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Little is known about the role of the private sector in low and middle income countries moving towards universal health coverage (UHC). This thesis presents a case study of the role of the private sector (health maintenance organisations (HMOs) and healthcare providers) in the national health financing system in Nigeria. The analysis draws on both economic and policy analysis theories and frameworks. The analysis of the policy development process for national health insurance in Nigeria reveals that private sector actors and the political context influenced the pace and outcome of the policy-making process, including the institution of a role for HMOs to supply the government’s social health insurance (SHI) alongside their private health insurance (PHI) plans. However, an analysis of the market for the health insurance products supplied by HMOs revealed imperfect competition in the (PHI) sub-market which was characterised by product differentiation, multiple private pools, relatively higher premiums for benefits compared to the SHI, and adoption of harmful pricing strategies. The analysis of the agency relationship between HMOs as purchasers, and healthcare providers also revealed that healthcare providers respond to incentives created by the business strategies of purchasers, in such a way as to protect their own income, but their ability to do so rests on the distribution of power within the agency relationship. Finally, the weak regulatory system that emerged from the policy making process influenced (and was influenced by) the behaviours of actors in the HMO industry, and influenced the agency relationship between HMOs and healthcare providers. Overall, this thesis provides insights about the influence of context on policy processes for national health insurance proposals, and considers the effectiveness of PHI and private financing organisations in a national healthcare financing system that aims to achieve UHC.

The private sector in national health financing systems: the role of health maintenance organisations and private healthcare providers in Nigeria