Actuarial Assessment of Social Health Insurance Sustainability in Ekiti State

This study conducts an actuarial assessment of the financial sustainability of the Ekiti State Contributory Health Insurance Scheme, examining contribution adequacy, claims experience, and long-term viability. Social health insurance schemes at the state level have emerged as a practical mechanism for advancing universal health coverage in Nigeria, with Ekiti State among the pioneers of state-level health insurance legislation. However, the actuarial basis of premium setting in state-level schemes has often been inadequate, leading to recurrent funding shortfalls. This study uses administrative data from the Ekiti State Health Insurance Agency covering enrollment, contribution, and claims records for 2018 to 2023, supplemented by a survey of 80 enrolled beneficiaries and healthcare providers in Ado-Ekiti, Ikere, and Efon-Alaaye. Actuarial projection models estimate 10-year sustainability under three scenarios of enrollment growth, claims cost escalation, and investment return. Loss ratio trends and benefit utilization patterns are analyzed. Findings reveal that the scheme's loss ratio averaged 108 percent over the study period, indicating chronic premium inadequacy. Claims cost inflation driven by drug costs and specialist referrals is not adequately captured in annual premium adjustments. Under a moderate growth scenario, the scheme faces insolvency within six years without premium revision or benefit restructuring. The study concludes that actuarial underpinning of state health insurance premium setting is urgently needed in Ekiti State. It recommends annual actuarial reviews as a mandatory governance requirement for the scheme.

Keywords: social health insurance, Ekiti State, sustainability, premium adequacy, actuarial assessment.