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Making Health Insurance Affordable to 'Average' Nigerians
[July 25, 2014]

Making Health Insurance Affordable to 'Average' Nigerians

(AllAfrica Via Acquire Media NewsEdge) To make health care accessible and affordable to all Nigerians, the World Health Organisation (WHO), the World Bank and other experts recommend among other things: mandatory and publicly subsidized health insurance scheme even as the National Health Insurance Scheme (NHIS) in partnership with MTN Nigeria and Salt & Einstein MTS have rolled out a cheap mobile scheme at a premium of N250 weekly.

FIFTY-YEAR-OLD Mr. Joseph Akanji is married with five children: two girls, Sola and Kike; and three boys, Gboye, Wole and Rotimi, ages twelve, nine, seven, five and two. The wife, Kike, is a housewife.

Akanji was diagnosed of end stage renal disease or rather kidney failure on February 2, 2014, at a popular hospital in Lagos; after a two-week history of vomiting and urgently needs to travel to India for a kidney transplant to live.

Akanji, a graduate of Economic was a vibrant Assistant Manager with one of the new generation Banks about a year ago with the prospect of making it to the top of the banking carrier but suddenly lost his job due to rationalisation in the industry.

With the challenges of fatherhood and a legion of family problems and cost of dialysis and treatment for his current condition, Akanji has completely cleaned out of his small savings and now needs at least N10 million being estimated cost of transplantation operation (N8 million) in Nigeria and that of gratuitous reward to a kidney donor and if abroad plus cost travel logistics for himself and that of another who will accompany him for the oversea treatment.

Akanji cannot afford the cost of saving his life.

Hadiza is a 65-year-old grandmother in Nassarawa district in Kano State. She has been struggling to care for herself and her grand children aged eight, six, four and three. The children had been left with Hadiza when their parents died of Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS).

Shortly thereafter, Hadiza became ill, leaving her unable to work selling fried been cakes in the street corner for an income. She was forced to borrow money from other family members to pay for her medical expenses. When she could no longer borrow money she had to reduce spending on food items for herself and her grandchildren to buy medicine from the local medicine vendor in her village.

Akanji and Hadiza represent two of the over 150 million Nigerians that cannot afford and access health care when they need it because they have to pay out of pocket.

Akanji and Hadiza are some of the majority of poor Nigerians not covered by the National Health Insurance Scheme (NHIS) because they are not formally employed.

Akanji and Fatima's stories are very common in Nigeria. The inability to pay for health care expenses, which forces people to reduce spending on food or other basic needs, and the lack of access to quality care are unfortunately common realities seen by many poor and underprivileged.

Several studies have shown that falling ill can have devastating and long-lasting consequences especially for poor households, both through income loss and high medical expenditures.

Data from the World Bank suggests that more than 150 million people globally suffer financial catastrophe every year due to out-of-pocket health expenditures and Nigeria has about the highest out-of-pocket health spending and poorest health indicators in the world.

A recent study by Obinna E. Onwujekwe, B. S. Uzochukwu, O. P. Ezeoke, and N. P. Uguru published in Journal of College of Medicine noted that the NHIS is planned to attract more resources to the health care sector and improve the level of access and utilization of healthcare services. It is also intended to protect people from the catastrophic financial implications of illnesses.

A key feature of UHC is that it includes prepayment and that it supports risk pooling, which ensures the spread of risk across time and across individuals.

Indeed, a broad range of risk-pooling mechanisms or insurance schemes are increasingly being utilized across the developing world to increase access and reduce the financial burden of health.

In Nigeria, the Federal Ministry of Health (FMoH) is driving the concept of UHC through the NHIS and the National Primary Health Care Development Agency (NPHCDA).

The Guardian learnt that while the NHIS is in-charge of the administrative part of the UHC that includes registration and regulation, the NPHCDA takes care of the implementation especially through the established Primary Health Care (PHC) centres nationwide.

Executive Secretary of NHIS, Dr. Femi Thomas, insists that expanding access to health insurance is an important part of an overall strategy to achieve UHC.

To the Executive Director of NPHCDA, Dr. Ado Gana Mohammed, UHC implies ensured access to and use of high-quality healthcare services by all citizens and protection for all individuals from any catastrophic financial effect of ill health.

Mohammed said UHC could be a major determinant of improved health outcomes for all citizens, especially the poorest.

According to the World Health Organisation (WHO), "a health system where individuals have to pay out of their own pockets at the moment of seeking treatment restricts access to only those who can afford it, and is likely to exclude the poorest members of the society." Director-General of WHO, Dr Margaret Chan, said: "I regard universal health coverage as the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way, based on primary health care." Chan described universal coverage as "the single most powerful concept that public health has to offer." In launching the "World health report 2013: Research for universal health coverage", Chan said: "Universal coverage is the best way to cement the health gains made during the previous decade. It is a powerful social equalizer and the ultimate expression of fairness." History of Health Insurance in Nigeria Nigeria is eager to achieve UHC. Since its launch in 1999, the NHIS has been the major initiative to expand health insurance in Nigeria. However, as of mid-2012, NHIS still covered only about three percent of the population that is five million individuals.

Policymakers in Nigeria are interested in learning from the experiences of other developing countries in achieving higher health insurance coverage. In 2013, the agenda for reform of the NHIS will pick up pace, with several different proposals being considered, including parliamentary legislation to create a 'health fund' to cover the costs of health insurance for certain groups.

Currently, NHIS programmes exist that target the formal and self-employed sectors, with mixed success. The formal-sector programme operates as a social health insurance scheme. Recently, the NHIS launched a rural community-based social health insurance programme to cover more Nigerians. However, uptake has been slow.

Current situation Despite its launch in 1999, the NHIS was actually kicked off in 2005 by President Olusegun Obasanjo. However, the first Community-based Health Insurance Scheme (CHIS) was set off in 2009, in Kwara State, by then Minister of Health, Prof. Eyitayo Lambo.

Unfortunately, nine years after NHIS and five years after CHIS roll outs, which promised universal access to health services by 2015, less than 10 per cent of Nigerians are enrolled with any form of health insurance meaning that most Nigerians still cannot afford basic health services; 90 per cent of the population who can, pay out-of-pocket, while others patronize quacks and traditional healers for 'cheaper' services.

Little wonder the poor health indices being recorded by the country.

Until now, health insurance is recommended by the World Health Organisation (WHO), endorsed by several studies and certified by various professional bodies as a single tool that will help ensure universal access to affordable health, reverse poor health statistics and strengthen the health system.

But statistics from the Multiple Indicator Cluster Survey, Nigeria, 2011 and the State of the Worlds' Children, 2012, indicate that with average life expectancy of 48 years, infant mortality rate of 97 deaths per 1000 live births and maternal mortality rate of 550 deaths per 100,000 live births, which is among the worst five in the world.

Nigerians can get health insurance cover with N250 weekly premium With a premium of only N250 weekly, that is N1,000 monthly and N12,000 yearly, mobile subscribers will have access to standard and convenient health insurance cover on a pre-paid basis and are able choose their Health Management Organizations (HMO's) and retainer hospitals using their mobile phones for a range of pre-defined medical treatments.

Infant, the NHIS, MTN Nigeria and Salt & Einstein MTS said Nigerians on MTN network can subscribe to the scheme by simply dialing *616 # and there are plans to engage Airtel Nigeria, Glo Network and Etisalat into the scheme.

Executive Secretary NHIS, Dr. Olufemi Thomas, said this is part of efforts to meet the Presidential mandate of providing health insurance for at least 30 per cent of Nigerians by 2015, that is about 48 million.

NHIS, MTN Nigeria and Salt & Einstein MTS, yesterday, in Lagos, officially rolled out a pilot of mobile health insurance in the country tagged 'Y'ello Health,' even as the NHIS said that only about 5.2 million Nigerians are presently covered.

Thomas said it plans to begin mass registration of pupils in public schools starting from September 2014 targeting 24 million school children nationwide with federal government providing 40 per cent and state government funding the remaining 60 per cent.

He said the Scheme would be able to provide free medical care for pregnant women and children under five as soon as the National Health Bill is passed by the National Assembly and signed into law by President Goodluck Jonathan.

Thomas said: "This is the first time mobile health insurance partnership is happening in Nigeria and indeed the whole world. It is my single honour to welcome you to the official digitalization of health insurance programme in Nigeria. It is one of the latest additions to our programme and in a bid to achieve the Presidential mandate to put 30 per cent of Nigerians on health insurance by end of 2015.

"At that time, that was in January 2014, the coverage was 2.6 per cent, which was not too good situation. Today, 3.5 million Nigerians are in the formal sector scheme while between 1.5 million and 1.6 million are covered in the informal sector. The fluctuation between 1.5 and 1.6 million in the informal sector scheme is because pregnant come and exit. So 5.1 million to 5.2 million lives today are covered by health insurance.

"So the scheme is to leap frog from 5.2 million to 30 per cent of Nigerians by 2015. The mobile health insurance is firstly affordable and accessible by Nigerians. Since 2010, the World Health Organisation (WHO) has championed the concept of universal health coverage. The scheme is leveraging on mass penetration of mobile telephony.

"Although we are starting with MTN, this programme is expected to extend to other operators as we go along. It is an application of information technology in the operations of NHIS. With the scheme, enrollees can choose their HMOS and healthcare providers. The most important thing is flexible and convenient. One critical design is this adoption tree where you can be your brothers keeper and pay for the less privilege to benefit. This is another platform for us to demonstrate this social solidarity.

"We are creating a national health exchange for Nigeria. The complementary Q programme to monitor enrollees encounter with health facility. We have about 7,000 health facilities and plan to expand to 10,000 by the end of the year. We have this device, which we have in all the facilities. This is what is used to detect and detail the enrollees when they get to the health facility. It is detailed and works with four SIM cards- MTN, Airtel, Glo and Etisalat. It can work for 18 hours without electricity." Thomas appealed to Nigerians to make health insurance a campaign issue in the fort coming elections and be patient with the new programme because there are bound to be hiccups.

He explained: "You should be able to ask politicians what they want to offer in terms of health care... The programme may not be perfect initially and takes time to build. The whole process is learning process because we are the pioneers and do not have the opportunity to learn from other people. We are appealing to Nigerians that at this pilot phase there are bound to be problems. We are ready to learn and turn this into a brand for the rest of the world to look at." Thomas said another challenge facing the programme is the inequitable distribution of health facilities across the nation and it is only a pilot scheme.

Executive chairman of Salt and Einstein MTS, Dr. Ernest Ndukwe, said: "This creates adequate grounds for direct health insurance provision to Nigerians who without this would have no access to the National health Insurance scheme." Managing director and chief executive officer of Salt and Einstein MTS, Lai Labode, said: "Findings, show that, Nigeria still has less than four per cent of its population covered with basic health care at this time in our nation's history.

"There is no disputing the fact that, one of the best things to do at this time is to come together, working with NHIS and of course, starting off with Nigeria's leading telecommunications operator, MTN, to bring this health insurance cover to Nigerians who have been hitherto excluded from access to good health care service.

"MTN has demonstrated that they are interested in the social good and welfare of Nigerians. We hope to create more products that benefit Nigerians across the country." Chief Executive Officer and Managing Director MTN Nigeria, Mr. Michael Ikpoki, said: "MTN's motivation to partner on the health insurance initiative with the Salt & Einstein MTS and NHIS, is driven by the firm's passion to reduce exclusion and social disparities by supporting government's vision of delivering health care for all as well as to make health care mobile by integrating it into the MTN broader digital strategy.

"The focus market for the Y'ello Health Cover is Nigerians who have no health insurance cover principally because they cannot afford the regular health insurance services in the market. These individuals like everyone else, need medical care.

"However, without access to insurance, they probably would be having occasional challenges paying for medical treatment, because such expenses would usually be without or at short notice. It is to take away this burden of impromptu medical expenses that we are partnering to introduce this product." Presidential commitment and summit on Universal Health Coverage A school of thought believes that less than five per cent of Nigerians are presently under any kind of health insurance. Even some unpublished studies put the figure to less than 10 million Nigerians.

In fact, almost 100 per cent of beneficiaries are in the formal sector. Besides some pockets of social and community health insurance schemes across the country, most enrollees of the NHIS are in the formal sector.

Interestingly, The Guardian reliably gathered that the federal government workers who constitute almost 100 per cent of the beneficiaries are yet to start paying five per cent of their salary, which is supposed to be their contribution to 15 per cent from the federal government. The Guardian learnt that the Nigerian Labour Congress (NLC) is yet to conform.

However, to reverse the situation, President Goodluck Jonathan has mandated the NHIS to put at least 30 per cent of Nigerians or rather about 70 million on the scheme by December 2015.

President Goodluck Jonathan on Monday March 10, 2014, hosted a Presidential Health Summit on UHC.

Jonathan reiterated the Federal Government's commitment to make every effort to ensure that Nigerians have access to qualitative and affordable healthcare services under the UHC.

Jonathan who was represented by the Vice President, Namadi Sambo, said this while declaring open the Presidential Health Summit held on Monday March 10, 2014, in the Presidential Villa.

He said that whereas the country had made progress but that the nation was not where it ought to be in health care coverage.

He said while the country's health insurance programme had been mostly successful with federal employees and private health insurance for the organised private sector, it was unacceptable that there were still several pilot schemes that had yet to cumulatively result in adequate level of cover for the people.

He said the country needed to keep abreast of other countries in its development bracket in social health insurance.

While saying that health insurance must become a part of the social culture, the President said Nigerians needed to be encouraged to imbibe the benefits of affordable and regular contributions to achieving guaranteed and sustainable long term health services.

He said the theme of the summit, "Universal Health Coverage: The Vehicle for Sustainable Growth and Development" captured the emphasis which his administration's transformation agenda placed on health care for all in Nigeria.

The President said the government was determined to elevate UHC to a national movement with substantial participation by local and international stakeholders, supported by the government and the private sector at all levels.

Jonathan said: "Government is not unaware of the numerous challenges limiting the attainment of UHC in our country, and the importance of political commitment in surmounting these challenges.

"The World Bank's case study of 11 countries that have made significant progress in UHC, affirmed that political leadership and commitment is the key driving force for achieving UHC.

"Our gathering here is to reaffirm our commitment as political leaders both at federal and state levels that we will do all within our powers to provide Universal Health Coverage for our people.

"As a member of the United Nations, Nigeria subscribes to the 68th General Assembly resolution calling on member-nations to accelerate efforts toward achieving Universal Health Coverage. In 2010, we also set the bold target of achieving thirty per cent health insurance coverage by the end of 2015.

"Every Nigerian, who earns an income, has an obligation to contribute to his/her health care, and we all owe it to those who do not have the means, to provide for themselves.

"If all the states, LGAs and the organised private sector join some form of pre-payment scheme today, our coverage level will increase by over 100 per cent." Minister of Health, Prof. Onyebuchi Chukwu, said that the summit was organised to find solutions to the nation's health challenges.

He said the summit was also meant to attract more investment into the nation's health sector to discourage medical tourism by Nigerians.

Chukwu said the Federal Government of Nigeria has commenced plans to enroll 24 million primary school pupils nationwide to join the NHIS as part of the efforts to increase UHC to 30 per cent by 2015.

Chukwu said universal health coverage was crucial to Nigeria's vision to be among top 20 nations by 2020, but insisted health for majority of Nigerians required that health infrastructure and services be both available and accessible.

"This is the beginning of a journey. There is no way within one year we will get 100 per cent but we have never tried it at all in Nigeria, so this is the beginning," said Chukwu.

The WHO country representative, Dr. Rui Vaz, in his goodwill message on behalf of the WHO Director General, Dr. Margaret Chan and the Regional Director for the African Region, Dr. Luis Gomes Sambo, remarked that while there is no universal panacea for increasing coverage, "each country must curve its own way forward" and added that "Nigeria is defining its own UHC roadmap; rooted in the country's own culture, political system and institutions; the legacy of existing health systems and above all, aspirations of all Nigerians." The Presidential Summit which was preceded by a two-day pre-summit technical meeting with the lead paper Achieving Universal Health Coverage: Analysis of relevant options presented by WHO and attended by Executive Governors, Ministers of the Federal Republic, Legislators, Health Commissioners, Traditional Rulers, development partners among others, concluded with the Presidential Summit Declaration on UHC.

The Declaration affirmed that health is a fundamental human right and the responsibility of government in assuring the health of all Nigerians. It acknowledged the progress made despite the existing challenges towards attaining UHC in Nigeria through initiatives at all levels of government.

The Declaration recommended that the Government of Nigeria should work towards instituting mandatory health insurance in Nigeria, with contributions from all income earners-formal and informal- and make available special funds to cover the poor- UHC Fund.

It was further recommended that a standard benefit package of essential health services that address priority health care needs of all Nigerians should be defined. In addition, it was said that UHC cannot happen unless there is a functional health system, where there is adequate human resource for health, life saving commodities and supplies, sustainable financing and a mechanism to maintain quality services.

It was also proposed that there should be a committee or taskforce to ensure that UHC is initiated, implemented and sustained in Nigeria for all Nigerians.

Best practices for moving forward universal health coverage As the country works towards meeting the Presidential mandate of putting at least 30 per cent of Nigerians on NHIS, there is need to learn from working models both locally and internally from Rivers State and countries such as India, Colombia and Thailand who have achieved UHC.

While the NHIS and most of the CHISs have so far failed to deliver on their promises, a new model of CHIS introduced in Obio Cottage Hospital Port Harcourt, Rivers State, is working.

The partnership model tagged Public Private People/Community Partnership (PPPP) ensures community buy-in, sustainability and key stakeholders engagement.

The State government representing the Public built the facility and provides staff for secondary care; the Private, which is the Nigerian National Petroleum Corporation (NNPC)/Shell Joint Venture (JV) takes care of structural improvements, capacity building and service excellence in the Hospital; and the People, the community, champions the scheme through Board of Trustees who provides oversight of hospital insurance plan and support via volunteerism and donations.

The scheme was kicked off in February 2010 and was formally launched on March 25, 2010, and re-launched in 2011 for more sensitization among community members by Shell Petroleum Development Company (SPDC) in partnership with the Industrial Area (IA) Cluster Communities Development Foundation, the Obio-Akpor Local Government Area (LGA) and Rivers State government.

The IA cluster communities include; Rumuobiakani; Rumuomasi; Rumueziolu; and Oginigba.

The Guardian who visited the facility found that with a premium of N3,600 per annum for indigenes and N7,200 for non indigenes for registration into a model CHIS offered by the Hospital, patients can obtain 'free' secondary health services including: antenatal, delivery and postnatal care; obstetric and gynaecological services; Caesarean Section (CS); Prevention of Mother to Child Transmission (PMTCT) of Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) and HIV Counselling and Testing (HCT); minor surgeries; breast examination and cancer screening programme; treatment for minor illnesses such as malaria, typhoid, d iabetes and hypertension.

Other services offered by the scheme include: family planning; immunization and growth monitoring; health education; nutrition education and food demonstrations; baby friendly care services.

It was also gathered that with the new CHIS concept, the Hospital which had only two nurses and no resident doctor before 2010 now has six doctors on permanent basis, two visiting professors of medicine in obstetrics and gynaecology and paediatrics, 42 nurses, 39 non medical staff, 13 volunteers, three National Youth Service Corp (NYSC) members, and two Industrial Training (IT) students.

Obio Health Centre, now cottage hospital, which is located at Rumuobiokani in Obio-Akpor LGA is one of the 27 health facilities supported by the SPDC in six Niger Delta States in its community health care scheme.

A 2013 Health Policy Project publication titled 'Scaling Up National Health Insurance in Nigeria: Learning from Case Studies of India, Colombia, and Thailand,' has enumerated how the aforementioned countries achieved UHC. The authors are: Arin Dutta and Charles Hongoro.

The Health Policy Project (HPP), a publication of the United State Agency for International Development (USAID) works to strengthen developing country national and subnational policy, advocacy, governance, and finance for strategic, equitable, and sustainable health programming.

Colombia Colombia approved its universal health insurance scheme in 1993, creating the National Social Security System for Health, which currently covers more than 95 percent of the population. There are two insurance regimes: the Contributory Regime (CR), which covers workers and families with monthly incomes above $170 (N29,070) per month (those who can afford to pay), and the Subsidized Regime (SR), which targets poor or informal workers. Since 2012, both groups have been able to access the same health benefits package. A mandatory payroll tax contribution of 11 percent funds the CR. National and local tax revenues and a 1.5 percent payroll tax fund the SR.

There are several lessons from the Colombian experience for Nigerian policymakers: -Colombia's first action was to pass Law 100, which provided the legal basis for implementing a national social security system. Establishing a legal basis for health financing reforms could facilitate implementation in a federal system such as Nigeria's.

-Colombia's fiscal capabilities allowed for a gradual expansion of coverage. A prioritization policy enacted alongside a means-testing policy would allow better targeting of spending. The key lesson for Nigeria is to plan gradual implementation as a function of available resources.

-Colombia's experience with an effective national equalization fund that pools mandatory contributions from workers and government contributions from taxation should be instructive for Nigeria, where the social health insurance scheme currently has no pooling across the contributory populations.

-Colombia's expanded SR scheme is possible through financial contributions from the federal government, local authorities at the district and municipal level, and solidarity contributions from members of the CR. Nigeria has large numbers of individuals with higher income who could also make such solidarity contributions, as well as sources of tax revenue at local government levels.

-Payroll-based funding needs a strong employment base, preferably with additional mechanisms to tax the self-employed. Self-employed people are generally not as easy to tax, especially if they are not registered taxpayers. It is important to devise other mechanisms for collecting contributions, such as the flat monthly rates or installments proposed for Nigeria's rural community-based social health insurance program (RCSHIP).

-When designing a contracting model, it is important to avoid disadvantaging public providers by saddling them with additional rules or obligations. In addition, public providers may not be competitive for service contracts. In Colombia, a modernization program was necessary to bring public hospitals up to par with private providers.

-True universal coverage may require a higher percentage of spending as a proportion of gross domestic product (GDP), so it is possible that countries such as Nigeria will need to compromise between comprehensiveness and sustainability, as Colombia did.

-Monitoring and evaluation systems are crucial to measuring performance and ensuring the efficient use of resources. Colombia invested in a database of all members, which is updated monthly. Nigeria is investing in a similar system, which needs strengthening.

India India has three federal-level, government-sponsored health insurance schemes and nine state schemes, which together cover about 240 million citizens, or 19 percent of the population. With private insurance and other programs, more than 25 percent of the population has access to health insurance.

The Rashtriya Swasthya Bima Yojana (RSBY) is the premier national health insurance programme established in 2008 to cover secondary care for families living below the poverty line. Contributions are very low and are required only at the time of enrollment into the scheme. The programme receives funds from the federal level covering 75 percent of the total costs, with state (provincial) contributions covering the remaining 25 percent.

A recent review of RSBY suggests that it is "on track" to achieving its objectives of increasing access to healthcare as well as reducing the financial risk among its beneficiaries.

As described in this report, lessons learned from RSBY's operational experience are appropriate for the NHIS: - The successful launch and continuation of a massive health insurance scheme targeted at the poor is only possible if there is political will and fiscal commitment at all levels of government.

*Creation of a clear-cut targeting mechanism based on established lists and appropriate incentives for insurers and third-party administrators, along with the use of technology, can help lower the cost of enrollment for the poor.

*Any health insurance scheme that aims to target the very poor may learn from the foundational premises of RSBY: Make the system cashless, paperless, and portable.

*Standardization of documents and processes along with the proper use of technology helps in situations of low administrative and managerial capacity.

*The focus on secondary care (i.e., lower complication inpatient procedures) within a defined package of benefits for RSBY members has meant lower cost per family covered.

- Use of IT applications for enrollment and patient management at the provider level has benefited the scheme, beginning with the smart cards similar to those used by NHIS in Nigeria.

*Health insurance is now 24 percent of the central government budget for health. This is evidence of considerable political support and budgetary commitment. Moreover, these percentages have been achieved while keeping premiums to insurers low, thanks to competition among companies.

The debate in India about the best course toward UHC reveals the complexities that arise when governments face difficult fiscal choices. India may move to a national health insurance model, where the government uses public and private providers to allow all citizens access to a comprehensive benefit package. Such a strategy would come at significant cost.

The public sector has already invested significant funds in the primary healthcare system. It has also invested in improved access to secondary healthcare and financial protection in its use of RSBY and other schemes.

Therefore, India may encounter sustainability challenges as the government expands toward UHC. In response, pragmatic proposals for India involve a mixed strategy: expand health insurance further for the poor using the existing schemes (that is, approximating a national health insurance model funded from general taxation) and consolidate other insurance schemes that use mandatory contributions for formal- sector employees.

India's choices may have important lessons for Nigeria. Nigeria can also learn from the processes and operational strategies used to expand government-funded health insurance in India. Nigeria must continue its current programs to strengthen primary healthcare and forge meaningful resource investment partnerships between states and the federal government, as India has tried to do.

Thailand Thailand introduced its Universal Coverage Scheme (UCS) in 2001, aimed at reaching the 75 percent of the population not covered by health insurance at that time.

Copyright The Guardian. Distributed by AllAfrica Global Media (

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