Although Nigeria is an economic giant in sub-Saharan Africa, it lags behind many other African countries in terms of health outcome indicators. For example, UNICEF cross-sector indicators data show the mortality rate in Nigeria in 2020 of children under five years of age was 114 per 1000 live births, which is one of the highest in the world.
While demand-side barriers are found to be contributing factors to low health service utilization, supply-side barriers such as unqualified health workers, staff absenteeism, inadequate staff, limited operating hours and informal payments also have been found to contribute significantly to the low level of health service utilisation. Strengthening the health system could potentially improve service delivery mechanisms, which could lead to improved health outcomes.
In Adamawa State, the under-five mortality rate is 104 per 1,000 live births. Although Adamawa performed better than the national average in neonatal mortality, child mortality and under-5 mortality, the State performed poorer than the national average in post neonatal mortality and infant mortality. Furthermore, the State performed better than the national average in percentage of women without antenatal care, percentage of women who deliver at home, percentage of women with postnatal checks for their new-borns (in a facility or at home). However, the State performed poorer in percentage of women with unmet need for contraception (spacing).
The first major implication of the indicators is the urgency of taking deliberate and targeted steps within the context of available resources to begin to reverse the negative trend as well as sustaining and improving on the relatively positive trends. The second implication is the need to increase the resource outlay through domestic resource mobilization for the task of promoting improvements in health indicators and the third is the need to improve value for money and resource optimization in the deployment and expenditure of the available resources.
Improving the standard of health in the State in a constrained fiscal environment will require the mainstreaming of health in governance through the whole of government and health in all policies approach to the realization of the right to the highest attainable standard of physical and mental health using PHC as the entry point towards universal health coverage.
Indeed, there is a state obligation to take concrete and targeted steps and to use the maximum of available resources for the progressive realization of the right to health including primary health care. This is to be done with a view to the realization of UHC. Resource includes financial resources appropriated through the budget and other finances leveraged through collaboration with state and non-state actors. Resources also include information, environment, technology and human resources. There are standards used to benchmark state financial resources dedicated to health. For example, under the Abuja Declaration, Nigeria (and this is binding on Adamawa State being a component of the Federation of Nigeria) made a commitment to dedicate not less than 15% of its overall budget to funding the health sector.
Data from the state’s ministry of finance show that the year 2018 had a 6.7% vote on health. It appreciated to 8.7% in 2019 and appreciated even further to 13.8% in 2020. It then depreciated to 7.9% in 2021 and depreciated further to 7.4% in 2022. The highest vote of 13.8% was recorded in 2020 while the lowest vote of 6.7% was recorded in 2018. The average vote of the period was 8.9% which represents 59% of the Abuja Declaration. The variance in terms of shortfall between the expected 15% in the Abuja Declaration and allocated resources amounts to N54.336 billion. The implication is that the State has not met the demands and commitments of the Abuja Declaration. The 59% mark should be scaled up progressively towards the Abuja Declaration target.
Also, there is a deep divide between appropriated and approved health budget and actual releases. For example, in 2019, N21, 171,310,673.00 was approved but only N6, 184,870,963.00 was released. Also, in 2021, N11, 015,130,000.00 was approved and N5, 855,347,974.32 was released. This shows that 29.21% and 53.16% respectively were utilised in the years 2019 and 2021. This is an average budget utilisation of 41.185% over the two years. This shows that the Adamawa State budget requires more credibility to reduce the gap between appropriation, releases and utilized budgets sum.
It is suggested that the state ministry of health should take steps towards the preparation of a Health Medium Term Sector Strategy (MTSS). This is to complement section 20 of the Adamawa State Fiscal Responsibility Law which demands the preparation of a Medium Term Expenditure Framework. It is mandatory for the compositional distribution of the annual budget to be in accordance with the priorities of the Medium Term Expenditure Frameworks (MTEF).
The right to health, which is to be realised progressively, under the jurisprudence of economic, social and cultural rights is a “forward ever, backward never” right. Therefore, deliberate retrogressive measures are not permitted and if any such measure is to be undertaken by the State, it requires the most careful consideration and justification by reference to other compelling rights and in the context of the full use of the maximum of available resources.
Okeke is a programme officer with the Centre for Social Justice (CSJ) Nigeria.