Efforts to expand mandatory health insurance across Nigeria are being undermined by persistent insecurity, inadequate funding, bureaucracy, and rising healthcare costs, stakeholders have warned.
Speaking during a panel discussion at a National Health Financing Dialogue on Wednesday in Abuja, Muhammad Safana, Chief Executive Officer of the Katsina State Health Insurance Authority (SHIA), said that while awareness of health insurance has grown since Katsina began its program in 2019, affordability and insecurity remain major obstacles to achieving universal coverage.
He explained that when the scheme was first introduced, about 97.5 per cent of the state’s population had no understanding of what health insurance meant.
“That figure has improved, with about 35 to 40 percent of residents now familiar with the concept, but between 80 and 90 percent of those who understand it are still unable to pay for services”, he said.
Safana recalled how insecurity in rural communities often disrupted enrollment drives, sometimes with tragic consequences.
He recalled that during one operation, his team were forced to withdraw abruptly after receiving intelligence that bandits were approaching the area.
“Sadly, some villagers who had come forward to enroll in the program were later attacked and killed”, he added.
The Katsina SHIA boss said that beyond insecurity, the scheme also faces funding gaps, rising healthcare costs, and shortages of health workers.
“To improve efficiency, the state developed a capitation control mechanism which dedicates most of the funds to medicines, with further provisions made for human resources, laboratory supplies, administration, and emergency reserves”, he said.
According to him, this reform eliminated frequent stockouts and improved service delivery in state facilities.
However, he stressed that the arrangement applies only to the formal sector program and does not extend to the Basic Health Care Provision Fund, which has its own rules.
Safana added that community involvement and transparency are crucial to building public confidence in health insurance.
He explained that when traditional institutions, local governments, and community leaders are engaged in running primary health centres, accountability improves.
“In Katsina, local governments are informed of every allocation to each facility so that they can track how funds are being used”, he said.
Other stakeholders at the dialogue pressed for stronger enforcement mechanisms to guarantee state compliance.
Oritseweyimi Ogbe, Secretary of the Ministerial Oversight Committee, recommended deductions at source, similar to the management of ecological funds, to secure steady health financing.
He also argued that states should domesticate health insurance laws so that finance commissioners and governors are compelled to release funds promptly.
Without legislation, he warned, enforcement would remain weak, suggesting that states which fail to comply should be publicly identified, a form of naming and shaming that could pressure reluctant governments to act.
On his part, Aminu Hassan, Executive Chairman of Jalingo Local Government, called for performance-based financing as an incentive for compliance.
He insisted that local councils must be allowed to manage their funds directly in line with the Supreme Court’s judgment on financial autonomy.
Hassan argued that states that meet their obligations should receive additional support from the federal government, while those that fall short should face consequences.
Akin Oyebode, former Ekiti State Commissioner for Finance, emphasised that subnational governments must leverage recent fiscal gains to strengthen healthcare financing.
He noted that ongoing federal reforms had grown Federation Account revenues by nearly 50 per cent year-on-year, creating new opportunities to fund health.
However, he warned that the challenge lies in translating fiscal gains into better outcomes for citizens.
According to him, while states now have more budgetary space, only a fiscal compact that ensures resources are used effectively can guarantee real improvements.
Oyebode cautioned that fragmented state-level health insurance schemes remain too weak to scale or integrate into national frameworks.
He also flagged manpower challenges, noting that sudden federal salary increases for doctors often cause state-employed medical workers to migrate to federal hospitals, leaving state health facilities understaffed.
The dialogue also discussed the Basic Health Care Provision Fund, where some participants questioned why allocations were being split among agencies beyond what the National Health Act of 2014 prescribes.
Officials clarified that subsequent legislation had created new carve-outs, including a share for the Nigeria Centre for Disease Control, but acknowledged that harmonisation is necessary to remove confusion and strengthen implementation.
Samuel Gajere, representative of the Association of Local Governments of Nigeria (ALGON), underscored their willingness to commit more funds to healthcare if granted full financial autonomy.
He described the Supreme Court’s recent ruling on local government independence as a potential turning point for primary healthcare, agriculture, and nutrition.
Gajere said that if the judgment is enforced, councils would be able to prioritise essential services without relying on state discretion.
Safana also revealed that Katsina State is working with the United Nations Children’s Fund (UNICEF), the National Population Commission, and the Ministry of Digital Economy to strengthen data systems.
“These efforts include digital birth registration, house numbering, and the introduction of proof-of-address systems, all of which will improve planning, generate revenue, and support broader healthcare reforms”, he explained.
However, participants warned that without transparency, accountability, and stronger grassroots inclusion, the new revenue streams could be wasted on populist projects instead of strengthening health systems.
They called for the creation of a health sector compact, an agreement between federal, state, and local governments to ring-fence funds for healthcare and ensure accountability, with civil society groups also playing a role in monitoring and oversight.
