The Road to Universal Health Coverage (UHC) in Nigeria.
Updated: May 4
Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship. Achieving UHC is one of the World Health Organization's Sustainable Development Goals (SDGs) (1). The WHO advocates for UHC and equal access to health services for all citizens through its remarkable policy report in 2010 captioned 'Health systems financing: The path to universal coverage' (2). The policy explains that the healthcare financing system of a country is a critical determinant for achieving Universal Health Coverage (UHC) as they determine the availability, affordability, and accessibility of health services to its citizens, and a good healthcare financing strategy is fundamental to the ability of health systems to maintain and improve human welfare. Although Nigeria has a national policy for universal health coverage, little progress has been made due to several factors, including ineffective use of available resources, increasing population and existing population inequities, insufficient financing for healthcare, and sub-optimal deployment of available health funding to purchase health services. According to basic UHC statistics, Nigeria has the lowest government health financing and the highest out-of-pocket (OOP) cost in Africa, further pushing the populace into impoverishment and poverty (3, 4). The primary target of the WHO in this special policy report is to reduce reliance on OOP payments for health services and promote prepayment mechanisms, such as health insurance. However, the National Health Insurance Scheme Strategic Plan (2020-2030) stated that only about 4.2 percent of Nigerians are under Social Health Insurance (5).
Major Healthcare financing mechanism in Nigeria.
Healthcare in Nigeria is a concurrent responsibility of the three tiers of government. Nigeria's states rely on a mixture of the government budget using general tax revenue. The Formal Sector Health Insurance Program (FSSHIP) is by the National Health Insurance Scheme (NHIS), external funding (donor), and private OOP spending to finance healthcare.
Limitations of the significant health financing mechanism in Nigeria
The government budget for health financing is perceived to increase because they allocate a large proportion of the health budget to personnel costs. It mainly funds tertiary hospitals, whereas the highest disease burdens are at the primary and secondary levels. Secondly, there needs to be a system to ensure financial resources are fairly distributed based on epidemiological or demographic factors in the country (7).
Coverage of FSSHIP is only limited to Federal Government (FG) employees and their dependents, and this category of people makes up less than 5% of the Nigerian population. Another central area for improvement is that the FSSHIP needs to be more comprehensive. Hence insured patients sometimes have to make direct OOP payments for treatments. (6,7)
OOP payment in Nigeria remains worrisomely high, and this is supported by the world bank statistics as its proportion of total health and gross private health expenditure is still above 70% (8). This excess reliance on OOP expenditure for medical bills deepens unequal access to quality health care. It exposes Nigerian households to catastrophic health expenditure (CHE), failing to realize the UHC goal.
The New National Health Insurance Bill
May 2022 signifies a landmark in the healthcare delivery history of Nigeria as the National Health Insurance Scheme (2004was replaced by the National Health Insurance Authority Act (NHIA). The hallmark of the new legislation is that health insurance coverage has been made compulsory for all Nigerians and legal residents (9). The new law represents a watershed moment in which institutional prioritization of health investments, sustainable social contracts, and fruitful private partnerships can accelerate Nigeria's progress toward UHC.
The 2022 Lancet Nigeria Commission provides compelling evidence of the need for a "new social contract" between the people and the state. This contract is crucial for implementing the National Health Act (NHA), the NHIA Act, and national strategies and plans for health (10).
In Nigeria, achieving an efficient healthcare financing system remains challenging. Hence, there is a need to review the plan and ensure the use of resources while reducing financial risk by shifting focus from OOP payments to other resources. It will help protect the poor and vulnerable populations from facing economic catastrophe due to health payments.
Increasing general revenues to fund public health services is essential to ensure adequate coverage of quality health care services. Higher government revenue will lead to higher health financing, allowing the social determinants of health. Achieving this would require strong political will and an optimistic political approach by prioritizing UHC at the three tiers of government.
There is a need to increase coverage of insurance programs. A viable health system requires dedicated, efficient, and equitable health financing mechanisms complemented by comprehensive health insurance.
Health spending should be more results-driven and out-put based, using relevant evidence. Economic evaluations allow for optimal distribution of funds, rationing of resources according to areas where they can have the most significant impact, and implementing interventions to regions with a higher prevalence of disease burden, guided by evidence-based epidemiological studies, economic evaluations, and priority-setting strategies.
These measures will help guide Nigeria on the right path to universal health coverage.
World Health Organization (2022). Universal Health Coverage (UHC). Key Facts. Available at: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)
World Health Organization. (2010). The world health report: health systems financing: the path to universal coverage. World Health Organization. https://apps.who.int/iris/handle/10665/44371
Statista (2022). Health in Nigeria. https://www.statista.com/topics/6575/health-in-nigeria/#topicHeader__wrapper
The World Bank. UHC Service Coverage Index-Nigeria. https://data.worldbank.org/indicator/SH.UHC.SRVS.CV.XD?locations=NG
National Health Insurance Scheme Federal Republic of Nigeria (2020). Strategic Plan 2020 – 2030. https://www.nhis.gov.ng/?media_dl=3056
.Onoka, C.A., Onwujekwe, O.E., Uzochukwu, B.S., and Ezumah, N.N. (2013). 'Promoting Universal Financial Protection: Constraints and Enabling Factors in Scaling Up Coverage with Social Health Insurance in Nigeria.' Health Research Policy and Systems, 11(20), pp. 1-10. http://doi.org/10.1186/1478-4505-11-20
Onwujekwe, O., Ezumah, N., Mbachu, C., Obi, F., Ichoku, H., Uzochkwu, B., and Wang, H. (2019). ‘Exploring Effectiveness of Different Health Financing Mechanisms in Nigeria; What Needs to Change and How Can it Happen’? BMC Health Services Research, 19(661), pp. 1-13. https://doi.org/10.1186/s12913-019-4512-4
The World Bank (2022). Out-of-pocket expenditure (% of current health expenditure) https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=NG
NHIA ACT (2022). https://nhis.gov.ng/2022/09/03/nhia-act-2022/
The Lancet Commissions (2022). The Lancet Nigerian Commission: Investing in Health and the Future of the Nation. https://thelancet.com/commissions/health-in-nigeria