Uptake and Satisfaction with NHIA: A Study of Formal and Informal Sector Employees in Kano, Nigeria
Abstract:
Universal health coverage (UHC) is a global imperative, yet
Nigeria’s National Health Insurance Authority (NHIA) continues to reflect deep
inequalities, particularly between formal and informal sector workers. This cross-sectional comparative study surveyed 440 NHIA enrollees
(205 formal, 235 informal) from all 44 Local Government Areas in Kano State,
Nigeria, to assess NHIA uptake, satisfaction, and service utilization.
Participants were adults enrolled for ≥6 months and had accessed
NHIA-accredited outpatient services in the preceding three months. Socio-demographic
characteristics, enrollment pathways, satisfaction across financial and service
domains, and key predictors of satisfaction and continued enrollment were
analyzed. Formal sector workers reported higher NHIA awareness (87.3% vs.
83.0%), longer enrollment duration (≥7 years: 27.6% vs. 5.6%; p<0.001), and greater satisfaction across financial indicators
including co-payments (81.4% vs. 31.1%; p<0.001) and co-contributions (71.7% vs. 28.5%; p<0.001). While 98.5% of formal and 98.3% of informal
respondents desired to continue enrollment, informal enrollees were
significantly more likely to report neutrality on key satisfaction metrics.
Notably, informal respondents were more likely to believe that NHIA improved
their health (66.8% vs. 36.1%; p<0.001). Qualitative data
highlighted affordability, trust, and family coverage as motivators, but also
underscored persistent awareness and access barriers for informal workers. While satisfaction with NHIA services is high overall, structural
disparities persist between sectors. Formal workers benefit from embedded
payroll systems and employer facilitation, whereas informal enrollees face
awareness, affordability, and access barriers. Targeted reforms such as
simplified enrollment, premium subsidies, and expanded community outreach are
essential to achieve equitable UHC in Nigeria.
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