“The true measure of health insurance is not the card in a patient’s wallet, but the care waiting behind the clinic door. Nigeria has the laws. It has the policies. It has the institutions. It has the numbers. What it still lacks is the guarantee that the card in her hand means something real..”
Imagine Mrs. Halima Yusuf, a petty trader in Kano. She walked into her local Primary Healthcare Centre last month with her NHIA enrolment card. She had finally done what the government asked—registered for health insurance under the new mandatory scheme.
Her card was supposed to open the door to free maternal care, essential drugs, and emergency treatment. Instead, she was told that the clinic had no antimalarial in stock, that the midwife was on leave, and that the laboratory equipment had been broken for three months.
She left with her card in her hand and her dignity in tatters. “They counted me,” she said quietly. “But they did not care for me.”
Valid Card, Empty Clinic
Nigeria has successfully distributed millions of health insurance cards. It has not yet succeeded in guaranteeing healthcare. Having a card is not the same as having care.
The Number Behind The Promise
Two days ago, the headline was striking: 22.03 million Nigerians are now enrolled in health insurance, representing 35 per cent year-on-year growth. The Director-General of the National Health Insurance Authority (NHIA), Dr. Kelechi Ohiri, revealed this at the Annual General Meeting (AGM) of the Nigerian Association of Insurance and Pension Editors in Lagos on 8 July, 2026.
But then he said something more important than all the numbers. “The decisive variable,” Dr. Ohiri declared, “is now implementation—consistent, rigorous and accountable execution that converts political commitment into healthcare access for real Nigerians.”
That single sentence contains the entire story. The question is not whether 22 million is a good number. The question is whether Mrs. Halima Yusuf can walk into a clinic and be treated with dignity.
The Law Behind The Number
The National Health Insurance Authority (NHIA) Act, 2022, made health insurance mandatory for every person resident in Nigeria. Section 14(1) states: “Subject to the provisions of this Act, every person resident in Nigeria shall be required to obtain health insurance.” Section 14(2) explicitly includes “informal sector employees” among those residents.
This was a radical departure from the old National Health Insurance Scheme (NHIS) Act of 1999, which was voluntary and covered less than five per cent of the population—mostly federal civil servants and employees of large private firms. The NHIA Act recognised what the old scheme ignored: that the vast majority of Nigerians work outside formal employment—in markets, on farms, in workshops, and on digital platforms.
The Act also established the Vulnerable Group Fund, financed through the Basic Health Care Provision Fund, health insurance levies, special government allocations, and other sources, to subsidise coverage for those who cannot afford premiums.
And the Act rests on a constitutional foundation. Section 17 of the 1999 Constitution establishes, as a directive principle of state policy, that “the State shall direct its policy towards ensuring that there are adequate medical and health facilities for all persons.” Section 34 guarantees the right to the dignity of the human person—a right that is meaningless if a sick Nigerian must choose between treatment and starvation.
The Gap Between Card And Care
Dr. Ohiri’s announcement was not merely about enrolment numbers. He revealed that the NHIA has resolved 3,878 complaints, representing an 87 per cent resolution rate, with 95 per cent of cases concluded within prescribed timelines. More than ₦14.2 million has been refunded to enrollees. Non-compliant healthcare facilities have been sanctioned. The Authority has introduced service standards, including a one-hour target for commencing treatment for enrollees requiring urgent care.
These are welcome developments.
But they also tell us something troubling: if 3,878 complaints were lodged, how many more were never lodged because the patient simply went home? How many Mrs. Halima Yusufs walked away silently, their cards useless, their dignity bruised, too weary or too poor to navigate a complaints system they did not know existed?
The Dignity Question
Your health insurance card is not dignity. Dignity is the confidence that when illness comes, treatment will follow.
Dignity is the assurance that the card in your hand is not a piece of plastic, but a promise—a promise that the state will be there for you when your body fails you.
Dignity is knowing that the clinic you walk into has drugs, has a doctor, has electricity, and has a midwife who is not on leave.
Dignity is receiving treatment within the one-hour target, not watching the sun set on a bench until you are told to return tomorrow.
When a patient is told the clinic has no drugs, no equipment, and no staff, the card becomes a cruel joke. The state has counted you. It has recorded your name in a database. But it has not fulfilled its promise. And the dignity violation is profound.
The Vulnerable Group Fund
The Act established the Vulnerable Group Fund to cover those who cannot afford premiums—people with disabilities, children under five, pregnant women, internally displaced persons, refugees, victims of human trafficking, and other marginalised groups. The Fund is supposed to be the safety net beneath the safety net.
But in a country where budgetary releases are often delayed and counterpart funding from states is frequently not forthcoming, the Fund’s sustainability is far from assured.
A 2023 analysis by Nigeria Health Watch noted that although the NHIA Act makes health insurance mandatory, “uptake remains low and there is insufficient awareness about the programme, especially within the informal sector.” The informal sector, it noted, constituted over 65 per cent of Nigeria’s total employment at that time—a figure that has likely grown as formal job creation lags behind population growth.
The question is not whether the Fund is a good idea. It is whether the Fund is real—whether the money flows, whether the beneficiaries know they are covered, and whether the clinics they are sent to can actually treat them.
What Must Be Done
First, the NHIA must ensure that accreditation is tied to actual service readiness—not merely paperwork—and publish facility-level data on service quality, drug availability, and compliance rates. Only facilities capable of delivering the promised package should remain accredited. This would make the Authority accountable to the public and create competitive pressure for improvement—much as the Central Bank’s financial stability reports discipline the banking sector.
Second, the NHIA should publish an annual Patients’ Rights Report detailing complaints, sanctions, refunds, waiting times, and compliance rates. This would reinforce transparency and give civil society and the press the data needed to hold providers accountable.
Third, the complaints system must be accessible to the illiterate and the rural poor. A trader in Kano who cannot read English will not navigate an online portal. A farmer in Benue who has never used a smartphone will not lodge a digital complaint. Community health workers, ward development committees, and local language radio programmes must become the frontline of grievance redress.
Fourth, the Vulnerable Group Fund must be shielded from political interference and budgetary delay. The Act provides the legal framework. The implementation requires ring-fenced funding, independent auditing, and clear criteria for eligibility applied uniformly across states.
Fifth, we must resist the temptation to celebrate numbers while ignoring lived experience. The measure of success is not 22 million enrollees. It is whether Mrs. Halima Yusuf, the next time she walks into her PHC with her card, receives the care she was promised. It is whether the child with malaria gets treatment within the hour. It is whether the woman in labour finds a midwife waiting.
The Trust Question
Health insurance is sustained not only by legislation but by public confidence. Every failed encounter weakens that confidence. A patient who repeatedly encounters empty clinics, unavailable medicines, or unlawful charges stops believing in the system. And once trust disappears, enrolment eventually suffers.
If the government asks Nigerians to enrol, it owes them one thing: the guarantee that the card works. Not sometimes. Not when the clinic has stock. Every time.
A Final Thought
The true measure of health insurance is not the card in a patient’s wallet, but the care waiting behind the clinic door.
Nigeria has the laws. It has the policies. It has the institutions. It has the numbers. What it still lacks—what Mrs. Halima Yusuf still lacks—is the guarantee that the card in her hand means something real.
Dr. Ohiri was right. The decisive variable is implementation. Not the formulation of beautiful policies in Abuja, but the conversion of political commitment into healthcare access for real Nigerians—in Kano, in Benue, in every ward where a mother holds a card and hopes.
Health law is not just about statutes and enrolment figures. At its core, it is about protecting the dignity of the human person—especially at their most vulnerable.
Your health insurance card is your dignity. But only if the clinic behind the card is worthy of your trust.
Because the true measure of any health system is not the laws it enacts, but the dignity it protects.
•Sanu is a Nigerian lawyer and health law scholar. This column breaks down complex health laws for everyday Nigerians.
