National Health Insurance Act: 2yrs after, states underenrol as 90% Nigerians still pay out-of-pocket

• Delta, Lagos, Kano top list at over a million mark
• Akwa Ibom, Kebbi, Taraba, Abia, Ebonyi, Zamfara rank low, at sub 200,000 enrolees
• Nigerians (in informal sector) want insurance but can’t afford N13,000 yearly fee – stakeholder
• National enrolment low, slow, but on track, says NHIA

Despite the cost-push inflation that has made healthcare almost unaffordable for most Nigerians lately, many states are ignoring the opportunity that abounds in the mandatory national health insurance coverage to bring succor to citizens.

Over two years after the National Health Insurance Act (NHIA) made insurance coverage mandatory for all Nigerians – be it in the formal or informal sector of the economy – all the states still have an abysmal low number of enrolees in relation to their population density.

The Guardian checks showed that besides Delta, Lagos, and Kano that have enroled over a million each in the health insurance scheme, several of the states have below the 500,000 threshold. The worst culprits are Akwa Ibom, Kebbi, Taraba, Abia, Ebonyi and Zamfara, boasting less than 200,000 enrolees apiece.

It will be recalled that the cost of healthcare across public and private hospitals has increased by an average of 200 per cent in the last one year, with most care seekers unable to pay out of pocket.

The World Health Organisation (WHO) estimated that Nigeria has the highest out-of-pocket expenditure on health in West Africa, and many Nigerians are falling into poverty due to ill health.

To unseat the albatross of out-of-pocket expenses and enhance universal health coverage in national life, the Muhammadu Buhari-led administration on May 19, 2022, signed the National Health Insurance Authority Bill into law, making health insurance mandatory for all citizens and legal residents.

The Act also empowers the NHIA to be a more effective regulator and integrator and also creates a mechanism to finance health service delivery for the poor and vulnerable.

Essentially, the NHIA Act 2022 was a culmination of efforts to repeal and reenact the NHIS Act, which was originally Decree 24 of 1999 and it took almost 23 years to reach the goal.

Section 13 of the Act provides for the operation of State Health Insurance Agencies (SSHIAs) and the Federal Capital Territory (FCT) health insurance agency and by implication and law, the task of expanding coverage to 220 million Nigerians now rests with not only the NHIA but also State Social Health Insurance Agencies (SSHIAs) nationwide.

The combined effect of sections 3(b) and 14(1) gives legal effect to ensuring that every Nigerian accesses health care through the channel of health insurance.

Specifically, official records show that the 25-year-old scheme currently has only 18,675,088 (8.5 per cent of 220 million population) Nigerians covered by health insurance nationwide. A survey by NOI Polls, an opinion polling and research organisation in West Africa, has it that 80 per cent of adults in Nigeria pay for their health out-of-pocket, and only 17 per cent have health insurance coverage. Either way, the numbers indicate a high financial barrier to healthcare services for the population.

Figures obtained by The Guardian showed that out of the 18.67 million enrolees, over 3.5 million are from the formal sector scheme of the federal government, about two million are under private sector health insurance, two million enroled under the vulnerable group, and over eight million are from the state Social Health Insurance.

The statistics show that Delta (with six million-plus population) has enroled 2,584,215, followed by Lagos State (with over 20 million people) with  2,366,596 enrolees; Kano (by 16 million-plus) 1,194,578; Kaduna 952,900 out of eight million-plus population, and FCT 850,402 out of over four million population. Akwa Ibom State has the least number with 128,174 out of over five million residents, followed by Taraba with 148,620 out of four million, and Abia State with 159,121 out of 4.8 million population.

A breakdown of enrolees per state as of Q2 2024, revealed that Abia state has 159,121, Adamawa: 281,317, Akwa Ibom: 128,174, Anambra: 404,586, Bauchi: 344,797, Bayelsa: 267,999, Benue: 269,753, Borno: 306,601, Cross River: 237,877, Ebonyi: 197,989, Edo: 485,426, Ekiti: 462,707 and Enugu: 440,527.

Others are Delta 2,584,215, FCT 850,402, Gombe 261,787, Imo, 287,908, Jigawa 439,765, Kaduna 952,900, Kano 1,194,578, Katsina 693,682, Kebbi 181,615, Kogi 308,288, Kwara 271,711, Lagos, 2,366,596, Nasarawa, 365,776, Niger, 381,869, Ogun, 383,005, Ondo, 380,309, Osun 507,248, Oyo 660,269, Plateau 341,142, Rivers 361,950, Sokoto 250,550, Taraba 148,620, Yobe 340,074 and Zamfara 173,955 making a total of 18,675,088.

Appraising the operationalisation of the NHIA Act, Chairman, Health and Managed Care Association of Nigeria (HMCAN) Dr Leke Oshunnyi, told The Guardian that over 90 per cent of the Nigerian population doesn’t have any form of health insurance.

Oshunniyi argued that with the NHIS Act making health insurance mandatory for every resident of Nigeria, anyone who does not have a health plan is contravening the law.

He said:  “It is obligatory, mandatory and compulsory for every Nigerian resident to have a social health insurance. For those who can afford to pay, they should go online and look for the website for NHIA and enrol. But for those who cannot pay, the government has promised to bridge the gap.”

Oshunniyi noted that the new law took into consideration, state social health insurance agencies, adding that states like Lagos and Kaduna have geared up to implement the new law.

He said: “The implementation of the mandatory health insurance will not be 100 per cent immediately because we are in a transition period. There has been a change of leadership in the agency entrusted with the implementation of the Act, which is the National Health Insurance Authority (NHIA).

“A lot of changes need to be made to accommodate the major change in the law, which is that health insurance is now compulsory for all Nigerians whereas the original law was optional. You can imagine the logistics and other problems for a scheme that has to capture over 200 million Nigerians.”

He stated that to increase enrolment, a huge advocacy is required adding that the kind of advocacy to be deployed is the type used for the new currency that will reach every nook and cranny of the country.”

NHIA Director General, Dr Kelechi Ohiri, told The Guardian that the law made it mandatory for everyone to get health insurance, but the challenge now is how to collaborate with all the relevant institutions to enforce that mandate and make it work.

Ohiri pointed out that most state governments have begun to bring in their workers into the scheme, adding that the NHIA is on track and getting to a point where health insurance begins to work in every state.

He noted that the insurance coverage is still low because some people cannot afford it, while there are people who can pay but choose not to do so as the scheme was voluntary before it just became mandatory.

Ohiri revealed that the NHIA recently began to revise the guidelines and one of the key reforms is the introduction of verification of enrolees using their National Identity Number.

The NHIA boss said the government has done well through the National Health Act by creating a basic healthcare provision fund through the NHIA Act, the vulnerable group fund will help the poor and vulnerable groups like the elderly, the internally displaced person, people living with disabilities and even prison inmates.

On his part, the Executive Secretary, Nasarawa State Health Insurance Agency (NASHIA), Dr Yahaya Ubam, told The Guardian that the state commenced mandatory health insurance before 2022. The law establishing the state Health Insurance Scheme was signed in 2018 and became effective in 2019. It presently has about 245,000 enrolees in the programme.

Ubam explained that as of 2022, the agency’s target was to reach about 500,000 by 2027 and had enroled 245, 000 persons in just two years. “We want to achieve Universal Health Coverage by 2030,” he added.

Also speaking, the Public Relations Officer, Federal Capital Territory Health Insurance Scheme (FHIS), David Barua, said a total of 175,438 FCT residents have been enroled in the health insurance programme.

He noted that out of the figure, 134,420 are from the formal sector consisting of FCT and the Area Council staff with their spouses and four children, while 5018 persons are from the informal sector and 31,000 enroled through the Basic Health Provision Fund (BHCPF).

Barua added that the BHCPF programme is a free insurance for the poor and vulnerable persons, adding that the names were harvested from the National Social Register developed by the last administration, while some names were gotten from charity organisations, religious institutions, disability societies and networks.

He said: “The FCT is embarking on free enrolment for vulnerable persons through the BHCPF, we recently had free health insurance enrolment for pregnant women, and registered all the persons living with HIV that were present at the programme including persons living with disabilities.

“Our informal sector enrolment fee for one year costs N13,500 per person. So many people are showing interest in the programme, but the complaint is that they cannot afford the cost. We have approached the FCT Micro Finance bank to help pay the complete amount for interested residents.”

Barua stated that the agency is working to increase enrolment through a programme tagged “Adopt and Enrol Campaign” which is targeted at big industries and spirited individuals who can afford health insurance for themselves and other persons like the Coca-Cola company, Julius Berger and estate developers.

“We have approached them to enrol poor and vulnerable persons as part of their Corporate Social Responsibility and we have actually gotten positive feedback from them. An estate development firm has made commitments to enrol 10,000 residents of FCT.

“This adopt-and-enrol programme of the FCT Health Insurance Scheme is supported by the United States Agency for International Development (USAID) IHP. This is a strategy they used to increase enrolment in Sokoto state health insurance scheme, they targeted these companies, and this helped to increase enrolment,” he said.