“The gap between what the law promises and what hospitals deliver could not be wider. This is not isolated. In too many public hospitals, it is an accepted practice.”
The following scenario is a composite drawn from countless Nigerian experiences…
She arrived at a teaching hospital with a referral for emergency surgery. At the gate, a security guard asked for “something for the boys.” At records, a clerk demanded ₦2,000 for a folder. The nurse mentioned a “materials fee” payable in cash. An orderly suggested extra payment might ensure prompt attention.
Silent Extortion In Public Hospitals
By morning, the unofficial charges rivalled the official bill. No receipts. No certainty. No option but to pay.
She was a civil servant enrolled under the National Health Insurance Scheme (NHIS).
The NHIA Act 2022 prohibits providers from demanding extra payments for services already covered by the insurance package, under the established quality standards. Yet, she paid — because enforcement remains extremely weak, and patients have no practical way to assert that right.
The gap between what the law promises and what hospitals deliver could not be wider. This is not isolated. In too many public hospitals, it is the accepted practice.
The Scale Of The Silence
According to the World Health Organisation, approximately 70 per cent of Nigeria’s health expenditure is out of pocket – one of Africa’s highest rates. A 2023 national survey found that 51.27 per cent of households acknowledged making informal payments in public facilities.
The amounts vary: a few thousands naira for quicker attention, or tens of thousands for surgery, maternity, or emergency care.
Patients who encounter informal charges are significantly more likely to delay or abandon treatment. The result is a system where access depends on navigating unofficial financial demands.
Anatomy Of Informal Payments
These payments occur at every stage. Before treatment, to reduce waiting times. During treatment, for supplies or consumables. After treatment, as gifts for future favours.
Not every demand arises from greed. In some facilities, patients buy gloves or syringes because hospital stores are empty – procurement has failed. The line between corruption and survival blurs when both healthcare workers and patients improvise around chronic shortages.
But the central fact remains: patients should not bear institutional failure through unauthorised charges. Yet, that is precisely what happens.
A Financing Problem Disguised As Corruption
Informal payments are a corruption issue. But they are also a symptom of a deeper health financing crisis.
When 70 per cent of health spending comes from household pockets, unofficial charging becomes predictable. Healthcare workers point to inadequate salaries. Hospitals point to insufficient budgets. Patients navigate the gap between what care formally costs and what it actually requires.
None of this justifies extortion. But it explains why informal payments persist, despite the anti-corruption rhetoric. A chronically underfunded system creates fertile ground for unofficial transactions.
The Legal And Institutional Vacuum
Nigeria has relevant laws. The National Health Act 2014 contains patient rights provisions. The ICPC Act prohibits bribery. The EFCC Act addresses financial misconduct. But none specifically defines or prohibits informal healthcare payments. The National Health Act does not mention informal charging or establish penalties for it.
Enforcement is sporadic – not because agencies are unwilling, but because their mandates focus on large-scale corruption, not the diffuse, low-level demands that characterise hospital extortion. The problem falls between legal categories: too routine for major anti-corruption action, yet too harmful to ignore.
Effective reporting mechanisms are absent. Patients fear retaliation. Healthcare workers who object face isolation. The result is a culture of silence.
Hospital administrators rarely authorise unofficial payments formally. Yet many operate in environments where the practice is widely known and seldom sanctioned. A patient cannot pay unofficial fees at multiple points without broader organisational failure. Accountability cannot stop with frontline workers. The system must examine the institutional conditions that allow the practice to flourish.
The Gender Dimension
Women seeking maternal care face the highest rates of informal payment demands. Studies show catastrophic gaps in prenatal care access between wealthy and poor women – 95 per cent versus 37 per cent. The woman in labour who is asked for cash before receiving delivery services is not merely being extorted; she is being denied dignity at the most vulnerable moment of her life.
The Dignity Imperative
Section 34 of the Constitution guarantees human dignity. While the commitment to adequate healthcare appears in the Directive Principles (non-justiciable), it sets a governance standard. Nigeria is also a party to the African Charter on Human and Peoples’ Rights (Article 16), which recognises the right to health.
Access to healthcare should depend on medical need – not on a patient’s ability to negotiate unofficial payments.
When a pregnant woman pays unofficial charges during labour, when an elderly patient must provide cash before treatment, the issue becomes a question of justice. The patient becomes a source of revenue in a system that monetises vulnerability. That is a dignity failure.
Towards Meaningful Reform
First, amend the National Health Act to define and prohibit informal healthcare payments explicitly, with protections for reporters.
Second, improve health financing. Review insurance reimbursement and provider payment rates to reflect actual costs.
Third, require every public hospital to publish clear fee schedules and maintain accessible complaint channels.
Fourth, establish independent patient ombudsman offices in tertiary hospitals nationwide. (Lagos State’s HEFAMAA offers a model that should be replicated across the country.)
Fifth, expand electronic payment systems and minimise cash transactions. Transparency reduces abuse.
Finally, ensure fair remuneration and institutional support for healthcare workers. Sustainable reform cannot ignore their economic realities.
Know Your Rights
You are entitled to a written receipt for every payment. No receipt means no proof – and no accountability.
If a healthcare worker refuses to treat you without an unofficial payment, document names, dates, amounts, and conversations. Report to the ICPC, EFCC, or your state Ministry of Health.
NHIS enrollees: The NHIA Act 2022 forbids providers from imposing extra charges for covered services, but enforcement is weak. If you are asked to pay, complain to your HMO and the NHIA – and keep records.
Ask for a written fee schedule before agreeing to any payment.
Keep records of all payments, official and unofficial.
The Bottom Line
Informal payments thrive in silence. They survive because patients fear losing care, workers fear economic hardship, and institutions fear confronting truth.
Yet silence costs us dearly.
A public hospital that routinely demands unauthorised payments undermines trust. A system that makes patients pay twice – through taxes, insurance, and then unofficial charges – betrays its purpose.
The poor patient who slips cash into a folded file is not purchasing a privilege. She is paying a ransom for a service already promised by law.
And when access depends not on medical need but on unofficial payment, the victim is not merely the patient. It is the rule of law itself.
•Sanu is a Nigerian lawyer and health law scholar. This column breaks down complex health laws for everyday Nigerians.
