Prior to his appointment in October 2023 as the Director General and Chief Executive Officer of the National Health Insurance Authority (NHIA), Kelechi Ohiri was the Chief Strategy, Policy, and Innovation Officer at GAVI, the Vaccine Alliance. He is a public health expert whose career interests have spanned clinical medicine, health policy, and strategic leadership. In these, he has held prominent positions.
At NHIA, Ohiri is leading a mission to provide accessible, affordable, and quality healthcare to all Nigerians through a revitalised public-private partnership framework to achieve Universal Health Coverage (UHC) in Nigeria.
“On integration, there’s the challenge of harmonising the national health insurance system with state health insurance schemes, the private sector-led insurance systems and the schemes of other organisations in the insurance value chain.”
In this exclusive interview with a BusinessDay team, led by its General Manager, Bashir Ibrahim Hassan, Ohiri discusses the systemic challenges facing the NHIA and the agency’s response through deliberate policy reforms and other initiatives, including actions to enforce mandatory and equity-based health insurance for all Nigerians.
What accomplishments stood out in your career before you came on board the NHIA ship?
These are in terms of what we’ve done and the impact it’s had on people. My role was to develop GAVI’s strategy. It was called GAVI 6.0, which is essentially GAVI’s strategy for 2026 to 2030. We successfully landed that, and that built on many elements.
One element was an unprecedented amount of new vaccines introduced globally, including the fact that over 1 billion children have been immunised thanks to GAVI and the countries that work with it. The second thing was really the fact that GAVI began to strengthen health systems by strengthening the vaccine supply chain across the country.
The third thing was that we began to rethink the success of GAVI’s model, and that is the fact that it enables countries to build sustainability by paying progressively for the cost of vaccines until they “graduate”. And so revising and reviewing that in light of the kind of challenges the countries were facing was also something that was on my desk. And, finally, we were looking at shaping vaccine markets. We saw how GAVI was able to negotiate during COVID for low-income countries to have access to COVID vaccines. And the model continues to work with industry and other stakeholders to ensure that, at the end of the day, by aggregating demand and pooling procurement, the unit cost of the vaccines is much cheaper, and that the poorest countries are subsidised and countries can pay progressively based on the level of their income.
By creating that market and creating that financing mechanism, vaccines are made accessible to all. That was the model, and my job as Chief Strategy Officer was to bring that together to see how we could guide GAVI into the next five years in a world post-COVID, where things had changed all over the world. That was what I was doing when the announcement came, and I was able to land that with the board in December before starting this role.
What was your assessment, generally, of the extent to which NHIA was discharging its constitutional mandate? What has changed with your assuming its leader?
First, we know that the macroeconomic situation has not been good for many countries post-COVID. As if that was not serious enough, Nigeria has been grappling with economic challenges, including issues around currency devaluation and high inflation that have eroded spending power. That meant there was a lot more health poverty: if you don’t have money, you can’t afford health care. It was very clear that out-of-pocket expenditure in Nigeria was really high at about 70 percent. That means 70 percent of the population pays for health care by themselves, and by paying out of their pockets.
The second part of health poverty also meant that there were those who previously could pay for their care out of their own pockets and could afford it, but they are one major illness away from being plunged into poverty because of the cost of care. Owing to medical inflation, we saw medical care costs rise and drug prices rise. So, the cost of delivering care became very unaffordable to even those who previously could afford it.
People started looking and asking themselves why they have to pay so much for health care when there is an organisation called NHIA that’s supposed to address this.
We also met an organisation whose mandate had changed. In 2022, the NHIA Act was put in place that gave it a role to not just regulate, but also to promote insurance and to integrate it (into the healthcare delivery system). The regulatory aspect was really important because health insurance evolved in Nigeria first through the private sector, and there was no clear framework for how you regulate the sector. This lot fell on NHIA to regulate and bring some sort of order to that industry.
The promotion role was really important because there was very low awareness of health insurance. In fact, people don’t even understand it, even when they know it’s there. Health insurance means different things to different people. Some people feel that by buying (health) insurance, they’re inviting evil or sickness to themselves.
It’s very important to create awareness, but by creating awareness about how insurance works. Insurance doesn’t mean we’re walking into a place that’s free. We’ve tried free programmes in Nigeria politically across the spectrum, and it never works because someone has to pay for the care, even if it is not the patient who pays for it. And when we say free care without it being matched with resources, it’s a recipe for disaster. So, explaining how insurance works is also really important.
On integration, there’s the challenge of harmonising the national health insurance system with state health insurance schemes, the private sector-led insurance systems and the schemes of other organisations in the insurance value chain. So, for the synergies to be achieved, an integrated mechanism needed to be put in place to reduce the fragmentation that exists and the inefficiency to create a more sustainable industry.
This new organisation needed to step up to the task that it had been entrusted with. And we had a population that was very restless, asking more and more questions. A lot of people who couldn’t afford health care saw a rise in health care costs. That created a storm that we walked into.
However, the situation was helped by Mr. President having signed a compact between the federal government and the states, with his signing into law the Health Sector Renewal Investment Initiative that is championed by the Coordinating Minister for Health and Social Welfare.
We began to develop a sector-wide approach to have just one plan, one form of accountability for the system. He articulated a very clear vision of what he wanted the health system to be. This, together with Mr President’s full backing for our journey towards UHC, provided the strategic direction. This ended the chaos that we met.
What vision did you come up with, and what plan do you have to deal with all these many problems that you have inherited?
Thank you for that. When I got into this place, the first thing to do was to first engage and listen to stakeholders to understand the entire ecosystem and what the issues are. So, starting with my team internally, we had management meetings for about three days just to get an understanding of the challenges facing the institution.
Secondly, we began to engage with different stakeholder groups, other health insurance entities, state health insurance agencies, private health insurance, the HMOs as they are called, other civil society, the ministry and other people, just to get a better sense of the lay of the land, and to also understand the policy space and the authorising environment in which we can make change. So about a year ago, we set out a strategy. And of course, the ultimate goal of NHIA is to enhance financial access to good quality healthcare for all Nigerians. And that’s where we want to get to.
We laid out four strategic pillars to help us get here and three enablers for our own institutional transformation. Those four things are coverage, equity, quality and sustainability. On coverage, when we came in, there were roughly about 16 million Nigerians covered by health insurance, by any form of health insurance.
In my view, there were three things that needed to be done to expand that coverage. The first thing was to make it mandatory; the second thing was awareness. And the third thing was to rebuild trust, which has been broken in the past.
We began conversations first with the Attorney General and then with the office of the SGF to understand how we can take a whole-of-government approach to implementing and enforcing the mandate. It is not something NHIA alone can do; we have to depend on other MDAs. working through how to make sure insurance is mandatory. Nigeria has a large informal sector, so it makes it tricky to enforce anything, even taxes. We are now doubling down on how we are going to work with the informal sector and organise the informal sector in order to bring people into the scheme.
How are you doing this, bringing the disorganised informal sector?
We have revised the guidelines for the Basic Healthcare Provision Fund to ensure that more money goes to covering the poor. We’re working with the states to identify the poorest people to make sure that they are enrolled. We have designed a benefit package and revised it to make sure the minimum basic care is provided.
How many have you added to the insurance net since you took over? How much should we expect to see, and when and how can Nigeria reach this target?
Under the leadership of Mr President and his commitments, the numbers have grown from about 16.7 million to, let’s say, 20 million, roughly 3 million people in the last year.
When we started, we were given a target, which is a 20 percent increase by 2027. We’ve exceeded the target for 2025, and we are at the 2026 target. But those targets don’t mean anything if there are still Nigerians out there who have not been covered. It’s not going to be a linear increase; it’s going to require unlocking a few things that will drive growth.
I would like to know your top three priorities – what should Nigerians expect?
My first priority would be an equity-based increase in coverage, which means that coverage increases, but not just for the wealthy, but includes the poor and underserved. That would be my top priority, and people know that.
My second priority would be to improve the quality of care that we purchase through health insurance. The strategic purchasing aspect of our work is making sure that the experiences that enrollees have in accessing good-quality care are improved. And that is by ensuring that HMOs and providers act right when it comes to our enrollees, and that NHIA will continue to push actuarially determined premiums that make sense for Nigerians, so the quality of care that enrollees get is better. It means that if you treat them badly, we will come for you. Rebuilding that trust is critical. That’s the compact we have, because if you’re covered, it must mean something.
The third thing that we must do is more internal. NHIA has to be fit for purpose for the 21st century. NHIA has to undergo its own transformation, including digital transformation, be more citizen- and enrollee-centered, and have the skills and capabilities it needs for the level of trust that we have been given to actually care for Nigerians.
What is your biggest challenge as far as the work you do is concerned?
I’ll start from the macro to the meso to the micro. On the macro, we have limited resources. The drive to coverage would have been great if the government had more money. NHIA has the ability to give you 50 million lives if the government had money to cover 50 million lives. So, there’s a macro issue about finances and about how we finance and resource health insurance. We now have to start thinking creatively and innovatively. Because no matter what you do, the yardstick with which you’ll be judged is how many people are covered. Are we ready to finance health insurance? If you give us the money, NHIA will deliver.
The second thing is that the health insurance industry is currently fragmented. If you look at benchmarks across many countries, they are not federal. They don’t have state health insurance schemes the way we do, plus almost 100 HMOs. So it’s a very fragmented system. Our political economy structures make this the case. I would have designed it differently, but this is what we have, so we must make it work. We have no excuses, no matter what it is. But it is not easy, because there will be some states that are performing better than others, as we’ve seen in everything related to healthcare in Nigeria. But this is insurance, which means everybody must be covered to the same level of coverage that we are providing in the benefit package. That means, rather than steering one ship, we have to steer about 120 ships and make sure that they are viable, that they are delivering, and that they are providing good quality services to all Nigerians.
So there is that element of a fragmented system that must be integrated. That’s why one of our three mandates is the integration of health insurance.
The last challenge, the micro, is within the NHIA. What is required to make it fit for purpose is reorganisation, which involves reskilling, restructuring, improving the welfare of staff, upskilling people and bringing in people. And that has to be done in the context and constraints of public service.
We are two or three years old as NHIA. If you’re building a new organisation from scratch, it’s easy. If you’re building a new organisation from another organisation, it’s harder – new ways of working, new structures, new mindsets, new alignments, and new skill sets to be an effective regulator. There’s a lot that has to be done.
But we have a lot of support from Mr President and the minister. We will keep doing our own part to ensure that more Nigerians are covered and that NHIA still remains the best organisation to deliver the UHC mandate for the country.
What country or countries do you see as the best example that you can model from in terms of UHC?
The first thing that you need to understand is that Nigeria is unique. There are bits and pieces of many places you can adapt. But there is a need for localisation and contextualisation. There are certain countries where certain similarities exist; Indonesia is one. It’s also big; it’s also relatively decentralised and de-concentrated. And they’ve managed to get to universal healthcare coverage. They had to implement certain reforms.
In fact, it’s one of the places that I want to take some of my team to actually see and understand the evolution of their reforms and some of the good practices. They have about 96 percent coverage, up to 98 percent in terms of insurance. But it’s not without a very significant outlay of resources to do that. So, there are things you learn from different places, but we also have to adapt it to the Nigerian context for it to work.
Where and how can Nigeria reach, like, 100 percent UHC or close to that?
There is a phrase in UHC parlance called “progressive realisation”. It’s a way to understand that there are different paths to UHC and that there are different elements of UHC.
How many have you added to the insurance net since you took over?
Under the leadership of Mr President and his commitments, the numbers have grown from about 16.7 million to about 19.7 million, roughly 3 million people, in the last year.
How much should we expect to see, and when and how can Nigeria reach this target?
When we started, we were given a target, which is a 20 percent increase by 2027. We’ve exceeded the target for 2025, and we are at the 2026 target. But those targets don’t mean anything if there are still Nigerians out there who have not been covered. It’s not going to be a linear increase; it’s going to be unlocking a few things that will drive growth.
If we are successful at the mandates, you’ll have a burst. If the awareness and working with the informal sector catch on, you’ll have a burst. What will sustain it is the integrity and the trust that when you are insured, it actually means something. That is the sustainability plan. If Nigerians don’t see value, then it just becomes a tax, and they will still seek health care from other sources.
So that’s why I said progressive realisation is not just about increasing your numbers or increasing the scope of what is covered. It means that for the benefit package that has been carefully defined, we are making sure that the poor and vulnerable are explicitly in our target. That is the way we are progressively doing ours in Nigeria.
There’s an equity mandate, there’s a benefit package, there’s a focus on primary care, and it’s a mixed system comprising the public sector (national, subnational) and the private sector. You don’t see this in many countries coexisting. But in Nigeria, the question now is, how do we bring out the best so that we are greater than some of our individual parts? And to minimise the fragmentation we have, which is where that role as an integrator of health insurance comes in.
