Achieving UHC in Nigeria: Options
for Federal, State and LGAs
Professor Obinna Onwujekwe: MBBS, MSc, PhD (Health
University of Nigeria, Enugu-Campus, Enugu, Nigeria
March, 2014
Federal Ministry of Health
1.0 Objectives
Highlight key UHC indicators in
Share international experiences in
Proffer options for Options for
Federal, States and LGAs
Enumerate key action points for the
implementation of UHC in Nigeria
Federal Ministry of Health
2.0 Background
Four target indicators proposed by WHO to M&E
progress to achieving UHC…
Total health expenditure should be at least
4% - 5% of gross domestic product
Out-of-pocket spending should not exceed
30-40% of total health expenditure
Over 90% of the population is covered by
pre-payment and risk pooling schemes
Close to 100% coverage of population with
social assistance and safety-net programmes
Federal Ministry of Health
Is Nigeria on track to achieve UHC?
Total health expenditure was 6.7% of GDP in
2009 (more than the baseline of 4-5%)
Out-of-pocket spending is more than 60% of
total health expenditure instead of the
recommended 30-40%
Less than 5% the population is covered by prepayment and risk pooling schemes instead of the
recommended 90%
Less than 2% coverage of population with
social assistance and safety-net programmes
instead of the recommended 100%
Federal Ministry of Health
Nigeria is not on track to achieve UHC..
High level of use of OOPS for healthcare
Minimal coverage with health insurance
and other pre-payment mechanisms
States, LGAs and private sector unwilling
to start mandatory health insurance
scheme for their workers
Low level of access to healthcare
Struggle to achieve MDGs
Federal Ministry of Health
3.0 Key Points
Constraining Factors to Adoption of the formal sector social health
insurance programme (FSSHIP) [Onoka, Onwujekwe et al, 2012]
States should have their own insurance schemes/HMOs
and have the fund circulate within the state.
It was unacceptable and inefficient the process of
sending state contributions up to the NHIS, having the
NHIS deduct 10% as administrative cost and having this
money come back to the state again grossly reduced
Making health facilities work is more of a challenge than
starting insurance and this should first be corrected
Concern about the governance and accountability
system of the NHIS: lack of information to stakeholders at
all levels about the activities of the scheme.
Federal Ministry of Health
International Experiences and Lessons for UHC in
Moving towards UHC involves expansion of
coverage in three ways (WHO, 2010) :
The breadth of coverage: the proportion of the
population that enjoy social health protection
The depth of coverage: the range of essential
services necessary to effectively address people’s
health needs
The height of coverage: the portion of health-care
costs covered through pooling and pre-payment
Federal Ministry of Health
International lessons (McIntyre, 2011)
Mandatory pre-payment: Core of UHC systems
Out-of-pocket payments do not allow for
financial protection – minimise their role
Voluntary pre-payment: “It is impossible to
achieve universal coverage through insurance
schemes when enrolment is voluntary” (World
Health Report 2010) – Largely a complementary
funding mechanism
Way to ensure the widest cross-subsidies
Federal Ministry of Health
Several common design features of UHC across
countries (Giedion et al, 2013)
The coexistence of UHC schemes
Heterogeneity in design and
Widespread effort to include the
poor in the schemes
Prevalence of mixed financing
sources (contributions plus taxes)
Federal Ministry of Health
African and developing countries moving towards
UFC – Case Studies
Has extended mandatory health insurance coverage
to more than 50% of the Ghanaian population
About 90-95 percent of Rwandans in the informal sector
are enrolled in health insurance and are accessing health
During 2005–2011, deliveries at health facilities
increased by 78 percent, new curative consultations by 51
percent, and family planning users by 209 percent
Federal Ministry of Health
Case Studies (Cont’d)
Total Health Expenditure (4.8% of GDP)
Out-of-pocket expenditure as a % THE =30.7%
Comprehensive safety nets for vulnerable
Tax-based financing mechanism
South Africa
40% mandatory health insurance; 40% voluntary
pre-payment; 20% out-of-pocket
Federal Ministry of Health
Case Studies (Cont’d)
Achieved Universal health
coverage (100%):
Used a variety of pre-payment
mechanisms (75% mandatory health
insurance and 25% other prepayment mechanisms)
The 30 Baht scheme
Federal Ministry of Health
4.0 Implications and
Relevance for Nigeria
Options for Federal, States and LGAs - the innovative imperative
Conceptual framework
Universal health coverage depends on:
‒Enabling policies, legislation, strategic
plans, capacity, advocacy, perceptions
‒More health for money (improved
‒More money for health (increased funding)
‒Innovative health financing
Improve Equity
‒Better health indices, achieve MDGs
Federal Ministry of Health
Implications and Relevance for Nigeria
The Foundation
“UHC can only be achieved when
the health system is strong”
- (WHO, 2010)
Federal Ministry of Health
Four international lessons with UHC (Giedion et al, 2013).
Affordability is important but may not
be enough
Target the poor, but keep an eye on
the non-poor
Benefits should be closely linked to
target populations' needs
Highly focused interventions can be a
useful initial step toward UHC
Federal Ministry of Health
Option 1: Mandatory Health Insurance
Mandatory health insurance for all
federal, state and LGA public workers
Exists at the Federal level only
States and LGAs should start health insurance
schemes for their workers
Workers must contribute a mutually agreed
proportion of basic salary at all levels
Benefit package to be improved with increased
Capitation payment to providers should be
Federal Ministry of Health
Option: Special Mandatory Health Insurance
Special mandatory health insurance for all
children under 12 years and pregnant women
Start with children under five years and pregnant
All nursery and primary school children should
be enrolled (independent of their parents)
Funding from federal, state and LGA government
budgets, special earmarked taxes and donors and
other funding sources
Part funding from UBEC resources for school
Federal Ministry of Health
Options 3: Free services
For high priority life-saving public health
services through increased use of
government revenue:
Immunization services
Prevention and treatment for HIV/AIDS
Prevention and treatment of tuberculosis (TB)
Prevention and treatment Malaria and some noncommunicable diseases
Maternal, Neonatal and Child health services,
especially antenatal, child birth and postnatal services
Federal Ministry of Health
Option 4: Community-based health insurance
scheme for people
For people employed in the informal sector
For secondary and tertiary school students
‒Existing free programmes can be the core of
CBHI scheme
‒Motivating all telecom and oil producing
companies to enrol their catchment
communities in health insurance schemes
‒Government subsidy using general tax
Federal Ministry of Health
Option 5: Creating health safety nets for the poor
and other vulnerable groups = equity funds
‒Harness the conditional cash transfers from
SURE-P towards UHC
‒Funding from local and international
‒Local earmarked taxes – proportion of VAT or
some levy on tobacco, alcohol and airtime etc.
‒Develop and implement strategic plans for
mainstreaming ‘Health in all Policies’ (HiAP)
‒Funding from Sovereign Wealth Fund (through
social investments), interests from unclaimed
dividends, NHIS investments, etc.
Federal Ministry of Health
Option 6: Private-sector involvement
Providing robust and enabling
guidelines for the establishment and use
of Private Voluntary Health Insurance
Certain categories of the informal sector
Formal private sector
Federal Ministry of Health
5.0 Recommended
Strive for more health for money (improved
efficiency in use of available funds)
Develop cost strategic plans for achieving UHC in
Nigeria: develop and cost 38 plans (for the Federal,
36 states and the FCT)
Continually generate and use evidence to improve
the functioning of the UHC schemes in Nigeria
Information Education and Communication to the
strategic decision makers, and to the general public
Federal Ministry of Health
6.0 References
AFHEA. Toward universal health coverage in Africa: Key issues. AfHEA 2nd Conference – 2011.
Palm Beach Hotel, Saly – Sénégal: 15th - 17th March 2011
CBHI Nigeria Brief rev UN CPG 052912
Chua HT and Chah JCH (2012). Financing Universal coverage in Malaysia: a case study. BMC
Public Health, 12(Suppl 1) S7:S7
Di McIntyre. Conceptual issues related to universal coverage. AHPSR Proposal Development
Workshop. Cape Town, 22 March, 2011.
More Health for the Money CPG rev UN 052912
More Money for Health Nigeria Brief RG CPG rev UN 052912
National Bureau of Statistics (NBS) 2007, Nigeria Multiple Indicator Cluster Survey 2007 Final
National Bureau of Statistics (2006).
Obinna Onwujekwe & Benjamin Uzochukwu(2009). Benefit incidence analysis of priority public
health services and financing incidence analysis of household payment for healthcare in Enugu and
Anambra states, Nigeria.
Obinna Onwujekwe, Ogo Ezeoke, Felix Obi and Benjamin Uzochukwu (2011). Situation analysis of
financial health risk protection: Nigeria. Health Policy Research Group, College of Medicine, University
of Nigeria and RESYST Consortium: London School of Hygiene and Tropical Medicine.
Federal Ministry of Health
Onoka CA, Onwujekwe OE, Hanson K, Uzochukwu BS (2011). Examining catastrophic health
expenditures at variable thresholds using household consumption expenditure diaries. Trop med int
health doi: 10.1111/j.1365-3156.2011.02836
National Bureau for Statistics (NBS), 2004. The 2004 National Living Standard Survey (NLSS).
Abuja: NBS.
Obinna Onwujekwe & Edit Velenyi: Feasibility of private voluntary health insurance in Nigeria:
valuation of benefits and equity assessment
National Population Commission and ICF Macro (2009): Nigeria Demographic and Health Survey
Federal Ministry of Health