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Almost three months after the federal government announced free Caesarean section (C-section) for all women in need, implementation remains slow and uneven across the country.
LEADERSHIP checks revealed that the initiative, aimed at reducing maternal mortality and financial barriers to life-saving childbirth procedures, has yet to reach its intended scale, as many women are still forced to pay out of pocket for C-sections.
According to a recent report by the World Health Organisation (WHO), the maternal mortality ratio (MMR) in Nigeria is 1,047 deaths per 100,000 per 100,00 live births. A related study found that among 76 maternal deaths in Nigeria, 64 infants were born alive. However, only 31.3% survived beyond five years, while 68.6% did not.
While the policy has been welcomed as a game-changer for maternal healthcare, bureaucratic delays, inadequate health insurance coverage, and other challenges are hampering its full rollout.
Towards Ending Maternal Mortality: Federal Govt’s Healthcare Initiative
The coordinating minister of health and social welfare, Prof. Ali Pate, had, on November 7, 2024, announced that the government would cover the costs of C-sections nationwide, and make the procedure free for women who require it.
The announcement signalled the administration’s commitment to reducing Nigeria’s alarming maternal mortality rate, with the impression that the necessary arrangements were already made for smooth implementation.
The National Health Insurance Authority (NHIA), in collaboration with the National Primary Health Care Development Agency and State Health Insurance Agencies, was tasked with overseeing the reimbursement process.
The plan sought to ensure that public and private healthcare providers could sustainably offer C-sections without straining patients financially.
However, almost three months after the announcement, the reality paints a different picture.
As of now, the initiative is still a work in progress. Sources in various hospitals across the country revealed that no such programme was going on, as only the women already enrolled in health insurance were benefiting from the coverage.
However, LEADERSHIP was told that the University of Abuja Teaching Hospital (UATH) had started implementing the policy, though no patient has benefited.
The hospital’s spokesperson, Suleiman Sani, said steps had been taken to roll out the programme.
“We have started. A committee was set up, and the committee has started work on it. We are just waiting for a qualified patient,” he stated.
State governments and many health facilities are yet to integrate the free C-section service into their healthcare systems. In the Federal Capital Territory (FCT), vulnerable women enrolled in the Basic Health Care Provision Fund (BHCPF) already had access to free C-sections. However, this pre-existing arrangement does not reflect the broader national implementation promised by the government.
The FCTA Mandate Secretary on Health and Environment, Dr Adedolapo Fasawe, said the free C-section was ongoing for all vulnerable women enrolled under the health insurance scheme via the Basic Health Care Provision Fund.
“So, any woman enrolled under BHCPF insurance in FCT that requires CS will be referred from the PHCs to any of our 14 secondary facilities; the CS will be done there, and it’s at no cost to the women because the government is paying for it.
“And due to the political will of the present administration, plans are already being concluded to capture even more vulnerable women in the health insurance scheme, and anyone who requires CS will have it at no cost to them.
“Presently, in the FCT, we have enrolled over 36,000 poor and vulnerable persons, including pregnant women, in the scheme who are benefiting from the free ANC, laboratory investigations, treatment, delivery including CS, blood transfusion, immunisation, family planning and other preventative and protective services for the women and their babies,” she explained.
Meanwhile, the director-general of the NHIA, Dr. Kelechi Ohiri, said states had been asked to provide lists of designated referral hospitals.
“We have written to every commissioner to give us the list of their referral hospitals, whether a general hospital or a tertiary hospital, so that we can go and engrave it and make sure it has quality. We’ve sent letters to all the commissioners throughout the country. So, when they give it to us, we can make sure that every state in Nigeria has a referral hospital, and we can publish the list. So, we have to work with our state counterparts.”
At the federal level, Dr Ohiri said the NHIA had signed a Memorandum of Understanding with 20 tertiary health facilities and had met with the medical directors of tertiary hospitals.
“I have explained the programme to them. A lot of them have signed up. They are sending an MOU so that we can kick off,” he explained.
LEADERSHIP reports that the initiative relies heavily on the NHIA and state health insurance schemes to fund the C-sections. However, the country’s health insurance coverage remains low, with a large portion of the population uninsured.
Many hospitals are reluctant to perform free C-sections without clear financial backing and clear guidelines.
Despite assurances from the health minister, onboarding hospitals, signing MoUs, and finalising reimbursement mechanisms have been slow. Many hospitals remain uncertain when they will fully integrate into the programme.
While some states, like the FCT, already have mechanisms for free C-sections under health insurance schemes, many are still struggling to set up referral systems. This has led to uneven access, with some women benefiting from the policy while others continue to face high costs.
While the initiative has yet to reach its full potential, experts have said it remains a critical step toward addressing the country’s maternal health crisis. C-sections can be life-saving in complicated deliveries, and financial barriers have long forced many women to seek alternatives, including faith-based healers or home births, often with fatal consequences.
A consultant gynaecologist, Dr Philip Ikpe, acknowledged the initiative as a positive step: “It is a good gesture by the minister. However, being tied to health insurance is also a huge problem because the coverage is poor, and the cost is very low. When we talk about free C-sections, it’s not for the elite and the rich; it’s for the poor, those who need it.”
Dr Ikpe suggested that a better approach would be to ensure that funds contributed to health insurance are channelled toward financing free C-sections for indigent women. He also emphasised the need to enforce a long-standing policy that mandates health insurance for all Nigerians.
“This should also prompt the government to begin implementing the law signed by former President Buhari making health insurance mandatory for everyone. Right now, that is not being enforced,” he said.
Despite the challenges, Dr. Ikpe expressed optimism about the policy’s potential impact. He stressed that since the initiative targets underserved and indigent populations, it would be feasible if funded adequately through health insurance contributions.
Public health experts, who spoke anonymously, acknowledged the government’s intention to reduce out-of-pocket healthcare costs, which often drive pregnant women to faith healers and unregulated birth centres due to their inability to afford emergency C-sections.
He said, “I don’t want to comment on it. But, firstly, I think the government is looking to ameliorate the suffering of paying out of pocket. If someone doesn’t have to pay for an emergency C-section, they won’t be going to churches or faith healers to give birth. One of the reasons people go to faith healers is because they are told they need a C-section but can’t afford it,” the expert explained,
The expert emphasised that the policy could significantly lower maternal mortality rates by ensuring that financial constraints do not prevent women from accessing life-saving surgery. However, he also warned of possible unintended consequences, particularly the risk of hospitals performing unnecessary C-sections for financial gain.
“If the government pays facilities based on the number of C-sections they conduct, you’ll start to see a rise in unnecessary surgeries,” the expert cautioned. “Hospitals will have an incentive to justify why more women need C-sections, even when it may not be medically necessary.”
While the policy has the potential to reduce maternal mortality and financial hardship significantly, its slow implementation risks leaving many women behind.
The public health expert said that urgent action was needed to remove bureaucratic bottlenecks, ensure equitable access across states, and provide clear financial frameworks for hospitals for the initiative to succeed.
If properly executed, this policy could mark a turning point in Nigeria’s maternal healthcare landscape, saving thousands of lives.
The chairman of the Association for the Advancement of Family Planning (AAFP), Dr Ejike Orji, who advocated emergency health services, said while the policy is well-intentioned, the country’s healthcare infrastructure is ill-equipped to handle the potential surge in demand.
“The doctors are already overworked, the facilities are few, and access remains a major challenge. Even at the primary healthcare centres, many people struggle to get medical attention,” he said.
A key solution proposed is expanding hospital capacity and implementing the long-awaited National Ambulance Service.
Dr Ejike recalled advocating the implementation of the National Health Act, which allocated 5 per cent of health funding to emergency services, a provision that remains unimplemented.
He suggested that strengthening health insurance could offer a more immediate solution by allowing private hospitals to absorb some patient load.
“Health insurance covers both public and private facilities. If emergencies can be directed to private hospitals with available beds, it would ease the burden on public hospitals while ensuring that private hospitals receive payment through insurance,” he said.
Despite repeated recommendations, Dr Ejike expressed frustration that policymakers have not prioritised hospital capacity expansion or enforced mandatory health insurance.
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