Health
A Lifeline under Life Support: How National Health Insurance Scheme Robs Nigerians of Quality Healthcare
By Blessing Udeobasi
When the Nigeria Health Insurance Scheme was set up by Decree 35, of 1999, it promised to alleviate the healthcare challenges faced by millions of Nigerians. However, nearly two and half decades later, the scheme has been marked with numerous shortcomings leading to a near defeat of its purpose.
The NHIS was created to ensure universal health coverage for Nigerians, starting with federal employees and expanding to formal and informal sectors. In theory, the brilliant initiative covers a range of services, from consultations to surgeries and maternity care by pooling funds together, to provide healthcare without the financial shock associated with sudden illness or accidents.
While some Nigerians expressed sincere gratitude for a scheme of this nature, many believe that there is still much room for improvement so that the scheme can meet the needs of citizens better.
“My experience with NHIS has been fair despite its ups and downs. I’m already aware that nothing is perfect in Nigeria but I’d say they’re trying to an extent. It feels good to go to the hospital sometimes and not pay a dime,” says Ms Cynthia*, A federal government employee’s dependent residing in Nsukka.
For employees of federal institutions, both private and public, the NHIS automatically deducts a small portion of salaries to fund the scheme, while other segments of the population can voluntarily enroll. However, despite these efforts, the NHIS’s reach and efficiency are limited.In 2018, Nigeria had the third highest out-of-pocket health expenditures in the world, with 76.6% of all health spending in the country paid directly by individuals.
The World Health Organization also estimates that Nigeria has the highest out-of-pocket expenditure on health in West Africa.Our Dream NHIS Exists Only on Paper In a bid to salvage this situation and to achieve universal health coverage, former President Mohammadu Buhari, in May 2022 signed the National Health Insurance Authority Act into law.
According to the Act, each employer wishing to participate in the scheme registers with the NHIS and is assigned a registration number. They select an accredited HMO and the NHIS issues an ID card to the enrollee and their eligible dependents. The Primary Care Provider (PCP) takes care of all the primary health care issues of the enrollee based on the NHIS benefit while the HMO pays the PCP a global capitation per member every month, which has been pre-agreed.
The HMO also reimburses the specialist on the pre-agreed Fee-For-Service tariff as prescribed by the NHIS whenever the claim is presented.As revealed on the NHIS website, enrollees are entitled to benefits such as out-patient care, prescribed drugs, pharmaceutical care and diagnostic tests, maternity care for up to four live births for every insured couple in the Formal Sector Programme, preventive care, including immunization, family planning, antenatal and postnatal care, consultation with a specialist such as physicians, paediatricians, obstetricians, gynaecologists, etc., and hospital care in a standard ward for a stay limited to a cumulative 15 days per year among other benefits.
Current Reality of NHIS EnrolleesWorthy of note is the fact that it is one thing to enact a law, but another thing to ensure strict implementation across the board. This now begs the question: Is the NHIS meeting the healthcare needs of Nigerians as purported in their mission statement and guidelines? What challenges are preventing the effective implementation of the scheme? How are the failures of the NHIS impacting the health and welfare of Nigerians?
According to a 2017 study conducted by the Research Department of the Central Bank of Nigeria, limited coverage, in-extensive prescriptions, conflict of interests between the NHIS and HMOs, low participants’ coverage, issues of mistrust, total government financing limitation as well as low budget allocation compared to need, were the major issues confronting the achievement of quality healthcare delivery from the Scheme.
“One of the major challenges is that some drugs especially very expensive ones are not made available through the NHIS. Oftentimes, the hospital tells us to either pay out of pocket or buy those drugs from the market because the NHIS does not cover them. There may be other similar drugs that the program covers but in most cases, the most effective one is never covered by NHIS,” says Mr Romanus Ikeh*, a staff of the University of Nigeria Nsukka, who has been enrolled since 2016.
It is not just Ikeh who has faced similar experiences with the health insurance scheme. Ms Rita*, a stay-at-home mum resident in Anambra State told this reporter that she recently visited the hospital and the doctor prescribed a medicine worth N12,000 for her. However, when she got to the hospital’s pharmacy, she was told it was not available and that she should buy it from the market.
“Meanwhile, I saw them giving the same medicine to someone else. When I tried to find out the reason for that, I discovered that the patient they gave the medicine to was not enrolled under NHIS.” Ms Rita said. Similarly, Ms Chinenye* a nursing mother, also a resident in Anambra State said she was denied a delivery mat on one of her visits to the hospital. “When I registered for antenatal using my insurance card, one of the things the doctor prescribed for me was a delivery mat, but when I got to the pharmacy, they just gave me some of the prescribed medications and asked me to pay for the delivery mat because it’s part of surgical equipment which my HMO did not cover,” she said.
Discrimination, Nonchalant Attitude Towards EnrolleesEnrollees of the NHIS have expressed concerns over the discrimination and lackadaisical attitude displayed by NHIS staff towards them in offering healthcare services. “Their services are very poor. You go wait tire. I don’t know if they intentionally scatter patients’ folders. At the hospital where I’m currently enrolled, you’ll spend more than one hour before they even locate your file. They are not organized at all. They will just be looking for your folder everywhere, at the doctor’s office, pharmacy, or registration office. Just everywhere,” Ms Chinenye continued.“As an NHIS patient, if the doctor prescribes a high-priced medication for you, you’ll have to go through a whole lot of processes to get it.
First, they will write to your HMO to ascertain your eligibility for that medication and you will wait for hours for your HMO to reply before you’ll be attended to. And probably, by the time your HMO is sending the referral code, the hospital may have closed for the day. There’s this medicine called MMR vaccine, I needed two doses for my son and it was around N16,000 each. They delayed me for several hours in the name of getting a referral code,” Chinenye added.
For Cynthia, It all depends on the hospital one is enrolled in. She told this reporter that most public hospitals are guilty of neglecting or discriminating against NHIS patients while they give better attention and service to non-NHIS patients. However, she added that private hospitals tend to treat patients better. Even when they discriminate, they don’t do it with impunity as in public hospitals. “I noticed that sometimes when you bring your child to the hospital for a presumed ‘minor illness’ like cough or headache, they don’t take you seriously because they think you’re abusing the insurance and that the sickness is not serious enough to warrant a hospital visit. That’s the kind of attitude we usually face as NHIS enrollees”, Cynthia continued.
The experiences of Chinenye, Cynthia, and Romanus corroborate the findings of a recent study which revealed that academic staff find it difficult to utilize the NHIS due to inadequate staffing, poor management, and negative attitude of health workers.
Way Forward The National Health Insurance Scheme was envisioned as a solution to Nigeria’s healthcare challenges, but it is clear that the system is struggling to live up to its promise. The current economic reality of Nigeria, characterized by inflation, depreciating naira, and rising living costs, has significantly impacted the efficiency of the scheme in several ways. This puts pressure on healthcare providers participating in the NHIS. Many hospitals are forced to either increase out-of-pocket charges for patients or reduce the quality and availability of services covered under NHIS to cope with rising operational expenses.
Essential services like medications, diagnostics, and treatments that should be fully covered are often inadequately provided, leading to a gap between the scheme’s promises and its actual service delivery.In May 2024, the Association of Nigeria Private Medical Practitioners (ANPMP) issued an ultimatum threatening to pull out of the national health insurance scheme indefinitely starting from August should the NHIA fail to adjust the Fee-For-Service tariff, which has remained at N750 for the past 12 years.“We have resolved that within the next three months if we don’t get a proper and equitable review of the national health insurance scheme tariff, we are going to boycott that scheme until further notice,” Kay Adesola, the Association’s president told BusinessDay.
For the NHIS to truly fulfill its promise, more funding is necessary to improve health infrastructure. Much of this funding should not only come in the form of budgetary allocations but also an upward review of the tariff paid to hospitals for the services they render to NHIS enrollees.
There is also a need for better monitoring of the scheme’s implementation to ensure that funds meant for healthcare are not diverted elsewhere. Strengthening partnerships with private healthcare providers and leveraging technology to streamline service delivery could also play a key role in improving the scheme.
N.B: Sources’ names have been changed to protect their identities
The Federal Government has intensified emergency measures to contain the possible spread of Ebola Virus Disease in Nigeria, with plans to establish treatment and isolation centres in states hosting designated ports of entry.
The development follows an increase in the number of persons identified as contacts of Nigeria’s confirmed Ebola patient from 44 to 53.
The national incident management system has also been activated under the coordination of the Minister of Health and Social Welfare, Prof Muhammad Ali Pate.
The confirmed case involves a woman who travelled to Nigeria after visiting Uganda, following an earlier trip to the Democratic Republic of the Congo.
She reportedly developed symptoms on October 7, sought medical attention in Abuja on October 11 and tested positive for the Bundibugyo strain of Ebola on October 20.
The World Health Organisation is investigating the possible source of the infection.
Health authorities have urged Nigerians to remain calm, maintain proper hygiene, avoid direct contact with the bodily fluids of suspected Ebola patients and promptly report suspected infections.
The NCDC also warned against stigmatising persons undergoing monitoring, stressing that public cooperation, early detection and effective contact tracing remain critical to preventing further transmission.
The woman who tested positive for Ebola in Nigeria has been identified as the wife of a Swiss diplomat stationed in Abuja, with preliminary investigations suggesting that she contracted the deadly virus during a recent trip to Uganda.
According to Reuters, Switzerland’s Federal Department of Foreign Affairs confirmed on Thursday that the 42-year-old Ugandan-born woman tested positive on October 20, marking Nigeria’s first confirmed Ebola case in over a decade.
The Swiss authorities disclosed that the patient had spent approximately one week receiving treatment at a private hospital in Abuja after developing symptoms before laboratory tests confirmed the infection.
The ministry explained that the woman was believed to have contracted the virus during a visit to Uganda about two weeks earlier.
Her husband, who accompanied her on the trip, has since been placed in isolation as a precautionary measure, although he has not exhibited any symptoms of the disease.
However, uncertainty remains over the actual source of the infection, as international health agencies intensify efforts to reconstruct the patient’s travel history and identify possible exposure routes.
Ugandan authorities had suggested that the woman visited eastern Democratic Republic of the Congo before travelling through Uganda, but the World Health Organisation (WHO) and Africa Centres for Disease Control and Prevention (Africa CDC) said the claim had not been independently verified.
Africa CDC official Wessam Mankoula disclosed during an online briefing that Nigerian and Ugandan health authorities were exchanging information to establish the patient’s movements.
He maintained that there was currently no validated evidence confirming that the woman travelled to the Democratic Republic of the Congo.
Providing further clarification, WHO Representative in Nigeria, Pavel Ursu, said available records indicated that the patient travelled to Uganda on September 16 and returned to Abuja on October 3.
Ursu also confirmed that the woman remained hospitalised, adding that medical indicators showed signs of improvement.
Meanwhile, WHO Emergency Response Manager Patrick Otim said investigations were continuing to establish where the infection originated and identify health facilities the patient visited after developing symptoms.
The Nigerian case has been linked to an outbreak involving the Bundibugyo strain of Ebola, first reported in the Democratic Republic of the Congo in May.
Ebola is transmitted through direct contact with the blood or bodily fluids of infected persons, including deceased victims. Common symptoms include fever, vomiting and diarrhoea, while severe infections can result in death.
Health authorities are currently tracing the patient’s contacts and reviewing her movements to identify individuals who may have been exposed and prevent further transmission of the virus.
The Enugu State Government says it has strengthened its disease surveillance and puts health officials on alert within the 17 council areas in the state.
The Commissioner for Health, Prof. George Ugwu, said this on Wednesday in Enugu during a press conference on Actions of the State Government in Response to Confirmed Case of Ebola in Abuja.
Ugwu said that following the confirmation of the case, the government had reactivated and strengthened the Enugu State Public Health Emergency Operations Centre (PHEOC) to coordinate preparedness, surveillance and response activities.
“Specifically, the State has intensified disease surveillance across its 17 Local Government Areas and strengthened coordination with relevant agencies and partners.
“Surveillance activities around the Akanu Ibiam International Airport are also being strengthened in collaboration with Port Health Services and other relevant stakeholders.
“The state is further maintaining its Rapid Response Teams and relevant technical personnel on standby, while preparedness measures are being reviewed to ensure that the state is able to respond promptly should a suspected case be identified.
“Public awareness and risk communication activities are also being strengthened to ensure that members of the public receive accurate and timely information,” Ugwu, who is a Member of Presidential Committee on Ebola Prevention, said.
He said that health ministry would continue to work closely with Federal Ministry of Health and Social Welfare, its agencies and other partners to ensure effective preparedness, early detection, appropriate response and timely communication
The commissioner said that the government considers the health security of the state’s residents as a major priority and had taken appropriate precautionary measures without creating unnecessary fear or panic.
He urged health workers to maintain a high index of suspicion, strictly observe infection prevention and control measures, use appropriate protective equipment, and promptly report any suspected case through the established channels.
According to him, the government will continue to provide the necessary support and guidance to ensure health workers safety and effective response.
“To the good people of Enugu State, I urge you to remain calm and vigilant. There is currently no confirmed case of Ebola in Enugu State, and the measures being taken are precautionary.
“The public is advised to maintain good hand hygiene, avoid contact with the body fluids of sick persons, seek medical attention promptly when necessary, and report suspected sick person,” he said.
He specifically urged public and private health facilities across the state to remain on heightened alert and maintain a high index of suspicion for suspected cases, particularly among persons with relevant travel or exposure history.
“All suspected cases should be promptly isolated and immediately reported to the appropriate Disease Surveillance and Notification Officer (DSNO) or the State Public Health Emergency Operations Centre, while strict infection prevention and control measures are observed.
“I urge all health facilities to cooperate fully with the Enugu State Ministry of Health and other response agencies, as early detection and prompt notification are critical to preventing transmission,” he said.
It would be recalled that state government, through the Ministry of Health, for months had been undertaking Ebola Prevention Preparedness mesdures at Akanu Ibiam International Airport, Enugu, which is an international entry point.
The current Ebola Prevention measures at the airport is undertaking with collaboration of the Nigeria Centre for Disease Control and Prevention (NCDC), Federal Ministry of Health and Social Welfare, Port Health Services, airport authorities and other relevant partners.
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The Enugu State Government says there is no confirmed case of diphtheria in the state, urging residents to disapprove unfounded ongoing rumours.
The Commissioner for Health, Prof George Ugwu, made the clarification in a briefing on Wednesday in Enugu on update on the rumoured suspected case of a diphtheria patient in University of Nigeria Teaching Hospital (UNTH), Ituku/Ozalla, Enugu.
“In response to this, the Public health and Surveillance unit of the State Ministry of Health are already at alert and to ensure appropriate prevention control measure and early detection as may be necessary.
“A few days ago, there was a report of suspected case of diphtheria at the University of Nigeria Teaching Hospital (UNTH), Enugu which was followed by our team.
“However, the diagnosis of diphtheria could not be sustained or confirmed; while the patient, wito was rumoured and suspected to have diphtheria,
had tonsillitis,” he said.
The commissioner noted that accordingly, contact traces and other appropriate measures are ongoing and “yet diphtheria are not diagnosed or confirmed in the state.”
He explained that the suspected patient had been traced to his home in Achara Layout in Enugu and he did not have any record of travel and had not being to the northern part of the country as rumoured.
“Our surveillance and tracing teams have also contacted his family members and others but no trace of diphtheria established,” he said.
Ugwu noted that although the state had remained on high alert against infectious diseases, “Enugu State is never at high risk of contacting diphtheria”.
“For the state, we have a robust routine and mop up vaccination especially on Penta 3, which provides effective immunisation against diphtheria for a whole life time.
“In 2026 Vaccination, we had 91 per cent record of coverage on Penta 3 vaccination, which is even above the national target or threshold,” he said.
The commissioner urged residents to remain calm and avoid spreading rumours or unverified information as well as seek medical attention promptly if they develop symptoms of any sickness.
He said, “The ministry is calling on parents and caregivers to ensure children are fully immunised with diphtheria containing vaccines (Penta 3).
“Residents are urged to follow the advice of health authorities during contact tracing and monitoring.
“Healthcare workers are urged to maintain appropriate standard precautions, promptly notify suspected cases through the surveillance system and ensure appropriate infection prevention and control measures.
“The Enugu State Ministry of Health, in collaboration with UNTH and relevant international partners, continues to monitor the situation and will be proactive for further information as necessary,” he added.
It would be recalled that there is an outbreak of diphtheria in Nigeria and 19,799 suspected cases sent to molecular laboratory test; with 15,309 confirmed cases and 517 confirmed death across 26 states and 357 Local Government Areas.
The worst affected states accounting for over 98 per cent cases of diphtheria are Kano, Bauchi, Borno, Kastin, Sokato, Zamfara, Kaduna and Plateau according to Nigeria Centre for Disease Control and Prevention (NCDC).
Diphtheria is a serious but vaccine preventable bacterial disease that can spread though respiratory droplets and close contact.
Symptoms of Diphtheria include: fever, sore throat, difficulty or pain when swallowing, cough, difficulty breathing, swelling of the neck and greyish/white membrane in the throat.
The University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu State, has urged patients, visitors and members of the public to remain calm following the management of a clinically suspected case of diphtheria at the hospital.
The reassurance followed concerns over the admission and subsequent death of a paediatric patient at the hospital’s Children’s Emergency Room (CHER).
According to a statement issued by the hospital management on Wednesday, the patient received medical intervention immediately after admission but died two days later despite efforts by the attending medical team.
The hospital said a subsequent clinical post-mortem review suggested that the severe symptoms may have been caused by severe pharyngotonsillitis with massive exudate, rather than diphtheria as initially suspected.
However, as a precautionary measure, UNTH said comprehensive contact tracing had commenced to identify and monitor individuals who may have had close contact with the deceased.
The hospital also confirmed that the Children’s Emergency Room had undergone standard decontamination in line with established infection prevention and control protocols.
UNTH said it had previously managed sporadic cases of diphtheria successfully and possesses the specialist personnel, isolation facilities and medical equipment required to manage infectious disease cases.
The management urged members of the public to remain vigilant for symptoms associated with diphtheria, including persistent fever, severe sore throat and difficulty swallowing.
It advised anyone experiencing such symptoms, as well as parents whose children develop them, to seek immediate medical attention at a recognised healthcare facility and avoid self-medication.
Healthcare workers, patients and visitors were also advised to maintain proper hand hygiene and respiratory etiquette while within the hospital premises.
The hospital management assured the public that it would continue to prioritise community safety and public health, while providing updates based on verified medical information.
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