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    Nigeria: Closing Nigeria’s Insurance Gap for Maternal and Child Through Health Impact Bonds.

    OneAfricaYTBy No Comments7 Mins Read
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    Chinwendu Iroegbu and Prudence Enema (Lead writers)

    A recent study drawing on data from the 2018 Nigeria Demographic and Health Survey (NDHS) examined the relationship between women’s access to health insurance and maternal mortality. The findings were significant, for every 1% increase in health insurance enrolment among women, maternal mortality dropped by more than 50%. This raises an important question, if inadequate funding has been a bottleneck in Nigeria’s health sector, what possibilities might emerge if the model of health financing were reimagined?

    This is where innovative approaches such as Health Impact Bonds come in. Health Impact Bonds are an innovative financing model that links funding directly to measurable health outcomes. “A Health Impact Bond is essentially a results-based financing tool,” explained Njide Ndili, Country Director of PharmAccess Nigeria. “Private investors or institutions put up money up-front for a specific health outcome. If that outcome is achieved, the public sector repays the investor with a return.”

    In other words, the government only pays when results are delivered. The risk shifts from the public to the private sector, but accountability is integrated. Ndili offers a practical example: “Let’s say we want to enrol 500,000 pregnant women into health insurance. An investor provides the money upfront to pay their premiums. If that target is achieved, the government repays the investor, plus an agreed return of about 10-20%.”


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    This is not theory. Similar models have worked before:

    • In Cameroon, a Development Impact Bond (DIB) mobilised $800,000 to scale up Kangaroo Mother Care (KMC), a proven intervention where premature or low-birthweight babies are kept in constant skin-to-skin contact with their mothers. The bond supported 10 hospitals to expand KMC services, with financing tied to clear health outcomes, such as hospitals working towards measurable targets for instance exclusive breastfeeding rates and infant survival. The programme exceeded these targets, demonstrating that outcome-linked financing can drive efficiency and accountability in maternal and newborn care.
    • In India, impact bonds have been used to tackle maternal mortality by linking funding to service uptake and health outcomes. The model incentivised providers to improve the quality and reach of maternal health services with financing disbursed only when targets were met, for example, reductions in maternal deaths or increases in accessed antenatal care, facility deliveries, and skilled birth attendance. This mechanism ensured that money was not just spent, but spent effectively, translating directly into lives saved.

    For Nigeria, where maternal mortality remains among the highest in the world, Health Impact Bonds could make a difference. By funding insurance premiums for pregnant women and tying reimbursements to outcomes like skilled deliveries and immunisation, every naira spent could saves lives. If progress is to be made, policymakers must prioritise results-based financing that delivers both accountability and impact for mothers and newborns.

    The reality of childbirth in Nigeria

    Every year, about 7 million Nigerian women give birth, yet less than 5% have health insurance coverage to help them navigate the costs of maternal care. This gap contributes to high out-of-pocket spending that often pushes many families deeper into poverty. With Nigeria accounting for around 20% of global maternal deaths and 25% of under-five deaths, the need for sustainable health financing solutions cannot be overstated.

    The numbers paint a stark picture. In 2023 alone, over 75,000 Nigerian women died from pregnancy-related complications, making up nearly a quarter of global maternal deaths. Meanwhile, only 10% of Nigerians are covered by any form of health insurance, leaving most families vulnerable to catastrophic health costs.

    These financial barriers are life-altering. Women without health insurance are less likely to attend the four antenatal visits recommended by WHO and more likely to give birth outside health facilities, putting both mother and child at greater risk.

    Behind these numbers are real families, like the mother in Suleja who did not deliver in a maternity ward, but in a crowded female ward because her local primary healthcare centre (PHC) had only one delivery couch for dozens of women, or the families in rural communities who delay seeking care, not because treatment is unavailable, but because it is unaffordable.

    These are not isolated stories; they are the everyday struggles of millions of Nigerians and until health financing meets people where they are, those struggles will continue.

    What Must Change

    1. Expand coverage beyond civil servants: The National Health Insurance Authority (NHIA) still reaches only a fraction of Nigerians, mostly formal sector employees. The informal sector, about 92.2% of the labour force, remains largely uninsured as many workers lack regular payrolls employer ties. Government programmes, including the Vulnerable Group Fund designed to insure those who cannot afford it, and initiatives such as the Vesicovaginal Fistula (VVF) programme, exist but are far from sufficient. Low awareness of how health insurance works, coupled with cultural and religious reluctance to pay in advance when not sick, also limits enrolment . For health insurance to succeed, it must move from being a piece of legislation to being an everyday reality. This will require aggressive awareness campaigns, clear benefit packages, and simplifying enrolment processes so people feel health insurance is as normal as buying mobile airtime.
    2. Domestic financing must step up: For far too long, Nigeria’s health system has leaned heavily on donor funds, but this is not sustainable. Domestic financing, through budget prioritisation, innovative taxes, and efficient use of the Basic Health Care Provision Fund (BHCPF), is critical. Without these, even the best-designed insurance schemes risk collapse. Countries that have made progress, like Ghana and Rwanda, did so by putting domestic funding behind health insurance.
    3. The system must be built on trust: Many Nigerians hesitate to pay premiums because they lack of confidence in public institutions. For health insurance reform to succeed, people need to trust the system. This trust comes when the scheme is transparent about how funds are used, have strong oversight, and gives communities a voice in decision-making. When people see these safeguards in place, they are far more likely to enrol and continue paying their premiums.
    4. Health insurance must go beyond the urban areas: Access to insurance is still largely an urban privilege In Nigeria, about 45.7% of the population lives in rural areas. And these communities are frequently excluded from health insurance coverage. Reform must intentionally expand inclusion in underserved areas through models like community-based health insurance, partnerships with local cooperatives, and ensuring that primary health centres (PHCs) are equipped and duly reimbursed for insured patients. Without this rural integration, Universal Health Coverage (UHC) will remain unfulfilled.