Tzar Oluigbo (Lead writer)
Men in oil-stained overalls, shouting vehicle conductors and market women rushing to catch a Keke — a commercial tricycle. Nothing about this chaos at Caeli Park in Awka suggests that health insurance is being quietly rolled out. But that is exactly what is happening.
Sunday Nwankwo, a taxi driver, was not feeling himself that morning. It was nothing dramatic for him. Just a lingering headache, a bout of dizziness, and a gut feeling that he needed to see a doctor. The normal course of action would have been to rely on traditional home remedies such as Agbo, a widely used traditional herbal concoction commonly used in Nigeria and other parts of West Africa, but instead he went straight to the hospital.
At the reception desk, he braced himself for the usual struggle over payment. However, to his surprise, the receptionist checked his name and simply said, “you’re covered under ASHIA.” Confused, he asked, “Which ASHIA?”
The Anambra State Health Insurance Agency (ASHIA) is expanding access to health insurance across the state, enabling residents to seek quality healthcare without facing financial hardship. The scheme is designed to cover a broad range of common health conditions that typically bring people to hospitals. At its core is the principle of equity, recognising that social protection is essential in a system where people once paid heavily out-of-pocket, often at the risk of being impoverished or financial crisis due to healthcare costs.
That was when it clicked. The weekly charge of 1,000 Naira he paid at the motor park was not just a park fee. It included a small premium for health insurance monthly. “I didn’t know I was paying for health insurance,” he later said, shaking his head in disbelief. “But today, it saved me.”
Cutting out of pocket expenses
Within Nigeria’s fragmented health coverage landscape, extending insurance to the informal sector remains one of the most persistent challenges. Nearly 90% of the workforce operates outside formal payroll systems, placing them beyond the reach of conventional employment-based insurance models and leaving a significant proportion of the population without financial protection for healthcare.
Dr Simeone Onyemaechi, the Executive Secretary of ASHIA explained the rational behind the agency’s innovative approach to enrolling the informal sector. “We needed to bring these people into our pool by expanding health insurance coverage to this critical segment, who, in many cases, typically bear the greater brunt of the day’s economic realities,” Onyemaechi noted. “For our 235,000 active enrolees, we have reduced out-of-pocket healthcare spending from 92.1% to 10% for people enrolled in our scheme. There is a co-payment of only 10% of the cost of medications prescribed to an enrolee whether as outpatient or inpatient, made to the healthcare provider at the point of care.”
How ASHIA works
ASHIA’s model starts with the people. The system does not just wait for citizens to come. They go to them in the markets, mechanic villages, churches and motor parks. They speak in local dialects. They share testimonials and use trust to shift mindsets.
According to Mrs Thompson Oluchukwudili, a beneficiary of ASHIA whose husband is a Keke driver, “I used to cook food to sell, but since I got pregnant, I stopped. It was too stressful. My husband, a graduate, now drives a keke. We heard delivery was free at government hospitals but when we went, we still had to pay. Then someone told us about ASHIA.”
Her voice brightens as she describes the different the scheme has made. “Before ASHIA when I had my first child, I would wait until 8 months before going for antenatal. I didn’t have 8,000 or 10,000 Naira for all the visits. But now, I started at three months. I pay just 300 or 500 Naira depending on the drugs. They even teach us things I’ve never heard before.”
Dr. Jide Okwudili, Medical Director, Divine Hospital and Maternity, Awka noted that, “we currently have over 2,000 enrolees under the ASHIA scheme, and I believe our patients have been consistently satisfied with the services provided. The relationship with ASHIA has been very cordial, and notably, they have never defaulted in their payments.”
Timely reimbursement is critical to sustaining health insurance schemes. Across Nigeria, one of the major challenges for providers is the delay or default of payments after delivering care. Such delays can undermine service delivery, strain hospital finances, and erode trust in the system. ASHIA’s record of consistent on-time payments help keep facilities financially stable, ensuring they can deliver uninterrupted, quality care to enrolees.
Expanded coverage through unique innovations.
One of ASHIA’s unique innovations is its cooperative-based model. Instead of enrolling individuals one by one, the agency partners with informal groups such as trade unions and women’s associations to form health cooperatives. These cooperatives pool resources, monitor payments, and take ownership of the scheme.
Image credit: ASHIA
To further improve accessibility and affordability, ASHIA introduced a mobile health insurance platform that enables market traders, artisans, and other informal sector workers to pay the annual 12,000 naira premium in smaller, managebale instalments.
By simply dialling the USSD code *6700*001 , users can access the Anambra Mobile Health Insurance platform to create an electronic wallet, top it up gradually, and complete premium payments at their own pace. This service is also available through the ASHIA’s website, providing another convenient channel for both enrolment and renewal. By leveraging USSD technology and digital wallets, ASHIA is removing access barriers and making health insurance more inclusive and easier to adopt for every resident.
To further extend health coverage to road transport union workers who face a high risk of road accidents and other health emergencies, ASHIA introduced a tax-for-service model. This is a financing mechanism targeting commercial tricycle riders and urban bus drivers , linking routine levies or dues to their health insurance contributions.
“This was an ingenious way to reach informal workers who may not ordinarily pay for health insurance. Today, when they have accidents, they no longer depend on their union’s emergency contributions, they go straight to hospitals and receive care,” Dr. Onyemaechi explained.
Under this model, the government increased their initial weekly ticket fee for transporters from 500 Naira to 1,000. Unbeknown to them, 250 Naira from each payment is allocated to health insurance, amounting to1,000 Naira monthly and 12,000 Naira annually, effectively covering their ASHIA premium without requiring separate enrolment. As a result, many transporters, who previously had no access to health insurance, now walk into hospitals believing they are receiving free healthcare.
Image credit: ASHIA
Adoption Model (ADM)
ASHIA’s philanthropic Adoption Model is a pioneering strategy launched in early 2019 to extend health insurance to people in the informal sector. In this model, generous individuals (adopters) agree to pay the annual premium for vulnerable residents (adoptees). The goal is to bridge the gap between ability to pay (ATP) and willingness to pay (WTP), using community-driven social support networks.
Dr. Onyemaechi explained that “in some cases when you go to certain individuals to market health insurance to them, they outrightly say ‘Are you praying for me to be sick’ that having health insurance means that I have accepted that I would be sick. They believe that paying for health care in advance attracts sickness or disease to their families So those belief systems that have been engrained in some citizens have hampered a lot of the progress that we hoped to have made through the ADM.”
In Umueri, the benefits of ASHIA’s affordable health insurance are already being felt at the community level. King Ben Emeka of the Umueri Kingdom highlighted how the scheme has eased the financial burden of healthcare for his people: “Health insurance is a wonderful thing that has come to Anambra state and my people, Umueri people because before now, they’d use to pay heavily, through the nose. The rich can now help the poor get health insurance, the poor can also pay for him or herself because the price has become affordable.”
Through careful mapping of philanthropists and collaborative outreach with religious, traditional, and community leaders, ASHIA organises adoption events for registration. This innovative approach proved effective. By 2021, ADM accounted for over 80% of all informal sector enrolees, translating into tens of thousands of individuals gaining access to coverage, and significantly expanding ASHIA’s funding pool. Traditional rulers are critical to the success of this drive as they play two roles. “They help bring their daughters and sons that can help to give these people the insurance. They also help to preach its acceptance to the people,” Dr Afam Obidike, the Commissioner for health, Anambra State said.
ASHIA’s model for sustainability and efficiency
ASHIA has built a resilient and future-ready health insurance system. According to Dr. Onyemaechi, “this scheme will not go under. We are confident that we have built a system that is going to last.” The agency is also leveraging in its operations. This is enabling it to provide:
- Real-time, indigenous digital platform for seamless enrolee verification and service access.
- Pre-authorisations granted within 30 minutes.
- Self-enrolment available online for convenience.
- Capitation paid by the 25th–30th of the preceding month, for example, July paid on June 25th.
- Fee-for-service reimbursements completed by the 14th of the new month.
However, while ASHIA demonstrates innovation and impact, it is not without its constraints. One of the current limitations of the Tax-for-Service model is it had restricted application across the informal sector.
“We intend to take the Tax-for-Service model to market women and men,” Dr Onyemaechi explained, “but the fees they pay are often collected at the local government level. Due to autonomy, this isn’t straightforward but we’re working closely with local government chairmen to find a way forward.”
With Nigeria’s goal of achieving Universal Health Coverage (UHC) by 2030, ASHIA’s example raises critical questions for national replication. Can this model, built by starting small and scaling up gradually in line with available resources, community trust, and informal sector inclusion, be scaled and successfully adapted in other states where political will, institutional capacity, or public confidence may be weaker?
More importantly, can Nigeria build a truly inclusive health system if informal sector workers, who make up over 90% of the labour force, remain largely uninsured across the country?
As Nigeria moves toward UHC, models like this remind us that equity is not accidental it must be deliberately built, one household, one market, and one community at a time.