On mandatory health insurance in Nigeria

THE Federal Government recently made progress in the health sector by repealing the National Health Insurance Scheme Act 2014 and enacting the National Health Insurance Authority Act 2021. The goal of the Act is to ensure effective implementation of a national health insurance policy that ensures the attainment of universal health coverage in Nigeria. For decades, stakeholders in the health sector have clamoured for the implementation of universal health coverage to make it mandatory for all Nigerians irrespective of their status in the formal and informal sector to be captured in any form of prepaid health insurance package. This became necessary given the fact that 70 per cent of Nigerians incur out-of-pocket expenses on health. When citizens are not covered in any form of prepaid insurance, they are left with no option but to pay for every health related service incurred. Out-of-pocket expenditure contributes largely to the poor health indicators and mortality rates in Nigeria.  In a society with scarce resources and competing needs for survival, out-of-pocket expenditure leaves families with the choice of taking care of their emerging health needs and satisfying other basic necessity such as education, food and shelter. When compared with other countries in sub Saharan Africa, Nigeria’s out-of-pocket expenditure is high. Countries like Angola, Benin, Burkina Faso, Cote D’Ivoire, Gabon, Kenya and Rwanda all have lower out of pocket expenditure than Nigeria.

The Sub Saharan African average is 29.98 per cent as against Nigeria’s 70.52 per cent. With the recently signed law, 80 million vulnerable Nigerians, including the elderly, children, pregnant women and persons living with disabilities are entitled to free health insurance coverage under the vulnerable group fund. States are to enjoy these funds with the establishment of their own compulsory state health insurance scheme. The law also provides that every person resident in Nigeria shall be required to obtain health insurance. S. 14 (2) of the Act provides that nothing under this Act shall preclude a resident in Nigeria from obtaining private health insurance provided such a person  participates in any state mandated health scheme. The implication of this section is that health insurance is mandatory for all residents in Nigeria.

Nigerians should applaud the new law given its huge benefits. First, beyond reducing the out of pocket expenditure, it will serve as a huge resource mobilisation for the health sector. The health sector has historically suffered from the dearth of resources. For the past 10 years, Nigeria’s budgetary allocation to the health sector has hovered between 3 to 5 per cent of the total national budget. Considering the huge demands for health commodities, infrastructure and human resources for primary, secondary and tertiary healthcare, the budget has been invariable low. The budget for the health sector also negates the Abuja declaration of 15 per cent of the total budget for health. Again, Nigeria falls amongst countries with the lowest allocation for health in the sub-Saharan region. The minimum allocation for health in most countries in sub-Saharan Africa is 7 per cent, whereas some countries in Africa allocate 15 per cent of their budgets to health. Prepaid insurance is a pool of funds which would aid investment in the health sector and provide for the much needed health commodities, infrastructure and human resources.

Secondly, the new law will boost the country’s attainment of the Sustainable Development Goal 3, which seeks to promote good health and well-being for all at all ages. It will increase universal health coverage from its current ratio of less than 5 per cent of the population to at least 70 per cent of the population.  However, for the Health Insurance Authority Act to be effectively implemented, the operational guidelines should be quickly developed. The guideline should provide key directives on mandatory enrollment and coverage of all citizens under any of the prepaid health schemes. The possession of a health insurance identity card or certificate by citizens should be considered as necessary requirements to derive certain benefits from the government. Health facilities should be properly equipped and they should be manned by trained medical personnel who would respect the rights of patients. The equipping of facilities with professional treatments of citizens would serve as an incentive for Nigerians to key into the scheme.

Recent interactions with stakeholders on the evolvement of health insurance coverage in Sokoto State, shows the willingness of citizens in the formal sector to key into the prepaid health scheme of the state. The state has succeeded in enrolling vulnerable citizens into its health insurance scheme under the Basic Health Care Provision Fund but citizens in the formal sector feel left behind. The Federal Government should work with sub-national governments to ensure that the right categories of people are enrolled under the vulnerable group fund without leaving those in the formal sector behind. Stakeholders in charge of implementation of the law should be open and accountable to the public. Civil society organisations should set up an accountability framework to monitor the implementation of the new law.

• Emejuiwe, a/public affairs analyst, writes in from Abuja’

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