Nigeria has 22 million people on health insurance. Why are millions still paying medical bills themselves?
More Nigerians are entering health insurance schemes, but high out-of-pocket spending shows that having an insurance card does not always mean being protected from the cost of illness.
For years, health insurance in Nigeria has been sold as the answer to one of the country’s most difficult healthcare problems: the amount people have to pay when they fall sick.
The idea is simple. Instead of waiting until illness arrives and finding money for consultation, tests, drugs or hospitalisation, people contribute to an insurance pool that pays for covered healthcare when they need it.
Nigeria now has more than 22 million people enrolled in health insurance, according to the National Health Insurance Authority. The figure reached 22.03 million in July, representing a 35 percent increase from a year earlier.
It sounds like significant progress. It is. But there is another number that tells a different story.
About 71 percent of Nigeria’s current health expenditure still comes directly from people’s pockets, according to the World Health Organisation. In other words, while insurance enrolment is growing, Nigerians remain heavily dependent on their own money to pay for healthcare.
The contradiction raises a bigger question: what exactly does being insured protect Nigerians from?
An insurance card does not cover everything
Health insurance is not a promise that every medical expense will disappear.
Under the NHIA system, patients can still encounter co-payments, exclusions and limits on certain services. Public insurance schemes, for example, require a 10 percent co-payment on covered drugs. Some treatments have restrictions, while services outside an enrollee’s benefit package may have to be paid for separately.
The network of approved healthcare providers also matters. An insured patient generally has to receive care from an accredited facility. If a preferred hospital is outside the network, the insurance card may not be enough to make treatment there free.
This becomes particularly important when illness is complicated or prolonged.
A routine consultation may be comfortably handled by an insurance plan. A serious condition requiring repeated tests, expensive medicines, specialist treatment or prolonged hospitalisation can expose the limits of that cover.
Kidney disease illustrates the problem. The NHIA’s published guidance places limits on dialysis coverage, meaning a patient requiring treatment beyond the covered allowance can still face substantial bills.
So the number of insured Nigerians tells us how many people have entered the system. It does not tell us how much financial protection each person actually has.
Millions are still outside the insurance net
There is an even bigger problem. More than 22 million people represents only a small proportion of Nigeria’s population.
The latest NHIA data for the fourth quarter of 2025 recorded 21.74 million enrollees. State schemes accounted for the largest share, with about 9.74 million people enrolled.
Coverage is also uneven across the country. Delta recorded about 2.93 million enrollees, while Lagos had about 2.76 million. Taraba, by comparison, had fewer than 214,000.
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The differences reflect more than population size. Nigeria’s health insurance system is increasingly dependent on the ability of states to establish functioning schemes and bring people into them.
The informal economy remains one of the hardest groups to reach. A civil servant can be enrolled through an employer and have contributions deducted regularly. A trader, artisan, farmer, driver or self-employed worker has no equivalent payroll system.
For people whose income is already uncertain, paying for insurance today in anticipation of an illness tomorrow can feel less urgent than paying for food, rent or school fees.
This is why expanding insurance requires more than telling Nigerians to enrol. Poor and vulnerable households need subsidies, while the informal sector needs affordable and practical ways to participate.
Nigeria must make insurance worth having
The ultimate test of health insurance is not how many cards have been issued. It is what happens when the cardholder gets sick.
If a patient has insurance but cannot find the required medicine, has to travel to another facility for treatment, discovers that a procedure is excluded or reaches the limit of their benefit, the financial burden simply moves rather than disappears.
The healthcare system itself also affects the value of insurance. Nigeria continues to face shortages of health workers and uneven access to functional healthcare facilities. The World Health Organisation’s Universal Health Coverage service coverage index puts Nigeria at just 38.4 percent.
At the same time, rising drug prices, hospital operating costs and medical equipment expenses are putting pressure on providers and insurers. If premiums and reimbursements do not keep pace with the cost of delivering healthcare, patients can ultimately feel the pressure through higher charges and reduced access.
Nigeria’s growing insurance enrolment is therefore encouraging, but it is only the beginning.
The country does not simply need more people to have health insurance. It needs insurance that people can trust, facilities that can provide the promised care and benefit packages capable of protecting families from the financial shock of serious illness.
Until that happens, the uncomfortable reality will remain: millions of Nigerians may have insurance, but when illness comes, many will still need their wallets.
