Socioeconomic inequalities in health insurance enrolment among Nigerian women

Out-of-pocket (OOP) payments remain the dominant means of healthcare financing in Nigeria. To reduce OOP dependence and improve access to quality care, the National Health Insurance Scheme (NHIS) was introduced. However, limited coverage leaves many women paying for maternal care OOP. This study examines equity in NHIS enrolment and factors predicting non-enrolment among Nigerian women. Data from the 2023/2024 Nigeria Demographic and Health Survey (NDHS) involving 38,912 women were analysed using Stata MP 17. Sampling weights adjusted for design effects. Descriptive statistics summarised respondents’ characteristics, while binary logistic regression identified predictors of non-enrolment, presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Equity was assessed using the concentration index and Lorenz curve. Significant inequities in NHIS enrolment were found. The coverage rate ranges between 0.10% for the poorest wealth quintile and 9.77% for the wealthiest quintile. Enrolment favoured urban, educated, wealthy and Southern Nigerian women.Women who had attained at least secondary education, whose partner or husband had attained at least secondary education, who belonged to wealthy households, and who had healthcare decision-making power were significantly less likely to be unenrolled in a health insurance scheme. NHIS enrolment in Nigeria is inequitable, excluding poor, rural, and uneducated women. Expanding coverage requires subsidised premiums, empowerment initiatives, and community-based insurance schemes to promote equity and advance universal health coverage.