Introduction
As health systems aspire towards universal health coverage (UHC), healthcare decision makers are constantly faced with certain financing questions, such as ‘How much is spent on health?’ and ‘Who pays for what?’.1 Health accounts present a useful approach to answering these critical health financing questions by analysing the health system from an expenditure perspective.1
Health accounts, produced and used routinely in many high-income countries for decision making, provide a systematic description of financial flows related to the consumption of healthcare goods and services.1 In low-income and middle-income countries, health accounts are increasingly conducted to generate evidence on the state of health financing.1 In addition, evidence from the National Health Accounts (NHA) in many countries has led to several policy reforms on health insurance, increased prioritisation of health, reprioritisation of public spending and earmarked taxes.
In Nigeria, four rounds of health accounts have been successfully conducted at the national level between 1998 and 2016. These revealed low government spending and high out-of-pocket health expenditure disproportionately borne by households.2 The findings from the 2010–2014 NHA were important inputs into the policy dialogues that ultimately resulted in the signing into law of the National Health Act 2014. This Act provides a legal framework for the regulation, development and management of Nigeria’s health system.
In spite of this, evidence suggests that national level health accounts findings do not necessarily reflect the realities at the subnational level, especially for countries like Nigeria with a decentralised government and health system structure. Thus, while NHA findings may be reliably used to inform resource allocation and health planning at the national level, health accounts studies at the subnational level are also required to inform decisions and planning at state levels. This rationale has spurred a few of the states in Nigeria such as Anambra, Bauchi, Sokoto and Kaduna to conduct their first System of Health Accounts to aid evidence-based decision making.3
This paper profiles Kaduna State (see box 1) and presents information on health spending in the state, the sources of funding and a description of funds that flow through the health system based on the health accounts framework, with a view to providing more reliable evidence for decision making in the Kaduna Health system.
An overview
Kaduna State is one of 36 states in Nigeria; it is in the north-western part of the country and is the third most populous state with a projected population of 8.3 million in 2016. The state is predominantly rural; on average, 50% of rural household members are engaged in agriculture compared to 15% in urban households, while an estimated 22% of the labour force is unemployed. Poverty rate was estimated at 56.5%% in 2018 based on the multidimensional poverty index. The state is composed of 23 local government areas which are categorised into three geosenatorial zones.
The health system in Kaduna is decentralised from the national level with administrative oversight provided by the State Ministry of Health. Private participation also exists from donors, non-governmental organisations (NGOs) and health insurance organisations. These organisations play an important role in providing and maintaining access to healthcare across the over 1200 public and private facilities in the state. The state government funds the provision of health services in state-owned health facilities, while federal health institutions domiciled in the state receive funding from the federal government. Donors and NGOs are also involved in providing health services through faith-based health facilities and donor-supported public health facilities in the state. Health indices from the National Demographic and Health surveys (NDHS), 2013 revealed that Kaduna State lagged behind similar economically active states such as Lagos, Enugu and Rivers in the access to basic maternal, neonatal and child health services.7
This low level of performance in the health sector spurred the government in 2015 to undertake a data-driven primary healthcare system diagnostic to uncover the root causes of underperformance in the state. The diagnostic revealed, among other things, weak budgeting, poor financial management and lack of transparency around resource flows in the health system, and provided a basis to conduct several demand-side analytical studies in the state.
This study presents a profile of the health financing system for the year 2016 in the state using the System of Health Accounts (SHA) 2011 framework to answer specific policy questions:
How are resources mobilised and managed for the health system?
Who pays for health and how much is paid?
How much do development partners contribute financially to the health system?
Which health providers receive health expenditure?
How much is spent on primary healthcare in Kaduna State?