Universal Health Coverage is the cornerstone of global and national health system policies and planning. In developing countries like Nigeria, healthcare services are often paid for out-of-pocket. Despite the importance of health insurance in providing a safety net for catastrophic health expenses, a national survey, according to the Lancet Nigeria report, indicates that only about 3 per cent of Nigerians are covered by any form of health insurance. Most enrolees are federal and state government employees and their dependents. The National Health Insurance Scheme was signed into law in 2004, but its implementation faced numerous challenges.
One major impediment was the federated nature of the Nigerian state, which hindered the effective implementation of the NHIS 2004 law. In response, several states began establishing their own state health insurance schemes. According to a 2019 PwC report, 19 state governments are at different stages of establishing their own. Other issues included funding sources and the willingness and ability of people to pay for insurance, especially in a region where insurance culture is not mainstream.
The funding available for insurance coverage, capitation, fee-for-service, and administrative overheads was insufficient to cater to the number of vulnerable groups in the country. As a result, both the NHIS and state-based insurance schemes turned to yearly premium payments, but many people were either unwilling or unable to pay. To address these issues, the Nigeria Health Insurance Authority Act 2022 was signed into law, repealing the NHIS 2004 law. This new law aims to enhance the role of the state in promoting, accrediting, licensing, and integrating state health insurance schemes, providing a basic minimum package of care to all Nigerian residents in collaboration with states and the FCT.
Both the NHIS 2004 and NHIA 2022 laws aim to deliver quality healthcare to all Nigerians. The 2004 law allowed the NHIS to regulate, accredit, license, and ensure equitable distribution of standardised healthcare. The 2022 law enhances this role by integrating state health insurance schemes and providing a basic minimum package of care. The NHIS 2004 determined capitation, fee-for-service, and other payments to healthcare providers. The NHIA 2022 will perform these functions and additionally determine criteria for states to benefit from the basic healthcare provision fund as outlined in the National Health Act of 2014. Both laws emphasise the importance of information and data exchange. The NHIA 2022 law extends this to include professional regulatory bodies, individuals, and researchers.
Indeed, the NHIA Act 2022 mandates the Authority to “provide and maintain information and communications technology infrastructure and capability for the integration of all data on health schemes in Nigeria, including state health insurance schemes.” This requirement extends to every state and the Federal Capital Territory, which must establish ICT infrastructure for managing data, integrated with the Authority’s ICT infrastructure.
Several ways ICT can drive inclusiveness and effective implementation of health insurance schemes nationwide include:
Firstly, ICT can identify vulnerable groups. The law defers to the states to determine vulnerable groups. ICT can be instrumental in this process. For example, the Nigeria Primary Healthcare Development Agency has used geospatial data to identify zero-dose and under-immunized children in states like Borno and Bauchi. This geo-enabled identification can be adapted to identify communities inhabited by vulnerable groups, supported by digitized community and primary healthcare service uptake offerings.
Secondly, ICT can ease identity management. The NHIA 2022 targets covering approximately 93 million Nigerians in the vulnerable group bracket. To avoid scaling bottlenecks, enrollees need unique identification across service points. Currently, health facilities and health maintenance organizations manage patient identification. A combination of multiple identifiers, including the National Identity Number as the master identifier, can improve integration and management. The Health Level Seven-curated Fast Healthcare Interoperability Resource international standard provides the necessary framework for this.
Thirdly, ICT can enhance the automation of capitation and fee-for-service systems. Health facilities vary in their service offerings and reimbursement structures. The NHIA 2022 law defines capitation and fee-for-service, emphasising the need to track patient service usage accurately. Automating these processes can mitigate data quality concerns and reduce fraud.
Crucially, ICT can reduce administrative costs. Automating the NHIA secretariat can reduce health insurance administrative costs, estimated to be up to 25 per cent in some low-income countries. Digital tools can automate administrative charges and improve data quality for decision-making.
Although the NHIA Act 2022 highlights the importance of information sharing, digital systems facilitate efficient information exchange with the National Health Management Information System and other stakeholders. Digitized records enable quick feedback and continuous process improvement.
An optimal health system uses data for planning, collection, processing, analysis, dissemination, and decision-making. Integrated health data can be used for forecasting, predictive care, and strengthening health systems. Disease spread data from laboratories and health facilities can enhance response efforts.
While the NHIA Act empowers the Authority to work with states and the FCT to accredit health facilities, health maintenance organizations, mutual health associations, and third-party administrators, digitising license management for healthcare practitioners can improve service quality.
Digitizing health facilities in low- and middle-income countries can track services delivered and amounts due to health facilities. This reduces fraud and accelerates fund disbursement for fee-for-service schemes.
Although supply chain issues are beyond the NHIA’s scope, digitally managing commodities can enhance facility efficiency. Linking health facility commodity management systems to service delivery and state-level requests can significantly support Universal Health Coverage.
Importantly, emplacing a multi-channel system for complaints management is vital. Channels can include WhatsApp, USSD, SMS, and automated interactive voice response systems. These channels can be configured to build self-help algorithms, decentralising and staging complaint responses for hierarchical escalation.
Crucially, the deployment of Machine Learning and Artificial Intelligence can revolutionise health insurance by enhancing data analytics, risk assessment, and fraud detection. ML algorithms can analyse vast amounts of data to identify patterns and predict healthcare needs, improving personalised care. AI can streamline claims processing, reducing administrative burdens and errors. Integrating AI into health insurance systems can lead to more accurate premium calculations, better management of healthcare resources, and improved patient outcomes.
The NHIA 2022 law provides frameworks for improving healthcare services. The new law explicitly mandates the use of digital infrastructures, which stakeholders, particularly at the state level, can leverage for significant improvements. Embracing ICT and AI technologies can enhance health insurance administration, improve service delivery, and ultimately achieve Universal Health Coverage in Nigeria.
Chukwu is a digital health consultant and researcher based in Abuja
