president and project director at the Medical Women’s Association of Nigeria — a PACFaH@Scale partner — said that this is a multifaceted problem and that solutions are multisectoral.

She argued that “supportive supervision” at every level of the government, as well as constant monitoring of specific targets and indicators, would help effectively implement health care laws and policies, address challenges, and foster more coordination across agencies and states.

Innovative funding mechanisms, public-private partnerships, and intramural practices could help meet the 15% target, Oseji said.

2. Health capital not growing to match increasing expenditure

In 20 years, recurrent — also known as operational — expenditure represents 78% of the total health expenditure, while capital only represents 22%. Comparing the growth rate, recurrent expenditure has increased by 2,822% between 2001 and 2021, while capital has only increased over 400%.

This significant difference shows the government has prioritized human resources and office overheads. However, the reality is that Nigeria is in dire need of health workers.

PACFaH@Scale — implemented by 23 Nigerian health advocacy civil society organizations and anchored by dRPC — is addressing the challenges of suboptimal budget performance in Nigeria at national and state levels.

The project builds the capacity of Nigerian nonprofits’ evidence-informed policy advocacy through training on budget literacy, gender analysis, budget tracking, and monitoring. PACFaH@Scale is supported by the Bill & Melinda Gates Foundation.

Read more about dRPC.

“The country trains great health professionals, but many leave the country due to the lack of health infrastructure that would motivate them to stay and instead search for higher financial returns abroad,” said Dr. Olanrewaju Tejuoso, former chairman of the Senate Committee on Health in Nigeria’s National Assembly, pro-chancellor at the University of Lagos, and a PACFH@Scale champion.

Suboptimal allocation to capital in the budget was a concern raised by a number of PACFaH@Scale nonprofit leaders. With 20% of global maternal deaths occurring in Nigeria, Jibril stressed the need for better roads connecting rural areas with health care facilities and questioned whether the number of primary health centers in rural communities was adequate.

Jibril gave the example of pregnant women facing complicated journeys when going into labor. “[They are] being transported by bikes to a main road [to then] be picked [up] by other transport means, like motorcycles, before they reach a health center,” she said.

3. Poor utilization of funds

Between 2009 and 2019, a total of 576.36 billion naira was allocated as capital expenditure for the health sector. From this sum, 408.79 billion naira was released, but only 318.65 billion naira was spent.

The amount released in this period represents 70.9% of the total cumulative allocation, while the total amount spent constitutes 77.9% of the released fund and 55.3% of the total allocation. Of the funding released, 22.1% was not used.

These figures showcase the inefficiency of the system, according to Dr. Francis Ohanyido, president of the West African Institute of Public Health, a PACFaH@Scale partner. He said that while official development assistance seems to be more effective than Nigeria’s own resources, he asked for aid to be used as a catalyst to help local resource mobilization efforts and push for system changes.

 “The economy of Nigeria in the future depends on the health investments we make now.”

— Dr. Francis Ohanyido, president, West African Institute of Public Health

“Donors can help in building up domestic resources. We should use ODA as catalytic finance” he said.

The budget for health can be found across different thematic areas and across government departments. Ohanyido said that the delayed and disjointed budget process together with highly bureaucratic procedures contribute to the slow implementation of the budget. He suggested mapping the existing resources and harmonizing strategies and policies across sectors to achieve targeted and impactful results.

“We talk to ourselves in the health community. We should talk to other sectors, they [also] have a say in the health of the country,” he said.

4. Funds returned to Treasury despite small health allocations

Of the 408.79 billion naira released between 2009 and 2019, only 318.65 billion naira was spent and 90.15 billion naira was returned to the Treasury. The return of the released funding, earmarked for various health projects, might relate to the fact that such funding was not spent at the end of the designated fiscal year. Internal rivalry, delay in the bidding process, and conflicts of interest are just some of the issues that could delay the release of the fund to the assigned activities.

This could further create setbacks to designated health programs or activities that would improve the life of the Nigerians.

Ohanyido said: “Nigeria is set to be one of the most populated nations by 2050. The population is what fuels the economy. But a good economy needs healthy people. The economy of Nigeria in the future depends on the health investments we make now.”

5. Other funding sources for health need to be considered

There is a need for the government to increase efficiency of health service delivery, address waste, and consider other sustainable sources of funding the sector, such as surcharges on commodities, as well as improve accountability to attract more donations from the corporate bodies, such as the Dangote Foundation.

With the above revenue generation efforts in mind, PACFaH@Scale holds that allocations to the health sector at national and state government levels will approximate, more closely to the 15% commitment made 20 years ago in the Abuja Declaration.

Tejuoso, who as a senator had a longstanding experience walking the corridors of power in Nigeria, argued that a phased and planned budget increase is the best option.

“Politicians need to be more aware of the importance of health as a cross-cutting priority, regardless of their focus sector,” he said.

For more data insights, read the full dRPC-PACFaH@Scale report.

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