Health insurance in Nigeria: Findings from the People's Voice Survey

Using 2023 People's Voice Survey data, this paper reveals that while health insurance in Nigeria significantly improves access to care and preventive services, coverage remains critically low at 2% and is disproportionately concentrated among socioeconomically advantaged groups, failing to reach the broader population needed to address systemic health funding challenges.

The Gist

Imagine Nigeria's health system as a massive, bustling city with millions of people trying to get medical care. For a long time, this city has had a major problem: getting sick is incredibly expensive, and the public hospitals (the "city-run" clinics) are often underfunded and crowded. To fix this, the government tried to build a "safety net" called Health Insurance, hoping it would catch everyone before they fell into financial ruin.

This paper is like a snapshot photo taken in 2023 to see how that safety net is actually working. The researchers used a tool called the "People's Voice Survey," which is basically a giant, random phone call to 2,500 Nigerians to ask, "Do you have insurance? Where do you go when you're sick? How do you feel?"

Here is the story of what they found, explained simply:

1. The Safety Net Has Huge Holes

The most shocking finding is that the safety net is barely holding anyone up.

• The Stat: Only 2% of Nigerians had the main government insurance (NHIS). Even if you count all types of insurance (private, company, community), only 7% of the population is covered.
• The Analogy: Imagine a stadium with 200,000 seats, but only 14,000 people have tickets. The rest are standing in the rain, hoping the roof doesn't leak.
• Who has the tickets? The tickets aren't being given to the people who need them most (the poor or the sick). Instead, they are mostly held by people who are wealthier and more educated. It's like a VIP lounge that only the rich can afford to enter, leaving the rest of the crowd outside.

2. The "Usual Doctor" Problem

The researchers asked people, "When you are sick, where do you usually go?"

• The Uninsured: They mostly try to use public primary care clinics (the small, local neighborhood clinics).
• The Insured: They almost never go to the small local clinics. Instead, they skip straight to private hospitals or big secondary care centers.
• The Metaphor: Think of the health system like a video game with different levels.
  • Level 1 (Public Primary Care): The starting zone. It's cheap but often lacks supplies.
  • Level 2 (Private Hospitals): The "Boss Level." It's expensive but has better gear.
  • The Twist: People with insurance have a "skip-level" cheat code. They bypass the starting zone entirely and jump straight to the Boss Level. The researchers worry this is bad because the "Boss Level" is expensive to run, and the "starting zone" (which is supposed to catch small problems early) is being left empty and underused.

3. Insurance = More Check-ups (But Not for the Right Reasons)

The study looked at whether having insurance actually helps people stay healthy.

• The Good News: People with insurance are getting more preventive screenings. They are more likely to have their blood pressure, blood sugar, and cholesterol checked. They are also more likely to have been hospitalized if they were really sick.
• The Bad News: This doesn't necessarily mean they are sicker than everyone else. In fact, the insured people reported being just as healthy as the uninsured.
• The "Adverse Selection" Myth: Usually, in insurance, people only buy a policy if they know they are sick (like buying car insurance the day after you crash). The researchers checked for this, but found no evidence that the insured people were sicker to begin with.
• The Real Reason: The insured people just have better access. They know how to navigate the system, they have the money for the co-pays, and they feel more confident going to the doctor. It's like having a key to a library; you don't go there because you're illiterate, you go there because you have the key to get the books.

4. The Big Picture: A System Out of Balance

The paper concludes that while the government has passed new laws to fix this (like the 2022 National Health Insurance Authority Act), the reality on the ground in 2023 was still very unequal.

• The Current State: The insurance system is currently acting like a luxury upgrade for the wealthy, rather than a lifeline for the poor. It is reinforcing the gap between the rich and the poor rather than closing it.
• The Future: The researchers are hopeful. They note that as of late 2024, enrollment numbers have jumped significantly (to 19 million people!). However, they warn that just having more people with insurance isn't enough.
  • The Analogy: You can give everyone a ticket to the stadium, but if the stadium seats are broken, the lights are out, and the food is too expensive, the game still won't be enjoyable. The government needs to fix the "seats" (the quality of public clinics) and the "food" (the cost of care) so that the insurance actually works for everyone, not just the rich.

Summary in One Sentence

This paper tells us that in Nigeria, health insurance is currently a VIP pass for the wealthy that helps them skip the line to better hospitals, while the poor remain stuck in the rain without a ticket, and the government is now trying to rewrite the rules to make the safety net strong enough to catch everyone.

Technical Summary

1. Problem Statement

Nigeria faces critical challenges in achieving Universal Health Coverage (UHC) and Sustainable Development Goal (SDG) target 3.7. Key obstacles include:

• High Out-of-Pocket Expenditures (OOPE): A significant burden on households seeking care.
• Underfunding: The public health sector receives a low percentage of GDP.
• Low Insurance Penetration: Despite the 2014 National Health Act and the 2022 National Health Insurance Authority (NHIA) Act, insurance coverage remains negligible. Previous data (2018) suggested only 3% of adults had coverage.
• Equity Concerns: There is a lack of recent, granular data on who is covered, whether coverage is pro-poor, and how insurance status influences health service utilization and access to preventive care.

2. Methodology

• Data Source: The study utilizes the first round of the People's Voice Survey (PVS) conducted in Nigeria in June–July 2023.
• Sampling: A random digit dialing (RDD) mobile phone survey with a total sample size of 2,555 adults.
• Languages: Interviews were conducted in Hausa, Igbo, Pidgin, Yoruba, and English.
• Weighting: To address the inherent bias of mobile phone surveys (which often oversample higher socioeconomic groups), the data was reweighted by education, age, region, and gender to represent the adult population of Nigeria.
• Analytical Approach:
  • Descriptive Statistics: Calculation of coverage rates and means for key variables.
  • Multivariate Logistic Regression: Used to estimate associations between:
    • Insurance status (NHIS, Private, None) and socioeconomic predictors (education, income, age, region).
    • Insurance status and health system utilization (usual source of care, facility visits, inpatient stays).
    • Insurance status and preventive screening receipt (blood pressure, sugar, cholesterol, eye, dental).
  • Controls: Models controlled for urban/rural residence, gender, education, age, region, and income terciles.
• Ethics: The study was deemed non-human subjects research by the Harvard T.H. Chan School of Public Health IRB as it utilized a fully anonymized, publicly available dataset.

3. Key Contributions

• Baseline Data: Provides the first comprehensive, nationally representative baseline of health insurance coverage in Nigeria circa 2023, post-2022 NHIA reforms but prior to their full implementation effects.
• Granular Utilization Analysis: Moves beyond simple coverage rates to analyze how insurance affects the type of care accessed (public vs. private, primary vs. secondary/tertiary).
• Equity Assessment: Explicitly tests whether current insurance schemes are reaching vulnerable populations or reinforcing existing inequalities.
• Methodological Demonstration: Validates the use of rapid, mobile-phone-based surveys (PVS) for tracking health system performance and insurance metrics in low-resource settings.

4. Key Results

A. Coverage Levels and Determinants

• Overall Coverage: Only 7% of the population has any form of health insurance.
  • Private Insurance: 3.6%
  • National Health Insurance Scheme (NHIS): 1.7%
  • Community/Other: <2%
• Predictors of Coverage:
  • Education and Income: The strongest predictors. Higher education (OR 5.86 for NHIS; OR 3.6 for private) and higher income are significantly associated with having insurance.
  • Demographics: NHIS coverage is positively associated with age groups 40–49 and 50–59, and residence in the North-West zone. Private insurance is associated with the South-West zone.
  • Health Status: Chronic illness and self-reported health status were not associated with insurance status, suggesting no significant "adverse selection" (i.e., sick people are not disproportionately enrolling).

B. Access to Care and Facility Utilization

• Usual Source of Care:
  • Public Primary Care: Usage is extremely low. Only 2% of NHIS enrollees and 0% of private enrollees use public primary care as their usual source, compared to 15% of the uninsured.
  • Private Secondary Care: Enrollees are significantly more likely to use private secondary facilities (41% for NHIS, 47% for private) compared to the uninsured (21%).
• Inpatient and Visit Frequency:
  • Insured individuals have higher average annual visits (2.9 for NHIS vs. 1.9 for uninsured).
  • Inpatient hospitalization in the past year was highest among NHIS enrollees (22%) compared to the uninsured (9%).

C. Preventive Screenings

• Insured individuals are significantly more likely to receive key preventive screenings (blood pressure, blood sugar, cholesterol, eye, and dental exams) compared to the uninsured, even after adjusting for socioeconomic factors.
• Example: For blood sugar screening, rates were 75% (NHIS), 74% (Private), and 44% (Uninsured).

D. Health Status

• There is no statistically significant difference in self-reported health or the prevalence of chronic conditions between insured and uninsured groups, further indicating that the current insurance pool is not driven by adverse selection based on poor health.

5. Significance and Policy Implications

• Inequitable Access: Current insurance coverage is heavily skewed toward the educated and wealthy, failing to reach the poor or rural populations who need financial protection the most.
• System Fragmentation: Insurance is driving utilization toward private secondary/tertiary facilities rather than strengthening the public primary care system. This risks exacerbating the "two-tier" system where the insured bypass under-resourced public primary care.
• Reform Context: While the 2022 NHIA Act mandates universal coverage and establishes a Vulnerable Groups Fund, the 2023 data shows these mechanisms have not yet translated into broad, equitable coverage.
• Future Directions:
  • Mandatory Enrollment: The findings support the necessity of the mandatory coverage provisions in the new NHIA Act to overcome voluntary enrollment barriers.
  • Strategic Purchasing: Policymakers must ensure that insurance funds are used to strengthen primary care and public facilities, not just subsidize private secondary care.
  • Monitoring: Rapid surveys like PVS are essential for tracking the progress of these reforms and ensuring they correct, rather than reinforce, systemic imbalances.

Conclusion: While health insurance in Nigeria is associated with increased access to care and preventive services, it currently functions as a privilege for the advantaged rather than a tool for universal financial protection. The transition from the NHIS to the NHIA offers a critical opportunity to address these structural inequities through mandatory enrollment and targeted support for vulnerable groups.