Health Insurance in Nigeria: From Statutory Reform to Effective Financial ProtectionA Critical Narrative Review

Abstract

Nigeria has replaced the National Health Insurance Scheme framework with the National Health Insurance Authority Act 2022, which makes health insurance participation mandatory and establishes a Vulnerable Group Fund. This critical narrative review examines the evolution and architecture of Nigerian health insurance and synthesises evidence on enrolment, service use, financial protection, beneficiary experience, provider participation and implementation constraints. Official legal and policy documents were considered alongside purposively selected peer-reviewed Nigerian studies and international health-financing sources, with a targeted supplementary search and source verification completed on 1 October 2026. Evidence from programmes operating before the 2022 reform, particularly the Kwara programme combining subsidised insurance with facility improvements, indicates increased utilisation and reduced out-of-pocket expenditure among enrollees. These findings do not establish the nationwide effects of the NHIA Act. Household out-of-pocket payments accounted for approximately 71.9% of current health expenditure in 2023. Survey and stakeholder evidence identifies uneven enrolment, limited informal-sector participation, funding constraints, fragmented pools, provider-payment problems and administrative barriers. The synthesis supports recommendations to strengthen public subsidies for vulnerable groups, improve informal-sector enrolment and payment arrangements, review provider tariffs transparently, and coordinate coverage and claims information. Evaluation should distinguish registration from active coverage and assess access, quality, residual payments and financial hardship. The 2022 Act provides a stronger statutory foundation, but its long-term effects on equitable coverage and financial protection remain to be established.