The Political Economy of the Design of the Basic Health Care Provision Fund (BHCPF) in Nigeria: A Retrospective Analysis for Prospective Action.

Nigeria has instituted health financing reforms in the past, yet Universal Health Coverage (UHC) remains elusive and out-of-pocket spending accounts for over 70% of the country's total health expenditure. A current reform, the Basic Health Care Provision Fund (BHCPF), was established by the National Health Act of 2014 to increase the coverage of quality basic health services and promote UHC in Nigeria. However, there is limited knowledge of the political economy of health financing reforms in Nigeria and the impact on reform outcomes. This study applied the Political Economy Framework for Health Financing Reforms as described by Sparkes et al. in assessing the political economy of the BHCPF design. The study found that the BHCPF design was considerably influenced by the interplay of stakeholders' interests. The National Assembly was pivotal in ensuring the first BHCPF appropriation in 2018, and the Minister of Health, using donor-funded support, hastened the early BHCPF design. However, certain design elements were opposed by the legislature, bureaucratic and interest groups, which led to the suspension of the BHCPF and its subsequent redesign, led by bureaucratic groups. This produced changes in the BHCPF utilization, governance, pooling and counterpart funding arrangements, some of which increased the influence of bureaucratic groups and diminished the influence of the health ministry and external actors. These changes have implications for BHCPF implementation subsequently, including reduced accountability, potential stakeholders' conflicts, and fragmentation in external contributions. Understanding and managing these stakeholders' dynamics can create an accelerated consensus, minimize obstacles, and efficiently mobilize resources for achieving reform objectives.