Health
HMO Controversy: What Nigerians, hospitals need to know about health insurance
A viral social media post about the use of Health Maintenance Organisations (HMOs) has sparked controversy among Nigerians and healthcare professionals over health insurance.
The post, made on X on 2 August by user @106_36_52, who identifies as a medical doctor on the platform, criticised a family who, according to him, visited a hospital after church for medical checks under their HMO plan.
“I give the federal government 24 hours to ban this thing called HMO in Nigeria. Full family, straight from church with matching Ankara. Third set only today. God abeg,” he wrote.
The post had generated more than 1.9 million views as of 12 August and was subsequently shared by blogs, attracting reactions from Nigerians and healthcare professionals.
While some Nigerians questioned why healthcare providers should be concerned about how frequently insured patients use their health plans, others argued that the reactions failed to recognise the financial and administrative pressures faced by healthcare providers and HMOs.
In this explainer, PREMIUM TIMES examines how health insurance works in Nigeria, the responsibilities of patients, healthcare providers and HMOs, and what the law says about their obligations.
How health insurance works
One of the biggest misconceptions exposed by the debate is the idea that an HMO patient is receiving free treatment.
The patient may not pay the hospital at the point of service, but that does not mean the service is free or that the provider is working for free.
Health insurance is built around pooling financial contributions to pay for healthcare when members need it. The National Health Insurance Authority (NHIA) describes social health insurance as a system in which contributions are pooled to provide a defined package of healthcare services.
Pelumi Akinboade, a senior executive officer and insurance nurse, explained that HMOs perform important administrative functions within this arrangement, including enrolment, claims management, authorisation, quality assurance and coordination between enrollees and healthcare providers.
He said providers are paid through arrangements such as capitation and fee-for-service, depending on the level and nature of care.
“Patients may not bear the bulk of their care costs out of pocket, as their respective insurance companies pay their healthcare providers directly through capitation and fee-for-service,” Mr Akinboade told PREMIUM TIMES.
A patient using an insurance plan is not asking a doctor to treat them for free. They are accessing a service that is supposed to be financed through an insurance arrangement.
Doctors’ frustration
The viral post, however, also highlights another side of the system. It is easy to dismiss a doctor’s complaint as hostility towards HMO patients.
Healthcare providers depend on HMOs to pay for services they have already provided, and problems with payments or authorisations can affect how facilities deliver care.
Mr Akinboade identified delayed payments, administrative bottlenecks, limited coverage, and disputes between providers and HMOs as factors that can contribute to delays or denials of care.
The NHIA Act 2022 specifically provides penalties for failure to remit payments to healthcare providers within the stipulated period and for failure to settle fee-for-service and other claims within the required timeframe.
The federal government has also acknowledged pressure on provider financing. In announcing revised payment rates under the national health insurance scheme, the NHIA said capitation fees had increased by more than 90 per cent, while fee-for-service payments had risen by 378 per cent.
The Coordinating Minister of Health and Social Welfare, Muhammad Pate, said the adjustment was intended to reduce the financial burden on healthcare providers and improve services for enrollees.
So while a patient’s use of their insurance should not automatically be blamed for a provider’s frustration, neither can the financial concerns of healthcare facilities be dismissed.
The law, dispute
Section 47 of the NHIA Act 2022 provides that disputes among parties under the Act should first be referred to the Authority for mediation and conciliation. The Act specifically identifies HMOs, healthcare providers, contributors, and the Authority as parties that may be involved in such disputes.
Section 48 makes it an offence to fail to remit payments to healthcare providers within the period specified in the operational guidelines, fail to settle fee-for-service or other provider claims within the stipulated period, or fail to provide care to a duly registered enrollee.
These provisions suggest that the law itself recognises the possibility of disputes over payments, claims and access to care within the health insurance system. This means the tension playing out online between patients, healthcare providers and HMOs is not simply a question of patients “overusing” their insurance.
It also raises questions about whether the obligations imposed on each party are being fulfilled.
In other words, while enrollees are expected to understand the terms of their health plans and follow the applicable procedures, healthcare providers and HMOs also have obligations under the regulatory framework governing health insurance in Nigeria.
Insured patients still have rights.
Mr Akinboade said healthcare providers must recognise this distinction. Hospitals, he said, should have trained personnel who understand health insurance and can properly guide patients through the process.
He rejected the idea that insured patients should receive a lower standard of care because they are not paying directly at the point of treatment.
“Insurance patients are not secondary patients. They own the right to quality healthcare services,” he said.
That position is consistent with the NHIA’s own statement of enrollee rights. The Authority says Nigerians covered under its programmes have the right to easy access to quality healthcare without hindrance and to be treated with respect and dignity.
The distinction is particularly important in Nigeria, where health insurance coverage remains low, and households continue to shoulder a large share of healthcare costs.
A 2025 Nigeria Health Systems and Services Profile published through the African Health Observatory Platform, with World Health Organisation (WHO) involvement, reported that out-of-pocket spending accounted for more than 75 per cent of total health expenditure and estimated that only about five per cent of Nigerians were covered by health insurance, prepayment or other risk-pooling mechanisms.
In such a system, health insurance is intended to protect households from the financial consequences of illness.
Patients also have responsibilities.
Mr Akinboade said patients also need to understand the health insurance package they have enrolled in.
Different plans have different benefits, exclusions and limitations. Enrollees therefore need to understand the services covered by their plans, the facilities available to them and the procedures for referrals and authorisations.
Patients should also know how to report problems when care is delayed or denied. Mr Akinboade advised enrollees to keep the contact details of their HMO’s customer service or quality assurance unit and escalate complaints when necessary.
Health insurance, therefore, is not simply a card presented at a hospital. It is an arrangement that creates responsibilities for patients, healthcare providers and HMOs.
What needs to change
Improving the system will require action from all sides, Mr Akinboade said.
He added that HMOs need to process claims and pay healthcare providers promptly while ensuring that referrals and authorisations do not create unnecessary barriers to care.
Healthcare providers need trained insurance desk officers who understand the terms of different plans and can communicate them clearly to patients.
Regulators also need to enforce existing rules and impose consequences where organisations fail to meet their obligations.
Meanwhile, patients need to understand their benefits, exclusions and responsibilities and use available complaint mechanisms when they encounter problems.
The NHIA Act provides a framework for resolving disputes between HMOs, healthcare providers, contributors and the Authority, including mediation and conciliation.
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Médecins Sans Frontières (MSF) has warned that shortages of a lifesaving medicine are forcing medical teams to ration treatment for diphtheria patients in northern Nigeria, where more than 28,000 confirmed infections and 1,100 deaths have been reported this year.
The warning comes as figures attributed to the Nigeria Centre for Disease Control and Prevention (NCDC) show that the outbreak continues to spread, particularly among children who are unvaccinated or have not received all their recommended vaccine doses.
In a statement issued on Friday, MSF said supplies of diphtheria antitoxin (DAT), which neutralises the toxin responsible for potentially fatal complications, were dangerously low.
The organisation called on federal and state authorities, donors and international partners to urgently secure additional medicines and vaccines, ensure their timely clearance at ports and improve distribution to affected communities.
Treatment shortage threatens patients
MSF’s Medical Coordinator in Nigeria, David Kizito, warned that the shortage could compromise the treatment of severely ill patients.
“Our stocks are dangerously low, and we risk being unable to treat children and save lives as the outbreak continues,” he said.
Diphtheria is a vaccine-preventable bacterial infection that can cause fever, sore throat and a thick membrane in the throat, sometimes obstructing breathing. Severe infections can damage the heart, nerves and kidneys.
According to the World Health Organisation (WHO), diphtheria antitoxin neutralises toxins circulating in the bloodstream, while antibiotics help eliminate the bacteria and reduce transmission.
Early administration of antitoxin is particularly important because it cannot reverse damage once the toxin has entered body cells.
MSF said limited global production and inconsistent availability had left treatment facilities struggling to obtain adequate supplies.
However, the organisation did not specify which facilities had exhausted their stocks, how many patients had been unable to obtain treatment or whether any deaths were directly attributable to the shortages.
Nigeria records 1,126 deaths
The warning comes amid a prolonged outbreak that began in late 2022.
PREMIUM TIMES reports that a situation report issued on 11 November by the International Federation of Red Cross and Red Crescent Societies (IFRC) and the Nigerian Red Cross Society, citing NCDC data, indicates that Nigeria recorded 37,529 suspected diphtheria cases, 28,151 confirmed infections and 1,126 deaths in 2026 as of 7 November.
The report said the outbreak had affected 26 states and the Federal Capital Territory, covering 361 local government areas.
Kano accounted for 12,008 confirmed cases, approximately 43 per cent of the national total.
The figures are substantially higher than those in MSF’s latest statement, which relied on NCDC statistics from 9 August, when 406 deaths had been reported for 2026.
The difference reflects reporting from separate periods and may include subsequent updates to surveillance records.
Katsina: 70 severe cases in 18 days
In Katsina State, MSF reported managing 86 diphtheria cases between 26 October and 12 November, including 70 classified as severe and 16 as non-severe.
Severe infections accounted for approximately 81 per cent of the patients managed by its teams during the period, although the figures do not represent the severity of all diphtheria infections recorded across the state.
MSF said its teams also reached 1,315 contacts through surveillance and contact-tracing activities. Of these, 1,301 received vaccinations, while 1,311 were given preventive antibiotics.
The organisation did not provide the locations of the cases or a breakdown of recoveries and deaths.
The development follows earlier concerns about the capacity of health facilities to manage the outbreak.
On 31 August, PREMIUM TIMES reported that the Federal Teaching Hospital (FTH), Katsina, was struggling with an influx of suspected and confirmed diphtheria patients, leaving its children’s ward under considerable pressure.
The hospital attributed the overcrowding partly to referrals from other facilities across the state.
In response, the federal government announced an emergency multi-agency task force to strengthen surveillance, immunisation and access to treatment in Katsina and Kano.
The intervention included plans to supply additional antitoxin, antibiotics, medical personnel and protective equipment to FTH Katsina.
Authorities also announced plans to establish treatment annexes across Katsina’s three senatorial districts — Katsina, Daura and Funtua — to reduce pressure on the referral hospital.
MSF’s latest statement did not indicate whether those facilities had become operational or how much additional antitoxin had been delivered since the intervention was announced.
Zamfara vaccine shortage
In neighbouring Zamfara State, MSF said its supported facilities in Gusau recorded more than 671 diphtheria admissions over approximately one month beginning on 6 October.
Most patients were children, while four out of every five had not been vaccinated.
The organisation also reported a substantial shortfall in vaccine supplies for an emergency immunisation campaign.
Of the 90,000 doses required, only 25,000 had been supplied, representing approximately 28 per cent of the stated requirement.
MSF said it was working with government health authorities to secure the outstanding doses and expand vaccination activities.
The shortfall highlights the continuing difficulties facing efforts to protect children against the disease.
In October, PREMIUM TIMES reported that the Executive Director of the National Primary Health Care Development Agency (NPHCDA), Muyi Aina, said about 93 per cent of children affected by recent diphtheria outbreaks had not received their full recommended vaccine doses.
Mr Aina said some had never been vaccinated, while others had received fewer than the three recommended doses. He identified misinformation and vaccine hesitancy among the challenges affecting immunisation uptake.
MSF’s response
Despite the challenges, MSF said its teams had treated more than 9,000 diphtheria patients through facility-based and community interventions since the beginning of its 2026 response.
In Kano, the organisation supported vaccination campaigns in April and June, administering more than 835,000 doses to children in partnership with the state Ministry of Health.
READ ALSO: Meningitis: Anambra, Ebonyi, Enugu intensify vaccination, urge residents to stay hydrated
It also supported two vaccination rounds in Sokoto between February and April, reaching 49,018 children under 15.
The organisation said it was supporting treatment, surveillance, infection prevention and vaccination efforts in several northern states, alongside government health authorities.
MSF called for increased global production of diphtheria antitoxin and sustained investment in routine childhood immunisation to prevent further outbreaks.
The latest warning also draws renewed attention to the emergency measures announced by the federal government in August, particularly the delivery of antitoxin supplies and the proposed expansion of treatment facilities in Katsina.
The extent to which those interventions have improved access to treatment remains to be established.
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Women in northern Nigeria continue to bear a disproportionate burden of maternal deaths, with the Northwest and Northeast geopolitical zones accounting for about three-quarters of reported fatalities in health facilities, according to the 2026 Joint Annual Review (JAR) Statistical Book.
The report also highlights significant disparities in maternal health outcomes between rural and urban areas, with rural women recording a maternal mortality ratio of 656 deaths per 100,000 live births, compared with 444 deaths per 100,000 live births in urban areas.
Produced by the Federal Ministry of Health and Social Welfare, the report reviews the third year of implementation of the Health Sector Strategic Blueprint. It was presented at the third Nigeria Health Sector Joint Annual Review in Abuja on 10 November.
The findings highlight persistent inequalities in maternal healthcare access and outcomes, despite a reported decline in maternal deaths across health facilities nationally.
According to the report, Nigeria recorded thousands of maternal deaths in health facilities between January and September 2026, although the figures represent only deaths captured by the facility reporting system.
The ministry acknowledged that the figures could be underreported or overreported but described the data as reliable for monitoring trends in the health sector.
Maternal mortality remains high
Maternal mortality refers to the death of a woman during pregnancy, childbirth or within 42 days of the termination of pregnancy from causes related to or aggravated by the pregnancy or its management.
Most maternal deaths are preventable through timely access to quality antenatal care, skilled birth attendance, emergency obstetric services and appropriate postnatal care.
Despite the reported improvements, Nigeria’s maternal mortality ratio remains a major public health concern.
The JAR Statistical Book puts the country’s maternal mortality ratio at 572 deaths per 100,000 live births, significantly above the Sustainable Development Goal (SDG) target of fewer than 70 deaths per 100,000 live births by 2030.
The burden is particularly concerning given Nigeria’s contribution to global maternal deaths.
In its 2023 report, titled “Improving Maternal and Newborn Health and Survival and Reducing Stillbirths: Progress Report 2023”, the World Health Organisation (WHO) estimated that Nigeria recorded 82,000 maternal deaths, 181,000 stillbirths and 277,000 neonatal deaths in 2020.
The combined 540,000 deaths accounted for 12 per cent of global maternal, stillbirth and neonatal deaths, despite Nigeria contributing only six per cent of global live births.
The report ranked Nigeria second after India among countries with the highest combined burden of maternal deaths, stillbirths and neonatal deaths.
Reported maternal deaths decline
The JAR data indicate a downward trend in facility-reported maternal deaths over the review period.
The country recorded 5,391 maternal deaths in health facilities in 2024, compared with 4,455 in 2025.
The figure declined further in 2026, although the exact total requires confirmation against the final statistical table. The quarterly data also indicate improvements.
Following a peak in the second quarter of 2024, maternal deaths and the maternal mortality ratio generally declined. By the third quarter of 2026, the maternal mortality ratio had fallen to 128 deaths per 100,000 live births, representing a reduction of about 46 per cent from the earlier peak.
Maternal deaths during the same period also declined by approximately 40 per cent to 947.
However, these improvements have not been evenly distributed across the country.
Northern states bear the burden
According to the report, maternal deaths over the past three years were heavily concentrated in the Northwest and Northeast geopolitical zones.
By 2026, the two zones together accounted for approximately three-quarters of all documented maternal deaths in health facilities.
The five northern states with the highest maternal mortality burden were Kano, Borno, Jigawa, Yobe and Katsina.
While the national figures showed a downward trend, maternal deaths reportedly increased across the two northern zones, contrasting with reductions recorded in southern parts of the country.
ALSO READ: Faith leaders urged to confront beliefs, family decisions driving maternal deaths in Kano
In most southern states, fewer than 50 maternal deaths were reported. The states with the lowest recorded numbers included Osun (four deaths), Abia (five), Enugu (eight), Ekiti (nine), and Bayelsa (nine).
Maternal morbidity
Beyond deaths, the report also highlights the burden of maternal morbidity, including complications that can have lasting effects on women’s health, wellbeing and livelihoods. In 2026, approximately 3,060 women were diagnosed with vesicovaginal fistula (VVF), compared with 4,350 in 2025.
VVF is an abnormal opening between the bladder and vagina that can result in continuous, involuntary leakage of urine, often following prolonged or obstructed labour.
Of the women diagnosed in 2026, 1,737 underwent surgical repair, representing 56.8 per cent of those diagnosed. This was lower than in 2025, when 2,564 women (59 per cent) underwent repairs.
The Northwest and Northeast again recorded the highest burden, with 1,420 and 982 cases, respectively, in 2026. The figures underscore the need to strengthen access to emergency obstetric care, timely referrals and surgical treatment, particularly in underserved communities.
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