Social Protection Profile of Nigeria - A Working Paper

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Social Protection Profile of Nigeria (Working Paper)/Chinedu Moghalu/RPU/Abidjan/Sept/2004 2

Table of Content

Table of Content………………………………………………………………….………...21. Introduction …………………………………………………………………………….41.1. Demographic and employment situation since 1990……………………………….….81.2. Economic and social Context ………………………………………………………....91.3. The Labour Force and Employment Status by Sector ..................................................101.4. The Implications of the Economic and Social Situation................................................122. The Nature of Poverty in Nigeria ..................................................................................133. Health Sector Profile …………………………………………………………………..73.1. Health supply characteristics and challenges …………………………………………193.2. Health financing in Nigeria ….......................................................................................213.3. Tackling the HIV/AIDS Challenge …………………………………………………...223.4. National Health policy ………………………………………………………………...243.5. Description of traditional medicine …………………………………………………...253.6. Attitude Concerning Traditional Medicine…………………………………………....253.7. The Socio-Economic Implications: Policy Response……………………….................264. Inventory and description of public social security programmes ………….....................284.1. AGE 0 -5 (Early Childhood Development Activities) ………………………………..284.2. Age 6 – 14 …………………………………………………………………………….294.3. Ages 15 –64 ……………………………………………………………………….. ....304.4. The National Poverty Eradication Council (NAPEC) ……………………………...…324.5. Protection against Old Age Risks ……………………………………………………..334.6. The National Health Insurance Scheme (NHIS)……………………………………….364.6.1. Role of Health Maintenance Organisations (HMOs) under the NHIS………………404.7. The National Emergency Management Agency (NEMA)..…………………................445. Description of community-based (not-for-profit) social Protection mechanisms ……….455.1. What the Government Can Do…………………………………………………………486. Conclusion and Axis for extension of social protection in Nigeria………........................506.1.1. 0-5 Age Group and Nursing Mothers………………………………………………...516.1.2. 6-14 Age Group………………………………………………………………………526.1.3. 15-24 and 25-64 Age Groups…………………………………………………………536.1.4. 65 and Above Age Groups……………………………………………………………546.2. Other Axis for Extension: The Role of Faith-Based Organisations………………….....556.3. The Role of Other Bi/Multilateral Organisations and Donor Agencies………………....58

Annexes……………………………………………………………………………………………….63 - 67

Selected Bibliography……………………………………………………………………………...68


Tables

I. BASIC DEMOGRAPHIC INDICATORS OF NIGERIAII. II. STRUCTURE OF THE NIGERIAN ECONOMYIII. PERCENTAGE OF INCOME DISTRIBUTIONIV. PROGRESS IN MEETING THE MDGs

Annexes

I. NIGERIA AT A GLANCEII. SOCIAL INDICATORSIII. PRIVATE PRE-PAID HMO SCHEMES IN NIGERIAIV. THE MAIN DONOR ACTIVITIES IN NIGERIA

Currency Equivalents (October 1, 2004)

Currency Unit Nigerian Naira (N)1United States Dollar ($) N1301British Pound Sterling (£) N233.991EU Euro (€) N160


1. Introduction

Adequate social security coverage is increasingly being recognised as both a means to and theultimate goal of most poverty reduction programmes. Affording minimal social protection for theentire population is a prominent political issue and a priority for the Government of Nigeria. With anestimated population of 125 million people, planning for an all inclusive social security programmefor the entire citizenry has proved a difficult and costly task for Nigeria. Over the years, theGovernment has tried designing and implementing various programmes aimed at providing thepeople with assistance in the areas of job creation, housing, social security, health insurance andprotection, etc. From the way these programmes were designed, most of them proved to beunsustainable in both the short and long terms. Some of these were programmes drawn up bydifferent military regimes to score some credibility, and consequently, as it happened, each regimecame and left with its own social protection (assistance) programmes.

With the advent of the present civilian administration, the country appears to have finally designed adevelopment plan to guide its policies and interventions. The National Economic Empowerment andDevelopment Strategy (NEEDS) document strategically outlines the priority areas for Nigeria’sdevelopment within the framework of the Poverty Reduction Strategy Papers (PRSP). Drawing onthe Millennium Development Goals (MDGs), the NEEDS targets all the impediments to nationaldevelopment and realization of the overall agenda of the Government for the Nigerian people. Thedocument identifies poverty as both the cause and outcome of various political, social, economic,and other problems the country has ever faced. In setting out measures for fighting poverty, theNEEDS calls for a holistic approach that targets illiteracy, poor healthcare delivery systems,unemployment, etc. It stated, among others, that for most of Government programmes to be realizedthere is an urgent need to review the various social protection systems that were already in place.

The idea is towards creating synergies and making policy level interventions more meaningful andimpacting to the lives of the people. In view of the poor state of the country’s healthcare system andthe increasing problem of HIV/AIDS among others, the Government came up with a national healthinsurance plan towards making health for all Nigerians a reality.

The current Healthcare delivery system in the country has some major shortfalls including, but notrestricted to limited accessibility. It is estimated that less than 54% of Nigeria’s population hasaccess to modern health care services, with a disproportionately high expenditure on curativeservices as compared to promotive and preventive health services. The healthcare managementsystem has some inherent weaknesses that often translate into waste and inefficiency, as shown bythe failure to meet targets and goals. With different levels of governments, voluntary organizationsand other agencies providing health care, the various inputs remain poorly coordinated. The variouscommunities’ involvement at critical points in the decision-making process, even on health-relatedissues, is minimal. The lack of basic health data is a major constraint at all stages of planning,monitoring and evaluation of health services. The financial resources allocated to the health services,especially to some priority areas, are inadequate to enable them function effectively. The basicinfrastructure and logistic supports are often defective owing to inadequate maintenance ofbuildings, medical equipment and vehicles; inadequate and unreliable supply of potable water andelectricity; and the poor management of drugs, vaccines and supplies system.


Presently, some reforms are being pursued by the Government aimed at implementing restructuringthe pension and gratuity system on the one hand, and the health system on the other. Accordingly,the Pension Reform Act 2004 establishes a uniform set of rules, regulations and standards for theadministration and payments of retirement benefits for the Public Service of the Federation, FederalCapital Territory and the Private Sector. The Act also hopes to ensure that every person who hadcontributed to the Scheme will receive his retirement benefits as and when due. In regard to thehealth system, the National Health Insurance Scheme (NHIS) which Act had been promulgated inMay 1999 is being given a fresh impetus. The broad objectives of the health scheme are to increaseaccess, ensure equity, and provide social and financial protection, increase quality and utilization ofhealth care services, increase private sector participation as well as secure financial sustainability inthe health care sector. The scheme has distinct programmes for the different segments of thepopulation as represented by the formal sector, informal sector, children under-five, permanentlydisabled and prison inmates’ social health insurance programmes.

Implementation of the scheme is supposed to begin with the formal sector where the mechanisms fora successful roll-out are readily existent and would require minimal redesigning or restructuring.

The situation with the informal sector, which constitutes about 70% of the population, poses anentirely different question. Implementing the NHIS at this level would require more extensive andelaborate preparation in view of the lack of formal structures on which to base premium collectionand other important operational functions. Already, the Government has launched some pilotschemes in some rural communities under the Rural Community Social Health InsuranceProgramme (RCSHIP), but without the full involvement of the communities for which the schemesare intended, it remains to be seen how sustainable these schemes would be in the long run.

This study seeks to explore and profile the social protection situation in Nigeria, with a specialfocus on the developments in the country’s social security, especially, the health sector. Thepurpose is to seek for ways of establishing viable windows for extending coverage to all withinthe decent work agenda of the International Labour Organisation (ILO). To fully understand theILO’s approach to social protection, it may be apposite to look at its two-pronged strategy ofsocial security and labour protection. Social security is the protection that a society provides toindividuals and households to ensure access to health care and to guarantee income security,particularly in cases of old age, unemployment, sickness, invalidity, work injury, maternity orloss of a breadwinner. Labour Protection, on the other hand, consists of all the rules and policiestargeted at providing an enabling environment for the maximal output of labour. These include allinterventions aimed at ensuring the safety and health of workers in the course of their jobs,favourable working conditions free from discrimination on the basis of health, race, or colour anda free mobility of labour.

Accordingly, social protection consists of policies and programmes designed to reduce povertyand workers’ vulnerability by promoting decent work. This necessarily entails establishingefficient mechanisms for social dialogue, efficient labour markets, non-discriminatory workplaceenvironment, and income generation. Enhancing the effectiveness and coverage of socialprotection for all requires not only a set of sound policies and strategies but most of all, a clearvision, relentless will, sustained effort and resilience to adapt to evolving circumstances and newchallenges.

http://www.ilo.org/public/english/protection/safework/index.htm





For the purposes of this study, social security is used most of the time to describe identifiableoutcomes of government’s socio-economic policies and other interventions in the area of labourprotection. Certain public sector social protection programmes described under sections 4.1, 4.2,4.3 and to some extent 4.4 are less relevant for the primary purpose of the study, but have beenincluded to provide a panoramic view of government’s social protection initiatives.

Relying on previously documented works on community involvement in health insurance inCentral and West Africa1, this study had targeted a detailed profile on such community-basedhealth insurance schemes (CBHIS) existing in Nigeria. According to the survey findings, someMutual Health Organisations had existed in Nigeria namely, the Community Partners for Health(CPH), Country Women’s Association of Nigeria’s (COWAN’s) Health Development Fund(HDF) and the Ibughubu Improvement Union, all operating in Southwestern Nigeria. The CPHwere modeled as informal sector mutual health insurance schemes involving some privateprimary health care (PHC) providers and community-based organisations that finance and jointlymanage their members’ primary health care needs.

However, visits to the locations of some the MHOs, and discussions with their managers revealedthat the present economic situation in Nigeria has seriously affected the viability of the schemes. Asit were, the schemes were comprised of community-based organisations (CBOs) that purportedlycontributed towards provision of quality health care to members and their families. Surprisingly,interviews with the managers of two of the Schemes – Amukoko Community Partners for Health(AMPH) and Lawanson Community Partners for Health (LCPH) – in Lagos revealed that there maynot have been health insurance in the traditional meaning of the term.

The reason is that most of the members of the CBOs lacked the financial capacity to sustain any kindof premium payment. The annual contribution for each member was N100 (less than $1), andconsidering the high cost of living and healthcare in Nigeria, even if the membership is up to athousand, the total sum collectible would not be adequate to treat a serious case of malaria.Presently, these schemes have resorted to other activities which do not directly or holistically dealwith primary healthcare delivery. As non-governmental organisations (ngos), the various CPHs nowseek funding from donors and other international agencies to enable them engage in preventivecampaigns against HIV/AIDS, capacity building workshops, micro-credit schemes, environmentaland sanitation campaigns, etc. (See, however, page 55 – s.6.2, on Other Axis for Extension: TheRole of Faith-Based Organisations)

Accordingly, the study redirected focus to profiling the general social protection situation in Nigeria,with a particular emphasis on the developments in the country’s social security, particularly as itrelates to health care, towards determining what would work most appropriately. This is based onthe understanding of the ILO that in assisting member states to develop strategies and policies toextend social security coverage, there is no single right model. Rather effort is always made toexplore the possibility of extending coverage through the “Classical” social security, communitylevel interventions, as well as establishing linkages between community initiatives and publicpolicies.

1 Atim, Chris. 1998. The Contribution of Mutual Health Organisations (MHOs) to Financing, Delivery, and Access toHealth Care: Synthesis Research in Nine West and Central African Countries. p.2.


With the findings made from this report it is hoped that the ILO would be able to engage the nationaland state governments, ministries, representatives of employers and employees, and otherstakeholders in a meaningful dialogue to identify practicable strategies for extending social securitycoverage in Nigeria. This process should critically examine the social security needs of workers inthe formal and informal economy, as well as assess the effectiveness of statutory and community-based initiatives to cover the majority of the population.

The objective is to seek and establish partnerships with the Nigerian government, social partners,donor community and other stakeholders to design and implement sustainable initiatives that wouldassist the country in combating social exclusion and poverty. The vehicle for achieving this is theGlobal Campaign on Social Security and Coverage for All scheduled to be launched by the ILO andits constituents and social partners in Abuja, Nigeria in January, 2005.


1.1. Demographic and employment situation since 1990

The total population of Nigeria as reported in the 1991 census was 88,992,220. Using a growth rateof 2.83 percent per annum, the National Population Commission (NPC) in 2003 estimated thepopulation to be about 126 million.2 This makes Nigeria the most populous nation in Africa and thetenth most populous nation in the world. The spatial distribution of the population within the countryis uneven. Extensive areas in the Chad Basin, the middle Niger Valley, the grass plains, and theNigerDelta, among others, are sparsely populated. In contrast, there are large areas of denselypopulated rural districts, which support more than 400 persons per square kilometre in parts of AkwaIbom, Imo, Anambra, and Enugu States, as well as Kano, Katsina and Sokoto States. Except forLagos, all states with high population densities are located in the South East of Nigeria. Kano State,with an average density of 281 persons per square kilometre, is by far the most densely populatedstate in the north.

The population of Nigeria is predominantly rural; approximately one-third live in urban areas. Thestates with the largest population are Lagos (94 percent), Oyo (69 percent), and Anambra (62percent). The least urbanised states, with an urban population under 15 percent, include Sokoto (14percet), Kebbi (12 percent), Akwa Ibom (12 percent), Taraba (10 percent), and Jigawa (7 percent).3

Table 1. Basic demographic indicators for Nigeria

Data generation in Nigeria has not been very easy over the years, owing, perhaps, to the large size ofthe country and the inadequate capacity and infrastructure to conduct extensive surveys. However,from the available data sources, Nigeria has a young population with a median age of 17.4 years.Children under 15 years account for 45 percent of the population while the aged are estimated to be

2 National Population Commission (NPC) [Nigeria] and ORC Macro, 2004, Nigeria Demographic and Health Survey2003. Calverton, Maryland: National Population Commission and ORC Macro, p.33 NPC, 1998.


about 3.5 percent. The age dependency ratio in the country is 93.2 per 100 and the index ofeconomic dependency is 259 depedents per 10 workers.4

Nigeria comprises of over 250 ethnic grups with an equal number of language and dialects. Themajor groups are the Hausas in the north, Yorubas in the southwest and the Igbos in the southeast.The southern population is mainly Chistian while the northern population has a muslimconcentration. Rural-urban migration has created big cities such as Lagos, Ibadan, Kano and PortHarcourt with the corresponding problems of unemployment, slums, overcrowding, and otherenvironmental degradation.

1.2. Economic and social ContextThe economy of Nigeria has widely fluctuated within the past thirty years. Before the discovery ofoil, the economy and national development initiatives heavily depended on the revenue fromagricultural activities. Also, agrculture provided gainful employment to over 75 percent of thecountry’s labour force and satisfactory livlihood to over 90 percent of the population at the time ofthe country’s independence. In real terms, it accounted for over 50% of the GDP, and was the mainsource of export earnings and government revenue. Most of the manufactured consumer goods,including those capable of using local sourced agrocultural products and minerals as raw materialswere imported. An import liberalisation strategy was adopted and few industires were set up toproduce outputs such as cememt, textiles, sugar, tanneirs, wood products and vegetable oil. Between1965 and 1966, agrivulture contributed about 55% of the GDP, with the figure declining to 45% in1970/71. However, the discovery and intense exploitation of petroleum brought an end to thedominant role of agriculture in the economy, especially in terms of foreign exchange earnings.Evidently, this came with some lessons and unpleasant experiences for the economy.

Encouraged by the revenue flow from oil, the government started to invest in large-scal, capitalintensive and strategic industries like petro-chemical, refineries, iron and steel, fertilizers, etc. Smalland medium-scale industries were left to the private sector. Increased demand for manufacturegoods led to the establishemnt of many industires for such goods. Arrangements were also made forthe development of cottage industires at the rural level of the economy in addition to exportpromotion, technical skills training and employment generation. This period witnessed a rapidexpansion of education at all levels – primary, secondary and tertiary. Aggregate student enrolmentfor primary school rose to 6.9 million in 1975 from 2.9 million in1960. The secondary school levelenrolment rose from 135,360 in 1960 to 735,905 in 1975/76 (as at 1998/99 this figure has increasedto 5.2 million), while university enrolment rose from 1,395 in 1960 to 31,515 in 1975/76 (319,914in 1998/99).

The import-substitution strategy turned the domestic terms of trade against agriculture andsubsequently led to rapid rural-urban migration. The contribution of agriculture to GDP fell from48.8% in 1970 to 22% in 1980, while that of oil and mining rose from 10% to 26.8% for the sameperiod. The share of manufacturing rose 7.2% in 1970 to 8.4% in 1980, while trade and financesectors rose from 13% to 15%.5

However, the era of oil boom was short lived. The economy witnessed a progressive declinefollowing the collapse of oil prices in the 1980s and the failure of the Government to promote

4 WHO Country Cooperation Strategy: Federal Republic of Nigeria: 2002 – 2007, p. 2.5 Federal Republic of Nigeria: National Employment Policy document, p.2.


agricultural sector and non-oil exports. In the wake of the downward economic trend, theGovernment did not make any structural changes to its budgeting and development initiatives, butcontinued on ‘busines-as-usual’ basis. This necessitated sourcing for loans from external creditorsand placing restrictions on external trade. By 1986, the Structural Adjustment Programme (SAP)was introduced. The standard objectives were stabilisation of the economy through restoration offiscal and monetary measures, liberalisation of consumer and producer prices in favour of tradables,the progressive movement towards a realistic market – dtermined exchange rate regime throughdepreciation and elimination of foregin exchange restrictions, strengthening of balance of payments,privatisation of public enterprises, etc. In the agricultural sector, SAP led to the abolition ofagrciultural commodity boards with favourable effects on the sector. Effectively, these broughtabout a high depreciation of the Nigerian currency – Naira.

The GDP from the oil and mining sector fell from 26.8% in 1980 to 13.2% in 1990 and to 12.7% in1995. However, the bulk of government foreign revenue earnings, up to 75 – 87%, were derivablefrom it. By 2002, the total GDP derivable from oil export was 51.4% (see Table 2). The share of theindustrial sector contribution to GDP also fell from 10.7% in 1985 to 7.3% in 1991 and 5.7% in1995. The level of capacity utilisation by the manufacturing sector remained low, and by 1990 itstood at 27%, with a further steep to about 27% in mid-1995. Trade and finance sectors stabilised atabout 21% of the GDP, while the Government share was 10.2% in 1995. However, agriculture, (ifbroadly defined to include crops, livestock, forestry and fisheries), still remains the principal activityof the Nigerian population accounting for about 39% of the GDP in 1998. (See also, Nigeria at aglance, Annex 1)

Under the SAP in 1986 - 1992, GDP grew at about 5.2% compared to -0.5% per annum rate in thepre-SAP era of 1981-1985. Agriculture also grew comparatively to 3.2% in 1981 – 1985 to 4.2% in1986 – 92, while manufacturing grew from -4.0%to 4.9% under the same period. The objective ofcontrolling the fiscal deficit, however, was not met. Rather, fiscal deficit, as a proportion of GDPincreased from 12.9% in 1986 to 25% in1990 and stood at 11.7% in 1993. The implementation ofSAP was abandoned following a change of govenrment in 1993.

Summarily, the average GDP growth rate was estimated at -2.0% between 1979 and 1989, and 2.7%between 1989 and 1999. By 2002, the country had experienced about 3.3 % growth rate in real GDPwhich was actually a drop from the rate of about 4.2% in 2001. The annual growht estimate for1999-2003 was 2.5% (See Table 2, below on the structure of the Nigerian economy, and Annex 1.)

1.3. The Labour Force and Employment Status by SectorThe intractable problem of inadequate and often inacurate data on Nigeria makes it difficult to derivea reliable time series for the labour force and to estimate the corresponding annual growth. Relyingon the 1963 population census, the potential labour force was estimated at 32.2 million in 1980; and34 million in 1991 based on 1990 population census figures. This had reached 39.0 million in 1996and 44.4 in 1999, at an annual growth rate of 2.8%.6

A cross-referenced analysis of the employment stuation in Nigeria shows that since independence,agriculture has remained the largest single income generating domain for the work force. Though itsteeped to 57.8% in 1985 from its high figure of 71.7% in 1960, the SAP years saw it rebound to an

6 A Study of Nigeria’s Informal Sector, (FOS Document) Vol. 1


impressive 61%. However, betwen 1994 and 1999, it dropped again to about 54.8% and 59.48%respectively.

The above statistical figures notwithstanding, the reality of the Nigerian employment situation is thatthe agricultural sector has become the last resort for the majority of Nigerian work force fallingoutside any regular employment. With a population growth estimated at 2.83% per annum, a vibrantand dynamic agricultural sector is important if food security is to be guaranteed.

The manufacturing sector accounts for about 10% of the employment in 1989, which is a markeddecline from an estimated 18% of the oil boom years. The oil sector, being highly capital intensive,accounted for a mere 0.4%, despite its contribution of about 51.4% to the GDP. The service sectoraccounts for about 9% of the employed, while distribution accounts for about 16%. Small andmedium scale ecterprises and othe informal sector activities account for over 60% of economicactivities in the country and over 35% of urban employment.

From the figures released by the National Manpower Board, the formal sector employment wasestimated at 2.1 million in 1985, 2.8 million in 1990, and 4.4 million in 1999. It was furtherestimated that in 1985, formal sector employment constituted 9% of total employment and 11.3% in1999. The two top employers of labour in the formal sector were the manufacturing and servicesindustries which accounted for about 59.5% in 1985, and 67.26% in 1999. The National RollingPlan (1999 – 2001) further showed the total emploment to be 38.85 million in 1999, out of whichabout 88% were engaged in small-scale enterprises, while about 12% were in large-scaleenterprises.7

Table 2

7 Ibid.


1.4. The Implications of the Economic and Social SituationAccording to the 2004 Human Development Report, Nigeria’s human development index (HDI)value is 0.466.8 Notwithstanding the vast natural resources, abundant oil reserves, impressive humancapital, agricultural potential and emergeing industrialisation, Nigeria is clasified among the 20poreset countries in the world. The current average per capita income is about $320, which is farbelow that of neighbouring Gabon at $5,500 (2003 est.)9 Political and social instability, critical shiftsin economic policies, inequitable wealth distribution and global oil recession constitute part of thereasons for the the downward economic growth.

Over the years, the level of poverty in the country has deepened. It has been reported by the WorldBank that Nigeria is many respects two economies. Part of it is a middle-income oil-producingeconomy covering a small prcentage of the population, with a per capita of US$2200. The rest of thepopulation is part of a very poor non-oil producing economy, of whom as many as 75 million (about66%) may be living in abject poverty, with an average per capita of les than US$200.10 This is linewith the estimates by the Nigeria’s Federal Office of Statistics survey show that in 2000, about 66%of Nigerians lived below the poverty line of one US dollar per day compared to 43% in 1985.11

Most households spend two-thirds of their income on food alone, while the poorest householdsspend up to 90%. The gap between the poor and rich has also widened, with remarkable inequalitiesexisting in the society. For example, the poverty index is lowest in the southeast and highest in thenorthwest; in addition, only about 48% of the rural population and 53% of the urban population haveaccess to sanitation. The poverty level is worsened by low literacy among the generality of thepopulation. According to 1999 MIC data, the overall adult literacy rate is 49%, which is markeddecline from the 1990 figure of 57%. The female literacy level declined also from 44% in 1990 to41% in 1999. The average literacy rate in sub-Saharan Africa is 57%.12

Evidently, the preceding decades of miltary rule, political instability and the attendant economicmalaise did contribute to the deterioration in the socio-economic situation, infrastructure andproductive sector. In the final analysis, the socio-demographic, political and economic challengesarising from the increased population, general poverty, low literacy level, urbanisation and relatedrural-urban migration will determine the burden of disease in the country and the effectiveness of thehealth system.

8 Human Development Report 2004, Country Fact Sheets: Nigeria.9 CIA World Fact Book on Gabon10 The Memorandum of the President of the International Development Association and International FinanceCorporation to the Executive directors on an Interim Strategy Update for the Federal Republic of Nigeria, February 13,2002, p. 6.11 Consumer Expenditure Survey, Federal Office of Statistics, 1996.12 FOS Multiple Indicator Cluster Survey, 1999.


2. The Nature of Poverty in Nigeria

As earlier stated, the UNDP’s Human Development Index (HDI), has ranked Nigeria low in thehuman development category – 151 out 177 countries for which data was available. The HumanPoverty Index (HPI), which focuses on the proportion of people below a threshold level in basicdimensions of human development – living a long and healthy life, having access to education, and adecent standard of living, puts the the HPI-1 value for Nigeria at 35.1%. This ranks Nigeria 57thamong 95 developing countries for the index has been calculated.Household surveys describe the following characteristics of poverty in Nigeria:

a) a substantial increase in poverty between 1980 and 1996;a) a higher percentage of households are poor in the rural areas than in urban areas;b) the North tends to be poorer than the South, with the Northwest zone being the poorest and

the Southeast zone the least poor – empahasing the regional disparities in the incidence ofpoverty;

c) on the whole, poverty increases as the size of the household increases;d) the percentage of households with no education (illiteracy) was 30.3 in 1980 and by 1996,

the percentage had reached 73. On the whole, there is a substanital decrease in poverty whenthe head of household has some primary education; and

e) by gender desegregation, both men and woman have been aflicted by poverty, but the mencarried a higher proportion of the poverty burden (64% in 1986) than women (58.5% in1996)13. (See Table 3.)

Table 3

It has been adduced that the fundamental cause of poverty is the economic stagnation that thecountry has experienced for more than two decades. Persistent low productivity in agriculture hasmeant that most of the rural population has had limited opportunities for income improvement. Inaddition, stagnation of the non-agricultural economy has meant negative growth in the formal

13 The National Economic Empowerment and Development Strategy (NEEDS) document, National PlanningCommission, Abuja 2004. Table 4, p.31.


employment and limited demand for informal activity. A very uneven distribution of income hadcaused high demand for imported consumer goods and lower demand for goods produceddomestically. But with the almost blanket ban the President placed on the importation of mostconsumer goods, the trend has shifted to locally manufactured goods significantly.

However, given the nature of the above disparities and constraints, poverty in Nigeria will not bereduced without substantial acceleration of growth in the non-oil, non-governmental sectors.Substantial poverty reduction would require annual growth of around 5% in agriculture and 8% to10% in the non-agricultural economy (excluding government and the oil and gas sectors.

The National Planning Commission in designing the National Economic Empowerment andDevelopment Strategy (NEEDS) document, which is the Nigeria’s PRSP, recognises that povertyhas many strands and must therefore be tackled from several different deirections simultaneously.The Government has been advised to work not only to improve incomes, but to tackle the manyother social and political factors that contribute to economic disempowerment, social exclusion andpoverty.

See Nigeria’s Social Indicators – Annex 2

In regard to poverty and gender, the cultural and religious factors in Nigeria have manifestimplications for the social and economic roles ascribed to women and men. In traditional societies,especially in the Northern parts of the country, women’s roles and access to wealth are narrowlycircumscribed, while women in the Southern states have have substantial economic independence.Despite the slow pace of economic growth, significant changes have persisted in the Nigerianeconomy, and the roles of women and men are changing.

According to a 1999 study by the World Bank, the UK’s Department for International Development(DFID) and the National Planning Commission (NPC) of the Federal Government of Nigeria,participants widely associated poverty (among women) in their communities with a lack of dignity,status, security and hope. In addition to material deprivation, insecure housing, food insecurity andlimited access to utilities and services, the poor were described as wretched and lacking in anyopportunity to change their situation or provide their children with greater opportunity. They werecommonly identified as unable to educate their children above primary school, that is where this isaffordable in the first instance. Their livelihood strategies are highly limited by a narrow asset basewith income commonly derived from casual labouring or petty sales, often accompanied byindebtedness.

The powerlessness of the poor was further manifested in a lack of access to justice when wrongedand an exclusion from the benefits of local political patronage and corruption. Cummulatively, thisanalysis often gave rise to perceptions that poverty is inherited from one generation to another.Social breakdown accompanies poverty often resulting in community-level crime and other forms ofviolence. Within households, stress and the undermining of male roles as providers throughunemployment and job insecurity were seen to be contributing to conflict and violence. Traditionalcoping mechanisms had been stretched to the breaking points, increasing the burden at the familylevel and forcing both men and women to take on a greater variety and number of income generatingactivities.


It has been observable that the social and economic gaps between men and women are closing upwith accompanying changes in role ascription – particularly due to the empowerment of womenthrough education and the changing situations. The political power relation, however, has notsignificantly changed. At the national level, the Government is committed to improving the situationof women and girls. Presently, there are a number of women occupying sensitive positions in theObasanjo Administration. However, more needs to done translate the Government’s intention in thisarea into action.

To significantly affect the situation, there is need to pay strategic attention to the following areas:

Girls’ education – Enrolment rates for girls (38% for elementary and secondary combined) remainsubstantially below those for boys (48%). Under the NEEDS, the government plans to establishscholarship schemes at the secondary and tertiary levels to expand educational opportunities forfemale students where necessary. It also intends to expand adult and vocational educationprogrammes that cater to women beyond formal school age.

Agriculture – Studies suggest that rural women do more farm work than men. They often workfor some fourteen hours a day (nine hours in agriculture and five in other unpaid tasks) comparedto a little over eight hours per day for men. Any investment to reduce women’s burden (such aswater supply, means of transportation, woodlots and labour-savig technology for householdtasks) will free up time to increase income and to allow girls to attend school. These investmentswill also have important beneficial effects on the health conditions of women and the country as awhole.

Security – Th poor are particularly more vulnerable to crime. This is even more so for womenwhere an unequal power relationship sometimes leads to sexual harassment and in the worst cases toteenage pregnancies and the spread of HIV/AIDS. The Government has stated its plans toimplement the provisions of the UN Convention on Elimination of all forms Discrimination againstWomen, and to support legislation for the abolition of alll forms of harmful practices against womensuch as vaginal mutilation.

Political Power – While women’s roles are changing, women are under-represented at most levelsof authority. This seems particularly the case in traditional communities and at the local governmentlevel. This has important implications for ensuring gender-responsiveness in Community-DrivenDevelopment (CDD) work. Under the NEEDS, the Government plans to adopt measures to ensureequitable representation of women all over the country in all aspects of national life by usingaffirmative action to ensure that women represent at least 30 percent of the workforce, wherefeasible.

Access to Assets – Women’s control of houshold assets varies across Nigeria’s traditional societies.In the Christian South, for example, women are expected to earn their own keep as well as that oftheir children, and thus have substantial economic independence. This is significantly different fromthe Moslem North, where tremendous gender imbalances in access to and control of assets directlylimit productivity and growth, and are impediments to the realisation of poverty reductionobjectives. Again, the NEEDS has made provision for measures aimed at increasing access ofwomen to microfinance and other poverty alleviation strategies, with a view to reducing povertyamong women.


Nigeria’s indicators also show dramatic differences between the poor and non-poor, both ineducation and health status and in access to these services. Deaths under the age of 12 months andunder the age of 5 years are twice as high for the poorest (40% of the population) as they are for therichest quintile. Forty percent of the children in the poorest groups are underweight, against 20% forthe richest. Girls aged 15 to 19 in the poorest quintile are three times as likely to have a child out ofmarriage than those in the richest quintile. Almost 50% of the children in the poorest half of thepopulation have no immunization at all, as against 12%in the richest. Only 31% of the poorestpregnant women visit a medically trained person, against 91% of the richest women.

Accordingly, in view of the above, Nigeria will require a rapid and dramatic revamping and growthin all sectors of the economy as well as service delivery if it is to meet the (World Bank’s)International Development Goals. (See Table 4 below.)

Table 4

PROGRESS IN MEETING THE IDGs

Source: World Bank CD ROM.


3. Health Sector Profile

Demographic data on health are not very reliable in Nigeria. Data obtained from various censusexercises, vital registration and sample surveys are often inaccurate and sometimes contradictory.However, there is evidence that the key health indicators have either stagnated or worsened. Lifeexpectancy dropped from 53.8 years for females and 52.6 years for males in 1991 to 48.2 years forfemales and 46.8 years for males in 2000. The infant mortality rate (IMR) rose from 87.2 per 1,000live births in 1990 to 105 in 1999 (and by 2003, it was 115/1,000).

About 52% of under-five deaths are associated with malnutrition. The maternal mortality rate(MMR) of 948/100,000 (range 339/100,000 to 1.716/100,000) as compare to 800 per 100,000 livebirths in 1999 is one of the highest in the world. This could be attributed to the shortage of skilledmedical personnel at the primary health care level. For example, in a recent survey14 only 41.9%of primary health facilities provide antenatal and delivery services and 57.73% of such healthfacilities work without any midwife. Furthermore, 18.03% of such facilities operate withoutmidwives or senior community health extension workers (SCHEWs). With disability adjusted lifeexpectancy (DALE) of 38.3 years and the rank of 187 in the World Health Report 2000, theperformance of the Nigerian health system is worse than many sub-Saharan countries. There isthus an urgent need to support the health system with adequately trained personnel in order toimprove provision of the health services.

Disease prevalence rates include malaria, 919/100,000; dysentery, 386/100,000; pneumonia,146/100,000; measles, 89/100,000. In 2001, there were 250,000 new cases of tuberculosis detected.The national median prevalence rate of HIV is 5.8%, with over 5 million adults living withHIV/AIDS. Over 40 million Nigerians are exposed to onchocerciasis; 20 million are infected andabout 120,000 have gone blind from the disease. Schistosomiasis is prevalent in rural areas whichlack potable water, and control of the infection has been limited by the high cost of the drug ofchoice. It was estimated that only 10 percent of Nigerians have access to essential drugs, while theratio of physicians to patients stood at 30:100,000. All these conditions and diseases combine tocause high morbidity and mortality in the population.15

Nigeria continues to suffer outbreaks of cholera, cerebrospinal meningitis, measles, yellow fever andLassa fever with significant human losses due to weak emergency preparedness and responsemechanisms. Between 1987 and 1994, Nigeria experienced 17 severe yellow fever epidemics.Cholera outbreaks were recorded between 1996 and 1997, affecting more than 18 states andclaiming over 10,000 lives. Sporadic complex emergencies from petrol explosions (caused byvandalism), floods and civil unrest are becoming common occurrences with significant human andmaterial losses. The Integrated Disease Surveillance System will need to be strengthened for bothcommunicable and non-communicable diseases, while emergency preparedness and responsemechanisms will need to be put in place.

There is growing incidence and prevalence of non-communicable diseases such as hypertension,coronary heart disease, diabetes and cancer as well as illnesses related to stress, behaviour and

14 Nigeria Reproductive Services and Manpower Survey (2001). Reproductive Health Division, Federal Ministry ofHealth, Abuja, Nigeria.15 FMOH, NHMIS (Preliminary Health Profile Figures), 1999


lifestyle. In 1989, a nationwide survey revealed that 3.5 million people had mild hypertension, 1.2million had moderate hypertension and 0.5 million had severe hypertension. The prevalence ofhypertension is generally estimated at 8–10% for rural and 10 –12% for urban communities. Theproportion of smokers is 9%, and the prevalence of diabetes mellitus is 2.75%.16 Genetic diseasessuch as sickle-cell anaemia and, glucose-6-phosphate dehydrogenise affect an appreciableproportion of the population. In Nigeria,2 –3% of the population have sickle-cell disease, while the prevalence of glucose-6-phosphatedehydrogenise is estimated at 18% for males and 7% for females. Control efforts in respect of non-communicable diseases have generally received little attention in the country.

In recent years, Nigeria has responded positively to global initiatives such as Roll Back Malaria(RBM), HIV/AIDS control, Polio Eradication Initiative (PEI), directly-observed treatment short-course (DOTS) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Notableprogress has been made towards eradication of guinea-worm disease, resulting in a decrease in thenumber of cases from over 600,000 in 1989 to about 13,000 per year in the late 1990s. In addition,Nigeria has reached the WHO leprosy elimination target of less than one case per 10,000 of thepopulation.

For some of these initiatives, national level strategies and plans have been developed. However,there is need to develop state level plans that will make the national plan operational. There is a needto sustain the focus of disease prevention and eradication programmes and scale up various plannedinterventions in order to serve more and more of the population.

The goal of the NEEDS health component is to improve the health status of Nigerians in order toreduce poverty. It promises to support and consolidate ongoing efforts at strengthening of preventiveand curative primary healthcare services though comprehensive health sector reforms. In the longrun, it hopes to achieve strong national health system that guarantees the delivery of effective,efficient, good quality, and affordable health services.

Accordingly, the policy thrusts of NEEDS are to:a) improve government’s stewardship over policy formulation, health legislation,

regulation, resource mobilisation, coordination, monitoring, and evaluation;b) strengthen the national health system and improve its management;c) improve the availability and management of health resources (financial, human,

infrastructure, etc);d) reduce the disease burden attributable to priority diseases and health problems,

including malaria, tuberculosis, HIV/AIDS;e) improve physical and financial access to good quality health services;f) increase consumers’ awareness’ of their health rights and obligations; andg) foster effective collaboration and partnership with all health actors.

The major strategies and areas of intervention outlined in the NEEDS to meet the above goalsinclude,

a) redefining the roles and responsibilities of the Ministry of Health and other federal publichealth structures and institutions in providing and financing good-quality health services;

16 Health Systems Development Project II. FMOH, 1989


b) review of existing policies and strategies as well as health legislation. Publish a new NationalHealth Act that defines the national health system and the health functions of each of thethree levels of government;

c) development and implementation of a strategy to enhance community participation inproviding and financing health services;

d) refurbishing of primary health care facilities and strengthening local governments’ capacityto adequately manage such;

e) constructing and institutionalising National Health Accounts;f) development and implementation of a comprehensive health care financing strategy,

including the fast-tracking of the National Health Insurance Scheme;g) development and improvement of an appropriate response to the HIV/AIDS pandemic;h) creating and/or strengthening the mechanisms for checking the transmission of polio by the

end of 2004; detecting, diagnosing, and responding to epidemics in a timely manner, andrapidly increasing routine immunisation coverage in a sustainable manner;

i) strengthening the ability of the National Food and Drug Administration and Control toperform its regulatory functions;

j) determining how the results of the study on the private health sector could be used toformulate policy for promoting public-private in health care provision and financing;

k) integration of tiers of care, as well as traditional medical practitioners. Currently, traditionalmedical practitioners are included in the referral chains of medical care as they provide low-cost care and are the first point of contact for rural dwellers.

3.1. Health supply characteristics and challengesThe health system in Nigeria and the health status of Nigerians are in a deplorable state. As statedearlier, Nigeria’s overall health system performance was ranked 87th position among the 191Member States by the World Health Organization in 2000. Health status indicators are worse thanthe average for sub-Saharan Africa. For example, as stated above, the infant mortality rate is115/1,000; under-5 mortality rate of 205/1,000; and maternal mortality ratio of 948/100,000 (range339/100,000 to 1.716/100,000) is one of the highest in the world17

The poor state of Nigeria’s health system is traceable to several factors: organization, stewardship,financing and provision of health services. These have been compounded by other socio-economic,political and environmental factors. The overall availability, accessibility, quality and utilization ofhealth services decreased significantly or stagnated in the past decade. Available data from theFMOH indicate that in 1999, there were 18,258 registered PHC facilities, 3,275 secondary facilitiesand 29 tertiary facilities across the country. The public sector accounted for 67% of PHC facilities,25% of secondary facilities and all but one of the tertiary facilities.18

The proportion of households residing within 10 kilometres of a health centre, clinic or hospital is88% in the southwest, 87% in the southeast, 82% in the central, 73% in the northeast and 67% in thenorthwest regions. However, the fact that health facilities physically exist does not mean that theyfunction. Most of them are poorly equipped and lack essential supplies and qualified staff. In

17 Federal Ministry of Health: Health Sector Reform Program, Strategic Thrusts; Key Performance Objectives and Plan ofAction 2004 – 2007. p.4.18 Children’s and Women’s Rights in Nigeria: A Wake up Call Situation Assessment and Analysis. UNICEF, 2001


particular, the coverage of critical PHC interventions such as immunizations and access to safe waterand sanitation has declined, and marked inequalities exist between the regions, the rich and the poor,and rural and urban areas. The organization of health services in Nigeria is pluralistic and complex.It includes a wide range of providers in both the public and private sectors: private for profitproviders, NGOs, community-based organizations, religious and traditional care providers.

The National Health Policy (1998)19 is based on the national philosophy of social justice and equity,and reiterates that primary Health Care (PHC) is the cornerstone of the health system. The policyprovides for a health system with three levels: primary, secondary and tertiary. It also spells out thefunctions of each tier of government and provides for the establishment of the advisory NationalCouncil on Health chaired by the Federal Minister of Health (the Minister of State for Health andState Commissioners of Health are members). Other organs set up by the policy include the StateHealth Advisory Committees and Local Government Health Committees. Their potential has not yetbeen fully realized. As part of the health sector reform process, there is a need to review thefunctions of these organs in order to maximize their use. Under NEEDS, the government has set upthe machinery to redefine their various roles and responsibilities.

According to the National Health Policy, the federal government is responsible for policyformulation, strategic guidance, coordination, supervision, monitoring and evaluation at all levels. Italso has operational responsibility for disease surveillance, essential drugs supply and vaccinemanagement. In addition, the Government shall provide specialized health care services at tertiaryhealth institutions (university teaching hospitals and federal medical centres). These should serve asreferral institutions for the secondary health facilities.

At the lower level, the states and Local Government Councils (LGCs) share responsibility for healthcare. States largely operate secondary health facilities (general hospitals and comprehensive healthcentres), providing mostly secondary care and serving as referral level for the LGAs which providethe essential elements of primary health care. Operationally, the decentralized health structures ofthe federal government are in the states, while those of states are in the LGCs. However, some statesbuild and operate tertiary facilities or specialist hospitals.

While the federal government is responsible for the management of teaching hospitals and medicalschools for the training of doctors, the states are responsible for training nurses, midwives andcommunity health extension workers (CHEWs). The LGCs provide basic health services andmanage the PHC facilities which are normally the first contact with the health system. Under theNEEDS, the government has resolved to refurbish the primary health care facilities and furtherstrengthen the capacity of the LGCs for better management.

Some parastatals exist within the health system. The National Agency for Food and DrugAdministration and Control (NAFDAC), National Primary Health Care Development Agency(NPHCDA), National Programme on Immunization (NPI), Nigerian Institute for Medical Research(NIMR) and National Action for Prevention and Control of AIDS (NAPCA) were created to dealwith priority health issues. Overall, the roles of the different parastatals of the public sector are notwell delineated, and activities need to be coordinated in order to avoid overlapping of efforts.

19 National Health Policy, FMOH


As in other sectors, the federal government arrangement constrains the leverage that the FederalMinistry of Health (FMOH) has over the State Ministry of Health (SMOH). For instance, FMOHcannot compel SMOH to implement some health policies and programmes. This makes stewardshipof the health sector very challenging. Consequently, the gap between policy formulation by theFMOH and implementation by states and LGCs is wide.

The above shortcoming is traceable to the provisions of the 1979 and 1999 constitutions onhealthcare delivery. In the Nigerian Constitution of 1979, health is supposed to be on the concurrentlist of responsibilities (for the three level of Government), with the exception of international health,quarantine and the control of drugs and poisons which is exclusively the responsibility of the FederalGovernment. The Constitution also assigned specific responsibilities to the State and LocalGovernments. The 1999 Constitution, which is still the operative document, is almost silent onHealth Care delivery except the vague reference made on Local Governments’ responsibility forHealth.20 In section 45 (under the fourth schedule) the constitution also made provision for theoverriding of individual rights, if it is in the interest of, among other things, public health.

As part of its major strategies and interventions under the NEEDS to enhance delivery in the healthsector, the government plans to reorganise and restructure the Ministry of health and other publichealth structures within the context of redefined roles and responsibilities. The National Health Bill(when passed and signed into law) shall be able to clearly state the various roles and responsibilitiesof each tier of government in relation to healthcare delivery in Nigeria.

3.2. Health financing in NigeriaFinancial resources for health in Nigeria come from a variety of sources, including budgetaryallocations from government at all levels (federal, state and local), loans and grants, private sectorcontributions and out of pocket expenses. The value of contributions from the private sector and outof pocket expenditure is yet to be determined. According to a World Bank source, per capita publicspending for health is less than US$ 5 and is as low as US$ 2 in some parts of Nigeria. This is farbelow the US$ 34 recommended by WHO for low income countries. The reduction in healthspending in the late 1980s was due to the Structural Adjustment Programmes (SAPs) which de-emphasized spending on health and social services. At its lowest point in 1989, federal governmenthealth expenditure was 77% less in real terms than it was at the height of the oil boom in 1980.Though there was some recovery in the 1990s, health expenditure in 1999 was still 32% less than in1980.In per capita terms, the decline in health expenditure was even more precipitous, 82% between 1980and 1989 and 57% between 1980 and 1999, due to continued rapid population growth. Although thefederal government recurrent health budget showed an upward trend from 1996 to 1998 and 1999 to2000, available evidence indicates that the bulk of this expenditure goes to personnel. Recurrenthealth expenditure as a percentage of total federal recurrent expenditure was 2.55% in 1996, 2.96%in 1997, 2.99% in 1998, 1.95% in 1999 and 2.5% in 2000.21 This is an indication that the bulk ofgovernment funding is still not to the health sector.

20 See generally, S.17(3) (c) and (d) of the 1999 Constitution of the Federal Republic of Nigeria under chapter 2(fundamental objectives and directive principles of State policy), and the 4th schedule of the Constitution (functions of

local government councils).21 Central Bank of Nigeria: Annual Reports and Statement of Accounts, 1972 - 2000


In an effort to mitigate the low per capita funding to health, the government has embarked on aseries of initiatives such as revolving fund schemes for some services in hospitals and the NationalHealth Insurance Scheme. Plans by Government to come up with a national policy on healthfinancing are currently underway. Donor assistance for the health sector also experienced a declineduring the 1990s. External funding declined when many bilateral donors, including the United Statesand the United Kingdom, stopped aid in response to the anti-democratic military regime. While UNagencies continued to provide modest assistance to the health sector throughout the 1990s, widerdonor assistance did not resume until the return to civilian government in 1999. Presently, there arepositive indications of interest in assisting with various healthcare delivery programmes in thecountry from the DFID, CIDA, USAID, GTZ, JICA, etc.

3.3. Tackling the HIV/AIDS ChallengeHIV/AIDS is a cross-cutting issue, with links to education, health, agriculture, defence, labour, andother sectors. The HIV/AIDS epidemic in Nigeria has extended beyond high-risk groups. Like otherstatistics in Nigeria, the correct number of people infected with the disease is not known, but generalestimates have put it at between 4 and 5 million. A 2001 estimate conservatively put the prevalencefigure at 5.4 percent of the population. Whatever the correct figure may be, the reality is that thecountry is in real danger of facing explosive escalation in the epidemic level with dire consequencesfor economic growth and social development.

HIV/AIDS is already having a disastrous impact on social and economic development in Nigeria. Ifnot adequately contained, the epidemic will prove to be the greatest single obstacle to reachingnational poverty reduction and other targets for social and economic development. The devastationcaused by HIV/AIDS is unique, because it is depriving families, communities, and the entire nationof their young and productive people. The epidemic is deepening poverty, reducing humandevelopment achievements, increasing gender inequalities, eroding the ability of government toprovide essential services, reducing labour productivity and supply, and putting a brake on economicgrowth.

By 2001, it had become clear that the issue of tackling HIV/AIDS in Nigeria required adevelopmental, holistic, coordinated, and multisectoral approach. The strong political commitmentof the President of Nigeria to fight HIV/AIDS served as powerful catalyst and motivator forestablishing a supra-ministerial and sectoral body to coordinate efforts at fighting and containing theepidemic. This was the National Action Committee on AIDS (NACA) under the Presidency. Anational policy on HIV/AIDS was subsequently launched in August 2002 to give policy directionand to make a policy statement on the transformation of NACA from a committee to a full-fledgedagency that is well positioned and poised to scale up the fight against the epidemic.

From the beginning, NACA adopted the ILO Code of Practice on HIV/AIDS at the workplace as itsoperational blueprint and shares the ILO position that HIV/AIDS threatens the livelihoods of manyworkers and those who depend on them - families, communities and enterprises. It recognisesthat the accompanying discrimination and stigmatization against women and men with HIVthreaten fundamental principles and rights at work, and undermine efforts for prevention andcare. Accordingly, NACA focuses on the challenges of containing the epidemic; fighting denial of


human rights of the victims; and preventing new infections through advocacy, information andeducation campaigns, behaviour change and communication, condom distribution, targeting ofgroups particularly vulnerable to infection, and other key interventions. It also focuses on treatmentand care of people living with HIV/AIDS. By concentrating on prevention and treatment, NACAplans to achieve the dual objective of saving lives and reducing human suffering on the one hand,and limiting the future impact of the epidemic on human development and poverty reduction effortson the other.

Through an International Development Association credit, NACA provides funds for NGOs,community-based organisations, and federal line ministries throughout the country to supportimplementation of high-priority and demand-driven programmes. NACA is also the principalrecipient of funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The funds aredisbursed to the Ministry of Health to finance voluntary counsel and testing, prevention of mother-to-child transmission of HIV, and antiretroviral treatment for people living with AIDS. Themultisectoral response is being implemented in collaboration with development agencies includingthe Department for International Development (DFID), the Joint United Nations Programme onHIV/AIDS, UNAIDS (comprising UNHCR, UNICEF, WFP, UNDP, UNODC, ILO, UNESCO,WHO, World Bank) the U.S. Agency for International Development, the Canadian InternationalDevelopment, etc. Positive outcomes of these efforts have resulted in increased flow of resources forcommunity and sectoral responses, as well as broad ownership of the national response beyond thehealth sector.

It is interesting to note that the ILO, as part of its assistance to NACA, has translated the Code ofPractice on HIV/AIDS and the world of work into three dominant languages in Nigeria namely,Hausa, Igbo, and Yoruba.

The central focus of government policy and strategy against HIV/AIDS under the NEEDS is tocontrol the spread and provide equitable care and support for those infected with the virus. It alsoaims to mitigate the impact to the point where it is no longer of public health, social, or economicconcern. This is line with the overall government plan to create an environment in which allNigerians will be able to live socially and economically productive lives free from disease and itseffects.

Towards achieving the above policy objectives on HIV/AIDS, the following strategies, amongothers, have been proposed under the NEEDS to be pursued by NACA:

a) promote a national multi-sectoral and multidisciplinary response to the epidemic;and establish an appropriate legal and institutional framework for its coordination;

b) increase the advocacy level for awareness and sensitivity about HIV/AIDS amongthe general population;

c) improve understanding and acceptance of the principle that all people must acceptresponsibility for the prevention of HIV transmission and the provision of careand support for those infected and affected;

d) protect the rights of people infected and affected by HIV/AIDS, as guaranteedunder the Constitution and the laws of Nigeria;

e) ensure that prevention programmes are developed and targeted at vulnerablegroups, such as women and children, adolescents and youth, sex workers, longdistance commercial vehicle drivers, prison inmates, migrants, and others;


f) transform NACA into a statutory body, and provide adequate resources for it tomeet the goals and targets set for HIV/AIDS and control.

The above strategies are in line with the conclusions of the African Social Partners’ Forum thatmet during the “Extraordinary Summit of the African Union on Employment and PovertyReduction in Africa” held in Ouagadougou, Burkina Faso from 3-9 September 2004. Theyreaffirmed the ILO’s commitment to undertake concrete measures to extend social protection tothe poor and that specific proactive measures must be implemented to deal with the HIV-AIDSpandemic in Africa through preventive measures and initiatives to facilitate access to affordablemedicines by the poor. In this regard, they would want a waiver of the patent rights of genericHIV/AIDS drugs for African countries in order to make them affordable. In addition, targetededucation and sensitisation programmes for working women and men also need to beimplemented.22

3.4. National Health policyThe Nigeria’s National Health Policy and Strategy to Achieve Health for All Nigerians, promulgatedin 1988 currently represents the collective will of the government and people of the country toprovide a comprehensive health care system that is based on primary health care. It describes thegoals, structure, and strategy and policy direction of the health care delivery system in Nigeria. Itdefines the roles and responsibilities of the three tiers of government without neglecting the non-governmental actors. Its long-term goal is to provide the entire population with adequate access notonly to primary health care but also to secondary and tertiary services through a well-functioningreferral system. However, following from recommendations contained in the NEEDS, it has becomeimperative to review the Policy towards making it reflect the new realties and trends in the nationalhealth situation.

From the period it came into force, the 1988 Decree appeared to have not fully captured the variousaspects of healthcare delivery in Nigeria. This made subsequent Governments to continue exploringthe possibilities of coming up with a better guide towards improving the health situation ofNigerians. Seven years later in 1995, a National Health Summit was convened, which broughttogether experts, leaders, policy makers, providers, planners and administrators in health and otherrelevant sectors within Nigeria and from the international agencies. The agenda of that Summit wereto examine the factors that have militated against improvement in Nigeria’s health status, and chart acourse of remedial action that would take the country into the next decade and beyond.

Under the present civilian Administration, the Minister of Health has constituted a Committee ofExperts to review the recommendations that emerged from the 1995 summit and other such fora.The Committee has been mandated to come up with a national health policy document that wouldsynergise all development efforts and make the goals of Nigeria’s healthcare system more realizable.It is the expectation that such a Policy document would serve as the point of reference in providing asound foundation for the planning, organization and management of the nation's overall health

22Contained in the Conclusions of the African Social Partners’ Forum, Ouagadougou, Burkina Faso, 3rd-4th

September 2004.


system. It is also hoped that it will provide a suitable framework for the design and successfulimplementation of a government-led comprehensive health sector reform in Nigeria which process iscurrently being introduced.

In the draft Health Policy, the various levels of Government have made declarations andcommitments to attain the goal of health for all citizens. As stated in NEEDS, this would mean alevel of health that will permit them to lead socially and economically productive lives at the highestpossible level.

Under, the Health Sector Reform (HSR) Plan of Action (2004 – 2007), currently beingimplemented, a blueprint is established to guide investments and actions by all levels of government,the private sector, donors and all development partners in health. The Plan of Action maps outmedium term objectives in seven strategic intervention areas: primary health care, disease control,sexual and reproductive health including STIs/HIV/AIDS, secondary and tertiary care, drugproduction and management, coordination of development partners, organization and management.A dynamic policy process involving extensive consultation among all the levels of government isalready being pursued in order to build consensus around health policies. The FMOH has created theDivision of International Health to coordinate development aid to the health sector and the Forum ofMinisters and Heads of International Agencies has also been established.

3.5. Description of traditional medicineTraditional medicine refers to health practices, approaches, knowledge and beliefs incorporatingplant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises,applied singularly or in combination to diagnose, treat, and prevent illnesses or maintain well-being23. It also includes the sum total of knowledge and practise, whether explicable or not, used indiagnosis, prevention and elimination of physical, mental and social imbalance and relyingexclusively on experience and observation handed down from generation to generation, whetherverbally or writing.

3.6. Attitude Concerning Traditional MedicineAbout 80 per cent of all Africans rely to some extent on traditional, village-based practitioners andremedies, since manufactured medicines or regular health care services are often unavailable or tooexpensive. In Ghana, Mali, Nigeria and Zambia, the first line of treatment for 60% of children withhigh fever resulting from malaria is the use of herbal medicines at home. World Health Organisationestimates that in several African countries traditional birth attendants assist in the majority of births.

In Nigeria, like in most African countries, there is a widespread belief that good health, disease,success or misfortune are not mere occurrences but outcomes of individual actions and ancestralspirits depending on the balance or imbalance between the individual and the social environment.This situation is further bolstered by inaccessibility of biomedicine to most of Nigeria's populationbecause of escalating costs which has necessitated a search for alternative ways of managingillnesses.

23 World Health Organisation


Invariably, traditional and modern health systems coexist in many Nigerian communities. The lackof primary health care systems in the rural areas forces local people to treat themselves, either byusing medicinal plants or by buying high-cost medicine in the rural markets. In the rural areas, as awhole, people begin by treating themselves before going to a traditional practitioner or a moderndoctor. Certain diseases are believed to be better treated by one of these systems. In spite ofincreased interest in the technical aspects of traditional health care, forms of true co-operationbetween the two systems are still rare. Medicinal plants, which are comparatively more affordable,are used at an early stage of sickness, while resort to the relatively more expensive biomedicine ismade at a later stage, often as a last option.

Recent findings by WHO funded research have shown that alternative medicine is flourishing inNigeria society neither because users are dissatisfied with conventional medicine nor because theyseek self-control over their health care decisions. The driving force for the majority of users appearsto be the holistic belief that the health of body, mind and spirit are related and that this should betaken into account by whoever cares for their health.

In December 2000 the first International Conference on Traditional Medicine in HIV/AIDS andMalaria took place in Abuja Nigeria, signalling a renewed interest in the role of traditional medicinethe treatment of HIV/AIDS and other disease. More than one hundred scientists in the medical andsocial science fields, traditional healers, and allopathic practitioners attended the conference.Conference participants produced a communiqué in which they emphasized the need forcomprehensive efforts at the national and trans-national level for the utilization of traditionalmedicine in the fight against these two major diseases (International Centre for Ethno-medicine andDrug Development 2000).

3.7. The Socio-Economic Implications: Policy ResponseThe social context of the therapeutic process requires reciprocity of some sort and this paymentcontributes to the effectiveness of treatment. However, over the years, the types and methods ofpayments for traditional healing have changed. Especially in urban settings, practitioners areincreasingly demanding monetary payments. For reasons unconnected with the current acuteunemployment and poverty situation in Nigeria, the practise of traditional medicine has becomeprone to a lot of abuses. Whilst the practise ran along ancestral lines in the olden days, it is notuncommon these days to find young men and women advertising their supernatural prowess and‘wonder drugs’ in various media and motor garages around the country. This problem has escalatedwith the worsening epidemic of HIV/AIDS in Nigeria. Within the past four years, more than fivehomeopathic healers have come up with claims of having discovered the cure for the virus.

In an attempt to checkmate and regulate the practice of traditional medicine towards making it moreeffective and beneficial to the Nigerian public, the proposed National Health Policy intends tointegrate the practice of traditional medicine with orthodox medicine by ensuring the establishmentof minimum standards for the practice. It also seeks to ensure that:

a) institutions for the training of traditional health practitioners are accredited by a regulatoryboard;


b) the regulatory board shall from time to time review curricula for training of traditionalhealth practitioners and shall provide appropriate guideline towards their integration intothe mainstream of Health care delivery;

c) traditional health practitioners are to be retrained and certificated in order to increase theirskills and effectiveness in line with the regulatory guidelines; and

d) they shall be instructed on how to make effective use of the referral system of orthodoxmedical care.

The WHO's "Strategy for Traditional Medicine," released early in 2001, urges countries to adoptlegislation and develop regulations for traditional medicine, to help provide safer and more effectivecare. The agency commends Nigeria, Ghana, Lesotho and other African countries that havedeveloped health care training programmes for traditional birth attendants.


4. Inventory and description of public social protection programmes

Most social protection programmes in Nigeria are linked with various poverty alleviation schemesbeing operated by the Government at various levels. According to the NEEDS document, poverty inNigeria is dynamic and has many dimensions, which must be tackled from different directionssimultaneously. It recommends that the government (and civil society) must work not only toimprove incomes, but to tackle the many other social and political factors that contribute to poverty.

Social protection strategies in Nigeria are carried out through informal and formal means. Theformer is organised along individual, family, and community lines, while the latter is centered on theactivities of the Government in the public sector. The public sector interventions are mostly on thepromotion of income security, employment and income generation.

Generally speaking, there are no explicit regulatory framework and or encompassing strategy forsocial protection in Nigeria. The available social insurance covers only a minimum of thepopulation, while in the case of social assistance there is no comprehensive and effective socialsafety net. In a survey by the National Population Commission, comprehensive reviews werepresented on the types of social risks faced by Nigerians over various life cycles. It also reviewed thetypes of risks by age group and the various policies and programmes put in place to protect the poorand the vulnerable, as well as their coverage and performance gaps.

According to their categorization, social protection in Nigeria could be discussed in terms ofcoverage for the following groupings, viz.

4.1. AGE 0 -5 (Early Childhood Development Activities)Nigeria exhibits a young population structure, with about 19.6% falling within the age bracket of 0 –5 years old. According to the UNICEF report, the main risk faced by this group is early childhooddevelopment with the primary risk indicators being malnutrition and low pre-school educationallevel. In terms of poverty and social exclusion, 67.8% of this group falls below the poverty line.Accordingly, this group represents a primary target for any social protection intervention.Coordinated programmes and activities at this level will ensure that in both the short and long runmore families escape the poverty trap.

The next issue is that of malnutrition among this group. The four main indicators prevalent inNigeria are usually Vitamin A deficiency, stunting (low height for age), wasting (low weight forheight), and underweight (low weight for age). As reported in the 1999 multiple indicator clustersurvey, 9.2% of all children within this age range are deficient in Vitamin A consumption, while33.5%, 15.6%, and 30.7% are stunted, wasted, and underweight respectively. Evidently, from thisdata, a large proportion of children are presently at risk of malnutrition.

With regard to preschool childhood educational development, Nigerian children have very fewopportunities. In some parts of the country, as much as 81.8% of the children within this age groupare not attending any form of schooling or educational programme.


Over the years, there have been several efforts and interventions aimed at ameliorating the abovesituation. Specifically, in 1996, the Federal Ministry of Health (FMOH), the National PrimaryHealth Care Development Agency (NPHCDA) in collaboration with the UNICEF jointly developeda work plan for the virtual elimination of Vitamin A Deficiency (VAD) in Nigeria. Then in 1999, abroader framework was developed by UNICEF, WHO, DFID, USAID, the National Programme onImmunisation Agency (NPIA) and FMoH to ensure that Vitamin A distribution is synergisticallylinked to the Polio eradication campaign. Also, other polio eradication campaigns such as theNational Immunisation Days (NIDS) and its State variants, sub-National Immunisation Days(SNIDS), were also used as effective vehicles to fully distribute Vitamin A capsules.

As it were, most of these supplements were mainly provided by the donor community, while theGovernment provided the network for their distribution. According to UNICEF report, the averagecoverage of Vitamin A distribution in the country is 70% of children aged 6 – 59 months. Theinteresting thing about the VAD supplementation programme is that it is targeted at every childregardless of the social status or class of the parents.

Equally important was the National Programme on Immunisation (NPI) which was an offshoot ofthe Expended Programme on Immunisation (EPI) which was launched in 1975. The aim was toachieve a universal child immunisation in Nigeria. It was implemented mostly through the NationalImmunisation Days (NIDs) at the national level and State Immunisation Days (SNIDs) at the statelevel.

4.2. Age 6 – 14According to the MICS data, the proportion of Nigerians in this age group is 25.3% with an averageof 66.7% of them living in poverty. The primary risks faced by this group include poor humancapital development, gender issues, and poor health. By far, the crux of this group’s problem hasbeen that of education.

Despite the provision in the Nigeria Constitution that education should be provided to all children ona free and compulsory basis, Nigeria is yet to achieve a universal basic education. The net primaryschool enrolment rate is about 58.2%, while 34.1% of the children within this age bracket are yet toaccess any form of formal primary education. Several reasons have been adduced as beingresponsible for this anomaly, with delayed school enrolment being the most pervasive. As stated byMICS, the average years of delay before being enrolled for formal school is 4.7 years and 2.5 yearsfor rural and urban households respectively. Again, the rate of enrolment varies in relation to thestatus of the social status of the child’s family. While the net primary school enrolment rate is 46.9%for the poor, it is 77.0 for the non-poor.24 When various religious, ethnic and cultural factors areconsidered, the disparities become even wider.

Other risks prevalent among this group are those associated with gender such as early marriages andpregnancy.

The Federal Government had in 1999 launched the Universal Basic Education Scheme with theprimary objectives of prescribing a minimum standard of basic education throughout Nigeria; and

24 Olaniyan, O., Oyeranti, O., Bankole, A., and Oni, O. Evaluation of Risk Management Agencies in Nigeria: Report forthe World Bank/NPC Social Risk Assessment Exercise, p. 14.


monitoring, supervising and coordinating the implementing the specific programme for theattainment of the UBE.The ultimate aim of the UBE is to assist children acquire adequate cognitive skills that will ensure abetter secured life in the future. The approach is to make basic education compulsory and universalup to junior secondary school (first grade) level. The funding comes mainly from FederalGovernment with the World Bank providing some soft loans at other times.

However, deriving a reliable data on the annual expenditure on basic education and teacher-pupilratio has not been feasible. As at 2001, the teacher-pupil ratio according to UBE figures stood at anaverage of 1:56 and 1:40 for primary and secondary schools respectively. This is low compared tothe UNESCO ratio of 1:40 and 1:30 in that order. Arguably, about 29% and 25% of primary andsecondary schools pupils are not effectively covered in terms of teacher - pupil ratio adequacy.Relating to this is the issue of out-fostering children and their possible withdrawal from school. Insome cases, this has led to an increase in child trafficking and child labour.

The Government set up the Education Tax Fund in 1993 towards scaling up funding in the country’seducation sector. The Decree 7 of 1993 which established the Fund provides that all companiesoperating in Nigeria should pay 2% of accessible profit in any one year as education tax which thengoes into a fund that would be known as Education Tax Fund. The Fund is ordinarily intended for alllevels of education and it is designed to improve the financing of infrastructures and other resourcestowards improving the quality of education in the country. Between 1998 and 2002, the bulk ofresources from this fund have gone into the primary education. However, due to the way it wasdesigned, there is no special consideration to the poor or the schools they mostly attend.

Notwithstanding the obvious gains from the interventions of the Government, about 34% ofNigerians within this age group is still without any form of formal education.

4.3. Ages 15 –64This is quite a large group comprising of people in two major age brackets. According to the samplepopulation drawn by the Nigeria Demographic and Health Survey 2003, there are more 31 millionpeople within the are range of 15 – 24 years and 23.4 million people within the age group 25 – 64years representing 19.1 and 32.7% of the population respectively. Within these groups, the pooraccounts for 63.1% of the 15 – 24 age group and 67% of persons within 25 – 64 age group.

The main risks for the 16 – 24 years categories include low human capital development as revealedby low secondary education completion rate, high dropout rates from schools, teenage pregnancies,violence and substance abuse. Technical and other vocational education are not presently wellorganised in the country. Since the majority of the people enter the labour market at this period, theissue of securing some form of employment is quite palpable.

As it were, a significant percentage of this group has found it difficult to secure any form ofemployment. There have been several programmes initiated by the Government to help train andprovide employment and other income generating activities to a majority of the socially excluded inthis group. Some of these programmes include the National Directorate of Employment (NDE)Schemes, the National Poverty Eradication Programme (NAPEP), etc.


With technical assistance from the ILO at the request of the Nigerian Government, the NDE wasestablished in November 1986, but it wasn’t till October 19, 1989 that the decree enacting it cameinto force. Its mandate includes the following among others, viz.

a) to design and implement programmes to combat mass unemployment;b) to articulate policies aimed at developing programmes with labour intensive contents; andc) obtain and maintain a data bank on employment and vacancies in the country with a view to

acting as a clearing house to link job-seekers with vacancies in collaboration with othergovernment agencies.

The NDE focuses on 2 types of risks, which are unemployment and income insecurity. Primarily,the NDE was directed “to concentrate its efforts on the reactivation of public works, promotion ofdirect labour, promotion of self employment, organisation of artisans into cooperatives andencouragement of a culture of maintenance and repairs”. The targeted beneficiaries of the NDEprogrammes are mainly youths and unemployed persons. The targeting mechanism is to cover ageographical area (usually a State) in which applications are sought from prospective participantswho are then short-listed and assisted to get employed or trained.

Under the Scheme, there are four basic programmes promising potentials for mass job generation invarious sectors of the economy. Each of the programmes has supplementary sub-programmes. Theprogrammes are strictly designed to put beneficiaries through some skill acquisition orentrepreneurial training prior to resettling them with appropriate loan packages.

The Directorate has over the years pursued its mandate within the ambit of resources available to it.However, in regard to the third mandate – obtain and maintain a data bank on employment andvacancies in the country with a view to acting as a clearing house to link job-seekers with vacanciesin collaboration with other government agencies – the NDE still has a lot shortfalls. The idealarrangement was that the Federal Office of Statistics (FOS) would be a partner with the NDE in this,but this has not really been the case. To date, there is still no up-to-date data of unemployed personsin Nigeria. Also, due to an upsurge in the ranks of employed persons in Nigeria within the pastdecade, the NDE has not really been able to serve as an efficient clearing house to link job-seekerswith potential employers. Moreover, some of the schemes of the NDE have not been sustained overthe years in view of its mandate. This could be attributable to inadequate planning andimplementation based on unreliable statistical data, among other mitigating factors.

Notwithstanding the foregoing, the NDE has been able to affect the life of the Nigerian unemployedsignificantly. The National Open Apprenticeship Scheme (NOAS) appears to be the most vibrantscheme implemented by the NDE. As at December 2000, the NOAS had trained about 935,533persons. However, this is no longer the situation presently. Beneficiaries under the scheme havedwindled remarkably over the years.

From the Report of the Nationwide Registration of Unemployed Persons (August 2002), the NDEhas only been able to assist less than 20% of the total number of applicants. Apart from 1992 when62.34% of the number which applied was considered, the performance of the NDE in this regard hasfallen to less than 3% by the year 2001. Furthermore, the gender desegregation has not been veryencouraging. Report showed that more male applicants than female have benefited from the scheme,and there are presently no orchestrated efforts to make the programme more pro-poor.


The NDE programmes have mainly relied on the patronage of the Federal Government funding andtechnical assistance from international organizations. Accordingly, the Scheme has benefited fromvarious employment creation programmes designed by the International Labour Organisation (ILO)to assist the poor work of poverty. These include the Start Your Business (SYB), the Start andImprove Your Business (SIYB), among others.

While the NDE has faired commendably over the years, the major problem remains inadequatefunds for its revolving loan scheme for successful trainees. Linked to this is the issue of high defaultin loan repayment by the beneficiaries. The sustainability of the programme therefore depends onthe commitment of the Federal Government in terms of finance and outcomes of the Directorate.With the establishment of the National Poverty Eradication Programme (NAPEP), the NDE hasceased to be the central employment procuring agency for the poor and the unemployed.

4.4. The National Poverty Eradication Council (NAPEC)Following the policy shift in the new millennium for pro-poor programmes in most developingcountries, the Government established the NAPEC in 2001 to be in charge of all projects andactivities aimed at eradicating the worst forms of poverty in Nigeria. The Secretariat of this councilis the National Poverty Eradication Programme (NAPEP) which, as it were, came into operationsince 2000.

The NAPEP has two primary objectives, viz.a) to oversee, monitor and coordinate all relevant programmes and projects particularly of

government at all levels, which are aimed towards eradicating poverty; andb) to periodically extend intervention projects to complement the efforts of the implementing

ministries, departments and relevant parastatals throughout the country.

From its inception, the NAPEP was designed to make up for the shortfalls of previous anti-povertyprogrammes in the country. Hitherto, efforts at combating poverty and social exclusion had hadlimited impact due to reasons of poor policy formulation and coordination, lack of synergy, poormonitoring and uniformed focus.25 NAPEP therefore was constituted as a multi-sectoral approach tocomplement other policy initiatives of the Government especially in line with the NationalEconomic Empowerment and Development Strategy (NEEDS) paradigm.

Towards realizing this goal, NAPEP initiated five programmes, namely,a) Capacity Acquisition – aimed at training primary/secondary school leavers in vocational

trades, and providing the graduates with minimum micro-credit;b) Mandatory Attachment Programme – designed to attach graduates of tertiary institutions to

public/private sector organizations for 2 years to enable them practice their profession andto enhance their employability in the labour market;

c) Credit Delivery Programme – designed to provide cash on a micro-credit basis to smallscale entrepreneurs thereby creating better employment;

d) Keke NAPEP – a hybrid motor vehicle targeted at providing income generation for driversand spare parts dealers; and

25 Social Protection Strategy for Nigeria: Policy Note for National Planning Commission (NPC), Olanrewaju, O.,Sulaiman, A., Omobowale, O., (April 2004).


e) Vesico Vaginal Fistulae (VVF) Programme targeted at women at the risk of VVF.Since inception, the NAPEP has embarked on activities aimed at eliminating job and incomeinsecurity in Nigeria. In the years of its operation, it has trained about 130,000 youths and alsoengaged more than 216,000 persons who were attached to various establishments. According toOlaniyan et al (2003), the poor were not specifically the target of the NAPEP in its programmesimplementation.

Like the NDE before it, the Programme is fully funded by the Federal Government. However, thelevel of funding has been decreasing over the years. At inception, the NAPEP received the sum of10 billion Naira; but in 2001, this was reduced to half and by 2002, the total funding came to total of2 billion Naira. By evaluation, the NAPEP has not been able to effectively actualize its firstobjective as stated above. Secondly, the idea of intervention activities has translated to a duplicationof sorts between the NAPEP and NDE. This has resulted in wastage of valuable scarce financial andother requisite resources for combating unemployment.

4.5. Protection against Old Age Risks

Government and (organised) Private Sector Pension SchemesBefore the Pension Reform Act, 2004 came into effect in June, 2004; the Government had a pensionprogramme for all the public sector employees. While the organised private sector workers werecovered by the Nigeria Social Insurance Trust Fund (NSITF). The Government Scheme providedtwo types of benefits to the workers namely, Gratuity and Pension. The Scheme was operated on anon-contributory basis with a qualifying period for gratuity and pension set for 5 and 10 yearsrespectively. Also, the retirement age was set at 60 years, and there was a provision for a minimumpension payable. However, as it was operated, the public sector pension programme could not fullydeliver benefits for which it was established. Over the years, potential beneficiaries have been owedtheir gratuities and monthly pension allowances. Although the Pension act of 1982 had provided forpension adjustment in line with adjustment in minimum wage, lack of prompt payment of pensionsimpoverished most pensioners. It was widely acknowledged by the generality of Nigerians thatpensioners were not getting their entitlements as at when due. Even when they were paid, theminimum monthly pension of N2400 was well below the poverty line.

The Nigeria Social Insurance Trust Fund (NSITF) is a defined contribution-based scheme foremployees in the (organised) private sector. The NSITF has come a long way from the era of thedefunct National Provident Fund established in 1961 by an Act of Parliament. The law was latermodified in 1962 to make the Fund exclusive to organised private sector employees who were notcovered by the public sector scheme. The initial objective was to provide succour to private sectoremployees in the event of old age, cessation of employment, or even death. Considering that thesecategories of workers were mostly employed by the multinational companies, the scheme wasactually an attempt to provide an institutional mechanism for ensuring social security and to insulatethe workers from the vagaries and the possible uncertainties in contract relations and in the occasionof old age.

However, the NPF could not fully deliver the objectives for which it was created. In the over 33years of its existence, the scheme was mired in corruption, ineptitude, mismanagement and


maladministration by officials, evasion by employers and overall poor service delivery by the Fund.The Fund was eventually converted to NSITF following the recommendations26 (NIR/91/012/R.18)of an ILO team of technical experts appointed by the Federal Government for that purpose in theearly 1990s. The technical assistance project was financed by the UNDP.

An enactment by the Federal Military Government in 1994 established the NSITF by a decree. TheNSITF then became responsible for administering the revised scheme for private sector employerswith more than five employees. Subsequently, the NSITF became a self-accounting governmentparastatal under the Federal Ministry of Labour and Productivity, without any subsidy from thegovernment. The main objective of the scheme, as stated in the NSITF mission statement, is to assistworkers save towards their sustenance after retirement or in case of disability or death as a result ofinjury associated with employment.

The NSITF covers all the workers employed by a company incorporated or required by law to beincorporated under the 1990 Companies and Allied Maters Act. It also covers those who areemployed by other employees or organizations which have a place of business so long as they havethe minimum number of 5 employees. However, it exempts all categories of civil servants as well asworkers in establishment with diplomatic privileges and immunities, and foreign nationals who areemployed in Nigeria for a period less than 6 years at a time; or are covered by the social securityscheme of other countries. Also exempted are the clergy of various faith-based organizationsengaged in the propagation of religious activities.

The procedure is that a participant in the scheme makes regular contributions while still inemployment for an eventual enjoyment of pension and gratuity benefit upon retirement, disability ordeath. The current rate of contribution is 10.0% of a member’s gross insurable earning, subject to amaximum of N528, 000.00 per annum. Out of the 10.0%, the member is expected to contribute3.5% while the employer contributes 6.5% making a total of 10.0% to the credit of the member'scontribution record. This rate of contribution is subject to periodic reviews in line with actuarialvaluations by the NSITF Management Board aimed at sustaining the scheme and providingmeaningful benefits to members. Members' contributions are expected to be paid monthly byemployers through remittance to an NSITF office where the employee was registered. Contributionsare required to be remitted to the Fund not later than the 16th day of the following month. Forexample, the contributions for the month of January are expected to be remitted to the Fund not laterthan the 16th of February. As at March, 2004, the membership strength of the NSITF was 40,859employers and 4,251,370 employees.

In an official gazette dated 30th June, 2004, the Pension Reform Act came into force, andestablished a Contributory Pension Scheme (the Scheme) for any person employed in theRepublic of Nigeria. Unlike the previous arrangement that created different pension benefitsystems for the public and private sector employees, the Act provides, among other objectives,that the Scheme shall “…establish a uniform set of rules, regulations and standard for theadministration of and payments of retirement benefits for the Public Service of the Federation,Federal Capital Territory and the Private Sector.”27

26 Federal Republic of Nigeria: Development of Social Security (NIR/91/012/R.18),International Labour Office Geneva, United Nations Development Programme.

27 Section 2(c) Pension Reform ACT 2004, Federal Government Press, Lagos, Nigeria.


Various stakeholders, including the organised labour in Nigeria - the Nigeria Labour Congress(NLC), Trade Union Congress (TUC), and the Congress of Free Trade Unions (CFTU), have raisedsharp criticisms on various aspects of the Pension Reform Law. According to them, the Act does notaddress existing pension liabilities accruing from the large number of pensioners of primary schools,dissolved Federal Government boards, the military, railways, etc whose benefits were due forpayment before the set cut-off date. Also, they questioned the rationale for setting the rate ofworkers’ contribution at 7.5% which they consider excessive and counter-productive. This becomesmore worrisome when consideration is given to a plethora of existing monthly deductions such aspersonal income tax (10 – 15%), National Housing Scheme (2.5%) etc. The argument is that thesecontributions would divest the worker of more than 30% of her/his disposable income, andconsidering the average salary of most civil servants, this will deepen the already high level ofpoverty among the wage earners.

The other issues included the non-definition of expected benefits and inadequate representation ofstakeholders on the board of the National Pension Commission (NPC), and the need for the retentionof in-house provident or pension schemes in the private sector and some parastatals which arefunded under a satisfactory arrangement between employers and their employees.

Before the Pension Reform Law, the NSITF was the sole administrator of pension funds for everycontributing member under the old arrangement. However, under the new Act, pension funds wouldnow be administered by agencies other than the NSITF. Specifically, the Act requires the NSITF toregister a company as (one of the) Pension Fund Administrators (PFAs) to manage the savingsaccount of contributors in competition with other PFAs.28

Perhaps, the most seemingly ambiguous provision of the Act to the NSITF is that contained inSection 71. This is the issue of a “minimum pension guarantee” and the requirement for the NSITFto provide social security insurance services other than pension in accordance with the NSITF Act1993. To this extent, the Act deems the NSITF Act amended to bring it in full compliance with itsintendments.

As at the time of this report, the NSITF Act is yet to be amended, but already, the Management hadset up a Committee on Social Security and NSITF Act Review. This Committee has held technicalmeeting to deliberate on what other types of social security insurance services to offer itssubscribers.In their draft report to the Management, they made the following recommendations:

a) sickness Insurance;b) maternity;c) Medicared) family Benefit;e) unemployment Insurance;f) insurance against Employment Accident and Occupational Disease; andg) social Assistance/Housing.

28 See generally, Ss. 42 and 44 of the Pension Reform Act.


What the Committee appeared not to have addressed was the issue of how these social securityinsurance services would be marketed. Some of the members were of the opinion that theGovernment should provide the funding to enable NSITF meet these services. Whether theGovernment would provide funding or subsidize the cost for the provision of these services is notyet known. However, with the current trend of developments in Nigeria, especially in the healthsector, it may be possible that some kind of public-private partnership arrangement may be workedout in the future between the Government and some private companies to design and market similarservices.

4.6. The National Health Insurance Scheme (NHIS)The introduction of a National Health Insurance Scheme has been under consideration by theGovernment of Nigeria since 1962 when the idea of a national health insurance scheme was mootedat the floor of the Federal Parliament then in Lagos. This was revived in the 1980s when the FederalMinister of Health appointed a National Committee to examine and make recommendations onprerequisite for the establishment of a National Health Insurance Scheme. The Committee’sconclusions were accepted by the Government and it was decided that a comprehensive NationalHealth Insurance should be introduced. It was considered that such a scheme would provide a majorcontribution to the problem of financing health care and ensuring health care delivery on anequitable basis.

Towards assisting the Government of Nigeria undertake this task, a technical co-operation projectwas signed in August 1991, which was funded by the UNDP and executed by the ILO. Theobjective of the project was to finalise the planning and establish the administrative infrastructureand expertise required to operate a National Health Insurance Scheme (NHIS) through a NationalHealth Insurance Council and State Health Insurance Boards. However, it was not until 1997 that theformal launching of the NHIS was effected, and by 1999, the NHIS Decree No. 35 was promulgatedand signed into law in May 1999. To date, the NHIS is the most comprehensive attempt by theNigerian government to provide quality healthcare to the entire population.

As provided in the law establishing it, the objectives of the Scheme include ensuring access to goodhealthcare without financial hardship to families and limiting the rise in cost of healthcare services.It also aims at maintaining high standard of healthcare delivery services and improving andharnessing private sector participation in the provision of healthcare services; ensure equitabledistribution of health facilities within the Federation. Finally, it seeks to ensure appropriatepatronage of all levels of healthcare; and ensure the availability of funds to the health sector forimproved service.

The following, among others, are the functions of the NHIS:

a) registering Health Maintenance Organisations (HMOs);b) issuing of guidelines to maintain the viability of the scheme;c) approving the format of contracts proposed by the HMOs for all healthcare providers;d) determining, after negotiation, capitation and other payments due to healthcare providers,

by the HMOs;


e) advising the relevant bodies on inter-relationship of the scheme with other social securityschemes;

f) advising on the continuous improvement of quality of services provided under the schemesthrough guidelines issued by the Standards’ Committee established by its enabling law;and

g) all other such functions as are necessary or expedient for the purpose of achieving theobjectives of the scheme.

From the above functions, it could be reasoned that the NHIS is expected to be a regulatory andsupervisory agency for the operators involved in the service of health insurance provision andsafeguarding the interest of the consumers of health products.

The NHIS Decree specifies that only public and organised private sector employers and employeeswill make compulsory contributions to the Scheme. The Council of the NHIS is empowered by theenabling law to issue guidelines on the employers and employees liable to contribute under theScheme. Under this programme, which is now referred to as the “Formal Sector Social HealthInsurance Programme” (FSSHIP), 15% of the basic salary of employees will be contributed to thescheme. Out of this, the employee contributes 5% while the employer matches the balance of 10%.The benefit package covers the employee, the spouse and four children under the age of 18. For twoworking spouses, their contributions cover both and not more than four dependants under the age of18. For other dependants, the employee will be surcharged.

Participants can enjoy services after a defined waiting period and are issued with an identity (ID)cards to minimize fraud. Fund disbursement to providers is based on fixed ratios. Thus, 10% goes toservice delivery, 2% each to HMO and NHIS for operational cost, while the balance of 1% is setaside in a reserve fund. This translates to 67% of the premium being spent on service delivery, 22%will further be spent on administrative charges and the remaining 11% set aside for the reserve fund.

For those in the unorganized informal sector, or the so-called self-employed, membership to theScheme is voluntary. This implies that the Scheme, if implemented as presently conceived, willcover a very negligible percentage of the population since the formal sector employs not more than10% of the Nigerian work force.

Towards resolving this obvious limitation, the Scheme came up with two programmes to reach theinformal sector workers. These are the “Urban Self-Employed Social Health Insurance Programme”(USESHIP) and the “Rural Community Social Health Insurance Programme” (RCSHIP). Both ofthese programmes are not-for-profit arrangements to cover self-employed individuals within theurban and rural areas respectively which are bound a common economic engagement.

The USESHIP prescribes that to qualify, aspiring participants must constitute a minimum 500persons belonging to a registered programme so as to be able to pool sufficient resources. Thebenefit package, which depends on the group’s willingness to pay, is to be selected from the NHIScost benefit package list. The contribution rate is fixed by the NHIS at N150 (about $1.08) perperson month. Access to service is on presentation of ID cards, and when there are defaults, theymust be cleared before access.


The RCSHIP also requires the existence of 500 registered members with similar benefit packages asthat under the USESHIP. However, the monthly contribution is fixed at N120 per person.

For both programmes, the provider is compensated using capitation at the primary care level, fee-for-service at the secondary care level and out-of-pocket at the tertiary care level. They are bothmanaged by a seven-member Board of Trustees (BOT) which collects the prepayments, manages thefund, pays providers, and maintains necessary records. The NHIS audits their accounts and carriesout general coordination in both cases. As with the FSSHIP, disbursement of contributions under theRCSHIP is by fixed rates. In practice, before operation, the NHIS assists the affected communities inrehabilitating health facilities and in provision of essential inputs.

Presently, the Scheme has launched 7 pilot projects in the six geo-political zones of the countryunder the USESHIP and the RCSHIP. These are:

a) The Ijah Project - this was a Rural Social Insurance project for the Ijah Community locatedin Niger State (North Central Nigeria);

b) The Deidei Project – this was the first USESHIP organised for the international timbertraders and was launched alongside the Ijah project;

c) The Ibogun Olaogun Project – this was another RCSHIP for the Ibogun Olaguncommunity in Ifo LGA, Ogun State (South-East);

d) The Warrake Project – for the Warrake Community in Owan East LGA, Edo State (South-South);

e) The Zangon Aya Project located in Kaduna State for the (North-West);f) Aba Projects – there were three separate associations comprising of shoe cobblers, shoe

manufactures, and other traders in the community market under this project. The project islocated in Aba, Abia State (South East); and

g) Jada Project is located in the Jada LGA of Adamawa State (North –East)

Evidently, the NHIS has adopted a ‘up – bottom’ approach in the way most of the pilot projects werelaunched. The intention is that the Government would provide the critical funding necessary for theoperation of the rural schemes thereby raising some question regarding how people-oriented andsustainable they would be in the long run.

In addition to the above, there are three other programmes scheduled to be launched in due course.These are described as subsidy programmes initiated at the directive of the Presidency, namely,

Children under Five Social Health Insurance Programme (CFSHIP)Permanently Disabled Persons Social Health Insurance Programme (PDPSHIP), andPrison Inmates Social Health Insurance Programme (PISHIP).

For the above programmes, the NHIS would provide 100% subsidy for both primary and secondaryhealthcare services for all beneficiaries. As in other social insurance programmes, the primaryproviders are paid by capitation, while secondary providers are paid on a fee-for-service basis.

Aside from the pilot schemes already launched across the six geo-political zones of the country, adecision has been taken to pilot the implementation of the formal sector programme with themainstream Federal Civil Servants in the 36 States and the FCT. This decision was informed by the


need to implement the new monetization policy of the present Administration. Unlike other benefitsavailable to the civil servants, it was decided that health benefits should not be monetized; rather the10% government’s contribution for the health insurance of its employees should be set aside in afund that will be used to pilot the formal sector scheme. The registration of the Federal CivilServants and their dependants had long begun, and the President is billed to officially launch theFSSHIP on October 1, 2004.

In consideration of the foregoing, it would be interesting to see how the NHIS would deliver thebenefits and other services for which it has been set up. In a memorandum from the HonourableMinister of Health on a “Blueprint for the Accelerated Implementation of National HealthInsurance in Nigeria”, concern was expressed on the poor level of consultation that has takenplace among the various stakeholders. These include the civil servants, National EmployersConsultative Association (NECA), Nigeria Labour Congress (NLC) and other Workers’ Unions,Local Government Areas, National Assembly, State Assemblies, State Executive, NationalCouncil on Health, Professional groups, Health Maintenance Organisations, etc.

Despite the launching of the Scheme in the six geo-political zones of the country, most StateCommissioners of Health are not happy with the limited role given to the State Governments underthe Scheme. Most states of the Federation would rather prefer to regulate the Scheme in theirrespective States by establishing their own State Health Insurance Boards (SHIB). Furthermore, theNigeria Labour Congress (NLC) has registered its dissatisfaction with the design of the NHIS.Recalling the poor performance of similar Schemes in the past, such as the National Provident Fundand the National Housing Fund that did not render many benefits to contributors (workers), the NLCcalled on its members to reject any attempt to make deductions from their salaries for the purposesof the NHIS.

The employers of labour under the banner of the National Employers Consultative Association(NECA) also advised the government to make the Scheme optional, as most of their membersalready provide health insurance to their employees. According to the NECA demanding itsmembers to contribute towards the Scheme would amount to double payment for similar benefits.Reacting to various positions, the Minister of Health has repeatedly stated that private sectoremployers should not be allowed to contract-out on the grounds that they already provide medicalcare to employees.

Another topical issue is the number dependants allowable under the Scheme. As already stated, ithas been proposed that the benefit package will cover the employee, the spouse and four childrenunder the age of 18. In a country where polygamy has a cultural and religious connotation and largefamilies perceived as desirable, many potential subscribers to the Scheme has vehemently objectedto this arrangement. The Government on its part understands that this is contrary to Article 12 ofILO Convention No.102, but wishes to start the scheme on this basis due to reasons ofadministrative practicality and keeping the contribution rate at an acceptable level. Whateverhappens, experiences with accessing the medical benefits as formerly provided by for publicservants by the Government have shown that this could be a source for fraud and moral abuse. Thecountry is yet to introduce the national identity card scheme, and unless a proper photo identity cardis utilized under the Scheme, the limit on the number of dependants may not be easily enforceable.


4.6.1. Role of Health Maintenance Organisations (HMOs) under the NationalHealth Insurance Scheme.A Health Maintenance Organization (HMO) could be defined as "a company of multi-disciplinaryprofessionals put together for effective healthcare financing and delivery with the aim of optimalcost and maximal healthcare delivery utilising ethical medical practice, hospital administration skillsblended with insurance, actuarial valuations and risk management techniques."29 Generally, theHMOs epitomize the “Managed Care Concept”, in that they manage rather than actually providehealth care services to individuals. They are an integral part of the National Health InsuranceScheme, and are set to play an intermediary role between the employers/employees on one hand andthe Health Care Providers on the other hand. The HMO is a limited liability company (public orprivate) which contracts with Health Care Providers (HCP) on one hand and employers/employeeson the other towards managing the provision of health care on behalf of the two parties. The HealthMaintenance Organizations are the fund managers of the Scheme.

The following are the characteristics of HMOs in Nigeria:

a) Ownership StructureThe ownership of an HMO may be categorized into:i) Provider Based:The HMO may own its own health care provider facility to render health care services to theregistered participants of the Scheme.ii) Purchaser Based:The HMO will use the health services provided by other health care providers. In this respect, theHMO will enter into a contract with the health care provider organization to render health careservices to registered participants of the HMO.iii) Investor Based:The HMO may be owned by an entrepreneur who invests in an HMO as a business investment, withthe objective of making a profit.

b) Size and structureHMOs may be small or big depending on the area of coverage and share capital base. The area ofcoverage may be National or Zonal. A national HMO is an HMO that has coverage for the wholecountry with an authorized share capital of N100, 000,000. It must have offices in at least two thirdsof the states in the country. A zonal HMO on the other hand operates within a particular geo-political zone in the country, with an authorized share capital of N50, 000,000. The minimumoperational requirement for an HMO is zonal coverage. The size of an HMO may therefore besummed up as a function of area of coverage and share capital base.Before an HMO is permitted to operate by the Scheme, the HMO must deposit N50, 000,000security deposit with an accredited NHIS approved bank for national HMOs while zonal HMOs willdeposit N25, 000,000.

This amount is a guarantee against financial impropriety, sharp practice or default on the part theHMO so that the Scheme could meet its fiduciary obligations.

29 Bimbo Banjoko, quoted in the article: Search for a way round the Health Insurance Scheme, by Ronke Olawale,Guardian Newspapers, September 15, 2004.


Other requirements and attributes of HMOs in Nigeria include,

c) Formation and RegistrationTo form an HMO, the subscribers have to incorporate the company as a limited liability companywith the Corporate Affairs Commission. Having incorporated the company, the company will applyto the National Health Insurance Scheme for registration and pay the necessary registration fees.Upon receipt of an application for registration from an HMO, the Scheme through its staff will carryout an inspection of the facilities of the HMO to ascertain the suitability of such application.

The Scheme will ascertain the following:a) The Board of Directors of the HMOs to ascertain whether or not they are fit and proper

persons to run or manage HMOs;b) The policy documents and manuals of the HMOs;c) The organizational structure of the HMO with a view to ascertaining how the structure could

enhance the efficiency and ability of the HMO;d) The composition of the Management Team of the HMO;e) The provider network of the HMO including development and management networks;f) Health management procedures as it relates to HCPs;g) Marketing management procedures, relation to clientele;h) Information management process that shall include computer based technology;i) Evidence of registration with Corporate Affairs Commission and minimum paid-up capital;j) Certificate of mandatory deposit of N50, 000,000 for national and N25, 000,000 for zonal

HMOs with any of the accredited Banks;k) Evidence of tax payment and returns, and adherence to legal obligations under the NHIS;

andl) Minutes book with a view to ascertaining attendance of Directors and adherence to the Rules

and Regulations by the Board of Directors and Management team as provided from time totime by Government through NHIS.

With regard to Registration the Scheme reserves the discretion, after the necessary inspection toregister or reject the application for registration. If the application is successful, the Scheme willissue a certificate of registration.

In addition to the above, the Decree (Act) provides as follows:The Council shall approve and register for the Scheme private and public Health MaintenanceOrganizations. The registration of an organization under the Scheme shall be in such form andmanner as may be determined, from time to time, by the Council, using guidelines, which shallinclude provisions requiring the organization to:

a) be financially viable before and after registration;b) make a complete disclosure of the ownership structure and composition of the organization;c) have account with one or more Banks approved by the Council;d) be insured with an Insurance company acceptable to the Council; ande) give an undertaking that the organization shall manage and invest the funds accruing to it

from contributions received pursuant to this Decree (Act) in accordance with guidelines to beissued, from time to time by the Council.


The registration of a Health Maintenance Organization under the Scheme shall be valid for suchperiod as may be determined by Council and may be renewed at the expiry of every registration.However, no registration shall be renewed unless the organization concerned has complied withguidelines issued under this Decree (Act).

d) Functions under the ActIn the NHIS Decree (Act), the functions of an HMO include:

a) the collection of contributions from eligible employers and employees;b) the collection of contributions from voluntary contributors;c) the payment of capitation fees for services rendered by HCPs registered under the Scheme;d) rendering to the Scheme returns on its activities as may be required by Council;e) contracting only with HCPs approved by the Scheme for the purpose of rendering health

care services;f) ensuring that contributions are kept in accordance with the guidelines issued by the Council,

and in banks approved by Council;g) establishing a quality assurance system to ensure that qualitative care is given by the Health

Care Providers.

Other functions include,h) regular inspection and proper medical audit of each HCP as a means of maintaining quality

assurance (the NHIS will also carry out external quality assurance audit);i) management Information System on its operations and on the activities of HCPs;j) ensuring that all HCPs in its network comply with the requirement of having adequate

professional indemnity insurance; andk) setting up an internal quality assurance programme that is formal, systematic and ongoing.

This must focus on accessibility, acceptability, continuity of care, facility and personnelprovisions, preventive services, emergency services, pharmacy services, waiting time,inpatient services, equipment, laboratory and radiological services; follow up treatment,grievance system, physician/enrollee ratio.

In addition to the above, and to ensure accessible quality care for the insured, an HMO, must also:a) pay capitation to the HCP in advance;b) must not withhold funds due to the provider, as sanctions will be applied where this happens;c) must apply the generally accepted accounting conventions to measure value of its assets and

liabilities;d) shall not engage in any business that is not related to healthcare;e) cannot enter or leave the Health Insurance Market haphazardly; and

In the case of exit, an HMO must provide:f) A reasonable notice of at lest six months to the provider/s and NHIS.g) Details of how his claims and obligations will be settled.

Delinquent exit will be subject to criminal prosecution of all directors of the company.

An HMO is expected to submit yearly actuarial opinion of the adequacy of resources and premiumsto cover provider claims, in addition to the audited accounts of the company.


Finally, State and FCT arbitration panels have been provided for in the Decree (Act) which shallconsider complaints from an aggrieved participant against a Health Care Provider (HCP). Thedecisions of the board shall be binding, on all parties. Furthermore, the Tribunal established underthe Special Tribunal Miscellaneous Offences Decree (Act) 1984 shall try offenders that run foul ofthe NHIS decree. Sanctions and penalties for various offences are clearly laid out in the decree(Act).

e) Mechanisms for Bill SettlementEach insured person would have a free choice of approved private practice or governmentprimary health care centre for himself and dependents. The chosen practice centre registers eachpatient and notifies the Zonal Office of the National Health Insurance Scheme and is paid acapitation for each person registered whether or not that person needs any health care or not (atprimary level). An insured person may change his/her practice/centre provided he/she has beenregistered for at least six months with a previous practice/centre. Except in emergency, healthcare is obtained by first visiting the chosen practice/centre. In other words access to other doctorsor to hospital can only is covered on referral from the practice with which the patient isregistered.

f) Responsibilities to the SchemeA registered Health Maintenance Organization with the Scheme has the following responsibilities tothe Scheme, which are crucial in its operation.

These include:a) an HMO is expected to develop operational manuals in conformity with the Operational

Guidelines of the Scheme;b) an HMO shall provide relevant data for planning and improvement of health care delivery

system;c) develop efficient and functional health services marketing and financial management

programmes for overall benefit of the Scheme;d) develop Disease Management Guidelines, which shall make Providers to achieve both high

quality and cost effective care;e) provide quality assurance programmes for providers and carry out regular surveys to

measure compliance;f) shall have Primary and Specialist Health Care providers within their area of operation; andg) Embark on health promotion programmes, develop and promote health care practices to

reduce the need for curative services.

As at June 2004, there are thirteen registered Health Maintenance Organisations in Nigeria (seeAnnex 3)30. Out of these, about eight or nine companies are believed to have been authorised by theby NHIS to act as intermediaries or brokers/insurance companies for the Scheme as provided insection 20 of NHIS Act. These are the Total Health Trust Ltd.; Hygeia Health Maintenance Ltd;

30 The appendix details the number of HMOs and the estimated number of lives covered by them. It is instructive to seethat the HMOs in Nigeria aggregately cover less than 120,000 lives.


Healthcare International Ltd.; Southern Rose Nig Ltd.; Clearline International Ltd.; Multishield Ltd.;Managed Health Services Ltd; First Health Ltd.; and Expat Care HMO.

4.7. The National Emergency Management Agency (NEMA)Under the law establishing it, the National Emergency Management Agency (NEMA) has theprimary mandate to formulate policies relating to emergency management activities as well ascoordinate programmes and plans directed at responding to disasters in Nigeria. As an off-shoot ofthe National Emergency Relief Agency (NERA), which was established by Decree 48 of 1976, theNEMA was created to engage in the prevention, control, mitigation and rehabilitation of disastervictims rather than the ordinary provision emergency relief materials as obtainable under NERA.The new orientation towards disaster management rather than mere relief provision was expected tomake the agency more anticipatory, effective, efficient and dynamic at responding to emergencysituations.

In a country where natural and man-induced disasters are rampant, the role of an agency like NEMAcannot be underplayed. The agency is funded by the Federal Government, however, the Decree alsomade provisions for State level intervention (and funding) under the State Emergency ManagementAuthority (SEMA). Notwithstanding, most state governments are yet to initiate activities in line withthe provisions of the enacting law.


5. Description of community-based (not-for-profit) social protection mechanisms

In Nigeria, like most African countries, access to health care is reserved to employees of the publicand private sectors. There is no health insurance for the rest of the population most of which is oftenpoorer than the salaried workers of the public and private sectors. Workers of the informal sector andrural areas account for over 70% of the workforce in Nigeria but find themselves in a peculiarsituation of vulnerability resulting from the often difficult working conditions, lack of a long-termview and poor access to health care.

In many African countries, the excluded people have understood that they can only rely onthemselves to provide social protection responding to their needs. Micro-health insurance systemsprovide an interesting alternative for addressing the problem of the financing of health care. Theconcept of micro-health insurance covers a wide variety of systems, which are currently developingin Africa and all developing countries, such as health mutual societies, health savings systems andmicrofinance systems which also include an additional health/accident financing component. Theyare usually based on the following characteristics: voluntary membership, non-profit objective, linkto a health care provider (often hospital in the area), risk pooling and relying on an ethic of mutualaid/solidarity. Their advantage lies in being able to reach low-income people working in both ruralareas and urban informal sector who are otherwise difficult to reach, exploit social capital inbringing about greater awareness, correcting for adverse selection and moral hazard problems andencouraging preventive measures, and increased access to health care.

In a 1998 study funded by ILO’s Strategies and Tools against Social Exclusion and Povertyprogramme (ILO-STEP) in collaboration with other international cooperation agencies, it wasreported that these mutual societies were functional in some Western and Central African countries,including Nigeria. These health mutual societies are social and professional groupings thatdeveloped gradually over the years and were democratic, mindful of equity and voluntary in nature.They are found among women’s groupings, decentralized financing structures, socio-professionalfederations, village groupings, etc. The members freely choose to join and pay their contributionsregularly thus enabling them to have a fund to cover their health care. They were also generallysmall or medium sized in relation to the number of members.

According to Atim (1998) there were three of these MHOs in existence in Nigeria, namely theCommunity Partners for Health (CPH), Country Women’s Association of Nigeria’s (COWAN’s)Health Development Fund (HDF) and the Ibughubu Improvement Union, all operating inSouthwestern Nigeria. The CPH were modeled as informal sector mutual health insurance schemesinvolving some private primary health care (PHC) providers and community-based organisationsthat finance and jointly manage community members’ primary health care needs.

As sated earlier, the present economic situation in Nigeria has seriously affected the viability of theschemes. As it were, the schemes were comprised of community-based organisations (CBOs) thatpurportedly contributed towards provision of quality health care to members and their families. Butinterviews with the managers of two of the Schemes – Amukoko Community Partners for Health(AMPH) and Lawanson Community Partners for Health (LCPH) – in Lagos revealed that there maynot have been health insurance in the traditional meaning of the term.


The reason is that most of the members of the CBOs lacked the financial capacity to sustain any kindof premium payment. The annual contribution for each member was N100 (less than $1), andconsidering the high cost of living and healthcare in Nigeria, even if with large membership, thetotal contribution collectible may not be adequate to treat a serious case of malaria. Presently, theseorganisations have resorted to other activities which do not directly or holistically deal with primaryhealthcare delivery. As non-governmental organisations (ngos), the various CPHs now seek fundingfrom donors and other international agencies to enable them engage in preventive campaigns againstHIV/AIDS, capacity building workshops, micro-credit schemes, environmental and sanitationcampaigns, etc.

The above experience, however, does not suggest the impracticability of implementing healthinsurance schemes or the importance of exploring avenues for such schemes in Nigeria. It is onlya pointer to how a good initiative could go wrong if not properly designed and administered.Amidst shrinking government budgets, failure of the markets to reach the poor and widespreadcriticism of levying user charges, community based health insurance arrangements could still meetthe healthcare needs of those excluded from various formal schemes by serving as an importantfinancing tool for protecting them from adverse financial consequences in the event of sickness.While the out-of-pocket expenditure on illness in spot payments imposes great financial hardship onthe poor, community based health insurance is seen as an effective way in financing health carecosts. Health insurance by pooling of risks across members who participate in health insurancelessens the financial burden of members affected by illness.

Some of these are community based, while others are based on membership to a particular group.In some cases, health insurance feature is embedded in the other types of functions that acommunity or member based organisations provide31. (See again, Section 6.2. on Other Axis forExtension: The Role of Faith-Based Organisations)

Over the years, the ILO has been assisting several member states in addressing the twin issue ofpoverty and social exclusion through promoting and strengthening community-based socialsecurity organizations. This innovative initiative, implemented by the ILO-STEP Programme,aims at improving the knowledge base on community-based social security organizations (suchas micro-insurance and mutual health organizations), which are growing rapidly in manycountries of west and central Africa. They are designed to devise ways to support suchorganizations and enable them to grow, and to determine their potential for becoming part of awider, integrated national strategy for the extension of coverage.

This initiative targets poor and excluded groups in the informal economy and rural areas, as wellas low-income formal economy workers whose social security coverage does not meet theirneeds. In many countries the rapid proliferation of community-based social security schemes hasdemonstrated their important potential to contribute to the extension of social security servicesresponding to the priority needs of the excluded segments of the population, mainly with regardto health care, maternity protection and life insurance. However, there is a need for broader

31 The WAEC Cooperative Thrift and Consumers Society Ltd in Lagos, Nigeria was established with the primaryobjective of providing micro-credit to its members. But it also provides quality primary healthcare insurance services toits members (and other subscribers) based on voluntary contributions.


awareness and understanding of these schemes and their potential for helping countries expandsocial security coverage.

The ILO-STEP Programme has already carried out 35 technical cooperation projects oncommunity-based schemes in 38 countries of Africa, Asia, Latin America and the Caribbean. Intotal, these projects provided direct technical support to more than 100 community-basedschemes. ILO-STEP played a leading role in the design and dissemination of a wide range oftraining materials and tool kits as well as in the setting up of coordination networks. It alsosupports the design and development of national policies and legislation to strengthencommunity-based schemes.

Other researches on social exclusion have shown that approaches focusing on a single dimensionor cause of social exclusion are not very effective. While theoretical and analytical works on theissue abound, there are few technical reference materials available on the implementation of alocal approach, which combines integrality, participation, partnership and territoriality. It istherefore necessary to draw up a framework for action that can articulate the contributions ofvarious sectors towards producing an effective intervention.

The potential of up-scaling, extending and expanding of micro-insurance programs dependscrucially on the issue of affordability, that is, to what extent resources for meeting health care costscan be mobilised from the people themselves.32 Limited reach and coverage of the previous micro-insurance programs by itself is not sufficient to question the affordability of premium by the poorand hence justify the need for subsidising premium.

However, it is important to note that insurance is not the only way of dealing with risks, and notall risks are insurable. However, health risks such as those confronting most of the informalsector people such as illness, injury, disability, maternity and the like are considered to beeminently insurable as these risks are mostly preventable. Moreover, among several risks facingpoor households in Nigeria, health risk is considered to be crucial as it has a destabilising effecton household finances - directly, by thrusting health expenditure in the event of illness andindirectly, by affecting the income earning capacity of households. (Asfaw et al., 2002)33. Hencethe need for a two-pronged strategy: one, aimed at improving the health status of the poor, andtwo, protecting them from the financial consequences in the event of illness. For this reasonmicro-insurance that essentially protects households against the financial consequence of illnessis regarded as a complement to, and not as a substitute for, other health interventions.

But community based schemes also have certain weaknesses such as low capital base, low levelof revenue mobilisation, frequent exclusion of the poorest of the poor, small size of risk pool,

32Unlike micro-credit where transfer in the first instance takes place from the credit provider to the poor, in case of

insurance a reverse transfer takes place, i.e., from the poor to the insurance provider (for a promise of covering the lossresulting from a particular event). Therefore, in the context of insurance affordability becomes an important issue. SeeRajeev Ahuja and Johannes Jutting, Are the Poor too Poor to Demand Health Insurance? Indian Council for Research onInternational Economic Relations (2004)33

It has been recognised that improvement in health status is not just the result of higher incomes but is also an input intogenerating higher incomes, especially for the poor. This linkage has been demonstrated in the work of the Commissionon Macroeconomics and Health of the WHO (CMH 2001).


limited management capacity, isolation from more comprehensive benefits. In the countrieswhere they are operated, their reach is still low and attempts are still being made to bring in moreand more people by up-scaling, extending and replicating the schemes. In extending the reach ofmicro insurance, demand side and supply side factors and factors relating to design anddevelopment of scheme are important. A few micro-level studies that have tried to estimatedemand for health insurance based on the willingness-and ability-to-pay for health insurancehave come out with positive findings. A survey-based study (funded by the DeutscheGesellschaft für Technische Zusammenarbeit – GTZ - or German Technical CooperationAgency,) on the willingness to pay in three Nigerian States which are relatively not aseconomically viable as the States in South - shows that the poor are willing to pay up to 4 % oftheir monthly income (David 2004)34 for having a scheme that can take care of their costs ofillness.

A review of various existing schemes by Jakab and Krishnan (2001) highlights that,(a)micro-insurance schemes can raise substantial resources but need to get additional funds fromdonor agencies, the state or health care providers; and(b) the poorest of the poor in a community are often excluded from the schemes.

In order to increase the access of these people some schemes have developed mechanisms whichlower entrance barriers for the poorest, e.g. flexibility in premium collection and exemptionmechanisms35.

5.1. What the Government Can Do: Involving Community-Based Organisationsin Schemes Tailored towards their Needs.As part of major strategies and interventions towards improving health care delivery in Nigeria,the NEEDS outlined among others, refurbishing primary health care facilities and strengtheningthe capacity of local governments’ personnel for better management. It also stated that it willdevelop and implement a strategy to enhance community participation in providing and financinghealth services. However, as already discussed in this paper, the Government of Nigeria hadlaunched the National Health Insurance Scheme in 1997, and has within the years of its operationset up pilot programmes in the six geo-political zones of the country. That most of these schemeswere set up in rural and suburban communities would have ordinarily suggested that they arepeople oriented. But that does not appear to be the situation. A visit to one of the RCSHIP in theSoutheast zone revealed that the scheme may not necessarily enjoy the confidence of the people.The community healthcare centre that is supposed to be the provider was not sufficientlyequipped – both in medical personal and other medical accessories to deliver the expectedservices. The general view appears to be that the centre is more political than beneficial to thecommunity members. Despite lessons from past attempts to provide healthcare pro bono, the

34 Adeola David, Assessment of Professional and Voluntary Organisations/Associations’ Willingness and Ability-to-Payfor Group Health Insurance in Nassarawa, Niger States and the FCT of Nigeria: The Basis for Establishment of Centresfor Health Insurance Competencies. Funded by German Technical Cooperation Agency (gtz), Federal Republic ofGermany. (2004)35 This could be allowing the poorest members pay lump sum contribution during harvest seasons when they have mostliquidity, or to pay with their produce or other in kind methods.


scheme appears to have been introduced to the communities from the top without necessarilyconsidering its sustainability.

From interviews with the managers of the CPH in Amukoko and Lawanson in Lagos and followingfrom views expressed above, the people can afford and are willing to pay for health insurance giventhe opportunity to be engaged in some form of income generating activity. Various povertyalleviation and job creating programmes of the Government could have been set up in such a way toincorporate a health insurance component. That way, it would be practicable for the beneficiaries tohave the income to meet their contributions.

Moreover, the Government can also extend the provision of public utilities such as pipe borne water,electricity, and feeder roads to the rural communities in addition to setting up these schemes. Notonly would this measure make the communities more economically viable, it would also make itpossible for primary hygiene to be possible in these communities. Furthermore it may then bepossible for qualified medical personnel to reside among the people they serving. The practicepresently is for the personnel to pay day-time visits twice of thrice every week.


6. Conclusion and Axis for extension of social protection in Nigeria

Nigeria has abundant human and material resources to initiate and sustain rapid and broad-basedgrowth and development. It can also take advantage of opportunities offered by globalization(including prospects for leapfrogging) and by the preferential and differential trade arrangementsand concessions under the Economic Community of West African States (ECOWAS) Treaty; theAfrican Growth and Opportunity Act etc. However, since independence, most social protectionschemes were either directly initiated or fully funded by the Government. But as has been seen, thepoor state of the economy has made continued Government patronage difficult or simplyimpracticable. With an estimate of 70% of Nigerian people living in poverty and earning less than$1 per day, social exclusion and poverty have assumed alarming proportions.

The response of various administrations to the poverty problem appears to have been largely ad hocand uncoordinated. A recent survey of policies and interventions chronicles 28 federal projects andprogrammes with poverty reduction thrusts. Several state governments have also put povertyreduction schemes in place. Programmes such as community banks, family support programmes, theNational Directorate of Employment, the Peoples Bank, Better Life for Rural Women, and theDirectorate of Food, Roads, and Rural Infrastructure were established by different governments toaddress various manifestations of poverty, such as unemployment, lack of access to credit, and ruraland gender dimensions of poverty. Whilst none of these programmes was completely without merit,none of them had a significant, lasting, or sustainable effect. Several community-based schemesearlier set up by the people for purposes of social assistance also become defunct as they lacked thefinancial will to sustain such efforts.

With the advent of democratic government in 1999, measures were adopted to streamline poverty-related institutions, review past poverty alleviation programmes, and harmonise sectoral efforts.Several critical factors hindering the success of government efforts to reduce the level of povertywere identified. These include, poor coordination; absence of a comprehensive policy framework;excessive political interference; ineffective targeting of the poor, leading to leakage of benefits tounintended beneficiaries; the unwieldy scope of programmes, which caused resources to be thinlyspread across projects; overlapping functions, which led to institutional rivalry and conflicts; theabsence of sustainability mechanisms in programmes and projects; and lack of involvement ofbeneficiaries in project design, implement, monitoring, and evaluation.

Under the NEEDS paradigm, the Government of Nigeria reaffirms its obligations to the peopleand recognises the individual’s rights and responsibilities and promises to deliver the basicnecessities for a decent human existence. These include potable water, food, clothing, shelter,adequate nutrition, basic education, primary health care, productive assets, security, andprotection from shocks and risks.36 The government has declared its intention to significantlyimprove the quality of life of Nigerians, create social safety nets for the vulnerable, and meet theneeds of people who may be displaced by the reform process. Economic empowerment is the mainfocus of the new strategy. The NEEDS’ logic shows that there is no poverty of effort in Nigeria,but a poverty of opportunity. Poverty reduction will not succeed without jobs. Given that overall

36 NEEDS. The Social Charter: Investing in the Nigerian People, p. 28.


economic growth may not generate poverty reduction at the desired pace, actions to facilitateindividual economic empowerment, particularly among the poor and other vulnerable groups, areimperative. This appears to be a clear focus on practical action. Among others, it would entailagricultural and rural development, labour-intensive infrastructure, upgrading the informaleconomy, and capacity building across the board, and many other key issues.

Being people oriented and pro-poor, the NEEDS paradigm sees the challenge as not only being thatof reforming the economy in order to boost economic growth, but also to empower the people asmeans of revitalising the weakened social pillar. It correctly places great emphasis on respecting,developing and strengthening community-based organisations. In this regard, it may serve thepurpose of the Government to derive strategies for the extension of existing public schemes to covercertain excluded groups such as those who work for small employers, the professional selfemployed, domestic servants etc, and also improve the administrative capacity and performance ofsuch schemes. Also, there is need to modify some public schemes in order to better equip them torespond to the needs and circumstances of those not presently covered; and to find alternative meansfor providing basic social protection for the poor and the most vulnerable. In Nigeria, the majorityof the uncovered are in the informal sector economy.

The ILO’s research on the informal sector over the years has demonstrated that a wider concept ofsocial security is needed in order to fully respond to the realities faced by the workforce in thissector. The traditional concept of social security is contained in various ILO standards. According tothe Income Security Recommendation, 1944 (No. 67), income security schemes should relieve wantand prevent destitution by restoring, up to a reasonable level, income which is lost due to inability towork (including old age) or to obtain remunerative work, or by reason of death of a breadwinner.Also, the Medical Care Recommendation, 1944 (No. 64), suggests that medical care should beprovided either through a social insurance medical service with supplementary provision by way ofsocial assistance, or through a public medical service. The Social Security (Minimum Standards)Convention, 1952 (No. 102), identifies nine areas for social insurance, that is, medical care as wellas benefits in case of sickness, unemployment, old age, employment injury, family circumstances,maternity, invalidity and widowhood.

Notwithstanding that Nigeria has not ratified most of the ILO Conventions on social security, thegoals and objectives of the Government in this area are palpable. As deducible from the NEEDSdocument, and the policy note on Social Protection Strategy for Nigeria, the country subscribes tothe provisions of Article 9 of the International Covenant of Economic, Social and Cultural Rightsthat the right to social security for everyone is a sine qua non for sustainable development andpoverty reduction. Accordingly, the main goal of social protection in Nigeria should be to reducepoverty and protect vulnerable groups through effective and sustainable prevention mechanism.

Using the categorisation from the ‘Social Protection Strategy for Nigeria: Policy Note’, thefollowing axis for extension of social protection are prescribed:

6.1. 1.0-5 Age Group and Nursing MothersAs stated earlier, about 19.6% of Nigeria’s population fall within the age bracket of 0 – 5 years old.Considering the high level of infant mortality and other child survival issues, social protection


interventions should proactively address the need and priorities of this group. In this connection,child development shall be accorded the central place in the development of human capital inNigeria. There is a need for the Government and other stakeholders to provide adequate mechanismsfor ensuring child survival through immunisation against childhood diseases, post-natal primaryhealth care, nutrition, etc.

The traditional approach of shifting the burden of managing this risk to families, relatives, friendsand neighbours should be reviewed. With the proposed introduction of Under 5 Social HealthInsurance Programme, which the Government would provide at no cost, it is hoped that morewomen and children would receive much needed assistance. The ILO Maternity ProtectionConvention, 2000 (No.183) recognises the maternity care needs of women engaged in atypicalforms of work, and prescribes that commensurate health care and other forms of social protectionshould be provided to this grouping.

The Government should be better committed to creating a viable climate for the vaccination andnutrition supplementation programmes by various international agencies. It should also facilitate theoperation of child care development centres/school at the community level by securing the servicesof professionals who have proper training on child development. In addition, the NationalProgramme on Immunization should be implemented using existing primary health care centres tomake it more cost effective. It is suggestible that this should be an integral agenda for the Under 5SHIP under the NHIS. As it were, the government has indicated its plans, under the NEEDS, todevelop and strengthen mechanisms for checking the transmission of polio and other epidemicsaffecting infants by the end of 2004. This will involve detecting, diagnosing, and responding toepidemics in a timely manner, and sustainable increase in routine immunisation coverage.

Moreover, there is need for international development agencies, donors and other stakeholders toexplore possibilities of extending maternity protection to women, especially those in the informaleconomy using micro-insurance and other people-oriented schemes. Traditionally, variouscommunities have local midwives or traditional labour attendants which could be organised andtrained to better deliver these services.

6.1.2. 6-14 Age GroupThe primary concern for this group is to enhance the number of pupil enrolment into formaleducational institutions under the Universal Basic Education. There is a need to increase the numberof teachers or redistribution of teachers in Nigeria’s primary and secondary school system in order toachieve the recommended UNESCO standards of teacher-pupil ratio. Secondary, the UBEprogramme should mount National Campaigns to educate Nigerians that education is free andcompulsory in Nigeria up to Junior Secondary School.

Considering the dire economic situation of most families in Nigeria, it is not difficult to understandthe reason behind the high incidence of child trafficking, out-fostering and child labour in Nigeria.There are presently in Nigeria, on-going ILO-IPEC projects targeted at combating child labour andtrafficking; areas of collaboration should be identified to incorporate social protection componentsinto the IPEC initiative.


Under the NEEDS, the government has promised to ensure and protect children’s welfare by strictenforcement of the Child Rights Act of 2003 by the child rights implementation committees at thefederal, state, and local government levels. These committees’ actions will be targeted at protectingchildren from:

a) communal and armed conflict;b) all forms of abuse, neglect, and exploitation, including economic exploitation, sexual

exploitation, and the use of children in criminal activities and trafficking of narcotics andpsychotropic substances;

c) child trafficking;d) all forms of violence;e) all forms of hazardous work;f) preventable diseases and diseases associated with hunger and malnutrition, particularly early

in life; andg) bridge the gap in school enrolment and retention.

In this regard, it is noteworthy that under the present civilian Administration, Nigeria, on October 2,2002 ratified both ILO Conventions 138 and 182 on Minimum Age Convention, 1973 and onWorst Forms of Child Labour Convention, 1999 respectively.

6.1.3. 15-24 and 25-64 Age GroupsThe majority of Nigeria’s workforce is within these groups and most of them reside in the urbancentres of the country. Nigeria’s urbanisation rate of about 5.3 percent a year has not been matchedwith a corresponding economic advancement. Consequently, a considerable percentage (about 10.8)of urban dwellers is unemployed. Unless the manufacturing/services sectors grow sufficiently toabsorb the surge of labour to urban areas, or the rural areas are transformed to stem migratory flowsto the urban areas, the rate of unemployment could become unmanageable. The implications forpoverty, crime, conflict and maintenance of democracy could be grave. The government recognisesthe urgency of the unemployment situation as well as the need for specific steps to facilitateindividual empowerment particularly among young people and other vulnerable groups through thecreation of new jobs.

As contained in the ILO Director General’s Report (2003), “Working out of Poverty”, work is theonly route out poverty. In order to create viable opportunities for those excluded from any form ofsocial protection, there is need to afford them voice and representation. It is necessary to enlist thepeople in setting policy and designing initiatives that touch on their lives. The starting point shouldalways be social dialogue towards finding means and strategies that are practicable, which will helpwomen and men to join the economic mainstream in order to build assets and a better life.

With more than 60 universities, the country has a highly educated work force comparable to any inother developing countries. In order to effectively combat unemployment and low income, thegovernment should come up with viable initiatives to introduce unemployment insurance, incomesupport programmes and formulate a coherent policy in response not only to combat the prevailinghigh rate of unemployment, but underemployment as well. As contained in the NEEDS, theGovernment is poised to work towards improving incomes and tackling other social and politicalfactors that contribute to unemployment and poverty.


In pursuing the above objectives, the Nigerian Government could well be guided by the three policyissues posed in the Working out of Poverty report, namely,

a) what could be done to increase the demand for labour and raise the productivity and incomesof people living and working in poverty;

b) what could be done to integrate socially excluded communities into the labour market andovercome the endemic discrimination particularly against women and girls; and

c) what financial mechanisms could be put in place to enable the working poor access micro-credit to start or improve own business?

An integrated effort in these three areas holds the potential of creating a virtuous cycle in whichimproving the earning power and productivity of the poor removes a restraint on the overall capacityof the economy and ensures that growth is pro jobs and pro poor. Strong community level action,responsive to local needs, backed up by a supportive framework of laws and public policies is abasic building block for progress.

There is need for the Federal Government of Nigeria to reposition NAPEP and resuscitate theNational Directorate of Employment (NDE) through adequate funding and guided management sothat the scope of their activities and beneficiaries would be enlarged. There is need for theinterventions of the United Nations agencies and other international organisations in the area ofpoverty alleviation and job creation to be coordinated towards achieving the greatest impactpossible. The ILO, through its tripartite reach was instrumental to setting up the National Directorateof Employment (NDE) and the Nigeria Social Insurance Trust Fund (NSITF). From pastexperiences at programme implementation, it has been proven that disparate interventions have notachieved the much needed impact in the campaign against social exclusion and poverty.Accordingly, inter-agency efforts are being recommended to increase synergy and achieve results inthis area.

As stated in the NEEDS document, the Government has to concretise its plans for creating jobs,improving health care services, strengthening the skills base, promoting the vulnerable, andpromoting peace and security. Such initiatives should aim at increasing demand for labourconsumption by developing macroeconomic strategy that promotes labour-intensive growth (that isjob creation through active labour market programs such as incentive to small and medium sizedenterprises). The government believes that a coordinated implementation of NEEDS by allstakeholders at the federal, state and local levels will lead to about 7 million new jobs.37

6.1.4. 65 and Above Age GroupsThis group consists mostly of the pensioners who often are without any reliable means of livelihood.Past experiences in Nigeria have shown that most pensioners have been owed their pensionallowances for months and even years. There is need for the Government to develop a subsidisedprogramme under the NHIS for the benefit of this class of people. As it were the burden of caring forthe aged fell on their family and relatives, but with the continued loss of jobs and risingunemployment in the country, family support structures have dwindled considerably with attendantgrave consequences.

37 NEEDS document, p.44.


With the introduction of the Pension Reform Law which has unified pension regimes for both publicand private sectors along a contributory pattern, it is hoped that adequate mechanisms would be putin place to ensure that the Pension Fund Administrators fully deliver on their mandate. There is alsoa serious need to clarify the intendment of the Pension Law in regard to the section on “MinimumPension Guarantee”. It is recommended that this should be subject to occasional review on order totake care of inflationary currents in the national economy.

6.2. Other Axis for Extension: The Role of Faith-Based OrganisationsIn Nigeria's current situation of dwindling resources, economic hardship, poor health care, lack ofmedicines, corruption, unmotivated staff and inadequate management capacities, and a literallyparalyzed public health system, the role of churches in health care provision readily fills a much-needed gap in services.

Faith-based organisations have immense influence in their communities. However, this influencehas not been fully exploited in extending social security to the uncovered members of theNigerian population. The fact that about 40% of Africa’s health care systems are controlled byFBOs, underscores their influence and reach. This means that religion also has an indirect effecton the delivery of health services, and such services can be used for conveying issues on the waypeople access healthcare. Interviews with some FBOs leaders in Nigeria during the fieldwork forthis report showed that most of them have well instituted social assistance programmes that aretargeted at meeting the health and other socio-economic needs of their members and public.However, without adequate design and planning, most of these gestures have provedunsustainable over time.

Spurred by concern to assist its members and public cope with the reality of Nigeria’s socio-economic reality, the Catholic Church established the Catholic Health Insurance Programme(CHIP) in 2003. Through its franchise system, it hopes to support the various dioceses, Catholichealth care institutions and other interested partners in planning and introducing local healthinsurance schemes. The franchise principle works as follows: from the insurance scheme to beestablished, CHIP will receive a one-off joining fee set according to the scheme’s size andbenefits package offered. It will also charge an annual franchise fee of two percent of grossincome. On its part, CHIP will give a start-up help to the health insurance schemes, and furnishthem with information and marketing material. It will also organize and take charge of stafftraining, support partners in recruiting members and negotiating contracts with service providers,and will be responsible for quality assurance.

To circumvent the great disparity in economic circumstances in various parts of Nigeria, theinsurance policies offered by CHIP are tailored to the people’s needs and life situations. Forexample, in Enugu, a relatively low-income state located in South-eastern Nigeria, the CHIP hastwo health centres that cater to the health needs of the population. Malaria has been identified asthe most pervasive illness in the suburb covered by the programme. For a yearly payment ofN800 (about five euros a year) and other incidental low co-payments, the subscribers have accessto a range of health care services, namely:

a) outpatient malaria therapy;b) treatment of ten other (per-determined) illnesses;


c) provision with 40 medicines;d) free vaccinations under the national immunization programme; ande) the provision of every second family member with a mosquito net free of charge.

However the insured people must enrol with one of the two health centres for a year. The healthcentres, in turn, are obliged to have a qualified nurse or midwife on duty seven days a week intwo shifts. Furthermore, a doctor must be available twice a week for at least four hours to holdoutpatient clinics. CHIP ensures that the centres comply with these requirements.In Onitsha, a commercial suburb in Anambra state (also in South-eastern Nigeria) the economicsituation of the population is better compared to Enugu. Hence, it was possible for CHIP to offerthem different tariffs and benefits packages. Under the “Admission Package” costing 5.50 eurosper member per year, the health insurance scheme covers hospital costs including surgery. Forhigher income earners, there is a “Comprehensive Package” for around 50 euros. In addition tothe benefits provided in the “Admission Package”, those insured can also claim for the costs ofoutpatient treatment for a total of 52 (predetermined) illnesses.

Prospectively, the CHIP has high potentialities for success in Nigeria based on the good level oftrust and confidence the Catholic Church enjoys in Nigeria. Presently, some Health MaintenanceOrganisations (HMOs) are exploring how they could establish some form partnership with theCHIP in order to extend their coverage and clientele. According to cautious estimates, five to tenCHIP health insurance schemes should be able to start up by the end of 2004. The CatholicChurch hopes to enrol at least 100,000 Nigerian men and women in these insurance schemeswithin the next three years. With the level of patronage and commitment it has received from itspublic, the CHIP is strategically looking at expanding its franchise system to cover the wholecountry. 38

In Emene, another town in South-eastern Nigeria, the Annunciation Specialist Hospital (ASH),owned and run by the Daughters of Divine Love Congregation (D.D.L.), has been operating ahealth scheme since 1998. The scheme has around 2,200 covered members and provides healthcare coverage with two different policies: admission cost coverage and comprehensive treatmentcost coverage. The scheme encountered some confidence-related problems during its pilot due tothe negative prejudice and mistrust against insurance business in Nigeria. However, based on thecommitment of the Catholic Sisters and the reliable delivery of health services, the localpopulation was subsequently convinced to start enrolment.

The Household of God Mission Inc. which is a Pentecostal Church located in Lagos, Nigeria with anestimate of 4,000 regular members. In addition to other social assistance services to its lessprivileged members such as benevolent cash assistance, housing, job placing, etc, it organises ayearly programme known as “G.R.A.C.E.”. The G.R.A.C.E. means “God’s Riches At Christ’sExpense” and has served as a vehicle for reaching out to the less privileged in the community and ademonstration of the objective reality of the Church’s compassion. At various times, the Church had

38Social Health Insurance: Systems of Solidarity Health, Education, Social Protection Sector Project Social Health

Insurance Experiences from German development cooperation (sponsored by Federal Ministry for EconomicCooperation and Development, June 2004. pp 23-24.


disbursed cash awards up to N1, 000,000 to selected members of the community who do notnecessarily belong to the church.

Also, the St. Dominic’s Catholic and the Redeemed Christian Church of God, both in Lagos runshealthcare schemes for the less privileged members of its community using goodwill offering frommembers (and non-members) of the church. Again, this is in addition to other social assistanceservices like housing, scholarships, mass feeding of the poor that these churches provide to theirmembers and public. The largest non-governmental health care provider in Nigeria ChristianHealth Association of Nigeria (CHAN) and has over 300 health institutions and 3,000 outreachfacilities. CHAN facilities serve at least 40% of the country's population, primarily those in ruralareas or urban slums and those with the fewest resources. Plans are presently underway to includeCHAN as one of the HMOs in the NHIS.

For reasons connected to the large membership and organisational structure of these FBOs, somebi-lateral and multilateral donor agencies such as USAID, DFID, etc in Nigeria have been usingthem to implement their programmes on the campaign against HIV/AIDS, malaria, andtuberculosis. The Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) or GermanTechnical Cooperation Agency is currently setting up a higher-level institution, known as aCentre of Health Insurance Competence (CHIC) in Nigeria. Under CHIC small private and publichealth insurance schemes will come together in a network and establish their own competencecentre. Like the sub-regional internet-based network “La concertation”, to which the ILObelongs, CHIC’s primary objective is to develop insurance products and quality standards, carryout seminars and training courses, and represent members’ interests on the political level. In July2003, the GTZ held the first CHIC seminar in Minna, Niger State in the North-central Nigeria.Also, a study to determine the potential for implementing micro-health insurance in Nigeria as ameans of addressing the needs of the informal sector populations has just been completed. Asearlier stated, the study examined the potential for mutual health organizations three states basedon a measure of the ability and willingness of the sample population to pay for group healthinsurance within the CHIC franchise model.

It might be interesting to explore how the ILO could jointly design projects with these churches totechnically assist them in setting up well designed community-based social security schemes. Ontheir part, the churches have the willingness and the funds to administer such schemes, but withoutadequate technical planning, most of their social assistance may not be sustainable in the long run.From the meetings held with them, the idea of a community-based health insurance (and such otherbenefit) schemes for their members as well as their public was quite prospective. Presently, theHousehold of God Inc. is in the process of registering a “Household of God Health InsuranceScheme” as a separate NGO. It has also indicated interest to participate (at own cost) in any trainingworkshop or seminar the ILO or its social partners may be organising in the future.


6.3. The Role of Other Bilateral and Multilateral Organisations and DonorAgencies.With its huge population, Nigeria is of critical importance to the development of the continent andthe achievement of the Millennium Development Goals. Its history of decay under military rule hasmeant that it has about the worst record on progress to the MDGs of countries that are not in conflictor post-conflict. Tackling poverty and its underlying causes pose a considerable challenge to theGovernment of Nigeria (at federal, state and local levels), and its development partners. It has beenstated that whether Africa attains the Millennium Development Goals (MDGs) by 2015 depends to alarge extent on Nigeria’s success in reducing poverty39. Despite the situation, the level of OverseasDevelopment Assistance (ODA) to the country appears quite insignificant to its myriad developmentproblems. The DFID in Nigeria alluded to this situation when it declared “…that considering thesize of the development challenge, Nigeria's level of international assistance at less than $1.50 percapita (compared to a Sub-Saharan average of $21) makes it one of the most under-aided countriesin the world.”40

The World Bank’s Interim Strategy document (2001) had indicated, among other findings that, byand large, Nigeria has sufficient resources of its own to achieve sustainable development. Itcategorically stated that the resources brought by the donor community and other developmentorganisations are always going to be relatively small compared to the resources which Nigeria hasavailable to it. Hence, the major role of the most bilateral and multilateral organisations and donoragencies has been more targeted at helping Nigerians build the capacity to manage their ownresources effectively. However, the point remains that Nigeria requires international assistanceand solidarity now than ever before. There is a need for donors and international and regionalfinancial institutions to contribute to the development of social protection systems in the countryin support to the NEEDS paradigm. It would also be necessary to invest in the retraining andeconomic restructuring which can promote more equitable adjustment and a fairer distribution ofthe gains derivable from the ongoing reforms. Private solidarity initiatives can also contribute. Atthe very least, technical assistance in this field should be strengthened.

The ILO, as a specialised agency of the United Nations, has a close working relationship withvarious bi/multi-lateral organisations and donor agencies and shares the goals and objectives ofthe NEEDS document. In addition to promoting social dialogue among its tripartite constituents andother social partners towards developing effective strategies and plans for implementing socialsecurity reforms, the ILO is involved in organising donor support as a key element of its GlobalCampaign on Social Security and Coverage for All. It recognises that social protection is anessential tool in the fight against poverty and social exclusion and for promoting decent work. Tothe ILO, work does not just represent a source of income, but rather encompasses an individual’sdignity, family stability, peace in the community, and a democracy that delivers41. Work impliessocial protection for families and communities as well as social dialogue for lasting solutions.The ILO shares the view that people who lack social protection suffer from a broader social

39 NEEDS document, p.12. See also THISDAY Newspaper, 04/06/2004 – article on “DFID’s plans to assist Nigeriain poverty reduction towards achieving the UN MDGs”40 Ibid.41 Contained in an address by Juan Somavia, Director-General of the International Labour Officeto the African Union Extraordinary Summit on Employment and Poverty Alleviation in Africa (Ouagadougou,Burkina Faso, 8 September 2004)


exclusion, particularly with regard to access to education and training, to credit or employment.To reduce exclusion in a lasting manner, it is necessary to tackle its causes and symptoms.

The report by the World Commission on the Social Dimension of Globalization, “FairGlobalization: Creating Opportunities for All”, rehashes ILO’s position that basic security is arecognized human right, and a global responsibility42. The report opined that all industrializedcountries devote substantial resources to social protection and social transfers but such policiesare extremely limited at the global level. It deplored the gaps in income and security betweencountries and prescribes that certain minimum level of social protection needs to be accepted andundisputed as part of the socio-economic floor of the global economy. The report calls forincreased international support to buoy the efforts of poor countries at providing some levels ofsocial protection to their populations, and concluded that to provide legitimacy to globalization, itis critical that the global community deals with insecurity with a high level of commitment.

At the “Extraordinary Summit of the African Union on Employment and Poverty Reduction inAfrica” held in Ouagadougou, Burkina Faso from 3-9 September 2004, (presided by the AUChairman and Nigeria’s President, Olusegun Obasanjo), the representatives of the 15 UNagencies met with Juan Somavia, Director General of the ILO, and reaffirmed their commitmentto Africa. The agencies defined key priority problems facing Africa and proposed concreteassistance initiatives, based on their respective experiences and competencies, within theframework of the African Union and the New Economic Partnership for Africa's Development.As one of the outcomes of their meeting, all the actors concerned, including the representatives ofcivil society, agreed that employment must play a primordial part in the struggle against poverty.The Director General, giving fresh impetus to ILO’s onerous commitment to Africa, stated that“ILO is in the service of Africa and at the disposal of the governments, the workers and theentrepreneurs to help them work together."43 The broad objectives of the ILO are to generateincreased attention of the world community on the low-rate of coverage in most Africancountries; strengthen donor resolve to assist them extend coverage as a means of reducingpoverty; and serve as a catalyst for efforts to support national action. In Nigeria, the realisation ofthese objectives will be very vital to the success of the Global Campaign.

The donors with major programs currently active in Nigeria are the World Bank, the IMF,African Development Bank, the UNDP, the European Community, UK's Department forInternational Development (DFID), and the U.S. Agency for International Development(USAID). Others include the German Technical Cooperation Agency (GTZ), CanadianInternational Development Agency (CIDA), Japan and a number of specialized UN agencies.Excluding support from the World Bank, it is unlikely that the total value of ODA to Nigeria willexceed US$500 million per year. However, more donors are just starting up. As a result, there is ahigh level of donor coordination presently in Nigeria. In almost every sector - economicmanagement, community development, education, HIV/AIDS or other healthcare delivery

42 A Fair Globalization: Creating Opportunities for All, World Commission on the Social Dimension ofGlobalization, February 2004, p. 109.43 ILO NEWSLETTER on the Extraordinary Summit of the African Union on Employment and Poverty Reduction, opcit.


interventions, there is a strong commitment for donors to work together. (See Appendix 4 -matrix on the main donor activities in Nigeria)

Generally, these donors and other development organisations agree on the seriousness ofNigeria’s development issues, and on the broad outlines of how these issues should be addressed.As already stated, these outlines are as contained in the well-articulated Nigeria’s reform agenda,the National Economic Empowerment and Development Strategy (NEEDS). NEEDS is Nigeria’shome grown poverty reduction strategy, and, according to DFID Nigeria, the donor communityhave accepted it as the basis for every support towards poverty reduction in the country.44

As stated in the NEEDS, the Government intends to reduce poverty in Nigeria by pursuing thefollowing targets:

Increase average per capita consumption by at least 2 percent a year; Create about 7 million jobs by 2007; Increase immunisation coverage to 60 percent by 2007; Increase the percentage of the population with access to safe drinking water to at least 70

percent by 2007; Significantly increase school enrolment rates, especially for girls, and increase the adult

literacy level to at least 65 percent by 2007; and Significantly improve access to sanitation.

It needs to be noted that despite the high level of manpower and resources in Nigeria, mostdevelopment plans and efforts have not been satisfactorily implemented to achieve the setobjectives. Indeed, experience has shown that most well formulated plans, policies, programmes,and projects have failed because of ineffective implementation or no implantation at all. Undermost military regimes in the past, the government, as the dominant producer and controller in theeconomy, created a lot of perverse incentives that made corruption, mismanagement and grafteasy ways for wealth accumulation. Under such regime, private enterprise, transparency andaccountability were not commensurately rewarded.

Consequently, for all its elegance and practicality, for the Government to achieve the targets setout in the NEEDS, it is likely that the various socio-economic reforms proposed therein mighttrigger the need for frequent adjustments to national production processes, and hence to jobs andthe life strategies of women and men. These adjustments would take time and it necessary thatpublic policy interventions are put in place to support the restructuring of production systems andthe creation of new opportunities. As a minimum, systems of social protection are required whichcan stabilize incomes, distribute some of the gains of the NEEDS reform to groups which wouldotherwise be excluded, and support the development of new capabilities. There is need forcommitment, discipline, and a strong will at all levels - from the Presidency and federal executivebranch to the grassroots - to stay the course of the reforms. In addition, implementation has to beholistic, consistent, and persistent. It would also be necessary to have in place an effectiveinstitutional framework, particularly a public service dedicated to excellence and efficiency andsupportive of reforms. Equally important is adequate infrastructure and an enabling environment

44 Ibid


in which private investment can thrive. Other critical measures include education, health care,and abiding faith and commitment to change.

Nigeria’s population have become highly sceptical of the government’s intentions due to severalyears of failed promises. The Government seems to understand this, and hopes to simultaneouslypursue the goals and objectives as set out in the NEEDS at all levels of government. Accordingly,and in line with its broad agenda, the state governments in Nigeria are developing StateEconomic and Development Strategies (SEEDS). Within the states, local governments will beencouraged to develop medium-term development programmes, specifying programmes,benchmarks and targets, deliverables, timelines, and implementation guides. These plans, calledLocal Economic Empowerment and Development Strategies (LEEDS), will complement SEEDSand NEEDS. NEEDS recognises that effective planning at the local levels is critical to reduce oreliminate waste and inefficient resource allocation and to ensure rural development and povertyreduction. Though Nigeria operates a somewhat centralised federal structure, the state and localgovernments are much closer to the people and are better positioned to deliver many socialbenefits.

Considering the extensive development goals and objectives set out in the NEEDS, and itsreception by the international community, it is interesting to observe the current impetus donoragencies have given to development projects in the country. For reasons relating to its land massand population, most international agencies have resorted to picking and choosing on areas ofintervention among the 36 states and the Federal Capital Territory based on the local prioritiesand realities. For instance, DFID has been assisting Nigeria in the area of health sector reforms,and has ongoing projects in a number of states across the country. The Partnership forTransforming Health Systems (PATHS), which it runs in collaboration with Federal and StateGovernments as well as non-state sector, aims to bring about sustainable health benefits for thepoor by addressing the deep-seated systemic constraints to effective health service delivery.45

DFID has decided to double its financial assistance from £35 million, (about N82.2 billion) in2003, to £70 million, (about N945 billion), while £43 million is earmarked for 2004. The UKGovernment on its part expresses intention to double its development assistance to Nigeria from£35 million in 2003/04 to £70 million in 2005/06.

As part of its efforts in the Global Campaign on Social Security and Coverage for All, the ILOhas launched a worldwide survey to understudy as many existing community-based socialsecurity schemes as possible in order to gain more knowledge from the experience and potentialfor extending coverage. This is in addition to more than 35 technical cooperation projects oncommunity-based schemes in 38 countries of Africa, Asia, Latin America and the Caribbean. Intotal, these projects provided direct technical support to more than 100 community-basedschemes, covering about 4000,000 members. These projects have also supported the design anddevelopment of policies and legislation to strengthen community-based schemes. Theinformation collected will lay the foundation for further technical assistance activities, whileencouraging the development of partnership networks among the various schemes and otherinterested groups. Such networks could follow the successful example of the coordinationnetwork - “La concertation” – which the ILO, in partnership with other some agencies, includingthe GTZ, set up in (French-speaking) West Africa. Wherever possible, these experiences have

45 The PATHS has a budget amount of £39 million, and was initially designed to cover 4 states, but expansion to otherstates is being considered.


been harnessed towards strengthening the technical capacities of various schemes in the areas offinancial and risk management (prevention and reparation mechanisms).

Overall, the ILO pays special attention to the most vulnerable groups in the informal economy,particularly women, and to other at-risk groups, and tries to give them voice and representation atthe local and national levels. It is envisaged that in line with its mandate, reach and added-valueadvantage, the launching of the Global Campaign on Social Security and Coverage for All inNigeria will provide a good platform for all stakeholders to optimally use the available resourcesto the benefit of country’s vulnerable majority. The first step in this direction should be to start aprocess social dialogue among its constituents and other interest groups in the civil societyincluding the private sector on the most practicable approach towards poverty reduction andextension of social security coverage in Nigeria.

63

Annex 1

64

65

Annex 2.

66

Annex 3.

PRIVATE PRE-PAID HMO SCHEMES IN NIGERIA

HMO Estimated No of Lives –June ‘04Total Health Trust Ltd. 27,500Hygeia Health Maintenance Ltd. 50,000Healthcare International Ltd. 9,000Southern Rose Nig Ltd. 3,000Clearline International Ltd. 15,000

Multishield Ltd. 3,500

Managed Health Services Ltd 3,000

First Health Ltd 800Expat Care HMO 3,000Royal HMO 100Ronsberger Nig ?United Healthcare International Ltd ?Premier Medicaid Nig Ltd ?

Total lives covered 114900

67

Annex 4: The main donor activities by in Nigeria:

Donor Economic Governance CDD/Social ServicesAFDB Support for Economic Governance,

Capacity Building and PovertyReduction

Health Systems DevelopmentProject

Community-Based PovertyReduction Project

CIDA Primary Healthcare Roll Back Malaria HIV/AIDS

DFID Economic reform, debtmanagement, povertymonitoring

Human Rights/Democracy State Capacity Building Local Police Service and Justice

Health Reform Project (withWB)

HIV/AIDS Community Education Education Sector Analysis

EU Economic Governance Democracy

Micro projects – health, credit, etc

JICA Rural Water Supply andSanitation

Malaria ControlUNICEF Primary education

Non-formal education Early child care

USAID Support for Economic PolicyCoordinating Committee

EMCAP support Domestic Debt Management Judicial Assistance

HIV/AIDS Family Planning Health Systems Polio Immunisation Roll Back Malaria Educational Sector Assessment State Education Support

WHO Roll Back MalariaHealth Sector

WBGroup

EMCAP PER Support to PRSP State/Local Governance Study IFC support to SMEs,

privatisation, investment

Community-Based UrbanDevelopment

Health Systems Support HIV/AIDS Project Education Systems Support Micro-watershed CDD Project Universal Basic Education

Source: Adapted (with some modifications) from WB Document, Report No. 23622-UNI

68

Selected Bibliography (Published texts and journals)

1. Atim, Chris: The Contribution of Mutual Health Organisations (MHOs) toFinancing, Delivery, and Access to Health Care: Synthesis Research in Nine Westand Central African Countries (1998)

2. Cripps, Gilbert et al: Guide to Designing and Managing Community-based HealthFinancing Schemes in East and Southern Africa (2000)

3. Dror, David and Preker, Alexander: Social Reinsurance: A New Approach toSustainable Community Health Financing (2002)

4. Jutting, Johannes: The Impact of Health Insurance on access to Healthcare andFinancial Protection in Rural Areas of Developing Countries: The Example ofSenegal (2001)

5. A Fair Globalization: Creating Opportunities for All, World Commission on theSocial Dimension of Globalization, ILO, Geneva, February 2004

6. Children’s and Women’s Rights in Nigeria: A Wake up Call Situation Assessmentand Analysis. UNICEF, 2001

7. Central Bank of Nigeria: Annual Reports and Statement of Accounts, 1972 - 20008. Constitution of the Federal Republic of Nigeria 19999. FEDERAL MINISTRY OF HEALTH: HEALTH SECTOR REFORM PROGRAM

Strategic Thrusts; Key Performance Objectives and Plan of Action 2004 – 200710. Human Development Report 2004, Country Fact Sheets: Nigeria11. Memorandum of the President of the International Development Association and

International Finance Corporation to the Executive directors on an Interim StrategyUpdate for the Federal Republic of Nigeria, February 13, 2002.

12. National Economic Empowerment and Development Strategy (NEEDS) document,National Planning Commission, Abuja 2004.

13. National Population Commission (NPC) [Nigeria] and ORC Macro, 2004, NigeriaDemographic and Health Survey 2003. Calverton, Maryland: National PopulationCommission and ORC Macro

14. Nigeria Reproductive Services and Manpower Survey (2001). Reproductive HealthDivision, Federal Ministry of Health, Abuja, Nigeria.

15. Olanrewaju, O. et al: Social Protection Strategy for Nigeria: Policy Note forNational Planning Commission (NPC) (April 2004)

16. WHO Country Cooperation Strategy: Federal Republic of Nigeria: 2002 – 200717. World Bank Group: Health Systems Development: Community Financing (2001)

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Social Protection Profile of Nigeria - A Working Paper

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