27 years after: Drug shortages, out-of-pocket payments dog health scheme

The National Health Insurance Scheme (NHIS) established by Decree 35 in 1999, though signed into law then, didn’t become operational until June 6, 2005 when it was officially launched. Nigeria’s National Health Insurance Scheme, now operating under the National Health Insurance Authority (NHIA), was established to make quality health care affordable and accessible to every […]

The National Health Insurance Scheme (NHIS) established by Decree 35 in 1999, though signed into law then, didn’t become operational until June 6, 2005 when it was officially launched.

Nigeria’s National Health Insurance Scheme, now operating under the National Health Insurance Authority (NHIA), was established to make quality health care affordable and accessible to every Nigerian. While the scheme has expanded over the years and increased enrolment across the country, many beneficiaries say gaps in implementation continue to undermine its objectives.

Investigations by Weekend Trust show that although thousands of Nigerians now enjoy subsidised health care through the scheme, many still struggle with shortage of essential medicines, delayed referrals, inadequate information about their benefits, long waiting hours and out-of-pocket payments for drugs and medical investigations.

 

‘Our plight’

For many enrollees,  the realities inside hospitals differ sharply from the promise of affordable health care.

Abigail Chukwudi recalled registering for delivery at a federal medical facility under the NHIS and fulfilling all the necessary requirements, including ensuring that her husband donated blood ahead of childbirth. But according to her, despite meeting the conditions, she was informed while in active labour that there was no available bed space. She alleged that repeated requests for medical attention and referral were ignored until her condition deteriorated and she insisted on being transferred elsewhere.

She said she was eventually referred to another hospital but the process lacked proper coordination. According to her, the receiving hospital was not adequately briefed about her condition, while payments made at the first facility were not recognised.

As a result, she said she had to purchase delivery materials again, pay fresh hospital bills and even make another payment for blood she believed had already been covered. She added that none of the money paid at the initial hospital was refunded.

Another beneficiary, Ada Ikenna, described her experience during childbirth as equally frustrating.

She alleged that nearly every drug, laboratory investigation and scan required during treatment was declared outside the NHIS package, forcing her family to make repeated payments.

“When I had my son, the extortion was very high. Honestly, it was a very bad experience for me. I would say the NHIS does not exist in that hospital. We were extorted,” she said.

She said a similar experience occurred during the birth of her second child.

“Literally, everything they said the NHIS did not cover. ‘Go and pay for this, go and pay for that.’ When you push further and say, ‘But this card is from the NHIS.’ They will insist you pay. We kept paying until we spent more than N300,000,” she alleged.

Another enrollee, Yunusa Hadiza, said the scheme remained useful for routine health care but fell short whenever specialised treatment is required.

She cited delays in obtaining approval from HMOs before certain procedures could be carried out, warning that such delays could be dangerous during emergencies.

“In emergencies, patients are often left on their own because approvals take too long,” he said.

Hadiza also observed that while private hospitals generally provide faster services, some are reluctant to fully accommodate NHIA patients because of concerns over reimbursement, forcing beneficiaries to spend additional money despite being insured.

Ezeh Daniella, a trader enrolled under a community-based insurance programme, said although the scheme helped reduce her medical expenses, she still paid for some laboratory tests.

For an entrepreneur, Gbenga Azeez, the greatest challenge remains bureaucracy. “You go from one desk to another before you finally get attention,” he lamented.

Some enrollees have decried poor access to essential medicines and inadequate emergency care in hospitals under the National Health Insurance Scheme (NHIS) despite the Federal Government’s huge investments in the scheme.

Other enrollees, who spoke to our correspondent in separate interviews in Abuja, expressed mixed reactions over the quality of healthcare services given, saying while some hospitals provide satisfactory treatment, while others are plagued by persistent shortages of drugs and other challenges.

A federal civil servant, Emmanuel Antswen, said his experience under the scheme had improved significantly after transferring from a government-owned health facility to a private hospital.

He said although no healthcare system is perfect, he is satisfied with the quality of care he currently receives.

“I receive good services. While nothing is perfect in Nigeria, I am grateful for the quality of care and services I have received.

“I must also state that before I transferred from a government health facility to a private one, the services I received were not satisfactory. However, since making the switch, I have experienced significant improvement in service delivery and overall care,” he said.

Antswen explained that the drugs prescribed have been effective in treating the illnesses presented, noting that he could not determine whether the drugs are substandard since he is neither a pharmacist nor a medical doctor.

He added, “Consultants attend to me, although not on every visit. My Caesarean section (CS) surgery (for my wife) was covered 100 percent. I have not undergone any other major surgery. I have not yet been referred to another facility or specialist, so I cannot comment on that for now.”

Another enrollee, Dorathy Sabo, however, lamented that the unavailability of prescribed drugs in hospital pharmacies has remained a major challenge.

“There are times you go to the hospital and they tell you they don’t have the drugs at the pharmacy, so you have to buy them outside the hospital at a higher cost.

“Though they attend to enrollees promptly, the challenge we face is getting the prescribed drugs in the hospital,” she said.

Sabo further disclosed that concerns about substandard products mostly relate to drugs that may have stayed too long on the shelves, alleging that instead of replacing them, they are dispensed to patients.

According to her, “Except if your NHIS is with a private clinic, then you can see a consultant, but once it is a government hospital, you get to see the general medical doctors like everyone else. You have to book a separate appointment to see a consultant.

“NHIS mostly covers only C-section, appendix removal and other minor surgeries. If you are going for a major surgery, then you have to pay from your pocket. Some of us hardly go to the hospital and may visit only twice in a year, but the deductions keep happening.

“The delays are not always frequent; it depends on the case. If it is a complicated case and the person has to be transferred outside the state where his or her NHIS is registered, it takes time for them to process the referrals.”

Similarly, another federal worker, Aloysius Umalo, described his experience under the scheme as disappointing, alleging that many essential drugs are unavailable in accredited hospitals.

“The answer is obviously no. The experience is so terrible that essential drugs are not found in those pharmacies. Patients are forced to buy expensive drugs outside the hospitals.

“Another nasty experience is that there is no room for emergency cases,” he said.

Umalo also said he was not aware of substandard drugs because he had never encountered such an experience, stressing that the lack of drugs in hospital pharmacies remained his major challenge.

“I have never been attended to by any consultant. Each time I go, I am attended to by general doctors. Major surgeries are paid at 20 percent. Yes, there are always delays in getting referrals and, most importantly, seeing even the general doctors is always a herculean task,” he said.

For Moses Adikwu, who works with a federal corporation, he expressed optimism that the drugs he has been given over time are not substandard.

Adikwu noted that consultants are readily available whenever he visits the facility, although the number of consultants relative to patients is inadequate.

He, however, said he had no experience regarding major surgeries not being completely covered despite being enrolled.

“I have not had an experience in processing referrals to specialist facilities or higher levels of care, so I cannot comment on it,” Adikwu added.

A patient in the female surgical ward at Abubakar Tafawa Balewa University Teaching Hospital (ATBU-TH), Betti Daniel, also alleged that service providers under the NHIS scheme are frustrating patients because of the persistent unavailability of prescribed drugs.

“For the past three days, whenever the doctor prescribes drugs and drips and we go to the NHIS office to collect them, they tell us they don’t have the prescribed medications. The same thing happens with the drips. Sometimes they give us only two out of the four prescribed drips, which forces us to buy the remaining drips and drugs outside the hospital,” she said.

Another patient and NHIS enrollee at ATBU-TH, Alaba Damilola, who recently underwent surgery, expressed a similar concern.

“I underwent surgery, and the NHIS covered the cost of the operation. However, my challenge has been the drugs. Almost every day, my sister goes to their office to collect my medications, but they keep saying they don’t have them in stock. We have had to buy the drugs outside the hospital to support my recovery. We are tired of their attitude. After making us wait in the queue for hours, they eventually tell us the drugs are unavailable,” Damilola said.

To this end, the respondents called on the relevant authorities to strengthen monitoring of healthcare providers under the NHIS to ensure hospitals are adequately stocked with essential medicines and that enrollees receive the quality healthcare services expected under the scheme.

They also urged the Federal Government to address the gaps in drug supply and emergency response to enable beneficiaries to enjoy the full benefits of the health insurance programme.

 

Drug shortage, poor emergency response worry beneficiaries

Findings from Benue State suggest that the concerns raised by Abuja enrollees are not isolated. Several beneficiaries complained about persistent shortage of essential medicines and poor emergency response despite the huge public investments made in the NHIA programme.

Speaking separately in Makurdi, respondents gave mixed assessment of the scheme.

A federal civil servant, Emmanuel Antswen, said his experience improved considerably after moving from a government-owned hospital to an accredited private health care facility.

“I receive good services. While nothing is perfect in Nigeria, I am grateful for the quality of care and services I have received.

“I must also state that before I transferred from a government health facility to a private one, the services I received were not satisfactory. However, since making the switch, I have experienced significant improvement in service delivery and overall care,” he said.

Dorathy Sabo, another enrollee, said obtaining prescribed medicines from hospital pharmacies remained the biggest challenge. “There are times you go to the hospital and they tell you they don’t have the drugs at the pharmacy, so you have to buy them outside the hospital at a higher cost.

“Though they attend to enrollees promptly, the challenge we face is getting the prescribed drugs in the hospital,” she said.

Aloysius Umalo also criticised the scheme, alleging that many accredited hospitals lack essential medicines, while emergency cases receive inadequate attention.

“The answer is obviously no. The experience is so terrible that essential drugs are not found in those pharmacies. Patients are forced to buy expensive drugs outside the hospitals.

“Another nasty experience is that there is no room for emergency cases,” he said.

The respondents called on the authorities to improve the oversight of health care providers, strengthen emergency services and ensure that accredited hospitals are consistently stocked with essential medicines.

 

Awareness, diagnostic challenges persist

In Bauchi State, investigation showed that the NHIA has enrolled more than 85,000 beneficiaries across 60 accredited health care facilities.

Despite the expansion, many enrollees complained about drug availability, delay in referrals, poor understanding of benefit packages and difficulties obtaining refunds after paying for laboratory investigations outside hospitals.

A senior NHIA official who requested anonymity explained that many complaints arose because beneficiaries were unfamiliar with the scheme’s benefit package.

According to the source, treatment is largely covered, but beneficiaries are expected to pay a 10 per cent co-payment for drugs at the point of service.

The source also explained that while the NHIA benefit package covers most common illnesses, some services remained either partially or totally excluded.

Partial exclusions include services such as renal dialysis, while total exclusions cover drug abuse, occupational injuries, epidemics, cosmetic surgery and family planning commodities.

The official further alleged that although official drug price lists exist, some hospitals still overcharge beneficiaries.

“No out of stock in the NHIA. Any facility that doesn’t have a particular drug on its counter should source it for enrollees,” the source added.

Checks by Weekend Trust also revealed that inadequate public awareness leaves many enrollees vulnerable to exploitation whenever health care providers claim that certain drugs or investigations are excluded from the scheme.

Fatima Audu, who underwent surgery at the Abubakar Tafawa Balewa University Teaching Hospital, told Weekend Trust that she paid for several laboratory tests outside the hospital because laboratory workers were on strike.

After presenting the results, she requested reimbursement but was informed that the hospital could not refund the money.

“I underwent surgery some months ago when some health workers were on strike. The doctor asked me to carry out about five laboratory tests outside the hospital. After I submitted the results, I requested a refund, but they told me there was nothing they could do about the money I spent,” she said.

Another enrollee who identified herself as Maimuna said she repeatedly bought medicines outside the hospital after being informed that they were not covered by the insurance package.

“On two occasions after medical examination and treatment, the service provider told me that the prescribed drugs were not covered under the scheme and I had to buy them from outside pharmacies,” she said.

She urged the NHIA to intensify public enlightenment campaigns so that beneficiaries would understand the services and medicines covered under the programme.

 

Positive reviews overshadowed by shortage of medicine

In Kano, many beneficiaries commended the NHIA for making consultations, medical examinations and routine health care services more affordable. However, the most consistent complaint remained shortage of medicines.

At the Aminu Kano Teaching Hospital, a civil servant, Aisha Abdullahi, said the scheme eased her health care burden.

“We get attention from doctors without paying, and most services are covered. The only issue is with drugs: you may get seven out of 10 prescribed, then buy the rest outside,” she said.

Another enrollee, Yushau Usman, said consultations and laboratory tests were largely free, but noted that beneficiaries often faced long queues because of the growing number of people enrolled under the scheme.

“Consultations and tests are free; and the doctors attend to us well. The only gap is that sometimes, the NHIA pharmacy doesn’t have all the drugs, but at least, most are given,” he said.

Some beneficiaries receiving care at private hospitals expressed stronger concerns.

Nafiu Yusuf alleged that some private facilities deliberately withheld medicines that should ordinarily be available under the scheme.

“We suspect that they often deliberately hide some of the prescribed drugs and ask us to go and buy outside. This defeats the primary purpose of the health insurance scheme,” he said.

 

What is obtainable globally

Weekend Trust reports that the Nigerian experience contrasts sharply with what obtains in many developed countries. In the United Kingdom and Canada, patients generally receive necessary treatment without worrying about immediate hospital bills.

Germany operates a compulsory insurance system that guarantees broad health care benefits, while even in the United States, where health care is often criticised for being expensive, insurance significantly reduces patients’ financial burden through negotiated costs and wider coverage.

 

Common concerns 

Across Abuja, Benue, Bauchi and Kano, beneficiaries acknowledged that the NHIA expanded health care access and reduced treatment cost for many Nigerians.

However, recurring complaints continue to cast doubt on the scheme’s effectiveness. Among the major issues identified were shortage of essential medicines, delay in referrals and approvals, inadequate public awareness of benefit packages, bureaucratic bottlenecks, reimbursement challenges, long waiting times and persistent out-of-pocket payments for drugs and diagnostic services.

Respondents urged the NHIA, health maintenance organisations and accredited health care providers to strengthen monitoring, improve transparency, ensure uninterrupted medicine supplies and enhance service delivery so that the promise of affordable, accessible and quality health care becomes a reality for all Nigerians.

 

NHIA steps up enforcement of mandatory insurance

The NHIA has launched a renewed drive to enforce Nigeria’s compulsory health insurance law among self-funding government agencies as part of efforts to fast-track progress toward Universal Health Coverage (UHC).

Speaking at a one-day engagement programme, the Director of the Formal Sector Department, Nuhu Ajodi, a pharmacist, who represented the NHIA Director- General, Dr Kelechi Ohiri, said the Authority was taking decisive steps to ensure full compliance with its 2022 Act, which makes health insurance mandatory for all Nigerians.

Ajodi noted that for nearly two decades, Nigeria’s health insurance coverage stagnated at seven per cent, largely due to weak enforcement and low public awareness under the old National Health Insurance Scheme (NHIS) Act.

“Before the implementation of the NHIA Act in 2022, coverage remained stagnant for almost 20 years. However, following the Presidential Pronouncement and Circularization of Mandatory Health Insurance, enrollment has begun to rise,” he explained.

He described the new act as “a call to action” that empowers the NHIA to mobilise agencies, expand coverage and strengthen accountability across all sectors.

According to him, the NHIA is collaborating with regulatory bodies and stakeholders to rebuild public confidence in health insurance through targeted reforms, enhanced transparency and improved service delivery.

“We are introducing new initiatives, such as the Obstetric Fistula Care Programme and Emergency Care Intervention to remove financial barriers for women and patients with life-threatening conditions,” Ajodi said.

 

‘Scheme has improved access to healthcare’

In Abuja, the Health Services and Environment Secretariat supervises the Federal Capital Territory (FCT) Health Insurance Scheme (FHIS), which has recorded increased enrolment in recent years.

The Mandate Secretary, Dr Adedolapo Fasawe, said the programme had significantly improved access to health care, particularly for vulnerable groups, such as pregnant women, children and the elderly.

She, however, acknowledged that several challenges remain, including inadequate public awareness, delays in referrals and occasional disagreements between Health Maintenance Organisations (HMOs) and health care providers.

“We have seen more people seeking care early instead of waiting until conditions worsen. That alone is a major win,|” she said.

Officials at major public hospitals, including the Federal Medical Centre (FMC), Jabi, and the National Hospital, Abuja, also acknowledged that health insurance had encouraged more Nigerians to seek preventive and routine medical care.

However, they noted that delayed reimbursements from HMOs, limitations in the insurance benefit package and unrealistic expectations from some enrollees continued to create operational difficulties.

A senior staff at the FMC, Jabi who spoke on condition of anonymity, said hospitals were sometimes unable to provide certain treatments because they fall outside the approved benefit package.

“At times we are constrained by what the insurance package allows. Patients often assume that everything is covered, but that is not always the case,” the source said.