The National Health Insurance Scheme (NHIS) was enacted in 2004 to make it affordable for all citizens to have medical insurance, and to provide Nigerians relief from high out-of-pocket spending for health-related services. In 2019 a three-point rebranding was unveiled to improve the transparency and accountability of the insurance scheme, make the organisation result-oriented and accelerate efforts to attain universal health coverage (UHC). The recent National Health Insurance Scheme Strategic Plan 2020-30 highlights that more work will be required to advance in UHC as around 4.2% of Nigerians were covered under social health insurance when it was initially put in place.
As of the first quarter of 2022, 36 states had implemented the basic health care provision fund; however, overall coverage was low, covering approximately 15m Nigerians. According to the NHIS, it would cost around N15,000 ($35.74) to bring each citizen into the health insurance system each year, and as such hundreds of millions of naira will be necessary to cover all non-insured citizens.
In the short term, the majority of Nigerians will still need to finance their health care through out-ofpocket expenditure. The universal health insurance system is based on a prepayment plan that requires members to pay regular fixed amounts to health maintenance organisations (HMOs).
The National Health Insurance Authority (NHIA) Act of 2022 was signed into law in May of that year, thus replacing the NHIS. The new NHIA will collaborate with state-level government health insurance schemes to accredit primary and secondary health care facilities. Unlike the NHIS, the NHIA will make health insurance mandatory for all Nigerian citizens. This is a significant step forwards, as the non-mandatory nature of the previous insurance scheme was a significant obstacle to increasing insurance penetration, especially within the informal sector.
Implementation
According to Section 4 of the NHIA Act of 2022, a governing council will be instituted to perform key roles, including the approval and registration of third-party administrators (such as HMOs), implementing related policies and guidelines, and regulating and supervising the various NHIA health insurance schemes, among other responsibilities. However, as of October 2022 this governing council had yet to be constituted.
Moreover, to reinforce access to UHC for the population, the government will establish a vulnerable group fund to ensure the coverage of 83m Nigerians who do not have sufficient income to afford the premium. For this purpose, vulnerable groups include children under five, pregnant women, seniors, individuals with physical or mental disabilities, and the indigent. However, the lack of precise population data may be an obstacle to implementing the fund’s activities. Moving forwards, it will be important that details related to the NHIA’s enforcement capabilities be clarified, especially regarding non-compliance at the state level with the provisions of the new legislation. The governing council will have discretion over this important area.
Way Forward
For Nigeria to realise its goal of delivering universal health insurance to all citizens before 2030, sustained effort and commitment will be needed by all stakeholders to ensure funding is allocated and delivered. The aims of the NHIA are ambitious, and will require federal and state governments to work together to clarify details regarding funding sources. Coordination and goodwill among all states will also be key to ensure that states establish the corresponding governing councils and decision-making processes to implement the policy goals of the NHIA. Moreover, education campaigns may increase the awareness of the population over the new health regime and may help increase health insurance penetration in a more organic fashion.
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