POTENTIAL GOVERNANCE RISK AREAS IN THE IMPLEMENTATION OF BASIC HEALTH CARE PROVISION FUND
BLOG by Dr Mohammed Jibril Abdullahi, Health System Consultant and Blogger, Convener/CEO of a health NGO, Initiative for Health Accountability and Transparency (IHAT), based in Abuja.
You can reach IHAT through:
Email: abdullahionly@yahoo.com or IHAT
Phone: +2348036170644
INTRODUCTION
The National Health Act was enacted into law in 2014 to provide a politico-legal framework for the regulation, development and management of the national health system and set standards for rendering health services in the federation, and other matters connected therewith.
Specifically, Part 1 Section 11 of the National Health Act 2014 provide for the establishment of the Basic Health Care Provision Fund (BHCPF) to be financed from not less than one per cent Consolidated Revenue Fund.
It states how the fund is to be generated and disbursed.
The section specified that:
- There is establish the Basic Health Care Provision Fund (in this Act referred to as "the Fund")
- The Basic Health Care Provision Fund shall be financed from: (a) Federal Government annual grant of not less than one per cent of its Consolidated Revenue Fund. (b) grants by international donor partners; and ( c) funds from any other source.
- Money from the Fund shall be used to finance the following:
- 50% of the Fund shall be used for the provision of basic minimum package of health services to citizens, in eligible 'primary or secondary health care facilities through the National Health Insurance Scheme (NHIS);
- 20 per cent of the Fund shall be used to provide essential drugs, vaccines and consumables for eligible primary health care facilities;
- 15 per cent of the Fund shall be used for the provision and maintenance of facilities, equipment and transport for eligible primary healthcare facilities; and
- 10 per cent of the Fund shall be used for the development of human resources for primary health care;
- 5 per cent of the fund shall be used for emergency medical treatment to be administered by a Committee appointed by the National Council on Health.
- The National Primary Health Care Development Agency shall disburse the funds for subsection 3 (b ),( c) and (d) of this section through State and Federal Capital Territory Primary Health Care Boards for distribution to Local Government and Area Council Health Authorities.
- For any State or Local Government to qualify for a block grant pursuant to sub-section (1) of this section, such State or Local Government shall contribute: (a) in the case of a State, not less than 25 per cent of the total cost of projects; and (b) In the case of a Local government, not less than 25 per cent of the total cost of projects as their commitment in the execution of such projects.
- (6) The National Primary Health Care Development Agency shall not disburse money to any: (a) Local Government Health Authority if it is not satisfied that the money earlier disbursed was applied in accordance with the provisions of this Act; (b) State or Local Government that fails to contribute its counterpart funding; and (c) States and Local Governments that fail to implement the national health policy, norms, standards and guidelines prescribed by the National Council on Health.
- The National Primary Health Care Development Agency shall develop appropriate guidelines for the administration, disbursement and monitoring of the Fund with the approval of the Minister.
The Act assigns the implementing pathways to the National Primary Health Care Development Agency, the National Health Insurance Scheme and the Federal Ministry of Health.
Consequently, the Federal Ministry of Health, Implementing Agencies and relevant stakeholders have developed the Operations Manual for the implementation of Basic Health Care Provision Fund, 2018.
Vital Areas of Concern
However, a critical scrutiny and analysis of the document will uncover two (2) potential governance risk areas that can have grave implication in the implementation of BHCPF.
These are:
- Roles and Responsibilities of the National Steering Committee
- Roles and Responsibilities of the Department of Hospital Services in Emergency Medical Treatment (EMT)
CONCEPT OF STEERING COMMITTEE
The Operations Manual for the implementation, 2018 among others, provide for Roles and Responsibilities of Stakeholders. Stakeholders who have been assigned specific roles and responsibilities include the National Council on Health, National Steering Committee, National Primary Health Care Development Agency (NPHCDA), National Health Insurance Scheme (NHIS), State Steering Committee (SSC), State Ministry of Health (SMOH), State Primary Health Care Agency (SPHCA), State Health Insurance Scheme (SHIS), Local Government Health Authority (LGAs HA) etc
However, what is of great concern and most troubling is the roles and responsibilities assigned to the National Steering Committee and its Secretariat.
While the idea of a steering committee is good to ensure proper coordination of the multiple implementing organs involved the implementation of the Fund, some of the assigned roles and responsibilities can become the achilles-heel of the programme.
Traditionally, steering committees provide clear understanding of project scope and strategic goals, provide direction, support and guidance and oversight of progress, ensure proper project performance of activities and approves project deliverables, help resolve issues and policy decisions, and most importantly, establishes risk tolerances and limits.
It is usually made up of high-level stakeholders and/or experts who provide guidance and support on key issues such as policy and objectives, implementation strategy and budgetary control and resource allocation.
Steering Committees are not established to take over the statutory roles of the management of implementing organs. However, going by the information available in the BHCPF Operations Manual 2018, the BHCPF National Steering Committee would constitute a grave potential governance risk and considerable challenge to implementation.
ROLES AND RESPONSIBILITIES OF THE NATIONAL STEERING COMMITTEE
The Operations Manual provide that the NSC shall meet at least quarterly and provide cross-functional leadership, strategic operational direction, oversight, ensure programme visibility and serve as an advocacy group for increased resource mobilization.
The above is perfect for steering role in the federal Ministry of Health.
Other functions provided for in the Operations Manual include:
- Function as a national strategic group promoting true collaboration in the development and implementation of the BHCPF and be fully transparent in its decision-making.
- Coordinate the operations of the different stakeholders to ensure alignment with the overall objectives of the BHCPF.
- Review and approve annual work plans and budgets of Federal and State implementing entities and the Secretariat of the NSC.
- Review updates on funds flow, performance management and verification of results as collated by the Secretariat of the NSC.
- Evaluate programme report presented by the implementing agencies (NPHCDA, NHIS and EMT (FMoH and NCDC)).
- Have the responsibility to ensure compliance of all participating agencies and entities with the Operations Manual.
- Review performance of the implementing entities based on a clear set of agreed upon Key Performance Indicators (KPIs) across the programme.
- Review quality improvement performance of enlisted facilities arising from the programme’s quality monitoring system.
- Review reports from system of complaints and redress mechanism and provide necessary directives and guidance for resolutions.
- Proactively identify programme risks.
- Ensure that monies are disbursed, managed, and accounted for in a transparent and accountable manner and in accordance with this Operations Manual.
- Review patient satisfaction based on feedback obtained through the fund’s grievance and redress mechanism.
- Advocate and ensure the provision of the required resources for planning and delivery of the programme. Notably, the NSC shall ensure that health and the BHCPF becomes a recurring agenda at the meetings of the National Economic Council (NEC) to ensure the mobilization of required national, subnational and private resources.
- Monitor programme progress against approved plans and guidelines.
- Facilitate implementation of financial audits by appointing independent external auditors.
- Appoint independent verification agents following due procurement processes.
- Review and ensure the reports to be made to the NCH, NEC and other stakeholders are robust and technically sound.
- Resolve disputes or issues arising from implementation of the BHCPF.
The Secretariat of the NSC
The Operations Manual also provide that the National Steering Committee shall be served by a secretariat domiciled in the FMoH and headed by a Director of the FMoH.
The secretariat shall be supported by a team drawn from the FMoH and the implementing agencies. Each implementing agency would deploy two members of staff to the Secretariat of the NSC.
The administrative costs of carrying out its functions shall be based on a budget and work plan presented and approved by the NSC.
The Secretariat of the NSC acting on instructions of the National Steering Committee shall carry out the following responsibilities:
- Preparation of collated reports from the Gateways which will include:
- Programmatic - which shall be categorized into two (2) sections
(i) technical presentations made to relevant stakeholders during technical sessions of the NCH
(ii) policy briefs that synthesize insights from programme implementation, enumerates policy options and recommendations.
- Financial – which will provide information on funds flow to each gateway, State and service delivery points. The report will also contain the total amount available to the gateways at the time of reporting.
- Secretariat Functions
- Serve as The Secretariat of the NSC and ensure communication of the mandate of the NSC in a manner that facilitates the alignment of stakeholders and their activities with the Fund’s strategic goals and objectives
- Organize the joint routine review of the BHCPF Operations Manual at pre-determined intervals with the NHIS, NPHCDA, FMOH and other stakeholder’s sequel to the approval of the NSC.
iii. M&E
- Collate the reports from quarterly randomized surveys by assigned independent verification agents (IVAs); the Independent Verification Agent shall preferably be third party Government or Academic Institution and reports collated will be presented to NSC and other stakeholders
- Planning and Budgeting
- Collate, and present to the NSC the implementation plans from implementing agencies.
- Organize review meetings bi-annually or as directed by the NSC.
- Communication, Advocacy and Grievance redress mechanism
- Collate and review high level advocacy materials from the gateways for the NSC
- Facilitate the harmonization of communications and advocacy messaging and brand elements amongst the Gateways and present same to the NSC.
ROLES AND RESPONSIBILITIES OF THE DEPARTMENT OF HOSPITAL SERVICES IN EMERGENCY MEDICAL TREATMENT
In the like manner, the Operations Manual provide that the Department of Hospital Services of the Federal Ministry of Health shall ensure the provision of basic Emergency Medical Treatment (EMT), by eligible Ambulance Services and designated Emergency Care facilities.
Specifically, the DHS shall be responsible for:
- Accreditation of Ambulance Service Providers nationwide, which may include the Federal Road Safety Corps (FRSC), State Ambulance Services, National Emergency Management Agency (NEMA), Private Sector Ambulance Service Providers and Voluntary Sector Ambulance Service Providers
- Developing a strategic purchasing and payment system (upon approval by the NSC) for Emergency Initial Evaluation, Diagnosis & Resuscitation and any required basic care
- Hospital Care at accredited Healthcare Facilities
- Provision of technical support to the accredited parties
- Timely payment of the EMT service providers
- Other functions delegated by the Minister of Health
NATIONAL STEERING COMMITTEE AS A POTENTIAL GOVERNANCE RISK AREA
While some of the roles and responsibilities are core “steering” functions, there are exceptions that are not only appropriating the responsibilities of the implementing agencies but equally setting up a parallel organ or agency other than those intended by the National Health Act, 2014.
Key worrisome responsibilities of note assigned to the NSC include the following:
- Facilitate implementation of financial audits by appointing independent external auditors.
- Appoint independent verification agents following due procurement processes.
The implanting organs are government agencies to which BHCPF are statutorily appropriated. The agencies have statutory structures like the governing board and the management team with heads who are the accounting officers.
Erroneously, the National Steering Committee and its Secretariat has been programmed to be a central coordinating body for the Administration, Disbursement, Monitoring and Financial Management of the Fund in the Federal Ministry of Health.
Thus, further assigning these responsibilities to the NSC will constitute area of potential governance risk and a cause for concern. It portends the possibility of conflicts between the National Steering Committee and the management structures at the implementing institutions.
The creation of the National Steering Committee in the Federal Ministry of Health can be considered as manifestation of the usual jurisdictional fighting across various Ministries, Departments and Agencies (MDAS) desperate to safeguard their jurisdictions in the implementation of national programmes.
Therefore, National Steering Committee is potential risk area with grave implication as implementation of BHCPF may well be truncated before it starts. Some of the committee’s roles and responsibilities are more or less a duplication of the roles of existing structures of the implementing institutions.
It is a subtle way of meddlesomeness, micromanaging or taking over the implementation and the development is likely to pose grave danger and mar the good intentions of the government on the programme.
It will equally pose risk as dual responsibility pose significant fiduciary risk.
DEPARTMENT OF HOSPITAL SERVICES IN EMERGENCY MEDICAL TREATMENT AS A POTENTIAL GOVERNANCE RISK AREA.
Since BHCPF was conceived to be a funding mechanism rather than a federal intervention project or programme, the approach enunciated in the implementation of emergency medical treatment is a panacea for programme inefficiency and failure considering the long route of accountability.
Incidentally, the other funding pathways at the National Primary Health Care Development Agency and the National Health Insurance Scheme already operate by disbursing funds to the states through the State Primary Health Care Agencies and the State Health Insurance Schemes.
It is therefore, conceivable that the department of hospital or medical services in the State Ministry of Health be assigned the implementation roles under the Emergency Medical Treatment Scheme.
* My next Blog will be on the Potential Implementation Risks in the Basic Health Care Provision Fund.
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