Nigerians want Health Insurance, Probably not what’s being Offered: Our findings
The concept of insurance originates from the fundamental idea of reducing risk or diversification of risk. In simple terms, how does one reduce the impact of negative events on their lives?
In some sense, human history shows that to survive, we needed to be in groups to reduce the likelihood of dying off and it became a trait that was transferred through generations. According to a study by Swiss Re, Chinese traders in 3,000 BC first developed the idea of risk diversification. By the 1900s insurance started becoming mainstream and with globalization, both state and private players got a chance to sell policies all around the world.
This idea of risk-sharing can be seen in the African context in the form of “Osusu” (a form of micro-financial money rotation scheme) or in the African proverb “It takes a village to raise a child” or “Ubuntu” meaning “I am because we are” but mainstream insurance started around the 1950s. In Nigeria and some other countries, there were (and still, in existence,) companies like Guinea Insurance Plc formally called “BEWAC’s Legal and General Assurance” and Law Union and Rock Insurance Plc. When it comes to health insurance, research was already on the way as other countries developed their models, and the National Health Insurance Service (NHIS) was established under the act of 1999 and started its operation in 2005 and currently covers less than 4% of the population mostly federal government employees.
The right to health is globally recognized as a fundamental human right but due to inequalities caused in-part by globalization, access to healthcare hasn’t been equitable especially in developing countries. With this arises the problems with the mode of health services purchase and utilization by service users. In a country of more than 200 million people, 40% are living under the poverty line (N137,430 per annum) which changes the dynamics with failing systems along with other socioeconomic factors can create a vicious cycle in the system, leaving everyone feeling powerless to make any change.
With this brief history, this article aims to compare current beliefs surrounding healthcare and health insurance to our findings in a survey we carried out to understand the utilization, perception, and expectations of healthcare and health insurance services in Nigeria.
Globalization without the shiny numbers
Before we get to the assumptions and our findings, I need to introduce the concept of globalization to you. In a bid to avoid macro-economic issues, GDP statistics, and country budget statistics mentioned in public discussion in and out of context, I will attempt to introduce this and then you can learn how each part might affect your life.
Employee view:
Imagine Nigeria is a company (Nigeria Ltd. such a catchy name, lol) and you are its employee. Your passport (ID card) comes with a promise that it will take care of your needs and protect you in a wider market. Your needs are healthcare benefits, holidays, professional development, and so on while your obligations are to work hard and make sure Nigeria Ltd. gains profit which is its primary goal so it can sustain all your needs and promises, brand goals, etc.
Organization view:
Nigeria Ltd. has lots of competitors and they operate by a code the industry that favors some and doesn’t favor others. In this case, it’s not the biggest player but a start-up (I know it’s harsh, lol). It has limited resources and has to make alliances to keep up with the demands from both employees ad customers. It’s a very promising start-up by the way and did I mention that it has done an IPO so people own parts of it and also have a say in their decisions.
Industry view:
There are regulatory organizations that have different mandates and push for reform and try to keep the balance. Those related to occupational health continually tell organizations to take care of employees, those in charge of regulating trade encourage more transactions between organizations. While all these associations and groups communicate, their employees also do so by transferring cultural norms, ideology, techniques from one organization to another. In all, Nigeria Ltd. needs profits and sees health benefits for its employees as a black hole from which no profit comes out from.
All these interactions same as globalization are not easily seen or known by people but it affects them down to their everyday life. Not prioritizing healthcare in Nigeria increases the rate of doctors leaving the country for better wages or deaths from avoidable causes which in turn affects families sometimes physically, emotionally, and might induce economic stress.
There is a global call for Universal health coverage by the World Health Organization (WHO) and with countries like Rwanda leading the way in universal health coverage, Nigeria won’t be far behind as efforts to address this are already ongoing.
Current assumptions
In my opinion, the current assumptions which plague Nigeria are the result of sensational headlines, negative media and click-bait statistics, comparisons that don’t highlight the context, and most importantly, social media discussions that are not grounded in evidence and don’t represent the thoughts of everyday Nigerians. A majority of research or data used to validate these assumptions are focused on the problem and sometimes the idea that there is only one way to fix the problem and other assumptions are just retweeted for so long that it becomes ‘fact’ in the minds of Nigerians.
Assumptions:
- “The NHIS is not functioning and if it is functioning, it is no good”
- “Less than 1% of people have health insurance in Nigeria”
- “Nigerians don’t like going to the hospital because of religious and cultural beliefs”
- “The healthcare experience is so bad in Nigeria compared with…”
Living in Nigeria will make you feel this way about everything around you and this phenomenon is normal but to get a sense of reality is the difference between making decisions with evidence or fake news.
Our findings
Currently, my team and I are working to create a micro health insurance model that primarily reduces the burden of out-of-pocket payments for some health services. To kickstart this process we sent out a survey. The question on our minds was “how do service users utilize healthcare services and facilities?”. This survey aimed to, understand utilization patterns, their perspective of the health system, and their expectations, especially for health insurance. 225 people majorly located in Abuja, Lagos, and Rivers state responded to this survey.
Demographics
About 83% of people who responded to this survey were between the ages of 18 to 34 years old with Bachelor’s, Master’s, and secondary school degrees being more prevalent. A majority are employed (full-time and part-time) with the private sector being the highest employer of labor. They mostly earn between N50,000 to N100,000. They reported that they fall sick between 1 to 4 times a year with the cause of sickness being mostly Malaria, headaches diarrhea, and stomach ulcer. Most of the respondents recorded that they didn’t have chronic diseases but those who had, preferred not to say.
Utilization
Our assumptions were proven right when we observed that most respondents visit pharmacies without prescription when ill and in casual discussions with people, we came across this finding. It was interesting to see that few respondents buy traditional medicine as well. 55.5% of respondents recorded that within a calendar year they visit a physician 1 or more times but we might assume that this is done when they are ill (it is still encouraging that people see medical professionals). 60% of respondents reported that when ill, they didn’t take time out to stay at the hospital or home to recover and for those who did take time off, most did it for between 1 to 7 days. Which might signal the attitude towards ‘recovery time’ or ‘resting’ in Nigeria. Health conditions can vary and we can speculate that it might be because of the severity of the illness or just money and time concerns that need to do with their personal economics.
We were not surprised to see that most Nigerians don’t save for health expenses. We can’t conclusively say that this is because of the hardship or Nigerians are chronic spenders, we just think it is more about the nature of economic forces both local and global which influences our personal opportunity cost decisions. On a global scale, there are mutations of this savings problem. Another interesting finding was that most respondents said they spend less than N20,000 on medication and this is often self-funded from salary, health insurance, and family savings which mirrors the reality of so many Nigerians.
Perception
It was really surprising to see that a majority of respondents neither had a good or bad experience (middle ground). We further aggregated the data from 1 to 4 (poor experience) compared with 6 to 10 (good to excellent experience) and it was shocking seeing that we have the majority of people who think they have had a good experience (38.2% — Good experience, 37.3% — bad experience). It wasn’t surprising to see that people are more likely to go to a pharmacy as a first resort when compared with hospitals because this is the Nigerian reality which means they still spend money outside the hospital on health. When asked why they didn’t utilize health facilities like health centers or hospitals, they mostly said that “they end up spending too much time there”, “they can easily treat themselves at a pharmacy”, “If they go, they will spend a lot of money”, “too much bureaucracy” and, “medication is easier to get outside the hospital”. A good proportion said they do go to the hospitals but others site that doctors and nurses are rude and Insurance companies won’t cover the cost. Someone said, “they are covered by the blood of Jesus”.
73.8% of respondents said they didn’t have insurance cover. For the 24.4% of respondents who have health insurance, most are covered by employers (private and public organizations) followed by self-funded premiums from private insurers. It was exciting to see some people being covered by their schools as students. Like you already thought some people said their ‘Jesus’ is their insurance provider. For those who said they didn’t have health insurance, their main reasons were, “they don’t know how it works”, “they don’t get sick often so they don’t need it”, “it is too expensive”, “bureaucracy is too much” and, “they think they will be cheated by HMO”. Others either never thought about it or they have but there is a delay from the government. But I think it was encouraging to see that more than 50% of respondents who don’t have insurance will be like to get health insurance.
Expectations
Healthcare:
Most people long for access to healthcare that is affordable and recognizes them as humans. This might involves empathy and attention from medical professionals. Reduce bureaucracy, increase comfort, and price for treatment should be right.
There are two sides of the coin and as we have just learned from globalization, systems are complex although there identifiable areas, or I will say “knobs” of improvement which moves the system in the right way even if it takes some time.
Health Insurance Organizations:
People want more awareness and education on health insurance. They need more transparency and trust. If you are Nigerian, you know how much trust plays in our dealings with organizations. Affordable plan, reduction in the bureaucracy, and personalized service.
A respondent to HMOs:
“Stop hiding dodgy clauses in the fine print that take advantage of and cheat sick people out of coverage when they need it”
The NHIS is working and has so many plans for people. The problems which the agency might be facing are lack of marketing activities and mistrust between both Health Management Organizations and the people they serve. They wear so many hats as they both regulate the system and provide health insurance. A Staff told me in an informal interview that they have seen cases where they disburse money for a patient's bills but an HMO might keep it for their business and waits for days before paying the charges.
In essence, this might be a part of the full picture but a picture that should be viewed at least. The results from the survey are not to discredit anyone but to bring attention to the importance of user-centered design for initiatives or system improvements backed by evidence. As the Nigerian government attempts to make health insurance mandatory for all Nigerians with the National Health Insurance Authority (NHIA), let's hope that this will represent the needs of people.
Going forward
Like every well-meaning initiative, more questions arise as time goes on and some we think you should think about are:
- How can we rethink health insurance to encourage the utilization of health facilities and services without pressuring service users?
- Are there other models that work best in Nigeria and reduce out-of-pocket payments no matter how little?
- How can HMOs and the government win the trust of people?
- What role will technology play in all these?
There are other questions on our minds as a team but these are a few for you to think about. If you will like to know more about our survey and project, you can reach out via email at tamunotonye.harry@gmail.com. We would love to hear from you.
