Tosin Jaiyeoba, a mother of three, sat quietly in the post-delivery ward at the comprehensive health centre in Okesha, Ado-Ekiti, the capital city of Ekiti State. She was breastfeeding her newborn, having delivered at the facility without paying out-of-pocket.
The hospital buzzed with activity around her, being one of the pilot facilities for the Ulerawa Health Insurance Programme. Patients moved in and out of consultation rooms, while healthcare workers attended to routine check-ups, and mothers lined up for their children's immunisation.
"If not for Ulerawa, I would have spent so much on this pregnancy and delivery," Tosin said, adjusting her baby's blanket. "Now, the money I would have used for hospital bills and drugs I can use to feed my children at home."
Tosin's experience is not unique. Across Ekiti State, thousands of residents benefit from health insurance designed to ensure cost is never a barrier to quality care. Ulerawa, meaning "Our Health", was launched in 2022 by the Ekiti State Health Insurance Scheme (EKHIS) under the Ekiti State Ministry of Health and Human Services.
It was set up to provide financial protection for all residents, especially the most vulnerable, ensuring equity in healthcare access. It also operates as a case-bundled system, meaning healthcare services are offered as a package, instead of charging for each treatment separately. This ensures that essential care like maternal and child healthcare and malaria treatment are fully covered for those who need it.
"Ulerawa is more than just another health insurance programme, it is a comprehensive strategy to improve maternal and child health outcomes, increase healthcare utilisation, and provide financial risk protection to the most vulnerable. If you are in Ekiti state, you're covered by Ulerawa," Oyebanji Filani, Commissioner for Health and Human Services in Ekiti State, explained.
How Ulerawa works
Many Nigerians have a poor perception and awareness about health insurance . It is seen as only accessible to formal sector workers who receive coverage through employer-backed payments. Many citizens, particularly low-income earners, market traders, and rural dwellers, pay for healthcare out-of-pocket, which tends to delay healthcare seeking.
Nigeria's Basic Health Care Provision Fund (BHCPF) has been a primary funding source for healthcare coverage for the poor and vulnerable. "However, its reach has been limited," Doherty Charles Olusegun, the General Manager of Ekiti State Health Insurance Scheme (EKHIS), said. He further explained that under the BHCPF, a specific quota is allocated to each state.
In Ekiti, coverage for 19,000 people was provided, this figure was later increased to 23,000 and now stands at approximately 35,000 beneficiaries. "However, with an estimated 1.3 million people living below the poverty line in a total population of 3.5 million, this allocation remains insufficient to meet the healthcare needs of all vulnerable residents," Doherty explained.
Ulerawa was designed to change this reality. Doherty noted that, "Malaria accounts for 75% of the disease burden in Ekiti, and the Ulerawa scheme fully covers malaria treatment for all residents, alongside comprehensive maternal and child healthcare services."
He added that "pregnant women receive free care from antenatal visits to delivery and postnatal care, children under five get full coverage for basic health needs. Family planning services are [also] available at no cost to promote reproductive health."
Ulerawa is designed to increase access to essential primary healthcare services by ensuring health facilities receive payments monthly based on the care they provide. This means facilities are reimbursed for delivering a set of crucial health services which targets the most common health issues in the state, covering 75% of its disease burden.
The Ekiti State Health Insurance Agency (EKHIA), which oversees the scheme, operates a monthly post-payment model, meaning that hospitals and healthcare providers are reimbursed based on the services they deliver. This is an alternative from capitation models, where hospitals receive fixed payments upfront regardless of actual patient visits. By tying payments to service delivery, Ulerawa ensures accountability, improves efficiency, and incentivises better patient care through a real-time claims review system. When a patient visits a facility, their diagnosis and treatment details are entered into a database where EKHIS officers check and approve claims before payments are made.
To prevent fraud and errors, live monitoring is in place. For example, when an ANC claim was filed for a 13-year-old, a verification call revealed it was an age error, and it was corrected. In another case, a hospital report showed a questionable number of antenatal visits. An unannounced investigation revealed the increase was due to the Officer-in-Charge doing rounds of community sensitisation. This somewhat strict oversight tries to prevent false claims and ensures funds are properly used for patient care.
Ulerawa also uses Electronic Medical Records (EMRs) systems to track treatments and ensure claims match actual medical services provided. By cross-checking patient history, they flag repeated or suspicious claims. They also carry out quality checks by calling patients to verify service received.
From pilot phase to state-wide coverage
When Ulerawa was first introduced in 2022, the scheme started with 25 pilot healthcare facilities. However, early assessments revealed low utilisation rates, with only 12,000 people accessing the service in the first year. Recognising the need for greater accessibility, the Ekiti State Government took decisive action.
By August 2023, the number of facilities under the Ulerawa scheme had expanded from 50 to 177, ensuring that all 177 wards in Ekiti had at least one facility offering insured services. This expansion was accompanied by state-wide sensitisation campaigns aimed at educating communities about the benefits of Ulerawa and encouraging its use.
Healthcare workers were also trained to improve service delivery, ensuring that residents not only had access to care but also received quality treatment. Since its inception, Ulerewa has provided healthcare services to over 500,000 residents.
A data-driven approach
One of the unique aspects of Ulerawa is its real-time monitoring. To enhance transparency, the EKHIA has implemented a live data monitoring system, tracking patient visits, healthcare utilisation trends, and funds disbursed to facilities, monitoring treatment patterns to identify gaps and improve service delivery.
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Yemi Ogunyemi, Director of Planning, Research and Statistics at EKHIS, explained that "with real-time data, we can identify which hospitals are overburdened, which services are in high demand, prevent stockouts and where we need to improve."
While Ulerawa has significantly improved healthcare access in Ekiti, the programme still faces challenges that must be addressed for long-term success. Oyebanji Filani acknowledged the need for further expansion beyond the 177 facilities currently covered by the Ulerawa. "We recognise that demand is growing, and our goal is to ensure that every resident, no matter where they live, has access to quality healthcare under this scheme," he said.
At Okesha Healthcare Centre, Rachael Olayinka, the Officer-in-Charge (OIC), highlighted a critical workforce gap. "Many of our healthcare workers are retiring or leaving the country, and there are no immediate replacements. Yet, we are managing over 1,000 out-patients monthly with 160 antenatal visits and 60 to 100 deliveries," she explained.
Lessons for scaling up Universal Health Coverage (UHC) in Nigeria
Ekiti's Ulerawa Health Insurance Scheme is setting an example for other Nigerian states looking to improve healthcare access and equity.
By addressing the gaps left by BHCPF, expanding coverage, and leveraging technology for transparency, Ulerawa is proving that UHC is achievable, even in resource-limited settings.
For residents like Tosin, Ulerawa is not just a scheme, it is a promise. A promise that no woman should have to choose between medical care and feeding her family. A promise that no citizen should have to choose sickness over life-saving healthcare.
