BACKGROUND: In order to accelerate universal health coverage, Nigeria’s National Health Insurance Scheme (NHIS) decentralized the implementation of government health insurance to the States in 2014. Lagos has passed its State Health Scheme (LSHS) into law with a statewide roll out set to commence in 2018. The LSHS aims to improve access to quality care by reducing the financial burden of obtaining care for Lagos residents. Public and private healthcare providers are a critical component of this ambitious insurance roll out. Yet, little or no understanding exists on how to engage providers, the factors that influence their participation in insurance and expectations from the LSHS. In addition, little is known about the geographic distribution of NHIS accredited facilities and enrollees in Lagos State. METHODS: This study used a mixed-methods cross sectional design to analyze primary and secondary data. Primary data included both quantitative and qualitative data and were collected from representatively selected 60 healthcare providers in 6 Local Government Areas (LGAs) in Lagos State through questionnaires probing issues on the challenges and benefits of insurance participation, capacity pressure, resource availability and changes in financial management. Secondary data were obtained from NHIS and Lagos State inventory of health facilities, and household survey reports, and were visually mapped using a geographic information system (GIS) software. RESULTS: Facilities participating in insurance were more likely to be bigger with mid to very high patient volume and workforce. In addition, private were more likely than public facilities to participate in insurance. Furthermore, increase in patient volume and revenue were motivating factors for providers to participate in insurance, while low tariffs, delay and denial of payments, and patients’ unrealistic expectations were inhibiting factors. Also, NHIS enrollees were more likely to be located in the urban than rural LGAs. However, many urban LGAs have larger population sizes and as a result, were also characterized with higher number of non-NHIS enrollees and fewer NHIS accredited facilities. For the LSHS, many private facilities anticipate an increased patient volume and revenue but also worry that low tariffs without guaranteeing a high patient volume would be a major challenge. For many public facilities, inadequate infrastructure, lack of workforce, and insufficient drugs and commodities remain major challenges. CONCLUSION: For the LSHS to be successful, effective contracting of healthcare providers especially those in the low income and densely populated LGAs is essential. However, this would require that provider payment is adequate and regular. In addition, the government would need to invest heavily in improving the infrastructure and the amount of workforce, drugs and commodities available to public facilities.

Philosophiae Doctor - PhD / This study is a philosophical analysis of the National Health Insurance (NHI) policy and legislation, including the related NHI Fund, with a view to assessing its prospects in realising Universal Health Coverage (UHC). The NHI system is about ensuring universal access to quality healthcare for all. The rationale is to provide free healthcare for all at the point of care/service. This legislation has the potential to transform, on the one hand, the relationship between the public and private healthcare sectors and, on the other, the nature of public funding for healthcare. Part of the challenge with the NHI system is that it seeks to provide healthcare for all, but by seeking to integrate the private sector it runs the risk of commercializing healthcare. The study is philosophical in that it holds that ideas have consequences (and conversely actions have presuppositions with certain meanings). In part, it aims to show that an implementing mechanism of the NHI system as presently envisaged has socio-political and economic implications with fundamental contradictions within it; for it seeks to incorporate the private healthcare sector in offering free public healthcare services. This introduces a tension for private healthcare services operate with a neoliberal outlook and methodology which is at odds with a public approach that is based on a socialist outlook. The analysis may make explicit conceptual and ideological tensions that will have practical consequences for healthcare. Much of the commentary on the NHI system have focused on the practical consequences for healthcare; my intervention is to explore and critically assess the various philosophical assumptions that lie behind these practical concerns. Some of these practical consequences are related to the possibility that healthcare is likely to become commercialized and the public healthcare sector will remain in a crisis. This study argues for the provision of access to high quality healthcare facilities for all members of the South African population. Healthcare must be provided free at the point of care through UHC legislation or by the setting up of the NHI Fund as financing mechanism. The study provides reason for the decommercialization of healthcare services completely – that is for eliminating private healthcare from contracting with the NHI Fund. Essentially, it argues for the claim that healthcare should not be traded in the market system as a commodity and that the NHI system in its current incarnation seeks to do precisely that. I further argue that in theory and in practice the neoliberal and socialist assumptions underlying the NHI system in its present formulation do not fit together. On the contrary, rather than a two-tiered system incorporating the private and public healthcare sectors, the dissertation argues for a different way of conceptualizing the NHI system that privileges the latter.

Health financing policies implemented by nations around the world vary based on who receives coverage and what health system resources are covered. Although, many health systems are attempting to move towards Universal Health Coverage, part of their populations continue to incur out-of-pocket payments for using all or some health services. Some health systems restrict health insurance for certain migrant populations, providing coverage for emergency care only, or none at all. Other health systems fail to provide coverage for prescription drugs, leaving those without the ability to pay out-of-pocket for medications behind. The lack of financial protections against catastrophic or impoverishing healthcare expenditures for these patients may deter them from seeking the care they need or increase the risk of severe financial hardships. This dissertation addresses these migrant and drug coverage gaps by examining the impacts of health financing policies and how these can be changed to move health systems towards Universal Health Coverage. First, this dissertation examines restrictions to refugee health policy in Canada by conducting an interpretive policy analysis to reveal how political actors strategically use causal stories to enact policy change. Second, quantitative studies assessing the effects of health insurance on migrants’ health-related outcomes are systematically reviewed. Third, this dissertation explores a provincial health system without universal prescription drug coverage to establish associations between health services use, prescription drug coverage and immigrant category. Finally, given migrants experience health outcome and health services utilization disparities, an exploratory analysis of factors that impede or assist migrants’ access to prescription drugs is conducted to uncover how these factors influence their health. While each study is distinct, together, these chapters build on each other using mixed methodological approaches to identify ways that address health financing policy gaps to reduce health inequities, build inclusive and cost-effective health systems and strengthen global health security. / Dissertation / Doctor of Philosophy (PhD)