Basic Healthcare Provision Fund.pdf

GUIDELINE FOR THE ADMINISTRATION,

DISBURSEMENT AND MONITORING OF THE

BASIC HEALTH CARE PROVISION FUND (BHCPF)

Developed by:

National Primary Health Care Development Agency (NPHCDA)

National Health Insurance Scheme (NHIS)

National Emergency Medical Treatment Committee (NEMTC)

FEDERAL MINISTRY OF HEALTH

FEDERAL REPUBLIC OF NIGERIA

September 2020

GUIDELINE FOR THE ADMINISTRATION, DISBURSEMENT AND MONITORING OF THE BASIC HEALTH CARE PROVISION FUND (BHCPF)

FEDERAL MINISTRY OF HEALTH| 2

TABLE OF CONTENTS

ABBREVIATIONS

DEFINITIONS

EXECUTIVE SUMMARY

1.0 INTRODUCTION

1.1 Aim of the Basic Health Care Provision Fund

1.2 Objectives of the Basic Health Care Provision Fund

1.3 Establishment of Implementation Gateways

1.4 Guiding Principles for Implementation of the Basic Health Care Provision

Fund

1.5 Purpose of the Guideline

1.6 Basic Minimum Package of Health Services

1.7 Review of Guidelines

2.0 GENERAL ADMINISTRATION OF THE BASIC HEALTH CARE PROVISION

FUND (BHCPF)

2.1 Federal Government Level

2.1.1 Ministerial Oversight Committee (MOC) for the Basic Health Care Provision

Fund (BHCPF) ........................................................................................ 30s

2.1.2 Basic Health Care Provision Fund (BHCPF) Gateways Forum

2.2 State Government Level

2.2.1 State Oversight Committee (SOC) for the Basic Health Care Provision

Fund (BHCPF)

2.3 Local Government Level

2.3.1 Local Government Area (LGA) Primary Health Care (PHC) Advisory

Committee

2.4 Partnership Framework

2.5 Non-Governmental Organisations (NGOs) and Civil Society Organisations

(CSOs)

3.0 FINANCIAL MANAGEMENT OF THE BASIC HEALTH CARE PROVISION

FUND 38

3.1 Disbursement of the Basic Health Care Provision Fund (BHCPF)

3.2 Disbursement Process for the Basic Health Care Provision Fund (BHCPF)

3.3 Counterpart Funding by State Governments

GUIDELINE FOR THE ADMINISTRATION, DISBURSEMENT AND MONITORING OF THE BASIC HEALTH CARE PROVISION FUND (BHCPF)

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3.4 Administrative Costs for the Ministerial Oversight Committee (MOC) and the State Oversight Committee (SOC)

3.5 Audit

4.0 GUIDELINE FOR THE IMPLEMENTATION OF THE 50% NATIONAL HEALTH

INSURANCE SCHEME GATEWAY

4.1 Guideline for Funds Disbursement

4.2 Eligibility and Scope of Coverage

4.3 Enrolment

4.4 Benefit Package

4.5 Service Provision

4.6 Institutional and Administrative Framework (Governance)

4.7 Quality Assurance

4.8 Monitoring and Evaluation

4.9 Provider Accreditation

4.10 Ex-Post Verification of Utilisation at Provider Level

4.11 Assessment of Quality of Care at Provider Level

4.12 Health Care Provider Rights and Responsibilities

4.13 Accreditation of Health Facilities

4.14 Basic Minimum Package of Health Services (BMPHS)

5.0 GUIDELINE FOR IMPLEMENTATION OF THE 45% NATIONAL PRIMARY

HEALTH CARE DEVELOPMENT AGENCY GATEWAY

5.1 Introduction

5.2 Institutional Structure for the National Primary Health Care Development

Agency (NPHCDA) Gateway

5.3 Guiding Principles for the Implementation of the National Primary Health

Care Development (NPHCDA) Gateway

5.3.1 Allocation of National Primary Health Care Development Agency

(NPHCDA) Gateway Funds

5.4 Eligibility Criteria for States to Access Funding

5.4.1 Counterpart Funding

5.5 National Primary Health Care Development Agency (NPHCDA) Gateway

Operations

5.6 Structure of State Proposals

5.6.1 Process for Quarterly and Annual Submissions

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5.7 Roles and Responsibilities of the National Primary Health Care

Development Agency (NPHCDA) Gateway

5.7.1 National Primary Health Care Development Agency (NPHCDA)

5.7.2 State Primary Health Care Development Agencies (SPHCDAs) or State

Primary Health Care Boards (SPHCBs)

5.7.3 Local Government Health Authority (LGHA)

5.7.4 Ward Development Committee (WDC)

5.7.5 Primary Health Care Centres (PHCs)

5.7.6 Secondary Health Care (SHC) Facilities

5.8 Referral Services

5.9 Financial Management of the National Primary Health Care Development

Agency (NPHCDA) Gateway

5.9.1 Funds Disbursement

5.9.2 Operational Costs

5.9.3 Financial Reporting

5.9.4 Signatories to NPHCDA Gateway Accounts

5.10 Monitoring and Evaluation for the National Primary Health Care

Development Agency (NPHCDA) Gateway

5.11 Quality Assurance and Improvement

5.12 Penalties for Non-Compliance

5.13 Deployment of Appropriate Technology

6.0 GUIDELINE FOR THE IMPLEMENTATION OF 5% EMERGENCY MEDICAL

TREATMENT GATEWAY

6.1 Background

6.2 Justification

6.3 Governance Structure

6.3.1 Composition of the National Emergency Medical Treatment Committee ... 78

6.3.2 State Emergency Medical Treatment Committee (SEMTC)

6.4 Criteria for State Participation in the Emergency Medical Treatment (EMT)

Gateway

6.4.1 Operational Costs for State Emergency Medical Treatment Committees

(SEMTCs)

6.5 Mission and Vision

6.6 Terms of Reference

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6.7 Office and Administration (Operational Centre)

6.8 Operations of the Emergency Medical Treatment (EMT) Gateway

6.9 Categories of Services

6.10 Accreditation and Certification of Providers for Emergency Ambulance

Services and Emergency Centre Services

6.11 Tariff and Reimbursement

6.12 Emergency Medical Service Database

6.13 Monitoring and Evaluation

6.14 Cost Recovery

6.15 Deployment of Appropriate Technology

6.16 Fund Management and Disbursement

6.17 Quality Assurance

6.18 Research

6.19 Emergency Medical Care Providers Rights and Responsibilities

6.20 National Emergency Medical Treatment Committee (NEMTC) Operational

Guideline

7.0 MONITORING AND EVALUATION OF THE BASIC HEALTH CARE PROVISION

FUN 91

7.1 Scope of the Basic Health Care Provision Fund (BHCPF) Monitoring and

Evaluation (M & E)

7.2 Approach

7.3 Indicators

7.4 Data Sources

7.5 Impact Evaluation

7.6 Evaluating Results from Health Investments

7.6.1 Parameters for Monitoring and Evaluation Framework

7.6.2 Key Performance Indicators for the Basic Health Care Provision Fund

(BHCPF)

7.7 Reporting

7.8 Transparency and Accountability

7.8.1 Objective of the Accountability Framework

7.8.2 Reporting for Accountability Framework

7.8.3 Rewards and Sanctions

7.8.4 Accountability Framework

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7.9 Fraud

CONTRIBUTORS

LIST OF FIGURES

Figure 1: Governance Structure of the Basic Health Care Provision Fund

Figure 2: Framework for Partnership Engagement and Contribution to the BHCPF

Figure 3: Fund Management Flow Chart

Figure 4: Framework for Funds Disbursement under the NHIS Gateway

Figure 5: Monitoring and Evaluation Flow

Figure 6: Institutional Structure for NPHCDA Gateway

Figure 7: Scorecard Template………………………………………………………………..76

Figure 8: Schematic for Emergency Medical Response for National and States……

GUIDELINE FOR THE ADMINISTRATION, DISBURSEMENT AND MONITORING OF THE BASIC HEALTH CARE PROVISION FUND (BHCPF)

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FOREWORD

The Basic Health Care Provision Fund (BHCPF) is enshrined in the National Health

Act 2014, of the Federal Republic of Nigeria. It is an irrevocable testament of the national commitment to achieving universal health coverage. This large-scale health sector reform effort is intended to expand the fiscal space by deploying financial resources to the frontlines, for primary health care services. The BHCPF is designed to be a sustainable model for ensuring equity and financial risk protection for vulnerable populations, by guaranteeing access to a basic minimum package of health services.

It is funded from “not less than one percent” of the federal consolidated revenue fund, supplemented by grants from local and international donors, partners, the private sector and philanthropic organisations.

Prudent implementation of the BHCPF will improve national health indices and firmly place Nigeria on the path to achieving universal health coverage. To ensure transparency, accountability, efficiency, and value for money, this Guideline for the Administration, Disbursement and Monitoring of the Basic Health Care Provision Fund (2020), is developed following revision of the previous Operations Manual (2018). The review was necessary to reset the implementation processes to better align with the National Health

Act and address fundamental issues with the mechanism for administration of the fund, among other concerns. This revised guideline is the outcome of extensive conversations, consultations and consensus building among representatives of federal and state government, legislators, partners, civil society organisations and the private sector.

Successful implementation shall require the staunch commitment of all stakeholders, including healthcare providers and citizen end-users.

Responsibilities are now clearly defined; from the Ministerial and State Oversight

Committees in the offices of the Honourable Minister and Honourable Commissioners of

Health, to the Ward Development Committees. These parties oversee and hold the core implementing entities accountable: these being the National Primary Health Care

Development Agency, the National Health Insurance Scheme, and the National

GUIDELINE FOR THE ADMINISTRATION, DISBURSEMENT AND MONITORING OF THE BASIC HEALTH CARE PROVISION FUND (BHCPF)

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Emergency Medical Treatment Committee, together known as the “Gateways”, and the primary health care service providers. This guideline also defines the roles and functions of stakeholders who wish to support or contribute to the BHCPF and is reference material for training institutions and researchers.

The health sector will find this revised guideline to be an innovative, catalytic framework that ultimately allows access to quality health care services on demand and at no cost at the point-of-care. I enjoin everyone to support implementation of this revised BHCPF

Guideline 2020, for the achievement of universal health coverage.

Dr. E. Osagie Ehanire

Honourable Minister of Health, Nigeria

September, 2020

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ABBREVIATIONS

AFB Acid-Fast Bacillus

AGPMPN Association of General and Private Medical Practitioners of Nigeria

AIDS Acquired Immune Deficiency Syndrome

AMSWoN Association of Medical Social Workers of Nigeria

BHCPF Basic Health Care Provision Fund

BMGF Bill and Melinda Gates Foundation

BMPHS Basic Minimum Package of Health Services

CBHIS Community-Based Health Insurance Scheme

CBO Community-Based Organisation

CEA Cost Effectiveness Analysis

CHIPS Community Health Influencers and Promoters

CMD Chief Medical Directors

CRF Consolidated Revenue Fund

CSO Civil Society Organisation

DFF Decentralised Facility Financing

DHIS District Health Information System

DLI Disbursement Linked Indicator

ED Executive Director

EmOC Emergency Obstetric Care

EMR Electronic Medical Record

EMS Emergency Medical Service

EMT Emergency Medical Treatment

ES Executive Secretary

FBO Faith-Based Organisation

FCCPC Federal Competition and Consumer Protection Commission

FCT Federal Capital Territory

FFS Fee-for-service

FGoN Federal Government of Nigeria

FMoF Federal Ministry of Finance

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FMoH Federal Ministry of Health

FRSC Federal Road Safety Commission

GDP Gross Domestic Product

GIFMIS Government Integrated Financial Management Information System

GMD Guild of Medical Directors

HB Haemoglobin

HCH Honourable Commissioner for Health

HCP Health Care Provider

HIV Human Immunodeficiency Virus

HMB Hospitals Management Board

HMH Honourable Minister of Health

HMO Health Maintenance Organisation

HRH Human Resources for Health

ICT Information and Communications Technology

ICU Intensive Care Unit

IE Impact Evaluation

IV Intravenous

KPI Key Performance Indicator

LGA Local Government Area

LGHA Local Government Health Authority

LQAS Lot Quality Assurance Sampling

M & E Monitoring and Evaluation

MDCN Medical and Dental Council of Nigeria

MICS Multiple Indicator Cluster Survey

MMR Maternal Mortality Ratio

MNCH Maternal, Neonatal and Child Health

MOC Ministerial Oversight Committee

MoU Memorandum of Understanding

NAFDAC National Agency for Food and Drug Administration and Control

NANNM National Association of Nigerian Nurses and Midwives

NARTO Nigerian Association of Road Transport Owners

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NASS National Assembly

NBS National Bureau of Statistics

NBTS National Blood Transfusion Service

NCC Nigerian Communications Commission

NCDC Nigeria Centre for Disease Control

NCH National Council on Health

NDHS National Demographic and Health Survey

NEC National Economic Council

NEMA National Emergency Management Agency

NEMRC National Emergency Medical Response Centre

NEMSAS National Emergency Medical Service and Ambulance System

NEMTC National Emergency Medical Treatment Committee

NGO Non-Governmental Organisation

NHAct National Health Act

NHIS National Health Insurance Scheme

NHMIS National Health Management Information System

NIMC National Identity Management Commission

NMA Nigeria Medical Association

NPF Nigeria Police Force

NPHCDA National Primary Health Care Development Agency

NPopC National Population Commission

NSHDP II 2nd National Strategic Health Development Plan

NURTW National Union of Road Transport Workers

OAGF Office of the Accountant General of the Federation

OIC Officer-in-Charge

OOP Out-of-pocket

P/PROM Preterm and Pre-Labour Rupture of Membrane

P3 or PPP Public-Private Partnership

PCV Packed Cell Volume

PHC Primary Health Care, Primary Health Care Facility

PHCUOR Primary Health Care Under One Roof

GUIDELINE FOR THE ADMINISTRATION, DISBURSEMENT AND MONITORING OF THE BASIC HEALTH CARE PROVISION FUND (BHCPF)

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PM Programme Manager

PPE Personal Protective Equipment

QIT Quality Improvement Team

RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health

RMNCAH+N Reproductive, Maternal, Newborn, Child and Adolescent Health and

Nutrition

RTI Road Traffic Injury

SCD Sickle Cell Disease

SDG Sustainable Development Goal

SHC Secondary Health Care

SHIA State Health Insurance Agency

SHIS State Health Insurance Scheme

SMoF State Ministry of Finance

SMoH State Ministry of Health

SOC State Oversight Committee

SOP Standard Operating Procedures

SPHCB State Primary Health Care Board

SPHCDA State Primary Health Care Development Agency

TMM Top Management Meeting

TOT Training-of-Trainers

TSA Treasury Single Account

UHC Universal Health Coverage

UNDARSTIP United Nations Decade of Action on Road Safety and Traffic Injury

Prevention

UTI Urinary Tract Infection

VCT Voluntary Counselling and Testing

WDC Ward Development Committee

WHO World Health Organization

WHS Ward Health System

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DEFINITIONS

Actuary: a statistician who calculates risks and probabilities for a payment plan

Administrative Charge: amount set aside for operations

Affordability: ability to pay for health services so people do not suffer financial hardship when using them. This can be achieved in a variety of ways including access to essential medicines and technologies to diagnose and treat medical problems, sufficient capacity of well-trained, motivated health workers to provide the services to meet patient needs based on the best available evidence

Benefit: benefit or advantage of any kind derived from a scheme

Capitation: payment method in which all providers in the payment system are paid in advance, whether the enrolee uses the services or not, a predetermined fixed rate to provide a defined set of services for each individual enrolled with the provider for a fixed period

Catastrophic Spending: (for each individual or household) occurs when hospitalisation spending for that person or household, as a proportion of ability to pay (household consumption spending minus combined survival income for all household members) exceeds a certain threshold. The threshold value can range from 5 to 40%

Civil Society Organisations (CSOs): associations (usually Non-Governmental

Organisations (NGOs)) and institutions that reflect and represent the interests and will of citizens through advocacy

Community-Based Health Insurance Scheme (CBHIS): a form of voluntary, not-for-profit insurance mechanism that often involves some form of community management.

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CBHIS schemes are typically based on a collective entity defined by geographic, professional, or religious affiliations

Cost Effectiveness Analysis (CEA): economic cost of a health intervention divided by an estimate of the health effects; the interventions with the smallest ratios are considered the most cost-effective. CEA is a tool for identifying which health interventions achieve the greatest level of health impact per unit of investment, and the results can be used to evaluate ongoing health interventions or to plan for future health programmes

Electronic Medical Record (EMR): digital version of a paper record that contains an individual's full medical history with the health care provider including diagnosis, treatment and medical services rendered

Enrolee: eligible person enrolled in a health insurance scheme or health plan, or the eligible person’s qualifying dependent

Faith-Based Organisation (FBO): public or private organisation consisting of individuals united based on religious or spiritual beliefs and directing their efforts toward meeting the spiritual, social, and cultural needs of the members of their community

Fee-for-service (FFS): payment model of payment per service rendered to an enrolee by a health care provider for health services not classified under capitation

Financial Catastrophe: high out-of-pocket (OOP) payment for health services in the presence of low household financial capacity and absence of prepayment mechanisms, results in financial catastrophe. This high expenditure for health care results in households or individuals reducing or becoming unable to pay for necessities like food, clothing and even education of children

Fiscal Space: availability of budgetary room that allows a government to provide resources for a desired purpose without prejudice to the sustainability of a government’s

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financial position. Usually, in creating fiscal space, additional resources can be made available for some form of meritorious government spending

General Government Expenditure: total amount expended by a government and reflects the total expenditure that the government needs to finance from revenues generated such as taxes, economic income and borrowed funds. Current government expenditure includes purchasing goods and services, salaries and wages, national defence, security, and health

General Government Expenditure on Health: the sum of outlays by government entities to purchase health care services and goods. It comprises the outlays on health by all levels of government, social security agencies and direct expenditure by parastatals and public firms. Aside from domestic funds, it also includes external resources passing through the government as grants or loans, channelled through the national budget

Gross Domestic Product (GDP) per Capita: gross domestic product divided by the midyear population. GDP is the sum of gross value of all resident producers in the economy plus any product taxes and minus any subsidies not included in the value of products. It is calculated without making deductions for depreciation of fabricated assets or for depletion and degradation of natural resources

Health Care Provider: any government or private health care facility, hospitals, maternity centres, community pharmacies and all other service providers accredited for the provision of prescribed health services for insured persons and their dependents

Health Maintenance Organisation (HMO): a limited liability company formed by private or public establishments or individuals, to facilitate the provision of health care services to a defined group of enrolees and financed by prepaid employer-employee insurance premium payments. Care is provided by participating health care providers and all parties are bound by agreements

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Local Government: public administration at local levels exercised through representative councils established by law, exercising specific powers within a defined geographical area. These powers give the local government substantial control over local affairs as well as the staff to direct the provision of services and implement projects, which complement the activities of state and federal government

Medical Documents: all prescriptions, laboratory forms, excuse duty, death certificate and other documents used in patient management

Medical Practitioner: a person with a medical or related degree registerable with the

Medical and Dental Council of Nigeria (MDCN)

National Health Insurance Scheme (NHIS): social health insurance scheme in established by the National Health Insurance Scheme Act of 1999 of the Federal Republic of Nigeria Laws No. 42 VOL II 2004

National Primary Health Care Development Agency (NPHCDA): corporate body established by Degree 29,1992 with statutory responsibilities of providing policy and guidance, technical support, and resource mobilisation to state and local governments for the implementation of primary health care

Pooling: accumulation and management of revenues so that members of the pool share collective health risks, thereby protecting individual pool members from large, unpredictable health expenditures

Primary-Level Health Care Facility: typically staffed by general practitioners or nurses with limited laboratory services for general, unspecialised pathological analysis; bed size ranging from 0-20 beds; often referred to as first level referral

GUIDELINE FOR THE ADMINISTRATION, DISBURSEMENT AND MONITORING OF THE BASIC HEALTH CARE PROVISION FUND (BHCPF)

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Private Expenditure on Health: includes direct household (out-of-pocket) payment, private insurance, charitable donations, and direct service payment by private corporations

Provider Payment Mechanism: mechanisms used to transfer payment for services rendered from the purchaser or a proxy to the health care provider. The provider payment mechanism accomplishes far more than simply the transfer of funds to cover the costs of services

Public-Private Partnership (P3 or PPP): legally binding contract between government and the private sector for the provision of assets and the delivery of services that allocates responsibilities and business risks among the various partners. The goal is to combine the best capabilities of the public and private sectors for mutual benefit

Secondary-Level Health Care Facility: highly differentiated by function with 5-10 clinical specialties; bed size ranging from 20-100 beds; often referred to as Specialist

Hospital

Social Health Insurance Scheme: health insurance scheme provided by government, especially to low- and middle-income populations

Specialist Care: care provided by secondary-level health care facilities that focuses on specific organs or diseases (cardiology, neurology, oncology, etc.) including special diagnostic and therapeutic services such as biopsy or dialysis

Strategic Purchasing: planning and purchasing of preventive, curative and rehabilitative clinical services to meet the health needs of a population

Tertiary-Level Health Care Facility: highly specialised staff and technical equipment, (cardiology, intensive care unit (ICU) and specialised imaging units); clinical services are

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highly differentiated by function; may have teaching activities; bed size ranging from 100-

800 beds; often referred to as Teaching or Tertiary Hospital

Total Expenditure on Health: sum of public and private health expenditure that covers provision of all health services, family planning services, nutrition activities and emergency aid designated for health

Universal Health Coverage (UHC): process that ensures all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services

User Fees: charges levied on any aspect of health services at the point of delivery

Vulnerable: persons at higher risk for poor health because of barriers to resources, and limitations due to illness or disability. In the BHCPF, the following categories of people are classified as vulnerable: (a) pregnant women, (b) children under 5 years, (c) the elderly over 85 years, (d) person with disability, (e) the poor, and others falling within the group

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EXECUTIVE SUMMARY

The enactment of the National Health Act (NHAct) 2014 and establishment of the Basic Health

Care Provision Fund (BHCPF) in Section 11, represents a watershed moment in the journey toward providing equitable access to health care and universal health coverage (UHC).

Implementation will be informed by this guideline which details the governance, administrative, funding and monitoring mechanisms for the BHCPF.

In accordance with the National Health Act, the BHCPF is derived from (a) an annual grant from the Federal Government of Nigeria (FGoN) of not less than one percent (1%) of the Consolidated

Revenue Fund (CRF); (b) grants by international donor partners; (c) funds from any other source, inclusive of the private sector. Implementation is aimed at increasing the fiscal space for health, strengthening the national health system particularly at primary health care (PHC) level, and ensuring access to health care for all, particularly the poor, thus contributing to overall national productivity.

The BHCPF will be managed by a robust governance framework led by the Honourable Minister of Health (HMH) at the federal level and Honourable Commissioners for Health (HCHs) at the state level. The governance framework and operational protocols outlined herein eliminate additional layers of bureaucracy and strengthen implementation by leveraging the mandates and structural advantages of the main implementers i.e. the National Health Insurance Scheme

(NHIS), the National Primary Health Care Development Agency (NPHCDA), and the National

Emergency Medical Treatment Committee (NEMTC), thereby ensuring operational synergy. This efficiency is achieved with the support of the National Assembly (NASS) Committees on Health, the Ministerial Oversight Committee (MOC), the State Oversight Committees (SOCs) and the

Gateways Forum, the Local Government Health Authority (LGHA) Advisory Committee, the Ward

Development Committee (WDC) and Primary Health Care Centre (PHC) Management

Committees; comprises implementers and beneficiaries across the tiers of government and health care delivery structure.

The overall objective of the BHCPF is to ensure the provision of a Basic Minimum Package of

Health Services (BMPHS), strengthen the Primary Health Care (PHC) system and provide emergency medical treatment. This is to be achieved by:

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Disbursing 50% of the BHCPF through the National Health Insurance Scheme (NHIS) via a pathway to be called the “NHIS Gateway”, for the provision of a BMPHS in eligible primary and secondary health care facilities;

Disbursing 45% of the BHCPF through the National Primary Health Care Development

Agency (NPHCDA) via a pathway to be called the “NPHCDA Gateway”, for the provision of essential drugs, vaccines and consumables for eligible primary health care facilities (20%), the provision and maintenance of facilities, laboratory, equipment and transport for eligible primary health care facilities (15%) and the development of Human Resources for Primary Health Care

(10%); and

Utilising 5% of the BHCPF through the National Emergency Medical Treatment Committee

(NEMTC) via a pathway to be called the “EMT Gateway”, for the provision of emergency medical treatment

This Guideline details the governance structure and operations of each of the gateways, and fiduciary measures and sanctions.

The sections on the NHIS Gateway outline the process for individuals and health care providers to enrol as beneficiaries of the BHCPF, which shall enable access to care included in the BMPHS, in designated PHC and secondary health facilities. The gateway shall purchase the BMPHS from the State Health Insurance Agencies and State Health Insurance Schemes (SHIA, SHIS), at an agreed premium. Payment for services rendered at the PHC level shall be by capitation, while services at the secondary level shall be paid by fee-for-service.

The sections on the NPHCDA Gateway outline roles and responsibilities for the NPHCDA, the

State Primary Health Care Development Agencies (SPHCDAs) and State Primary Health Care

Boards (SPHCBs), the LGHAs, WDCs and PHC facilities. The gateway actions shall provide skill, capacity, and technical support; fund the availability of essential medicines and health commodities; ensure availability of vaccines and human resources; maintain PHC facilities and sustain outreach services; all culminating in improvement in the quality of PHC services.

Funding through the NPHCDA Gateway is based on annual improvement and quarterly business plans of the PHC facilities, and annual proposals by the SPHCDAs and SPHCBs. Investment by the SPHCDAs and SPHCBs shall be initially guided by the outcome of baseline assessments and prevailing health priorities in each state. Subsequent investments shall be determined by

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outcomes of quality improvement assessments, monitoring and supervision, and other surveys and financial audits. On a quarterly basis, PHC facilities will receive decentralised Facility

Financing from the NPHCDA through their SPHCDA or SPHCB, while SPHCDAs and SPHCBs shall receive and manage quarterly grants for human resources. SPHCDAs and SPHCBs shall be required to retire a statement of expenditure before receipt of funding for subsequent quarters.

Closing the gap between need and access to health care in emergencies, is the Emergency

Medical Treatment (EMT) Gateway, managed by the National Emergency Medical Treatment

Committee (NEMTC), appointed by the National Council on Health (NCH). Sections for the EMT

Gateway outline the administrative structures and processes for the establishment of a National

Emergency Medical Service and Ambulance System (NEMSAS). The ambulance system shall operate with extensive private sector participation and utilise an emergency call centre system to be co-located with the national emergency call-centre, both at the federal and state levels.

This Guideline ensures transparency and accountability through the application of a robust monitoring and evaluation (M & E), and accountability framework; key performance indicators

(KPIs) at federal and state levels; and the governance structure of the BHCPF. Development partners and CSOs shall also support the implementation and monitoring of the fund as outlined in the sections on monitoring and evaluation.

Judicious implementation of this Guideline shall enable Nigeria effectively fast-track the implementation of the BHCPF and yield impactful health benefits for all.

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1.0 INTRODUCTION

The National Health Act (NHAct) 2014 is a milestone in the national momentum to strengthen the health system, achieve universal health coverage (UHC), and improve health indices with the consequential improvement in economic productivity.

National commitment to UHC was symbolised by the passage of the National Health Act

(NHAct) of 2014, which in Section 11, mandates the establishment of a Basic Health Care

Provision Fund (BHCPF) to support the effective delivery of primary and secondary health care services through the provision of a Basic Minimum Package of Healthcare

Services (BMPHS) and Emergency Medical Treatment (EMT).

The NHAct 2014 was enacted to ensure improved health outcomes, by providing a legal framework for the provision of health care services and establish an organisational and management structure for the health system in Nigeria. To achieve these important objectives, the NHAct specifies that all Nigerians shall be entitled to a Basic Minimum

Package of Health Services (BMPHS). The BMPHS is a set of preventive, protective, promotive, curative, and rehabilitative health services to be developed and reviewed from time to time by the Honourable Minister of Health (HMH), in consultation with the National

Council on Health (NCH).

The Basic Health Care Provision Fund (BHCPF) or “The Fund”, was established under

Section 11 of the National Health Act, as the principal funding vehicle for the BMPHS, and serves to increase the fiscal space and overall financing in the health sector. It is expected that the attendant service upscale from application of this funding, shall enable

Nigeria to achieve UHC. Funding the BHCPF shall be derived, as stipulated in the NHAct, from (a) an annual grant from the Federal Government of Nigeria (FGoN) of not less than one percent (1%) of the Consolidated Revenue Fund (CRF); (b) grants by international donor partners; (c) funds from any other sources, inclusive of the private sector.

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The purpose of the BHCPF is threefold:

1. Ensuring the provision of a Basic Minimum Package of Health Services (BMPHS) by applying 50% of the funds towards purchase of the BMPHS, to be managed by the

National Health Insurance Scheme (NHIS);

2. Strengthening the Primary Health Care (PHC) system, with 45% of BHCPF to be disbursed by the National Primary Health Care Development Agency (NPHCDA) for the provision of essential drugs, vaccines and consumables for eligible primary health care facilities (20% of BHCPF); the provision and maintenance of facilities, laboratories, equipment, and transport for eligible primary health care facilities (15% of BHCPF) and the development of Human Resources for Primary Health Care (10% of BHCPF); and

3. Providing Emergency Medical Treatment, with 5% of the BHCPF to be administered by the National Emergency Medical Treatment Committee (NEMTC) as appointed by the

National Council on Health (NCH).

It is noted that primary health care (PHC) is the foundation for the provision of health care and this fundamental role is recognised by the NHAct, in sections designed to strengthen

PHC. The health care agenda of the administration of President Muhammadu Buhari is centred around the establishment of at least 1 (one) fully functional primary health care centre in every political ward, with the ultimate objective of ensuring UHC; the BHCPF is key to accomplishing this agenda.

In order to adequately fund health care services under the current challenging economic climate in Nigeria, the federal government considered radical options and made important choices including: a review of the current system of annual allocations to public health care facilities; a reorientation in disease burden priorities, ensuring efficiency savings to reduce costs; and increased private sector participation, especially in the delivery of care.

All these factors were taken into consideration in defining the BMPHS.

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Childbirth difficulties and health challenges of children under-five remain significant causes of the national disease burden and untimely death. These are brought into sharp focus by the extremely high Maternal Mortality Ratio (MMR) and under-five mortality rates in Nigeria; estimated at 512 per 100,000 births1 and 132 per 1,000 live births, respectively. Given the huge impact of maternal and under-five morbidity and mortality on disease burden, targeted cost-effective interventions and services have been prioritised in the BMPHS.

The treatment of medical emergencies is a significant challenge to health care delivery;

there is no coordinated national emergency medical response system or ambulance service. This is against a backdrop of rising trends of non-communicable disease (NCD) and injuries in adults; Nigeria has the highest road traffic injury death rate (52.4 per

100,000) of any country globally2. Road Traffic Injuries (RTIs) are now the fifth leading cause of death in Nigeria, up from eleventh in 19903. The rate of death from medical emergencies thus remains extremely high and the development of an Emergency

Medical Service (EMS) is therefore a priority under the BHCPF, for effective access to emergency medical care. Additional justification for prioritising RTIs is the Sustainable

Development Goal (SDG) 3.64: “Halve the burden due to global road traffic crashes by halving the number of fatalities and serious injuries by 2030 compared to 2010”.

1.1 Aim of the Basic Health Care Provision Fund

The overall aim is to significantly move Nigeria towards achieving Universal Health

Coverage (UHC) utilising the 2nd National Strategic Health Development Plan (NSHDP II)

(2018-2022) in the medium term; and in line with the health-related sustainable

1 Nigeria Demographic and Health Survey 2018. National Population Commission Abuja, Nigeria 2014

2 Bhalla, K, Harrison, J, Shahraz, S, Abraham, JP, Bartels, D, Yeh, PH, Naghavi, M, Lozano, R, Vos, T, Phillips, D, Chou, D, Bollinger, I, Gonzalez-Medina, D, Wurtz, B, and Murray, CJL, 2013, Burden of Road Injuries in Sub-Saharan Africa, Department of Global Health and

Population, Harvard School of Public Health, Boston, MA, africa.globalburdenofinjuries.org

3 Bloom, D, Cafiero, ET, Jane-Llopis, E, Abrahams-Gessel, S, Bloom, L, Fathima, S et al., 2011. The Global Economic Burden of Non-

Communicable Diseases. Geneva: World Economic Forum

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development goals (SDGs) in the long-term. The BHCPF therefore, in an initial phase over the next 3 years, is targeting the NSHDP II goals of reducing maternal mortality from

576 to 400 per 100,000 live births representing a 31% reduction; reducing neonatal mortality from 39 to 26 per 1,000 live births representing a 33% reduction; and reducing under-5 mortality from 120 to 85 per 1,000 live births representing a 29% reduction

(NSHDP, 2018). The BHCPF will also ensure that medical emergencies are attended without delay to minimise mortality and morbidity.

1.2 Objectives of the Basic Health Care Provision Fund

The specific objectives of implementing the Basic Health Care Provision Fund (BHCPF) are:

1. To achieve at least 1 (one) fully functional public or private primary health care (PHC) facility in each political ward; at least 30% of all wards over the next 3 years, 70% within

5 years, and 100% within 7 years.

2. To achieve at least 3 (three) fully functional public or private secondary health care facilities, benefitting from the BHCPF in each state; at least 50% of all states over the next 3 years, and 100% within 5 years.

3. To establish effective emergency medical response services in 36 states and the

Federal Capital Territory (FCT) in 5 years, including a national ambulance service.

4. To reduce out-of-pocket expenditure by 30% in 5 years and increase financial risk protection through health insurance.

5. To increase life expectancy to at least 60 years over the next 10 years.

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1.3 Establishment of Implementation Gateways

In line with the NHAct 2014, which stipulates that at least 1% of the CRF of the Federal

Government shall be deducted as a statutory first line charge; which shall be disbursed to and through the NHIS, NPHCDA and NEMTC in predetermined percentages; the

NHAct sets out important drivers and streams for the disbursement and utilisation of the

BHCPF. These streams have been identified as the 3 (three) “Payment and

Implementation Gateways”. The percentage and nomenclature for each gateway is outlined below.

1. Fifty percent (50%) of the Fund shall be disbursed through the National Health

Insurance Scheme (NHIS Gateway) and deployed towards purchasing (and thus ensuring availability) of the Basic Minimum Package (BMPHS) in eligible primary or secondary health care facilities nationwide.

2. Forty-five percent (45%) of the Fund shall be disbursed through the National Primary

Health Care Development Agency (NPHCDA Gateway) and deployed to strengthening

Primary Health Care (PHC) facilities; through the provision of essential drugs, vaccines and consumables, provision and maintenance of health facilities, equipment and transport; and development of human resources.

3. Five percent (5%) of the Fund shall be administered by the National Emergency

Medical Treatment Committee (EMT Gateway) and deployed towards emergency medical treatment.

1.4 Guiding Principles for Implementation of the Basic Health Care Provision

Fund

The implementation of the BHCPF will comply with the following overarching principles under the NHAct 2014: These principles have informed the content of this Guideline.

1. Population Coverage:

The BHCPF shall focus on provision of a BMPHS in line with the NHAct 2014.

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2. Service Provision:

Provision of health care services within the BHCPF shall be by Primary and Secondary

Health Care facilities duly registered by the State Ministries of Health (SMoHs) or the

FCT Health Secretariat and granted a Certificate of Standards. As a prerequisite for registration as a provider, the NPHCDA will certify Primary Health Care Facilities

(according to the Standards for Primary Health Care in Nigeria) in alignment with sections

12 and 13 of the NHAct 2014; and by the NHIS based on the NHIS Operational Guideline.

Accredited and registered public and private primary and secondary health care facilities and emergency service providers may serve as BHCPF delivery points.

3. Scope of Services:

This is based on the Basic Minimum Package of Healthcare Services (BMPHS) as defined by the Honourable Minister of Health in line with the NHAct 2014.

4. Governance Structure:

In line with the NHAct 2014, the 3 payment gateways shall be responsible for management of the funds, under the supervision of the Honourable Minister of Health and Honourable Commissioners for Health at federal and state levels, respectively.

5. Flow of Funds:

Funds will be transferred from the Consolidated Revenue Fund account by the Federal

Ministry of Finance (FMoF) to the 3 gateways (NHIS, NPHCDA, and NEMTC). The NHIS and NPHCDA gateways will in turn allocate the funds to the corresponding state gateways (SHIA and SHIS, SPHCDA and SPHCB). For the NPHCDA gateway, the state organs shall then disburse directly to health facilities. For the NHIS gateway, the SHIA or

SHIS shall pay health facilities according to the number of persons enrolled and services rendered for referred cases, while the NEMTC will reimburse emergency service providers directly, for the delivery of services itemised in the BMPHS. Donor funds shall be disbursed in accordance with section 2.4 of this guideline.

6. On-boarding:

On-boarding to each gateway by state level organs can be achieved by fulfilling the eligibility criteria for each gateway as documented in this guideline, and the designation of 25% of the total cost of projects as counterpart funding as stipulated in the NHAct

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2014. State governments may wish to set aside 25% of the cost of the project from their annual budgetary provision as first line charge.

7. Enrolment (NHIS Gateway only):

Enrolment activities may be carried out by NHIS as well as state level health insurance agencies and schemes.

8. Monitoring and Evaluation:

There shall be routine monitoring and periodic evaluation of activities related to the Fund by the respective gateways and their state counterparts. Implementation reports

(programmatic and financial) are to include successes, challenges, and limitations for all planned activities in the initial proposals. The Honourable Minister may, at discretion, periodically constitute a team to monitor the implementation of the Fund.

1.5 Purpose of the Guideline

This Guideline has been written with thorough reference to the National Health Act 2014 and following extensive consultation with stakeholders in the health sector. They define the requirements for administration, disbursement, monitoring and financial management of the Fund. All stakeholders including (but not limited to) participating health care providers, health care facilities, federal government parastatals and partner organisations, will work to adopt, implement and comply with the stipulations set out in this guideline, in collaboration with the gateways (the National Health Insurance Scheme

(NHIS), the National Primary Care Development Agency (NPHCDA), the National

Emergency Medical Treatment Committee (NEMTC)); state and local governments; and their participating agencies including the State Primary Health Care Boards and Agencies

(SPHCDAs, SPHCBs) and State Health Insurance Agencies and Schemes (SHIAs, SHISs).

The overarching strategic objective of this guideline is to ensure that utilisation of the

Fund catalyses improved health outcomes. This will be achieved by targeting specific areas of concern such as maternal, newborn and child health and non-communicable diseases. In developing this guideline, great emphasis was placed on the ease and speed of implementation, safeguarding equity in health service delivery across Nigeria, as well

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as entrenching a robust accountability and probity framework to guarantee prudent financial management of the BHCPF.

Specifically, the primary purpose of this guideline is to:

1. Set out the criteria for administration, disbursement, monitoring and financial management of the Basic Health Care Provision Fund as provided under Section 11 of the National Health Act.

2. Specify the eligibility requirements, terms of participation and attendant responsibilities for parties to access the Fund.

3. Set out the requirements to be met by beneficiary health facilities.

4. Enumerate the course of action for all other matters which shall ensure that the Basic

Health Care Provision Fund achieves its intended objectives, as stated in the National

Health Act.

In addition, it is expected that each of the implementing gateways may, out of exigencies of programme implementation, publish and disseminate detailed protocols for use by actors within the various gateways. However, such protocol and standards of practice shall not, in any form, be contradictory to this guideline or the NHAct 2014.

1.6 Basic Minimum Package of Health Services

The Fund specifically stipulates the provision of a Basic Minimum Package of Health

Services (BMPHS) which is to be provided by eligible primary and secondary health facilities, enrolled under the NHIS Gateway. The additional fiscal space created by the

BHCPF will, however, be insufficient to finance a comprehensive health care package for all Nigerians but, if utilised efficiently, can serve as a catalyst for creative disruption of existing trends in poor health outcomes. The BMPHS is a defined and actuarially costed baseline entitlement, this guideline outlines the components that will be provided under the BHCPF.

1.7 Review of Guidelines

This guideline shall be subject to review after 3 years in the first instance, and every 5 years subsequently.

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2.0 GENERAL ADMINISTRATION OF THE BASIC HEALTH CARE PROVISION

FUND (BHCPF)

Figure 1: Governance Structure of the Basic Health Care Provision Fund

2.1 Federal Government Level

The Honourable Minister of Health shall have oversight over the implementation of the

Basic Health Care Provision Fund (BHCPF) and approve annual plans and budgets for the 3 gateways.

2.1.1 Ministerial Oversight Committee (MOC) for the Basic Health Care Provision

Fund (BHCPF)

The Ministerial Oversight Committee (MOC) is to be chaired by the Honourable Minister of Health and shall serve as a platform to routinely brief stakeholders on the implementation of the BHCPF by the 3 gateways. The briefings shall provide updates on programme implementation and financial reporting.

Honourable Minister of Health

(MOC)

Ward Development Committee (WDC)

Honourable Commissioner for Health (SOC)

LGA Chair (LGA PHC Advisory C’ttee)

NEMTC

Gateways Forum

Gateways Forum

SEMTC (TSA)

Local…