The Healthcare Delivery System in Nigeria: Legal

Framework, Obstacles and Challenges to Providing a

Public Insurance System

By Darlynton Okiemute Ofekeze*

ABSTRACT

This work seeks to examine the Nigerian Healthcare system through the lens of its public
health insurance laws to access its successes and challenges and also make recommedations
towards an effective healthcare delivery system.

INTRODUCTION

Healthcare delivery in Nigeria is both a private and government business. The Federal and
State goverment are allowed to set up hospitals and other health facilities. Effective health‐
care delivery is usually a function of the quality, accessibiity and affordability of the ser‐
vice.
Over the years, there has been a rise in Nigeria’s poverty level.1 Consequently, the abili‐
ty to afford basic healthcare for common illnesses by the average Nigerian reduced drasti‐
cally and in more extreme illnesses, citizens had to resort to sale of personal effects and/or
real property, rely strongly on personal savings and/or resort to taking loans in order to be
able to attend to their health needs adequately.2
Also, Nigeria’s healthcare system have been bedevilled by lack of adequately trained
personnel available to carry out medical work as well as lack of required medical equip‐
ment needed to aid the delivery of qualitative healthcare.
The establishment of the Nigerian Health Insurance Scheme was the Government effort
towards improving the quality, availability and affordability of medical services to its citi‐
zenry.

* Managing Partner, Onyx & Bricks (Barristers and Solicitors) Nigerian General Service Law Firm,
dofekeze@onyxandbricks.com.ng
1 Statistics from Nigeria’s National Bureau of Statistics show that the poverty index of the country
between the early 80s and the mid 90s progressed from 27.2 % to 65.6 %. See Zunumhan Da‐
pel, 'Poverty in Nigeria: Understanding and Bridging the Divide between North and South' (Center
for global development, 6th April) <https://www.cgdev.org/blog/poverty-nigeria-understanding-and
-bridging-divide-between-north-and-south> accessed 20 September, 2020.
2 A. O. Abiola et al., 'Knowledge and utilisation of National Health Insurance Scheme Among Adult
Patients Attending a Tertiary Health Facility in Lagos State, South-Western Nige‐
ria' [2019] 11(1) African Journal of Primary Healthcare & Family Medicine.

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LEGAL FRAMEWORK OF NIGERIA’S HEALTHCARE DELIVERY SYSTEM

Quality healthcare is not a fundamental human right in Ngeria,however, it forms part of the
Fundamental Objectives and Directive Principles of State policy.3 The implication of this is
that quality health is not a right that can be enforced in a court of law but every government
has an obligation to provide quality healthcare services to it citizens.
The major legislations which regulate healthcare delivery in Nigeria are as follows;
1. National Health Act
2. Medical and Dental Practitioners Act (MDPA) CAP M8, LFN2004
3. Nursing and Midwifery (Registration, etc.) Act 1979
4. The Compulsory Treatment and Care for Victims of Gunshot Act 2017
5. The code of Medical Ethics in Nigeria.
6. National Health Insurance Scheme Act (NHIS), 2004
The NHIS Act established the National Health Insurance Scheme for the purpose of impro‐
ving the health of all Nigerians by providing social health insurance in Nigeria where heal‐
thcare services of contributors are paid from the common pool of funds contributed by the
participants of the scheme.4 The scheme was introduced by the federal government of Nige‐
ria with the following objectives namely:
A. Ensuring that every Nigerian has access to good healthcare services;
B. Protecting families from the financial hardship of huge medical bills;
C. Limiting the rise in the cost of healthcare services;
D. Ensuring equitable distribution of healthcare costs among differentincome groups;
E. Maintaining high standard of healthcare delivery services within the Scheme;
F. Ensuring efficiency in healthcare services;
G. Improve and harness private sector participation in the provision of healthcare services;
H. Ensuring adequate distribution of health facilities within the Federation;
I. Ensuring equitable patronage of all levels of healthcare;
Ensuring the availability of funds to the health sector for improved services.5
THE MACHINERY OF THE NATIONAL HEALTH INSURANCE SCHEME
The NHIS Act sets up a Governing Council which is responsible for management of the
scheme. The NHIS Act outlines the role of the Council as follows;
A. Registering health maintenance organisations and healthcare providers under. the
Scheme;
B. Issuing appropriate guidelines to maintain the viability of the Scheme;
C. Approving format of contracts proposed by the health maintenance organisations for all
healthcare providers;

3 Section 17(3) (d) of the Constitution of the Federal Republic of Nigeria, 1999 (as amended).
4 In www.nhis.gov.ng/about-us/ (accessed 20th September, 2020).
5 See Section 5 of the National Health Insurance Scheme Act, CAP N42, L.F.N, 2004.

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The Healthcare Delivery System in Nigeria

D. Determining after negotiation, capitation and other payments due healthcare providers,
by the health maintenance organisations;
E. Advising the relevant bodies on inter-relationship of the Scheme with other social secu‐
rity services;
F. Conducting research and providing statistics of matters relating to the Scheme;
G. Advising on the continuous improvement of quality of services provided under the
Scheme through guidelines issued by the Standard Committee established under the
Act;
H. Determining the remuneration and allowances of all staff of theScheme;
I. Exchanging information and data with the National Health Management Information
System, Nigerian Social Insurance Trust Fund, the Federal Office of Statistics, the Cen‐
tral Bank of Nigeria, banks and other financial institutions, the Federal Inland Revenue
Service, the State Internal Revenue Services and other relevant bodies;
J. Doing such other things as are necessary or expedient for the purpose of achieving the
objectives of the Scheme under this Decree.6
The Act provides for the registeration of Health Care Providers. These registered Health
Care Providers are obligated to provide a range of medical services to persons enrolled un‐
der the scheme in consideration for a capitation payment in respect of each insured person
registered with it, or for payment of approved fees for services. The medical services as de‐
tailed under the Act are as follows7:
1. defined elements of curative care;
2. prescribed drugs and diagnostic tests;
3. maternity care for up to four live births for every insured person;
4. preventive care, including immunization, family planning, ante natal and post natal
care;
5. consultation with defined range of specialists;
6. hospital care in a public or private hospital in a standard ward during a stated duration
of stay8 for physical or mental disorders;
7. eye examination and care, excluding test and the ad provision of spectacles; and
8. a range of prosthesis and dental care as defined.
The Scheme is admnistered by registered Health Maintenance Organisations (HMOs). The
registeration of the HMOs is done by the Governing Council of the Scheme. The HMOs
have the responsibility for;
1. The collection of contributions from eligible employers and employees under the Act.
2. The collection of contributions from voluntary contributors under the Act

6 Section 6 of the National Health Insurance Scheme Act, CAP N42, L.F.N, 2004.
7 Section 18(1).
8 The NHIS Guidelines usually sets the duration of stay at a cumulative number of 21 days in a year.

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3. The payment of capitation fees for services rendered by health care providers registered
under the Scheme.
4. Rendering to the Scheme returns on its activities as may be required by the Council
5. Contracting only with the healthcare providers approved by the Scheme for the purpose
of rendering health care services under the Act.
6. Ensuring that contributions are kept in accordance with guidelines issued by the Coun‐
cil and in banks approved by the Council and
7. Establishing a quality assurance system to ensure that qualitative care is given by
healthcare providers.
Presently, the Scheme has developed various programmes to cover different segments of
the society and these are:

FORMAL SECTOR

1. Formal Sector Social Health Insurance Programme

2. Mobile Health
3. Vital Contributors Social Health Insurance Programmes

INFORMAL SECTOR

1. Tertiary Institution Social Health Insurance Programmes

2. Community Based Social Health Insurance Programmes
3. Public Private Partnership Social Health Insurance Programmes

VULNERABLE GROUP

1. Pregnant Women
2. Children Under five
3. Prison Inmates
4. Retirees
5. Aged

FORMAL SECTOR

The Formal Sector Social Health Insurance Programme9. is a social health security system
in which the health care of employees in the Formal Sector is paid for from funds created
by pooling the contributions of employees and employers.

9 National Health Insurance Scheme, “The Formal Sector Health Insurance Programme” in https://w
ww.nhis.gov.ng/formal-sector-social-health-insurance-programmefsship/ accessed (September 23,
2020).

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The Healthcare Delivery System in Nigeria

The Formal Sector consists of the following:

1. Public Sector
2. Organized Private Sector
3. Armed Forces, Police and other Uniformed Services

MEMBERSHIP

Employees of the public sector and organized private sector organizations employing ten
(10) or more persons shall participate in the Programme.10

CONTRIBUTIONS.

Contributions are earnings-related. For public (Federal) sector programme, the employer
pays 3.5 % while the employee pays 1.75 % of the employee’s consolidated salary. For the
private sector programme and other tiers of Government, the employer pays 10 % while the
employee pays 5 % representing 15 % of the employee’s basic salary. However, the em‐
ployer may decide to pay the entire contribution. The employer may also undertake extra
contributions for additional cover to the benefit package.

PAYMENT MECHANISM

NHIS pays capitation for primary care and Fee-for-service upon referral through accredited
HMOs to accredited Healthcare facilities

WAITING PERIOD

There shall be a processing/waiting period of ninety (90) days before a participant can ac‐
cess health care services.

SCOPE OF COVERAGE

1. The contributions paid cover health care benefits for the employee, a spouse and four
(4) biological children below the age of 18 years.
2. More dependants or children above the age of 18 are covered on the payment of addi‐
tional contributions by the principal beneficiary as determined by NHIS.
3. Principals are entitled to register four (4) biological children each, however a spouse or
a child cannot be registered.

10 Section 16(1) (2) of the National Health Insurance Scheme Act, CAP N42, L.F.N, 2004.

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VITAL CONTRIBUTORS SOCIAL HEALTH INSURANCE PROGRAMME

Vital Contributors Social Health Insurance Programme (VCSHIP)11is health insurance that
is taken up and paid for at the discretion of willing individuals or at the discretion of em‐
ployers on behalf of employee in organization with less than ten staff. It is a programme
designed for those who are not currently covered by any of the NHIS programmes and for
those who may not have been satisfied with the existing health care services.
This programme shall provide full or partial coverage for services that are excluded or
not fully covered by statutory health system. Premiums in Social Health Insurance are not
risk related and access to health care by voluntary contributors is always dependent on
proof of contribution.
Family members of persons voluntarily insured in Nigeria social health insurance
scheme are not covered as co-insured. The Enabling law establishing the Scheme and the
Operational Guidelines of NHIS refers to these group of people as:
● Large number of financially viable Nigerian businessmen and women with staff strength
of less than ten but could not be categorized under OPS programme and not yet covered.
● An active self employed individual not covered and categorized under CBSHIP but
willing to participate in the programme.
● Retirees who wish to continue under NHIS Formal Sector Programme
● Political office holders
● Foreigners living in Nigeria (legal residents),etc

MEMBERSHIP

Membership shall be voluntary and shall cover interested individuals, families, employers
of establishments with less than ten staff, and actively self employed persons, political of‐
fice holders at three tiers of governments and retirees not currently covered by any of the
NHIS prepaid programmes. Others are foreigners to Nigeria or persons with temporary resi‐
dency status and Nigerians in Diaspora.
Note: all extra dependants registered under formal sector programme should be trans‐
ferred and folded into VCSHIP.

FINANCING

The programme shall be financed from contributions made by interested individuals.

11 National Health Insurance Scheme, “Vital Contributors Social Health Insurance Programme” in
https://www.nhis.gov.ng/voluntary-contributor-social-health-insurance-programmevcship/
(accessed September 23, 2020). Also see the provisions of Section 17 (3) of the National Health
Insurance Scheme Act, CAP N42, L.F.N, 2004.

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The Healthcare Delivery System in Nigeria

INFORMAL SECTOR GROUP

Under the informal sector group, there is the the Tertiary Institution Social Health Insurance
Programme; the Community Based Social Health Insurance Programme; the Public Prima‐
ry Pupil Social Health Insurance Programmes.

TERTIARY INSTITUTION SOCIAL HEALTH INSURANCE PROGRAMME

The Tertiary Institutions Social Health Insurance Programme12 (TISHIP) is a social security
system whereby the health care of students in tertiary institutions is paid for from funds
pooled through the contributions of students. It is a programme committed to ensuring ac‐
cess to qualitative healthcare service for students of tertiary institutions thereby promoting
the health of students with a view to creating conducive learning environment. It takes co‐
gnizance of the current practices and challenges faced by students in accessing care both
during and out of session, as well as the potential of the current tertiary health facilities to
maximize access to quality health care. Tertiary institutions are categorized as Universities,
Colleges of Education, Polytechnics, Colleges of Agriculture, Monotechnics, Schools of
Nursing, Midwifery, Health Technology and other Specialized Institutions.
The purpose of TISHIP is to cater for the health care needs of Nigerian students in ter‐
tiary institutions who due to their studentship status cannot benefit under other health insu‐
rance programmes.
This population constitutes a very large percentage of the country’s population. By vir‐
tue of their age and their status as students, most of them cannot benefit from the public
sector programme as enrollees or dependants of enrollees. This necessitates a programme
designed to meet their needs.
Providing students access to qualitative and affordable healthcare is not only imperative
to the achievement of the presidential mandate which is to achieve universal coverage and
access to healthcare services for all Nigerians and legal residents but also to the overall de‐
velopment of our nation.
The ultimate goal is to ensure the health and well-being of this critical population 9
with a view to creating a conducive learning environment and contributing to the overall
development of the country.

12 National Health Insurance Scheme, “The Tertiary Institutions Social Health Insurance Pro‐
gramme” https://www.nhis.gov.ng/tertiary-social-health-insurance-programmetiship/ (accessed on
September 22, 2020).

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THE COMMUNITY BASED SOCIAL HEALTH INSURANCE PROGRAMME

Community Based Social Health Insurance Programme13 is a non-profit making pro‐

gramme for a cohesive group of households/individuals or occupation-based groups. It was
formed on the basis of the ethics of mutual aid and the collective pooling of health risks, in
which members take part in its management.

MEMBERSHIP

This shall be voluntary and open to all residents (families) of the participating communi‐
ties/occupation-based groups (including retirees). The family or individual members shall
be the unit of registration. In order to achieve a critical pool of funds to ensure financial
viability, as well as to address the problem of adverse selection, communities/occupation-
based groups shall have at least 50 % of members willing to participate (or a minimum of
1000 members).

REGISTRATION PROCEDURE

Registration of enrollees shall be by technical facilitators or BOTs. Each programme shall

have a clearly defined procedure for registering enrollees as well as a form of identification
(such as membership card) to assist in the identification of scheme members.

BENEFIT PACKAGE

The benefit package shall reflect preventive, promotive and curative components of health
care delivery. It shall aim at minimum primary and secondary curative care, taking into co‐
gnizance the prevailing local morbidity and mortality profile, including pre- & post-natal
care, normal delivery, child welfare services (including immunization), family planning and
health education services.

CONTRIBUTION/PREMIUM

This shall be actuarially determined flat rate fee per household/individual household mem‐
ber or member of an occupation based group and paid in cash monthly or seasonally in ad‐
vance.

13 National Health Insurance Scheme, Community Based Social Health Insurance Programme, https:/
/www.nhis.gov.ng/community-based-social-health-insurance-programmecbship/ (accessed on
September 24, 2020).

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DONATIONS

Project managers may seek for donations/grants by way of formal launching/fund-raising

events, or by targeting individuals, governmental and Civil Society Organizations, inclu‐
ding private companies, with the aim to boost the financial base of this scheme.

VULNERABLE GROUP SOCIAL HEALTH INSURANCE PROGRAMMES

Vulnerable Group Social Health Insurance Programmes14 are designed to provide health
care services to persons who due to their physical status (including age) cannot engage in
any meaningful economic activity.
They include the following:
1. Physically Challenged Persons Social Health Insurance Programme(PCPSHIP):- Physi‐
cally Challenged Persons Social Health Insurance Programme is a programme designed
to provide health care services to Physically/Mentally Challenged Persons who due to
their physical status cannot engage in any meaningful economic activity.
Membership:Physically/Mentally Challenged Persons will be covered under the pro‐
gramme
Contributions
The Federal, States, Local Governments, Development Partners and Civil Society Organi‐
zations will pay contributions in advance into the Vulnerable Group Fund.
2. Prison Inmates Social Health Insurance Programme(PISHIP):- A programme designed
to providehealth care services to inmates of Nigeria Prisons and offending minors in
Borstal Homes, who byvirtue of their restriction, cannot engage in any activity to earn
income.
Membership
1. Convicts
2. Awaiting trial (remanded in Prison custody).
3. Offending Minors in Borstal Homes.
Contribution: – The Federal, States and Local Governments, Development Partners and Ci‐
vil Society Organizations (CSOs) will pay contributions in advance into the Vulnerable
Group Fund.
3. Children Under Five (5) Social Health Insurance Programme (CUFSHIP):- Children
under Five Social Health Insurance Programme (CUFSHIP) is a programme designed
to cover the health needs of Children under the age of five (5) years across the country,
who are considered vulnerable.

14 National Health Insurance Scheme, Vulnerable Group Social Health Insurance Programmes, https:
//www.nhis.gov.ng/vulnerable-group/ (accessed on September 25, 2020).

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Membership: – Children under the age of five (5) years especially those whose parents are
participating in Community Based Social Health Insurance Programme (CBSHIP).
Contributions; – The Federal, State, Local Government, Development Partners and Civil
Society Organizations will pay contributions in advance into the Vulnerable Group Fund.
4. Pregnant Women
5. Aged
For the purpose of admnistration of the Scheme, the Country is divided into Zones by the
Council15. The Zonal office is responsible in the zone for-16
1. Determining the areas in which there are sufficient services for the scheme to operate;
2. Strategic planning for the successful implementation ofthe Scheme.
3. Undertaking programmes for phsing-in the Scheme
4. Maintaining a register of health care providers
5. Inspecting health care providers and their facilities to ensure that they maitain good
qulity services.
6. Developing health care services in areas where those services are not adequate.
7. Collecting statistics on consultations and admissions to hospitals, including length of
stay
8. Preparing report, accounts and statistical returns and forwarding them to the Council
9. The geneal admnistration of the Scheme
10. Promoting the good relations of the Scheme
Dispute Resolution under the Scheme is by an Arbitration Board set under the Act17
Any person (corporate body inclusive) who fails to pay into the account of any HMO
and within the time specified any contribution liable to be paid under the Act or deducts the
contribution from the employee’s wages and withholds the contribution or refuses or ne‐
glects to remit the contribution to the organisation concerned within the specified time is
guilty of a crimanal offence.18 The Act also makes a defaulting Director, Chief Executive,
Partner, Manager or Secretary of the Company personally laible for the crime19.
The Act also established a Standards Committee20 which is charged with the responsi‐
bility of recommending to the Scheme guidelines for the maintenance of quality assuarnce
among HMOs and Health Care Providers.
Since its operation, the Health insurance Scheme have provided better access to quality
medical services for its enrolles. It has also improved the quality of medical service deliv‐
ery as medical service providers now have access to more funds for medical equipment and

15 Section 21, NHIS Act.

16 Secion 22, NHIS Act.
17 Section 26, NHIS Act.
18 Section 28, NHIS Act.
19 Section 29, NHIS Act.
20 Section 46, NHIS Act.

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The Healthcare Delivery System in Nigeria

facilities. There is also more competiiton in the medical service industry which has im‐
porved service delivery. The scheme have also created opportunity for pooling of funds by
members of the public which in turn creates a form of subsidy as high income earners sub‐
sides healthcare for low income earners. It has eliminated the frequent out of pocket pay‐
ments for healthcare needs for its enrollees.

OBSTACLES AND CHALLENGES TO CREATING A PUBLIC INSURANCE

SYSTEM

A. PARTIAL IMPLEMENTATION AND UNDER SUBSCRIBTION TO THE SCHEME:

Despite being in operation for about 2 (two) decades, a great number of the populace
are still not disposed to subscribing to the scheme. Statistics show that only about 5 %
of the entire Nigerian population is covered by the Scheme21 and that percentage mostly
consists of individuals in the formal sector where employers compulsorily enroll thier
employees in the scheme. The vast majority of the populace still operate a “pay-as-go”
arrangment. This is largely due to lack of awareness of the cost effectiveness of the
scheme.
From available statistics, save for the Formal Sector programme of the Scheme, the other
programs have not been fully implemented.
B. POVERTY AND UNEMPLOYMENT: The country is still plagued with an epidemic of
widespread poverty.22 The rate of poverty in Nigeria as at the 2nd Quarter of 2020 is
estimated at 27.1 % which invariable translates to the fact that at least 21.7 million Ni‐
gerians are as it stands, unemployed.23 Due to the rising poverty rate which stems di‐
rectly from either unemployment or underemployment, a lot of persons struggle to have
thier basic needs of food and shelter and resort to orthodox medical care, quacks or self
medication when they fall sick.
C. THE GENERAL DISPOSITION TOWARDS INSURANCE: Traditionally, Nigerians
do not have an attraction towards insurance schemes. Hence most average Nigerians
see the Health Insurance Scheme as another ploy to strip individuals of their funds wi‐
thout adequate delivery of the benefits.

21 A. Onwuzoo, '15 Years After NHIS Establishment, Affordable Healthcare Still Eludes Nige‐
rians' (Punch Healthwise, 17th February) https://healthwise.punchng.com/15-years-after-nhis-estab
lishment-affordable-healthcare-still-eludes-nigerians/ accessed 30th September 2020.
22 The National Bureau of Statistics in its “Nigeria Living Standards Survey Report” for the year
2019 the percentage of poor people in Nigeria is currently measured at 40.1 % according to natio‐
nal standards in https://nairametrics.com/wp-content/uploads/2020/05/2019-POVERY-AND-INE
QUALITY-IN-NIGERIA.pdf Accessed October 10, 2020.
23 S. Oyekanmi, 'Nigeria’s Unemployment Rate Jumps to 271 % as at 2020 Q2' (Nairametrics, 14
August, 2020) https://nairametrics.com/2020/08/14/breaking-nigeria-unemployment-rate-jumps-to
-27-1/ accessed 14 October 2020.

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D. ABSENCE OF IMPLEMENTATION AT STATE LEVEL: Most states are yet to repli‐

cate the operation of the scheme at the state civil service level. Nigeria is a country
comprised of 36 states. Yet, only few states24 have taken steps to implement the
scheme.

RECOMMENDATIONS AND CONCLUSIONS

The Scheme is very laudble and its programmes are quite broad enough to cover a large
proportion of the Nigeria Populace. I therefore recommend the following;
A. COMPLETE IMPLEMENTATION: The Council should wholistically implement all its
progrmme to ensure a wider coverage of subscribers. This will provide a larger pool of
funds which will in turn improve the healthcare sector.
B. STATE WIDE IMPLEMENTATION: In Nigeria, the state at all levels remains the
largest employer of labour. Every state should enact laws which replicates the NHIS
Act that makes health insurance mandatory for all state and local government workers.

24 Onoka C, et al. “Why Are States Not Adopting the Formal Sector Programme of the NHIS and
What Strategies Can Encourage Adoption?” in https://www.who.int/alliance-hpsr/projects/alliance
hpsr_nigeriapolicybriefstates.pdf?ua=1 Accessed October 15, 2020.

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