UHC Forward: Towards Universal Health Coverage

Nigeria is on the brink of achieving Universal Health Coverage (UHC)... That is probably everyone’s wish. The reality though is that many hurdles separate Nigeria from that dream. Achieving UHC in Nigeria implies having financial risk protection for 150 million people, a step that for certain, will change African and global indices. Eight years after setting up a National Health Insurance Scheme (NHIS), 4% of Nigerians are covered by the scheme, largely through the Formal Sector Social Health Insurance Programme (FSSHIP) that currently, covers employees of the federal government and their families. The NHIS, an agency of the federal government, has established a plethora of social health insurance schemes (SHIPs) to ferry various population groups to the dreamland: Formal Sector SHIP (FSSHIP), Voluntary contributors SHIP (VCSHIP), Tertiary Institutions SHIP (TSSHIP), Community Based SHIP (CBSHIP), Rural Dwellers SHIP (RDSHIP), among others. Irrespective of the programme set up, states in Nigeria, which represent sub-national governments, have to take up one or more of these SHIPs for those living in or working in states.

With the prevailing federal system of government that allows states to make certain decisions about the welfare of local residents and citizens including the decision to adopt or not adopt health reforms such as the NHIS among other health reforms, states are clearly a major stakeholder in the national health insurance reform. But states have to find value in these SHIPs and this will include finding opportunities to fulfil political expectations. Additionally civil servants, as intended beneficiaries of one of the programmes - the FSSHIP - need to value and trust the system enough to make premium contributions. Health care providers will also see it as valuable, at least to the extent that helps them meet client needs, and provides financial rewards.

Using a policy analysis approach, the decision of states to adopt or not adopt the FSSHIP was reflected on in a recent publication, using information obtained from review of relevant documents and interviews of State-level policy makers, leaders of civil servants, and health care providers, NHIS officials, and managers of health maintenance organisations (intermediaries), operating in two states in Nigeria. The analysis showed that states had no role in governing the NHIS, nor its programmes apart from being included as ‘employers of labour’ by the NHIS law.

They were concerned that NHIS was not accountable to them and had never provided a report of how its money is used to them or the public. As a result, they frowned at the idea of handing over state funds to the NHIS, seen as a federal government agency, even though the idea of promoting financial risk protection appealed to them. While one state decided against adoption of the FSSHIP for its employees on this ground, the other which accepted it, did so only after a assessing the prospects of a state managed health insurance scheme, which would give them control over state funds. States determined the outcome of adoption because the law allowed them to do so.

On their part, the intended beneficiaries (civil servants) already had negative experiences from a previous contributory programme of the federal government and opposed the idea of contributing into a new one, even where they supported adoption. Health care providers had issues arising from the services they are currently providing for employees of the federal government including low capitation and an unrevised drug list which affected their ability to make profits from participating.

The NHIS and HMOs made efforts to promote adoption of the FFSHIP in both states. Although such efforts helped to engender trust in one state which subsequently adopted the FSSHIP, they seemed unable to address the main challenges which the other state had, including their inability to convince civil servants to make the required employee contribution, and also their unwillingness to allow the government to convert their ‘medical allowance’ (10% of their salaries which they were already receiving to defray health care costs), to employer contributions. The ensuing breakdown in communication between NHIS, HMOs and state policy makers arose because the state government did not believe that the FSSHIP sufficiently addressed its immediate political objective of providing health services to rural dwellers, since they believed the civil servants already had some financial support for health expenditures in the form of a medical allowance.

Overall, the research showed that adoption occurred or did not occur, mainly due to the political and economic interests of key stakeholders and the roles they played given the policy context and programme design. Policy implementers involved in scaling-up NHIS should develop strategies to address context-related challenges of individual states, such as the inability to reallocate funds into the programme, in order to help states overcome hindrances to adoption. Policy implementers also need to be aware that policy adoption can be influenced by perceptions and experiences related to the effectiveness of an existing, corresponding programme and such perceptions may hinder adoption or shape the outcome of the adoption process.