Barriers to enrollment in National Health Insurance Scheme among informal sector workers in Nigeria

• Published date: 01 March 2023
• Author: Bolaji S. Aregbeshola,Samina M. Khan
• Date: 01 March 2023
• DOI: http://doi.org/10.1002/wmh3.542

Received: 16 April 2021

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Revised: 8 March 2022

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Accepted: 6 June 2022

DOI: 10.1002/wmh3.542

ORIGINAL ARTICLE

Barriers to enrollment in National Health

Insurance Scheme among informal sector

workers in Nigeria

Bolaji S. Aregbeshola

1

|Samina M. Khan

2

1

Priority Research Centre for Health

Behaviour, School of Medicine and Public

Health, College of Health, Medicine and

Wellbeing, The University of Newcastle,

Callaghan, New South Wales, Australia

2

Department of Public Health, Pakistan

Institute of Medical Sciences (PIMS),

Shaheed Zulfiqar Ali Bhutto Medical

University, Islamabad, Pakistan

Correspondence

Bolaji S. Aregbeshola, Priority Research

Centre for Health Behaviour, School of

Medicine and Public Health, College of

Health, Medicine and Wellbeing, The

University of Newcastle, University Dr,

Callaghan, NSW 2308, Australia.

Email: bolajiaregbeshola74@gmail.com

Abstract

Extending health insurance coverage to informal sector

populations remains a major challenge toward achieving

universal health coverage. This study aimed to fill the

gap in the literature by examining barriers to enrollment

in National Health Insurance Scheme (NHIS) among

informal sector workers in Nigeria. Data were drawn

from the 2018 Nigeria Demographic and Health Survey.

The study population comprised of men (n= 10,163) and

women (n= 22,216) working in the informal sector.

Bivariate and multivariate logistic regression were used

to examine barriers to enrollment in NHIS. Results show

that the majority of men (98.9%) and women (98.6%)

were not enrolled in NHIS. Age, gender of household

head, educational level, socioeconomic status, geo-

political zone, distance to a health facility, frequency of

reading newspapers or magazines, and watching televi-

sion were significantly associated with non‐enrollment in

NHIS. Findings suggest that enrollment in NHIS in

Nigeria is very low. Additionally, there are significant

barriers to enrollment. There is a need for governments

and policymakers to address these barriers. The use of

voluntary prepayments from informal sector workers as

a strategy to extend health insurance coverage has not

been effective.

KEYWORDS

healthcare financing, informal sector workers, National Health

Insurance, Nigeria, universal health coverage

Key Points

•This study examined barriers to enrollment in National

Health Insurance Scheme (NHIS) among informal

sector workers in Nigeria.

World Medical & Health Policy. 2023;15:36–52.wileyonlinelibrary.com/journal/wmh336

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© 2022 Policy Studies Organization.

•Findings indicate that the majority of men (98.9%) and

women (98.6%) were not enrolled in NHIS.

•Authors also found that age, gender of household

head, educational level, socioeconomic status, geo-

political zone, distance to a health facility, frequency of

reading newspapers or magazines, and watching

television were significantly associated with non‐

enrollment in NHIS.

•The use of voluntary prepayments from informal

sector workers as a strategy to extend health

insurance coverage has not been effective.

INTRODUCTION

Since the World Health Organization's (WHO) World Health Assembly passed Resolution

58.33 in 2005, policy challenges associated with health insurance access have gained wider

attention globally (WHO, 2005). Expansion of health insurance is one of the strategies to

achieve universal health coverage, which is one of the targets of the United Nations'

Sustainable Development Goals. WHO member countries have been encouraged to work

towards universal health coverage through sustainable health financing (WHO, 2005)to

ensure equitable access to quality health care and financial risk protection

(Aregbeshola, 2017). Financial risk protection and accessibility to health‐care services

were enhanced through health insurance that in turn contributed to improvement in the

health status of populations of countries including Peru, Ghana, Indonesia, Vietnam,

Colombia, China, Burkina Faso, Mexico, Lao People's Democratic Republic, and India

(Erlangga et al., 2019).

Social health insurance was first introduced in Germany in 1883. However, over a period

of time it has been implemented by both developed and developing countries (Barnighausen

& Sauerborn, 2002). Similarly, some countries in Sub‐Saharan Africa have benefitted

through health insurance schemes to reduce out‐of‐pocket payments and inequity in access

to health care (Barasa et al., 2018). Health insurance is targeted at different population

groups in low‐and middle‐income countries (LMICs). social health insurance, a mandatory

health insurance scheme, and community‐based health insurance (CBHI) scheme which is

a voluntary health insurance scheme target both the formal and informal sector population,

respectively, while private health insurance targets the better‐off groups. However, countries

like Argentina, China, Colombia, Mexico, and Thailand are providing health insurance

coverage for informal sector workers using general taxation (Cotlear et al., 2015). Many

developing countries like Colombia, Brazil, Mexico, Thailand, China, India, Indonesia,

Kenya, Ghana, Philippines, Vietnam, Peru, and Turkey are targeting different population

groups as a strategy to extend health insurance coverage (Cotlear et al., 2015).

In Nigeria, formal sector workers, a spouse, and their dependents under the age of 18

years are automatically enrolled in National Health Insurance Scheme (NHIS) while workers

in the informal sector are expected to voluntarily enroll by making annual premium

payments, which vary depending on the health insurance plan (NHIS, 2020). Less than 5%

of the Nigerian population have health insurance coverage (Aregbeshola & Khan, 2018)

since the implementation of the NHIS, indicating that out‐of‐pocket payments remain the

main source of health‐care financing in Nigeria and account for 60%–75% of the total health

expenditure over the decades (WHO, 2014,2015,2016a). Out‐of‐pocket health

expenditures create barriers to accessing health‐care services and leads to catastrophic

and impoverishing health expenditures (Xu et al. 2003).

DEMAND FOR HEALTH INSURANCE

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