Social and financial risk protection for poor and vulnerable populations is a major development and policy issue across the globe. There are numerous definitions of social protection. In the context of health, social protection is defined as programmes and measures aimed at removing financial barriers preventing access to health care services and protecting poor and vulnerable populations from the impoverishing effects of medical expenditures. Financial risk protection is a key component of universal health coverage (UHC) and the health system goal of ensuring access to quality health care services without suffering financial hardship.
Social and financial risk protection can be provided through programmes and measures that are rooted in legislation. Lack of social and financial risk protection leads to high levels of poverty, vulnerability and inequality in health. When the majority of a country’s population encounters the aforementioned problems, governments have to be responsive and design programmes that are rooted in legislation.
The case of Nigeria:
Health care services
Since independence in 1960, Nigeria has had a very limited scope of legal coverage for social protection  besides over 90% of the Nigerian population being without health insurance coverage. The Nigerian health system has been evolving over the years through health care reforms aiming to address the public health challenges confronting it. This includes:
- National Health Insurance Scheme (NHIS),
- National Immunisation Coverage Scheme (NICS),
- Midwives Service Scheme (MSS)
- Nigerian Pay for Performance scheme (P4P). [7-10]
Even so, the inability to effectively address the country’s numerous public health challenges has contributed to the persistent and high level of poverty and the weakness of the health system. Political instability, corruption, limited institutional capacity and an unstable economy are major factors responsible for the poor development of health services in Nigeria. Households and individuals in Nigeria bear the burden of a dysfunctional and inequitable health system – delaying or not seeking health care and having to pay out of pocket for health care services that are not affordable.
After many attempts at implementing legislation on health insurance since 1960, NHIS, although established in 1999, was eventually launched only in 2005. The goals of the NHIS were to:
- ensure access to quality health care services,
- provide financial risk protection,
- reduce rising costs of health care services and
- ensure efficiency in health care through programmes such as the:
- Formal Sector Social Health Insurance Programme (FSSHIP),
- Mobile Health,
- Voluntary Contributors Social Health Insurance Programme (VCSHIP),
- Tertiary Institution Social Health Insurance Programme (TISHIP),
- Community Based Social Health Insurance Programme (CBSHIP),
- Public Primary Pupils Social Health Insurance Programme (PPPSHIP),
- and the provision of health care services for children under 5 years, prison inmates, disabled persons, retirees and the elderly. 
Vulnerable populations and free health care
The NHIS was expected to provide social and financial risk protection by reducing the cost of health care and providing equitable access to basic health services. The most vulnerable populations in Nigeria include children, pregnant women, people living with disabilities, elderly, displaced, unemployed, retirees and the sick. Although these vulnerable groups sometime benefit from free health care services and exemption mechanisms, they largely have to pay for health care services. Free health care services and exemption mechanisms are often politically motivated, are poorly implemented, do not become fully operationalised, and sometimes only last a few years.
States such as Osun, Niger, Kaduna, Kano, Ekiti, Lagos, Ondo, Enugu and Jigawa are known to have provided some free health policies at one point or another since the return of democracy in 1999.  Free health care services and exemption mechanisms are expected to provide financial risk protection for the most vulnerable populations but evidence suggest that they are ineffective and have failed to achieve this aim. [13-16]
Despite distinguishing pregnant women and children under five years as the only beneficiaries of free health policy in states like Niger, Kano and Kaduna, under five mortality rates in 2013 ranged between 100-150 per 1000 live births, similar to the national rates of countries such as Chad, Mali and Guinea Bissau. [12, 17] States in the northern region of Nigeria experience a much higher rate of under five mortality (100-250 per 1000 live births) compared with those in the southern region (50-100 per 1000 live births). 
The maternal mortality ratio for Nigeria remain quite high at 814 per 100000 live births according to 2016 World Health Statistics. Across the country, pregnant women and children under five years are generally charged fees when accessing health care services, despite the federal government’s declaration of free health for pregnant women and children under five years in 2005. The
Minister of Health, Professor Isaac Adewole in 2016 announced the Federal Government’s plan to provide free health services to 100 million Nigerians in the next two years. Under this new health agenda, pregnant women across Nigeria are expected to enjoy free maternal and delivery services at the primary health care (PHC) level.
Free health care services and exemption mechanisms often arise as campaign promises of political actors to the electorate and fall short in meeting the health needs of the most vulnerable populations. According to Nigeria Demographic Health Survey (NDHS) in 2013, over 60% of pregnant women aged 15-49 deliver their babies at home without any antenatal care visits. In rural areas, this value reaches 76.9%. The situation is critical in North East and North West regions of Nigeria where over 79% of pregnant women age 15-49 deliver their babies at home. Over 60% of pregnant women in Bayelsa, Plateau and Niger deliver at home rather than a health facility.
The distance of pregnant women’s homes from a health facility and the cost of health care are some of the reasons for not delivering at a health facility. The cost of health care and perceived low quality of care by the public have been argued to be the reason for the poor utilisation of maternal and child health services in Nigeria.[21-24] In addition, health spending in Nigeria is low  and this is responsible for the over-reliance on out of pocket payments for health care services.
Despite its launch in 2005, NHIS covers less than 10% of the Nigerian population  leaving the most vulnerable populations at the mercy of health care services that are not affordable. This means the most vulnerable populations in Nigeria are not provided with social and financial risk protection. Poor people constitutes about 70% of the Nigerian population.  They lack access to basic health services, which social and financial risk protection should provide, because they cannot afford it.
CBSHIP was expected to meet their health needs as well as provide social and financial risk protection to this group, which mostly reside in rural areas. As evidenced in the high rate of out of pocket payments for health care services , poor people financially contribute more to health care than official care and funds programmes in Nigeria. Out of pocket payments for health care services limit the poor from accessing and utilising basic health care services [23, 24 ,27, 28], hence, the low coverage of basic health services for the poor.
Health care quality
The quality of health care services delivered is poor and remains a huge source of concern. Most of the PHC facilities that are supposed to meet the health needs of the poor and rural dwellers are in a poor state due to poor budgetary allocation. [23, 29]
i. State health insurance
Policy makers and political actors need to devise health care reforms to address the lack of social and financial protection for the poor and vulnerable populations. Part of this reform is the expansion of the NHIS. States should be mandated to provide health insurance coverage to all residents. Making health insurance optional for states over the years has affected the ability of the NHIS to increase the level of coverage for the people.
ii. State funded private health insurance
While the mandatory CBHI scheme is being scaled-up as a supplementary measure, state governments should enrol poor residents in a private health insurance plan and bear the responsibility of paying the monthly premium per person to Health Maintenance Organisations (HMOs). It is not enough to have a national health insurance policy, it is important to ensure that health insurance coverage is provided to the poor and most vulnerable populations as a matter of the human right to health.
iii. Prioritising children and vulnerable populations
Although the NHIS Act made provision for children, who constitute the largest population in Nigeria , many children still have to pay for health care services in spite of being born into poor families that do not have the ability to pay for health care services and suffer financial hardship as a consequence. The free health policies and exemption mechanisms provided by some states, targeted at children, pregnant women and the elderly, are not social and financial risk protection policies, as these groups are largely responsible for the cost of health care with the free health care programme barely covering their basic health care services.
A study conducted in 2016 concluded that the Basic Health Care Provision Fund (BHCPF) as established by the NHA to strengthen and improve PHC cannot assure UHC or universal financial protection of a basic minimum benefit package for all pregnant women and children under five. However, governments have to design and implement UHC schemes as a strategy to address the issues of high level of poverty, vulnerability and high level of inequality in health for which the poor and vulnerable populations are disadvantaged.
iv. Universal Health Care
Another way of providing social and financial risk protection for poor and vulnerable populations is by establishing a legislative framework for a UHC scheme and setting aside funds for it. Evidence from Thailand has shown the effect of UHC schemes through PHC on expanding access to health care for the poor and vulnerable populations. [31-33] UHC schemes have also been proven to improve the utilisation of health care services and health status. 
v. Financing and coverage
Political actors, policy makers and all stakeholders in the health sector should establish a government funded social and financial risk protection scheme through a general tax financing system for the poor and vulnerable, and invest in basic infrastructure for health care in rural areas for quality health care service delivery. UHC schemes are important in addressing the problem of poor coverage, limited access to health care, and poor quality of health care services.
Nigeria is yet to adopt innovative ways to protect the poor and vulnerable populations against financial risk of ill health. It is important to guarantee by law the right to health care of all citizens in Nigeria. Although the National Health Act (NHA) that was signed into law in 2014 stated that all Nigerians are entitled to basic minimum package of health care services, it is not clear if the provisions made in the NHA are capable of achieving UHC in Nigeria. In addition, the NHA is yet to be implemented over two years after its signage into law.
Some low- and middle-income countries (LMICs) have been able to provide social and financial risk protection schemes for poor and vulnerable populations as a matter of the human right to health. Therefore, there is a need to provide social health protection schemes targeted at these groups in Nigeria. The poor and vulnerable populations should not become impoverished because of failure to obtain much needed health care services. Governments must reduce out of pocket payments for health care services by households through the adoption of a tax financed non-contributory UHC scheme.
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About the Author: Bolaji Aregbeshola is a specialist in the research and practice of Global Public Health with a focus on health systems, health economics, health policy, health care financing, human resources for health, governance in health system, implementation research, health insurance system, universal health coverage, health care delivery system, prevention and control of communicable and non-communicable diseases, pharmaceutical reforms and health system reforms.
Source: Social Protection