A New Dawn for Social Health Insurance in Nigeria

More money for health…and more health for the money

The news that a movement for the establishment and implementation of State Social Health Insurance Schemes (SSHIS) – as a way of providing better access to health services for the entire population in Nigeria – is starting to take root is cheering to both Nigerians and friends of the nation.

Though the 36 states, which have considerable political and financial autonomy have been clamouring for a greater role in the affairs of issues related to health insurance in the country, the emergence of SSHIS is largely ascribed to a new policy environment that is favourable to participation of states. The National Health Act (NHAct) No. 8 of 2014 that stipulated a Basic Health Care Provision Fund (BHCPF) into which at least 1% of the Consolidated Revenue Fund (CRF) would accrue, intends to use 50% of this fund to provide a basic minimum package of health services to citizens in eligible primary and secondary health care facilities through the National Health Insurance Scheme (NHIS). The National Council on Health (NCH), which also derives its authority from the NHAct as the highest policy making body in Nigeria on matters related to health, has directed states to set up SSHIS through which the BHCPF would be disbursed by the NHIS.

Prior to this time, other than having some of their health facilities serve as providers of the NHIS, states were left out in the scheme of things, since the law (Decree 35 of 1999) setting up this national health insurance programme failed to assign relevant roles to them. States were required to enrol their employees in the NHIS-administered social health insurance programme for federal government workers, in addition to mobilising their citizens to join the NHIS programme. On the contrary, most states preferred a decentralised system that gives them the right to manage their contributions and that of their residents by establishing and administering their own ‘health funds’ instead of being micro-managed by a federally driven programme from Abuja. Moreover, several states also desired to monitor health insurance provision within their domains by establishing State Health Insurance Boards. It was alleged that this was the original plan as contained in the draft NHIS Bill of 1996. The attitude of the administrators of the NHIS who attempted to invoke a clause in the country’s Constitution that gave exclusive right to the use of the term ‘insurance’ to the Federal Government, did not also help the position of the states. To avoid any constitutional confrontations, progressive states intent on implementing Social Health Insurance (SHI) programmes for their citizens started to adopt phrases such as ‘social health protection’, ‘contributory health schemes’, ‘health trust fund’ etc.

Paradoxically, the current move towards encouraging states to launch SHI schemes has also been catalysed by the NHIS. Concerned about the low coverage of the population with access to basic healthcare services in the country, a new generation of administrators at the NHIS reconsidered its role in expanding health insurance coverage and began to persuade states to take actions in setting up SSHIS. Other than developing a ‘Template for a SHI law’ that could be adapted by each state, the NHIS also provided direct technical assistance to states in various forms, including training on core health insurance functions, support to administrative procedures, preparations in readiness for take-off etc. And thanks to the NHAct that mandated the NHIS to oversee the disbursement of half of the BHCPF – apart from technical competence, this national agency now has an additional tool to gain traction in getting the states enthused about starting their SSHIS. As at the time of writing, 14 states have passed laws setting up SSHIS, while about another dozen or so are in the process of achieving this milestone. Bayelsa, Cross River, Delta, and Lagos are the front-runners though states are at different levels of implementation.

Meanwhile, in the intervening years of the impasse between the states and NHIS on this matter, based on experience elsewhere in sub-Saharan Africa (SSA), a lot of lessons related to successful implementation of SHI that could be valuable to SSHIS in Nigeria have been learnt. For example, contrary to popular beliefs, we now know that ‘public funding’ is critical as premium revenues are not enough to meet most of the costs of operating a SHI scheme. And the role of the State Ministries of Finance in making this happen is strongly emphasised. Related to this, we are also aware that as innovations tend to challenge the existing institutional arrangements, putting in place an enduring governance framework for SHI is critical to sustainability. The key issue is to ensure that the enabling environment for SSHIS is designed in such a way that this initiative is able to ‘survive and thrive’ when it arrives in the states. Apart from creating sufficient fiscal space for health (increased budgetary allocations and releases), gaining public trust and securing political buy-in are essential. States are also advised to aim for a ‘single pool’ of pre-paid contributions and accumulation of funds from all sources to avoid fragmentation, and apply a uniform ‘minimum benefits package’ across populations in order to achieve equity in access and efficiency.

Fundamentally, the NHIS has to properly redefine its role in the emerging insurance-based healthcare system in the country with a view to galvanising the myriads of stakeholders to jointly make progress towards achieving universal health coverage (UHC) in the near future. Consequently, mentoring and effectively supervising the SSHIS is expected to be one of the main functions of the NHIS in the coming years. But for the NHIS to effectively carry out this task, it has to first of all develop the capacity to manage itself properly and then be able to support the states in implementing SSHIS. And no doubt, the organisation has to also recognise that in a diverse nation such as Nigeria, there is the prospect that ‘many flowers may bloom’.

Health Insurance: making the Informal Formal


In his book Africa Rising, Vijah Mahajan portrayed the African economy as the 10th largest in the world, but often underestimated due to the large size of the informal economy. More like a parallel economy (almost 50% of GDP), the International labour Organisation in Geneva, estimated that the informal sector also accounts for over 70% of employment in Africa.

Over the years, policy makers and practitioners have had great challenges in making health insurance services available to this group – either as a means of financial protection against the risk of unexpected and expensive illness; or as a form of savings set aside to cover relatively predictable contingencies such as annual medical check-up or even treatment for acute malaria for example.

Past attempts at providing health insurance coverage for those working in the informal sector and their families through community-based or micro-health insurance schemes were seen to have not achieved their desired impact. This was largely attributed to the realisation that irrespective of the scale of operation or population segment that is covered, financing healthcare through insurance requires the same level of managerial and technical sophistication necessary to deliver real value to clients while remaining viable.

Therefore, in the era of Universal Health Coverage, there needs to be creative redesign of workable business models away from traditional approaches that are not scalable. Going by the Africa Rising script, one could propose that the challenge of expanding health insurance to the informal sector is similar to the problems of distribution of products to reach those at the bottom of the income pyramid being faced by manufacturers in Africa. And their experience in overcoming these difficulties appear to be the paradigm shift required for making health insurance products available to this group. It has been noted that by understanding local consumers and the small unorganised retailers, using computer routing to find the best path through a complex and fragmented retail network; many multinational companies such as Unilever and Coca Cola were able to bring the informal sector within their sphere of influence to join the mainstream of consumers of their products.

Learning from this model, the task in Africa for health insurance organisations (for-profit or non-profit) especially Health Maintenance Organisations and Health Insurance Companies is to organise health insurance for the informal economy in a manner that strategically aims at bringing this group into a ‘single pool’ of contributors and beneficiaries, along with their formal sector counterparts. This would require the use of creative means as outlined above to ensure that while offering the full range of services to this population, their premium contributions are fair enough for them to remain consumers of health insurance products and services. No doubt, there would be linkages with other aspects of the emerging market for health insurance in Africa including premium subsidies by government or other bodies, as well as incentives for insurers and providers to specifically target the informal sector population ◊◊◊