Reform fails to lift Nigeria’s health insurance coverage

...FG mulls health insurance as requirement for owning bank account, travels

Adaku Okafor, a local farmer and mother of five from Ihie in Abia State, recently faced a significant financial strain when her 13-year-old son was diagnosed with typhoid and malaria. The hospital bill, including medication, amounted to about N25, 000.

With an average monthly income of N50, 000, Okafor found it difficult to cover the medical bill, managing to pay N20,000 with help from friends to cover the cost of most essential medicines.

Okafor said she does not have any health insurance and barely knows how it operates.

“Everything is so expensive now,” Okafor shared in an interview with BusinessDay. “Food prices have gone up, medicine costs have gone up. Drugs I used to buy for as low as N100 or N200 now cost more than N500.”

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Okafor’s situation mirrors the experiences of many Nigerians who, without health insurance, struggle to cover the rising costs of healthcare.

Two years after Nigeria passed a law intended to reduce out-of-pocket healthcare expenses, over 90 percent of the country’s population remain without any form of health insurance as they grapple with escalating healthcare costs.

Health insurance in Nigeria has struggled for over two decades, with coverage persistently below 10 percent since the establishment of the regulatory agency in 1999. In 2022, the government enacted the National Health Insurance Authority (NHIA) Act, making health insurance mandatory for all Nigerians to enhance access to essential healthcare services.

However, findings show that the implementation of this law has been plagued by systemic challenges and several issues.

Read also: FG to make health insurance mandatory for travellers

Health experts say there is currently a lack of clarity on the roles that should be played by states in driving health insurance amid lack of synergy with the Federal Government.

Lekan Ewenla, chief executive officer of Ultimate Health Management Services and a stakeholder in the insurance implementation process, said some states are taking back seats, leaving the responsibility to provide insurance with the Federal Government, largely due to a lack of understanding of what the implementation process entails.

In contrast, states like Lagos have developed their own insurance products, leading to inconsistencies in coverage and access.

Ewenla said the implication is that residents in some states cannot access healthcare outside their domains, even though the NHIA is supposed to ensure that every Nigerian can access healthcare regardless of location.

Data from the NHIA reveals that only 18.6 million Nigerians are currently covered by insurance, representing 8 percent of the total population. This leaves over 200 million Nigerians, or 92 percent of the population, to pay for healthcare out of pocket.

The most vulnerable, including approximately 83 million people, are the most burdened. Data obtained from NHIA shows that only 1.9 million of this group have been enrolled in health insurance across the states and the Federal Capital Territory (FCT), despite the disbursement of N63 billion to states through the Basic Health Care Provision Fund (BHCPF) since 2019.

As a result, many Nigerians face tough choices between basic necessities like food and healthcare, as the costs of medical services, medications, and essential healthcare products continue to rise. Factors such as inflation, naira devaluation, and supply chain disruptions have exacerbated the situation.

“Ideally, the law says that states are meant to drive a centrally developed universally basic plan. Some states are now creating confusion developing their basic plans that are not properly determined,” Ewenla said.

“Also there is poverty of knowledge. The majority of the states do possess the knowledge to drive insurance. There are the issues that the NHIA is trying to dress,” he added.

A 2022 NOI poll revealed that although 80 percent of surveyed adults paid for healthcare out of pocket, 57 percent expressed willingness to pay monthly or yearly premiums to enroll in health insurance schemes. This suggests that access, rather than willingness, is a significant barrier to increasing health insurance coverage across the country.

President Bola Tinubu’s ambitious health policy aims to increase health insurance coverage to about 50 million people by 2027. The NHIA said that the number of enrollees has risen by two million to 18.6 million since Tinubu took office.

Tunde Ladele, former National Chairman, Health and Managed Care Association of Nigeria (HMCAN), decried that the uptake is very poor and not good enough, urging state and local governments to do more in driving the process.

He said the government must work out a way to drive compliance of mandatory health insurance as it is the best way to drive uptake as obtained in countries western countries.

Adaobi Onyechi, a public health expert, emphasised that progress is too slow, especially given Nigeria’s fast-growing population. She warned that without intensified measures from the NHIA to drive insurance coverage, more people, particularly the vulnerable, will remain uninsured.

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“More work is needed to raise awareness and address the low trust in the scheme,” Onyechi said.

Enrollees, particularly those in public health insurance, continue to report cumbersome and discriminatory processes when accessing healthcare services. Complaints include long wait times, unavailability of drugs, and the provision of substandard medications.

Achetu Musa, a civil servant in Abuja, shared her frustrating experience.

“I was enrolled in health insurance through my job under the Ministry of Health, but I haven’t used it in two years after my first experience. I waited four hours at the General Hospital in Bwari to see a doctor and get drugs. In the end, they didn’t have the drugs I needed, so I had to buy them from a pharmacy. What’s the point of the insurance?”

Confidence Simon, an Abuja-based banker, shared similar concerns. “Sometimes when you go to the hospital under your insurance package, they tend to prioritise those paying cash. Sometimes they have the drugs you need, sometimes they don’t, or they give you substandard options. If you ask for another brand, they say it’s not covered by your package. Some doctors won’t even see you unless you pay extra.”