Over the past decade Nigeria’s government has launched a variety of initiatives aimed at boosting awareness of the many benefits of insurance coverage among the general population. Perhaps the most ambitious of these plans is the National Health Insurance Scheme (NHIS), under which the state aims to provide universal health coverage across the country. Established in 2005, the programme’s initial target involved achieving 30% health coverage by 2015. However, by 2013 only around 3% to 7% of the country’s total population was enrolled in the programme, and the state was forced to temper its earlier forecasts. In 2015 and 2016 the new administration has worked to renew its commitment to the plan, developing new implementation timelines and partnering with the private sector to facilitate better access to care among low-income Nigerians, in particular. At the same time, the recent launch of the National Mobile Health Insurance Programme (NMHIP), which allows Nigerians to sign up and pay for health coverage on mobile handheld devices, has the potential to generate a significant uptick in health insurance participation in the future.
Long Planning Period
Under the 1999 NHIS Act, the government required NHIS registration for all federal government employees and all private sector firms with a workforce of 10 or more employees. While reliable, up-to-date data as to NHIS enrolment was not available at time of publication, estimates put the total number of enrollees at between 3% and 7% of Nigeria’s population as of 2013, for instance, which was equal to 5m-12m people in total. The bulk of these members are federal employees. As of 2013 some 98% of the federal employee workforce had been successfully registered in the programme, while an additional 2m private sector workers had also joined the scheme.
Hurdles To Growth
The low uptake stems from a variety of factors. First, while the 1999 NHIS Act mandates that federal employees join the programme, it does not require that state employees – who significantly outnumber the federal public sector workforce – to take part. Furthermore, a substantial percentage of Nigeria’s private sector companies do not formally register their employees with the government, preferring instead to pay employees under the table so as to avoid paying taxes and other related fees.
This development is unsurprising, as 90% of jobs in Nigeria are found in the informal sector. Thirdly, and perhaps more importantly, according to local press the NHIS has been underfunded since its launch in 2006. The scheme was initially designed to be financed primarily by its participants and by private sector employers: NHIS beneficiaries are expected to cede a small percentage of their salaries – between 1% and 2% – while their employers contribute a slightly larger amount.
These contributions are theoretically expected to cover the cost of operating the programme, with enough left over to pay for NHIS subscribers’ care. In practice, however, to date the plan has been financed almost exclusively by the government, due to poor enforcement of mandatory contributions. The vast majority of civil servants enrolled in the scheme since 2006 have not paid the 10% mandatory contribution to the federal government, and have faced no consequences.
This has forced the country’s new government to dip into its own coffers to fill the gap. Under the government’s 2016 budget, health expenditure was budgeted at N257.3bn ($812.3m), of which just N2.5bn ($7.9m) was formally allocated to NHIS operations. This latter figure, which accounts for just under 1% of total health spend, is widely regarded as insufficient to support the NHIS in its short- or long-term strategic goals. The programme has also had to grapple with limited awareness among the broader Nigerian population of the benefits of health insurance, as well as allegations of inefficiency and, more seriously, corruption.
In August 2016 the NHIS saw a leadership shake-up, which resulted in the appointment of a new executive secretary of the programme, Usman Yusuf. Upon taking office Yusuf announced that corrupt practices were preventing the health scheme from extending to the general populace. As an example, he cited cosy ties between health management organisations (HMOs) and politicians. Yusuf has vowed to curb endemic corruption through the use of advanced technology, and told local media that he expected HMOs to pay back ill-gotten funds to the government.
In recent years the NHIS has targeted a number of new segments of society for inclusion in the health care scheme. In December 2015 the organisation announced that it planned to add a minimum of 40m new participants to the scheme in 2016, including students enrolled in public primary schools, pregnant women and new mothers who seek care at public health facilities, internally displaced persons, and poor Nigerians, among others. Yusuf said in August 2016, “Special attention [will] be accorded to supporting the poor and the vulnerable in the informal sector to be able to access efficient health care without financial constraints.”
The NHIS has moved to implement these goals on a number of fronts. Under the State Supported Social Health Insurance Programme, the NHIS aims to partner with individual Nigerian states to provide comprehensive coverage at the state level. The programme, which requires states to enact local laws to set up their own health agencies at the state level, had attracted participation from a range of state houses of assembly, including those situated in Lagos state and Ekiti state, among others. Unlike previous iterations of this plan, many of which have sought to mandate NHIS participation among state employees, the new version of the plan allows states to run their own, semi-autonomous health insurance schemes, while still benefitting from NHIS support. “We are now decentralising the operations of the NHIS down to the state level,” Femi Akingbade, the acting executive secretary of NHIS at the time, said in an interview with local media in mid-2015. “We are saying keep your money in your states, run your agencies, man it with your own people, and we also give you a perk by adding counterpart funding to whatever funds you provide at the state level.”
Another key development currently under review at the NHIS is the NMHIP, which was initially rolled out in 2014 and formally launched in early 2015. Developed in conjunction with Nigeria’s four dominant mobile telecommunications operators – namely the South African firm MTN, the domestically owned Globacom, the UAE’s Etisalat and the Indian company Bharti Airtel – the plan involves operators selling pre-paid, low-cost health insurance plans on users’ mobile handsets, with most interactions taking place via texts. MTN, which ran a pilot version of the plan in mid-2014, partnered with local health management organisations to provide micro-insurance coverage to its subscribers on an opt-in basis. The plan enables the NHIS to focus on further boosting its user base from afar. Indeed, prior to the development of the NMHIP, the scheme registered new users manually, which is to say face to face. This was a major limiting factor given the size of Nigeria’s population and the percentage of that population that lives in remote rural areas.
Under the new mobile-focused programme, meanwhile, the NHIS has access to a total subscriber base of nearly 150m mobile telecoms users. Should even a relatively small percentage of this total register with NHIS, the scheme has the potential to double or triple in size in the coming years. As of mid-2016 the NHIS was working with the four large mobile operators to develop their insurance offerings for widespread uptake across Nigeria.