‘Nigeria Doesn’t Only Have a Coverage Problem. It Has a Protection Problem’ -Ilodigwe

Tolulope Oke

When the National Health Insurance Authority (NHIA) disclosed in September 2025 that only about 20 million Nigerians, roughly 10 percent of the population, currently carry any form of health insurance, the figure landed in Abuja with a familiar thud. After the 1999 NHIS Act, the 2014 National Health Act, the Basic Health Care Provision Fund (BHCPF), and the much-celebrated 2022 NHIA Act that finally made health insurance mandatory for every resident, the country is still asking the same question: why does coverage on paper translate so poorly into protection at the bedside?

Lucky Ilodigwe, a Nigerian-born Medicare Advantage strategy lead at Humana, a US-based health insurers. In this interview with ThisDay, he argues that the next phase of health reform at home is not about passing new laws, but about fixing how the system pays for care. ⸻

You have written that Nigeria has a protection problem, not just a coverage problem. What do you mean by this?

Ilodigwe: Coverage is a card in your wallet. Protection is what happens when you walk into a clinic with that card and a sick child. In Nigeria today those two things have come apart. I know federal civil servants enrolled in the Formal Sector Social Health Insurance Programme who are technically part of the 10 percent the NHIA counts as insured, and who still pay cash at the pharmacy counter, because the drug they need is not on the formulary, or the provider has not been reimbursed in four months, or the 10 percent co-payment on a stack of prescriptions is more than they have on them that morning. The system collected their premium. It did not transfer their risk. That gap, between being enrolled and being protected, is the real failure, and it is the one no new piece of legislation, by itself, can fix.

The fragmentation of schemes (NHIA at the centre, state agencies in Lagos, Kwara, Ogun, Delta, Kano, Enugu and elsewhere, private HMOs, BHCPF, community microinsurance) is often described as a strength of Nigerian federalism. You disagree.

Ilodigwe: I respect federalism. I do not believe federalism requires forty different risk pools. Insurance only works at scale: variance dominates the mean when the pool is small, and one bad quarter, a cluster of cancer claims or a dialysis spike, can break a state scheme. The NHIA’s own figure puts private HMO enrollment at just 1.8 million nationwide. Lagos State Health Management Agency, Kwara State Health Insurance Agency and their counterparts are doing important work, but each is, in actuarial terms, a small ship in heavy weather. Rwanda covers roughly 90 percent of its population through one community-based scheme with income-banded contributions. Ghana’s NHIS is funded by a 2.5 percent earmarked levy and covers a majority of Ghanaians. Both countries made an architectural choice early. Consolidate the pool, then differentiate delivery. Nigeria has done the opposite, and we are paying for it in instability.

You have also argued that Nigerian schemes pay for the wrong end of the disease. Could you shed more light on that?

Ilodigwe: Look at what we are actually treating. Nigeria still carries the unfinished communicable-disease agenda: malaria, tuberculosis, HIV, maternal haemorrhage, neonatal sepsis. But layered on top of that is a tide of non-communicable disease that is no longer optional to manage. The Nigerian Hypertension Society and successive Nigerian Heart Foundation surveys put adult hypertension prevalence in the 30 to 38 percent range, with awareness below one-third and control below 15 percent. Type 2 diabetes has roughly doubled in two decades. Sickle cell disease, of which Nigeria has more than any country in the world, needs lifelong outpatient management. These conditions are not won or lost in a hospital admission. They are won or lost in a primary-care clinic, every month, with a reliable supply of hydrochlorothiazide and metformin and a clinician who knows the patient. A scheme that pays generously for a stroke admission but stingily for the antihypertensive that would have prevented the stroke is, quite literally, financing the disease instead of the cure.

In September 2025 the NHIA Director-General, Dr. Kelechi Ohiri, announced a 93 percent increase in capitation rates and a 370 percent increase in service tariffs. Is that the breakthrough?

Ilodigwe: It is overdue and it is necessary, and I want to give Dr. Ohiri credit publicly for pushing it through. For years, capitation rates had drifted so far below the real cost of a primary-care visit that participating in the NHIA was, for many providers, a charitable act. When the economics of seeing an insured patient are worse than seeing a cash patient, the insured patient gets pushed to the back of the queue, gets refused at the counter, gets told the drug is ‘out of stock’ when it is not. The September 2025 reform begins to close that gap. But, and this is important, a tariff increase is a price; it is not yet a payment model. The harder work is blending capitation for primary care with case-based payments for hospital episodes and pay-for-performance bonuses tied to outcomes such as blood-pressure control or skilled birth attendance. Rwanda has been doing this with performance-based financing for over a decade. We know it works. We just have to build the data plumbing to do it honestly.

Roughly 80 percent of Nigerian workers are in the informal sector. How do you insure a Lagos market woman or an Onitsha trader?

Ilodigwe: You meet her where she is. The NHIA’s Group, Individual and Family Social Health Insurance Programme (GIFSHIP) is the right vehicle on paper. The execution challenge is enrolment and collection. A trader is not going to fill out a form in an HMO office in Victoria Island. But she is already on mobile money, she is already a member of an esusu or a market cooperative, and she already trusts the head of her trade association more than she trusts any government scheme. Kenya and Ghana have used mobile-money micro-payment rails to enrol the informal sector by the millions. Nigeria has the rails (NIBSS, mobile-money operators, USSD channels) and we have the cooperatives. We have not yet wired them together with NHIA enrolment. That is a 12-month project, not a 12-year one.

Where does the money come from? Federal health allocations have hovered around four to five percent of the budget for years, well short of the Abuja Declaration’s 15 percent target.

Ilodigwe: The premium base alone will not finance universal coverage in a country where most workers are not on a formal payroll. The Vulnerable Group Fund established under the 2022 NHIA Act is supposed to target 83 million indigent Nigerians, roughly 38 percent of the population, and it needs a far broader revenue base than appropriations alone. Ghana funds its NHIS through a 2.5 percent earmarked levy. The Philippines uses a sin tax on tobacco and alcohol that has raised billions of pesos for PhilHealth. Nigeria has the same instruments available: an earmarked health levy on tobacco, alcohol, sugar-sweetened beverages, and selected telecoms services would, by conservative modelling, finance a meaningful share of the VGF without touching the income tax. And then there is the diaspora, with roughly twenty billion US dollars in annual remittances. A small, well-governed diaspora health bond, with a credible benefit attached to a relative back home, is a serious untapped pool. I would buy one tomorrow.

Lucky Ilodigwe is a Medicare Advantage strategy lead at Humana Inc., one of the largest health insurers in the United States, based in Louisville, Kentucky. Prior to Humana, he was a strategy consultant at the Boston Consulting Group’s healthcare practice in the United States (2024–January 2026), where he advised national health plans, integrated delivery networks and life-sciences clients. He holds an MBA from the University of Chicago Booth School of Business (2024), where he concentrated in strategic management, economics and healthcare, and an undergraduate degree in medical biochemistry.