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Making Health Insurance Work for the Most Vulnerable in Nigeria

By guest contributors Omokhudu Idogho, Kenneth Okoineme, Yusuf H. Wada, Isibhakhomen Y. Ikhimiukor, Mogbonjubade Adesulure, and Jennifer Anyanti

In 2020, the Minister of Health unveiled the Nigeria’s Health sector roadmap guided by the 2019 President’s “Health Sector Next Level Agenda”. One of the key components of the agenda includes the implementation of a Mandatory Universal Health Insurance in collaboration with State governments and the Federal Capital Territory (FCT) Administration.

Fast forward to May 2022, when the President signed into law the National Health Insurance Authority (NHIA) Act which provides the framework for a health insurance scheme that enlists the states in achieving health insurance for all. Stakeholders, donors, partners and other Civil Society Organizations (CSOs) have commended the Government for taking actions towards universal health coverage – especially against the backdrop of a reported that 8 out of 10 Nigerians that have no access to health insurance.

The new law makes it mandatory for every Nigerian to be covered by health insurance, and it provides for collaboration between the NHIA and state governments especially in accreditation of primary and secondary health care facilities. It prioritizes access to the most vulnerable population with the set-up of a ‘vulnerable group fund’ expected to be funded by the Basic Health Care Provision Fund (BHCPF), which are insurance levies to fund the premiums of the most vulnerable.

Further, it provides room for cautious optimism; the reality of delivering health insurance need to be understood in the context of the broader health system challenges in the country. The vulnerable group fund as envisaged in the scheme design at the moment seems to be premised that a proportion of the population will require intervention from that pot. The reality is almost 50% of Nigeria live in the rural area according to the World Bank, and a vast population of expanding urban poor still do have relatively constrained ability to pay insurance on an ongoing basis.

The worries are the new law may not significantly expand scope beyond the formal sector as was the limitation of the old scheme. At best, it will achieve only a socialization of private health insurance scheme that are functioning relatively well with the public scheme. The net gain of which is unclear at the moment in terms of our national UHC ambition.  Moreover, published literature by Adewole et al. and Okpani et al. suggests that the bottlenecks to attaining Universal Health Coverage is less of a formal sector issue but more of expanding uptake of Health insurance in the informal sector and rural areas. The statutes as outlined now is unlikely to fundamentally change that narrative in the foreseeable future.

The proposed funding of the Vulnerable fund as envisaged by the law include the Basic Health Care Provision Fund (BHCPF) which draws 1% allocation from the consolidated revenue fund and a counterpart mobilized by states, premiums paid by enrollees and other sources. It is likely that the BHCPF will be the tripod on which the fund will function. This is worrying as the BHCPF fund itself is already constrained by shrinkage in public revenue mobilization that is undermined by debt obligations. However, at the presentation of the 2023 -2025 Medium Term Fiscal Framework/Fiscal Strategy Paper by the Federal Government (FG), the key highlight was that FG’s retained revenue for the period was N1.63 trillion and debt service stood at N1.94 trillion in the first quarter of 2022. The FG and most states are also in dire fiscal strain, all of which are pointers to how unlikely the new law will change the realities of, and health outcomes of Nigerians, especially in the informal sector and in rural areas. Many of whom are poor, vulnerable and in dire need of the ambition set out in the law.

Every situation provides its own opportunity, and this could be the time to think through innovative and sustainable resourcing approaches for the fund. One of such approaches would be to ring fence the “sugar tax” and direct it exclusively to fund the vulnerable pool fund. A structured review of alcohol, tobacco and other related items should be implemented and possibility of ringfencing elements of taxes imposed on them and directed to the funds should also be considered.

Designing service delivery channels and getting the bulk of resources to the point of service are the other two critical reflection point even as the law is rolled out. PHCs are the primary foundation and entry point into the health system, especially at rural areas. Report suggests that less than 50% of such public PHC facilities in the country are fully functional even after 3 cycles of BHCPF investment. Therefore, it is not surprising that 75% first point of care and PHC service uptake is delivered by informal health service providers such as Patent Proprietary Medicine Vendors (PPMV), and Community Pharmacists (CPs). Bold thinking and creative action are required to improve citizen interface with the health sector in light of this worrying situation.

Finally, policymakers must recognize the centrality of the social contract between citizen and government, and do everything to ensure that it is effectively implemented. We also hope that the celebration that heralds the enactment of this law will translate to actual change in the health outcomes of Nigerians, especially the poorest, and will accelerate Nigeria’s achievement of the health-related Sustainable Development Goals (SDGs) and Universal Health Agenda 2030.

About the authors:

Dr Omokhudu Idogho is the Managing Director, Society for Family Health (SFH), Nigeria, one of Nigeria’s foremost non-governmental organisations, with over twenty-five years’ leadership experience in developing and leading large development interventions at country and multi-country levels. Before joining SFH, he worked with ActionAid International in South Africa as the International HIV & AIDS Programme Coordinator overseeing ActionAid’s work in 22 countries in Africa, Asia and Latin America. He also worked as a Policy Advisor with ActionAid Alliance in Belgium, focused on shaping policy making in the European Union institutions.

Kenneth Okoineme is the Health Governance and Public Policy Specialist for Society for Family Health, with over 15 years’ broad-based experience across, governance, and public policy engagement. Much of his work has centered on  approaches to influencing public policy processes & outcomes in public finance, public service delivery, governance and democratic development.
He is passionate about effective civil society organizing and enabling communities build alternatives and taking actions to demand, claim and uphold rights to responsive public services, engagement with governance institutions, political processes and development initiatives to improve their effectiveness towards people centered development outcomes and social impact.

Yusuf H. Wada is a pharmacist and currently works as an executive assistant and a health policy trainee at the Society for Family Health. He is a fellow of the International AIDS Society HIV Cure academy and has published several research papers, presented at local and international conferences and written for many blogs.

Isibhakhomen Y. Ikhimuikor is a programme associate with the Society for Family Health. Previously, she worked with the Women’s International League for peace and freedom (WILPF Nigeria) where she oversaw the process of presenting a shadow report to the CEDAW committee and implementation of several other activities on women peace and security. She holds a bachelor’s degree in Pure and applied mathematics from the Federal university of technology, Minna and she is passionate about public health and committed to ensuring every Nigerian receives basic healthcare services.

Moghonjubade Adesulure is currently the Country Digital Media and Communications Coordinator on the Society for Family Health DISC project where she leads a wide range of campaign- and communications-related activities in Nigeria.  She’s a media enthusiast with considerable experience in media and communications, with a current focus on health communication. She holds a master’s degree in mass communication from the University of Lagos and a bachelor’s degree in Communication and Language Arts from the University of Ibadan.

Dr. Jennifer Anyanti is currently the Deputy Managing Director (Strategy and Technical) at Society for Family Health, one of Nigeria’s foremost non-governmental organisations, and a fellow of the West African Academy of Public Health. She is a graduate of Medicine from the Obafemi Awolowo University, Nigeria, and a Public Health expert with over two decades of experience in health advocacy, research and public-health related programming funded by a range of international donors. She is a well published author/co-author of over 50 peer reviewed articles, and beyond her professional accomplishments, she is a mentor, result-driven manager and a Board member of a number of national and international health focused organisations.

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