Insurance and Incentives: A Dual Approach to Try to Improve Maternal Health in Nigeria


Jun 10, 2014

Woman attends a health education session in northern Nigeria

Woman attends a health education session in northern Nigeria

photo by Susan Elden/DFID [CC-BY-SA-2.0]

While Americans may think their struggle with the Affordable Care Act is unique among nations, there has been a global drive in the last decade for universal health coverage. And though most countries in Africa have sought, at least in principle, to move toward universal coverage, there are substantial variations across the continent in who gets insured and how.

In Nigeria, less than five percent of the population has some form of health insurance; most Nigerians are ineligible for the National Health Insurance Scheme. (That plan covers those who cannot afford private insurance but are in the formal sector of the economy — that is they hold jobs with normal, regular hours and receive pay that is taxable by government.)

Private spending represents about 69 percent of the total health costs in the West African nation; 96 percent of that private spending goes for out-of-pocket payments. When people must pay out of pocket for health care at the point of service, this restricts access, excludes the poorest and most vulnerable, and leads to delays in patients seeking help, with, ultimately, poor health outcomes. This also increases the likelihood of patients getting pushed into poverty due to catastrophic health costs.

In Nigeria, some health officials have viewed favorably community-based insurance — another coverage alternative — as an innovative and effective means to help cover those in the informal sector of the economy. Because so many Nigerians fall in this sector — taking on jobs with irregular hours and pay and without government taxation and oversight — the NHIS is working with state governments and advocating for citizens to organize into community-based health insurance pools. The Nigerian states of Lagos and Kwara are trying this approach.

Officials in Ogun, a state in southwest Nigeria, have gone further, working jointly with development partners recently to launch the pilot phase of community-based insurance along with a program for targeted government assistance for expectant mothers. Under these efforts, participants pay about $25 for their annual health premium, with the government subsidizing $18 of that cost. This coverage entitles the insured to basic health care services in public healthcare facilities.

The Ogun state government went a step further, providing financial incentives aimed at improving the health of pregnant women and reducing infant mortality. Nigeria's newborn death rate, international experts estimate, is among the highest on the planet, with more than 500 babies dying daily. One woman every 10 minutes dies on account of pregnancy or in childbirth in Nigeria.

In Ogun, the new state program reimburses pregnant women the cost of their bus fares to get to and from doctor's offices, clinics and hospitals when they receive antenatal and postnatal care or when they bring in their babies for immunizations. Some expectant moms also get mobile phones so they can call health providers in an emergency. The Ogun government at the same time is upgrading health facilities in the state to improve the quality of care they can offer.

Studies have shown that incentive initiatives like those in Ogun, which also are known as conditional cash transfer programs because they provide money to poor families contingent on certain changed behaviors, help to increase the utilization of health care and to improve positive health behaviors in the developing world.

While the combination of health insurance and behavioral incentives may hold great promise to improve health outcomes, especially for expectant mothers, infants, and children, a huge concern rests in these programs' sustainability. These programs feature taxpayer-funded subsidies, meaning they may be abandoned if and when political leadership changes. Rigorous, objective research and evaluation of the programs' effectiveness might provide persuasive evidence to sway voters and politicians, while also allowing governments to find ways to improve them.

Adeyemi Okunogbe is an assistant policy analyst at RAND and a Ph.D. candidate at the Pardee RAND Graduate School. This blog was written for the Pardee Initiative for Global Human Progress.