Assessing efforts towards universal financial risk protection in low- and middle-income countries

National health insurance scheme in Nigeria: an analysis of constraints and enabling factors to adoption

The National Health Insurance Scheme (NHIS) was set up as a social health insurance programme in Nigeria that will ensure access to health care for all Nigerians. However, since its launch in 2005, only 4% of the population (mainly federal government employees) have been enrolled in the scheme despite efforts made to encourage enrolment across the country. Following the enrolment of federal civil servants, state governments were expected to adopt the programme for its employees and their dependents, an action which would have greatly expanded the breath of coverage. However, 6 years after the launch of the programme, two states Cross River State (in 2007) and Enugu (June 2010) have adopted the scheme while the remaining 34 states of the federation have not.

This study is aimed at understanding why different state governments have adopted or remained disinterested in participating in the NHIS and what packages, strategies and incentives are necessary to encourage programme adoption. The study will employ a case study approach to obtain information at the national level and two states. The states are Enugu and Ebonyi states which have and have not adopted the scheme and which have population sizes of 3,257,298 and 2,173,501 respectively. In-depth interviews will be used to obtain information from a range of policy makers, providers (including health care providers and Health Maintenance Organizations), as well as consumer groups.

At present, there is no published work about the adoption experiences with regards to the NHIS. In addition, factors that deserve consideration for improvement of such processes have not been documented. It is therefore important to understand how various factors have influenced the decisions at the sub-nationals levels towards adoption or otherwise of the programme. Such information will help those at different stages of adoption of the programme to facilitate the process and as such enhance expansion of the breath of coverage.

Research Goal
This study is aimed at understanding why different state (sub-national) governments have adopted/not adopted NHIS and what programme design packages and strategies are necessary to encourage programme adoption by state governments.

Specifically, the study will:
• determine how political contextual factors (resource flow system, political agendas and allegiances, changes in government leadership, vested interest) have enabled or constrained the adoption of the NHIS by the states
• examine how the decision-making process towards adoption in the two states has been influenced by the programme design, the management structure of the NHIS, competence of managers and the overall programme framework
• determine the institutional and individual influences and power that have been brought to bear in driving decision-making around NHIS at national and state levels including the issue of trust and how these have been deployed to influence decision making.

This study will generate information that is very much needed for evidence based programme improvement decisions for the National Health Insurance Scheme in Nigeria, and its expansion to across sub-national levels. This will help enhance the uptake of health insurance and help facilitate the attainment of the universal coverage objectives of the NHIS. Thus, this study will provide evidence of constraints to achieving universal coverage as Nigeria is one of the examples of countries where this global objective is not being realized.


Project description

Programme: Assessing efforts towards universal financial risk protection in low- and middle-income countries

Research title: National health insurance scheme in Nigeria: an analysis of constraints and enabling factors to adoption

Thematic Research Area: Health Financing

Grantee Country: Nigeria

Grantee Institution: University of Nigeria

Programme coordinator: Dr Onoka Chima

Start date: September 2010

Status of grant: Ongoing

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