Health Insurance Utilization in Rivers State, Nigeria
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Abstract
About This Research Topic
Rivers State is one of Nigeria's wealthiest states, powered by oil and gas revenue and a thriving urban economy in Port Harcourt. Yet wealth alone hasn't solved its health insurance problem. Most households in the state, like most households across Nigeria, still pay for healthcare out of their own pockets, exposed to exactly the kind of financial shock that health insurance is meant to prevent. That contradiction, high income sitting alongside low coverage, is what this article sets out to explain.
Drawing on a household survey conducted across Port Harcourt Municipal and Obio-Akpor Local Government Areas, this piece looks at who actually enrols in health insurance, who doesn't, why, and, just as importantly, whether the people who do enrol actually use their coverage. For readers interested in how this kind of household-level economic research is put together, our sample research projects library includes comparable studies across economics and related disciplines.
The findings carry weight well beyond Rivers State. They speak directly to Nigeria's push toward Universal Health Coverage and to a policy question that keeps resurfacing nationally: if income isn't the main barrier, what is? The sections below unpack the background to the problem, the study's approach, and what it suggests for closing the coverage gap.
Main Abstract
Health insurance is one of the central mechanisms for achieving Universal Health Coverage, protecting households from the kind of catastrophic financial hardship that a sudden illness can bring. Despite the creation of Nigeria's National Health Insurance Authority and various state-level schemes, enrolment nationally remains strikingly low, with fewer than 5 percent of Nigerians covered by any formal health insurance. Rivers State, despite ranking among Nigeria's wealthiest oil-producing states, mirrors this national picture: coverage clusters almost entirely within formal employment, leaving the much larger informal sector almost entirely uninsured.
This study examined the socioeconomic, attitudinal, and structural factors shaping health insurance enrolment and utilization among 348 households in Port Harcourt Municipal and Obio-Akpor Local Government Areas of Rivers State. Using a cross-sectional survey design, a structured 32-item household questionnaire was administered between October and December 2024. The study looked at two distinct outcomes: whether a household had enrolled in any formal health insurance scheme, and whether enrolled households had actually used their covered services in the past year.
Of the households surveyed, 120 (34.5 percent) had some form of health insurance enrolment. Among the 228 uninsured households, the inability to afford premium contributions was the single biggest barrier (43.0 percent), followed by simply not knowing which schemes were available (31.6 percent). Even among the 120 enrolled households, only 73 (60.8 percent) had actually used their covered services in the past 12 months, held back mainly by long facility waiting times (41.3 percent) and poor drug availability (30.4 percent).
Logistic regression identified formal sector employment, household monthly income, awareness of NHIA schemes, perceived quality of care, and education level as significant independent predictors of enrolment, while gender showed no significant effect once other factors were accounted for. A willingness-to-pay analysis found that households were, on average, willing to pay less per month than the current formal sector premium charged by the Rivers State Contributory Health Commission, pointing to a subsidy gap that a targeted government subsidy could realistically close.
Based on these findings, the study recommends mandatory employer-based enrolment across formal sector businesses, a subsidised enrolment pathway for informal sector workers, quality improvements at NHIA-accredited facilities, and a targeted awareness campaign reaching informal workers in markets, motor parks, and religious institutions. Together, these recommendations offer a data-driven route toward expanding health insurance coverage in Rivers State and moving closer to the Universal Health Coverage goal.
Chapter One Preview
Background to the Study
Universal Health Coverage, as the World Health Organization defines it, means everyone can get the health services they need without being pushed into financial hardship to pay for them. It sits at the heart of Sustainable Development Goal 3.8 and is one of the most ambitious health policy goals of this century. Reaching it depends on two things happening together: people being able to access essential care, and that care not costing so much that it threatens their financial security. Health insurance, through pooling risk across a wide population, is the main tool health systems use to try to deliver both at once.
Globally, at least one billion people face catastrophic health expenditure every year, spending more than 10 percent of their household budget out of pocket on healthcare. Around 100 million of them are pushed into extreme poverty as a direct result. Sub-Saharan Africa carries a disproportionate share of this burden. Despite holding only around 14 percent of the world's population, the region accounts for more than 40 percent of global out-of-pocket health spending as a share of total health expenditure, a reflection of chronically underfunded public health systems and thin insurance coverage.
Nigeria is a particularly stark example of this problem. Despite being Africa's largest economy and most populous country, Nigeria's health financing still leans heavily on out-of-pocket payments, which make up roughly 70 to 75 percent of total health spending, far above the WHO's recommended ceiling of below 20 percent for a system to realistically achieve universal coverage. Government health spending remains below 1 percent of GDP, well short of the 15 percent of national budget African Union member states, including Nigeria, committed to under the 2001 Abuja Declaration. More than two decades on, Nigeria has never spent more than 6 percent of total government expenditure on health.
The National Health Insurance Authority, established through the NHIA Act of 2022, replaced the earlier National Health Insurance Scheme and represents Nigeria's main legislative framework for expanding coverage. The 2022 Act marked real progress over its predecessor: it mandated insurance for both formal and informal sector workers rather than restricting coverage to formal employment, set out a Basic Minimum Package of Health Services, created a Vulnerable Group Fund for the most disadvantaged, and gave state governments more room to run their own complementary schemes.
Even so, implementation has lagged well behind the legislation. As of 2024, fewer than 5 percent of Nigeria's roughly 220 million people are enrolled in any formal health insurance scheme, one of the lowest rates in Africa and well under the sub-Saharan African average of around 12 percent. Coverage remains concentrated among federal and state government employees and a slice of formal private sector workers in major cities, while the roughly 80 million Nigerians working in the informal economy, traders, artisans, farmers, transport and domestic workers, remain almost entirely outside the system.
Rivers State sits in an odd position within this picture. As one of Nigeria's wealthier states, fuelled by oil and gas revenue and a diversified urban economy centred on Port Harcourt, average household incomes run well above the national norm, and the state hosts a sizeable formal sector across oil and gas, banking, law, and the public service. Yet its health insurance coverage mirrors the national trend: the Rivers State Contributory Health Commission, established under a 2017 state law, covered only around 8 percent of the state's estimated 8 million residents as of 2023, mostly formal sector and government workers.
This raises a genuinely interesting question. If income were the main barrier to health insurance uptake, Rivers State's relative wealth should translate into meaningfully higher coverage than poorer states. That it doesn't suggests other factors, awareness gaps, distrust of the quality of care at accredited facilities, labour market structure, and attitudinal barriers, are doing much of the work in keeping coverage low, independent of income. This study set out to identify and measure those factors directly, alongside a related and often overlooked problem: even among households that do enrol, a meaningful share never actually use the benefits they're paying for, undermining the financial protection insurance is supposed to provide.
Statement of the Problem
Despite the Rivers State Contributory Health Commission's establishment in 2017 and the national NHIA Act of 2022, health insurance coverage in Rivers State remains concentrated in formal employment and is nearly absent among the informal sector majority that makes up most of the state's economically active population. The 34.5 percent enrolment rate found in this study's urban sample, while well above the national average, still reflects a concentration of coverage in the state's two most economically active and urbanised Local Government Areas, suggesting the true statewide picture, including rural areas, is likely worse.
Multiple overlapping barriers constrain both enrolment and utilization. On the demand side, the inability to afford premiums, low awareness of available schemes, and limited trust in the quality of care at accredited facilities all hold enrolment back. On the supply side, service quality, drug availability, and waiting times at accredited facilities discourage even enrolled households from actually using their coverage, a distinct and often underexamined programme failure in its own right.
Much of the existing research on health insurance determinants in Nigeria relies on national-level data that doesn't capture the specific dynamics of high-income, oil-producing states like Rivers State, where a large formal sector, an even larger informal economy, and locally specific attitudes toward insurance may diverge meaningfully from national averages. This study addresses that gap directly, at the household level, in the state's most economically active LGAs.
Aim and Objectives of the Study
The primary aim of this study is to analyse the socioeconomic, attitudinal, and structural determinants of health insurance enrolment and utilization among households in Port Harcourt Municipal and Obio-Akpor LGAs of Rivers State, Nigeria.
Specifically, the study seeks to:
● Determine the proportion of sampled households enrolled in any formal health insurance scheme and characterise the distribution across scheme types.
● Describe the sociodemographic and economic profile of insured versus uninsured households.
● Identify the barriers to health insurance enrolment among currently uninsured households.
● Assess the utilization rate of covered services among enrolled households and identify barriers to utilization.
● Analyse catastrophic health expenditure incidence and its relationship to insurance status.
● Develop a logistic regression model identifying independent significant determinants of health insurance enrolment.
● Estimate households' willingness to pay for health insurance using the double-bounded contingent valuation method.
● Make evidence-based policy and programme recommendations for expanding health insurance coverage in Rivers State.
Research Questions
The study is guided by the following research questions:
● What proportion of households in Port Harcourt Municipal and Obio-Akpor LGAs are enrolled in formal health insurance, and which scheme types are most common?
● What are the primary barriers to health insurance enrolment among currently uninsured households?
● What is the utilization rate of covered services among enrolled households, and what barriers prevent utilization?
● Which household-level factors are independently and significantly associated with health insurance enrolment?
● What is the mean willingness to pay for health insurance among currently uninsured households, and how does it compare with current RSCHC premium levels?
Significance of the Study
This study offers value at several levels. For the NHIA and RSCHC, it provides direct evidence on which household groups current scheme designs underserve, and which barriers most urgently need attention. The willingness-to-pay analysis offers a technically grounded, locally calibrated premium benchmark for building out an informal sector enrolment module.
On policy, the finding that formal sector employment is by far the strongest predictor of enrolment underscores a structural weakness in payroll-based premium collection for reaching informal workers, strengthening the case for community-based contribution mechanisms paired with government subsidies for lower-income households.
Academically, the study adds to the still-limited literature on health insurance determinants in Nigerian states that combine relatively high income with a large informal sector, a profile increasingly common as Nigerian cities grow. It offers a replicable methodology for health insurance demand analysis in other oil-producing states. Students working on similar quantitative economics or public health research can get direct feedback on survey design and regression modelling through our research coaching service, where experienced researchers work one-on-one with students on projects like this one.
At a broader level, by quantifying catastrophic health expenditure among uninsured households and estimating the subsidy gap needed to make coverage accessible, the study grounds its policy recommendations in the lived financial reality facing Rivers State households, not just in abstract economic modelling.
Scope of the Study
The study is geographically restricted to Port Harcourt Municipal and Obio-Akpor Local Government Areas of Rivers State, Nigeria, selected because they represent the state's most economically active and populous areas, spanning both formal and large informal sector populations. The survey was conducted between October and December 2024. The unit of analysis is the household, defined as a group of individuals sharing a dwelling and eating from the same pot, and both insured and uninsured households were included in the sample.
Operational Definition of Terms
Health Insurance Enrolment: Active membership in any formal health insurance scheme at the time of the survey, including NHIA/NHIS, RSCHC, employer-based insurance, or private commercial health insurance.
Health Insurance Utilization: The actual use of healthcare services covered by the enrolled insurance scheme in the 12-month period preceding the survey, verified through facility attendance records or self-report.
Catastrophic Health Expenditure (CHE): Out-of-pocket spending on healthcare that exceeds 10% of total household consumption expenditure in the past 12 months, representing a commonly used threshold for financial catastrophe from health costs.
Willingness to Pay (WTP): The maximum monthly premium contribution a household head is willing to make for a defined health insurance benefit package, elicited using the double-bounded dichotomous choice contingent valuation method.
Formal Sector: Employment characterised by a formal employment contract, regular salary, tax registration, and eligibility for statutory deductions including pension and health insurance contributions.
Informal Sector: Economic activities conducted outside formal employment relationships, including petty trading, artisanship, transport operation, food vending, and domestic work, typically without formal employment contracts or social security coverage.
NHIA: National Health Insurance Authority, established by the NHIA Act of 2022, responsible for regulating and expanding health insurance coverage across Nigeria.
RSCHC: Rivers State Contributory Health Commission, the state-level agency managing Rivers State's contributory health insurance scheme, established under the Rivers State Health Contributory Management Agency Law of 2017.
Premium Subsidy Gap: The difference between the actuarially fair premium for a defined health insurance benefit package and the mean willingness to pay of target beneficiaries, representing the per-household government subsidy required to make insurance financially accessible.
Adverse Selection: The tendency of individuals with higher expected healthcare costs to disproportionately seek health insurance coverage, which can undermine the financial viability of voluntary health insurance schemes without universal mandatory participation.
Conclusion
Rivers State's health insurance gap isn't really an income problem, it's a coverage design problem. Formal sector employment, awareness of available schemes, and trust in the quality of care at accredited facilities all shape whether a household enrols, and even enrolled households often don't use the coverage they're paying for. Closing this gap will take more than economic growth; it requires purpose-built outreach and subsidy mechanisms for the informal majority, and real quality improvements at the facility level so that enrolment actually translates into care. Readers interested in related economic and policy research can browse more economics project topics for further reading.
Frequently Asked Questions (FAQs)
What percentage of households in Rivers State have health insurance?
Among the households surveyed in Port Harcourt Municipal and Obio-Akpor LGAs, 34.5 percent had some form of formal health insurance enrolment, well above Nigeria's national average of under 5 percent, but still leaving the majority of households uninsured.
Why do most uninsured households in Rivers State lack health insurance?
The leading barrier was the inability to afford premium contributions, cited by 43.0 percent of uninsured households, followed by a lack of awareness of available schemes, cited by 31.6 percent.
Do enrolled households actually use their health insurance?
Not always. Only 60.8 percent of enrolled households had used their covered services in the past 12 months, held back mainly by long facility waiting times and poor drug availability at accredited facilities.
What factors predict whether a household enrols in health insurance?
Formal sector employment, household monthly income, awareness of NHIA schemes, perceived quality of care, and education level all emerged as significant independent predictors of enrolment, while gender was not significant after adjustment.
What is the NHIA, and how is it different from the old NHIS?
The National Health Insurance Authority (NHIA), established by the NHIA Act of 2022, replaced the earlier National Health Insurance Scheme. It extended mandatory coverage to informal sector workers, created a Basic Minimum Package of Health Services, and established a Vulnerable Group Fund for indigent populations.
What is the Rivers State Contributory Health Commission (RSCHC)?
RSCHC is the state agency managing Rivers State's own contributory health insurance scheme, established under a 2017 state law. As of 2023, it covered only around 8 percent of the state's estimated population, mostly formal sector and government workers.
How much are Rivers State households willing to pay for health insurance?
The study found a mean willingness to pay of about 3,420 naira per household per month, notably below the current RSCHC formal sector premium of 4,800 naira, pointing to a subsidy gap that government support could help close.
What is catastrophic health expenditure?
Catastrophic health expenditure refers to out-of-pocket healthcare spending that exceeds 10 percent of a household's total consumption expenditure in a year, a widely used threshold for identifying financially devastating health costs.
Why does Rivers State have low health insurance coverage despite being a wealthy state?
Income alone doesn't explain the gap. Awareness deficits, limited trust in the quality of care at accredited facilities, the structure of the informal labour market, and attitudinal barriers all play significant independent roles in keeping enrolment low regardless of household wealth.
What policy changes could improve health insurance coverage in Rivers State?
Recommended measures include mandatory employer-based enrolment for formal sector businesses, a subsidised enrolment pathway for informal sector workers, quality improvements at NHIA-accredited facilities, and targeted awareness campaigns in markets, motor parks, and religious institutions.
Link Summary
Internal links (3):
● Sample research projects library — https://www.scholarnesthub.com/projects
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External links (2):
● World Health Organization — Tracking Universal Health Coverage — https://www.who.int/news-room/questions-and-answers/item/tracking-universal-health-coverage
● National Health Insurance Authority (NHIA) — Official Site — https://www.nhia.gov.ng/
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