Project – Community Awareness and Uptake of the National Health Insurance Authority (NHIA): A Study of Households in Ikorodu LGA, Lagos State.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Health is a fundamental human right and an essential component of sustainable socioeconomic development. Access to affordable, quality healthcare enables individuals to live productive lives, reduces poverty, improves educational outcomes, and contributes to national development. However, in many low- and middle-income countries, including Nigeria, healthcare financing remains heavily dependent on out-of-pocket expenditure, exposing millions of households to catastrophic health spending and preventing vulnerable populations from accessing essential medical services (World Health Organization [WHO], 2023). Universal Health Coverage (UHC), one of the Sustainable Development Goals (SDG 3.8), seeks to ensure that all people receive needed health services without suffering financial hardship, making health insurance a critical instrument for achieving equitable healthcare access.

Globally, health insurance has evolved as one of the most effective healthcare financing mechanisms for reducing direct medical costs and improving healthcare utilization. Countries with well-developed national health insurance systems have demonstrated improved maternal and child health outcomes, increased preventive healthcare utilization, reduced avoidable mortality, and greater financial protection for vulnerable populations. The World Health Organization emphasizes that expanding health insurance coverage is indispensable for achieving Universal Health Coverage because it pools health risks across populations and minimizes the economic burden associated with illness (WHO, 2023).

In Nigeria, healthcare financing has historically been characterized by high out-of-pocket payments. For decades, households have paid directly for consultations, medications, laboratory investigations, surgeries, and hospital admissions, resulting in financial hardship for many families. Studies have consistently shown that out-of-pocket expenditure accounts for more than two-thirds of total health expenditure in Nigeria, making the country one of the highest globally in direct household healthcare financing (Aregbeshola & Khan, 2018). This financing structure disproportionately affects low-income households, particularly those in urban informal settlements and rural communities where health insurance penetration remains relatively low.

Recognizing these challenges, the Nigerian government introduced the National Health Insurance Scheme (NHIS) in 2005 with the objective of improving access to affordable healthcare through social health insurance. Despite nearly two decades of implementation, enrollment under the NHIS remained limited, covering primarily federal civil servants and employees within the formal sector. Consequently, less than 10% of Nigerians were enrolled in health insurance before the introduction of the National Health Insurance Authority Act, leaving the overwhelming majority of citizens, especially those in the informal sector, without financial protection against healthcare costs.

populationmedicine.eu+1

A major policy transformation occurred in May 2022 when Nigeria enacted the National Health Insurance Authority (NHIA) Act, replacing the former NHIS Act. The NHIA Act established the National Health Insurance Authority as the regulatory institution responsible for promoting, integrating, and supervising all health insurance schemes operating within Nigeria. More importantly, the Act made health insurance mandatory for every Nigerian and legal resident, with special provisions for vulnerable groups through the Vulnerable Group Fund and the Basic Health Care Provision Fund. This legislative reform represents one of the most significant healthcare financing policies in Nigeria’s history and provides the legal framework for accelerating Universal Health Coverage.

Nigerian Health Insurance Authority+2

The NHIA differs substantially from its predecessor by extending coverage beyond the formal sector to include self-employed individuals, traders, artisans, market women, transport workers, students, rural residents, unemployed persons, and other members of the informal economy. The Act encourages state-supported health insurance schemes, private health insurance plans, community-based health insurance, and the Group, Individual and Family Social Health Insurance Programme (GIFSHIP), thereby expanding multiple pathways through which households can obtain health insurance coverage. According to Ipinnimo et al. (2022), the NHIA represents a paradigm shift from voluntary insurance participation toward a comprehensive national system designed to achieve equitable healthcare access.

Despite the robust legal framework established by the NHIA Act, legislation alone does not automatically translate into increased enrollment or utilization. Public awareness remains one of the strongest determinants of health insurance uptake. Community awareness refers to the extent to which individuals possess adequate knowledge regarding the existence, objectives, benefits, eligibility requirements, enrollment procedures, premium structure, accredited healthcare providers, and rights associated with a health insurance programme. Without sufficient awareness, households may misunderstand the scheme, perceive insurance as unnecessary, distrust government programmes, or remain excluded despite being eligible for enrollment.

Health behaviour theories suggest that awareness significantly influences healthcare decision-making. The Health Belief Model argues that individuals are more likely to adopt preventive health behaviours, including health insurance enrollment, when they perceive susceptibility to illness, recognize the benefits of preventive action, and possess sufficient knowledge about available interventions (Rosenstock et al., 1988). Similarly, Andersen’s Behavioural Model of Health Service Utilization identifies knowledge, enabling resources, and perceived need as critical determinants of healthcare utilization. Applied to the NHIA, these frameworks imply that community awareness is likely to influence households’ willingness to enroll and continuously utilize health insurance services.

Lagos State occupies a strategic position within Nigeria’s healthcare system because it has the largest urban population and one of the most developed subnational health insurance structures through the Lagos State Health Scheme (LSHS), popularly known as ILERA EKO. The Lagos State Health Management Agency collaborates with the NHIA to expand health insurance coverage among residents through accredited primary healthcare centres, private hospitals, and community enrollment initiatives. The integration of state and national insurance programmes provides households with multiple opportunities for accessing affordable healthcare while advancing Universal Health Coverage within Lagos State.

Wikipedia

Within Lagos State, Ikorodu Local Government Area presents an important context for studying community awareness and NHIA uptake. Ikorodu is one of the fastest-growing urban and peri-urban LGAs, characterized by rapid population growth, expanding informal settlements, diverse socioeconomic groups, vibrant commercial activities, and increasing demand for healthcare services. The LGA comprises civil servants, traders, artisans, transport operators, market women, entrepreneurs, and low-income households whose health insurance decisions are influenced by income, education, occupation, access to information, and trust in public institutions. As the NHIA expands toward mandatory national coverage, understanding awareness and enrollment patterns among households in Ikorodu becomes increasingly important for effective policy implementation.

Community awareness is particularly significant because health insurance enrollment is not merely an administrative exercise but a behavioural and social process requiring effective communication, public education, and community engagement. Information dissemination through radio, television, social media, religious organizations, community development associations, healthcare workers, traditional rulers, and market associations can substantially influence households’ understanding of NHIA benefits. Where awareness campaigns are inadequate, misconceptions regarding premiums, eligibility, quality of care, waiting periods, and provider choice may discourage enrollment even among eligible households.

Furthermore, socioeconomic inequality continues to influence health insurance participation in Nigeria. Households with higher educational attainment and stable income are generally more likely to understand insurance concepts and enroll than poorer households operating within the informal economy. Women, elderly persons, persons living with disabilities, and vulnerable families often experience additional barriers related to affordability, information access, digital literacy, and administrative registration processes. Consequently, evaluating community awareness alongside uptake provides valuable evidence for designing equitable health insurance interventions.

Recent implementation efforts by the NHIA have intensified public sensitization and operationalization of mandatory health insurance across federal and state institutions. Government directives issued after the NHIA Act emphasize nationwide enrollment, stronger collaboration with state health insurance agencies, and expansion of coverage to underserved populations. However, the effectiveness of these reforms ultimately depends on whether ordinary households understand and participate in the scheme.

Nigerian Health Insurance Authority+1

Although Nigeria has made substantial legislative progress toward Universal Health Coverage through the NHIA Act, the realization of its objectives depends largely on community acceptance, awareness, and household enrollment. Therefore, examining the relationship between community awareness and NHIA uptake among households in Ikorodu Local Government Area provides important evidence for strengthening health insurance implementation and improving healthcare access in Lagos State and Nigeria as a whole.

1.2 Statement of the Problem

Access to affordable healthcare remains a major public health challenge in Nigeria despite numerous healthcare financing reforms. The high dependence on out-of-pocket payment continues to expose households to catastrophic health expenditure, delayed treatment, poor healthcare utilization, and increased vulnerability to poverty. In response, the Nigerian government enacted the National Health Insurance Authority (NHIA) Act in 2022, making health insurance mandatory for all Nigerians and legal residents while expanding coverage to vulnerable and informal sector populations. The Act was specifically designed to accelerate Universal Health Coverage by ensuring equitable access to quality healthcare irrespective of socioeconomic status.

Nigerian Health Insurance Authority+1

However, the existence of a comprehensive legal framework does not necessarily guarantee widespread enrollment or utilization. Evidence suggests that health insurance coverage in Nigeria remains relatively low, particularly among households within the informal sector that constitutes the majority of the nation’s workforce. Many families continue to finance healthcare directly because they are either unaware of the NHIA, uncertain about enrollment procedures, skeptical about government insurance programmes, or inadequately informed about the benefits available under the scheme.

populationmedicine.eu

In Lagos State, although the Lagos State Health Scheme (ILERA EKO) complements the objectives of the NHIA, disparities persist in public awareness and health insurance participation across communities. Ikorodu Local Government Area has experienced rapid urbanization and population expansion, creating increased demand for accessible healthcare services. Nevertheless, anecdotal observations indicate that many households still rely on self-medication, patent medicine vendors, traditional treatment, or delayed hospital visits due to financial constraints, suggesting that health insurance uptake may not be commensurate with available opportunities.

Previous studies on health insurance in Nigeria have largely focused on healthcare workers, civil servants, formal sector employees, maternal healthcare utilization, and policy implementation. Comparatively fewer empirical studies have specifically examined how community awareness influences household uptake of the National Health Insurance Authority within rapidly urbanizing local government areas such as Ikorodu. More importantly, the transition from the former NHIS to the NHIA introduces new policy provisions—including mandatory enrollment and expanded informal sector coverage—that require fresh empirical investigation at the household level.

Furthermore, inadequate awareness may undermine government investments in Universal Health Coverage because households cannot enroll in programmes they do not sufficiently understand. Without empirical evidence on the level of community awareness, determinants of enrollment, barriers to participation, and factors influencing household uptake, policymakers may struggle to design effective communication and enrollment strategies tailored to local communities.

It is against this background that this study investigates Community Awareness and Uptake of the National Health Insurance Authority (NHIA): A Study of Households in Ikorodu Local Government Area, Lagos State.

1.3 Aim of the Study

The main aim of this study is to examine the relationship between community awareness and the uptake of the National Health Insurance Authority (NHIA) among households in Ikorodu Local Government Area, Lagos State.

1.4 Objectives of the Study

The specific objectives are to:

1. assess the level of community awareness of the National Health Insurance Authority (NHIA) among households in Ikorodu LGA;

2. determine the level of NHIA uptake among households in Ikorodu LGA;

3. identify the factors influencing household uptake of the NHIA; and

4. examine the relationship between community awareness and NHIA uptake among households in Ikorodu LGA.

1.5 Research Questions

The study seeks to answer the following questions:

1. What is the level of community awareness of the National Health Insurance Authority among households in Ikorodu LGA?

2. What is the level of NHIA uptake among households in Ikorodu LGA?

3. What factors influence household uptake of the NHIA in Ikorodu LGA?

4. What relationship exists between community awareness and NHIA uptake among households in Ikorodu LGA?

1.6 Research Hypothesis

Null Hypothesis (H₀):

There is no significant relationship between community awareness and the uptake of the National Health Insurance Authority (NHIA) among households in Ikorodu Local Government Area, Lagos State.

1.7 Significance of the Study

This study will be valuable to several stakeholders within Nigeria’s health sector.

National Health Insurance Authority (NHIA): The findings will provide empirical evidence regarding public awareness, enrollment behaviour, and barriers affecting household participation, thereby supporting improved policy implementation and communication strategies.

Lagos State Health Management Agency (LASHMA): The study will assist the agency in strengthening ILERA EKO enrollment campaigns, community mobilization, and collaboration with the NHIA to expand health insurance coverage across Ikorodu communities.

Public Health Policymakers: Evidence generated will support decisions relating to Universal Health Coverage, healthcare financing, social protection, and equitable access to healthcare among informal sector households.

Healthcare Providers: Accredited primary healthcare centres and hospitals will better understand factors affecting patients’ enrollment decisions and develop more effective community engagement strategies.

Community Development Associations and Civil Society: The study will highlight the importance of grassroots awareness campaigns through religious institutions, market associations, youth organizations, and traditional leadership structures.

Researchers and Students: The research will contribute to the growing literature on health insurance awareness, healthcare financing, and Universal Health Coverage in Nigeria while serving as a reference for future academic studies.

1.8 Scope of the Study

This study focuses on community awareness and uptake of the National Health Insurance Authority (NHIA) among households in Ikorodu Local Government Area, Lagos State.

Conceptually, the study examines community awareness, household enrollment, uptake determinants, and the relationship between awareness and participation in the NHIA. Geographically, the research is limited to selected households within Ikorodu LGA. The study is situated within the contemporary implementation period of the NHIA Act (2022–2026), reflecting the ongoing expansion of mandatory health insurance in Nigeria.

1.9 Operational Definition of Terms

Community Awareness: The extent to which households possess knowledge and understanding of the National Health Insurance Authority, including its objectives, benefits, eligibility, enrollment procedures, and healthcare services.

NHIA: The National Health Insurance Authority established by the NHIA Act 2022 to regulate, promote, and integrate health insurance schemes toward achieving Universal Health Coverage in Nigeria.

Uptake: The degree to which eligible households enroll in and utilize services provided under the National Health Insurance Authority.

Household: A person or group of persons living together under the same roof who share common living arrangements and healthcare decision-making.

Health Insurance: A healthcare financing mechanism through which individuals or families contribute premiums or receive subsidized coverage in exchange for access to specified healthcare services.

Universal Health Coverage (UHC): A health system objective ensuring that all people receive quality health services without experiencing financial hardship.

Informal Sector: Economic activities involving self-employed individuals, traders, artisans, market women, transport workers, and other workers outside formal wage employment who constitute a major target population for NHIA expansion.

Project – Community Awareness and Uptake of the National Health Insurance Authority (NHIA): A Study of Households in Ikorodu LGA, Lagos State.