Does Nigeria have the lowest health budget in Africa?

Africa’s biggest economy, with the largest population, spends less on health than Angola, South Sudan and Ethiopia. Or so Nigeria’s health minister is reported to have said. Is this correct?

After a controversial delay, Nigeria’s President Muhammadu Buhari signed the country’s 2016 budget into law last week. In the run up to the budget finalisation, remarks attributed to Nigeria’s health minister, professor Isaac Adewole, stirred a different sort of controversy.

After Minister Adewole toured the health facilities at the Lagos University Teaching Hospital, Punch newspaper reported on his visit with the headline: “Nigeria has lowest health budget in Africa – Adewole”.

Yet the first sentence of the article stated that the minister said that Nigeria has “one of the lowest” health budgets in Africa.

According to Punch, Adewole further said that Nigeria’s health sector “has suffered from chronic underfunding for many years now. We are even behind South Sudan, Angola and Ethiopia.”

Does  Africa’s most populous country, with its largest economy really have its lowest health budget?

How to measure a country’s spending on health

We contacted the journalist and the ministry of health to verify if the minister was quoted correctly but have not heard back from either.

Chair of the department of global health at Boston University, professor Frank Feeley, told us there are different ways in which one can compare how much governments spend on health. This includes health spending as a share of gross domestic product (GDP) and spending per person adjusted for the purchasing power of different currencies (called purchasing power parity, or PPP).

Feeley added: “For countries at relatively similar levels of development, I prefer to use total health expenditure as [a share] of GDP.”

This data is available from the World Health Organisation (WHO) and the World Bank. As the WHO’s dataset does not include information for South Sudan we opted for the World Bank’s. (Note: The database didn’t include information for two of Africa’s 55 recognised states, Somalia and Western Sahara.)

The World Bank’s data is based on a combination of WHO data, officially reported government health statistics and data from organisations such as the International Monetary Fund (IMF) and the Organisation of Economic Cooperation and Development (OECD).

Three-quarters of Nigeria’s health spending private

The data for health spending as a share of GDP showed that in 2014, Nigeria (at 3.7%) outperformed Angola (3.3%) and South Sudan (2.7%), but lagged behind Ethiopia (4.9%).

Country Total health spending (% of GDP) Ranking (53/55 African states)
Angola 3.3% 51st
Ethiopia 4.9% 36th
Nigeria 3.7% 45th
South Sudan 2.7% 53rd

However, Feeley cautioned against looking at total health spending alone as the bulk of Nigeria’s health spending was in the private sector.

“Nigeria, of course, is far from the poorest country in Africa, so its total health expenditure is higher than many,” he said. “But it is about 75% private, and most of that is out of pocket.”

Of the 3.7% of GDP that Nigeria spent on health in 2014, only 0.9% was publicly funded. On this measure, Nigeria dropped even below South Sudan.

Country  Government health spending (% of GDP) Ranking                    
Angola 2.1% 36th
Ethiopia 2.9% 23rd
Nigeria 0.9% 52nd
South Sudan 1.1% 50th

To get a better sense of the emphasis a specific government places on health, it is necessary to look at the share of a country’s budget spent on health, Feely added.

The 2001 Abuja Declaration committed African Union countries to allocating at least 15% of their budget “to improve the health sector”. In 2012 only Tanzania had reached this target, according to the WHO. In 2014, four countries had met this target: The Gambia, Malawi, Swaziland and Ethiopia (at 15.7%).

“Despite the Abuja declaration, Nigeria is at the low end of this range in Africa,” Feely said.

However, at 8.2% of its total budget dedicated to health Nigeria still outperformed Angola (5%) and South Sudan (4%).

Country Government health spending (% of total budget) Ranking       
Angola 5.0% 48th
Ethiopia 15.7% 3rd
Nigeria 8.2% 35th
South Sudan 4.0% 51st

(Note: In Nigeria’s newly-signed budget the allocation for health as a share of the total budget is 4.64% according to Nigeria Health Watch.)

If we compare government spending per person, where the amount has been adjusted to put all countries on an equal footing based on the cost of living, Nigeria (at $217 per person) is second to Angola (at $239), with Ethiopia and South Sudan (both at $73) falling far behind.

Country Health spend per person ($ in PPP/capita) Ranking                
Angola $239 20th
Ethiopia $73 45th
Nigeria $217 22nd
South Sudan $73 46th

Why does Nigeria spend comparatively little?

The Nigerian government spends comparatively less on health than other African countries because of low government spending in general, Dr John Ataguba, a health economics researcher at the University of Cape Town, explained to Africa Check.

“The tax base in Nigeria is very small,” he said. “Government revenues, which are mainly derived from individual taxes and through oil revenues, are very low.”

However, spending more on healthcare doesn’t necessarily lead to better health outcomes, Ataguba added. “You may also want to look at the role of the state. Reducing inefficiencies and improving accountability are also important.”

Conclusion: Nigeria doesn’t score the lowest in Africa on health spending

The Nigerian government’s spending on health is not the lowest in Africa on four measures of health spending used by health economists.

However, if the minister of health was talking about government spending on health as a share of GDP, he would be right that Nigeria spends less than Angola, Ethiopia and South Sudan. At 0.9% of GDP, Nigeria is ranked nearly the lowest of the 53 African states included in the World Bank’s database, with only the Democratic Republic of the Congo (DRC) coming in lower.

Nigeria also falls short of the declaration by the African Union that member countries spend 15% of their budgets on health, with 8.2% of its budget dedicated to health in 2014. However, government’s health care spending per capita in Nigeria is higher than many other countries on the continent.

Edited by Anim van Wyk

 

Additional resources

The Conversation Africa: Why individual Nigerians carry the heaviest malaria cost burden in Africa

Excel spreadsheets:

Total health spending (% of GDP)

Government health spending (% of GDP)

Government health spending (% of total budget)

Health spend per person ($ in PPP/capita)

 

 

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