Nigeria has since her independence in 1960 had very robust verbiage or policies by successive governments on health care reforms but with very little progress or success recorded in what might well be a lack of political will in reforming the health sector.
Over 90% of the Nigerian population is without health insurance coverage. The inability to effectively address the country’s numerous public health challenges has contributed to the persistent and high level of poverty and weakness of the health system.
Political instability, corruption, limited institutional capacity, and an unstable economy have also been major factors responsible for the poor development of health services in Nigeria. Households and individuals in Nigeria bear the burden of a dysfunctional and inequitable health system – delaying or not seeking health care and having to pay out of pocket for health care services that are not affordable.
The health challenges of the country include:
National Health Insurance Scheme (NHIS),
National Immunisation Coverage Scheme (NICS),
Midwives Service Scheme (MSS)
Nigerian Pay for Performance scheme
After many attempts at implementing legislation on health insurance since 1960, NHIS, although established in 1999, was eventually launched only in 2005 with the goals to ensure access to quality health care services, provide financial risk protection, reduce rising costs of health care services and ensure efficiency in health care through programmes such as the: Formal Sector Social Health Insurance Programme (FSSHIP), Mobile Health, Voluntary Contributors Social Health Insurance Programme (VCSHIP), Tertiary Institution Social Health Insurance Programme (TISHIP), Community Based Social Health Insurance Programme (CBSHIP), Public Primary Pupils Social Health Insurance Programme (PPPSHIP), and the provision of health protection services for children under 5 years, prison inmates, disabled persons, retirees and the elderly.
The NHIS was expected to provide social and financial risk protection by reducing the cost of health protection and providing equitable access to basic health services with the most vulnerable populations in Nigeria including children, pregnant women, people living with disabilities, elderly, displaced, unemployed, retirees and the sick.
Free health protection services and exemption mechanisms are expected to provide financial risk protection for the most vulnerable populations but evidence suggests that they are ineffective and have failed to achieve this aim.
The maternal mortality ratio for Nigeria remains quite high at 814 per 100000 live births according to 2016 World Health Statistics. Across the country, pregnant women and children under five years are generally charged fees when accessing health care services, despite the federal government’s declaration of free health for pregnant women and children under five years in 2005.
The Minister of Health, Professor Isaac Adewole in 2016 announced the Federal Government’s plan to provide free health services to 100 million Nigerians in the next two years. Under this new health agenda, pregnant women across Nigeria are expected to enjoy free maternal and delivery services at the primary health care (PHC) level.
Unfortunately, Free health care services and exemption mechanisms often arise as campaign promises of political actors to the electorate and fall short in meeting the health needs of the most vulnerable populations. According to the Nigeria Demographic Health Survey (NDHS) in 2013, over 60% of pregnant women aged 15-49 deliver their babies at home without any antenatal care visits. In rural areas, this value reaches 76.9%. The situation is critical in the North East and North West regions of Nigeria where over 79% of pregnant women age 15-49 deliver their babies at home. Over 60% of pregnant women in Bayelsa, Plateau, and Niger deliver at home rather than a health facility.
The cost of health care and the low quality of care by the public have been argued to be the reason for the poor utilization of maternal and child health services in Nigeria.
In addition, health spending in Nigeria is low and this is responsible for the over-reliance on out of pocket payments for health protection services.
Despite its launch in 2005, NHIS covers less than 10% of the Nigerian population leaving the most vulnerable populations at the mercy of health care services that are not affordable. This means the most vulnerable populations in Nigeria are not provided with social and financial risk protection. Poor people constitute about 70% of the Nigerian population. They lack access to basic health services, which social and financial risk protection should provide because they cannot afford it.
CBSHIP was expected to meet their health needs as well as provide social and financial risk protection to this group, which mostly reside in rural areas. As evidenced in the high rate of out of pocket payments for health care services, poor people financially contribute more to health care than official care and funds programs in Nigeria. Out of pocket payments for health care services limit the poor from accessing and utilizing basic health care services.
The quality of health protection services delivered is poor and remains a huge source of concern. Most of the PHC facilities that are supposed to meet the health needs of the poor and rural dwellers are in a poor state due to poor budgetary allocation.
In trying to solve these issues, healthcare in the country must be tackled headlong in order to stem the deteriorating development therein, which could portend grave danger for citizens of the country in the not-distant future.
Policy makers and political actors need to devise health care reforms to address the lack of social and financial protection for the poor and vulnerable populations. Part of this reform is the expansion of the NHIS. States should be mandated to provide health insurance coverage to all residents. Making health insurance optional for states over the years have affected the ability of the NHIS to increase the level of coverage for the people.
While the mandatory CBHI scheme is being scaled-up as a supplementary measure, state governments should enroll poor residents in a private health insurance plan and bear the responsibility of paying the monthly premium per person to Health Maintenance Organisations (HMOs). It is not enough to have a national health insurance policy, it is important to ensure that health insurance coverage is provided to the poor and most vulnerable populations as a matter of the human right to health.
Although the NHIS Act made provision for children, who constitute the largest population in Nigeria, many children still have to pay for health care services in spite of being born into poor families that do not have the ability to pay for health care services and suffer financial hardship as a consequence. The free health policies and exemption mechanisms provided by some states, targeted at children, pregnant women and the elderly, are not social and financial risk protection policies, as these groups are largely responsible for the cost of health care with the free health care program barely covering their basic health care services.
Another way of providing social and financial risk protection for poor and vulnerable populations is by establishing a legislative framework for a UHC scheme and setting aside funds for it. Evidence from Thailand has shown the effect of UHC schemes through PHC on expanding access to health care for the poor and vulnerable populations.
Political actors, policymakers and all stakeholders in the health sector should establish a government-funded social and financial risk protection scheme through a general tax financing system for the poor and vulnerable, and invest in basic infrastructure for health care in rural areas for quality health care service delivery. UHC schemes are important in addressing the problem of poor coverage, limited access to health care, and poor quality of health protection services.
Nigeria is yet to adopt innovative ways to protect the poor and vulnerable populations against the financial risk of ill health. It is important to guarantee by law the right to health care of all citizens in Nigeria. Although the National Health Act (NHA) that was signed into law in 2014 stated that all Nigerians are entitled to a basic minimum package of health care services, it is not clear if the provisions made in the NHA are capable of achieving UHC in Nigeria. In addition, the NHA is yet to be implemented over two years after its signage into law.
Some low- and middle-income countries (LMICs) have been able to provide social and financial risk protection schemes for poor and vulnerable populations as a matter of the human right to health. Therefore, there is a need to provide social health protection schemes targeted at these groups in Nigeria. The poor and vulnerable populations should not become impoverished because of failure to obtain much-needed health care services. Governments must reduce out of pocket payments for health care services by households through the adoption of a tax-financed non-contributory UHC scheme.