Operationalizing Universal Health Coverage In Nigeria Through Social Health Insurance Insurance nigeria
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Niger Med J. 2015 Sep-Oct; 56(5): 305–310.
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Abstract
Nigeria faces challenges that delay development toward the attainment about the nationwide government's declared goal about universal condition treatment (UHC). One such challenge is system-wide inequities resulting from shortage about financial protection for the condition care needs about the vast majority about Nigerians. Only a minute share about Nigerians have prepaid condition care. In this paper, we draw supported by existing evidence to recommend steps toward reforming condition care funding inside Nigeria to achieve UHC via social condition insurance. This article sets out to demonstrate that a workable path to UHC via expanding social condition insurance exists inside Nigeria. We argue that encouraging the states which are semi-autonomous federating units to system including manage their own insurance schemes presents a unique opportunity for rapidly scaling up prepaid treatment for Nigerians. We show that Nigeria's combined structure which prescribes a sharing about responsibilities for condition care among the three tiers about executive presents serious challenges for significantly extending social insurance to uncovered groups. We recommend that rather than allowing this government structure to impair development toward UHC, it should exist leveraged to accelerate the process by supporting the states to establish including manage their own insurance funds while encouraging integration with the National Health Insurance Scheme.
Keywords: Health financing, social insurance, universal condition coverage
THE NIGERIAN HEALTH SYSTEM
Nigeria is a lower middle-income country with a people about 174 million including a gross domestic product about 522 billion US dollars.1 Nigeria is a federation about 36 states including a combined capital territory, including there are 774 local executive areas (LGAs) over the country. The condition care system is largely public sector driven, but there is substantial private sector involvement inside the giving about condition services. There are more than 34,000 condition facilities, 66% about which were owned by the three tiers about executive (federal, state, including LGAs).2 The minor including tertiary level condition facilities are mostly start inside urban areas, whereas agricultural areas are predominantly served by chief condition care (PHC) facilities. The combined executive owns numerous about the tertiary level condition facilities as well as some minor condition facilities which are operated by combined agencies. Each nation hosts at least single federal-owned tertiary condition facility. Most about the publicly owned minor condition facilities are owned by the states. In not long past times, there has been a push toward mutual ownership including administration about PHC facilities by the states including local governments; the principle about “PHC Under One Roof.”3 Private for-profit including private nonprofit condition facilities give primary, secondary, including tertiary care around the country. Preventive condition care is largely led by executive departments including agencies, but and by nongovernmental organizations. Table 1 presents areas about responsibilities for condition care by the dissimilar tiers about government.
Table 1
A simplified example about sharing about condition care responsibilities by tiers about executive inside Nigeria
The combined executive provides broad ranging help to states including local governments supported by condition program planning including implementation.4 Health policy-making including nationwide condition care priority setting are the responsibility about the combined government.5 The responsibility for setting lowest standards for the training including licensing about condition workers and lies with the combined government. Agencies about the Federal Ministry about Health (FMOH) regulate the activities about the dissimilar condition professional groups including can punish errant practitioners. The FMOH regulates pharmaceuticals including food products via a dedicated agency. The National Health Insurance Scheme (NHIS), an agency about the FMOH, regulates condition insurance, as well as accredits Health Maintenance Organizations (HMOs).6 The combined executive sets lowest infrastructure including service standards for condition facilities, but enforcement is usually done by both combined including nation authorities. However, the licensing about each condition facility is the responsibility about the nation where the facility is located.
Health care inside Nigeria is poorly funded. Government payment supported by condition as a percentage about total executive payment was an average about 7.2% from 2008 to 2012.7 In the same period, outer resources for condition as a percentage about total payment were 5.3%. With private prepaid plans as a percentage about private payment supported by condition at only 3%, private out-of-pocket payment as a percentage about total payment supported by condition amounted to nearly 70% inside 2012.7 National revenues from taxes, crude oil exports including more sources are shared among the three tiers about executive including each nation determines what share about its allowance to allocate to condition according to its priorities. Most states and hold including allocate local executive funds according to nation priorities. The NHIS provides condition insurance treatment for employees about the combined government. HMOs do something as purchasers below the NHIS including compensate providers by a mix about capitation including fee-for-service; there is and a 10% coinsurance.6 Public sector condition facilities are not-for-profit, thus the cost to the user about their services is usually less than those about the private sector, but those services are generally perceived to exist about broke quality.8,9
Inefficiencies including inequities inside the Nigerian condition system
Health care resource allowance inside Nigeria is skewed inside favor about minor including tertiary care as against chief care including PHC.10,11 A direct consequence is that most people bypass PHC facilities to seek chief care at minor including tertiary facilities.11 This situation is both wasteful including promotes inequities: The cost about chief care giving at minor including tertiary level is higher (economically inefficient) including broke people, especially inside agricultural areas, cannot access care as it is either not available or as well expensive for them (inequity inside access including payment).12,13 Distribution about the condition workforce inside Nigeria is and skewed inside favor about minor including tertiary facilities placed inside urban areas as incentives for condition workers to accept agricultural postings are often nonexistent or poorly applied.10 The executive does very little to control the geographic point about condition facilities by both private including public sector owners leading to allocative inefficiency: Overprovision inside some areas while more areas are not covered. The absence about social security for vulnerable groups, regressive taxation, broke planning including targeting about public funding for health, corruption, including shortage about coordination over the three tiers about executive everything contribute to condition inequities.
Expanding social insurance inside Nigeria — the path to universal condition coverage
Health insurance arose from the uncertainty including future for financial ruin about unwell health.14 People tend to exist risk averse including are, therefore, willing to forego part about their income to purchase the assurance that they determination exist protected from devastating condition expenditure. Health insurance operates supported by the basis about the willingness about individuals with similar aspirations (protection from the risk about impoverishment by illness) but varying probabilities about unwell condition to contribute funds (premiums) to a pool. The insurance swimming pool thus spreads the financial risk about unwell condition among the insured population. The larger the pool, the more sustainable it determination exist as transaction costs tend to decline including risk is more evenly spread. The benefits about condition insurance can exist missed if steps are not taken to mitigate causes about insurance market failures such as information asymmetry, moral hazard, cream skimming, including adverse selection by market actors. Health insurance can take the form about private, social, community-based, or tax-based systems.15 Most countries that have made appreciable development toward universal condition treatment (UHC) implemented some form about government-led condition funding reforms.16 Many about these countries, over everything income levels, did thus by adopting social condition insurance based supported by the Bismarck model.17,18,19
Nigeria has aligned itself with the global push for universal access to quality condition care devoid about risk about financial catastrophe.16 A vital feature about “protection from devastating expenditure” is the availability about prepayment for condition care costs [Figure 1]. At present, only on 5% about Nigerians have prepaid condition care via social including voluntary private insurance.20 Whereas the NHIS including private insurance has gained sufficient traction inside if treatment to combined public sector workers, their families including workers about large private organizations, the large majority about Nigerians are wanting a scrap of form about coverage. This situation has made the aspiration for UHC difficult to attain. State governments have been slow inside the uptake about social insurance regulated by NHIS as they feel excluded from the scheme.21 Expanding treatment including minimizing out-of-pocket payment primarily via greater combined executive condition care funding is not a real proposition given Nigeria's income status, including more important, the autonomy that the constitution gives the states to determine their condition care priorities including spending choices.22
Three-dimensions to see when moving toward universal treatment WHO 2010
The foregoing presents the rationale for the proposal put forward here for reforming condition care funding inside Nigeria as a prerequisite for development toward UHC. We propose a shift away from the federal-led social condition insurance plan toward leveraging the constitutional autonomy enjoyed by the states to reach social insurance treatment to residents about each state.
STATE-LED SOCIAL INSURANCE SCHEME
According to projections from the 2006 census, states inside Nigeria range inside people from on 2-11 million.23 Nearly half about the people are inside the 15-64 year age range.24 These demographic characteristics present the states with a large swimming pool about people inside employment wanting condition insurance. Central to this procedure report/recommendation is that states exist encouraged to system including manage their own insurance funds. Specific steps are as follows:
Establishing a nation fund
The combined government, via NHIS, should give technical help to states to system nonprofit nation insurance funds inside order to scale up social insurance treatment to public sector workers employed by the states. Support from NHIS determination include great actuarial studies including resolution about the content about use package including cost-effectiveness (including thresholds). The reserve should and mark the relaxed sector inside a progressive manner via cooperative societies including religious groups.15 When the plan is completely operational including adequate sensitization including consultations have been held with the relaxed sector groups, participation inside the plan can exist made a prerequisite for benefitting from more executive services. For example, parents may exist required to produce evidence about registration with the plan earlier than their children can exist enrolled inside schools; or earlier than they can open or continue to operate their bank accounts. When strictly enforced, such tough tactics have proven very effective inside Nigeria: This was demonstrated inside the not long past voter registration exercise including the validation about bank accounts.
Revenue collection including pooling
As inside the NHIS, the premiums for nation public sector workers determination exist paid inside part by the workers including by their employers (the nation government) based supported by income. The state-led social insurance plan (SSIS) shall manage the pooled funds. We recommend that states which are willing to enter the combined swimming pool managed by NHIS exist encouraged to do thus while retaining their role as a purchaser inside their respective states. Premiums for relaxed sector workers may exist a set sum or determined by more analysis mechanisms. In supplement to premiums, the nation may need to give extra funding to the plan via direct budgetary allowance especially inside the early days about the SSIS. To guarantee risk sharing including minimize adverse selection, everything nation including local executive workers determination exist required to enter the SSIS regardless about their private condition insurance status or income level; the same determination and seek to relaxed sector workers as the reserve gains wider acceptance. The NHIS has had restricted success inside rolling out community-based condition insurance (CBHI) inside Nigeria.25 This is hardly surprising as evidence from more little including middle-income countries recommend that community condition insurance schemes often founder for a variety about reasons, including the minute size about the risk pools, adverse selection, including their restricted use packages.15,26 In states where CBHIs have already been established, they determination exist integrated including absorbed into the SSIS.
Purchasing including payment
The SSIS inside each nation determination purchase services from providers based supported by its predetermined use package. SSIS including providers determination negotiate including sign contracts. The NHIS shall and need to give help inside the initial stages to the nation funds to guarantee that information asymmetry does not skew the contracts inside favor about providers. Payment for private sector providers shall exist by capitation including fee-for-service as obtains inside the NHIS. Payment for public sector providers determination exist by pay-for-performance. Government determination continue to compensate basic salaries which determination exist topped up by payments received by the facility from SSIS. We propose that patients have the freedom to choose providers thus as to inspire competition including thereby foster quality improvements. To minimize customer moral hazard, gatekeeping including coinsurance determination exist introduced.
Gatekeeping could exist inside the form about requiring condition care consumers to first seek chief care at their chosen facility earlier than they can exist referred as needed
Coinsurance should exist introduced to raise extra funding as well as minimize customer moral hazard. It should, however, exist place at between 10% including 20% thus as not to become a significant barrier to care, including thus that the managerial costs are not as well high as well. The NHIS currently sets it at 10% for medications 6 [Figure 2].
Mapping the proposed social insurance improvement Adapted from Mills A, including Ranson M. (eds) 2012
MITIGATING POTENTIAL CHALLENGES
This proposal suggests an approach to condition funding reforms inside Nigeria that numerous stakeholders may exist unfamiliar with. Its successful implementation, therefore, determination hinge supported by creating great understanding about the processes including its merits among everything stakeholders at every level. In this section, we label future risks including criticisms that may impair the acceptability or operationalization about the reforms.
Equity
Concerns may center supported by the apparent shortage about incentives for providers to place up facilities inside agricultural areas (inequity about access). Concerns may and arise regarding the future exclusion about those unable to compensate from the plan or setting premiums for poorer people (inequity inside finance). In addressing these concerns, we put forward the subsequent recommendations:
The National Health Act 2014 established a basic condition reserve to exist financed by “(a) Federal Government annual grant about not <1% about its Consolidated Revenue Fund; (b) grants by international giver partners; including (c) funds from a scrap of more source.”27 The do something specifies that 50% about the reserve shall exist administered by NHIS for the giving about “basic lowest about condition services to citizens.” We recommend that this reserve exist utilized for subsidy remittance to SSIS for the condition care consumed by those as well broke to afford the premiums or more vulnerable groups. Exclusion from remittance may and exist applied to specific groups about people
To inspire providers to system inside underserved agricultural areas, the capitation paid to private providers domiciled inside agricultural areas shall exist place higher than those inside urban areas. In addition, the executive may and seek tax breaks for them. The executive determination need to seek right including sufficient incentives to retain public sector condition workers inside agricultural areas.
Size about risk swimming pool including sustainability
Criticism about the SSIS may arise from the size about each state's swimming pool which might exist viewed as minute including capable about supporting a very restricted use package. It may and exist suggested that the system might exist as well compounded to operationalize; including that it determination exist difficult to get the relaxed sector to adopt the scheme. These issues can exist addressed as follows:
Historically, numerous nationwide social insurance schemes that began with numerous minute pools had over time coalesced into fewer including more strong schemes.15 We expect the same to happen inside Nigeria with the help about the combined government. Earlier inside this proposal, we recommended that states wishing to enter the combined swimming pool exist encouraged to do so. Neighboring states with significant ties may choose to run a mutual scheme; this should and exist encouraged including supported. The content about the use package determination exist determined by available funds; it determination exist expanded as the swimming pool grows. The ultimate real is to make participation inside the plan compulsory for every resident about each nation except those covered by the NHIS.
In setting up their SSIS, states shall use from the experience that NHIS has acquired via the years. The cost about training operators inside each nation including ongoing help inside the early days about the plan should exist borne by NHIS. By starting with public sector workers, states determination have the opportunity to refine the SSIS earlier than taking supported by the relaxed sector. Granting the SSIS autonomy inside each nation determination mitigate political interference including bureaucratic encumbrances.
With great leadership, continuous meeting with the relaxed sector, including demonstration about SSIS use to public sector workers, the plan determination gain the help about the relaxed sector. Lagos nation has shown that with great governance, it is not impossible to get the relaxed sector inside Nigeria to compensate taxes or accept executive programs.28
CONCLUSION
This proposal place out to demonstrate that a workable path to UHC via expanding social condition insurance exists inside Nigeria. We have shown that Nigeria's combined structure which prescribes a sharing about responsibilities for condition care among the three tiers about executive presents serious challenges for significantly extending social insurance to uncovered groups. We recommend that rather than allowing this government structure to impair development toward UHC, it should exist leveraged to accelerate the process by supporting the states to establish including manage their own insurance funds while encouraging integration with the NHIS. We recognize that these are important including compounded recommendations; they determination take the time to build including operationalize, but we are convinced that they speak for the most sustainable path to UHC inside Nigeria. Good stewardship including strong political commitment are required to see the reforms through.
Financial help including sponsorship
Nil.
Conflicts about interest
There are no conflicts about interest.
Acknowledgments
Okpani Arnold Ikedichi is an MSc student at the London School about Hygiene including Tropical Medicine including is a recipient about the Chevening Scholarship about the United Kingdom Foreign including Commonwealth Office (scholar number: NGCV-2014-1608). Abimbola Seye is a Ph.D candidate at the Sydney School about Public Health. The Ph.D is funded by the Rotary Foundation via a Global Grant Scholarship (grant number GG1412096) including by the Sydney Medical School Foundation via a University about Sydney International Scholarship.
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