Health financing is one of the six building blocks of a health system, and health insurance is key to making progress with UHC, yet it continues to be a major challenge in the Nigerian health system. It is uncertain that Nigeria will achieve Universal Health Coverage (UHC) by 2030 as a target of the Sustainable Development Goals (SDGs).

The National Health Insurance Scheme (NHIS) is a combination of both compulsory and voluntary contributory health insurance schemes targeted at formal sector workers as well as informal sector workers. It aims to ensure access to quality health care services, provide financial risk protection, reduce rising cost of health care services and ensure efficiency in health care. Although formally established in 1999, Nigeria only launched the NHIS in 2005 after several attempts at introducing legislation on health insurance, since the 1960s. Since its launch over a decade ago, NHIS is yet to achieve the aim for which it was established, with less than 5 percent of the Nigerian population, mainly federal government workers and their dependents being covered by the scheme.

According to the National Health Account, government health expenditure as a share of Gross Domestic Product (GDP) is 0.59 percent, government health expenditure as a percentage of total government expenditure is 5.3 percent while out-of-pocket (OOP) expenditure as a percentage of total health expenditure is 72.3 percent. There has been limited progress in addressing the health financing challenge Nigeria faces, and the implementation of NHIS over a decade does little to inspire hope.

In 2017, a spotlight was put on the activities of the NHIS, Health Maintenance Organizations (HMOs) and health care providers (HCPs) in Nigeria, due to the numerous petitions filed by NHIS enrolees with regards to the unsatisfactory health care services provided to them and the inhumane treatment meted out to NHIS patients at hospitals by health workers. This revealed that the management of funds for health care had been fraught with corruption and a lack of transparency and accountability. Despite the disbursement of N411 billion to HMOs by the NHIS since 2005, HMOs were indebted to HCPs across Nigeria to the tune of N2.276 billion, and NHIS enrolees continue to be at the receiving end of this massive corruption with lack of improvements in their health status. Enrolees who together with their employers make these financial contributions are unsatisfied with the services they receive, and in fact most NHIS enrolees complain that they are treated badly at hospitals by health workers because of the indebtedness of HMOs to hospitals.

NHIS as an implementing and regulatory organization has also suffered from ineffective leadership, lack of succession planning and a poor governance structure over the years. This is why investments in the scheme have not resulted in equitable access to health care and improved health outcomes for NHIS patients. Nevertheless, some states have begun to develop their own health insurance schemes. This is a welcome development, considering the fact that the health insurance scheme was made optional for states under the NHIS Act. However, these states might also run into the same problems that currently bedevil the NHIS, if the design and implementation of State Social Health Insurance Schemes (SSHIS) are not well thought out and/or applied in context-specific ways, with the assistance of health financing and health systems experts. The current arrangement where states send their financial contributions/premiums to the central pool of the NHIS is not only inefficient, it also creates unnecessary bureaucracy.

The Director General of WHO, Dr Tedros Adhanom Ghebreyesus during his working visit to Nigeria affirmed that sustained political will and commitment are key to achieving UHC in the SDG era. While the 2014 Presidential Summit on UHC, the 2018 Health Policy Dialogue on UHC and the launch of the Basic Health Care Provision Fund (BHCPF) under the National Health Act (NHAct) of 2014 show that Nigeria supports the objectives of UHC; the implementation of NHIS which is critical to making UHC a reality leaves much to be desired. Despite its inefficiencies and pervasive corruption, NHIS as an implementing and regulatory organization is expected to manage 50 percent of the BHCPF for the provision of basic minimum package of health care services for the citizens. There is therefore, a need to re-examine its design and implementation, if the over 90 percent of the Nigerian population who lack any form of health insurance coverage must be catered for. Below are a few recommendations for tackling the issue.

First, health insurance must be made mandatory for states and all citizens as part of the amendment of the law establishing NHIS. States should desist from sending their premiums into a national pool while making the SSHIS independent of the NHIS. Furthermore, NHIS enrolees deserve better treatment by health workers in order to improve their health outcomes. The design of an effective feedback system where patients can report inhumane treatment of health workers and the development of disciplinary actions against any health worker found guilty would help address this problem.

In addition to this, the governance structure of NHIS must be strengthened while the issue of corruption as well as lack of transparency and accountability in the health sector which impede health care reforms must be tackled by political actors and policy makers, if Nigeria wants to the improve health status of its population. Closing the loopholes that exist in the health sector through innovative technologies is critical, so as to discourage corrupt individuals and groups that are bent on undermining health system strengthening in Nigeria.

Finally, there is a need for strong and effective public health leadership to ensure that the NHIS as an implementing and regulatory agency plays its role in helping to provide UHC to Nigerians. While the sustained implementation of the BHCPF under the NHAct has the potential to improve access to basic health services, it is also important to increase government health spending as a percentage of general government expenditure from the current average of 4 percent to the international benchmark of 15 percent as well as increase government health spending as a percentage of the GDP from less than 1 percent to at least 5 percent.

The declaration on UHC by governments and policy makers in Nigeria since 2014 must move beyond rhetoric into reality, and UHC must be pursued with vigour at both national and sub-national levels in order to ensure access to quality health care services, and improve financial protection.