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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 3  |  Page : 126-133

Health financing mechanisms and extension of health coverage to the poor and vulnerable groups: What options are available in the Nigerian context?


1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Submission25-Jul-2019
Date of Acceptance20-Aug-2019
Date of Web Publication27-Nov-2019

Correspondence Address:
Dr. Godpower C Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Zaria Road, P.M.B. 3452, Kano.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrr.jhrr_43_19

Rights and Permissions
  Abstract 

Background: Prepayment health-care financing mechanisms are recommended for achieving universal health coverage (UHC) as it prevents catastrophic health-care expenditure and poverty. This preference is due to the inadequacies of the out-of-pocket model in many low- and middle-income countries such as Nigeria. However, it took Nigeria several decades to operationalize the national health insurance scheme in 2005. This review aimed at highlighting various health-care financing options and their suitability for providing health care to all (including the poor and vulnerable groups). Materials and Methods: Data for this review were obtained from searching Google Scholar, MEDLINE (via PubMed), and African Journal Online, using relevant terms (in English language) that addressed health-care financing options and their suitability for UHC (including the poor and vulnerable groups) and were published between January 2007 and May 2019. Studies published in other languages were excluded for lack of resources to translate them. Results: Out-of-pocket, general taxation, private, community-based, and social health insurance, and innovative financing were found to have differing attributes. The social health insurance adopted by low- and middle-income countries such as Nigeria appears promising but not without challenges. Conclusion: A mixed model of social health insurance and general taxation is a prospect in extending health coverage to all citizens including the poor and vulnerable groups. Information on health financing options offers stakeholders the opportunity to understand the attributes of these options, an essential in the choice of a suitable mechanism that can deliver UHC.

Keywords: Health financing, National health insurance scheme, Poor, Universal health coverage, Vulnerable


How to cite this article:
Michael GC, Aliyu I, Grema BA. Health financing mechanisms and extension of health coverage to the poor and vulnerable groups: What options are available in the Nigerian context?. J Health Res Rev 2019;6:126-33

How to cite this URL:
Michael GC, Aliyu I, Grema BA. Health financing mechanisms and extension of health coverage to the poor and vulnerable groups: What options are available in the Nigerian context?. J Health Res Rev [serial online] 2019 [cited 2019 Dec 10];6:126-33. Available from: http://www.jhrr.org/text.asp?2019/6/3/126/271842


  Introduction Top


Health is a basic human right as enshrined in several treaties such as the United Nations Committee on Economic, Social, and Cultural Rights signed by many countries.[1] As a human capital, health determines an individual’s economic and job productivity, school-learning capacity, and intellectual growth, which eventually rubs off on the nation.[2],[3],[4],[5] However, prevailing global health inequality necessitated the 2005 World Health Assembly resolution on Universal Health Coverage (UHC).[6] It recommended that member states should design health financing systems that provide people with access to effective and quality health-care services that do not cause financial hardship on utilization.[7] In pursuance of this objective, goal 3.8 of the Sustainable Development Goals was also designed to achieve UHC (including quality essential service coverage and financial protection for all)[8] after the Millennium Development Goals (MDGs) ended in 2015. Access to needed health care, plus financial risk protection for all (including the poor and vulnerable groups such as the unemployed, elderly, handicapped, and under-five children)[9],[10] are therefore core principles behind UHC.

Unfortunately, approximately 80% of sub-Saharan Africa (SSA) and parts of Asia are without health protection;[11] for instance, only few countries in SSA spend $34–$40 per person annually (minimum amount recommended by World Health Organization [WHO]) to provide basic health care.[12] This leaves the region in dire need for sustainable health-care financing systems.

A health financing system is a means by which funds are generated, allocated, and utilized for health care.[13] To achieve UHC, choices must be made in the areas of revenue mobilization (equitable and efficient collection of contributions), pooling (pooled contributions to share the cost of illness), and purchase of health care (using pooled contributions to purchase care).

With a population of over 170 million people,[14] Nigeria has a predominantly out-of-pocket (OOP) health financing mechanism, thus making attainment of UHC a challenge.[15] Studies that improve stakeholders’ (e.g., policy makers, medical practitioners, and citizens) knowledge about the characteristics of health-care financing options becomes imperative. This information is useful in making informed decisions on the appropriate mix of health financing mechanisms toward UHC in Nigeria, and similar low- and middle-income countries, especially as many donor agencies tend to prescribe new health financing options as preconditions for benefiting from their funds.[16]


  Materials and Methods Top


To obtain data for this review, we searched Google Scholar, MEDLINE (via PubMed), and African Journal Online from January 1, 2007 to May 30, 2019, for publications addressing health-care financing options and extension of health coverage to poor and vulnerable groups. The keywords (in English language) for the search included but not limited to “healthcare financing,” “health care financing in Nigeria,” “financing health,” “financing policies,” and “healthcare financing for poor and vulnerable groups.” This was carried out to obtain maximum number of studies that addresses the issues of “universal health coverage,” “out-of-pocket financing,” “general taxation,” “micro health insurance,” “private insurance,” and “social health insurance.” The reference list of obtained articles was also scanned for additional relevant studies using electronic search. We also searched for gray literature from conference proceedings, documents from organizations (e.g., WHO), and book chapters. We excluded studies published in other languages because we lacked the resources for translation [Figure 1].
Figure 1: Flow diagram of article selection

Click here to view



  Discussion Top


There are two main health-care financing mechanisms, which are as follows:

  1. Direct or OOP payments: In half of the countries in Africa, at least 40% of their average total health expenditure is from OOP payments.[17] It is the predominant mode of payment for health services in Nigeria.[18],[19],[20],[21],[22],[23],[24] By this mechanism, health-care consumers purchase services (either partly or in full) on their own at the point of utilization.[24] Payments are made in the form of hospital consultation fees, payment for drugs, investigations, and other private payments (official or unofficial) to health-care providers for medical, surgical services, and other forms of treatment; co-payments and deductibles made by insured consumers also constitute OOP, even though they are used to curtail moral hazards.[24] This model of health financing has been described as the most regressive model;[17] it offers no protection to the consumer from the financial risk of ill-health. The poor and vulnerable groups (who need these services the most) often have to draw from their meagre savings, borrow, and sell productive goods such as farm produce, cattle, poultry, and land to settle the cost of illness.[25] This consequently results in financial catastrophe and poverty. This model also breeds inequity, as the concept of equity supports that individuals should contribute to health-care funding according to their ability to pay and should benefit from health services according to their health-care needs.[26] Another challenge of this model is that it discourages service utilization by poor and vulnerable groups; this often results in uptake of inferior and sometimes dangerous alternate health-care services to meet their needs.[20],[21] The WHO states that excluding poor funding of health-care services by various governments and the inefficient and inequitable use of available resources, and overreliance on OOP is the greatest obstacle to attaining UHC.[7] The elimination of user fees for women and under-five children was thereafter recommended as an effective strategy in achieving the health-related MDGs in low- and middle-income countries.[27],[28] Elimination of user fees in many African countries (including some states in Nigeria) for under-five children and pregnant women has resulted in increased utilization of services.[29],[30],[31] Finally, it has been argued that OOP payment confers some benefits to the user (especially the rich); for instance, the right to choose their health-care provider,[28] but it is clearly not suitable to extend health-care coverage to the poor and vulnerable groups.


  2. Prepayment mechanisms: Prepayment mechanisms are usually in the form of health insurance. The concept of health insurance arose from the uncertainty associated health-care goods and the inadequacies of the OOP payment for health care.[32] Health insurance operates where people with similar aspirations (seeking to protect themselves against impoverishment from ill-health) but varying probabilities of ill-health are willing to contribute funds to a common pool; the larger the pool the more sustainable the health insurance as the cost of care tends to be lower (from economies of scale) and the risk is evenly distributed among the insured population.[33] There are various unique models of health insurance, namely national, social, private, community-based, and mixed models.[34],[35],[36],[37]


National health insurance (general taxation)

This is often referred to as the Beveridge model, originating from the Beveridge report of 1942, which became the British National Health Service.[34],[38],[39] In this government-run national health service model, funding is solely by government via general taxation (from fiscal health budget allocation, value-added tax, income tax, federal royalties, and other local levies). This model may offer a large scope for raising funds, it is mandatory and it effectively covers households in the entire population (including the poor and vulnerable groups), it has simple mode of governance, and its universal coverage may reduce moral hazards.[28],[40] However, it has its limitations. Its benefit packages are usually fixed and determined by government; funding could be subject to political pressures (e.g., regime change or fall in revenue); there may be inefficiencies in health-care delivery derived from the lack of competition; beneficiaries lack the power to choose their health-care provider (nonresponsiveness); and it requires effective tax collection system, which is presently lacking in many developing countries;[28],[40] for instance, only 14 million (or one in five) of the 70 million economically active Nigerians were paying taxes in 2017,[41] and taxation is often limited to employees of the organized formal sector. In addition, there is a lack of participation and ownership by beneficiaries (who make no financial contribution), resulting in abuse of the scheme. Thus, general taxation requires strong political support (e.g., legislation and funding), involvement of all stakeholders, consideration of all sociocultural factors in the design and implementation (e.g., religious reservations with the concept of insurance) and monitoring and evaluation of the scheme.[28] Some benefits of Bismarck-based systems (social health insurance, discussed below) over the Beveridge model (such as the better overall mortality rates and life expectancy reported in the 1980s) could be attributed to the aforementioned limitations of general taxation.[39],[40]

Community-based, micro-health, or mutual health insurance

This insurance model offers opportunity to households, communities, low-income groups, and the informal sector to mobilize resources for financing all or part of their health-care cost.[42],[43] It is managed and operated by selected individuals from the community or organizations other than the government. It is funded from premiums paid by low-income individuals or households, sometimes augmented by subsidies from government and donor agencies; in some high-income countries such as the US, it is used to complement other forms of health insurance (such as social health insurance).[28],[44] In this model, subsidies are often required to facilitate premium payment for the poor and other vulnerable groups.[28] Success stories about community-based health insurance have come from Ghana,[45] Kwara State and Federal capital territory of Nigeria,[45] Kenya,[46] and India (as micro-health insurance), where this model has increased access to and utilization of health-care services.[36],[37],[47],[48] However, where it is practiced, subsidies are hardly sustainable, therefore excluding the poor who are unable to pay the premium. In addition, there is poor awareness and understanding of this model among rural, suburban, and even city dwellers.[49],[50] There is also perceived low quality of care; the risk pool is usually small, limiting financial risk protection of beneficiaries; there is a tendency to bankruptcy usually from its weak managerial capacity, poor technical design, fraud, adverse risk selection, and cost escalation; and its limited benefit package when used alone does not impact health-care delivery.[28],[48]

Private (voluntary) insurance

This model is ostensibly funded by premiums paid by households, employees, and employers of usually the middle- and high-income groups.[51],[52] It can be used to supplement other health financing models.[53] The advantages of this model in high-income countries include greater consumer choices, additional resource mobilization, higher individual responsibility, market competition, and better cost control, usually associated with better insurance management capacity.[28],[51],[52] However, the model typically excludes the poor and vulnerable groups, whereas it competes for healthy and wealthy members (adverse selection and cream-skimming);[52] some studies have estimated the cost of private insurance administration to be about 10 times higher than the administration cost of social health insurance.[35]

Social health insurance

This is often referred to as the Bismarck model.[38],[39],[40] Funding is from the contribution of employees and their employers; membership is mandatory with rich and healthy members subsidizing for poor and sick members.[28] The insured, irrespective of health risk, contributes a proportion of their income to access health care according to their health-care needs, irrespective of their socioeconomic status, age, ability to pay, or geographical location.[54],[55] The funds are usually specifically earmarked for health, making them a predictable and potentially sustainable funding option. Beneficiaries participation, ownership, and support impact health-care provider choices or responsiveness.[56] After considering the various health financing options in 2007, the African Union Conference of health ministers specifically called for the adoption of the social health insurance along with the abolition of user fees.[57] However, this model is often limited to employees of the formal sector. Again, with inflation, economic depression, massive job losses, or tax evasion funding of this model can be affected.[28]

Donor funding

This is the financial assistance that developing countries receive to support health and socioeconomic development. This assistance comes from external agencies and nongovernmental organizations such as the World Bank, WHO, and United Nations Children Fund.[5] Donor funding is usually temporary and often inadequate; it accounted for only 4% of Nigeria’s public health expenditure in 2005 and has been dwindling in recent years.[58] This has been a source of extra funding for health-care services at both state and federal levels in Nigeria.

Innovative financing

This refers to “non-traditional applications of official developmental assistants (e.g., donor funding), joint public-private mechanisms, and flows that either support fund-raising by tapping new resources or deliver financial solutions to developmental problems on the ground.”[59] It was designed at the time for low- and middle-income countries to fill the financial gaps of achieving the MDGs. Some countries, consequently, introduced special levies to raise additional funding for health care, (e.g., Gabon introduced 10% levy on mobile phone companies and Pakistan introduced tax on pharmaceutical companies).[60],[61],[62] A few notable organizations such as Global Funds, GAVI (global alliance for vaccines and immunization) alliance, and Unitaid are products of innovative financing.[63]

Universal health coverage in the Nigerian context

In Nigeria, health care is provided by both the private sector (private-for-profit, faith-based, nongovernmental, and traditional care providers) and the public sector.[64] The public sector is decentralized into federal, state, and local governments. The Federal Ministry of Health (FMOH) is the policy-making body and coordinates and supervises the other levels (36 states and the Federal Capital Territory and 774 local government areas). The FMOH provides tertiary care via teaching hospitals and federal medical centers; the States Ministry of Health provide secondary care via the state hospitals and comprehensive health centers, whereas the local government health departments provide care through the primary health centers (PHCs). However, the three-tiers of government and some agencies also participate in the management of the PHCs, which sometimes result in duplication and confusion of roles and responsibilities.[65] Health care in Nigeria is financed by a combination of user fees (constituting nearly 70% of total national health-care expenditure in 2012),[66] health insurance scheme (social and community), and donor funding.[67] However, fiscal allocation to health (both federal and state governments) has been dwindling in recent years; for instance, only 4% of Nigeria’s annual budget was allocated to health in 2018 (below the 15% target).[68],[69]

In response to the need for UHC, the Nigerian Federal Government launched the National Health Insurance Scheme (NHIS) in June 2005, to provide accessible, high-quality health-care services to all Nigerians while protecting them from the high cost of care.[70] This is a social health insurance model rolled out in three programs, namely the formal sector social health insurance programs (i.e., public sector—federal, states, and local governments, organized private sector, armed forces, police and other uniformed services, and students of tertiary institution social health insurance programs), the informal sector social health insurance programs (community-based social health insurance programs and voluntary contributors social health insurance programs), and vulnerable group social health insurance program (physically challenged persons, prisons inmates, children under five, refugees, victims of human trafficking, internally displaced persons and immigrants social health insurance program, and pregnant women).[70] The states were expected to buy into this model.

However, less than 5% of Nigerians are enrolled into the NHIS with mostly formal sector enrollees and very poor coverage of the informal sector.[18],[71],[72],[73] Several states have started enrolling their employees, whereas a few (Lagos, Kwara, Ogun, and Akwa Ibom) are implementing community-based health insurance program (voluntary) to cover the informal sector, though at varying levels of coverage and facing sustainability challenges.[74] It is known that no country can achieve UHC with voluntary health insurance;[75] hence, the need for government-led funding (i.e., a mixed model of general taxation and social health insurance) to make enrollment mandatory and provide subsidies to offset the cost of care for the poor and vulnerable members of society. With the signing of National Health Act (NHA), it is expected that more funds would be available to fast-track the achievement of UHC;[76] it is also expected that 50% of the funds will be managed by NHIS to ensure minimum package of health care for all Nigerians. However, the NHA is yet to be implemented, partly because of delays in counterpart funding from the states and local governments. Furthermore, the 2010 World Health Report estimated that 20%–40% of all health sector resources are wasted.[75] Therefore, current inefficiencies and corruption in the management of available health-care resources are challenges to overcome in order to achieve UHC.[77],[78]

Policy implication

A mixed model of social health insurance and general taxation appears suitable for extending health coverage to the poor and vulnerable groups. To achieve this, government must take the lead, make enrollment into NHIS mandatory to all Nigerians, and explore innovative ways of sustainable funding. Political support is required in funding and legislation, commitment by all stakeholders is also required for the provision of efficient services, and efficient and equitable use of resources must also be insured. Corruption in health care must be eliminated. Mass education on health insurance will be required to promote community participation and national solidarity necessary for sustaining its programs.


  Conclusion Top


User fees have become old-fashioned in the global quest for UHC. Various prepayment mechanisms have differing attributes. There are challenges with informal sector social health insurance, especially where the proportion of extremely poor people is high. A mixed model of social health insurance and general taxation should be explored as it may guarantee mandatory participation of all citizens and sustainable funding. Information on health financing options offers stakeholders the opportunity to understand the attributes of these options, which are essential in the choice of a suitable mechanism that can deliver UHC.

Ethical policy and institutional review board statement

This review article does not require ethical consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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