The practice of demanding 'pay before treatment' is a pervasive, yet largely unregulated, norm in Nigerian hospitals. This often forces patients, especially in critical conditions, to provide upfront deposits before receiving any medical attention. This situation, though ethically questionable in emergencies, is frequently attributed to low health insurance coverage, substantial out-of-pocket expenses for patients, and underfunding of healthcare facilities.
With an increasing number of fatalities linked to this controversial policy, there are widespread calls for stricter adherence to ethical medical standards, particularly concerning emergency cases. Weekend Trust investigates.
In the early hours of a Monday in Abuja, Aderonbi Folake was desperately trying to help her 13-year-old son, Seyi, who was struggling to breathe and burning with fever. Having already been turned away by two hospitals that night, she was met with the same response: 'No deposit, no treatment.'
Folake recounted being told she needed to provide N60,000 before her son could be admitted. Despite her pleas and explaining she only had N8,000, the hospitals insisted she return with the full amount.
Tragically, Seyi never reached a third hospital. He passed away in his mother's arms inside a tricycle, just a short distance from a private clinic in Kubwa.
Similarly, in Keffi, Nasarawa State, Mrs. Egbosa Ruth shared the harrowing experience when her husband was stabbed during a robbery. "He was losing blood fast. We rushed him to a private hospital near Ring Road, and they said we must deposit N50,000 before they would touch him. I begged them. I even knelt begging them," she recounted.
She described how some hospital staff merely observed as her husband lay on a stretcher, with one nurse stating, 'Make una bring the money first.' By the time they secured assistance elsewhere, it was too late, and her husband died.
Musa Hassana, in Mpape, faced a similar crisis late one rainy Thursday with her six-month-old son, Bello, who was struggling to breathe. "He was gasping for air, his lips were already turning blue," Hassana recalled.
A nearby private hospital demanded N40,000 for oxygen administration. "I told them I didn’t have that kind of money. I pleaded that they help my child first. They said it was the hospital’s policy," she stated.
Hassana rushed out to find help elsewhere, but Bello stopped breathing en route. "My baby died before we reached the next place. I still hear him crying in my head," she said, her voice filled with grief.
Thomas Okon suffered a fractured leg and internal injuries after being hit by a commercial bus. While in severe pain and struggling to communicate, he was taken to a private hospital. There, his relatives were allegedly told to either pay N70,000 upfront or sign documents accepting full responsibility if he died. "They were arguing while I bled, and a doctor said, 'We can’t start anything without clearance,'" he recalled, noting that he was eventually transferred to a government hospital and survived.
Fortune Ukanwa's elder sister, Precious, experienced severe abdominal pain in Uyo. What was initially thought to be minor worsened significantly overnight. At a private clinic, they were asked to pay N45,000 for tests. While they waited outside to sort out payment, Precious was in distress. By the time she was moved to another hospital, her appendix had ruptured. She did not survive the surgery, leaving Fortune to question if an earlier intervention could have saved her.
Adam Ibrahim's wife went into labour unexpectedly. At a private maternity facility in Ilorin, he was told to pay N100,000 before his wife could be taken into the delivery room. Despite having only N35,000 and pleading for help, he was told to find the remaining balance. His wife eventually delivered with the assistance of a local birth attendant, but the baby did not survive. "That night, I knew that money mattered more than life," he reflected.
These accounts are not isolated incidents. The practice of demanding advance payment for emergency medical care is a critical, nationwide issue in Nigeria, causing needless deaths and persisting despite existing legal protections.
The Law Versus Reality
The National Health Act, signed into law in 2014, includes provisions mandating that emergency treatment should not be denied. It obliges health facilities to provide emergency care and upholds patients' rights to such services.
However, in practice, many Nigerian hospitals continue to withhold or delay emergency care. Emmanuel Owu, a health rights advocate, stated, "Many families don’t know their rights. Others are too broken by grief to fight back. So, hospitals continue this illegal practice, and nobody is held accountable."
Why Hospitals Insist on Payment
Ajasa Kehinde, the managing director of God is Able Hospital in Kubwa, Abuja, explained that healthcare, like any other sector, incurs significant financial costs. Hospitals must cover expenses for electricity, water, salaries, equipment, consumables, and maintenance. Without a consistent revenue stream, especially for private facilities, services become unsustainable.
Kehinde noted that global health systems are funded through a combination of public spending, insurance, community contributions, and personal payments. While some nations offer fully state-funded healthcare, most rely on insurance schemes that shield patients from immediate out-of-pocket costs.
"In Nigeria, the government subsidises some services, but individuals and families are still expected to shoulder part of the cost," he added. He clarified that while government hospitals are obligated to treat emergency cases regardless of a patient's ability to pay, private hospitals have more discretion, depending on their financial capacity.
He strongly advised Nigerians to embrace health insurance, particularly the National Health Insurance Scheme (NHIS), as the most effective way to avoid situations requiring cash before treatment.
High Bills and TSA Remittances Cripple Public Hospitals
Professor Adewale Musa-Olomu, a former medical director of Federal Medical Centre (FMC), Abeokuta, highlighted that escalating electricity tariffs, high operational expenses, and compulsory remittances to the Treasury Single Account (TSA) are severely hindering public hospitals' ability to provide care without demanding deposits.
Musa-Olomu explained that although federal medical centres are theoretically fully funded by the government, they are mandated to remit a substantial portion of their internally generated revenue, leaving them with limited operational funds.
"We are fully funded by the government, yet we are required to remit 25 per cent of our profits to the TSA. Before I left FMC, Abeokuta, as medical director, I knew that this percentage had been increased, first to 40 per cent, then to 50 per cent," he revealed.
He further stated that these deductions are exacerbated by soaring electricity costs, over which hospitals have little control. "Whether you like it or not, you are placed in a 'bad tariff band.' And there is nothing you can do about it. Previously, I was paying N10 million to N12 million monthly for electricity. I heard that the bill increased to N25 million and N30 million per month. That is extremely serious."
Constant electricity supply is critical for hospital operations, especially for emergencies and intensive care. "Now, imagine a situation where diesel is not available, and the average person bringing in a patient does not want to pay upfront. Yet, when someone is unconscious, you must suction secretions from their airway. Electricity is needed every single day. Diesel is required to power the generators," he explained.
Musa-Olomu also pointed to the high cost of water supply. During his tenure, he had to personally ensure a steady flow, and later, two industrial boreholes were provided by the Ogun-Osun River Basin Development Authority, which helped stabilize supply but incurred additional costs.
Beyond utilities, hospitals struggle with the high cost of drugs and medical consumables. "Pharmacies and drug vendors must be paid. They sell drugs to hospitals at higher prices than private pharmacies because payment is delayed—sometimes for six or seven months. A drug that sells at N50 outside may cost significantly more in a hospital setting," he added.
Maintenance of equipment, buildings, and the provision of consumables also burden hospitals, particularly as they do not receive direct funding for running costs from the government. "The government does not give us money directly. We rely solely on what we generate internally. From that income, 25 to 50 per cent must be remitted to the TSA, leaving us with only about half to run the hospital. Yet, we are still required to present budgets and undergo inspections," he stated.
Despite these challenges, Musa-Olomu confirmed that public hospitals continue to provide free emergency care, especially for accident victims. "In road traffic accidents, patients receive free care for the first 24 to 48 hours: resuscitation, oxygen, antibiotics, analgesics, surgery – everything. The expectation is that once the patient stabilises, relatives will be contacted to make payment."
However, he noted that many families do not return to settle their bills. "Some families are sincere and grateful to pay, but the reality is that the majority do not. They promise to come back, saying they are holding family meetings, but they never return. Still, we cannot stop treatment. These are human beings," he lamented.
He highlighted the unique dilemma hospitals face compared to other public institutions. "A student who does not pay school fees is simply denied admission or barred from exams—they will not die. But a hospital cannot stop treating a patient who has not paid. If we do, the patient may die," Musa- Olomu stated. He also mentioned that some recovered patients overstay because they cannot afford to pay, occupying beds needed for others and still incurring utility costs.
As a way forward, the former medical director urged the federal government to reduce the revenue hospitals must remit to the TSA and to assume responsibility for essential infrastructure and consumables. "The government should reconsider the proportion of revenue hospitals are required to remit and reduce it. They should also take responsibility for consumables and infrastructure. There was once a plan to solarise all the hospitals nationwide, similar to what is done in the universities. If electricity costs, diesel, generator maintenance and water supply are removed from our burden, we can be far more lenient with patients," he suggested.
He noted a slight relief with recent changes in fuel pricing. "With the removal of fuel subsidy and the gradual reduction in fuel prices, we recently bought petrol at N739/N740 per litre, compared to N1,100 and N1,150 previously. I believe something is beginning to change," he said. However, Musa-Olomu cautioned that broader fiscal pressures on the government continue to affect the health sector.
He recommended that funds saved from subsidy removal should be strategically invested in healthcare for significant benefits to the populace. "If the funds saved from subsidy removal are properly invested, especially in health care, it will benefit the masses greatly. Health is wealth. A healthy population is productive and happy," he concluded.
Doctors Weigh In
In separate discussions, several doctors acknowledged that systemic funding gaps forced hospitals into difficult decisions regarding emergency care.
A senior doctor at Kubwa General Hospital, speaking anonymously, stated that funding shortages make emergency care challenging. "We don’t like turning people away. But when there are no drugs, no oxygen, no consumables, what do you do? Government hospitals are overwhelmed, and private hospitals want payment because suppliers won’t give them anything on credit," he explained.
However, he stressed that ethics must remain paramount. "No hospital should let a patient die because of money. Even if you save the person and later they don’t pay, you have done your duty as a doctor. That is what the Hippocratic oath means," he affirmed.
Dr. Hammed Alausa, another practitioner at the hospital, commented, "People are still dying because hospitals are running like business centres. In a true emergency, you don’t ask for money first. You save life first. But many hospitals fear that they won’t get paid, so they turn patients away. That fear is killing people."
Physician Chukwudi Ifeanyi emphasized that healthcare services require financial sustenance. "There is nothing wrong with charging for medical services. In emergencies, hospitals usually suspend payment requirements to save lives, but eventually, the cost must be recovered," he stated. He noted that while governments often cover costs for public hospitals, private facilities expect direct payment from patients.
Dismissing claims of heartlessness, Ifeanyi asserted, "This is not an emotional issue. Health care is a service that requires funding. Without proper financing, no hospital can survive."
Chuks Emmanuel, a trader, recounted an incident in 2004 when his younger brother, Ike, was shot. At a private hospital, treatment was delayed because a police report was required. "He was conscious when we got to the hospital and still talking, the bullet entered his shoulder and there was so much blood," Emmanuel said.
He alleged that hospital staff insisted on official documentation before commencing treatment, stating, 'Bring police report first. We cannot treat gunshot wounds without police paperwork.' Despite pleas to stop the bleeding, a nurse reportedly cited policy.
They left to obtain the police report, but by the time they returned, his brother had lost significant blood and died that night. Emmanuel believes his brother would have lived if treated immediately.
Musa Aisha shared the story of her cousin, Sadiq, who died after being taken to multiple hospitals following a shooting. The first hospital refused admission without police clearance, citing policy for gunshot cases. The delay proved fatal, with Aisha lamenting, "What killed him was the delay."
Ibrahim Abdulrasheed recounted the death of his neighbour, Taiye, after a shooting incident in 2021. At a private clinic, they were asked if the incident had been reported to the police, who stated they couldn't treat him without a police extract. By the time they obtained the necessary paperwork from the police station and returned, Taiye had weakened significantly and did not survive surgery.
Police Law on Gunshot Victims
The Compulsory Treatment and Care for Victims of Gunshot Act 2017 mandates that all hospitals, both public and private, provide immediate and adequate treatment to gunshot victims without requiring a police report or upfront payment. The law prohibits degrading treatment, mandates police notification within two hours of treatment, and requires security agents to assist victims.
Key provisions include:
* Mandatory Treatment: Immediate acceptance and treatment of gunshot victims without a police report.
* No Deposit Required: Treatment must be provided irrespective of initial payment.
* Assistance Obligation: All citizens and security agents must assist gunshot victims.
* Police Reporting: Hospitals must inform the police within two hours of starting treatment.
* Protection of Victims: Victims are protected from degrading treatment or torture.
* Police Investigation Constraint: Police cannot interrogate a victim until cleared by the Chief Medical Director.
* Penalties for Neglect: Violators face five years imprisonment or a N500,000 fine if their neglect leads to unnecessary death.
* Restitution: The High Court can order restitution for victims.
Dr. Samson Ogunyemi, a trauma surgeon in Abuja, stated that delays due to police clearance in gunshot cases have led to preventable deaths. "In gunshot injuries, every minute counts. The first hour is what we call the 'golden hour.' If a patient is bleeding internally and intervention is being delayed because of paperwork, that could be fatal," he explained.
He noted that while the law permits emergency treatment without prior police documentation, fear of legal repercussions makes some facilities hesitant. "Some hospitals are worried about being accused of harbouring criminals or interfering with investigation. But the priority must always be to stabilise the patient first. You cannot investigate a dead person," Ogunyemi said.
Dr. Akeem Ibrahim, a public health policy analyst, described the insistence on police reports for gunshot victims as a "systemic problem affecting young Nigerians caught in violent incidents." He cited documented cases where victims were moved between hospitals due to missing reports, leading to deterioration and loss of life.
Ibrahim attributed the fear of treating gunshot wounds without police involvement to past instances where hospital staff faced harassment or interrogation. "There is a climate of fear. Some health care workers have been detained or interrogated in the past, so facilities try to protect themselves. Unfortunately, the victim becomes the casualty of that fear," he said.
He called for clearer enforcement of existing laws and improved collaboration between hospitals and security agencies. "There must be a standing protocol: treat first, inform the police immediately after. No family should lose a loved one because of a missing document," he urged.
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