Social Protection Profile of Nigeria

Social Protection Profile of Nigeria
Chinedu MOGHALU
An ILO Working Paper
Table of Content
Table of Content....2 1. Introduction .4 1.1. Demographic and employment situation since 1990..8 1.2. Economic and social Context ....9 1.3. The Labour Force and Employment Status by Sector ..................................................10 1.4. The Implications of the Economic and Social Situation................................................12 2. The Nature of Poverty in Nigeria ..................................................................................13 3. Health Sector Profile ..7 3.1. Health supply characteristics and challenges 19 3.2. Health financing in Nigeria .......................................................................................21 3.3. Tackling the HIV/AIDS Challenge ...22 3.4. National Health policy ...24 3.5. Description of traditional medicine ...25 3.6. Attitude Concerning Traditional Medicine....25 3.7. The Socio-Economic Implications: Policy Response.................26 4. Inventory and description of public social security programmes .....................28 4.1. AGE 0 -5 (Early Childhood Development Activities) ..28 4.2. Age 6 14 .29 4.3. Ages 15 64 .. ....30 4.4. The National Poverty Eradication Council (NAPEC) ...32 4.5. Protection against Old Age Risks ..33 4.6. The National Health Insurance Scheme (NHIS).36 4.6.1. Role of Health Maintenance Organisations (HMOs) under the NHIS40 4.7. The National Emergency Management Agency (NEMA)..................44 5. Description of community-based (not-for-profit) social Protection mechanisms .45 5.1. What the Government Can Do48 6. Conclusion and Axis for extension of social protection in Nigeria........................50 6.1.1. 0-5 Age Group and Nursing Mothers...51 6.1.2. 6-14 Age Group52 6.1.3. 15-24 and 25-64 Age Groups53 6.1.4. 65 and Above Age Groups54 6.2. Other Axis for Extension: The Role of Faith-Based Organisations.....55 6.3. The Role of Other Bi/Multilateral Organisations and Donor Agencies....58
Annexes.63 - 67 Selected Bibliography...68
Social Protection Profile of Nigeria (Working Paper)/Chinedu Moghalu/RPU/Abidjan/Sept/2004
Tables
I. II. III. IV.
BASIC DEMOGRAPHIC INDICATORS OF NIGERIA

II. STRUCTURE OF THE NIGERIAN ECONOMY PERCENTAGE OF INCOME DISTRIBUTION PROGRESS IN MEETING THE MDGs
Annexes
I. II. III.
IV.
NIGERIA AT A GLANCE SOCIAL INDICATORS PRIVATE PRE-PAID HMO SCHEMES IN NIGERIA

THE MAIN DONOR ACTIVITIES IN NIGERIA
Currency Equivalents (October 1, 2004)
Currency Unit 1United States Dollar ($) 1British Pound Sterling () 1EU Euro ()
Nigerian Naira (N) N130 N233.99 N160
1. Introduction
Adequate social security coverage is increasingly being recognised as both a means to and the ultimate goal of most poverty reduction programmes. Affording minimal social protection for the entire population is a prominent political issue and a priority for the Government of Nigeria. With an estimated population of 125 million people, planning for an all inclusive social security programme for the entire citizenry has proved a difficult and costly task for Nigeria. Over the years, the Government has tried designing and implementing various programmes aimed at providing the people with assistance in the areas of job creation, housing, social security, health insurance and protection, etc. From the way these programmes were designed, most of them proved to be unsustainable in both the short and long terms. Some of these were programmes drawn up by different military regimes to score some credibility, and consequently, as it happened, each regime came and left with its own social protection (assistance) programmes. With the advent of the present civilian administration, the country appears to have finally designed a development plan to guide its policies and interventions. The National Economic Empowerment and Development Strategy (NEEDS) document strategically outlines the priority areas for Nigerias development within the framework of the Poverty Reduction Strategy Papers (PRSP). Drawing on the Millennium Development Goals (MDGs), the NEEDS targets all the impediments to national development and realization of the overall agenda of the Government for the Nigerian people. The document 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, the NEEDS 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 realized there 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 and impacting to the lives of the people. In view of the poor state of the countrys healthcare system and the increasing problem of HIV/AIDS among others, the Government came up with a national health insurance plan towards making health for all Nigerians a reality. The current Healthcare delivery system in the country has some major shortfalls including, but not restricted to limited accessibility. It is estimated that less than 54% of Nigerias population has access to modern health care services, with a disproportionately high expenditure on curative services as compared to promotive and preventive health services. The healthcare management system has some inherent weaknesses that often translate into waste and inefficiency, as shown by the failure to meet targets and goals. With different levels of governments, voluntary organizations and other agencies providing health care, the various inputs remain poorly coordinated. The various communities involvement at critical points in the decision-making process, even on health-related issues, 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 basic infrastructure and logistic supports are often defective owing to inadequate maintenance of buildings, medical equipment and vehicles; inadequate and unreliable supply of potable water and electricity; and the poor management of drugs, vaccines and supplies system.
Presently, some reforms are being pursued by the Government aimed at implementing restructuring the 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 the administration and payments of retirement benefits for the Public Service of the Federation, Federal Capital Territory and the Private Sector. The Act also hopes to ensure that every person who had contributed to the Scheme will receive his retirement benefits as and when due. In regard to the health system, the National Health Insurance Scheme (NHIS) which Act had been promulgated in May 1999 is being given a fresh impetus. The broad objectives of the health scheme are to increase access, ensure equity, and provide social and financial protection, increase quality and utilization of health care services, increase private sector participation as well as secure financial sustainability in the health care sector. The scheme has distinct programmes for the different segments of the population as represented by the formal sector, informal sector, children under-five, permanently disabled and prison inmates social health insurance programmes. Implementation of the scheme is supposed to begin with the formal sector where the mechanisms for a 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 an entirely different question. Implementing the NHIS at this level would require more extensive and elaborate preparation in view of the lack of formal structures on which to base premium collection and other important operational functions. Already, the Government has launched some pilot schemes in some rural communities under the Rural Community Social Health Insurance Programme (RCSHIP), but without the full involvement of the communities for which the schemes are 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 special focus on the developments in the countrys social security, especially, the health sector. The purpose is to seek for ways of establishing viable windows for extending coverage to all within the decent work agenda of the International Labour Organisation (ILO). To fully understand the ILOs approach to social protection, it may be apposite to look at its two-pronged strategy of social security and labour protection. Social security is the protection that a society provides to individuals 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 or loss of a breadwinner. Labour Protection, on the other hand, consists of all the rules and policies targeted at providing an enabling environment for the maximal output of labour. These include all interventions 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 and a free mobility of labour. Accordingly, social protection consists of policies and programmes designed to reduce poverty and workers vulnerability by promoting decent work. This necessarily entails establishing efficient mechanisms for social dialogue, efficient labour markets, non-discriminatory workplace environment, and income generation. Enhancing the effectiveness and coverage of social protection for all requires not only a set of sound policies and strategies but most of all, a clear vision, relentless will, sustained effort and resilience to adapt to evolving circumstances and new challenges.
For the purposes of this study, social security is used most of the time to describe identifiable outcomes of governments socio-economic policies and other interventions in the area of labour protection. 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 been included to provide a panoramic view of governments social protection initiatives. Relying on previously documented works on community involvement in health insurance in Central and West Africa1, this study had targeted a detailed profile on such community-based health insurance schemes (CBHIS) existing in Nigeria. According to the survey findings, some Mutual Health Organisations had existed in Nigeria namely, the Community Partners for Health (CPH), Country Womens Association of Nigerias (COWANs) Health Development Fund (HDF) and the Ibughubu Improvement Union, all operating in Southwestern Nigeria. The CPH were modeled as informal sector mutual health insurance schemes involving some private primary health care (PHC) providers and community-based organisations that finance and jointly manage their members primary health care needs. However, visits to the locations of some the MHOs, and discussions with their managers revealed that the present economic situation in Nigeria has seriously affected the viability of the schemes. As it were, the schemes were comprised of community-based organisations (CBOs) that purportedly contributed 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 may not 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 kind of premium payment. The annual contribution for each member was N100 (less than $1), and considering the high cost of living and healthcare in Nigeria, even if the membership is up to a thousand, 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 deal with primary healthcare delivery. As non-governmental organisations (ngos), the various CPHs now seek funding from donors and other international agencies to enable them engage in preventive campaigns against HIV/AIDS, capacity building workshops, micro-credit schemes, environmental and sanitation campaigns, etc. (See, however, page 55 s.6.2, on Other Axis for Extension: The Role 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 countrys social security, particularly as it relates to health care, towards determining what would work most appropriately. This is based on the understanding of the ILO that in assisting member states to develop strategies and policies to extend social security coverage, there is no single right model. Rather effort is always made to explore the possibility of extending coverage through the Classical social security, community level interventions, as well as establishing linkages between community initiatives and public policies.
Atim, Chris. 1998. The Contribution of Mutual Health Organisations (MHOs) to Financing, Delivery, and Access to Health 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 national and state governments, ministries, representatives of employers and employees, and other stakeholders in a meaningful dialogue to identify practicable strategies for extending social security coverage in Nigeria. This process should critically examine the social security needs of workers in the formal and informal economy, as well as assess the effectiveness of statutory and communitybased 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 would assist the country in combating social exclusion and poverty. The vehicle for achieving this is the Global Campaign on Social Security and Coverage for All scheduled to be launched by the ILO and its 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 rate of 2.83 percent per annum, the National Population Commission (NPC) in 2003 estimated the population to be about 126 million.2 This makes Nigeria the most populous nation in Africa and the tenth most populous nation in the world. The spatial distribution of the population within the country is uneven. Extensive areas in the Chad Basin, the middle Niger Valley, the grass plains, and the NigerDelta, among others, are sparsely populated. In contrast, there are large areas of densely populated rural districts, which support more than 400 persons per square kilometre in parts of Akwa Ibom, Imo, Anambra, and Enugu States, as well as Kano, Katsina and Sokoto States. Except for Lagos, 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 populated state in the north. The population of Nigeria is predominantly rural; approximately one-third live in urban areas. The states with the largest population are Lagos (94 percent), Oyo (69 percent), and Anambra (62 percent). The least urbanised states, with an urban population under 15 percent, include Sokoto (14 percet), 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 of the 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
National Population Commission (NPC) [Nigeria] and ORC Macro, 2004, Nigeria Demographic and Health Survey 2003. Calverton, Maryland: National Population Commission and ORC Macro, p.3 3 NPC, 1998.
about 3.5 percent. The age dependency ratio in the country is 93.2 per 100 and the index of economic dependency is 259 depedents per 10 workers.4 Nigeria comprises of over 250 ethnic grups with an equal number of language and dialects. The major 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 muslim concentration. Rural-urban migration has created big cities such as Lagos, Ibadan, Kano and Port Harcourt with the corresponding problems of unemployment, slums, overcrowding, and other environmental degradation.
1.2. Economic and social Context

The economy of Nigeria has widely fluctuated within the past thirty years. Before the discovery of oil, the economy and national development initiatives heavily depended on the revenue from agricultural activities. Also, agrculture provided gainful employment to over 75 percent of the countrys labour force and satisfactory livlihood to over 90 percent of the population at the time of the countrys independence. In real terms, it accounted for over 50% of the GDP, and was the main source 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 materials were imported. An import liberalisation strategy was adopted and few industires were set up to produce outputs such as cememt, textiles, sugar, tanneirs, wood products and vegetable oil. Between 1965 and 1966, agrivulture contributed about 55% of the GDP, with the figure declining to 45% in 1970/71. However, the discovery and intense exploitation of petroleum brought an end to the dominant 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, capital intensive and strategic industries like petro-chemical, refineries, iron and steel, fertilizers, etc. Small and medium-scale industries were left to the private sector. Increased demand for manufacture goods led to the establishemnt of many industires for such goods. Arrangements were also made for the development of cottage industires at the rural level of the economy in addition to export promotion, technical skills training and employment generation. This period witnessed a rapid expansion of education at all levels primary, secondary and tertiary. Aggregate student enrolment for primary school rose to 6.9 million in 1975 from 2.9 million in1960. The secondary school level enrolment rose from 135,360 in 1960 to 735,905 in 1975/76 (as at 1998/99 this figure has increased to 5.2 million), while university enrolment rose from 1,395 in 1960 to 31,515 in 1975/76 (319,914 in 1998/99). The import-substitution strategy turned the domestic terms of trade against agriculture and subsequently led to rapid rural-urban migration. The contribution of agriculture to GDP fell from 48.8% in 1970 to 22% in 1980, while that of oil and mining rose from 10% to 26.8% for the same period. The share of manufacturing rose 7.2% in 1970 to 8.4% in 1980, while trade and finance sectors rose from 13% to 15%.5 However, the era of oil boom was short lived. The economy witnessed a progressive decline following the collapse of oil prices in the 1980s and the failure of the Government to promote
4 5
WHO Country Cooperation Strategy: Federal Republic of Nigeria: 2002 2007, p. 2. Federal Republic of Nigeria: National Employment Policy document, p.2.
agricultural sector and non-oil exports. In the wake of the downward economic trend, the Government did not make any structural changes to its budgeting and development initiatives, but continued on busines-as-usual basis. This necessitated sourcing for loans from external creditors and placing restrictions on external trade. By 1986, the Structural Adjustment Programme (SAP) was introduced. The standard objectives were stabilisation of the economy through restoration of fiscal and monetary measures, liberalisation of consumer and producer prices in favour of tradables, the progressive movement towards a realistic market dtermined exchange rate regime through depreciation 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 of agrciultural commodity boards with favourable effects on the sector. Effectively, these brought about 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% in 1995. However, the bulk of government foreign revenue earnings, up to 75 87%, were derivable from it. By 2002, the total GDP derivable from oil export was 51.4% (see Table 2). The share of the industrial sector contribution to GDP also fell from 10.7% in 1985 to 7.3% in 1991 and 5.7% in 1995. The level of capacity utilisation by the manufacturing sector remained low, and by 1990 it stood at 27%, with a further steep to about 27% in mid-1995. Trade and finance sectors stabilised at about 21% of the GDP, while the Government share was 10.2% in 1995. However, agriculture, (if broadly defined to include crops, livestock, forestry and fisheries), still remains the principal activity of the Nigerian population accounting for about 39% of the GDP in 1998. (See also, Nigeria at a glance, Annex 1) Under the SAP in 1986 - 1992, GDP grew at about 5.2% compared to -0.5% per annum rate in the pre-SAP era of 1981-1985. Agriculture also grew comparatively to 3.2% in 1981 1985 to 4.2% in 1986 92, while manufacturing grew from -4.0%to 4.9% under the same period. The objective of controlling the fiscal deficit, however, was not met. Rather, fiscal deficit, as a proportion of GDP increased from 12.9% in 1986 to 25% in1990 and stood at 11.7% in 1993. The implementation of SAP 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 GDP which was actually a drop from the rate of about 4.2% in 2001. The annual growht estimate for 1999-2003 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 Sector

The intractable problem of inadequate and often inacurate data on Nigeria makes it difficult to derive a reliable time series for the labour force and to estimate the corresponding annual growth. Relying on the 1963 population census, the potential labour force was estimated at 32.2 million in 1980; and 34 million in 1991 based on 1990 population census figures. This had reached 39.0 million in 1996 and 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 it steeped 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 Nigerias Informal Sector, (FOS Document) Vol. 1
10
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 that the agricultural sector has become the last resort for the majority of Nigerian work force falling outside any regular employment. With a population growth estimated at 2.83% per annum, a vibrant and 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 marked decline 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 sector accounts for about 9% of the employed, while distribution accounts for about 16%. Small and medium scale ecterprises and othe informal sector activities account for over 60% of economic activities in the country and over 35% of urban employment. From the figures released by the National Manpower Board, the formal sector employment was estimated at 2.1 million in 1985, 2.8 million in 1990, and 4.4 million in 1999. It was further estimated that in 1985, formal sector employment constituted 9% of total employment and 11.3% in 1999. The two top employers of labour in the formal sector were the manufacturing and services industries which accounted for about 59.5% in 1985, and 67.26% in 1999. The National Rolling Plan (1999 2001) further showed the total emploment to be 38.85 million in 1999, out of which about 88% were engaged in small-scale enterprises, while about 12% were in large-scale enterprises.7 Table 2
Ibid.
11
1.4. The Implications of the Economic and Social Situation

According to the 2004 Human Development Report, Nigerias human development index (HDI) value is 0.466.8 Notwithstanding the vast natural resources, abundant oil reserves, impressive human capital, agricultural potential and emergeing industrialisation, Nigeria is clasified among the 20 poreset countries in the world. The current average per capita income is about $320, which is far below that of neighbouring Gabon at $5,500 (2003 est.)9 Political and social instability, critical shifts in economic policies, inequitable wealth distribution and global oil recession constitute part of the reasons for the the downward economic growth. Over the years, the level of poverty in the country has deepened. It has been reported by the World Bank that Nigeria is many respects two economies. Part of it is a middle-income oil-producing economy covering a small prcentage of the population, with a per capita of US$2200. The rest of the population is part of a very poor non-oil producing economy, of whom as many as 75 million (about 66%) may be living in abject poverty, with an average per capita of les than US$200.10 This is line with the estimates by the Nigerias 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 households spend up to 90%. The gap between the poor and rich has also widened, with remarkable inequalities existing in the society. For example, the poverty index is lowest in the southeast and highest in the northwest; in addition, only about 48% of the rural population and 53% of the urban population have access to sanitation. The poverty level is worsened by low literacy among the generality of the population. According to 1999 MIC data, the overall adult literacy rate is 49%, which is marked decline from the 1990 figure of 57%. The female literacy level declined also from 44% in 1990 to 41% 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 economic malaise did contribute to the deterioration in the socio-economic situation, infrastructure and productive sector. In the final analysis, the socio-demographic, political and economic challenges arising from the increased population, general poverty, low literacy level, urbanisation and related rural-urban migration will determine the burden of disease in the country and the effectiveness of the health system.
8 9
Human Development Report 2004, Country Fact Sheets: Nigeria. CIA World Fact Book on Gabon 10 The Memorandum of the President of the International Development Association and International Finance Corporation 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.
12
2. The Nature of Poverty in Nigeria

As earlier stated, the UNDPs Human Development Index (HDI), has ranked Nigeria low in the human development category 151 out 177 countries for which data was available. The Human Poverty Index (HPI), which focuses on the proportion of people below a threshold level in basic dimensions of human development living a long and healthy life, having access to education, and a decent standard of living, puts the the HPI-1 value for Nigeria at 35.1%. This ranks Nigeria 57th among 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 of poverty; 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 when the head of household has some primary education; and e) by gender desegregation, both men and woman have been aflicted by poverty, but the men carried a higher proportion of the poverty burden (64% in 1986) than women (58.5% in 1996)13. (See Table 3.) Table 3
It has been adduced that the fundamental cause of poverty is the economic stagnation that the country has experienced for more than two decades. Persistent low productivity in agriculture has meant that most of the rural population has had limited opportunities for income improvement. In addition, stagnation of the non-agricultural economy has meant negative growth in the formal
13
The National Economic Empowerment and Development Strategy (NEEDS) document, National Planning Commission, Abuja 2004. Table 4, p.31.
13
employment and limited demand for informal activity. A very uneven distribution of income had caused high demand for imported consumer goods and lower demand for goods produced domestically. But with the almost blanket ban the President placed on the importation of most consumer 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 be reduced 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% to 10% in the non-agricultural economy (excluding government and the oil and gas sectors. The National Planning Commission in designing the National Economic Empowerment and Development Strategy (NEEDS) document, which is the Nigerias PRSP, recognises that poverty has 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 many other social and political factors that contribute to economic disempowerment, social exclusion and poverty. See Nigerias Social Indicators Annex 2 In regard to poverty and gender, the cultural and religious factors in Nigeria have manifest implications for the social and economic roles ascribed to women and men. In traditional societies, especially in the Northern parts of the country, womens roles and access to wealth are narrowly circumscribed, while women in the Southern states have have substantial economic independence. Despite the slow pace of economic growth, significant changes have persisted in the Nigerian economy, and the roles of women and men are changing. According to a 1999 study by the World Bank, the UKs 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 and limited access to utilities and services, the poor were described as wretched and lacking in any opportunity to change their situation or provide their children with greater opportunity. They were commonly identified as unable to educate their children above primary school, that is where this is affordable in the first instance. Their livelihood strategies are highly limited by a narrow asset base with income commonly derived from casual labouring or petty sales, often accompanied by indebtedness. The powerlessness of the poor was further manifested in a lack of access to justice when wronged and an exclusion from the benefits of local political patronage and corruption. Cummulatively, this analysis 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 of violence. Within households, stress and the undermining of male roles as providers through unemployment and job insecurity were seen to be contributing to conflict and violence. Traditional coping mechanisms had been stretched to the breaking points, increasing the burden at the family level and forcing both men and women to take on a greater variety and number of income generating activities.
14
It has been observable that the social and economic gaps between men and women are closing up with accompanying changes in role ascription particularly due to the empowerment of women through education and the changing situations. The political power relation, however, has not significantly changed. At the national level, the Government is committed to improving the situation of women and girls. Presently, there are a number of women occupying sensitive positions in the Obasanjo Administration. However, more needs to done translate the Governments intention in this area 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) remain substantially below those for boys (48%). Under the NEEDS, the government plans to establish scholarship schemes at the secondary and tertiary levels to expand educational opportunities for female students where necessary. It also intends to expand adult and vocational education programmes that cater to women beyond formal school age. Agriculture Studies suggest that rural women do more farm work than men. They often work for some fourteen hours a day (nine hours in agriculture and five in other unpaid tasks) compared to a little over eight hours per day for men. Any investment to reduce womens burden (such as water supply, means of transportation, woodlots and labour-savig technology for household tasks) will free up time to increase income and to allow girls to attend school. These investments will also have important beneficial effects on the health conditions of women and the country as a whole. Security Th poor are particularly more vulnerable to crime. This is even more so for women where an unequal power relationship sometimes leads to sexual harassment and in the worst cases to teenage pregnancies and the spread of HIV/AIDS. The Government has stated its plans to implement the provisions of the UN Convention on Elimination of all forms Discrimination against Women, and to support legislation for the abolition of alll forms of harmful practices against women such as vaginal mutilation. Political Power While womens roles are changing, women are under-represented at most levels of authority. This seems particularly the case in traditional communities and at the local government level. This has important implications for ensuring gender-responsiveness in Community-Driven Development (CDD) work. Under the NEEDS, the Government plans to adopt measures to ensure equitable representation of women all over the country in all aspects of national life by using affirmative action to ensure that women represent at least 30 percent of the workforce, where feasible. Access to Assets Womens control of houshold assets varies across Nigerias traditional societies. In the Christian South, for example, women are expected to earn their own keep as well as that of their children, and thus have substantial economic independence. This is significantly different from the Moslem North, where tremendous gender imbalances in access to and control of assets directly limit productivity and growth, and are impediments to the realisation of poverty reduction objectives. Again, the NEEDS has made provision for measures aimed at increasing access of women to microfinance and other poverty alleviation strategies, with a view to reducing poverty among women.
15
Nigerias indicators also show dramatic differences between the poor and non-poor, both in education and health status and in access to these services. Deaths under the age of 12 months and under the age of 5 years are twice as high for the poorest (40% of the population) as they are for the richest quintile. Forty percent of the children in the poorest groups are underweight, against 20% for the richest. Girls aged 15 to 19 in the poorest quintile are three times as likely to have a child out of marriage than those in the richest quintile. Almost 50% of the children in the poorest half of the population have no immunization at all, as against 12%in the richest. Only 31% of the poorest pregnant 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 growth in all sectors of the economy as well as service delivery if it is to meet the (World Banks) International Development Goals. (See Table 4 below.)
Table 4 PROGRESS IN MEETING THE IDGs
Source: World Bank CD ROM.
16
3. Health Sector Profile

Demographic data on health are not very reliable in Nigeria. Data obtained from various census exercises, 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. Life expectancy dropped from 53.8 years for females and 52.6 years for males in 1991 to 48.2 years for females and 46.8 years for males in 2000. The infant mortality rate (IMR) rose from 87.2 per 1,000 live 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 live births in 1999 is one of the highest in the world. This could be attributed to the shortage of skilled medical 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 health facilities work without any midwife. Furthermore, 18.03% of such facilities operate without midwives or senior community health extension workers (SCHEWs). With disability adjusted life expectancy (DALE) of 38.3 years and the rank of 187 in the World Health Report 2000, the performance of the Nigerian health system is worse than many sub-Saharan countries. There is thus an urgent need to support the health system with adequately trained personnel in order to improve 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 with HIV/AIDS. Over 40 million Nigerians are exposed to onchocerciasis; 20 million are infected and about 120,000 have gone blind from the disease. Schistosomiasis is prevalent in rural areas which lack potable water, and control of the infection has been limited by the high cost of the drug of choice. It was estimated that only 10 percent of Nigerians have access to essential drugs, while the ratio of physicians to patients stood at 30:100,000. All these conditions and diseases combine to cause high morbidity and mortality in the population.15 Nigeria continues to suffer outbreaks of cholera, cerebrospinal meningitis, measles, yellow fever and Lassa fever with significant human losses due to weak emergency preparedness and response mechanisms. Between 1987 and 1994, Nigeria experienced 17 severe yellow fever epidemics. Cholera outbreaks were recorded between 1996 and 1997, affecting more than 18 states and claiming over 10,000 lives. Sporadic complex emergencies from petrol explosions (caused by vandalism), floods and civil unrest are becoming common occurrences with significant human and material losses. The Integrated Disease Surveillance System will need to be strengthened for both communicable and non-communicable diseases, while emergency preparedness and response mechanisms 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 of Health, Abuja, Nigeria. 15 FMOH, NHMIS (Preliminary Health Profile Figures), 1999
17
lifestyle. In 1989, a nationwide survey revealed that 3.5 million people had mild hypertension, 1.2 million had moderate hypertension and 0.5 million had severe hypertension. The prevalence of hypertension is generally estimated at 810% for rural and 10 12% for urban communities. The proportion of smokers is 9%, and the prevalence of diabetes mellitus is 2.75%.16 Genetic diseases such as sickle-cell anaemia and, glucose-6-phosphate dehydrogenise affect an appreciable proportion of the population. In Nigeria, 2 3% of the population have sickle-cell disease, while the prevalence of glucose-6-phosphate dehydrogenise is estimated at 18% for males and 7% for females. Control efforts in respect of noncommunicable 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 shortcourse (DOTS) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Notable progress has been made towards eradication of guinea-worm disease, resulting in a decrease in the number 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 the population. 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 need to sustain the focus of disease prevention and eradication programmes and scale up various planned interventions 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 to reduce poverty. It promises to support and consolidate ongoing efforts at strengthening of preventive and curative primary healthcare services though comprehensive health sector reforms. In the long run, 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 governments 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; and g) foster effective collaboration and partnership with all health actors. The major strategies and areas of intervention outlined in the NEEDS to meet the above goals include, a) redefining the roles and responsibilities of the Ministry of Health and other federal public health structures and institutions in providing and financing good-quality health services;
16
Health Systems Development Project II. FMOH, 1989
18
b) review of existing policies and strategies as well as health legislation. Publish a new National Health Act that defines the national health system and the health functions of each of the three levels of government; c) development and implementation of a strategy to enhance community participation in providing and financing health services; d) refurbishing of primary health care facilities and strengthening local governments capacity to 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, and rapidly increasing routine immunisation coverage in a sustainable manner; i) strengthening the ability of the National Food and Drug Administration and Control to perform its regulatory functions; j) determining how the results of the study on the private health sector could be used to formulate policy for promoting public-private in health care provision and financing; k) integration of tiers of care, as well as traditional medical practitioners. Currently, traditional medical practitioners are included in the referral chains of medical care as they provide lowcost care and are the first point of contact for rural dwellers.
3.1. Health supply characteristics and challenges

The health system in Nigeria and the health status of Nigerians are in a deplorable state. As stated earlier, Nigerias overall health system performance was ranked 87th position among the 191 Member States by the World Health Organization in 2000. Health status indicators are worse than the average for sub-Saharan Africa. For example, as stated above, the infant mortality rate is 115/1,000; under-5 mortality rate of 205/1,000; and maternal mortality ratio of 948/100,000 (range 339/100,000 to 1.716/100,000) is one of the highest in the world17 The poor state of Nigerias 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 of health services decreased significantly or stagnated in the past decade. Available data from the FMOH indicate that in 1999, there were 18,258 registered PHC facilities, 3,275 secondary facilities and 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 is 88% in the southwest, 87% in the southeast, 82% in the central, 73% in the northeast and 67% in the northwest regions. However, the fact that health facilities physically exist does not mean that they function. 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 of Action 2004 2007. p.4. 18 Childrens and Womens Rights in Nigeria: A Wake up Call Situation Assessment and Analysis. UNICEF, 2001
19
particular, the coverage of critical PHC interventions such as immunizations and access to safe water and 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 profit providers, 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 policy provides for a health system with three levels: primary, secondary and tertiary. It also spells out the functions of each tier of government and provides for the establishment of the advisory National Council on Health chaired by the Federal Minister of Health (the Minister of State for Health and State Commissioners of Health are members). Other organs set up by the policy include the State Health Advisory Committees and Local Government Health Committees. Their potential has not yet been fully realized. As part of the health sector reform process, there is a need to review the functions of these organs in order to maximize their use. Under NEEDS, the government has set up the machinery to redefine their various roles and responsibilities. According to the National Health Policy, the federal government is responsible for policy formulation, strategic guidance, coordination, supervision, monitoring and evaluation at all levels. It also has operational responsibility for disease surveillance, essential drugs supply and vaccine management. In addition, the Government shall provide specialized health care services at tertiary health institutions (university teaching hospitals and federal medical centres). These should serve as referral institutions for the secondary health facilities. At the lower level, the states and Local Government Councils (LGCs) share responsibility for health care. States largely operate secondary health facilities (general hospitals and comprehensive health centres), providing mostly secondary care and serving as referral level for the LGAs which provide the essential elements of primary health care. Operationally, the decentralized health structures of the federal government are in the states, while those of states are in the LGCs. However, some states build and operate tertiary facilities or specialist hospitals. While the federal government is responsible for the management of teaching hospitals and medical schools for the training of doctors, the states are responsible for training nurses, midwives and community health extension workers (CHEWs). The LGCs provide basic health services and manage the PHC facilities which are normally the first contact with the health system. Under the NEEDS, the government has resolved to refurbish the primary health care facilities and further strengthen the capacity of the LGCs for better management. Some parastatals exist within the health system. The National Agency for Food and Drug Administration 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 deal with priority health issues. Overall, the roles of the different parastatals of the public sector are not well delineated, and activities need to be coordinated in order to avoid overlapping of efforts.
19
National Health Policy, FMOH
20
As in other sectors, the federal government arrangement constrains the leverage that the Federal Ministry of Health (FMOH) has over the State Ministry of Health (SMOH). For instance, FMOH cannot compel SMOH to implement some health policies and programmes. This makes stewardship of the health sector very challenging. Consequently, the gap between policy formulation by the FMOH and implementation by states and LGCs is wide. The above shortcoming is traceable to the provisions of the 1979 and 1999 constitutions on healthcare delivery. In the Nigerian Constitution of 1979, health is supposed to be on the concurrent list 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 Federal Government. The Constitution also assigned specific responsibilities to the State and Local Governments. The 1999 Constitution, which is still the operative document, is almost silent on Health Care delivery except the vague reference made on Local Governments responsibility for Health.20 In section 45 (under the fourth schedule) the constitution also made provision for the overriding 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 health sector, the government plans to reorganise and restructure the Ministry of health and other public health 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 responsibilities of each tier of government in relation to healthcare delivery in Nigeria.
3.2. Health financing in Nigeria

Financial resources for health in Nigeria come from a variety of sources, including budgetary allocations from government at all levels (federal, state and local), loans and grants, private sector contributions and out of pocket expenses. The value of contributions from the private sector and out of pocket expenditure is yet to be determined. According to a World Bank source, per capita public spending for health is less than US$ 5 and is as low as US$ 2 in some parts of Nigeria. This is far below the US$ 34 recommended by WHO for low income countries. The reduction in health spending in the late 1980s was due to the Structural Adjustment Programmes (SAPs) which deemphasized spending on health and social services. At its lowest point in 1989, federal government health 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 in 1980. In per capita terms, the decline in health expenditure was even more precipitous, 82% between 1980 and 1989 and 57% between 1980 and 1999, due to continued rapid population growth. Although the federal government recurrent health budget showed an upward trend from 1996 to 1998 and 1999 to 2000, available evidence indicates that the bulk of this expenditure goes to personnel. Recurrent health 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 of government 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
21
In an effort to mitigate the low per capita funding to health, the government has embarked on a series of initiatives such as revolving fund schemes for some services in hospitals and the National Health Insurance Scheme. Plans by Government to come up with a national policy on health financing are currently underway. Donor assistance for the health sector also experienced a decline during the 1990s. External funding declined when many bilateral donors, including the United States and the United Kingdom, stopped aid in response to the anti-democratic military regime. While UN agencies continued to provide modest assistance to the health sector throughout the 1990s, wider donor assistance did not resume until the return to civilian government in 1999. Presently, there are positive indications of interest in assisting with various healthcare delivery programmes in the country from the DFID, CIDA, USAID, GTZ, JICA, etc.
3.3. Tackling the HIV/AIDS Challenge

HIV/AIDS is a cross-cutting issue, with links to education, health, agriculture, defence, labour, and other sectors. The HIV/AIDS epidemic in Nigeria has extended beyond high-risk groups. Like other statistics in Nigeria, the correct number of people infected with the disease is not known, but general estimates have put it at between 4 and 5 million. A 2001 estimate conservatively put the prevalence figure at 5.4 percent of the population. Whatever the correct figure may be, the reality is that the country is in real danger of facing explosive escalation in the epidemic level with dire consequences for economic growth and social development. HIV/AIDS is already having a disastrous impact on social and economic development in Nigeria. If not adequately contained, the epidemic will prove to be the greatest single obstacle to reaching national poverty reduction and other targets for social and economic development. The devastation caused by HIV/AIDS is unique, because it is depriving families, communities, and the entire nation of their young and productive people. The epidemic is deepening poverty, reducing human development achievements, increasing gender inequalities, eroding the ability of government to provide essential services, reducing labour productivity and supply, and putting a brake on economic growth. By 2001, it had become clear that the issue of tackling HIV/AIDS in Nigeria required a developmental, holistic, coordinated, and multisectoral approach. The strong political commitment of the President of Nigeria to fight HIV/AIDS served as powerful catalyst and motivator for establishing a supra-ministerial and sectoral body to coordinate efforts at fighting and containing the epidemic. This was the National Action Committee on AIDS (NACA) under the Presidency. A national policy on HIV/AIDS was subsequently launched in August 2002 to give policy direction and to make a policy statement on the transformation of NACA from a committee to a full-fledged agency 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 its operational blueprint and shares the ILO position that HIV/AIDS threatens the livelihoods of many workers and those who depend on them - families, communities and enterprises. It recognises that the accompanying discrimination and stigmatization against women and men with HIV threaten fundamental principles and rights at work, and undermine efforts for prevention and care. Accordingly, NACA focuses on the challenges of containing the epidemic; fighting denial of
22
human rights of the victims; and preventing new infections through advocacy, information and education campaigns, behaviour change and communication, condom distribution, targeting of groups particularly vulnerable to infection, and other key interventions. It also focuses on treatment and care of people living with HIV/AIDS. By concentrating on prevention and treatment, NACA plans 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 efforts on the other. Through an International Development Association credit, NACA provides funds for NGOs, community-based organisations, and federal line ministries throughout the country to support implementation of high-priority and demand-driven programmes. NACA is also the principal recipient of funding from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The funds are disbursed to the Ministry of Health to finance voluntary counsel and testing, prevention of motherto-child transmission of HIV, and antiretroviral treatment for people living with AIDS. The multisectoral response is being implemented in collaboration with development agencies including the Department for International Development (DFID), the Joint United Nations Programme on HIV/AIDS, UNAIDS (comprising UNHCR, UNICEF, WFP, UNDP, UNODC, ILO, UNESCO, WHO, World Bank) the U.S. Agency for International Development, the Canadian International Development, etc. Positive outcomes of these efforts have resulted in increased flow of resources for community and sectoral responses, as well as broad ownership of the national response beyond the health sector. It is interesting to note that the ILO, as part of its assistance to NACA, has translated the Code of Practice 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 to control the spread and provide equitable care and support for those infected with the virus. It also aims to mitigate the impact to the point where it is no longer of public health, social, or economic concern. This is line with the overall government plan to create an environment in which all Nigerians will be able to live socially and economically productive lives free from disease and its effects. Towards achieving the above policy objectives on HIV/AIDS, the following strategies, among others, 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 among the general population; c) improve understanding and acceptance of the principle that all people must accept responsibility for the prevention of HIV transmission and the provision of care and support for those infected and affected; d) protect the rights of people infected and affected by HIV/AIDS, as guaranteed under the Constitution and the laws of Nigeria; e) ensure that prevention programmes are developed and targeted at vulnerable groups, such as women and children, adolescents and youth, sex workers, long distance commercial vehicle drivers, prison inmates, migrants, and others;
23
f)
transform NACA into a statutory body, and provide adequate resources for it to meet 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 that met during the Extraordinary Summit of the African Union on Employment and Poverty Reduction in Africa held in Ouagadougou, Burkina Faso from 3-9 September 2004. They reaffirmed the ILOs commitment to undertake concrete measures to extend social protection to the poor and that specific proactive measures must be implemented to deal with the HIV-AIDS pandemic in Africa through preventive measures and initiatives to facilitate access to affordable medicines by the poor. In this regard, they would want a waiver of the patent rights of generic HIV/AIDS drugs for African countries in order to make them affordable. In addition, targeted education and sensitisation programmes for working women and men also need to be implemented.22
3.4. National Health policy

The Nigerias National Health Policy and Strategy to Achieve Health for All Nigerians, promulgated in 1988 currently represents the collective will of the government and people of the country to provide a comprehensive health care system that is based on primary health care. It describes the goals, structure, and strategy and policy direction of the health care delivery system in Nigeria. It defines the roles and responsibilities of the three tiers of government without neglecting the nongovernmental actors. Its long-term goal is to provide the entire population with adequate access not only to primary health care but also to secondary and tertiary services through a well-functioning referral system. However, following from recommendations contained in the NEEDS, it has become imperative to review the Policy towards making it reflect the new realties and trends in the national health situation. From the period it came into force, the 1988 Decree appeared to have not fully captured the various aspects of healthcare delivery in Nigeria. This made subsequent Governments to continue exploring the possibilities of coming up with a better guide towards improving the health situation of Nigerians. Seven years later in 1995, a National Health Summit was convened, which brought together experts, leaders, policy makers, providers, planners and administrators in health and other relevant sectors within Nigeria and from the international agencies. The agenda of that Summit were to examine the factors that have militated against improvement in Nigerias health status, and chart a course 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 of Experts 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 would synergise all development efforts and make the goals of Nigerias healthcare system more realizable. It is the expectation that such a Policy document would serve as the point of reference in providing a sound foundation for the planning, organization and management of the nation's overall health
22
Contained in the Conclusions of the African Social Partners Forum, Ouagadougou, Burkina Faso, 3rd-4th September 2004.
24
system. It is also hoped that it will provide a suitable framework for the design and successful implementation of a government-led comprehensive health sector reform in Nigeria which process is currently being introduced. In the draft Health Policy, the various levels of Government have made declarations and commitments to attain the goal of health for all citizens. As stated in NEEDS, this would mean a level of health that will permit them to lead socially and economically productive lives at the highest possible level. Under, the Health Sector Reform (HSR) Plan of Action (2004 2007), currently being implemented, 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 out medium term objectives in seven strategic intervention areas: primary health care, disease control, sexual and reproductive health including STIs/HIV/AIDS, secondary and tertiary care, drug production and management, coordination of development partners, organization and management. A dynamic policy process involving extensive consultation among all the levels of government is already being pursued in order to build consensus around health policies. The FMOH has created the Division of International Health to coordinate development aid to the health sector and the Forum of Ministers and Heads of International Agencies has also been established.
3.5. Description of traditional medicine

Traditional medicine refers to health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to diagnose, treat, and prevent illnesses or maintain wellbeing23. It also includes the sum total of knowledge and practise, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental and social imbalance and relying exclusively on experience and observation handed down from generation to generation, whether verbally or writing.
3.6. Attitude Concerning Traditional Medicine

About 80 per cent of all Africans rely to some extent on traditional, village-based practitioners and remedies, since manufactured medicines or regular health care services are often unavailable or too expensive. In Ghana, Mali, Nigeria and Zambia, the first line of treatment for 60% of children with high fever resulting from malaria is the use of herbal medicines at home. World Health Organisation estimates 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 ancestral spirits 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 population because of escalating costs which has necessitated a search for alternative ways of managing illnesses.
23
World Health Organisation
25
Invariably, traditional and modern health systems coexist in many Nigerian communities. The lack of primary health care systems in the rural areas forces local people to treat themselves, either by using medicinal plants or by buying high-cost medicine in the rural markets. In the rural areas, as a whole, people begin by treating themselves before going to a traditional practitioner or a modern doctor. Certain diseases are believed to be better treated by one of these systems. In spite of increased interest in the technical aspects of traditional health care, forms of true co-operation between 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 is made at a later stage, often as a last option. Recent findings by WHO funded research have shown that alternative medicine is flourishing in Nigeria society neither because users are dissatisfied with conventional medicine nor because they seek self-control over their health care decisions. The driving force for the majority of users appears to be the holistic belief that the health of body, mind and spirit are related and that this should be taken into account by whoever cares for their health. In December 2000 the first International Conference on Traditional Medicine in HIV/AIDS and Malaria took place in Abuja Nigeria, signalling a renewed interest in the role of traditional medicine the treatment of HIV/AIDS and other disease. More than one hundred scientists in the medical and social science fields, traditional healers, and allopathic practitioners attended the conference. Conference participants produced a communiqu in which they emphasized the need for comprehensive efforts at the national and trans-national level for the utilization of traditional medicine in the fight against these two major diseases (International Centre for Ethno-medicine and Drug Development 2000).
3.7. The Socio-Economic Implications: Policy Response

The social context of the therapeutic process requires reciprocity of some sort and this payment contributes to the effectiveness of treatment. However, over the years, the types and methods of payments for traditional healing have changed. Especially in urban settings, practitioners are increasingly demanding monetary payments. For reasons unconnected with the current acute unemployment and poverty situation in Nigeria, the practise of traditional medicine has become prone to a lot of abuses. Whilst the practise ran along ancestral lines in the olden days, it is not uncommon 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 escalated with the worsening epidemic of HIV/AIDS in Nigeria. Within the past four years, more than five homeopathic 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 more effective and beneficial to the Nigerian public, the proposed National Health Policy intends to integrate the practice of traditional medicine with orthodox medicine by ensuring the establishment of minimum standards for the practice. It also seeks to ensure that: a) institutions for the training of traditional health practitioners are accredited by a regulatory board;
26
b) the regulatory board shall from time to time review curricula for training of traditional health practitioners and shall provide appropriate guideline towards their integration into the mainstream of Health care delivery; c) traditional health practitioners are to be retrained and certificated in order to increase their skills 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 orthodox medical care. The WHO's "Strategy for Traditional Medicine," released early in 2001, urges countries to adopt legislation and develop regulations for traditional medicine, to help provide safer and more effective care. The agency commends Nigeria, Ghana, Lesotho and other African countries that have developed health care training programmes for traditional birth attendants.
27
4. Inventory and description of public social protection programmes

Most social protection programmes in Nigeria are linked with various poverty alleviation schemes being operated by the Government at various levels. According to the NEEDS document, poverty in Nigeria is dynamic and has many dimensions, which must be tackled from different directions simultaneously. It recommends that the government (and civil society) must work not only to improve 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. The former is organised along individual, family, and community lines, while the latter is centered on the activities of the Government in the public sector. The public sector interventions are mostly on the promotion of income security, employment and income generation. Generally speaking, there are no explicit regulatory framework and or encompassing strategy for social protection in Nigeria. The available social insurance covers only a minimum of the population, while in the case of social assistance there is no comprehensive and effective social safety net. In a survey by the National Population Commission, comprehensive reviews were presented on the types of social risks faced by Nigerians over various life cycles. It also reviewed the types of risks by age group and the various policies and programmes put in place to protect the poor and the vulnerable, as well as their coverage and performance gaps. According to their categorization, social protection in Nigeria could be discussed in terms of coverage 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 childhood development with the primary risk indicators being malnutrition and low pre-school educational level. 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 run more families escape the poverty trap. The next issue is that of malnutrition among this group. The four main indicators prevalent in Nigeria are usually Vitamin A deficiency, stunting (low height for age), wasting (low weight for height), and underweight (low weight for age). As reported in the 1999 multiple indicator cluster survey, 9.2% of all children within this age range are deficient in Vitamin A consumption, while 33.5%, 15.6%, and 30.7% are stunted, wasted, and underweight respectively. Evidently, from this data, a large proportion of children are presently at risk of malnutrition. With regard to preschool childhood educational development, Nigerian children have very few opportunities. In some parts of the country, as much as 81.8% of the children within this age group are not attending any form of schooling or educational programme.
28
Over the years, there have been several efforts and interventions aimed at ameliorating the above situation. Specifically, in 1996, the Federal Ministry of Health (FMOH), the National Primary Health Care Development Agency (NPHCDA) in collaboration with the UNICEF jointly developed a work plan for the virtual elimination of Vitamin A Deficiency (VAD) in Nigeria. Then in 1999, a broader framework was developed by UNICEF, WHO, DFID, USAID, the National Programme on Immunisation Agency (NPIA) and FMoH to ensure that Vitamin A distribution is synergistically linked to the Polio eradication campaign. Also, other polio eradication campaigns such as the National 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 the Government provided the network for their distribution. According to UNICEF report, the average coverage of Vitamin A distribution in the country is 70% of children aged 6 59 months. The interesting thing about the VAD supplementation programme is that it is targeted at every child regardless of the social status or class of the parents. Equally important was the National Programme on Immunisation (NPI) which was an offshoot of the Expended Programme on Immunisation (EPI) which was launched in 1975. The aim was to achieve a universal child immunisation in Nigeria. It was implemented mostly through the National Immunisation Days (NIDs) at the national level and State Immunisation Days (SNIDs) at the state level.
4.2. Age 6 14
According to the MICS data, the proportion of Nigerians in this age group is 25.3% with an average of 66.7% of them living in poverty. The primary risks faced by this group include poor human capital development, gender issues, and poor health. By far, the crux of this groups problem has been that of education. Despite the provision in the Nigeria Constitution that education should be provided to all children on a free and compulsory basis, Nigeria is yet to achieve a universal basic education. The net primary school enrolment rate is about 58.2%, while 34.1% of the children within this age bracket are yet to access any form of formal primary education. Several reasons have been adduced as being responsible for this anomaly, with delayed school enrolment being the most pervasive. As stated by MICS, the average years of delay before being enrolled for formal school is 4.7 years and 2.5 years for rural and urban households respectively. Again, the rate of enrolment varies in relation to the status of the social status of the childs 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 are considered, the disparities become even wider. Other risks prevalent among this group are those associated with gender such as early marriages and pregnancy. The Federal Government had in 1999 launched the Universal Basic Education Scheme with the primary 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 for the World Bank/NPC Social Risk Assessment Exercise, p. 14.
29
monitoring, supervising and coordinating the implementing the specific programme for the attainment of the UBE. The ultimate aim of the UBE is to assist children acquire adequate cognitive skills that will ensure a better secured life in the future. The approach is to make basic education compulsory and universal up to junior secondary school (first grade) level. The funding comes mainly from Federal Government 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-pupil ratio has not been feasible. As at 2001, the teacher-pupil ratio according to UBE figures stood at an average of 1:56 and 1:40 for primary and secondary schools respectively. This is low compared to the UNESCO ratio of 1:40 and 1:30 in that order. Arguably, about 29% and 25% of primary and secondary 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. In some 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 countrys education sector. The Decree 7 of 1993 which established the Fund provides that all companies operating in Nigeria should pay 2% of accessible profit in any one year as education tax which then goes into a fund that would be known as Education Tax Fund. The Fund is ordinarily intended for all levels of education and it is designed to improve the financing of infrastructures and other resources towards improving the quality of education in the country. Between 1998 and 2002, the bulk of resources from this fund have gone into the primary education. However, due to the way it was designed, 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% of Nigerians within this age group is still without any form of formal education.
4.3. Ages 15 64
This is quite a large group comprising of people in two major age brackets. According to the sample population drawn by the Nigeria Demographic and Health Survey 2003, there are more 31 million people within the are range of 15 24 years and 23.4 million people within the age group 25 64 years representing 19.1 and 32.7% of the population respectively. Within these groups, the poor accounts 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 revealed by low secondary education completion rate, high dropout rates from schools, teenage pregnancies, violence and substance abuse. Technical and other vocational education are not presently well organised in the country. Since the majority of the people enter the labour market at this period, the issue 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 of employment. There have been several programmes initiated by the Government to help train and provide employment and other income generating activities to a majority of the socially excluded in this group. Some of these programmes include the National Directorate of Employment (NDE) Schemes, the National Poverty Eradication Programme (NAPEP), etc.
30
With technical assistance from the ILO at the request of the Nigerian Government, the NDE was established in November 1986, but it wasnt till October 19, 1989 that the decree enacting it came into 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; and c) 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 other government 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 of direct labour, promotion of self employment, organisation of artisans into cooperatives and encouragement of a culture of maintenance and repairs. The targeted beneficiaries of the NDE programmes are mainly youths and unemployed persons. The targeting mechanism is to cover a geographical area (usually a State) in which applications are sought from prospective participants who 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 in various sectors of the economy. Each of the programmes has supplementary sub-programmes. The programmes are strictly designed to put beneficiaries through some skill acquisition or entrepreneurial 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 and vacancies in the country with a view to acting as a clearing house to link job-seekers with vacancies in collaboration with other government agencies the NDE still has a lot shortfalls. The ideal arrangement 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 persons in Nigeria. Also, due to an upsurge in the ranks of employed persons in Nigeria within the past decade, the NDE has not really been able to serve as an efficient clearing house to link job-seekers with potential employers. Moreover, some of the schemes of the NDE have not been sustained over the years in view of its mandate. This could be attributable to inadequate planning and implementation based on unreliable statistical data, among other mitigating factors. Notwithstanding the foregoing, the NDE has been able to affect the life of the Nigerian unemployed significantly. The National Open Apprenticeship Scheme (NOAS) appears to be the most vibrant scheme implemented by the NDE. As at December 2000, the NOAS had trained about 935,533 persons. However, this is no longer the situation presently. Beneficiaries under the scheme have dwindled remarkably over the years. From the Report of the Nationwide Registration of Unemployed Persons (August 2002), the NDE has only been able to assist less than 20% of the total number of applicants. Apart from 1992 when 62.34% of the number which applied was considered, the performance of the NDE in this regard has fallen to less than 3% by the year 2001. Furthermore, the gender desegregation has not been very encouraging. 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.
31
The NDE programmes have mainly relied on the patronage of the Federal Government funding and technical assistance from international organizations. Accordingly, the Scheme has benefited from various 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 and Improve Your Business (SIYB), among others. While the NDE has faired commendably over the years, the major problem remains inadequate funds for its revolving loan scheme for successful trainees. Linked to this is the issue of high default in loan repayment by the beneficiaries. The sustainability of the programme therefore depends on the 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 has ceased 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 developing countries, the Government established the NAPEC in 2001 to be in charge of all projects and activities aimed at eradicating the worst forms of poverty in Nigeria. The Secretariat of this council is the National Poverty Eradication Programme (NAPEP) which, as it were, came into operation since 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; and b) 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-poverty programmes in the country. Hitherto, efforts at combating poverty and social exclusion had had limited impact due to reasons of poor policy formulation and coordination, lack of synergy, poor monitoring and uniformed focus.25 NAPEP therefore was constituted as a multi-sectoral approach to complement other policy initiatives of the Government especially in line with the National Economic 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 and to enhance their employability in the labour market; c) Credit Delivery Programme designed to provide cash on a micro-credit basis to small scale entrepreneurs thereby creating better employment; d) Keke NAPEP a hybrid motor vehicle targeted at providing income generation for drivers and 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).
32
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 income insecurity in Nigeria. In the years of its operation, it has trained about 130,000 youths and also engaged more than 216,000 persons who were attached to various establishments. According to Olaniyan et al (2003), the poor were not specifically the target of the NAPEP in its programmes implementation. Like the NDE before it, the Programme is fully funded by the Federal Government. However, the level of funding has been decreasing over the years. At inception, the NAPEP received the sum of 10 billion Naira; but in 2001, this was reduced to half and by 2002, the total funding came to total of 2 billion Naira. By evaluation, the NAPEP has not been able to effectively actualize its first objective as stated above. Secondly, the idea of intervention activities has translated to a duplication of sorts between the NAPEP and NDE. This has resulted in wastage of valuable scarce financial and other requisite resources for combating unemployment.
4.5. Protection against Old Age Risks Government and (organised) Private Sector Pension Schemes
Before the Pension Reform Act, 2004 came into effect in June, 2004; the Government had a pension programme for all the public sector employees. While the organised private sector workers were covered by the Nigeria Social Insurance Trust Fund (NSITF). The Government Scheme provided two types of benefits to the workers namely, Gratuity and Pension. The Scheme was operated on a non-contributory basis with a qualifying period for gratuity and pension set for 5 and 10 years respectively. Also, the retirement age was set at 60 years, and there was a provision for a minimum pension payable. However, as it was operated, the public sector pension programme could not fully deliver benefits for which it was established. Over the years, potential beneficiaries have been owed their gratuities and monthly pension allowances. Although the Pension act of 1982 had provided for pension adjustment in line with adjustment in minimum wage, lack of prompt payment of pensions impoverished most pensioners. It was widely acknowledged by the generality of Nigerians that pensioners were not getting their entitlements as at when due. Even when they were paid, the minimum monthly pension of N2400 was well below the poverty line. The Nigeria Social Insurance Trust Fund (NSITF) is a defined contribution-based scheme for employees in the (organised) private sector. The NSITF has come a long way from the era of the defunct National Provident Fund established in 1961 by an Act of Parliament. The law was later modified in 1962 to make the Fund exclusive to organised private sector employees who were not covered by the public sector scheme. The initial objective was to provide succour to private sector employees in the event of old age, cessation of employment, or even death. Considering that these categories of workers were mostly employed by the multinational companies, the scheme was actually an attempt to provide an institutional mechanism for ensuring social security and to insulate the workers from the vagaries and the possible uncertainties in contract relations and in the occasion of old age. However, the NPF could not fully deliver the objectives for which it was created. In the over 33 years of its existence, the scheme was mired in corruption, ineptitude, mismanagement and
33
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 the early 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. The NSITF then became responsible for administering the revised scheme for private sector employers with more than five employees. Subsequently, the NSITF became a self-accounting government parastatal under the Federal Ministry of Labour and Productivity, without any subsidy from the government. The main objective of the scheme, as stated in the NSITF mission statement, is to assist workers save towards their sustenance after retirement or in case of disability or death as a result of injury associated with employment. The NSITF covers all the workers employed by a company incorporated or required by law to be incorporated under the 1990 Companies and Allied Maters Act. It also covers those who are employed by other employees or organizations which have a place of business so long as they have the minimum number of 5 employees. However, it exempts all categories of civil servants as well as workers in establishment with diplomatic privileges and immunities, and foreign nationals who are employed in Nigeria for a period less than 6 years at a time; or are covered by the social security scheme of other countries. Also exempted are the clergy of various faith-based organizations engaged in the propagation of religious activities. The procedure is that a participant in the scheme makes regular contributions while still in employment for an eventual enjoyment of pension and gratuity benefit upon retirement, disability or death. The current rate of contribution is 10.0% of a members gross insurable earning, subject to a maximum of N528, 000.00 per annum. Out of the 10.0%, the member is expected to contribute 3.5% while the employer contributes 6.5% making a total of 10.0% to the credit of the member's contribution record. This rate of contribution is subject to periodic reviews in line with actuarial valuations by the NSITF Management Board aimed at sustaining the scheme and providing meaningful benefits to members. Members' contributions are expected to be paid monthly by employers through remittance to an NSITF office where the employee was registered. Contributions are required to be remitted to the Fund not later than the 16th day of the following month. For example, the contributions for the month of January are expected to be remitted to the Fund not later than the 16th of February. As at March, 2004, the membership strength of the NSITF was 40,859 employers and 4,251,370 employees. In an official gazette dated 30th June, 2004, the Pension Reform Act came into force, and established a Contributory Pension Scheme (the Scheme) for any person employed in the Republic of Nigeria. Unlike the previous arrangement that created different pension benefit systems 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 the administration 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.
34
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 raised sharp criticisms on various aspects of the Pension Reform Law. According to them, the Act does not address 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 for payment before the set cut-off date. Also, they questioned the rationale for setting the rate of workers contribution at 7.5% which they consider excessive and counter-productive. This becomes more worrisome when consideration is given to a plethora of existing monthly deductions such as personal income tax (10 15%), National Housing Scheme (2.5%) etc. The argument is that these contributions would divest the worker of more than 30% of her/his disposable income, and considering the average salary of most civil servants, this will deepen the already high level of poverty among the wage earners. The other issues included the non-definition of expected benefits and inadequate representation of stakeholders on the board of the National Pension Commission (NPC), and the need for the retention of in-house provident or pension schemes in the private sector and some parastatals which are funded under a satisfactory arrangement between employers and their employees. Before the Pension Reform Law, the NSITF was the sole administrator of pension funds for every contributing member under the old arrangement. However, under the new Act, pension funds would now be administered by agencies other than the NSITF. Specifically, the Act requires the NSITF to register a company as (one of the) Pension Fund Administrators (PFAs) to manage the savings account of contributors in competition with other PFAs.28 Perhaps, the most seemingly ambiguous provision of the Act to the NSITF is that contained in Section 71. This is the issue of a minimum pension guarantee and the requirement for the NSITF to provide social security insurance services other than pension in accordance with the NSITF Act 1993. To this extent, the Act deems the NSITF Act amended to bring it in full compliance with its intendments. As at the time of this report, the NSITF Act is yet to be amended, but already, the Management had set up a Committee on Social Security and NSITF Act Review. This Committee has held technical meeting to deliberate on what other types of social security insurance services to offer its subscribers. In their draft report to the Management, they made the following recommendations: a) sickness Insurance; b) maternity; c) Medicare d) family Benefit; e) unemployment Insurance; f) insurance against Employment Accident and Occupational Disease; and g) social Assistance/Housing.
28
See generally, Ss. 42 and 44 of the Pension Reform Act.
35
What the Committee appeared not to have addressed was the issue of how these social security insurance services would be marketed. Some of the members were of the opinion that the Government should provide the funding to enable NSITF meet these services. Whether the Government would provide funding or subsidize the cost for the provision of these services is not yet known. However, with the current trend of developments in Nigeria, especially in the health sector, it may be possible that some kind of public-private partnership arrangement may be worked out in the future between the Government and some private companies to design and market similar services.
4.6. The National Health Insurance Scheme (NHIS)

The introduction of a National Health Insurance Scheme has been under consideration by the Government of Nigeria since 1962 when the idea of a national health insurance scheme was mooted at the floor of the Federal Parliament then in Lagos. This was revived in the 1980s when the Federal Minister of Health appointed a National Committee to examine and make recommendations on prerequisite for the establishment of a National Health Insurance Scheme. The Committees conclusions were accepted by the Government and it was decided that a comprehensive National Health Insurance should be introduced. It was considered that such a scheme would provide a major contribution to the problem of financing health care and ensuring health care delivery on an equitable basis. Towards assisting the Government of Nigeria undertake this task, a technical co-operation project was signed in August 1991, which was funded by the UNDP and executed by the ILO. The objective of the project was to finalise the planning and establish the administrative infrastructure and expertise required to operate a National Health Insurance Scheme (NHIS) through a National Health Insurance Council and State Health Insurance Boards. However, it was not until 1997 that the formal launching of the NHIS was effected, and by 1999, the NHIS Decree No. 35 was promulgated and signed into law in May 1999. To date, the NHIS is the most comprehensive attempt by the Nigerian 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 good healthcare 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 and harnessing private sector participation in the provision of healthcare services; ensure equitable distribution of health facilities within the Federation. Finally, it seeks to ensure appropriate patronage of all levels of healthcare; and ensure the availability of funds to the health sector for improved service. The following, among others, are the functions of the NHIS: a) b) c) d) registering Health Maintenance Organisations (HMOs); issuing of guidelines to maintain the viability of the scheme; approving the format of contracts proposed by the HMOs for all healthcare providers; determining, after negotiation, capitation and other payments due to healthcare providers, by the HMOs;
36
e) advising the relevant bodies on inter-relationship of the scheme with other social security schemes; f) advising on the continuous improvement of quality of services provided under the schemes through 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 the objectives of the scheme. From the above functions, it could be reasoned that the NHIS is expected to be a regulatory and supervisory agency for the operators involved in the service of health insurance provision and safeguarding the interest of the consumers of health products. The NHIS Decree specifies that only public and organised private sector employers and employees will make compulsory contributions to the Scheme. The Council of the NHIS is empowered by the enabling law to issue guidelines on the employers and employees liable to contribute under the Scheme. Under this programme, which is now referred to as the Formal Sector Social Health Insurance Programme (FSSHIP), 15% of the basic salary of employees will be contributed to the scheme. 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 two working spouses, their contributions cover both and not more than four dependants under the age of 18. 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 to service delivery, 2% each to HMO and NHIS for operational cost, while the balance of 1% is set aside 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 the Scheme is voluntary. This implies that the Scheme, if implemented as presently conceived, will cover a very negligible percentage of the population since the formal sector employs not more than 10% of the Nigerian work force. Towards resolving this obvious limitation, the Scheme came up with two programmes to reach the informal sector workers. These are the Urban Self-Employed Social Health Insurance Programme (USESHIP) and the Rural Community Social Health Insurance Programme (RCSHIP). Both of these programmes are not-for-profit arrangements to cover self-employed individuals within the urban and rural areas respectively which are bound a common economic engagement. The USESHIP prescribes that to qualify, aspiring participants must constitute a minimum 500 persons belonging to a registered programme so as to be able to pool sufficient resources. The benefit package, which depends on the groups willingness to pay, is to be selected from the NHIS cost benefit package list. The contribution rate is fixed by the NHIS at N150 (about $1.08) per person month. Access to service is on presentation of ID cards, and when there are defaults, they must be cleared before access.
37
The RCSHIP also requires the existence of 500 registered members with similar benefit packages as that 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, feefor-service at the secondary care level and out-of-pocket at the tertiary care level. They are both managed by a seven-member Board of Trustees (BOT) which collects the prepayments, manages the fund, pays providers, and maintains necessary records. The NHIS audits their accounts and carries out general coordination in both cases. As with the FSSHIP, disbursement of contributions under the RCSHIP is by fixed rates. In practice, before operation, the NHIS assists the affected communities in rehabilitating health facilities and in provision of essential inputs. Presently, the Scheme has launched 7 pilot projects in the six geo-political zones of the country under the USESHIP and the RCSHIP. These are: a) The Ijah Project - this was a Rural Social Insurance project for the Ijah Community located in Niger State (North Central Nigeria); b) The Deidei Project this was the first USESHIP organised for the international timber traders and was launched alongside the Ijah project; c) The Ibogun Olaogun Project this was another RCSHIP for the Ibogun Olagun community 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 is located 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 were launched. The intention is that the Government would provide the critical funding necessary for the operation of the rural schemes thereby raising some question regarding how people-oriented and sustainable 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), and Prison Inmates Social Health Insurance Programme (PISHIP). For the above programmes, the NHIS would provide 100% subsidy for both primary and secondary healthcare services for all beneficiaries. As in other social insurance programmes, the primary providers 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, a decision has been taken to pilot the implementation of the formal sector programme with the mainstream Federal Civil Servants in the 36 States and the FCT. This decision was informed by the
38
need to implement the new monetization policy of the present Administration. Unlike other benefits available to the civil servants, it was decided that health benefits should not be monetized; rather the 10% governments contribution for the health insurance of its employees should be set aside in a fund that will be used to pilot the formal sector scheme. The registration of the Federal Civil Servants and their dependants had long begun, and the President is billed to officially launch the FSSHIP on October 1, 2004. In consideration of the foregoing, it would be interesting to see how the NHIS would deliver the benefits and other services for which it has been set up. In a memorandum from the Honourable Minister of Health on a Blueprint for the Accelerated Implementation of National Health Insurance in Nigeria, concern was expressed on the poor level of consultation that has taken place among the various stakeholders. These include the civil servants, National Employers Consultative Association (NECA), Nigeria Labour Congress (NLC) and other Workers Unions, Local Government Areas, National Assembly, State Assemblies, State Executive, National Council on Health, Professional groups, Health Maintenance Organisations, etc. Despite the launching of the Scheme in the six geo-political zones of the country, most State Commissioners of Health are not happy with the limited role given to the State Governments under the Scheme. Most states of the Federation would rather prefer to regulate the Scheme in their respective States by establishing their own State Health Insurance Boards (SHIB). Furthermore, the Nigeria 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 Fund and the National Housing Fund that did not render many benefits to contributors (workers), the NLC called on its members to reject any attempt to make deductions from their salaries for the purposes of 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 members already provide health insurance to their employees. According to the NECA demanding its members 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 sector employers should not be allowed to contract-out on the grounds that they already provide medical care to employees. Another topical issue is the number dependants allowable under the Scheme. As already stated, it has been proposed that the benefit package will cover the employee, the spouse and four children under the age of 18. In a country where polygamy has a cultural and religious connotation and large families perceived as desirable, many potential subscribers to the Scheme has vehemently objected to this arrangement. The Government on its part understands that this is contrary to Article 12 of ILO Convention No.102, but wishes to start the scheme on this basis due to reasons of administrative practicality and keeping the contribution rate at an acceptable level. Whatever happens, experiences with accessing the medical benefits as formerly provided by for public servants by the Government have shown that this could be a source for fraud and moral abuse. The country is yet to introduce the national identity card scheme, and unless a proper photo identity card is utilized under the Scheme, the limit on the number of dependants may not be easily enforceable.
39
4.6.1. Role of Health Maintenance Organisations (HMOs) under the National Health Insurance Scheme.
A Health Maintenance Organization (HMO) could be defined as "a company of multi-disciplinary professionals put together for effective healthcare financing and delivery with the aim of optimal cost and maximal healthcare delivery utilising ethical medical practice, hospital administration skills blended with insurance, actuarial valuations and risk management techniques."29 Generally, the HMOs epitomize the Managed Care Concept, in that they manage rather than actually provide health care services to individuals. They are an integral part of the National Health Insurance Scheme, and are set to play an intermediary role between the employers/employees on one hand and the Health Care Providers on the other hand. The HMO is a limited liability company (public or private) which contracts with Health Care Providers (HCP) on one hand and employers/employees on the other towards managing the provision of health care on behalf of the two parties. The Health Maintenance Organizations are the fund managers of the Scheme. The following are the characteristics of HMOs in Nigeria: a) Ownership Structure The 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 the registered participants of the Scheme. ii) Purchaser Based: The HMO will use the health services provided by other health care providers. In this respect, the HMO will enter into a contract with the health care provider organization to render health care services 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, with the objective of making a profit.
b) Size and structure HMOs may be small or big depending on the area of coverage and share capital base. The area of coverage may be National or Zonal. A national HMO is an HMO that has coverage for the whole country with an authorized share capital of N100, 000,000. It must have offices in at least two thirds of the states in the country. A zonal HMO on the other hand operates within a particular geopolitical zone in the country, with an authorized share capital of N50, 000,000. The minimum operational requirement for an HMO is zonal coverage. The size of an HMO may therefore be summed 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, 000,000 security deposit with an accredited NHIS approved bank for national HMOs while zonal HMOs will deposit N25, 000,000. This amount is a guarantee against financial impropriety, sharp practice or default on the part the HMO 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.
40
Other requirements and attributes of HMOs in Nigeria include, c) Formation and Registration To form an HMO, the subscribers have to incorporate the company as a limited liability company with the Corporate Affairs Commission. Having incorporated the company, the company will apply to 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 carry out 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; and l) 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 to time by Government through NHIS. With regard to Registration the Scheme reserves the discretion, after the necessary inspection to register or reject the application for registration. If the application is successful, the Scheme will issue 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 Maintenance Organizations. The registration of an organization under the Scheme shall be in such form and manner as may be determined, from time to time, by the Council, using guidelines, which shall include 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; and e) 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 be issued, from time to time by the Council.
41
The registration of a Health Maintenance Organization under the Scheme shall be valid for such period 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 with guidelines issued under this Decree (Act). d) Functions under the Act In 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; and k) setting up an internal quality assurance programme that is formal, systematic and ongoing. This must focus on accessibility, acceptability, continuity of care, facility and personnel provisions, 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 premiums to cover provider claims, in addition to the audited accounts of the company.
42
Finally, State and FCT arbitration panels have been provided for in the Decree (Act) which shall consider complaints from an aggrieved participant against a Health Care Provider (HCP). The decisions of the board shall be binding, on all parties. Furthermore, the Tribunal established under the Special Tribunal Miscellaneous Offences Decree (Act) 1984 shall try offenders that run foul of the NHIS decree. Sanctions and penalties for various offences are clearly laid out in the decree (Act). e) Mechanisms for Bill Settlement Each insured person would have a free choice of approved private practice or government primary health care centre for himself and dependents. The chosen practice centre registers each patient and notifies the Zonal Office of the National Health Insurance Scheme and is paid a capitation for each person registered whether or not that person needs any health care or not (at primary level). An insured person may change his/her practice/centre provided he/she has been registered for at least six months with a previous practice/centre. Except in emergency, health care is obtained by first visiting the chosen practice/centre. In other words access to other doctors or to hospital can only is covered on referral from the practice with which the patient is registered. f) Responsibilities to the Scheme A registered Health Maintenance Organization with the Scheme has the following responsibilities to the 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; and g) 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 (see Annex 3)30. Out of these, about eight or nine companies are believed to have been authorised by the by NHIS to act as intermediaries or brokers/insurance companies for the Scheme as provided in section 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 see that the HMOs in Nigeria aggregately cover less than 120,000 lives.
43
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 the primary mandate to formulate policies relating to emergency management activities as well as coordinate programmes and plans directed at responding to disasters in Nigeria. As an off-shoot of the National Emergency Relief Agency (NERA), which was established by Decree 48 of 1976, the NEMA was created to engage in the prevention, control, mitigation and rehabilitation of disaster victims 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 to make the agency more anticipatory, effective, efficient and dynamic at responding to emergency situations. In a country where natural and man-induced disasters are rampant, the role of an agency like NEMA cannot be underplayed. The agency is funded by the Federal Government, however, the Decree also made provisions for State level intervention (and funding) under the State Emergency Management Authority (SEMA). Notwithstanding, most state governments are yet to initiate activities in line with the provisions of the enacting law.
44
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 public and private sectors. There is no health insurance for the rest of the population most of which is often poorer than the salaried workers of the public and private sectors. Workers of the informal sector and rural areas account for over 70% of the workforce in Nigeria but find themselves in a peculiar situation of vulnerability resulting from the often difficult working conditions, lack of a long-term view and poor access to health care. In many African countries, the excluded people have understood that they can only rely on themselves to provide social protection responding to their needs. Micro-health insurance systems provide an interesting alternative for addressing the problem of the financing of health care. The concept of micro-health insurance covers a wide variety of systems, which are currently developing in Africa and all developing countries, such as health mutual societies, health savings systems and microfinance systems which also include an additional health/accident financing component. They are usually based on the following characteristics: voluntary membership, non-profit objective, link to a health care provider (often hospital in the area), risk pooling and relying on an ethic of mutual aid/solidarity. Their advantage lies in being able to reach low-income people working in both rural areas and urban informal sector who are otherwise difficult to reach, exploit social capital in bringing about greater awareness, correcting for adverse selection and moral hazard problems and encouraging preventive measures, and increased access to health care. In a 1998 study funded by ILOs Strategies and Tools against Social Exclusion and Poverty programme (ILO-STEP) in collaboration with other international cooperation agencies, it was reported that these mutual societies were functional in some Western and Central African countries, including Nigeria. These health mutual societies are social and professional groupings that developed gradually over the years and were democratic, mindful of equity and voluntary in nature. They are found among womens groupings, decentralized financing structures, socio-professional federations, village groupings, etc. The members freely choose to join and pay their contributions regularly thus enabling them to have a fund to cover their health care. They were also generally small 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 the Community Partners for Health (CPH), Country Womens Association of Nigerias (COWANs) Health Development Fund (HDF) and the Ibughubu Improvement Union, all operating in Southwestern Nigeria. The CPH were modeled as informal sector mutual health insurance schemes involving some private primary health care (PHC) providers and community-based organisations that 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 the schemes. As it were, the schemes were comprised of community-based organisations (CBOs) that purportedly contributed towards provision of quality health care to members and their families. But 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 may not have been health insurance in the traditional meaning of the term.
45
The reason is that most of the members of the CBOs lacked the financial capacity to sustain any kind of premium payment. The annual contribution for each member was N100 (less than $1), and considering the high cost of living and healthcare in Nigeria, even if with large membership, the total contribution collectible may not be adequate to treat a serious case of malaria. Presently, these organisations have resorted to other activities which do not directly or holistically deal with primary healthcare delivery. As non-governmental organisations (ngos), the various CPHs now seek funding from donors and other international agencies to enable them engage in preventive campaigns against HIV/AIDS, capacity building workshops, micro-credit schemes, environmental and sanitation campaigns, etc. The above experience, however, does not suggest the impracticability of implementing health insurance schemes or the importance of exploring avenues for such schemes in Nigeria. It is only a 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 widespread criticism of levying user charges, community based health insurance arrangements could still meet the healthcare needs of those excluded from various formal schemes by serving as an important financing 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 on the poor, community based health insurance is seen as an effective way in financing health care costs. Health insurance by pooling of risks across members who participate in health insurance lessens 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 a community or member based organisations provide31. (See again, Section 6.2. on Other Axis for Extension: The Role of Faith-Based Organisations) Over the years, the ILO has been assisting several member states in addressing the twin issue of poverty and social exclusion through promoting and strengthening community-based social security organizations. This innovative initiative, implemented by the ILO-STEP Programme, aims at improving the knowledge base on community-based social security organizations (such as micro-insurance and mutual health organizations), which are growing rapidly in many countries of west and central Africa. They are designed to devise ways to support such organizations and enable them to grow, and to determine their potential for becoming part of a wider, integrated national strategy for the extension of coverage. This initiative targets poor and excluded groups in the informal economy and rural areas, as well as low-income formal economy workers whose social security coverage does not meet their needs. In many countries the rapid proliferation of community-based social security schemes has demonstrated their important potential to contribute to the extension of social security services responding to the priority needs of the excluded segments of the population, mainly with regard to 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 primary objective of providing micro-credit to its members. But it also provides quality primary healthcare insurance services to its members (and other subscribers) based on voluntary contributions.
46
awareness and understanding of these schemes and their potential for helping countries expand social security coverage. The ILO-STEP Programme has already carried out 35 technical cooperation projects on community-based schemes in 38 countries of Africa, Asia, Latin America and the Caribbean. In total, these projects provided direct technical support to more than 100 community-based schemes. ILO-STEP played a leading role in the design and dissemination of a wide range of training materials and tool kits as well as in the setting up of coordination networks. It also supports the design and development of national policies and legislation to strengthen community-based schemes. Other researches on social exclusion have shown that approaches focusing on a single dimension or cause of social exclusion are not very effective. While theoretical and analytical works on the issue abound, there are few technical reference materials available on the implementation of a local approach, which combines integrality, participation, partnership and territoriality. It is therefore necessary to draw up a framework for action that can articulate the contributions of various sectors towards producing an effective intervention. The potential of up-scaling, extending and expanding of micro-insurance programs depends crucially on the issue of affordability, that is, to what extent resources for meeting health care costs can be mobilised from the people themselves.32 Limited reach and coverage of the previous microinsurance programs by itself is not sufficient to question the affordability of premium by the poor and 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 not all risks are insurable. However, health risks such as those confronting most of the informal sector people such as illness, injury, disability, maternity and the like are considered to be eminently insurable as these risks are mostly preventable. Moreover, among several risks facing poor households in Nigeria, health risk is considered to be crucial as it has a destabilising effect on household finances - directly, by thrusting health expenditure in the event of illness and indirectly, by affecting the income earning capacity of households. (Asfaw et al., 2002)33. Hence the need for a two-pronged strategy: one, aimed at improving the health status of the poor, and two, protecting them from the financial consequences in the event of illness. For this reason micro-insurance that essentially protects households against the financial consequence of illness is 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 level of revenue mobilisation, frequent exclusion of the poorest of the poor, small size of risk pool,
32
Unlike 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 loss resulting from a particular event). Therefore, in the context of insurance affordability becomes an important issue. See Rajeev Ahuja and Johannes Jutting, Are the Poor too Poor to Demand Health Insurance? Indian Council for Research on International 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 into generating higher incomes, especially for the poor. This linkage has been demonstrated in the work of the Commission on Macroeconomics and Health of the WHO (CMH 2001).
47
limited management capacity, isolation from more comprehensive benefits. In the countries where they are operated, their reach is still low and attempts are still being made to bring in more and more people by up-scaling, extending and replicating the schemes. In extending the reach of micro insurance, demand side and supply side factors and factors relating to design and development of scheme are important. A few micro-level studies that have tried to estimate demand for health insurance based on the willingness-and ability-to-pay for health insurance have come out with positive findings. A survey-based study (funded by the Deutsche Gesellschaft fr Technische Zusammenarbeit GTZ - or German Technical Cooperation Agency,) on the willingness to pay in three Nigerian States which are relatively not as economically viable as the States in South - shows that the poor are willing to pay up to 4 % of their monthly income (David 2004)34 for having a scheme that can take care of their costs of illness. 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 from donor 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 which lower entrance barriers for the poorest, e.g. flexibility in premium collection and exemption mechanisms35.
5.1. What the Government Can Do: Involving Community-Based Organisations in 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 strengthening the capacity of local governments personnel for better management. It also stated that it will develop and implement a strategy to enhance community participation in providing and financing health services. However, as already discussed in this paper, the Government of Nigeria had launched the National Health Insurance Scheme in 1997, and has within the years of its operation set up pilot programmes in the six geo-political zones of the country. That most of these schemes were set up in rural and suburban communities would have ordinarily suggested that they are people oriented. But that does not appear to be the situation. A visit to one of the RCSHIP in the Southeast 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 sufficiently equipped both in medical personal and other medical accessories to deliver the expected services. The general view appears to be that the centre is more political than beneficial to the community 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-Pay for Group Health Insurance in Nassarawa, Niger States and the FCT of Nigeria: The Basis for Establishment of Centres for Health Insurance Competencies. Funded by German Technical Cooperation Agency (gtz), Federal Republic of Germany. (2004) 35 This could be allowing the poorest members pay lump sum contribution during harvest seasons when they have most liquidity, or to pay with their produce or other in kind methods.
48
scheme appears to have been introduced to the communities from the top without necessarily considering its sustainability. From interviews with the managers of the CPH in Amukoko and Lawanson in Lagos and following from views expressed above, the people can afford and are willing to pay for health insurance given the opportunity to be engaged in some form of income generating activity. Various poverty alleviation and job creating programmes of the Government could have been set up in such a way to incorporate a health insurance component. That way, it would be practicable for the beneficiaries to have 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. Not only would this measure make the communities more economically viable, it would also make it possible for primary hygiene to be possible in these communities. Furthermore it may then be possible for qualified medical personnel to reside among the people they serving. The practice presently is for the personnel to pay day-time visits twice of thrice every week.
49
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-based growth and development. It can also take advantage of opportunities offered by globalization (including prospects for leapfrogging) and by the preferential and differential trade arrangements and concessions under the Economic Community of West African States (ECOWAS) Treaty; the African Growth and Opportunity Act etc. However, since independence, most social protection schemes were either directly initiated or fully funded by the Government. But as has been seen, the poor state of the economy has made continued Government patronage difficult or simply impracticable. 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 hoc and uncoordinated. A recent survey of policies and interventions chronicles 28 federal projects and programmes with poverty reduction thrusts. Several state governments have also put poverty reduction schemes in place. Programmes such as community banks, family support programmes, the National Directorate of Employment, the Peoples Bank, Better Life for Rural Women, and the Directorate of Food, Roads, and Rural Infrastructure were established by different governments to address various manifestations of poverty, such as unemployment, lack of access to credit, and rural and 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 schemes earlier set up by the people for purposes of social assistance also become defunct as they lacked the financial will to sustain such efforts. With the advent of democratic government in 1999, measures were adopted to streamline povertyrelated institutions, review past poverty alleviation programmes, and harmonise sectoral efforts. Several critical factors hindering the success of government efforts to reduce the level of poverty were identified. These include, poor coordination; absence of a comprehensive policy framework; excessive political interference; ineffective targeting of the poor, leading to leakage of benefits to unintended beneficiaries; the unwieldy scope of programmes, which caused resources to be thinly spread across projects; overlapping functions, which led to institutional rivalry and conflicts; the absence of sustainability mechanisms in programmes and projects; and lack of involvement of beneficiaries in project design, implement, monitoring, and evaluation. Under the NEEDS paradigm, the Government of Nigeria reaffirms its obligations to the people and recognises the individuals rights and responsibilities and promises to deliver the basic necessities for a decent human existence. These include potable water, food, clothing, shelter, adequate nutrition, basic education, primary health care, productive assets, security, and protection from shocks and risks.36 The government has declared its intention to significantly improve the quality of life of Nigerians, create social safety nets for the vulnerable, and meet the needs of people who may be displaced by the reform process. Economic empowerment is the main focus 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.
50
economic growth may not generate poverty reduction at the desired pace, actions to facilitate individual economic empowerment, particularly among the poor and other vulnerable groups, are imperative. This appears to be a clear focus on practical action. Among others, it would entail agricultural and rural development, labour-intensive infrastructure, upgrading the informal economy, 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 that of reforming the economy in order to boost economic growth, but also to empower the people as means 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 the purpose of the Government to derive strategies for the extension of existing public schemes to cover certain excluded groups such as those who work for small employers, the professional self employed, domestic servants etc, and also improve the administrative capacity and performance of such schemes. Also, there is need to modify some public schemes in order to better equip them to respond to the needs and circumstances of those not presently covered; and to find alternative means for providing basic social protection for the poor and the most vulnerable. In Nigeria, the majority of the uncovered are in the informal sector economy. The ILOs research on the informal sector over the years has demonstrated that a wider concept of social security is needed in order to fully respond to the realities faced by the workforce in this sector. The traditional concept of social security is contained in various ILO standards. According to the Income Security Recommendation, 1944 (No. 67), income security schemes should relieve want and prevent destitution by restoring, up to a reasonable level, income which is lost due to inability to work (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 be provided either through a social insurance medical service with supplementary provision by way of social 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 well as 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, the goals and objectives of the Government in this area are palpable. As deducible from the NEEDS document, and the policy note on Social Protection Strategy for Nigeria, the country subscribes to the provisions of Article 9 of the International Covenant of Economic, Social and Cultural Rights that the right to social security for everyone is a sine qua non for sustainable development and poverty reduction. Accordingly, the main goal of social protection in Nigeria should be to reduce poverty and protect vulnerable groups through effective and sustainable prevention mechanism. Using the categorisation from the Social Protection Strategy for Nigeria: Policy Note, the following axis for extension of social protection are prescribed:
6.1. 1.0-5 Age Group and Nursing Mothers

As stated earlier, about 19.6% of Nigerias 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
51
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 in Nigeria. There is a need for the Government and other stakeholders to provide adequate mechanisms for ensuring child survival through immunisation against childhood diseases, post-natal primary health care, nutrition, etc. The traditional approach of shifting the burden of managing this risk to families, relatives, friends and neighbours should be reviewed. With the proposed introduction of Under 5 Social Health Insurance Programme, which the Government would provide at no cost, it is hoped that more women and children would receive much needed assistance. The ILO Maternity Protection Convention, 2000 (No.183) recognises the maternity care needs of women engaged in atypical forms of work, and prescribes that commensurate health care and other forms of social protection should be provided to this grouping. The Government should be better committed to creating a viable climate for the vaccination and nutrition supplementation programmes by various international agencies. It should also facilitate the operation of child care development centres/school at the community level by securing the services of professionals who have proper training on child development. In addition, the National Programme on Immunization should be implemented using existing primary health care centres to make it more cost effective. It is suggestible that this should be an integral agenda for the Under 5 SHIP under the NHIS. As it were, the government has indicated its plans, under the NEEDS, to develop and strengthen mechanisms for checking the transmission of polio and other epidemics affecting infants by the end of 2004. This will involve detecting, diagnosing, and responding to epidemics in a timely manner, and sustainable increase in routine immunisation coverage. Moreover, there is need for international development agencies, donors and other stakeholders to explore possibilities of extending maternity protection to women, especially those in the informal economy using micro-insurance and other people-oriented schemes. Traditionally, various communities have local midwives or traditional labour attendants which could be organised and trained to better deliver these services.
6.1.2. 6-14 Age Group

The primary concern for this group is to enhance the number of pupil enrolment into formal educational institutions under the Universal Basic Education. There is a need to increase the number of teachers or redistribution of teachers in Nigerias primary and secondary school system in order to achieve the recommended UNESCO standards of teacher-pupil ratio. Secondary, the UBE programme should mount National Campaigns to educate Nigerians that education is free and compulsory in Nigeria up to Junior Secondary School. Considering the dire economic situation of most families in Nigeria, it is not difficult to understand the 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 and trafficking; areas of collaboration should be identified to incorporate social protection components into the IPEC initiative.
52
Under the NEEDS, the government has promised to ensure and protect childrens welfare by strict enforcement of the Child Rights Act of 2003 by the child rights implementation committees at the federal, state, and local government levels. These committees actions will be targeted at protecting children 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 and psychotropic 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; and g) 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 on Worst Forms of Child Labour Convention, 1999 respectively.
6.1.3. 15-24 and 25-64 Age Groups

The majority of Nigerias workforce is within these groups and most of them reside in the urban centres of the country. Nigerias urbanisation rate of about 5.3 percent a year has not been matched with a corresponding economic advancement. Consequently, a considerable percentage (about 10.8) of urban dwellers is unemployed. Unless the manufacturing/services sectors grow sufficiently to absorb the surge of labour to urban areas, or the rural areas are transformed to stem migratory flows to the urban areas, the rate of unemployment could become unmanageable. The implications for poverty, crime, conflict and maintenance of democracy could be grave. The government recognises the urgency of the unemployment situation as well as the need for specific steps to facilitate individual empowerment particularly among young people and other vulnerable groups through the creation of new jobs. As contained in the ILO Director Generals Report (2003), Working out of Poverty, work is the only route out poverty. In order to create viable opportunities for those excluded from any form of social protection, there is need to afford them voice and representation. It is necessary to enlist the people in setting policy and designing initiatives that touch on their lives. The starting point should always be social dialogue towards finding means and strategies that are practicable, which will help women 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 in other developing countries. In order to effectively combat unemployment and low income, the government should come up with viable initiatives to introduce unemployment insurance, income support programmes and formulate a coherent policy in response not only to combat the prevailing high rate of unemployment, but underemployment as well. As contained in the NEEDS, the Government is poised to work towards improving incomes and tackling other social and political factors that contribute to unemployment and poverty.
53
In pursuing the above objectives, the Nigerian Government could well be guided by the three policy issues 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 incomes of people living and working in poverty; b) what could be done to integrate socially excluded communities into the labour market and overcome the endemic discrimination particularly against women and girls; and c) what financial mechanisms could be put in place to enable the working poor access microcredit to start or improve own business? An integrated effort in these three areas holds the potential of creating a virtuous cycle in which improving the earning power and productivity of the poor removes a restraint on the overall capacity of 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 a basic building block for progress. There is need for the Federal Government of Nigeria to reposition NAPEP and resuscitate the National Directorate of Employment (NDE) through adequate funding and guided management so that the scope of their activities and beneficiaries would be enlarged. There is need for the interventions of the United Nations agencies and other international organisations in the area of poverty alleviation and job creation to be coordinated towards achieving the greatest impact possible. The ILO, through its tripartite reach was instrumental to setting up the National Directorate of Employment (NDE) and the Nigeria Social Insurance Trust Fund (NSITF). From past experiences at programme implementation, it has been proven that disparate interventions have not achieved 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 in this 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, and promoting peace and security. Such initiatives should aim at increasing demand for labour consumption by developing macroeconomic strategy that promotes labour-intensive growth (that is job creation through active labour market programs such as incentive to small and medium sized enterprises). The government believes that a coordinated implementation of NEEDS by all stakeholders at the federal, state and local levels will lead to about 7 million new jobs.37
6.1.4. 65 and Above Age Groups

This 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 pension allowances for months and even years. There is need for the Government to develop a subsidised programme under the NHIS for the benefit of this class of people. As it were the burden of caring for the aged fell on their family and relatives, but with the continued loss of jobs and rising unemployment in the country, family support structures have dwindled considerably with attendant grave consequences.
37
NEEDS document, p.44.
54
With the introduction of the Pension Reform Law which has unified pension regimes for both public and private sectors along a contributory pattern, it is hoped that adequate mechanisms would be put in place to ensure that the Pension Fund Administrators fully deliver on their mandate. There is also a serious need to clarify the intendment of the Pension Law in regard to the section on Minimum Pension Guarantee. It is recommended that this should be subject to occasional review on order to take care of inflationary currents in the national economy.
6.2. Other Axis for Extension: The Role of Faith-Based Organisations

In Nigeria's current situation of dwindling resources, economic hardship, poor health care, lack of medicines, corruption, unmotivated staff and inadequate management capacities, and a literally paralyzed public health system, the role of churches in health care provision readily fills a muchneeded gap in services. Faith-based organisations have immense influence in their communities. However, this influence has not been fully exploited in extending social security to the uncovered members of the Nigerian population. The fact that about 40% of Africas health care systems are controlled by FBOs, underscores their influence and reach. This means that religion also has an indirect effect on the delivery of health services, and such services can be used for conveying issues on the way people access healthcare. Interviews with some FBOs leaders in Nigeria during the fieldwork for this report showed that most of them have well instituted social assistance programmes that are targeted 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 proved unsustainable over time. Spurred by concern to assist its members and public cope with the reality of Nigerias socioeconomic reality, the Catholic Church established the Catholic Health Insurance Programme (CHIP) in 2003. Through its franchise system, it hopes to support the various dioceses, Catholic health care institutions and other interested partners in planning and introducing local health insurance schemes. The franchise principle works as follows: from the insurance scheme to be established, CHIP will receive a one-off joining fee set according to the schemes size and benefits package offered. It will also charge an annual franchise fee of two percent of gross income. On its part, CHIP will give a start-up help to the health insurance schemes, and furnish them with information and marketing material. It will also organize and take charge of staff training, 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, the insurance policies offered by CHIP are tailored to the peoples needs and life situations. For example, in Enugu, a relatively low-income state located in South-eastern Nigeria, the CHIP has two health centres that cater to the health needs of the population. Malaria has been identified as the most pervasive illness in the suburb covered by the programme. For a yearly payment of N800 (about five euros a year) and other incidental low co-payments, the subscribers have access to a range of health care services, namely: a) outpatient malaria therapy; b) treatment of ten other (per-determined) illnesses;
55
c) provision with 40 medicines; d) free vaccinations under the national immunization programme; and e) 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 health centres, in turn, are obliged to have a qualified nurse or midwife on duty seven days a week in two shifts. Furthermore, a doctor must be available twice a week for at least four hours to hold outpatient clinics. CHIP ensures that the centres comply with these requirements. In Onitsha, a commercial suburb in Anambra state (also in South-eastern Nigeria) the economic situation of the population is better compared to Enugu. Hence, it was possible for CHIP to offer them different tariffs and benefits packages. Under the Admission Package costing 5.50 euros per member per year, the health insurance scheme covers hospital costs including surgery. For higher income earners, there is a Comprehensive Package for around 50 euros. In addition to the benefits provided in the Admission Package, those insured can also claim for the costs of outpatient treatment for a total of 52 (predetermined) illnesses. Prospectively, the CHIP has high potentialities for success in Nigeria based on the good level of trust and confidence the Catholic Church enjoys in Nigeria. Presently, some Health Maintenance Organisations (HMOs) are exploring how they could establish some form partnership with the CHIP in order to extend their coverage and clientele. According to cautious estimates, five to ten CHIP health insurance schemes should be able to start up by the end of 2004. The Catholic Church hopes to enrol at least 100,000 Nigerian men and women in these insurance schemes within the next three years. With the level of patronage and commitment it has received from its public, the CHIP is strategically looking at expanding its franchise system to cover the whole country. 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 a health scheme since 1998. The scheme has around 2,200 covered members and provides health care coverage with two different policies: admission cost coverage and comprehensive treatment cost coverage. The scheme encountered some confidence-related problems during its pilot due to the negative prejudice and mistrust against insurance business in Nigeria. However, based on the commitment of the Catholic Sisters and the reliable delivery of health services, the local population was subsequently convinced to start enrolment. The Household of God Mission Inc. which is a Pentecostal Church located in Lagos, Nigeria with an estimate of 4,000 regular members. In addition to other social assistance services to its less privileged members such as benevolent cash assistance, housing, job placing, etc, it organises a yearly programme known as G.R.A.C.E.. The G.R.A.C.E. means Gods Riches At Christs Expense and has served as a vehicle for reaching out to the less privileged in the community and a demonstration of the objective reality of the Churchs compassion. At various times, the Church had
38
Social Health Insurance: Systems of Solidarity Health, Education, Social Protection Sector Project Social Health Insurance Experiences from German development cooperation (sponsored by Federal Ministry for Economic Cooperation and Development, June 2004. pp 23-24.
56
disbursed cash awards up to N1, 000,000 to selected members of the community who do not necessarily belong to the church. Also, the St. Dominics Catholic and the Redeemed Christian Church of God, both in Lagos runs healthcare schemes for the less privileged members of its community using goodwill offering from members (and non-members) of the church. Again, this is in addition to other social assistance services like housing, scholarships, mass feeding of the poor that these churches provide to their members and public. The largest non-governmental health care provider in Nigeria Christian Health Association of Nigeria (CHAN) and has over 300 health institutions and 3,000 outreach facilities. CHAN facilities serve at least 40% of the country's population, primarily those in rural areas or urban slums and those with the fewest resources. Plans are presently underway to include CHAN as one of the HMOs in the NHIS. For reasons connected to the large membership and organisational structure of these FBOs, some bi-lateral and multilateral donor agencies such as USAID, DFID, etc in Nigeria have been using them to implement their programmes on the campaign against HIV/AIDS, malaria, and tuberculosis. The Deutsche Gesellschaft fr Technische Zusammenarbeit (GTZ) or German Technical Cooperation Agency is currently setting up a higher-level institution, known as a Centre of Health Insurance Competence (CHIC) in Nigeria. Under CHIC small private and public health insurance schemes will come together in a network and establish their own competence centre. Like the sub-regional internet-based network La concertation, to which the ILO belongs, CHICs primary objective is to develop insurance products and quality standards, carry out seminars and training courses, and represent members interests on the political level. In July 2003, 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 a means of addressing the needs of the informal sector populations has just been completed. As earlier stated, the study examined the potential for mutual health organizations three states based on a measure of the ability and willingness of the sample population to pay for group health insurance within the CHIC franchise model. It might be interesting to explore how the ILO could jointly design projects with these churches to technically assist them in setting up well designed community-based social security schemes. On their part, the churches have the willingness and the funds to administer such schemes, but without adequate 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 other benefit) schemes for their members as well as their public was quite prospective. Presently, the Household of God Inc. is in the process of registering a Household of God Health Insurance Scheme as a separate NGO. It has also indicated interest to participate (at own cost) in any training workshop or seminar the ILO or its social partners may be organising in the future.
57
6.3. The Role of Other Bilateral and Multilateral Organisations and Donor Agencies.
With its huge population, Nigeria is of critical importance to the development of the continent and the achievement of the Millennium Development Goals. Its history of decay under military rule has meant that it has about the worst record on progress to the MDGs of countries that are not in conflict or post-conflict. Tackling poverty and its underlying causes pose a considerable challenge to the Government of Nigeria (at federal, state and local levels), and its development partners. It has been stated that whether Africa attains the Millennium Development Goals (MDGs) by 2015 depends to a large extent on Nigerias success in reducing poverty39. Despite the situation, the level of Overseas Development Assistance (ODA) to the country appears quite insignificant to its myriad development problems. The DFID in Nigeria alluded to this situation when it declared that considering the size of the development challenge, Nigeria's level of international assistance at less than $1.50 per capita (compared to a Sub-Saharan average of $21) makes it one of the most under-aided countries in the world.40 The World Banks Interim Strategy document (2001) had indicated, among other findings that, by and large, Nigeria has sufficient resources of its own to achieve sustainable development. It categorically stated that the resources brought by the donor community and other development organisations are always going to be relatively small compared to the resources which Nigeria has available to it. Hence, the major role of the most bilateral and multilateral organisations and donor agencies has been more targeted at helping Nigerians build the capacity to manage their own resources effectively. However, the point remains that Nigeria requires international assistance and solidarity now than ever before. There is a need for donors and international and regional financial institutions to contribute to the development of social protection systems in the country in support to the NEEDS paradigm. It would also be necessary to invest in the retraining and economic restructuring which can promote more equitable adjustment and a fairer distribution of the gains derivable from the ongoing reforms. Private solidarity initiatives can also contribute. At the 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 with various bi/multi-lateral organisations and donor agencies and shares the goals and objectives of the NEEDS document. In addition to promoting social dialogue among its tripartite constituents and other social partners towards developing effective strategies and plans for implementing social security reforms, the ILO is involved in organising donor support as a key element of its Global Campaign on Social Security and Coverage for All. It recognises that social protection is an essential tool in the fight against poverty and social exclusion and for promoting decent work. To the ILO, work does not just represent a source of income, but rather encompasses an individuals dignity, family stability, peace in the community, and a democracy that delivers41. Work implies social 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 DFIDs plans to assist Nigeria in poverty reduction towards achieving the UN MDGs 40 Ibid. 41 Contained in an address by Juan Somavia, Director-General of the International Labour Office to the African Union Extraordinary Summit on Employment and Poverty Alleviation in Africa (Ouagadougou, Burkina Faso, 8 September 2004)
58
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, Fair Globalization: Creating Opportunities for All, rehashes ILOs position that basic security is a recognized human right, and a global responsibility42. The report opined that all industrialized countries devote substantial resources to social protection and social transfers but such policies are extremely limited at the global level. It deplored the gaps in income and security between countries and prescribes that certain minimum level of social protection needs to be accepted and undisputed as part of the socio-economic floor of the global economy. The report calls for increased international support to buoy the efforts of poor countries at providing some levels of social protection to their populations, and concluded that to provide legitimacy to globalization, it is 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 in Africa held in Ouagadougou, Burkina Faso from 3-9 September 2004, (presided by the AU Chairman and Nigerias President, Olusegun Obasanjo), the representatives of the 15 UN agencies met with Juan Somavia, Director General of the ILO, and reaffirmed their commitment to Africa. The agencies defined key priority problems facing Africa and proposed concrete assistance initiatives, based on their respective experiences and competencies, within the framework 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 of civil society, agreed that employment must play a primordial part in the struggle against poverty. The Director General, giving fresh impetus to ILOs onerous commitment to Africa, stated that ILO is in the service of Africa and at the disposal of the governments, the workers and the entrepreneurs to help them work together."43 The broad objectives of the ILO are to generate increased attention of the world community on the low-rate of coverage in most African countries; strengthen donor resolve to assist them extend coverage as a means of reducing poverty; and serve as a catalyst for efforts to support national action. In Nigeria, the realisation of these 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 for International Development (DFID), and the U.S. Agency for International Development (USAID). Others include the German Technical Cooperation Agency (GTZ), Canadian International 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 will exceed US$500 million per year. However, more donors are just starting up. As a result, there is a high level of donor coordination presently in Nigeria. In almost every sector - economic management, community development, education, HIV/AIDS or other healthcare delivery
42
A Fair Globalization: Creating Opportunities for All, World Commission on the Social Dimension of Globalization, February 2004, p. 109. 43 ILO NEWSLETTER on the Extraordinary Summit of the African Union on Employment and Poverty Reduction, op cit.
59
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 of Nigerias 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 Nigerias reform agenda, the National Economic Empowerment and Development Strategy (NEEDS). NEEDS is Nigerias home grown poverty reduction strategy, and, according to DFID Nigeria, the donor community have 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 the following 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, most development plans and efforts have not been satisfactorily implemented to achieve the set objectives. Indeed, experience has shown that most well formulated plans, policies, programmes, and projects have failed because of ineffective implementation or no implantation at all. Under most military regimes in the past, the government, as the dominant producer and controller in the economy, created a lot of perverse incentives that made corruption, mismanagement and graft easy ways for wealth accumulation. Under such regime, private enterprise, transparency and accountability were not commensurately rewarded. Consequently, for all its elegance and practicality, for the Government to achieve the targets set out in the NEEDS, it is likely that the various socio-economic reforms proposed therein might trigger the need for frequent adjustments to national production processes, and hence to jobs and the life strategies of women and men. These adjustments would take time and it necessary that public policy interventions are put in place to support the restructuring of production systems and the creation of new opportunities. As a minimum, systems of social protection are required which can stabilize incomes, distribute some of the gains of the NEEDS reform to groups which would otherwise be excluded, and support the development of new capabilities. There is need for commitment, discipline, and a strong will at all levels - from the Presidency and federal executive branch to the grassroots - to stay the course of the reforms. In addition, implementation has to be holistic, consistent, and persistent. It would also be necessary to have in place an effective institutional framework, particularly a public service dedicated to excellence and efficiency and supportive of reforms. Equally important is adequate infrastructure and an enabling environment
44
Ibid
60
in which private investment can thrive. Other critical measures include education, health care, and abiding faith and commitment to change. Nigerias population have become highly sceptical of the governments intentions due to several years of failed promises. The Government seems to understand this, and hopes to simultaneously pursue 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 State Economic and Development Strategies (SEEDS). Within the states, local governments will be encouraged to develop medium-term development programmes, specifying programmes, benchmarks and targets, deliverables, timelines, and implementation guides. These plans, called Local Economic Empowerment and Development Strategies (LEEDS), will complement SEEDS and NEEDS. NEEDS recognises that effective planning at the local levels is critical to reduce or eliminate waste and inefficient resource allocation and to ensure rural development and poverty reduction. Though Nigeria operates a somewhat centralised federal structure, the state and local governments are much closer to the people and are better positioned to deliver many social benefits. Considering the extensive development goals and objectives set out in the NEEDS, and its reception by the international community, it is interesting to observe the current impetus donor agencies have given to development projects in the country. For reasons relating to its land mass and population, most international agencies have resorted to picking and choosing on areas of intervention among the 36 states and the Federal Capital Territory based on the local priorities and 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 for Transforming Health Systems (PATHS), which it runs in collaboration with Federal and State Governments as well as non-state sector, aims to bring about sustainable health benefits for the poor 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) in 2003, to 70 million, (about N945 billion), while 43 million is earmarked for 2004. The UK Government 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 ILO has launched a worldwide survey to understudy as many existing community-based social security schemes as possible in order to gain more knowledge from the experience and potential for extending coverage. This is in addition to more than 35 technical cooperation projects on community-based schemes in 38 countries of Africa, Asia, Latin America and the Caribbean. In total, these projects provided direct technical support to more than 100 community-based schemes, covering about 4000,000 members. These projects have also supported the design and development of policies and legislation to strengthen community-based schemes. The information collected will lay the foundation for further technical assistance activities, while encouraging the development of partnership networks among the various schemes and other interested groups. Such networks could follow the successful example of the coordination network - La concertation which the ILO, in partnership with other some agencies, including the 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 other states is being considered.
61
been harnessed towards strengthening the technical capacities of various schemes in the areas of financial 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 at the local and national levels. It is envisaged that in line with its mandate, reach and added-value advantage, the launching of the Global Campaign on Social Security and Coverage for All in Nigeria will provide a good platform for all stakeholders to optimally use the available resources to the benefit of countrys vulnerable majority. The first step in this direction should be to start a process social dialogue among its constituents and other interest groups in the civil society including the private sector on the most practicable approach towards poverty reduction and extension of social security coverage in Nigeria.
62
Annex 1
63
64
Annex 2.
65
Annex 3. PRIVATE PRE-PAID HMO SCHEMES IN NIGERIA HMO Total Health Trust Ltd. Hygeia Health Maintenance Ltd. Healthcare International Ltd. Southern Rose Nig Ltd. Clearline International Ltd. Multishield Ltd. Managed Health Services Ltd Estimated No of Lives June 04 27,500 50,000 9,000 3,000 15,000 3,500 3,000
First Health Ltd 800 Expat Care HMO 3,000 Royal HMO 100 Ronsberger Nig ? United Healthcare International Ltd ? Premier Medicaid Nig Ltd ? Total lives covered 114900
66
Annex 4:
The main donor activities by in Nigeria:

Donor AFDB Economic Governance Support for Economic Governance, Capacity Building and Poverty Reduction CDD/Social Services Health Systems Development Project Community-Based Poverty Reduction Project Primary Healthcare Roll Back Malaria HIV/AIDS Health Reform Project (with WB) HIV/AIDS Community Education Education Sector Analysis Micro projects health, credit, etc Rural Water Supply and Sanitation Malaria Control Primary education Non-formal education Early child care HIV/AIDS Family Planning Health Systems Polio Immunisation Roll Back Malaria Educational Sector Assessment State Education Support Roll Back Malaria Health Sector Community-Based Urban Development Health Systems Support HIV/AIDS Project Education Systems Support Micro-watershed CDD Project Universal Basic Education
CIDA
DFID
EU JICA
Economic reform, debt management, poverty monitoring Human Rights/Democracy State Capacity Building Local Police Service and Justice Economic Governance Democracy
UNICEF
USAID
Support for Economic Policy Coordinating Committee EMCAP support Domestic Debt Management Judicial Assistance
WHO WB Group EMCAP PER Support to PRSP State/Local Governance Study IFC support to SMEs, privatisation, investment
Source: Adapted (with some modifications) from WB Document, Report No. 23622-UNI
67
Selected Bibliography (Published texts and journals)

1. Atim, Chris: The Contribution of Mutual Health Organisations (MHOs) to Financing, Delivery, and Access to Health Care: Synthesis Research in Nine West and Central African Countries (1998) 2. Cripps, Gilbert et al: Guide to Designing and Managing Community-based Health Financing Schemes in East and Southern Africa (2000) 3. Dror, David and Preker, Alexander: Social Reinsurance: A New Approach to Sustainable Community Health Financing (2002) 4. Jutting, Johannes: The Impact of Health Insurance on access to Healthcare and Financial Protection in Rural Areas of Developing Countries: The Example of Senegal (2001) 5. A Fair Globalization: Creating Opportunities for All, World Commission on the Social Dimension of Globalization, ILO, Geneva, February 2004 6. Childrens and Womens Rights in Nigeria: A Wake up Call Situation Assessment and Analysis. UNICEF, 2001 7. Central Bank of Nigeria: Annual Reports and Statement of Accounts, 1972 - 2000 8. Constitution of the Federal Republic of Nigeria 1999 9. FEDERAL MINISTRY OF HEALTH: HEALTH SECTOR REFORM PROGRAM Strategic Thrusts; Key Performance Objectives and Plan of Action 2004 2007 10. Human Development Report 2004, Country Fact Sheets: Nigeria 11. Memorandum of the President of the International Development Association and International Finance Corporation to the Executive directors on an Interim Strategy Update 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, Nigeria Demographic and Health Survey 2003. Calverton, Maryland: National Population Commission and ORC Macro 14. Nigeria Reproductive Services and Manpower Survey (2001). Reproductive Health Division, Federal Ministry of Health, Abuja, Nigeria. 15. Olanrewaju, O. et al: Social Protection Strategy for Nigeria: Policy Note for National Planning Commission (NPC) (April 2004) 16. WHO Country Cooperation Strategy: Federal Republic of Nigeria: 2002 2007 17. World Bank Group: Health Systems Development: Community Financing (2001)
68

Social Protection Profile of Nigeria - A Working Paper

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Social Protection Profile of Nigeria - A Working Paper

Uploaded by

Copyright:

Available Formats

An ILO Working Paper

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

I. II. III. IV.

BASIC DEMOGRAPHIC INDICATORS OF NIGERIA

NIGERIA AT A GLANCE SOCIAL INDICATORS PRIVATE PRE-PAID HMO SCHEMES IN NIGERIA

Currency Equivalents (October 1, 2004)

Nigerian Naira (N) N130 N233.99 N160

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

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

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

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

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

1.1. Demographic and employment situation since 1990

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

1.2. Economic and social Context

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

1.3. The Labour Force and Employment Status by Sector

A Study of Nigerias Informal Sector, (FOS Document) Vol. 1

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

1.4. The Implications of the Economic and Social Situation

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

2. The Nature of Poverty in Nigeria

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

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

Source: World Bank CD ROM.

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

3. Health Sector Profile

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

Health Systems Development Project II. FMOH, 1989

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

3.1. Health supply characteristics and challenges

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

National Health Policy, FMOH

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

3.2. Health financing in Nigeria

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

3.3. Tackling the HIV/AIDS Challenge

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

3.4. National Health policy

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

3.5. Description of traditional medicine

3.6. Attitude Concerning Traditional Medicine

World Health Organisation

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

3.7. The Socio-Economic Implications: Policy Response

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

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

4. Inventory and description of public social protection programmes

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

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

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

4.4. The National Poverty Eradication Council (NAPEC)

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

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

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

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

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

4.6. The National Health Insurance Scheme (NHIS)

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

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

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

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

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