Fulfilling Nigeria's Commitment to Universal, Equitable Healthcare
By: Hussain Ibrahim, HP+ Nigeria
This blog was first published on Medium.
Across Nigeria, there are many fledgling state social health insurance schemes. While these schemes aim to provide access to affordable and high-quality healthcare for all, state governments generally lack the capacity to set them up and many Nigerians are not encouraged to participate. Consequently, poor enrollment results in insufficient funds to support implementation and sustainability of the schemes.
Enrollment issues range from lack of a viable strategy to increase insurance coverage to difficulty in getting local government administrators to buy into the schemes. Failure to address these problems has meant that residents pay for healthcare out of their own pockets, a situation that has proven catastrophic for most families considering the high disease burden in Nigeria.
Historically, few people in Nigeria have enrolled in health insurance, which has limited insurance agencies’ ability to pool resources from across the population. Getting more people enrolled into health insurance would expand the insurance funding pool and protect residents from catastrophic health costs. Enrollment is also critical for achieving Nigeria’s goal of advancing equitable access to healthcare.
Working in collaboration with state governments, Health Policy Plus (HP+) has begun to see improvements in insurance schemes in Osun State and the Federal Capital Territory (FCT). These improvements have led to an uptick in enrollment and funding pools.
Osun State’s Health Insurance Scheme – How it Developed
In 2017, Nigeria’s Osun State government set up its compulsory social health insurance scheme with a commitment to making it operational to serve its citizens. As mandated by law, the government also committed to provide a “take-off grant” to kickstart it and commence a statutory 1.5 percent deduction from staff salaries and a 3 percent subsidy contribution by the state government.
However, a year later, these commitments were not realized. The Osun State Health Insurance Scheme (OHIS) started operations without the necessary grants to support it, and the state government had yet to officially announce the state’s compulsory health insurance. Both slowed down operations and threatened the insurance agency’s ability to provide citizens with access to affordable healthcare. It also threatened the effective implementation of the Basic Health Care Provision Fund (BHCPF), the federal government’s reform program to provide access to high-quality healthcare for the poor and vulnerable, especially in rural communities. Under the BHCPF, state health insurance agencies are responsible for providing a basic minimum package of health services, including maternal and child healthcare, family planning, and immunizations, free to vulnerable populations.
HP+ began working with OHIS in 2018 to address some of its structural challenges and position the agency to live up to its mandate. HP+ provided capacity building support to agency staff and management and also engaged with key state decision-makers to garner support for the insurance agency’s work.
In March 2019, HP+ led advocacy efforts with the governor, Gboyega Oyetola, senior officials from the National Health Insurance Scheme, and OHIS’ management team. The group requested that the governor constitute a governing board for OHIS, release startup grants for the rollout of the social health insurance scheme, publicly announce a 1.5 percent salary deduction from state employees, approve the release of the state government’s cross-subsidy of 3 percent, and fill human resource gaps in OHIS. By July, tangible results had been made—Osun State government announced the employee salary deduction and released the take-off grant of ₦150,000,000 ($416,667) for OHIS’ rollout.
The Federal Capital Territory Health Insurance Scheme – Careful Collaborative Results
Since it was launched in 2009, the FCT Health Insurance Scheme (FHIS)’s coverage has been limited to about 100,000 enrollees, most of whom are civil servants working with the FCT Administration. Previous efforts to expand the insurance pool by enrolling FCT area council staff—potentially adding 17,000 employees and increasing coverage by 85 percent—have not been successful. Equally challenging is registering people employed in the informal sector.
Beginning in 2018, HP+ began collaborating with the FHIS to improve its operational systems and strategies. First, HP+ conducted a political economy landscape assessment that revealed the need for proper dialogue and negotiation around reforms for funding health insurance schemes. Hence, a strategy meeting was held with chairmen of the FCT’s six area councils to discuss the benefits of the scheme and ways to support area council employees to enroll. After the meeting, the area council chairmen committed to allowing upfront deductions of staff contributions into the scheme. By June 2019, 17,000 area council staff and 30,000 teachers were enrolled across the six area councils.
With the enrollment of area council staff, it is expected that ₦1.5 billion ($4,167,000) would be contributed annually into the health insurance pool and coverage would expand to about 170,140 FCT residents. Moving forward, HP+ will continue providing support to the FHIS on the development of a strategy to increase the number of informal sector workers enrolled in health insurance and increase the amount of funds in the insurance pool.
A Path Forward to Self-Reliance in Health Coverage
For now, these schemes are the most viable and cost-effective path toward universal health coverage for Nigerians. By strengthening local commitments for ensuring equitable access to health services, and with more people enrolled in Nigeria’s state-level insurance schemes, out-of-pocket payments for healthcare services should start to fall. Likewise, Nigeria’s disease burden should improve, with more people having access to preventive and curative care.
The hope is that as states—like Osun and the FCT—that have already adopted insurance schemes continue to improve and produce lasting benefits for enrollees, other states throughout Nigeria will be encouraged to follow suit, building momentum toward a self-reliant and responsive health sector.