The National Health Insurance Scheme (NHIS) is a combination of both compulsory and voluntary contributory health insurance schemes targeted at formal sector workers as well as informal sector workers. It aims to ensure access to quality health care services, provide financial risk protection, reduce rising cost of health care services and ensure efficiency in health care. Although formally established in 1999, Nigeria only launched the NHIS in 2005 after several attempts at introducing legislation on health insurance, since the 1960s. Since its launch over a decade ago, NHIS is yet to achieve the aim for which it was established, with less than 5 percent of the Nigerian population, mainly federal government workers and their dependents being covered by the scheme.

According to the National Health Account, government health expenditure as a share of Gross Domestic Product (GDP) is 0.59 percent, government health expenditure as a percentage of total government expenditure is 5.3 percent while out-of-pocket (OOP) expenditure as a percentage of total health expenditure is 72.3 percent. There has been limited progress in addressing the health financing challenge Nigeria faces, and the implementation of NHIS over a decade does little to inspire hope.

In 2017, a spotlight was put on the activities of the NHIS, Health Maintenance Organizations (HMOs) and health care providers (HCPs) in Nigeria, due to the numerous petitions filed by NHIS enrolees with regards to the unsatisfactory health care services provided to them and the inhumane treatment meted out to NHIS patients at hospitals by health workers. This revealed that the management of funds for health care had been fraught with corruption and a lack of transparency and accountability. Despite the disbursement of N411 billion to HMOs by the NHIS since 2005, HMOs were indebted to HCPs across Nigeria to the tune of N2.276 billion, and NHIS enrolees continue to be at the receiving end of this massive corruption with lack of improvements in their health status. Enrolees who together with their employers make these financial contributions are unsatisfied with the services they receive, and in fact most NHIS enrolees complain that they are treated badly at hospitals by health workers because of the indebtedness of HMOs to hospitals.

NHIS as an implementing and regulatory organization has also suffered from ineffective leadership, lack of succession planning and a poor governance structure over the years. This is why investments in the scheme have not resulted in equitable access to health care and improved health outcomes for NHIS patients. Nevertheless, some states have begun to develop their own health insurance schemes. This is a welcome development, considering the fact that the health insurance scheme was made optional for states under the NHIS Act. However, these states might also run into the same problems that currently bedevil the NHIS, if the design and implementation of State Social Health Insurance Schemes (SSHIS) are not well thought out and/or applied in context-specific ways, with the assistance of health financing and health systems experts. The current arrangement where states send their financial contributions/premiums to the central pool of the NHIS is not only inefficient, it also creates unnecessary bureaucracy.

The Director General of WHO, Dr Tedros Adhanom Ghebreyesus during his working visit to Nigeria affirmed that sustained political will and commitment are key to achieving UHC in the SDG era. While the 2014 Presidential Summit on UHC, the 2018 Health Policy Dialogue on UHC and the launch of the Basic Health Care Provision Fund (BHCPF) under the National Health Act (NHAct) of 2014 show that Nigeria supports the objectives of UHC; the implementation of NHIS which is critical to making UHC a reality leaves much to be desired. Despite its inefficiencies and pervasive corruption, NHIS as an implementing and regulatory organization is expected to manage 50 percent of the BHCPF for the provision of basic minimum package of health care services for the citizens. There is therefore, a need to re-examine its design and implementation, if the over 90 percent of the Nigerian population who lack any form of health insurance coverage must be catered for. Below are a few recommendations for tackling the issue.

First, health insurance must be made mandatory for states and all citizens as part of the amendment of the law establishing NHIS. States should desist from sending their premiums into a national pool while making the SSHIS independent of the NHIS. Furthermore, NHIS enrolees deserve better treatment by health workers in order to improve their health outcomes. The design of an effective feedback system where patients can report inhumane treatment of health workers and the development of disciplinary actions against any health worker found guilty would help address this problem.

In addition to this, the governance structure of NHIS must be strengthened while the issue of corruption as well as lack of transparency and accountability in the health sector which impede health care reforms must be tackled by political actors and policy makers, if Nigeria wants to the improve health status of its population. Closing the loopholes that exist in the health sector through innovative technologies is critical, so as to discourage corrupt individuals and groups that are bent on undermining health system strengthening in Nigeria.

Finally, there is a need for strong and effective public health leadership to ensure that the NHIS as an implementing and regulatory agency plays its role in helping to provide UHC to Nigerians. While the sustained implementation of the BHCPF under the NHAct has the potential to improve access to basic health services, it is also important to increase government health spending as a percentage of general government expenditure from the current average of 4 percent to the international benchmark of 15 percent as well as increase government health spending as a percentage of the GDP from less than 1 percent to at least 5 percent.

The declaration on UHC by governments and policy makers in Nigeria since 2014 must move beyond rhetoric into reality, and UHC must be pursued with vigour at both national and sub-national levels in order to ensure access to quality health care services, and improve financial protection.

The key drivers of disharmony and unhealthy rivalry among health professionals in Nigeria include among others, the struggle for the most important profession in health care, with some health professionals claiming superiority over others; the struggle for leadership positions; and the disparity in remuneration of health workers. The problem has been allowed to fester for decades without adequate intervention by policy makers and the government.

Over the years, medical doctors have laid claim to the leadership of Federal and State Ministries of Health, as well as other health institutions/agencies, and it is believed that the status of consultant is the exclusive preserve of doctors which non-medical health professionals cannot aspire to. Furthermore, evidence suggests that there is wide disparity in the remuneration of health workers of the same grade level across the federal, state and local governments, as well as in the remuneration of health workers of different professions. In addition to this, there is a widespread belief among other health professionals, that the Nigerian health system is designed to favour medical doctors, who due to their perceived autonomy and authority over other health professionals continue to dominate. The Joint Health Sector Union (JOHESU) was set up to challenge this dominance.

The medical, non-medical health professional dichotomy has been a major hindrance to the effective delivery of health services and the development of the health system and health services are often disrupted as a result of this battle for supremacy. This affects poor and vulnerable populations who must rely on public health facilities, the most, as the unaffordability of private health care services means that such people cannot access healthcare when public health facilities are shut down. Those that seek care either engage in self-medication or patronize traditional healers and alternative medicine dealers, and many have died as a result of this.

Efforts to reduce health inequalities and improve health outcomes must prioritise addressing the drivers of disharmony and unhealthy rivalry among health workers and preventing the strikes that are due to this petty rivalry among health professionals.First, equal opportunities to leadership positions must be provided for all qualified professionals, medical or non-medical and the pay and remuneration gap must be closed or at least reduced significantly. Second, the notion that medicine is the most important profession in health care must be changed; behavioural change communication efforts should focus on the key message that all professional groups are important in the delivery of health care services. Making these key two changes would be a first good step to addressing the issue.

A strong health workforce is critical in accelerating progress towards Universal Health Coverage (UHC) as a target of SDGs (Sustainable Development Goals) and increasing equity in access to quality health care services without financial hardship. This is of particular importance for the almost 70 per cent of the Nigerian population who live below the poverty line and suffer inequitable access to health care services. The SDGs focus on ensuring that no one is left behind and a strong health workforce that is able to work together to deliver patient-centred health care is one way of ensuring this.

It is myopic for some health professionals to claim superiority over other health professionals, since doctors, nurses, midwives, pharmacists, physiotherapists, laboratory scientists, community health workers, health economists, public health specialists and health managers all have a stake in addressing the health challenges Nigeria faces. A united health workforce is critical to strengthening the Nigerian health system which has over the decades been weakened considerably.

This blog post argues against a reliance on external funding for health projects, and suggests that while it is an important resource for financing in the Nigerian health care system, domestic resources must be prioritised and increased in the long-term.

Past experience of similar initiatives; the Pre-paid Health Scheme Pilot and Second Health System Development (HSDP II) for example, have demonstrated the danger of throwing money at public health challenges, particularly through additional finance sourced from financial organizations such as the World Bank. These interventions have not translated into better functionality of PHC facilities and improved health outcomes, because many states have over the years misused funds from such projects.

Yet, Nigeria continues to make annual repayments on these debts, with nothing substantial to show for it. The World Bank confirms that Nigeria has made limited progress in improving its health indices over the years, despite securing about 28 credit approvals, amounting to billions of dollars on different projects for the health sector from the World Bank in over two and half decades.

Even more troubling, is the news from the recently published report on SMOL which revealed that many states had performed poorly. This raises the question of whether the initiative is capable of removing barriers to health care services, and providing protection against the financial burden and impoverishment that results from seeking care. Of particular concern are vulnerable people such as pregnant women and children, who are facing financial barriers to accessing PHC services, which  could explain the poor performance recorded on the SOML indicators of maternal, new-born and child health. Some of the roadblocks to the success of the initiative have been a lack of political will, poor governance, poor financial management, and a lack of transparency and accountability.

Using loans to fund health projects shows a lack of political will on the part of governments to increase public spending on health and invest in health of the people. For instance, the PHC system in Nigeria has been bedevilled by poor budgetary allocation; it is estimated that the Federal Government budget decreased from 8.4% of total spending in the health sector in 2012 to 4.7% in 2015. It also, crucially, sometimes, shows an inability to successfully generate tax revenue, as is the case in Nigeria where in spite of the potential of using taxes to fund the health system, successive governments have not been able to improve total tax revenue as a percentage of Gross Domestic Product (GDP) beyond the current 1.6%.

In order to resolve this fundamental issue the government should increase the tax base. It should also improve efficiency in the use of resources and employ external aid in a prudent manner.

Increasing public spending and investing in health is vital for economic development, however, the financial sustainability of health systems can only be guaranteed when future funding is not constrained by huge debts from loans.