Introduction
On the 18 February 2025, Kemi Folajinmi, a heavily pregnant woman in the throes of labour, was denied emergency care in a private hospital in Lagos because her family could not afford the steep initial deposit of NGN 500,000 demanded by the hospital. She fought for her life until she died mere hours later.Footnote 1 Later in the year, it was reported that a former senator, Ibrahim Musa Kontagora, who had represented the Niger North senatorial district from 2011 to 2015, was in dire need of critical surgery but was denied any medical intervention until he had paid the USD 15,000 demanded by the Abuja hospital. This was impossible to raise within the short span of time that Ibrahim had left, and he died soon after.Footnote 2 National outrage erupted across media platforms, but once the dust had settled, a critical question remained: were these tragedies simply the results of medical negligence and a broken Hippocratic Oath, or did they signal a deeper legal and statutory crisis threatening both the poor and the rich?
As succinctly captured in the words of Virgil, an ancient Roman poet, “the greatest of wealth is health”.Footnote 3 A nation which seeks the prosperity of its people must first ensure their health and protect it at all costs. Nigeria, like many other developing countries, embraced several measures to ensure a proper living standard for its people, especially in relation to health, after it gained independence in 1960.Footnote 4 Among these measures was the establishment in 1988 of a national health policy, titled the “National Health Policy and Strategy to Achieve Health for All Nigerians”, with a key emphasis on primary healthcare and its component services: health education, immunization, essential drug provision and maternal and child healthcare, with a goal of achieving “Health for All by Year 2000”.Footnote 5 To better drive this agenda, the government founded subsequent initiatives, such as the Health Sector Development Framework and Reform Initiative, national health plans, reviews of the 1988 national health policy, and the National Health Insurance Scheme, which was signed into law in May 1999.Footnote 6 The latter was a creation of promise; it was officially launched in 2005, promising to guarantee a funding pool for health services to significantly increase the efficient management of the nation’s health resources, to take away the burden of exorbitant healthcare costs from the shoulders of the average Nigerian and to achieve coverage of every Nigerian by 2015.Footnote 7
Over two decades later, none of those promises are anywhere near fulfilment; instead there is a dark cloud of insecurity in Nigeria’s health sector. In a population of over 200 million, less than 10 per cent have been covered by the health insurance scheme since 2005, with over 70 per cent footing exorbitant healthcare bills through out-of-pocket expenses.Footnote 8 This backward development has opened several scholarly discourses on the intersection of human rights and health insurance, effectively raising the question: does the right to health comprise a right to health insurance, or is health insurance a special privilege for the affluent? This study aims to answer that question by analysing international health rights, examining their relationship with Nigerian law and identifying systemic challenges within Nigeria’s insurance policy. By comparing Nigerian practices with models in South Africa and Thailand, it ultimately recommends solutions to the crises in the nation’s health and insurance.
Local and international dimensions of the right to health
The right to health is arguably the most controversial fundamental human right. It first found its way into the International Bill of Rights in 1976, under the leadership of the World Health Organization’s (WHO) first director general, Brock Chisholm.Footnote 9 Decades later, the phrase “the right to health” is now directly or indirectly cited in a number of international treaties and declarations.Footnote 10 The 1946 WHO Constitution defines health as complete physical, mental and social well-being, recognizing the “highest attainable standard” as a fundamental right essential to global peace. It mandates cooperation between states and individuals for its realization. Similarly, the International Covenant on Economic, Social and Cultural Rights codifies the right to health as everyone’s entitlement to the highest possible standard of physical and mental well-being.Footnote 11 Fangjun defines the right to health as “a natural person’s right of personality, with the interest of the functioning of his various organs and of his whole body as its content, including the healthy physiological functioning of organs in his body as well as psychological or mental wellbeing”.Footnote 12
The right to health is the inextricable link between health and human rights. In international law, the only requirement for an entitlement to the right to health is simply that the claimant be human.Footnote 13 Over the years, international law has substantially and rapidly evolved with regards to defining and clarifying the scope of the right to health. Under international law, it now transcends a mere right to healthcare and extends into the territory of a societal obligation. This is based on the discovery that rights must also be recognized within the social sphere, that the determinants of health are not strictly biological or natural and that there exist social determinants such as the availability of clean drinking water, basic sanitation, healthy nutrition and adequate health laws and policies.Footnote 14
The 1948 Universal Declaration of Human Rights contains the first concept of the right to health under international law; it defines it as everyone’s right to a “standard of living adequate for the health and well-being of himself and his family, including medical care and the right to security in the event of sickness, disability or other lack of livelihood in circumstances beyond his control”.Footnote 15 This wording suggests that the right to health is more than just a right to medical care and that the state has a duty to provide an equitable social environment for all citizens, regardless of their physical or economic ability, as far as health is concerned.Footnote 16 States, which are parties to a plethora of international treaties on health, have three major, interconnected obligations: the first is to respect the right to health by desisting from any direct violations of it and any discriminatory practices in the healthcare structure. The second duty is to actively protect the right to health from violations by third parties who institute regulatory impediments to its enjoyment by citizens. The last duty is that of fulfilling the right to health and actively enforcing it by adopting viable measures that would lead to the achievement of accessible healthcare for all citizens.Footnote 17 These measures should include the encouragement of grassroots participation in health policy-making and other decisions that would ultimately shape their well-being. The duties in international law to respect, protect and fulfil the right to health can be summed up as the duty of the state to be accountable.Footnote 18
As with all rights in international law, the actualization of the right to health depends primarily on what goes on at the national level: the activities of the national judiciary and the national legislature. The actions of treaty-monitoring committees and judgments by quasi-judicial international institutions are less critical and of secondary importance.Footnote 19 This stirs up concern as to the effectiveness of international law and the utility of its legal and quasi-legal institutions and their overall impact on the enforcement of human rights, particularly the right to health. As Merton puts it, “Does anything really change when a nation becomes a State party to a Convention? If it is decided … that the State has violated its obligations, what are the real consequences?”Footnote 20
The scope of Nigeria’s legal framework on the right to health
The issue of health insurance in Nigeria has had a chequered history, particularly as it is a critical component of the fundamental and inalienable right of every human being to live, which therefore includes the right to health. The question is whether the Nigerian legal framework has adequately provided for the enjoyment by the public of the right to health by ensuring that there is an accessible healthcare system that is affordable and readily available. The first attempt made by way of legislation towards providing for a comprehensive health insurance scheme came in the form of the National Health Insurance Scheme, which was categorized as the National Health Insurance Scheme (NHIS) Act No 35 of 1999. However, this Act only became operational in 2005, with the primary goal of improving the health status of Nigerian citizens as a significant contributory element in reducing and possibly eradicating national poverty. The programme took off completely and successfully, beginning in the formal sector of the economy, which includes a social health-security system that uses money generated by combining the contributions of employers and employees to pay for the healthcare of workers in the sector. The formal sector is defined by the enabling law as the public sector, the organized private sector, the armed forces, police and related services, and post-secondary students, and also includes voluntary contributions.
However, the NHIS Act was riddled with a myriad of inadequacies, chief of which was its lack of broad-based applicability, as it captured only public workers and their immediate family and left out a larger percentage of the population. Consequently, it was overhauled and replaced with the National Health Insurance Authority via legislative intervention through the National Health Insurance Authority (NHIA) Act 2022. One laudable provision of this Act is that it makes health insurance mandatory for all citizens and legal residents, a step towards achieving universal health coverage, which means that all people have access to the health services they need, when and where they need them, without financial hardship.Footnote 21
Undoubtedly, every Nigerian possesses rights, duties, liabilities and privileges established under various existing laws. However, specific rights are constitutionally safeguarded under chapter 4 of the Constitution of the Federal Republic of Nigeria (CFRN) 1999, and these are regarded as fundamental human rights.Footnote 22 The 1999 Constitution guarantees everyone the right to sufficient medical and health care; this is part of the socio-economic rights provided for in the Fundamental Objectives and Directive Principles of State Policy under its chapter 2. Section 17(3)(d) of the CFRN 1999 mandates that “the state shall direct its policy towards ensuring that there are adequate medical and health facilities for all persons”. This is to be read alongside section 33, which provides for the right to life, to the extent that “every citizen of Nigeria shall have the right to life, save upon certain situations in which same can be denied”. In addition, section 17(3)(b) guarantees fair and humane working conditions, and section 17(3)(c) guarantees that the health, safety and welfare of all employees are protected and they are not jeopardized or mistreated. To guarantee Nigerians’ right to healthcare, experts argue that urgent actions must be taken to ensure its enforcement.Footnote 23
However, despite the provisions of chapter 2 of the Constitution, a chapter whose provisions, it has been argued, are unfortunately largely unenforceable, the question of its justiciability remains rife.Footnote 24 Following this, arguments have been made that the right to health is not legally protected under the current legal regime in Nigeria, and it may seem impossible to refute these claims. This is largely based on the ouster clause inherent in the Constitution, which precludes legal action or interpretation on any matter that is related to the provisions of chapter 2.Footnote 25 Meanwhile, several countries with socio-political and economic conditions comparable to Nigeria have consistently construed the right to life as encompassing the recognition and enforceability of the right to health, whether individual or environmental.Footnote 26 In Sunil Batra v Delhi Administration, the Indian Supreme Court ruled that the right to life extends to the right to live a healthy life, enabling the enjoyment of all human faculties in their optimal state.Footnote 27 Similarly, in Dr Mohiuddin Farooque v Bangladesh, the Supreme Court expanded the scope of the right to life in two specific respects: first, to include the protection of health, and second, to encompass the normal lifespan of an average human being.Footnote 28 The Court noted that if the right to life under articles 31 and 32 of the Constitution implies the right to protection of health and the normal longevity of an ordinary person, then this may be endangered by the consumption or potential consumption of contaminated food, goods, etc, and such a situation amounts to a threat or violation of the fundamental right to life. This interpretation means the right should be understood not merely as a universal human entitlement but as an indispensable right enjoyed by every citizen. The rationale is that health is intrinsically linked to other rights, and a citizen in poor health will inevitably lack the capacity to exercise many other human rights.
On the other hand, the 1999 Nigerian Constitution allows the enforcement of chapter 4 of the Constitution, which contains the fundamental rights provisions, most of which are civil and political in nature. In Federal Republic of Nigeria v Ifeagwu, the Supreme Court held that although fundamental rights are part of human rights, the trend in today’s society, where the rule of law operates, is to protect fundamental rights for the enhancement of human dignity and liberty.Footnote 29 However, in Okogie v AG Lagos, the Court held that:
“[w]hile Section 13 of the constitution makes it a duty and responsibility of the judiciary among other organs of government, to conform to, observe and apply the provisions of Chapter 4, Section 6(6)(c) of the same constitution makes it clear that no court has jurisdiction to pronounce any decision as to whether an organ of government has acted or is acting in conformity with the provisions of Chapter two of the Constitution.”Footnote 30
Furthermore, in Mustapha v Governor of Lagos State, the Nigerian Supreme Court similarly noted that “human rights must include all humans and these rights must be fully separated from civil, political, economic rights, etc”.Footnote 31 This state of affairs, which gives room for the government not to live up to its responsibilities, has resulted in limited access to healthcare across the nation. Consequently, Nigeria is ranked 142 out of 195 countries in a Lancet report that ranks the performance of health systems using healthcare access and quality as criteria.Footnote 32
While the issue of the enforceability or otherwise of chapter 2 of the Constitution (which the right to health falls under) remains, it is important to note that there are still avenues by which the right can be validly enforced as a human right in Nigeria. Hence it is not entirely correct to say that it is unenforceable. These avenues are outlined below.
Bypassing the non-justiciability conundrum by properly delineating section 6(6)(c) of the 1999 Constitution
By properly delineating section 6(6)(c), which seeks to create the problem of non-justiciability of the rights under chapter 2 of the Constitution, and with a view to exploiting the possible loopholes created therein to make enforceable its otherwise unenforceable provisions, the non-justiciability issue may be successfully bypassed. The opening phrase of the section, “except as otherwise provided”, operates as a proviso to the entire section and serves as an ouster clause precluding the enforceability or justiciability of the provisions of chapter 2. The effect of this is that salient provisions exist through which the provisions of chapter 2 may be validly enforced in court. In FRN v Aneche and 3 Others, the court held a reasoned opinion thus:
“Section 6(6)(c) of the Constitution is neither total nor sacrosanct as the subsection provides a leeway by the use of the words ‘except as otherwise provided by this Constitution’. This means that if the Constitution otherwise provides in another section, which makes a section or sections of Chapter II justiciable, it will be so interpreted by the courts.”Footnote 33
A typical instance is seen where a particular section of chapter 2 is mandated to be followed in furtherance of the justiciable sections. For example, section 197(3), which deals with the powers of the governor to make certain appointments, requires compliance with section 14(4), which is a section under chapter 2. In such a scenario, the governor is statutorily mandated to respect and enforce the provisions of section 14(4), which deal with the federal character principle and the promotion of unity among the people.Footnote 34
Similarly, the National Assembly is saddled with the power of legislating for the entire federation and may, by exercising such powers granted to it by the justiciable sections of the Constitution, make certain sections of chapter 2 justiciable. One example of this is found in item 60 of the Exclusive Legislative List under part 1 of the second schedule to the 1999 Constitution, which grants the National Assembly the power to enact laws governing the creation and regulation of authorities for the federation or any portion of it in order to promote and enforce the observance of the Fundamental Objectives and Directive Principles contained in the Constitution.Footnote 35 It is perhaps in the exercise of this power that the National Assembly has enacted the National Health Insurance Authority Act and the National Health Act providing for the right to health, in furtherance of the provisions of chapter 2 as well as various other statutes on other issues under the non-justiciable chapter 2.
The other method is when the application of the Constitution’s justiciable provisions will inevitably lead to the application of chapter 2’s non-justiciable provisions. Item 68 in the Constitution’s second schedule, which lists the National Assembly’s sole legislative authority, contains an omnibus clause that mentions “[a]ny matter incidental or supplementary to any matter mentioned elsewhere in this list”. Health protection is one of the issues covered by item 60(a) of this list, also known as the Exclusive Legislative List, which is subject to judicial review under section 4 of the Constitution. Therefore other arms of government cannot disregard the National Assembly’s authority to enact legislation protecting Nigerians’ health as a right if the legislation so made falls under this clause.Footnote 36
The right to health under the African Charter on Human and Peoples’ Rights
The African Charter on Human and Peoples’ Rights, ratified on 22 June 1983, obliges state parties under its article 16 to adopt necessary measures to safeguard the health of their citizens and guarantee them medical care when ill. This provision of the Charter upholds the individual’s right to the highest attainable standard of physical and mental health and means that all rights guaranteed by the Charter are enforceable before both the African Court and the African Commission.Footnote 37 In addition, as a member of the African Union, Nigeria is bound, as a regional commitment, to uphold and protect human rights in line with the Charter, improve the living standards of its people, eliminate diseases and promote good health across the continent.Footnote 38 Consequently, Nigeria bears an obligation, arising from both international and regional legal instruments to which it is a signatory, to ensure the provision of adequate healthcare for its population.Footnote 39
The preamble to the African Charter supports the view that the right to health cannot be extricated from the fundamental human rights of life and dignity (provided for under the justiciable chapter of the Nigerian Constitution), stating that civil and political rights are inseparable from economic, social and cultural rights in both their conception and their universality, and that the fulfilment of economic, social and cultural rights ensures the enjoyment of civil and political rights.Footnote 40 The Charter is a regional human rights treaty that has been recognized and incorporated into Nigerian law, thereby forming part of the country’s legal system.Footnote 41 According to the Constitution, international treaties (including regional treaties) acquire the force of law once incorporated into domestic legislation.Footnote 42 Therefore it has been contended that since the African Charter has been incorporated into Nigeria’s legal framework, the recognition and enforceability of socio-economic rights as human rights have, by extension, been accepted.
The Charter acknowledges an extensive spectrum of rights, encompassing civil, political, social, economic and cultural rights, as well as individual and collective ones. The right to health is expressly stipulated under its articles 16 and 18, to the effect that “[e]very individual shall have the right to enjoy the best attainable state of physical and mental health. States parties to the present Charter shall take the necessary measures to protect the health of their people and to ensure that they receive medical attention when they are sick.”Footnote 43 This position has also received judicial blessing in a number of cases in Nigeria, for instance in Ubani v Director SSS, the Court of Appeal held, inter alia, that “the African Charter is applicable in this country. The Charter entrenched the socio-economic rights of a person. The Court is enjoined to ensure the observation of these. A dispute concerning socio-economic rights such as the right to medical attention requires the Court to evaluate State policies and give judgment consistent with the Constitution.”Footnote 44 Similarly, in General Sani Abacha and Others v Chief Gani Fawehinmi, the defendant contested his arrest and detention by the military government as unlawful and unconstitutional, arguing that it violated his human rights under the relevant provisions of the African Charter.Footnote 45 The Supreme Court held that the Charter must be upheld by Nigerian courts, as it forms part of Nigerian law.
From the foregoing, it is evident that an individual may approach Nigerian courts, relying on the African Charter to seek enforcement of the right to health. Therefore, while the right to health is not enforceable under chapter 2 of the Nigerian Constitution, article 16 of the African Charter provides an avenue for its enforcement.Footnote 46
The National Health Act 2014 and the National Health Insurance Authority Act 2022
The main piece of legislation that establishes a framework for the administration, growth and regulation of Nigeria’s healthcare system is the National Health Act 2014. Since it spells out duties and rights regarding healthcare, it is important that it be considered a legal means of upholding the right to healthcare. The Act unifies public and private health services into a single framework and establishes the National Health System (NHS) to provide the best possible health services to Nigerians; the NHS sets out and regulates the framework for standards in health services across the country.Footnote 47 The Act aims to protect, promote and realize the right of Nigerians to access healthcare, and to ensure that the government provides the highest attainable standard of health services within the available resources, while clearly outlining the responsibilities of healthcare providers. The government is obligated to provide good-quality, safe and affordable essential medicines and medical supplies.Footnote 48 This is a notably commendable provision. Another commendable aspect of the National Health Act is its stipulation that all Nigerians are entitled to a basic minimum package of health services.Footnote 49
Furthermore, the Act, besides quite laudably making copious provisions for the accessibility of healthcare, spells out a consequence for denial of access to healthcare. While section 20(1) forbids refusing emergency medical treatment, it also ensures that all Nigerians have access to the bare minimum of basic health services. Enforceable legal claims may result from a violation of this clause. This provision is particularly important considering the prevalent practice in Nigeria where healthcare is denied to patients under emergency situations for failure to pay the necessary fees. For instance, it would be against the Act if an emergency Caesarean section – which, when performed promptly and for the appropriate reason, can save the lives of mother and child – were refused or postponed due to an inability to pay the initial surgery deposit.Footnote 50 Section 20 of the Act states that “[a] person cannot be denied emergency medical treatment for any reason by a healthcare provider, health worker, or healthcare facility”. “For any reason”, as used in the section, includes all of the typical justifications for postponing medical attention, such as the nature of the illness, the need for an upfront payment or police reports of gunshot wounds.Footnote 51 Commendably, the Act prescribes a penalty for neglecting section 20(1), to the effect that a violation of the right is punishable to the tune of NGN 100,000 or imprisonment for a term of six months.Footnote 52 It also lays out a procedure for aggrieved patients to bring a complaint with respect to how they have been treated by any healthcare provider.Footnote 53
On the other hand, the NHIA Act 2022 is aimed at the promotion, regulation and integration of health insurance schemes in Nigeria. The Act creates the National Health Insurance Authority, with the objectives of promoting, regulating and integrating private sector insurance schemes, enhancing and leveraging private sector involvement in the delivery of healthcare services and undertaking any other activities that will support the Authority in attaining universal health coverage for all Nigerians.Footnote 54 As mentioned above, the commitment by the Authority to achieving universal health coverage is quite laudable; however, its practicality and its implementation mean that a large question mark still hangs over it. This commitment is captured among the functions of the Authority spelt out under section 3 of the Act, to include, among other things, “ensur[ing] that health insurance is mandatory for every Nigerian and legal residents”.Footnote 55
The Act also makes commendable provision for vulnerable people (which includes children under five, pregnant women, persons with disabilities and the elderly), mandating the states and the Federal Capital Territory to make provision for such persons under the various health insurance and contributory schemes in their domains, financed through the Basic Health Care Provision Fund (BHCPF).Footnote 56 This fund is established to provide a basic minimum package of care to all residents of Nigeria.Footnote 57 Section 13(1) of the Act seeks to ensure that the government, as the primary duty bearer for health provision, fulfils its role by providing for the creation of state health insurance or contributory schemes to cater to residents in each state. While this provision is commendable for assigning such responsibility to state governments, it can be criticized for its weakness: the use of the term “may” in its wording implies that the obligation is discretionary rather than mandatory. As a result, although state governments are entrusted with the role of seeing to the establishment of such schemes, the practical reality remains a subject of concern.Footnote 58
Overall, by establishing statutory guarantees for patient rights, emergency care, funding and access to health services, the National Health Act 2014 operationalizes the right to health in Nigeria. It is an important legal tool for converting constitutional and international health rights obligations into enforceable claims, because violations of its provisions are actionable in court.
Challenges to accessing health insurance in Nigeria
The relationship between human rights and health insurance in Nigeria presents a challenging socio-legal reality, marked by a wide gap between well-developed laws and poor health outcomes. A central debate in contemporary academic scholarship is whether Nigeria’s struggle to attain universal health coverage is a result of weak legal frameworks or the persistent failure to effectively operationalize existing laws. Although some scholars contend that Nigerian laws are grossly insufficient in securing the right to health, a closer examination of the legal framework, from the 1999 Constitution to the African Charter, the National Health Act 2014 and the National Health Insurance Authority Act 2022 (as analysed above), suggests otherwise, and proposes effective avenues by which the right to health in Nigeria can be revived judicially. Rather than a shortage of legal provisions, the more pressing challenge lies in weak enforcement, systemic institutional shortcomings, underfunding, federal and state government fiscal misalignment, etc.Footnote 59
The major argument advanced by those who take the position that the issue is one of a de jure (lack of laws) problem rests prominently on the legal obstacle posed by section 6(6) of the 1999 Constitution, which restricts courts from enforcing the directive principles in chapter 2. This has traditionally led to the erroneous view that the right to health is non-justiciable and merely aspirational. However, this position is increasingly questioned, with scholars advocating a more progressive and enforceable interpretation. In this light, Obiajulu et al argue that although section 6(6) limits the enforceability of chapter 2, this has not prevented the Nigerian state from translating the right to health into concrete statutory obligations.Footnote 60 This highlights how laws such as the National Health Act 2014 and the National Health Insurance Authority Act 2022 give substantive content to the right to health by establishing funding mechanisms, defining minimum health service packages and creating institutional responsibilities for government actors. These statutes effectively operationalize the right outside the narrow constitutional justiciability debate.Footnote 61 They also reframe universal health coverage as a legal and administrative commitment, not a policy choice. They posit that mandatory health insurance schemes, pooled funding and statutory coverage of vulnerable groups reflect a shift from aspirational rights to enforceable socio-economic guarantees, even if enforcement is indirect or administrative rather than judicial.Footnote 62
Similarly, Falana takes the view that the right to health in Nigeria is no longer merely aspirational, despite its placement in chapter 2 of the Constitution.Footnote 63 He argues that through domesticated international instruments, particularly the African Charter, and enabling legislation such as the National Health Act, socio-economic rights have acquired practical enforceability. This approach displaces the rigid non-justiciability narrative by demonstrating that courts and institutions can operationalize the right to health, and by extension universal health coverage, through statutory mandates and international obligations binding on Nigeria through the instrumentality of section 13 of the Constitution. Eniola and Momodu argue that the right to health in Nigeria is operationally justiciable despite section 6(6)(c); they maintain that through the domestication of the African Charter, expansive interpretation of the right to life and human dignity, and the Fundamental Rights Enforcement Procedure Rules 2009, courts can and have enforced health-related claims.Footnote 64 This directly challenges the rigid non-justiciability narrative by reframing the right to health as legally actionable through existing constitutional and statutory mechanisms, rather than through constitutional amendment alone.
Despite this encouraging state of affairs, as portrayed by the literature examined above, the inaccessibility of health insurance, which is a vital link in enjoying the right to health, has remained a pressing issue. Twenty years after the inception of the National Health Insurance Scheme in 2005, Nigerians still die every day from an absence of healthcare, its insufficient provision or the denial of medical services due to exorbitant healthcare costs they cannot afford. Some of the factors elucidated below play major roles in the ineffectiveness of the scheme to date.
Lack of awareness and insufficient information
It has been proven that poor knowledge of benefits or entitlements under health insurance schemes in developing countries is a major barrier to the utilization of health facilities.Footnote 65 Information is power, yet many Nigerians do not know of the existence of the National Health Insurance Scheme or its benefits, structure or objectives. Studies conducted in communities in Anambra State in Eastern Nigeria, where a healthcare financing scheme operated, reported that there was about 15.5 per cent enrolment in the scheme in communities where awareness was low and about 48.4 per cent enrolment in communities where there was better awareness.Footnote 66 A representative of a health maintenance organization captured this challenge:
“Enrollee enlightenment is very poor, enrollee knowledge about the scheme is very poor, that’s one issue … The hospital themselves, most of them do not understand the scheme, they don’t understand when to request for [an] authorization code, they don’t understand how to prevent the abuse … Some HMOs [health maintenance organizations] do not give authorization when they are supposed to give authorization and that affects the patient.”Footnote 67
A survey conducted in Benue State in the North-Central region of Nigeria among hospital clients enrolled in the state health insurance scheme showed that almost 70 per cent of the enrollees had little to no knowledge of their entitlements under the scheme, such as maternity care for up to four childbirths, free antenatal and postnatal care, eye care, free immunization and others, and consequently never utilized these services. The negative perception of the scheme was also linked to insufficient information about it and its benefits.Footnote 68
Absence of trust in the National Health Insurance Scheme and its management
Studies have shown that mismanagement of public funds and corruption in the healthcare system, which has been the case in Nigeria, can undermine people’s confidence in the system and erode public trust.Footnote 69 Research carried out in rural areas of Anambra State showed that communities with very poor participation in the National Health Insurance Scheme also reported distrust of it and its efficiency.Footnote 70 Other research, carried out in the informal sector in Benin City in the South-South region, showed that poor enrolment in the National Health Insurance Scheme could be linked to a perception that government-championed health schemes are unreliable and likely to fail.Footnote 71
Abject poverty and the domination of the informal sector
The results of the 2022 Multidimensional Poverty Index survey released by the National Bureau of Statistics showed that 133 million Nigerians are poor on multiple dimensions and are deprived of basic living standards, including healthcare and education.Footnote 72 This is a staggering figure given that the country only has a population of about 200 million. Research by the World Bank also reveals that 87 million Nigerians are estimated to be living below the poverty line, with the nation bagging the title of the second largest poor population in the world, after India.Footnote 73 According to the World Health Organization, medical fees is one of the greatest obstacles to achieving universal healthcare coverage in most developing countries, as citizens pay through their noses to cover healthcare expenses.Footnote 74 In Nigeria, this is no different. It would be near impossible to expect the majority of Nigerians, who live in abject poverty, to save even the supposedly small sums required to enrol in the National Health Insurance Scheme or the monthly premium.
In addition, the informal sector in Nigeria, otherwise known as the unregulated sector, comprises businesses, entrepreneurs and other informal activities that exist outside the regulatory framework of the government. In Nigeria, over 80 per cent of the population works in the informal sector, which employs an estimated 5.5 million people in Lagos State alone. Yet working in the informal sector in Nigeria is tantamount to working in cramped workspaces under unhealthy working conditions, for overextended working hours and with little access to information, for instance about the National Health Insurance Scheme.Footnote 75 The informal sector is also plagued with disorganization, making it impossible for the insurance premium to be simply deducted from earnings as is done in the formal sector. The mode of payment for the insurance premium is also unfavourable to most Nigerians working in the informal sector, as it requires queueing for long hours in crowded bank halls. This would be distasteful to the average person working in the informal sector, who is paid for work per hour.Footnote 76
Weak and dysfunctional regulatory institutions and poor government funding
There are various institutions established for the purpose of implementing health policies and laws in Nigeria. For instance, the National Primary Health Care Development Agency was established in 1992 as an agency of the Federal Ministry of Health, and was given the responsibility of transforming national health policies into workable strategies, developing grassroots health amenities, conducting training sessions on technical know-how for primary healthcare, monitoring its delivery and sending reports to the Ministry of Health. However, the potential effectiveness of this agency was short-circuited by the government’s lack of support. This has also been the case with the various health regulatory institutions set up in the country.Footnote 77
Also, despite the legislative mandate of the BHCPF, Nigeria has consistently failed to meet international benchmarks for health spending. The 2001 Abuja Declaration, where African heads of state committed to allocating 15 per cent of their annual budgets to health, remains a distant goal for Nigeria. In the 2025 approved budget, the health sector allocation stood at NGN 2.38 trillion, representing only 4.33 per cent of the total budget.Footnote 78 This fiscal gap directly impedes the operationalization of the “basic minimum package of care” promised by the National Health Act and the NHIA Act.
The lack of standard health services and medical infrastructure and the shortage of competent healthcare professionals
One of the major hurdles facing healthcare utilization in Nigeria is the state of the health facilities and the medical infrastructure and the quality of health personnel. Many primary healthcare facilities in the country are below standard and lack the most basic resources, such as clean water, electricity, sufficient hospital beds, essential medical equipment, drugs and adequate space for optimum patient care. The limited availability of ambulances and emergency care services further worsens the situation.Footnote 79 It has also been discovered that the location and siting of health facilities in the country is based on political expediency, as opposed to necessity and need. This has meant that the inhabitants of some communities have had to travel over 5km to access basic healthcare.Footnote 80
There is also the issue of inadequately trained health personnel and a decreasing number of well-trained health professionals in the country. By 2024, the health personnel-to-patient ratio has increased to 1:10,000, against the global standard of 1:5, leading to extreme work stress and poorer healthcare services. This extreme shortage of health personnel is occasioned by poor compensation packages, shabby work conditions, debilitating economic policies and the mass exodus of medical professionals.Footnote 81 The quality of healthcare in Nigeria, especially in the rural areas of northern Nigeria, is far from ideal. There are reported cases of misdiagnoses, unclear communication, unhygienic facilities and embarrassing physical examinations, which greatly deter the utilization of these health services. A survey conducted in Benue State showed that many enrollees in the National Health Insurance Scheme identified the dilapidated health facilities and sub-par healthcare quality as significant barriers to the acceptance and durability of the scheme.Footnote 82
Religious and cultural bias
The low interest in the National Health Insurance Scheme could also be traced to religious and cultural beliefs and biases. For example, a Muslim may be distrustful and wary of any insurance schemes, even a health insurance scheme, as they are considered haram, while a Christian may prefer to believe in divine healing than to pay substantial sums as premiums to insure against medical costs.Footnote 83 Research has shown that in Kebbi State, religious and cultural beliefs such as gender bias resulted in inequality in the acceptance of the scheme.Footnote 84
Cultural practices may also limit women’s freedom of movement, autonomy or contact with formal healthcare systems, and are prevalent in the northern part of the country. Some cultural and religious beliefs also prohibit the use of some services available under the scheme, such as family planning, blood transfusions and others. In addition, some Nigerians living in rural communities prefer traditional medicine, as they feel safer and more comfortable with traditional practices and the personnel performing these services. This in turn is associated with distrust of or unease with Western-style health systems and medical care, which is the type available under the scheme.Footnote 85
Citizens’ access to health insurance in some jurisdictions
This section presents an analysis of the current state of health insurance systems and the enforceability of the right to health in Thailand and South Africa. It includes a concise comparison with what is obtainable in Nigeria, focusing on the respective structures, legal frameworks, achievements and prevailing challenges.
Thailand
As of 2021, about 98 per cent of Thailand’s 67 million people were enrolled in one of three public health insurance schemes, demonstrating the country’s strong and consistent commitment to health equity.Footnote 86 These public schemes, which constitute the fulcrum of Thailand’s health coverage system, include the Universal Coverage Scheme, which is managed by the National Health Security Office; it is the largest and most important scheme, covering about 75 per cent of the population, including low-income individuals and those in the informal sector.Footnote 87 It originally required a small co-payment, but this was removed in 2007, making healthcare services free at the point of use for its members. There is also the Civil Servant Medical Benefit Scheme, a programme overseen by the Thai Ministry of Finance, which offers health coverage to government employees and their eligible family members.Footnote 88 The third and last scheme is known as the Social Security Scheme, with its main focus being provision of health insurance for private sector employees.
Thailand’s Universal Health Coverage Service Coverage Index stood at 82 per cent, reflecting strong access to essential health services.Footnote 89 The Thai Ministry of Public Health plays a central and influential role in delivering healthcare, especially in rural regions, through a tiered network of community health centres and district and provincial hospitals. In addition to funding from general government revenue, health promotion initiatives are significantly supported by the Health Promotion Fund, financed through a 2 per cent levy on excise taxes from tobacco and alcohol sales.Footnote 90 This is a commendable financing structure, unlike what is obtainable in Nigeria, where the health insurance scheme is funded by a non-statutory pooled contributions scheme.
Unlike Nigeria, Thailand’s commitment to the right to health of its citizenry is firmly rooted in its constitutional and legal foundations. The Thai Constitution contains far-reaching provisions relating to healthcare and the right thereto. For instance, section 47 guarantees all individuals the right to use public health services offered by the state, and also provides that those who are destitute may receive these services at no cost, while the prevention and treatment of dangerous infectious diseases are available free of charge to everyone.Footnote 91 Section 55 affirms the right to universal healthcare and obliges the state to deliver health promotion and preventive services.Footnote 92 This is unlike the Nigerian Constitution, which renders nugatory its sole provision on the right to health, as discussed earlier. There is also the National Health Act, which in its section 3 broadens the definition of health to include a combination of physical, mental, spiritual and social well-being. It also, pursuant to section 5, provides for the right to live in a healthy environment, while section 6 makes a provision for safeguarding and promoting the right to health for vulnerable groups in society such as persons with disabilities, the elderly, women and children. Generally, these constitutional and legislative provisions serve as a solid and clear legal pathway for Thai citizens to access public health services.
Overall, Thailand’s success in achieving universal health coverage, despite very modest expenditure levels and being a middle-income nation, offers a compelling case study and perhaps a possible blueprint for other low- and middle-income countries to copy and implement. Its relative success shows that achieving universal health coverage is possible even with constrained fiscal resources.Footnote 93 The only downside, however, is the fact that despite Thailand’s universal health coverage removing financial barriers, about 46 per cent of beneficiaries still opt for private care or self-medication due to long queues, limited service hours, benefit gaps and quality concerns, creating an informal two-tier system where higher-income groups bypass public services.Footnote 94
South Africa
South Africa’s National Health Insurance (NHI) is its principal driver towards achieving universal health coverage, ensuring all residents can access quality health services without financial stress.Footnote 95 It seeks to create a centralized national fund as the sole purchaser of services from both public and private providers, enabling eligible residents to use accredited facilities without direct payment. The funding is expected to be raised via new taxes, payroll contributions and reallocating most provincial health budgets to the NHI Fund, consolidating current health financing streams. This, much like what is obtainable in Thailand, is commendable, as it lays out a clear pathway for financing the health insurance scheme, as opposed to Nigeria’s largely unclear and unrealistic funding plan. Furthermore, the NHI adopts an extensive multi-year reform plan, integrating public and private health sectors and aiming to strengthen governance for greater efficiency and effectiveness. President Ramaphosa signed the NHI Act into law on 15 May 2024; its implementation is rolling out gradually, depending on available financial resources, between 2024 and 2028. Phase 1, which began in 2023, will run through 2026, followed by Phase 2 from 2026 to 2028.Footnote 96
Again, much like Thailand and unlike Nigeria, in South Africa the right to health is clearly articulated and protected within the Bill of Rights of the South African Constitution. This constitutional provision provides a robust legal framework for the enforcement of the right to health. For instance, section 27(1)(a) provides that everyone has the right to have access to healthcare services, including reproductive healthcare. This provision is quite commendable as it goes beyond merely the issue of health to address a silent but very salient issue in the society, reproductive healthcare. Also, section 27(1)(b) makes it mandatory for the state to “take reasonable legislative and other measures, within its available resources to achieve the progressive realization of the right”. Perhaps most commendable are the provisions of section 27(3), to the effect that no one can be denied emergency healthcare service, and section 7(2), which imposes an obligation on the state to respect, protect, promote and fulfil all rights in the Bill of Rights.
Furthermore, judicially, the right to health as provided for in the South African Constitution has been tested and accorded the force of law by the South African Constitutional Court. In Minister of Health v Treatment Action Campaign (TAC), the Constitutional Court affirmed a ruling requiring the public health sector to provide the anti-retroviral drug Nevirapine to all HIV-positive pregnant women, reinforcing the state’s duty to deliver life-saving healthcare.Footnote 97 This decision reflects judicial activism as a driving force for the realization of health rights. In comparison with jurisdictions such as Nigeria where the constitutional right to health is partially hindered by justiciability issues, South Africa’s right to health is constitutionally enforceable, as exemplified by landmark rulings such as TAC.
However, despite the laudable provisions, some concerns persist over the government’s capacity to efficiently and transparently manage the large NHI fund and oversee the complex transition.Footnote 98 The reform drastically alters the private healthcare sector, which currently serves about 15 per cent of the population with high-quality services, as the state becomes the sole purchaser and price regulator, as contemplated by the National Health Insurance Authority Act. If implemented as absorption rather than integration, the approach may alienate the private sector and lose its capacity, expertise and infrastructure. We suggest that such major reforms must balance equity goals with the practical need to retain and utilize existing healthcare resources. A confrontational approach could trigger a brain drain, reduce service availability and lower healthcare quality, jeopardizing the long-term success of the anticipated universal health coverage.
Overall, the three countries – Thailand, South Africa and Nigeria – show strong dedication to achieving universal health coverage and protecting the right to health, but they pursue this goal using quite distinct approaches. Thailand has evolved a mature health coverage system with near-universal enrolment, though it still grapples with quality and accessibility gaps. South Africa, on the other hand, is rolling out its ambitious NHI reform while grappling with challenges such as governance capacity concerns and potential private sector resistance. Nigeria, meanwhile, is working to expand coverage through legislative frameworks like the National Health Act and the NHIA Act 2022 as a means to correct the non-enforceability of its constitutionally guaranteed health rights; however, it struggles with implementation, funding, corruption and other limitations.
Conclusion and recommendations
Nigeria’s ongoing universal health coverage crisis is less about weak laws and more about poor execution. This study shows that the real obstacle to realizing the right to health is not the absence of legal frameworks but the failure to make them work in practice. The NHIA Act 2022 has strengthened the legal basis for health coverage by making it mandatory, moving beyond the voluntary limits of the 2005 scheme. In addition, the domesticated African Charter offers a clear, enforceable route for protecting health rights despite constitutional constraints, as highlighted by several scholars. However, a persistent gap lies in the weak implementation of the Acts and the BHCPF. Until this implementation gap is addressed through better funding, transparency and a more proactive judiciary, the right to health will remain a legal promise without real meaning for most Nigerians.
To achieve a more robust health system as well as universal health coverage, the following steps are crucial:
Public awareness: The government is encouraged to launch nationwide grassroots campaigns to educate the public on the benefits of health insurance. This should be coupled with a mandate for greater transparency and accountability from the scheme’s management to rebuild public trust.
Innovative financing and community-based models: The government should explore and subsidize innovative financing options, such as public–private partnerships and micro-insurance schemes tailored for the large informal sector. This would make health insurance more accessible and affordable for low-income populations.
Investment in healthcare infrastructure and human resources: Significant investment must be channelled into upgrading medical facilities and infrastructure, particularly in rural areas. Simultaneously, a national strategy should be implemented to address the shortage of competent healthcare professionals through improved training, retention incentives and better working conditions.
Building institutional capacity: To achieve universal health coverage, Nigeria must strengthen the NHIA beyond mere regulation, equipping it with a robust data infrastructure for enrolment and transparent claims management. This involves digitizing the informal sector’s entry points and ensuring the BHCPF is managed by competent, accountable personnel. Without administrative resilience and technical expertise within these agencies, even the best laws remain dormant.
Competing interests
None
Open access
