Open access peer-reviewed chapter

Coverage: Measure of Achieving Universal Health Coverage in Nigeria

Written By

Habibu Salisu Badamasi

Submitted: 21 May 2021 Reviewed: 17 June 2021 Published: 09 February 2022

DOI: 10.5772/intechopen.98948

From the Edited Volume

Healthcare Access

Edited by Amit Agrawal and Srinivas Kosgi

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This chapter aims to show that extending social health insurance is a possible road to universal health coverage in Nigeria. We suggest that allowing states to set up and operate their own insurance schemes, which presents a unique opportunity to swiftly scale up prepaid coverage for Nigerians. This paper review various healthcare insurance towards achieving universal health coverage in Nigeria. The paper concluded by suggesting other insurance scheme to be covered towards achieving universal coverage.


  • universal health coverage
  • Coverage
  • healthcare insurance
  • health access
  • and Nigeria

1. Introduction

“Health is the most fundamental human right on which all other rights can be enjoyed. Universal Health Coverage is its guarantee.” Dr. Githinji Gitahi [1].

One of the most normal measures of healthcare access is whether an individual has healthcare coverage insurance_ percentage of the population with and without health insurance either by public or private [2]. Health insurance promotes good health by improving access to healthcare. Sufficient access to healthcare encourages individuals to seek health maintenance services more regularly than they otherwise would, thereby prevent potentially serious illnesses. Also, health insurance protects individuals from financial catastrophe that may result from large or unexpected medical bills [3]. In Nigeria, health insurance can be obtained from private organizations or from government agencies [3]. Agencies of the Federal Ministry of Health (FMOH) regulate the National Health Insurance Scheme (NHIS). The NHIS provides health insurance coverage for employees of the federal government. While some state government have adopted social insurance regulated by NHIS because they feel excluded from the scheme [4]. However, only 3% of men and women age 15–49 have health insurance coverage [3]. To achieve universal health coverage expansions have to be made to include other health insurance schemes [4].


2. Structure of Nigeria health system

Nigeria is a lower-middle-income country with a population of 174 million with 36 states, a federal capital territory and a total of 774 local government areas (LGAs) across the country. The healthcare system in Nigeria is mainly regulated by public sector, and partly private sector involvement in the provision of health services. There are more than 34,000 health facilities, 66% of which were owned by the three tiers of government (federal, state, and LGAs). The secondary and tertiary level health facilities are mostly found in urban areas, whereas rural areas are predominantly served by primary health care (PHC) facilities. The federal government owns many of the tertiary level health facilities and some secondary health facilities operated by federal agencies. Most of the publicly-owned secondary health facilities are owned by the states. Primary health care is largely led by government departments and agencies, but also by non-governmental organizations. Table 1 illustrates various health facilities regulate by tiers of government in Nigeria.

Health facilitiesTier of government
PrimaryGovernmental and non-governmental agencies

Table 1.

An illustration of various healthcare facilities regulate by tiers of government in Nigeria.


3. Health insurance coverage- pathway of achieving universal health coverage

Universal health coverage has being achieved in most countries through some of initiation by their government health financing reforms. These were achieved in many countries by adopting social health insurance scheme [4].

The World Health Report 2010 presents a cube in Figure 1 above to help policy makers think about the potential trade-offs in benefit design for UHC with the following three dimensions:

  • Who benefits from pooled resource?

  • For what services?

  • At what cost at the post of use?

Figure 1.

Three-dimensions to consider when moving towards universal coverage WHO 2010.

For effective coverage, the depth axis on which benefit are covered (service coverage) must be defined in terms of needed and effective services of good quality. The height axis on cost should reflect relative ability pay in order to assess affordability of care. The breadth axis who is insured, ensure that the needs of the poorest and most vulnerable are effectively covered first and at affordable cost.


4. Scope of health insurance coverage

Health insurance can take the form of private, social, community-based, or tax-based systems [4].

4.1 Tax-based systems

A tax-based system is a State’s tax-funded system, in which the State Ministry of Health (SMoH) purchases and provides public health services for the whole state population. The SMoH specifies a minimum package of healthcare services which covers promotive, preventive, and curative care at primary and secondary care levels, and includes services for communicable and non-communicable diseases, child survival, safe motherhood, nutrition, health education, laboratory services and community mobilization, but in some states it’s not compulsory. Additionally, SMoH may include other private providers to deliver selected services, such as mortuary and immunization services. However, services that are not on the SMoH’s package of services are mostly paid out-of-pocket with user fee required at the point of service utilization. General tax revenue, which the State Government gives to SMoH as part of the State Budget, is the primary source of funding for health services. In service delivery, all government-owned primary and secondary providers are involved. SMoH transfers resources to Primary Health Centers (PHCs) for vertical programs, despite the fact that primary health care is the responsibility of the Local Government Area (LGA) [5].

4.2 Social Health insurance programme

4.2.1 The formal sector health insurance programme (FSSHIP) The Health insurance program for the formal sector (FSSHIP)

The Nigerian National Health Insurance Scheme established the FSSHIP as a Social Health Insurance program (NHIS). Employees in the formal sector are required to participate in FSSHIP. In 2012, about 3% of Nigeria’s population was covered. Beneficiary contributions to the plan are calculated as a percentage of earnings and are accompanied by contributions from employer. Through the National Health Insurance Fund, the NHIS pools monies at the federal level (NHIF). The National Health Insurance Program (NHIS) hires commercial, for-profit Health Maintenance Organizations (HMOs) to run the purchasing system and distribute funds to providers. Healthcare professionals are paid on a capitation basis for primary care and on a fee-for-service basis for secondary care. A blend of NHIS-accredited public and private healthcare providers are contracted to deliver services under the FSSHIP. High-tech investigations (CT scans, MRIs, etc.) and occupational disorders are excluded from FSSHIP’s regular benefit package, which defines primary, secondary, and tertiary treatments. Members of the FSSHIP are assigned to specific HMOs, however they can choose their primary care providers from a list of NHIS-accredited providers [5]. National Health Insurance Scheme (NHIS)-MDG-MCH

The MDG-MCH program of the National Health Insurance Scheme (NHIS) was created to address the demand-side problem of financial obstacles to acceptance of prioritized MCH interventions. Its implementation mechanisms, on the other hand, include requiring facilities to use program income to purchase medications, which will improve the provision of PHC services. The Midwives Service Scheme program helps to address the shortage of midwives in frontline PHC facilities, and the Model Primary Health Centers Creation and Upgrading (MPHC) program assists in increasing the number of functional facilities and improving the state of some of those in dilapidated conditions [6].

National Health Insurance Scheme has developed various programmes to cover different segments of the society, In order to ensure that every Nigerian has access to good healthcare services [7], as show in Table 2.

Formal SectorInformal SectorVulnerable Group
Formal Sector Social Health Insurance ProgrammeTertiary Institution Social Health Insurance ProgrammesPregnant Women
Mobile HealthCommunity Based Social Health Insurance ProgrammesChildren Under five
Vital Contributors Social Health Insurance ProgrammesPublic Private Partnership Social Health Insurance ProgrammesPrison Inmates

Table 2.

Illustration of various NHIS scheme that covered different segment.


5. Conclusion

To fairly include more individuals In line with the goal of UHC, NHIS scheme should prioritize expanding coverage for low-income groups, rural communities, and other groups with limited access to services, health, or both. This is especially critical for services with a high priority. More individuals being fairly included may necessitate specific measures when they are beneficial.


  1. 1. Dr. Githinji Gitahi, UHC Day 2018 Global CEO, Amref Health Africa Co-chair, UHC 2030 Steering Committee
  2. 2. Berk ML, Schur CL. Measuring Access To Care: Improving Information For Policymakers: Even the most thoughtful persons find it difficult to disentangle the research on access. Health Affairs. 1998 Jan;17(1):180-186
  3. 3. Demographic N. Health Survey 2013. National Population Commission (NPC)[Nigeria] and ICF International. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International
  4. 4. Okpani AI, Abimbola S. Operationalizing universal health coverage in Nigeria through social health insurance. Nigerian medical journal: journal of the Nigeria Medical Association. 2015 Sep;56(5):305
  5. 5. Ibe O, Honda A, Etiaba E, Ezumah N, Hanson K, Onwujekwe O. Do beneficiaries’ views matter in healthcare purchasing decisions? Experiences from the Nigerian tax-funded health system and the formal sector social health insurance program of the National Health Insurance Scheme. International journal for equity in health. 2017 Dec;16(1):1-1
  6. 6. Atim C, Bhatnagar A. Toward synergy and collaboration to expand the supply of and strengthen Primary Health Care in Nigeria’s federal context, with special reference to Ondo State
  7. 7. Nigeria. Federal minister of Health, National Health insurance scheme [internet]. Formal social Health Insurance Programme (FSSHIP); 2020 (cited 2021 jul 15). Available from

Written By

Habibu Salisu Badamasi

Submitted: 21 May 2021 Reviewed: 17 June 2021 Published: 09 February 2022