THE NATIONAL HEALTH INSURANCE AUTHORITY OF NIGERIA AND IMPLICATIONS FOR UNIVERSAL HEALTH COVERAGE

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D.A. Adewole

Department of Health Policy and Management, College of Medicine, University of Ibadan

Abstract

Background: The National Health Insurance Scheme (NHIS) of Nigeria was established in the year 2005. The overall objective of the scheme was to enhance access to quality healthcare for all and minimize catastrophic health expenditures. However, since inception, the population coverage has been less than ten percent of the total. Very recently, the National Health Insurance Authority (NHIA) of Nigeria was enacted, which concomitantly repealed the NHIS Act. This article examined the design of the NHIA and other factors outside of the scheme but in the health system of Nigeria, in comparison to similar schemes in other settings. Finally, the newly implemented NHIA and the gaps it seeks to fill were examined.

Methods: Relevant literature extracted from databases such as PubMed, Google Scholar, and the ordinary Google website was reviewed. Findings from these sources were triangulated and used to write the manuscript.

Results: Compared with social health insurance schemes in other settings, the current population coverage under the NHIA of Nigeria is poor. Some of the factors that contributed to the poor performance of the NHIA were the features of the design of the scheme, which run contrary to the design of the majority of social health insurance schemes in other countries. In addition to this, the primary healthcare level that is most widespread in many countries and that was made use of as service providers in other social health insurance schemes was not made use of under the NHIA. In addition to these, and unlike in other settings, membership in the NHIA has been on a voluntary basis until very recently, when it was made mandatory.

Conclusion and recommendations: Presently, population coverage under the NHIA is very poor. The informal sector, especially in rural settings, is mostly at a disadvantage. This is unlike in the majority of other countries, which encourage population coverage across both the formal and informal sectors. Stakeholders in the health insurance industry are encouraged to make the scheme mandatory and enforce it. The PHC facilities should also be engaged as service providers under the NHIA

Keywords: National health insurance authority, Primary healthcare, Universal health coverage, Health maintenance organization.

Introduction

In Nigeria, the NHIA of 2022 was signed into law to repeal the NHIS Act of 1999. The NHIS was the social health insurance scheme (SHIS) through which the country had planned to achieve universal health coverage (UHC). The core objective of the NHIS was to facilitate equitable access to healthcare in Nigeria. However, participation in the NHIS is voluntary; financial contribution to the scheme comes only from the employer (mainly the federal government for its employees); that is, enrollees do not contribute the expected counterpart fund. 1 The NHIS partners with other actors in both the public and private sectors, such as health care providers and health maintenance organizations (HMOs), in its operations. The HMOs were the only third-party administrators and intermediaries to facilitate claims between the insurer and the insured. This also includes the administration of claims, the collection of premiums, enrollment, and other administrative activities.2

While the NHIS provides policy direction and licenses the HMOs and health care providers, the HMOs purchase health care services from the NHIS-accredited health care providers. Of the three levels (primary, secondary, and tertiary), only the primary level of care was not licensed to provide care under the scheme. The two accredited levels of providers serve as primary care providers (first contact facilities). The tertiary level of care is also designated as a referral level of care for the secondary level of care. Thus, patients could be referred from the secondary healthcare facilities to the tertiary-level facilities.1

Even though there are variants of SHIS in different countries, what is common to the majority of SHIS is the fact that enrollees pay wage-based, non-risk-rated contributions on a regular basis. In addition, there is the presence of the insurer, who, on behalf of the scheme, purchases and pays for health care services rendered by providers to enrollees. In addition, enrollment in the scheme is compulsory for individuals.

The employer contributes a fixed percentage of the total fee for each individual employee in its workforce.³ Globally, membership in a SHIS is made mandatory for the majority of the whole population except for individuals on high incomes in some countries, such as Germany and the Netherlands, who are allowed to buy private health insurance policies.^3,4 However, under the Act that established it, membership in the NHIS is voluntary.¹ This is unconnected with the political structure and the constitution of Nigeria, which, as it exists in the USA, is a federal, presidential system of government whereby the sub-national levels of government have some degree of autonomy regarding policies in certain sectors, including the health system.⁵

Thus, when the national government introduced SHIS, the majority of the enrollees were formal sector employees (of the national government). However, the states and the local (sub-national level) governments did not accept the idea to participate,⁶ while the informal sector was largely left out of the scheme for a lack of an efficient platform to enroll and collect premiums from that population group. This is a common challenge in other developing countries.⁴ In addition, the Nigeria Labour Congress, the national labour union of the formal sector employees, refused its members to pay the counterpart contribution of the premium from the inception of the scheme until the present time.¹ Consequently, funding for the scheme comes from only one source: the national government.

Thus, the scheme in Nigeria did not meet all the criteria of a viable SHIS, and therefore, in reality, the scheme is a quasi-form of social health insurance, which is one of the reasons it has performed poorly. This article examined the design of the NHIS and other factors in the health system of Nigeria in comparison to similar schemes in other settings. Finally, the newly implemented NHIA was examined. Conclusions and recommendations were made.