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A major challenge to achieve health coverage in Nigeria is expansion of health access to the poor, vulnerable and informal sectors, which constitute over 70% of the population of more than 186 million. Evidence from other countries suggests that it is difficult for contributory insurance schemes to achieve universal health coverage in such conditions, especially with such a large informal sector. In fact, Nigeria's national social health insurance program has provided coverage to less than 5% of the population since its implementation in 2005, private voluntary health insurance has shown poor potential to extend coverage, and community-based health insurance has failed to expand access to poor, vulnerable and informal sector populations as well. Decentralization of health insurance to the states has limited potential to expand health insurance coverage for the poor, vulnerable and those in the informal sector. Furthermore, social health insurance in many developed countries has taken many years to achieve universal health coverage. This paper suggests that policy makers should consider adopting a tax-based, noncontributory, universal health-financing system as the primary funding mechanism to accelerate progress toward universal health coverage. Social health insurance and its decentralization to states for formal sector workers should serve as a supplement, while private voluntary health insurance should cover better-off groups. Simultaneously, it is critical to tackle issues of poor governance structures, mismanagement of funds, corruption, and lack of transparency and accountability within regulatory and implementing agencies, to ensure that monies allocated for expanded health insurance coverage are well managed. Although the proposed universal health coverage reform may take some years to achieve, it is more feasible to collect taxes, improve tax administration and expand the tax base than to enforce payment of contributions from nonsalaried workers and those who cannot afford to pay for health insurance or for services out of pocket.

A Tax-based, Noncontributory, Health-Financing System Can Accelerate Progress toward Universal Health Coverage in Nigeria