By Benson N. Akpan

For the ordinary Nigerian, the true test of health insurance is not the sophistication of a policy, the number of agencies involved or the size of an enrolment database. It is what happens when illness strikes.

It is whether a pregnant woman in distress can receive emergency treatment without first looking for money. Whether a father can take his sick child to hospital without fearing that the medical bill will wipe out his savings. Whether an enrollee who has been denied a service can get a response quickly. And whether the hospital itself has enough confidence in the insurance system to continue providing quality care. By these practical measures, Nigeria’s health insurance system is beginning to change.

The transformation is still a work in progress, and the country remains a long way from universal health coverage. But the figures, reforms and interventions under the current leadership of the National Health Insurance Authority (NHIA) suggest that a stronger foundation is being built — one that could significantly improve the prospects of health insurance in Nigeria.

The progress has also received recognition from the highest level of government. On May 29, 2025, marking the second anniversary of his administration, President Bola Ahmed Tinubu specifically listed the expansion of health insurance coverage among his government’s achievements. In his anniversary address, he stated: “We have expanded Health Insurance Coverage from 16 million to 20 million within two years.”

As NHIA Director-General, Dr. Kelechi Ohiri, puts it, “The fundamental issue is how healthcare is financed.” When people have to find money at the point they become sick, the financial consequences can be severe, particularly for poorer households. Insurance pools risk so that the cost of illness is not borne entirely by the individual at the moment of need.

That philosophy is reflected in the numbers. NHIA coverage increased from 16.2 million people in the fourth quarter of 2023 to 22,025,342 by the first quarter of 2026 — a 35 per cent increase. The significance is not merely that more people are registered, but that the architecture supporting coverage is becoming stronger.

One of the most consequential changes is the requirement that patients should not be left waiting indefinitely for insurance authorisation before receiving care. Under the one-hour rule, hospitals must treat patients immediately in emergencies without waiting for HMO authorisation. For general consultations requiring authorisation, HMOs are expected to issue codes within one hour. If the deadline is exceeded, hospitals are required to proceed with treatment, while NHIA inspection and enforcement teams monitor compliance.

As Ohiri explains, “In an emergency, the patient should receive appropriate attention promptly. An insurance administration process should not become an obstacle to emergency treatment.” The difference can be enormous when a patient is bleeding, in labour, seriously injured or suffering a life-threatening condition.

The Authority is also becoming more systematic about problems encountered by enrollees. In 2025, 3,878 complaints were resolved, giving an overall resolution rate of 87 per cent. Sixty-two per cent were resolved within 48 hours and 95 per cent within 21 days. Some cases were escalated for enforcement, facilities suspended and more than ₦14 million refunded to affected enrollees.

There is another side to making insurance work: healthcare providers must be able to deliver services sustainably. For 12 years, provider payment rates had remained unchanged. The current review resulted in a 93 per cent increase in capitation and a 378 per cent increase in fee-for-service payments. If providers are consistently reimbursed below the cost of care, the pressure eventually reaches patients through reduced services, declining quality or unauthorised charges. The tariff review is therefore an attempt to make the insurance market more sustainable.

Perhaps the strongest indication that the system is moving beyond statistics is the increasing attention to Nigerians who are least able to pay for healthcare. The Basic Health Care Provision Fund (BHCPF) provides a mechanism for subsidising insurance coverage for vulnerable people. By the first quarter of 2026, 2,450,204 beneficiaries had been covered and verified with NIN, while cumulative disbursements since inception stood at ₦118.2 billion.

As Ohiri observes, “If somebody is too poor to contribute to their own health insurance, asking them simply to pay a premium doesn’t solve the problem.” There must be a mechanism for subsidising their coverage. That is the principle behind financial protection: the people who are most vulnerable should not be the people most exposed to catastrophic medical bills.

The informal sector remains one of the biggest challenges to universal coverage. A trader, farmer, artisan or small-business owner does not have the payroll structure through which a formal-sector worker can automatically enter an insurance scheme. The NHIA’s self-service electronic portal, launched in September 2025, allows Nigerians to enrol, add dependants and change healthcare providers electronically. The Authority is also working with the National Identity Management Commission to help people without NINs overcome an important barrier to enrolment.

It is part of a larger institutional change. The NHIA Act of 2022 transformed the former NHIS into an authority with a broader mandate to promote, regulate and integrate health insurance. Since then, provider accreditation, regulatory frameworks and enforcement have been strengthened, and all states now have State Social Health Insurance Agencies. This is perhaps the less visible but most consequential part of the reform: building an institutional architecture capable of sustaining health insurance beyond individual programmes or administrations.

The Federal Government’s wider health reform agenda has provided important political backing. Coordinating Minister of Health and Social Welfare, Professor Muhammad Ali Pate, has described the objective in human terms: “At the heart of our next phase of transformation is a simple but urgent mission: to save lives, to reduce both physical and financial suffering, and to deliver health for all Nigerians, without leaving anyone behind.”

The progress is significant and, just as important, NHIA is working hard to boost and sustain it. But problems remain. More than half of Nigerians are still outside the NHIA coverage figure, while the informal sector, sustainable financing, quality of care and fragmentation remain substantial challenges. The 2030 universal health coverage target will require faster expansion and continued improvements in services.

But there is a difference between having a system that is stagnant and one that is moving and gathering momentum like the NHIA under its current management. Ohiri is clear about what should be the priority – expanding insurance coverage to reduce the vulnerability of Nigerians to rising healthcare costs.He has consistently framed the ultimate objective in terms of financial protection. “No Nigerian should have to sell property or borrow money in the middle of the night to save his life.”

The good news is that the foundations are stronger: coverage is expanding; vulnerable groups are receiving protection; providers are being paid more sustainably; hospitals face stricter obligations to treat patients promptly; complaints are generating regulatory action; and digital tools are making insurance easier to access.

If the reforms continue to deepen, if the informal sector is brought into the insurance pool, if quality keeps improving and if financing remains sustainable, health insurance can become one of the strongest instruments for making healthcare accessible, affordable and less financially devastating for ordinary Nigerians. That is the foundation now being laid. And for a country that has struggled for decades to make health insurance work at scale, the emerging direction offers genuine reason for optimism.

Akpan is a public policy analyst