Health Care Accountability Across Africa
On Thursday, February 17, 2022, I was opportune to speak to nearly 100 persons both physically and online from the Open Gov Hub, Washington, DC. The conversation dissected what healthcare accountability looks like in the African context and how the project I am managing across nine countries in Africa- COVID-19 Transparency and Accountability Project- (CTAP) feeds into this broader agenda.
Discussing with the Director of the Open Gov Hub, Nada Zohdy, we touched on the broader issues affecting accountability in Africa; opaque procurement process, corruption, lack of transparency and accountability, Nepotism, frivolous items and duplicity of projects in proposed budgets.
The conversation also featured Andie Okon, Program Manager for Africa, Open Contracting Partnership(OCP) and Renzo Falla, Senior Research Officer, Open Government Partnership (OGP)
The conversation allowed me to narrow my answers to the following questions.
Question 1: What were some of the pre-existing challenges with PFM & fiscal governance accountability systems that have exacerbated these challenges, contributing to the types of issues we are seeing today with Covid accountability? Have you seen any positive developments? (Public Finance Management)
While we understand that PFM aims to manage limited financial resources to ensure efficiency in delivering outputs required to achieve desired outcomes, we need to know that the process that feeds the overall goal still stands challenged.
Using Nigeria as a case study, only 7% of the total 2021 budget was allocated to health which already sets us back by 8% as regards the Abuja declaration, which stated 15% of the budget must be assigned to the health sector. All these issues need a holistic overview to get sorted. However, to make things better, BudgIT has been involved in advocacy to ensure that the government institutionalises the culture and systems of transparency and accountability. Our advocacy work gave birth to Gov Spend, Tracka and the Open Treasury Platform. These platforms help keep the government accountable and allow citizens to ask questions.
However, allocations to healthcare have gotten worse in recent times. For example, in 2022, findings showed that the FG health budget now stood at 3%, a drastic fall from the 2021 figures that 7% was appropriated. Considering the pandemic that currently ravages the world, one would have ordinarily thought that the policymakers, the representatives and the senators would advocate for more quality allocation to the health sector. However, the reverse is the case. A sum of N711.28 billion dedicated by a Federal Government in a country we are in is a blatant failure. If you look at other sectors like defence, you’ll see that a total sum of 6.96% of the entire budget is dedicated, making it a higher priority than health.
If one compares Nigeria with other developed countries, one will see that Nigeria is not investing enough in the country’s health sector. For example, in the 2022 budget, a sum of N711.28 billion, the government simply says that its healthcare spend is put at f N3,453/person, a failure if you ask me! That’s by the standard sum of $6 to a Nigerian, which will not even buy you Tylenol.
A healthy country is a productive country by all standards. When the county is not ready to invest in the health of its people, then there would be gaps in its productivity. Considering that Nigeria is the poorest country in the world, it further calls for more reasons to take these investments seriously.
You’ll ask, where are the holes of corruption? The answer is in procurement! It’s important to note that as little as the funds allocated to the health sector are, a total capital budget for the ministry of health stands at N194.60 billion; how much infrastructure can the FG deliver with an amount less than $500m?
This low government input into the health sector budget has also fueled both medical practitioners’ apathy and the citizens’ weakening interest in seeking transparency and accountability in this sector. Will I say Nigerians are docile? I could say yes; however, I will also not do away with the fact that we have over the years, had the government and its representatives address matters in ways that berate the citizens of Nigeria. An example of this is the health minister saying, “not all doctors will practise, some of them will be tailors, and some will be farmers.”
It will shock you to know that Nigeria has never met the 15% benchmark of health sector budget allocation, an agreement which all participating heads of government in the African Union reached in April 2001 at Abuja. While countries like Rwanda and South Africa have acted on their commitment by allocating at least 15% of their total budget to health, Nigeria still falls far behind.
As stated earlier, the allocation to the health sector in the 2022 proposed budget is just 4.34% of the entire FG budget. This percentage does not improve at the state level as most Governors are fixated on building roads and mostly white elephant projects. You can’t expect to reap where the government made no investments; as a country and as part of the African continent, we must make conscious efforts to deepen the assets in the health sector.
Question 2: What have been some of the opportunities and challenges of putting in place and using Covid-19 open data platforms for tracking the use of public resources and improving health and social services?
In 2018, the Nigerian government, through the Bureau of Public Procurement (BPP), launched the Nigerian Open Contracting Portal (NOCOPO), which works via the nocopo.bpp.gov.ng. The website aims to avail citizens information to track contacts embarked by the government and allow CSOs to ask questions about each project. With the advent of COVID-19 in Nigeria, the Nigerian government launched an emergency response by purchasing some health items and equipment. The procurement of goods and services during the pandemic was published on the portal. While monitoring the flow of the funds used to achieve these purposes, we discovered many irregularities. We called out this by putting the word out there through our social media platforms which also went viral on traditional media. The response we got was one of the most significant shocks of my life! While Nigerians slept, the portal was deactivated, and some information changed overnight. We saw the opportunity to get information without using the back channels. In contrast, the government saw a threat from our analysis, breaking down the flow of funds by the government. It will interest you to know that a single contractor, “Marvellous Mike Press Limited”, got almost over N400m from the Ministry of Health in procurements; till now, we don’t know the criteria used in selecting the contractors who got the bids to make purchases.
We believe platforms like this should not only allow us to understand who gets selected to get the work done; it should give access to a clear and open framework engaged in making procurements done.
The Govspend platform (www.govspend.ng) launched by BudgIT in September 2021 is another opportunity to grant access to visualised and simplified data from the Nigeria government’s Open Treasury Portal and is targeted at citizens, civil society organisations (CSOs) and members of the media. The portal became important because advocacy only starts when many understand the information. However, the challenges abound — lack of consistent data supply to the Open Treasury Portal, uploading non-machine readable formats- makes data difficult to analyse for public understanding.
As it stands, without proper records of monies spent and activities in which the funds were expended, it becomes difficult to track success and investments.
All interventions on health and social services will only get better in Africa when the issue of identity systems is solved. In the United States, everyone has a Social Security Number, which allows you to have a social contract with the government. Without that, we can’t advance quality healthcare for people.
Question 3:How have you promoted citizen engagement and accountability around Covid-19? Any successes and lessons you would like to share about it?
We started with data, especially on the inflow of the funds coming into the country by both the internal donors and external parties. Examples of these donors were, e.g. (private and corporate organisations) from outside the country, e.g. (bilateral organisations, the IMF, World Bank, AFDB etc.) just to mention a few.
We started with digital infographics; we used illustrations to explain the inflow of monies into the system. We used this method to create an appraisal system with which we pitched states in Nigeria to each other, using the message to drive advocacy across the country. We started a competition among the states in Nigeria, thereby getting more states to publish details of donations received from individuals and corporate organisations.
Press conferences were held to allow citizens to interact with research papers on COVID-19 fund accountability across Africa. We used this platform to create a feedback mechanism to get answers to the questions asked by the Nigerian citizens about the transparency and accountability of COVID-19 Funds.
We listened to human-angle stories and narratives of people whose sources of livelihood and quality of life were affected due to COVID-19. The stories gathered helped us understand how much support the government gave to people living in their states, countries, and communities to help alleviate the pressure caused by COVID-19.
We facilitated coalition meetings between the citizens and representatives of the government to pass across pertinent messages to the government; we created a feedback loop that closed all loopholes for mismanagement.
Finally, we launched a digital platform that allows Africans to track all resources from the private, multilateral and bilateral resources committed to the COVID-19 pandemic. We have more substantial interests in Nigeria, Sierra Leone, Liberia, Ghana, and Malawi. Cameroon & Kenya.
Question 4: What are your thoughts on the current situation and the types of actions needed at the country and regional level to improve the African government’s efforts for COVID-19 response and recovery? How are you planning to contribute to these actions?
Well, I believe African governments and policymakers need to be more proactive; no one will take us seriously when we decide not to take action as when due. Serious kudos to all African countries and governments handling the pandemic so far. However, we need to invest more in research and development, health technology, and primary healthcare systems access.
For me, I will continue to advocate for equal opportunities to access basic healthcare systems across the African continent. As a Pandemic Action Ambassador, I will continue to use my platforms to encourage people to take the proper steps to ensure we are all safe and free from COVID-19.