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• Delta, Lagos, Kano top the list of cities that have crossed the million mark
• Akwa Ibom, Kebbi, Taraba, Abia, Ebonyi, Zamfara ranked lower with less than 200,000 registered residents
• Nigerians (informal sector) want insurance but cannot afford the N13,000 per year fee – Stakeholders
• NHIA says national enrollment is low, slow, but rising steadily
Despite recent cost-push inflation that has made healthcare virtually unaffordable for most Nigerians, many states continue to ignore the huge opportunity that mandatory national health insurance coverage could bring relief to their citizens.
More than two years after the National Health Insurance Act (NHIA), which made insurance mandatory for all Nigerians, whether in the formal or informal sectors of the economy, the number of insured persons in states remains extremely low relative to their population density.
The Guardian’s investigation shows that except for Delta, Lagos and Kano states, where the number of participants in medical insurance exceeds 1 million, the number of participants in other states is less than 500,000. Among them, the states with the largest number of participants are Akwa Ibom, Kebbi, Taraba, Abia, Ebonyi and Zamfara, with less than 200,000 participants each.
Recall that healthcare costs in both public and private hospitals have risen by an average of 200 per cent over the past year, with most people seeking care unable to pay out of pocket.
The World Health Organization estimates that Nigeria has the highest out-of-pocket health costs in West Africa, and many Nigerians are pushed into poverty due to poor health.
In order to eliminate the burden of out-of-pocket expenses and strengthen universal health coverage in the lives of the nation, the Muhammadu Buhari-led government signed the National Health Insurance Agency Act on May 19, 2022, making it mandatory for all citizens and legal residents to purchase health insurance.
The bill also authorized the National Health Service to become a more effective regulator and integrator and created a funding mechanism for providing health services to the poor and vulnerable.
Essentially, the National Health Insurance Act, 2022 is the result of efforts to repeal and re-enact the National Health Insurance Act, which was originally Act No. 24 of 1999, and it took nearly 23 years to achieve this goal.
Section 13 of the Act provides for the operation of the National Health Insurance Agency (SSHIA) and the Federal Capital Territory (FCT) Health Insurance Agency and under the law, the task of extending insurance coverage to 220 million Nigerians is now the task of not only the National Health Insurance Agency (NHIA) but also the National Social Health Insurance Agency (SSHIA) across the country.
The combined effect of Section 3(b) and Section 14(1) has the force of law to ensure that every Nigerian has access to healthcare through health insurance channels.
Specifically, official records show that the 25-year-old program currently covers only 18,675,088 Nigerians (8.5% of the 220 million population) with health insurance nationwide. A survey by NOI Polls, a West African polling and research organization, showed that 80% of adults in Nigeria pay for medical expenses out of pocket, and only 17% have health insurance. Regardless, these figures show that the financial barriers to accessing healthcare services are high.
Data obtained by The Guardian show that of the 18.67 million insured people, more than 3.5 million are from the federal government’s formal sector scheme, about 2 million are covered by private sector health insurance, 2 million are covered by vulnerable groups insurance and more than 8 million are covered by state social health insurance.
Statistics show that Delta State, with a population of over 6 million, has 2,584,215 students enrolled, followed by Lagos State, with a population of over 20 million, with 2,366,596 students enrolled; Kano State, with a population of over 16 million, has 1,194,578 students enrolled; Kaduna State, with a population of over 8 million, has 952,900 students enrolled; the Federal Capital Territory, with a population of over 4 million, has 850,402 students enrolled; Akwa Ibom State, with a population of over 5 million, has the least enrollment, with 128,174 students enrolled; Taraba State, with a population of over 4 million, has 148,620 students enrolled; and Abia State, with a population of over 4.8 million, has 159,121 students enrolled.
As of the second quarter of 2024, the number of registered persons in each state is distributed as follows: Abia State 159,121, Adamawa State 281,317, Akwa Ibom State 128,174, Anambra State 404,586, Bauchi State 344,797, Bayelsa State 267,999, Benue State 269,753, Borno State 306,601, Cross River State 237,877, Ebonyi State 197,989, Edo State 485,426, Ekiti State 462,707, and Enugu State 440,527.
Others are Delta 2,584,215, FCT 850,402, Gombe 261,787, Imo 287,908, Jigawa 439,765, Kaduna 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, for a total of 18,675,088.
Speaking to The Guardian while assessing the implementation of the NHIA Act, the President of the Health and Managed Care Association of Nigeria (HMCAN), Dr. Leke Oshunnyi, said that over 90% of the Nigerian population does not have any form of health insurance.
Oshunyi believes that the National Health Insurance Scheme makes it mandatory for every resident in Nigeria to purchase health insurance and anyone who does not have health insurance is violating the law.
He said: “Every Nigerian resident must purchase social health insurance. It is compulsory and mandatory. For those who can afford it, they should go online to find the NHIA website and register. But for those who cannot pay, the government is committed to bridge the gap.”
Oshunyi noted that the new law takes into account the National Social Health Insurance Agency, adding that states like Lagos and Kaduna were ready to implement the new law.
“Compulsory health insurance will not be fully implemented immediately because we are in a transition period,” he said. There have been changes in the leadership of the National Health Insurance Administration (NHIA), the agency responsible for implementing the law.
“Many changes were needed to accommodate the major change in the law whereby health insurance is now mandatory for all Nigerians whereas the original law made it optional. You can imagine how huge the logistical and other problems would be for a scheme that has to cover over 200 million Nigerians.”
He said that to increase school enrolment, a major outreach campaign was needed, adding that the campaign would have to be deployed in a way that would reach all parts of the country, just like the new currency.”
NHIA director general Dr Kelechi Ohiri told The Guardian that the law made it mandatory for everyone to have health insurance but the challenge now was to work with all the agencies involved to enforce it and make it work.
Oshiri noted that most state governments have already started enrolling their staff in the scheme, adding that the National Health Insurance Law is being implemented as planned and will gradually make health insurance functional in every state.
He noted that insurance coverage remains low because some people cannot afford it, while others are able to pay but choose not to because the program was voluntary before it was made mandatory.
Ohiri disclosed that the NHIA had recently started revising its guidelines and one of the key reforms was the introduction of a system for verification of registered persons using the national identity card number.
The NHIA chief said the government had done a good job in creating the Basic Healthcare Fund through the National Health Act and the Vulnerable Groups Fund would help the poor and vulnerable groups such as the elderly, internally displaced persons, persons with disabilities and even prisoners.
The Executive Secretary of the Nasarawa State Health Insurance Agency (NASHIA), Yahaya Ubam, told The Guardian that the state will start implementing compulsory health insurance by 2022. The law establishing the state’s health insurance scheme was signed in 2018 and came into force in 2019. Currently, there are about 245,000 participants in the scheme.
Ubam explained that as of 2022, the agency aims to cover about 500,000 people by 2027 and has already enrolled 245,000 people in just two years. “We want to achieve universal health coverage by 2030,” he added.
Also speaking, the Public Relations Officer of the Federal Capital Territory Health Insurance Scheme (FHIS), David Barua, said a total of 175,438 FCT residents were enrolled in the health insurance scheme.
He noted that 134,420 of them were from the formal sector, including Federal Capital Territory and District Council staff, their spouses and four children, 5,018 were from the informal sector and 31,000 were registered through the Basic Health Insurance Fund (BHCPF).
Barua added that the BHCPF scheme is free insurance for the poor and vulnerable, adding that the names were collected from the National Social Register developed by the previous government while some names were sourced from charitable organisations, religious institutions, associations and networks of persons with disabilities.
He said: “The Federal Capital Territory is providing free registration to vulnerable groups through the BHCPF and we recently registered pregnant women for free health insurance and registered all HIV-infected persons, including persons with disabilities, under the scheme.
“Our admission fee for the informal sector is N13,500 per person for one year. Many people are interested in the programme but complain that they cannot afford the fee. We have contacted the Federal Capital Territory Micro Finance Bank in the hope that they will cover the full fee for interested residents.”
Barua said the agency is working to increase enrollment through a program called the Adopt-and-Enroll Campaign, which targets large businesses and dynamic individuals who can afford health insurance for themselves and others, such as Coca-Cola Co., Julius Berger and real estate developers.
“We have approached them to enroll the poor and vulnerable as part of their corporate social responsibility and we did get positive feedback from them. A real estate development company has pledged to enroll 10,000 residents of the Federal Capital Territory.
“This adoption and enrolment programme for the Federal Capital Territory Health Insurance Scheme is supported by the United States Agency for International Development (USAID) IHP. This is the strategy they are using to increase enrolments for the Health Insurance Scheme in Sokoto State, they are targeting these companies and this is helping to increase enrolments,” he said.
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