National Health Insurance and the Nigerian nation

The bizarre drama that has been going on for several months now surrounding the National Health Insurance Scheme of Nigeria in many ways epitomizes the dysfunction of the Nigerian nation as constituted.

After discussion, vacillation and procrastination lasting several years, the Nigerian National Health Insurance Act 35 was signed in 1999.

At its most basic definition, the ‘insurance’ required the pooling of funds jointly contributed on regularly by an employer and his employee into a ‘health fund’. The prescribed ratio for the National Health Insurance planned for Nigeria, one is told, was something of the order of five percent of the worker’s monthly income from his side, with the , in this case the government, putting in ten percent to match. From this pool of funds, civil servants and other categories of citizens covered would be guaranteed a defined package of health services at one or more designated health facilities for themselves and their families. It made sense and was already working very well in different parts of the world.  The labour unions, while agreeing it was a good thing for the workers, declared bluntly that workers would not contribute.

The word is that President Obasanjo, not to be deterred, jump -started the scheme by paying the government’s ten percent contribution on every worker and asking the NHIS to get on with it. It is possible that that ten percent is what is still going into the coffers of the NHIS monthly up till this moment, although very little of the information about what has been paid and to whom is put in the public domain.

The important thing is that the arrangement ensures that roughly five percent of the population of Nigeria are currently enjoying insured healthcare without having to pay out of pocket, like the rest of their countrymen.

Obasanjo probably assumed that the virtues of being insured would become quickly obvious to the rest of the public, who would soon be clamouring to get on board. Government would then look at picking up the premiums for the disabled, unemployed and other ‘vulnerables’. Nigeria would achieve the lofty dream of Universal Health Coverage in short order.

It need not be said that nothing like that has happened. Instead, the Act, a product of nationalistic passion but incomplete and imprecise thinking, has provided in real life an agency ‘as rich as Croesus’, with ‘a warehouse full of cash’, but whose actual wealth or income is obscured from public view. The NHIS, with its huge treasure trove, has become a magnet for political parties, politicians, assorted carpet baggers, and a centre for the assertion of the suzerainty of ‘federal power’.

The latest episode in the long-running drama has surrounded the antics of a Chief Executive who wears a toga of moral exclusiveness and, from all accounts, is rude and crude in interpersonal interaction. The issues of his ‘war’, which till lately assumed such epic proportions the observer might be tempted to think the sky would fall on NHIS and Nigeria if this particular saviour was not there to hold it up, has been mostly about, so far as you can see, a festering grouse against the HMO’s (Health Management Organisations). The HMOs serve as a relationship and service bridge between the NHIS and the service providers who interact with the public.

Of course, there is a lot wrong with the NHIS, including the shenanigans of some of the HMOs, and everybody who knows anything about the Nigerian health system would acknowledge this. Surefooted firm, clear-eyed executive action, based on good thinking, and carrying along others in the leadership team, including this executive’s bosses, who cannot all be unpatriotic thieves and vagabonds, contrary to the implications of the body language of this individual, could have done a lot to improve things. In reality his ‘war’ has left an underperforming system in regression, with Nigeria’s Health Insurance coverage languishing in the doldrums.

But the posturing and recent travails of this ‘saviour’ are not the point of this piece, really.

What is wrong with our NHIS?

The design of the law itself is fundamentally flawed.

For one thing, National Health Insurance cannot be successful unless Health Insurance in one form or another is made compulsory for every Nigerian citizen. That is a political step no President to date has found the courage to take, fearful of its repercussions in political capital.

Secondly, and getting to the core of why the NHIS has been so troubled and looted over the years, the law should have created a separate entity to manage the ‘Health Fund’- a body independent of government, governed by eminent untainted citizens of Nigeria, of which there are, hopefully, still a good few. They – not the CEO of the NHIS, not even the Board of the NHIS, should be the ones doling out statutory payments, such as ‘service charge’ to the NHIS, and the payments to the HMOs and service providers.

Thirdly, the Abuja drama is one of the most compelling arguments for restructuring in Nigeria.  Health Insurance should be on the concurrent, not exclusive list. State governments can and should start their own health insurance.

This writer can recollect sitting in at some meetings when Lagos, always the outlier, was contemplating starting health insurance. A large part of the discourse was devoted to finding a name for it – anything but ‘health insurance’ – since that was ‘exclusive’ and might offend the ‘federal’ government of the day!

Another nugget from history. Asiwaju Bola Ahmed Tinubu, during his incumbency as governor, apparently was invited to get Lagos to ‘join’ NHIS. Presumably the expectation was that the state could pay the premiums for its civil servants to the coffers of NHIS in Abuja. If Lagos did it, other states were bound to follow. The treasure trove in the Abuja warehouse would be swollen exponentially. In private conversation with his health managers, he let it be known that not one kobo of Lagos money was ever going to go into any NHIS account in Abuja. Rather Lagos would do its own thing, whatever it took. Collaborate – yes. Be swallowed up – never.


The NHIS requires a revamping – root and branch. The funds need to be separated from itchy fingers as well as from power-magnates. A best-practice governance structure needs to be created for the Insurance funds. Protocols have to be developed and enforced for all stakeholders – HMOs, providers, and the managers themselves. The key requirement is not for messianic ‘rescuers’ but good clear-eyed insightful thinking guiding policy and implementation at all times.

Every state needs to be encouraged to set up the structure for at least a basic health insurance scheme. The private sector should also be encouraged to be more active in the area of social health insurance. A firm handshake of collaboration should then be made between the ‘federal’ agency, the states, and the private sector. This is especially important because the Nigeria Health Act, which is supposedly ready for implementation, prescribes that one percent of the nation’s consolidated revenue should go to basic health service provision for the citizenry. Fifty percent of this amount is to go to NHIS as a ‘basic health care provision fund’ for providing a ‘basic minimum package of health services to citizens’ all across the nation. A good bold step forward towards the goal of universal healthcare.

However, if the NHIS is not revamped and restructured wholesale, this will be just more money in the warehouse for ‘messiahs’ to lord it over, or for others to steal.

Nigeria itself requires a root and branch revamp to correct the structural flaws that keep it going round in circles seeking messiahs, but that is another story.

Ernest Hemingway in one of his celebrated short stories, wrote about a cyclist riding his bicycle through Spain during the reign of General Franco’s fascist regime. He only needed to interact with a traffic policeman and observe a couple of people on his way to understand what was wrong with Spain. A visitor to Nigeria only needs to observe the sad drama playing out in the NHIS to get a glimpse of what is wrong with Nigeria itself.


Femi Olugbile

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