Aligning public financial management system and free healthcare policies: lessons from a free maternal and child healthcare programme in Nigeria

Abstract

BackgroundRelatively little is known about how public financial management (PFM) systems and health financing policies align in low- and middle-income countries. This study assessed the alignment of PFM systems with health financing functions in the free maternal and child healthcare programme (FMCHP) of Enugu State, Nigeria.MethodsData were collected through quantitative and qualitative document review, and semi-structured, in-depth interview with 16 purposively selected policymakers involved in FMCHP. Data collection and analysis were by guided a framework for assessing alignment of PFM systems and health financing policies. Revenue and expenditure trend analyses were done using descriptive statistics and analysis of variance (ANOVA). Level of significance was set at ρ < 0.05. Qualitative data were analysed using a framework approach.ResultsThe results showed that no more than 50% of FMCHP fund were collected despite that the promised fund remained unchanged since inception. Revenue generation significantly varied between 2010 and 2016 (ρ < 0.05). Level of pooling was limited by non-compliance with contribution rules, recurrent unauthorised expenditure and absence of expenditure caps. The unauthorised expenditure significantly varied between 2010 and 2016 (ρ < 0.05). Misalignment of budget monitoring and purchasing revealed absence of auditing and delays in provider payment. Refunds to providers significantly varied between 2010 and 2016 (ρ < 0.05) due to weak Steering Committee, weak vetting team, paper-based claims management and institutional conflicts between Ministry of Health and district-level officials.ConclusionsThis study identified important lessons to align PFM systems and FMCHP. A realistic and evidence-informed budget and enforcement of contribution rules are critical to adequate and sustainable revenue generation. Clarity of roles for various FMCHP committees and use of clear resource allocation strategy would strengthen pooling and fund management. Enforcement of provider payment standards, regular auditing, and a stronger role for the parliament in budgetary processes are warranted.Electronic supplementary materialThe online version of this article (10.1186/s13561-019-0235-9) contains supplementary material, which is available to authorized users.

Effects of cancer treatment on household impoverishment: a multicentre cross-sectional study in China

“…Government investments need to be channelled to those most in need. 47 This may include cross-subsidising mechanisms between urban and rural insurance schemes. Meanwhile, strong cost containment measures need to be taken.…”

Performance assessment of the county healthcare systems in Kenya: a mixed-methods analysis

“…Prior work suggested bottlenecks in the flow of funding-and more broadly poor financial management-contributed to poor healthcare system performance in other countries like Mexico, Nepal, Ghana, Nigeria and Tanzania. [49][50][51][52][53] In Mexico, an evaluation of Seguro Popular-a social insurance programme for those most in need-cited the decentralisation of the Mexican healthcare system as a cause of funding bottlenecks. Similar to Kenya, a portion of the Mexican healthcare system was decentralised in an effort to increase the autonomy of local healthcare authorities, allowing them to tailor their services to meet the unique needs of their communities.…”

Ownership of health financing policies in low-income countries: a journey with more than one pathway

“…But multiple country experiences have taught us that things are, of course, not so simple 24. There are several implementation challenges, including appropriate budgetary allocations, a clear definition of the benefit packages, a sufficient and timely ordering of drugs and the right provider payment system 25 26. Often, technical staff have been involved too little and/or too late; and limited attention and learning have been granted to the required financial reengineering.…”