When Fatima Suleiman, a civil servant in Abuja, fell sick earlier this month, she anticipated her Nationwide Well being Insurance coverage card to cowl her fundamental lab checks and consultations.
As a substitute, she was requested to pay over N15,000 out-of-pocket at a public hospital.
“They informed me the plan not covers the checks and medicines I wanted.
“I used to be shocked. What’s the purpose of insurance coverage if I nonetheless must pay every part myself?” She mentioned.
Fatima’s case will not be distinctive.
1000’s of enrollees, a lot of them, low-income employees, market ladies, artisans, and even federal civil servants, are discovering that their medical insurance playing cards not assure them entry to care.
From non-public hospitals in Lagos to public clinics in Kano, extra Nigerians with legitimate medical insurance playing cards are being pressured to pay out-of-pocket for routine providers.
This rising development exhibits a deeper drawback in Nigeria’s medical insurance system, a transparent hole between what insurers promise and what hospitals can really present.
That is primarily because of outdated cost charges, rising inflation, and delays in funds from Well being Upkeep Organizations (HMOs).
Many hospitals, already struggling financially, at the moment are rejecting sure insurance coverage or chopping down on the providers they provide, leaving sufferers to bear the price.
This exhibits a significant drawback in Nigeria’s medical insurance system: an excessive amount of concentrate on growing enrolment and conserving premiums low, and never sufficient consideration to service high quality, reasonable pricing, and sustainability.
Well being specialists say the issue lies in what number of of Nigeria’s medical insurance plans are structured.
“The system prioritized entry, getting extra folks enrolled, however ignored the rising value of healthcare and what suppliers really need to remain afloat,” mentioned Dr. Ojo Sikiru, a public well being doctor primarily based in Lagos. “We’re now paying the worth.”
Well being Upkeep Organizations (HMOs), accountable for managing enrollees’ care below the Nationwide Well being Insurance coverage Authority (NHIA), function on fastened budgets.
Though NHIA just lately elevated capitation fastened yearly funds to healthcare suppliers per affected person by 93% and fee-for-service charges by 378%, hospitals say the cash nonetheless falls brief.
With inflation and rising prices of medical gear, checks, and medicines, many hospitals say they’re left with two selections: soak up the loss or cease accepting the affected plans.
The results of paying out-of-pocket regardless of being insured is a silent breakdown of Nigeria’s medical insurance system. In some circumstances, whole HMOs have been blacklisted by hospitals. In different areas, well being suppliers supply minimal care to enrollees, fundamental consultations with out important medicine, lab checks, or specialist referrals.
“Some hospitals now say, ‘insurance coverage sufferers solely on Tuesdays,’ or they provide you fewer medicine than wanted. It’s a two-tier system: money sufferers get full care, insured sufferers get leftovers,” mentioned Dr.Ojo.
With greater than 70% of well being spending in Nigeria nonetheless coming straight from people’ pockets, the weakening of insurance coverage protection might reverse years of progress in healthcare coverage.
The insurance coverage framework prioritizes enrolment numbers that look purposeful on paper however break down on the level of care.
Below the NHIA construction, public sector employers on the federal stage are required to contribute 3.25% of an worker’s consolidated wage, whereas the worker contributes 1.75%, making up a complete of 5%.
Within the organized non-public sector, employers are anticipated to pay 10% and staff 5%, amounting to fifteen% of the worker’s fundamental wage.
Regardless that these contributions appear sufficient on paper, they usually don’t assure the standard of care.
Consequently, many well being suppliers, particularly non-public hospitals, are quietly pushing again. Some now reject sure HMOs fully, whereas others restrict the providers they provide to insured sufferers.
Within the first quarter of 2022, N16 billion was disbursed to well being services to make sure entry to high quality providers.
One other N16 billion was disbursed within the second quarter of 2022.
In 2024, the Federal Authorities of Nigeria, by the Nationwide Well being Insurance coverage Authority (NHIA), disbursed a complete of N23.92 billion.
Whereas current well being reform bulletins promise extra funding and digital transparency, analysts say the problem goes past allocation; it lies in how effectively the funds are used, how promptly they attain suppliers, and whether or not tariff evaluations match {economic} realities.
Whereas current well being reform bulletins promise extra funding and digital transparency, analysts say the problem goes past allocation; it lies in how effectively the funds are used, how promptly they attain suppliers, and whether or not tariff evaluations match {economic} realities.
Dr. Ifeanyi Okey, who works at a non-public clinic in Benin, mentioned the {economic} strain on small well being services has turn into insufferable.
