We have followed this debate closely. One year on, we have started to test whether the data reflects the debates, speculations, and experiences that we, and our partners, have had.
We have gathered available data and conducted interviews with decision makers and civil society organisations to take stock of what has happened in Nigeria and Kenya. The findings demonstrated that, across Nairobi and Bungoma in Kenya, and Bauchi, Lagos, and Niger in Nigeria; funding for reproductive, maternal, new-born, child and adolescent health (RMNCAH) is in a precarious position. In the most recent financial years (2021 for Nigeria and 2020/21 for Kenya), the budget committed to RMNCH declined in Niger, Bauchi, and Bungoma. Only Nairobi and Lagos have increased funding for RMNCAH. However, these commitments are not translating into action. For example, in the first 2 quarters of Kenya’s 2020/21 financial year, Nairobi received only 5% and 3% of the planned health budget. In Lagos, 29% of the RMNCAH budget was released.
Interviews with government officials across both countries highlighted the challenges officials face in securing the release of funds, which were exacerbated by COVID-19. These include a lack of capacity on how to raise memos, and challenges in justifying expenditure to decision makers who either a) don’t see RMNCAH as a priority in the context of competing demands; or b) aren’t convinced that previous funding has been spent effectively to achieve results. The heavy reliance on external funding for RMNCAH spending has also reduced the incentive of decision makers to prioritise this area- with external funding accounting for up to 85% of the RMNCAH budget in some years.
Further detailed analysis and findings are provided in the case studies (links below). Here, we share our top 3 lessons from this research which will inform the way we think, advocate, and strengthen public investment in health during and beyond the pandemic.
1. Improve budgetary space for health to account for declining government revenue
E4A works with devolved governments who are reliant on internally generated revenue, revenue they receive from the national government, and donors, to pay for health services. Before the outbreak of the COVID-19 pandemic, Nigeria and Kenya were already facing weakening economic growth , climate change effects on agriculture and high levels of debt servicing .
In Bauchi and Niger state, stakeholders expressed that challenges with revenue have existed for a long time: “We have issues with revenue generation as the state government is heavily dependent on the Federal Government… we have issues since we have a low revenue”. Across the states and counties, these challenges were exacerbated by the pandemic with the federal and internal revenue being negatively impacted by lockdowns and tax breaks. Stakeholders expressed their concern about the future and about what portion of the shrinking revenue will be made available for the health sector, with both countries taking on increased levels of debt and expecting reductions in the levels of external funding.
The economic status of the counties and states we work in is unlikely to change in the short term. Revenue is likely to continue to decline during the aftermath of the pandemic and competing priorities will continue to rise.
Therefore, while it may be difficult to increase funding levels for health, it is important to ensure the funds that are committed are released, spent efficiently, and lead to results for citizens. In turn, this is likely to justify increased investment. To do this, our focus needs to shift from increasing fiscal space available for health to increasing budgetary space for health, which means that, in addition to advocating for increased funding, we are also ensure that each naira or shilling is spent as efficiently and as effectively as possible to deliver quality services to women and babies.
2. Strengthen evidence informed planning in facilities to lay the foundation for budget performance
Each year, counties and states develop annual plans. These plans should be based on longer term strategies and include evidence-based activities. The plans are costed and are used to guide implementation throughout the year, forming the basis for requests for funding release from the treasury.
In Kenya and Nigeria, stakeholders expressed that a key reason for poor budget performance was that the annual plans were not regarded by decision makers as aligned with government priorities or sufficiently leading to results. The lack of feedback loops between facilities and decision makers led to health activities not being prioritised by policy makers and delays or diversion of funds effecting the actual funding available to respond to community needs at lower levels of the health system.
With continued demands on resources, it is critical that evidence informed plans are not only developed but used to inform ongoing prioritisation of available funds across levels of the health system. Plans should align with broader political priorities, be founded on a strong evidence base, and be results oriented. E4A are expanding support to coalitions so that they are equipped to provide decision makers with the evidence they need so they can see what increased funding can buy. This will improve budget releases and ensure that lower levels of the health system have the funding they need to make decisions to improve access and quality of services.
3. Take a holistic view of health budgets to improve services for women and babies
The coalitions E4A partner with aim to improve access and quality of maternal and child health services. While coalitions have typically focused on improving specific health budget lines in states and counties, there is a growing awareness that sustainable improvements to maternal and child health services require strong primary health care, as this is where most women and children access services across the continuum of care .
Throughout the COVID-19 response, significant funds that had been committed to maternal and child health was repurposed to secondary and tertiary levels of the health system to combat the pandemic. “Resources were diverted to activities to curb the Covid 19 with things like palliatives, things like how hospital needs to function at that particular time…so many resources were channelled towards all that”. This highlighted the importance of taking a holistic approach to budget advocacy: using evidence to highlight to decision makers the interdependency between health security and primary health care, and the importance of investing in both through a coordinated approach.
Both Kenya and Nigeria have accelerated the roll out of funding schemes which will improve maternal and new-born health through a focus on improved funding for primary health care. The UHC programme and Linda Mama in Kenya; and the Basic Health Care Provision Fund in Nigeria, will enhance access to quality health services for women and new-borns through improved funding for primary health care. It is critical that civil society, service providers and decision makers are equipped to advocate for, and track funds to primary health care services. E4A are supporting coalitions to take a more holistic view of funding for health: identifying how a strong primary health care system can improve maternal and new-born health outcomes, and how different funding streams can be leveraged towards this goal.
Our research in Nigeria and Kenya emphasised that the coming years will be critical for the health sector. While continued emphasis on increasing investment is important, our findings highlight the importance of ensuring that funding gets to where it needs to go and is spent efficiently to improve health outcomes. Our analysis, in addition to our ongoing activities such as the health financing scorecard and expenditure briefs, have highlighted not only the difficulty in getting committed funding to health facilities, but the lack of information regarding how funds get to facilities, what they are spent on, and what can be done to improve efficiency to justify additional funding and increase budgetary space.
In a challenging context where resources for health are likely to remain limited, or even decline, E4A will focus on increasing transparency across the health system to optimise how resources are spent so that women and babies can access better quality services without financial risk. We will do this by equipping stakeholders across the health system to track how funding is used within and between health stakeholders, and how to use this information to improve budgetary space for primary health care, to improve maternal and new-born health outcomes.
We have exciting plans in development with service providers, policy makers and civil society organisations to ensure that all levels of the health system are equipped to optimise primary health care funding to strengthen quality services for women and babies. Watch this space!