A short national financing strategy for emerging markets to access additional sources of finance for the development of their health sector

1. Investing in the Nigerian
Health Sector

2. Nigeria’s health indicators have been poor over the years and
continue to lag behind the Sub-Saharan Africa average
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Nigeria SSA
Outcome Indicators 2003 2008 2013 2016 2016
Under 5 mortality rate per 1000 births 201 157 128 120 78
Infant mortality rate per 1000 births 100 75 69 70 53
Maternal mortality ratio per 100,000 live births 545 576 576 547
Stunting, Height for age (<-2SD) % 42 41 37 44 34
Low weight for age (<-2SD) % 24 23 29 32 19
Wasting, Weight for height (<-2SD) 11 14 18 11 8
Source: WHO, UNICEF

3. Total healthcare spend in Nigeria estimated at US$ 15.4 billion -
3.9% of national GDP, a relatively low percentage compared with
a global average of 10%, - leaving a gap of ~US$ 24 billion
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Nigeria Africa
Public expenditure on health as a
share of GDP (%)
1 3
Per capita public health expenditure
($)
55 164
Public expenditure on health as a
share of Total Health Expenditure
(THE) (%)
25 51
Out of pocket expenditure (OOP) as
a share of THE (%)
72 32
External expenditure as a share of
THE (%)
7 24
Source: WHO, World Bank
• Government spending accounts for 25% of
total health expenditure. With only 3.9% of the
2018 budget allocated to healthcare.
• Health spend per capita ranged between US$
55. Much lower than the global average of
~US$ 1,000.
• Nigeria’s OOP spend on healthcare is the
highest in Sub-Saharan Africa at over twice
(2x) the regional average and quadruple
(4x) the global average.
• The implications of the heavy reliance on
OOP, limited government spending and overall
low level of health spend per capita, are
evident in the country’s poor health
indicators.

4. Nigeria does not have the capacity to bridge its healthcare
funding gap as its domestic fiscal space is handicapped by low
tax collection rates and a large informal sector
Source: World Bank
6.10%
13.73%
15.15% 15.20% 15.90% 16.30%
19.79%
27.20%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Nigeria Rwanda Burkina Faso Malawi Ghana Kenya Senegal South Africa
Tax-to-GDP Ratio by Country
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5. There are an assortment of models available to financially
support healthcare in Nigeria
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Funding model Example Funding model Example
Policy fund: Funding for policy
reform in areas that impact
provision of healthcare. Alleviates
system-wide blockages to
progress.
USAID Health
Policy Project
Accelerator / start-up / SME-
focused fund: Assistance (often
combined with advice) to
entrepreneurs looking to grow
businesses in the healthcare sector.
Innovate for Life
Syntaxis Nigeria
Growth Fund
Aureos Africa
Fund
Systems strengthening fund:
Ability to work with a broad range
of actors across the healthcare
system to strengthen the
supporting environment for
healthcare delivery.
DFID PSP4H,
Kenya
BMGF Maternal,
Newborn and
Child Health
Innovation grant fund: Call for
proposals for innovative solutions to
particular issues. Selected projects
funded through non-returnable grant
capital.
WHO Africa
Innovation
Challenge
Direct service funding (broad or
vertical): Funding for service
provision.
BHCPF Fund of funds: Aggregation of
different fund types into a single fund
as a way to minimize management
fees.
UNFPA Basket
Fund
No potential for return on
private capital invested
Focused on public
healthcare provision
Potential for return
to private capital
Focused on private
healthcare provision

6. Some domestic sources of funds will include a mix of formal
sector contributions, government allocations, informal sector
contributions and donor funds
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Basic Healthcare
Provision Fund (BHCPF)
Informal sector
contributions
Donor funds
• BHCPF: this represents 1% of the national government’s consolidated revenue fund, which is allotted to the
health sector for the provision of primary healthcare and emergency services.
• Sin taxes: these are taxes which can be placed on items which raise the risk of diseases such as sugary
drinks, alcohol and cigarettes, to generate additional funding for the government to finance healthcare.
• Informal sector contributions: a tax / levy on mobile airtime, due to the ubiquitous nature of mobile devices in
Nigeria, can be used to pool additional funding from the informal sector to form a health insurance fund.
According to the Nigerian Communications Commission, Nigeria has over 145 million active mobile lines
belonging to c.80 million unique subscribers.
• Donor funds: these funds are specifically earmarked for handling high-priority, life-saving public health
services, such as, immunization, emergencies, and maternal, neonatal and child health care.
Sin taxes
Healthcare Fund

7. The Nigerian government recently started to implement the Basic
Health Care Provision Fund (BHCPF) to improve funding for
healthcare across the country
Source: Ministry of Health
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Distribution of BHCPF Funding
• Half of the Fund will be used to
provide a basic package of services
in PHC facilities through the National
Health Insurance Scheme (NHIS);
• 45% will be disbursed by the
National Primary Health Care
Development Agency (NPHCDA) for
essential drugs, maintaining PHC
facilities, equipment and transportation,
and strengthening human resource
capacity
• 5% will be used by the Federal
Ministry of Health (FMOH) to respond
to health emergencies and epidemics.
National Health
Insurance Scheme,
50%
National Primary Health
Care Development
Agency , 45%
Federal Ministry
of Health, 5%
Basic Health Care Provision Fund

8. • Technical assistance: MDBs such as the IFC and AfDB can provide the information required to for investors to
make informed decisions on investment in health. They can also provide the required advisory services such as
transaction structuring, due diligence, valuations, implementation support and monitoring and evaluation
required for each investment.
• Source of funding: all MDBs can serve as a source of the required funding to finance health investments in the
country. These funds can be in the form of outright grants, concessional loans and/or blended finance where
they use their funds to pull in additional private sector funding.
• De-risking investments: MDBs like MIGA, IFC, AfDB can help to de-risk investments in the Nigerian health
sector, either by providing insurance for investors, or providing guarantees on investments and returns to
investors.
Multilateral development banks (MDBs) can address the barriers
to accessing these sources of finance in a number of ways
including…
Source: World Bank Group
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