Thought Leadership

Rejoinder: NHIS in Nigeria

A few days ago we posted an interesting article by Chukwuma Muanya describing the evolution of the NHIS in Nigeria. This is a rejoinder sent in by an avid reader of this blog. Dr Joseph Ana is a colleague we hold in extremely high regard. In every generation of Governors in Nigeria, one always stands outs and catches the imagination of the people by his vision and action. In this dispensation, beyond doubt that person is Raji Fashola in Lagos State. In the 8 years of the Obasanjo administration, the one Governor that stood well ahead of the pack was Donald Duke in Cross River state. Many  will have heard of the several projects that are in the limelight but few would have followed the quiet but visionary changes in the health sector – led by Dr Ana. We think he has earned the right to be heard – Enjoy his contribution!

Thank you for highlighting the National Health Insurance Scheme (NHIS). I believe that in 50 years time when the scheme will be 60 years, historians will look back and celebrate its implementation as the golden hour of former President Olusegun Obasanjo. Few people know that Dr Majekodunmi, Nigeria’s first Minister of Health at Independence presented the first Bill for a Health Insurance Scheme in 1962! It took Obasanjo’s second coming as President 43-years after to see to its implementation in July 2005.

On going through the Guardian Newspaper article, what is missing is the fact that a major obstacle to the NHIS is the antagonism and cynicism of the labour unions to the scheme. Indeed the progress that has been made has been at least as far as the formal sector in the face of very stiff and continuing opposition by surprisingly from the Labour Unions (NLC and TUC).

This is an important point for people to be aware of as there seems to be a complete lack of understanding of the benefits of health insurance among the trade unions. In 1948 when NHS-UK was established it was a Labour Government – and the principle of free healthcare at the point of care – from the cradle to the grave – has been more or less maintained ever since. It is the one institution in the UK that is held sacrosanct. As is seen in the politics of the present election cycle in the UK, both parties are trying to do out do each other in who will protect the NHS more from impending economical challenges. This has only strengthened my disappointment that organised Labour in Nigeria is a major stumbling block on the way to full enrolment for the NHIS in Nigeria. I had a first hand experience of this unfortunate absurdity in 2006 when under former Governor Donald Duke, I signed Cross River State into the NHIS-Nigeria (the first state to do so). Again in 2008 as vice chairman of the Health Advisory Commiittee to Bauchi State Government of Malam Isa Yuguda, I encouraged Bauchi State to join the scheme (the second state to do so).

In Cross River State, the Labour Unions continue to oppose the scheme even in the face of glaring benefits and advantages to their members who have enrolled from the State’s civil service and Local Government Service. Both Unions cite the failed Housing scheme and failed National Provident Fund as their reason for opposing the NHIS. Indeed some Union Leaders not only preached against their members enrolling for the scheme but physically destroyed registration forms until the police was invited in!. The most astonishing part of the Unions’ action was the fact that State Government had not even started deducting the 5% of basic salary from each enrollee. The State Government was paying the full 15% of basic salary for each enrollee and yet the Unions were up in arms. I wonder what will happen when the State Government begins deductions. Therefore, the NHIS- Nigeria has some major work to do on ‘educating’ the Unions because they are a major BLOCK to the scheme.

All the other points listed in the article are true in my experience but as I have said at many fora the NHIS cannot achieve its laudable overdue objectives until the INFORMAL sector is covered!. The majority of Nigerians who stand to benefit the most from the NHIS because they fall under the poverty bracket are in the INFORMAL sector.

Joseph Ana

Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead

By Chikwe Ihekweazu

Chikwe Ihekweazu is an epidemiologist and consultant public health physician. He is the Editor of Nigeria Health Watch, and the Managing Partner of EpiAfric (, which provides expertise in public health research and advisory services, health communication and professional development. He previously held leadership roles at the South African National Institute for Communicable Diseases and the UK's Health Protection Agency. Chikwe has undertaken several short term consultancies for the World Health Organisation, mainly in response to major outbreaks. He is a TED Fellow and co-curator of TEDxEuston.

1 reply on “Rejoinder: NHIS in Nigeria”

I don’t think it’s enough to say the Labour Unions are blocking the implementation of the NHIS. The Labour Union is not made up of a few people but represent workers who make up majority of those in the formal sector of the economy.

The labour unions are said to be skeptic because of previous experience with the National Housing Fund and NSITF which are contributory schemes like the NHIS. We should consider whether these concerns are legitimate or not? What is being done by the relevant authorities to put things right?

It is also important to clarify that pay-roll contributions by employers and employees is not the only way to fund the provision of health care for the population. Population health can also be insured through general tax contributions (as it is in the NHS-UK and in Nigeria since independence and even in addition to the NHIS) among other means. So, the labour unions are not oppossing health insurance in Nigeria but deductions for health in addition to tax deductions.

Comparing the history of social insurance schemes in europe with what we’re trying to do in Nigeria, social health insurance schemes started as small sickness funds organized and limited to the work environment (formal and informal) before they became regulated and sometimes amalgamated by national or regional governments. This situation is unlike Nigeria where it’s starting from the national and we’re finding it difficult to extend to the informal sector. In formulating and implementing policies, it is not enough to observe a system in another country and trying to import to another with dissimilar systems and culture. If state and local governments are not logging-in, then there is a problem with the policy process. Were they carried along in the policy formulation process? Was there rigorous actuarial analysis of the short, medium and long-term implications for those arms of government? Was the scheme pilotted to ascertain feasibility before being rolled-out?

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