Social Health Protection for All: A Modus Operandi
What does it take to extend health coverage to informal economy workers and their families? The long-considered “one-billion-dollar question” need not remain unanswered. Success stories from social health protection schemes in low-and middle-income countries all over the world, from Rwanda to Thailand, remind us that not only is reaching Universal Social Protection (USP) and Universal Health Coverage (UHC) theoretically feasible – but is also, in practical terms, within reach.
In Nigeria, informal employment represented 92.3 per cent of total employment in 2022. The National Health Insurance (NHI) Scheme Act, adopted in 2004, was a first step towards extending social health protection coverage. Eighteen years later, the NHI Authority (NHIA) Act (2022) enshrined in law the design modalities for a universal scheme. It aims at achieving UHC by providing financial access to quality healthcare for all Nigerians, by making social health insurance mandatory for all citizens and legal residents - therefore for workers in the informal economy and their families.
In August 2025, a five-days capacity-building exercise was organised by the NHIA - with support from the ILO under the European Union funded project - Supporting Sustainable Social Protection System in Nigeria (SUSI) and participation from the Global Fund and the WHO Collaborating Centre on Health in All Policies and the Social Determinants of Health at Tampere University. It gathered staff from the NHIA and from four States’ Social Health Insurance Agencies (SSHIA) –Abia, Benue, Oyo and Sokoto.
While international examples to extend coverage were shared during the training, enlightening practices came from Nigerian States themselves – already implementing transformational policies. In Oyo State, the Oyo State Health Insurance Agency (OYSHIA) Scheme implements the “Irorun De Plus”, a scheme specifically targeting the informal economy by offering a grinding machine to new enrolees as well as access to loan facilities. In Sokoto, the Sokoto State Contributory Health Management Agency (SOCHEMA) Scheme began covering the informal sector before the formal sector and now relies on a 1 percent levy on State and local government capital projects. This innovative financing mechanism cushions the financial sustainability of coverage extension.
Strategic partnerships with key stakeholders were also instrumental in coverage expansion. In Oyo State, a scheme targeting public primary school pupils was implemented by OYSHIA earlier this year, thanks to UNICEF support. In this regard, the experience shared by the Global Fund in granting allocations covering SHI benefit packages for targeted vulnerable populations in different states, provided insights into how partners’ alignment and support of national systems can reduce fragmentation and empower social health protection institutions.
So, what are the main lessons learned for countries wishing to extend social health protection coverage to the informal economy?
Know your audience and enforce the law
While legal frameworks are a prerequisite to extend social health protection coverage to all, they are not sufficient to ensure effective protection. The nature of informal work and conditions present specificities, often particular to economic sectors, which can challenge workers’ enrolment and ability to pay through processes designed around the characteristics of the formal economy. Adapting front office processes, including awareness raising, identification, registration and contribution collection mechanisms, to the realities of different sectors, is a stepping stone towards ensuring systematic enrolment of informal economy workers and their families. In parallel, tailored incentives, such as linking social health insurance enrolment to access to public services or procedures, can make the difference, provided they are carefully designed.
Work across sectors
Countries that have made important strides towards USP and UHC have managed to work across sectors to link registration, data management and even contribution collection. This goes beyond mere technical collaboration: social protection and health sectors are two sides of the same coin – a coin fighting poverty, ill-health, and inequities, ultimately tackling inter-generational vulnerabilities and promoting healthy development. Coordinating among health and social sectors to address social determinants of health equity should be a policy priority for countries wishing to reduce poverty and inequity.
Trigger political will
Beyond technical solutions to extend coverage, one key enabler kept emerging in the discussions: political will is a precondition to adopt the necessary measures that prioritize health and social protection. However, we cannot afford to passively wait for political will to materialize on its own. While social health protection is ultimately the responsibility of the State, the responsibility of advocating for increased financing and law enforcement is a shared one. Ministries and institutions, development partners, social partners, and civil society organisations alike all have a role to play. Ultimately, this is a responsibility shared across social protection and health stakeholders.
At the end of the training, participants agreed on a joint roadmap towards social health protection coverage extension in Nigeria, to plan how to address the issue comprehensively and offer a platform for donors’ alignment. Countries like Nigeria have the potential to progress rapidly towards USP and UHC. It is up to international development partners to align on national priorities.
Picture : Participants of the 5-day Capacity Building Session on Social Health Protection in Keffi, Nasawara State, Nigeria. © ILO
