Adamawa

Jimmy John had been battling a severe toothache for days. The pain made eating and sleeping almost impossible. Early in the morning on Monday, July 7, 2025, he walked into New Boshang Hospital in Jimeta-Yola, northeastern Nigeria, hoping for relief. He queued, was registered, and eventually called in to see a clinician.

After an examination and scans, he was told that he needed a root canal, a dental procedure that removes infected or inflamed pulp from inside a tooth. Jimmy didn’t bother about the cost; the procedure is covered by his insurance under Adamawa State’s health insurance scheme. 

However, he was asked to wait. 

The hospital needed to confirm his insurance details. A desk officer explained that an authorisation code would be sent from his Health Maintenance Organisation (HMO). It would not take long, he was told. Two days at most.

Jimmy left the facility with painkillers and a promise, but the aches kept getting worse. 

“It was a terrible toothache,” he said. 

Two days passed. Then a week. “It took about three weeks,” Jimmy told HumAngle. “I had to be constantly calling and asking if it had been sent.” Each time, the answer was the same: they were still waiting for the code.

By the third week of waiting, Jimmy made a decision he had hoped to avoid. “I ended up paying ₦35,000 for something my insurance should have covered,” he said. “The money I planned to use for food was what I used for treatment.”

Growing coverage, inconsistent access 

Launched in 2020, Adamawa State’s contributory health insurance scheme has expanded in recent years. The Adamawa State Contributory Health Management Agency (ASCHMA) now covers the formal sector, informal sector, equity, retirees’, and tertiary students’ health plans. Official figures show that more than 170,000 people are enrolled across the state, a significant increase from its early years. 

Yet, Jimmy’s experience showed that being insured does not always mean being able to access care when it is needed.

Under ASCHMA’s design, access to healthcare operates at two levels. At the primary care level, enrollees are entitled to services such as malaria treatment, antenatal care, immunisation, and basic diagnostics by simply presenting their insurance ID card at their chosen facility.

According to ASCHMA’s Executive Secretary, Ujulu Amos, this process does not require involvement from HMOs. “Verification at that point only requires an ID card,” he explained. “Once the hospital cross-checks the enrollee’s number with the list sent to them, the person is entitled to access all primary care. The HMO is not involved.”

The process changes once a patient needs secondary or specialised care, such as surgery or a root canal procedure. At that stage, hospitals must request an authorisation code from the patient’s HMO before treatment can proceed. The code allows the hospital to later claim payment for the service.

Ujulu emphasised that this authorisation step is meant to be fast and tightly regulated.

“In our operational guideline, requesting a code should not take more than one hour,” he said. “Three hours is the maximum. If it takes three days, that is a problem.”

In Jimmy’s case, that process stretched into three weeks.

Where the system breaks down

At the heart of these delays is a lack of interoperable digital health infrastructure. While hospitals can confirm that a patient is enrolled, they cannot proceed with secondary care without explicit approval from the HMO, even when coverage is obvious. 

This multi-step process, often reliant on emails, phone calls, and individual responsiveness, leaves patients stuck in the middle.

Ujulu said patients are not powerless in such situations. According to him, ASCHMA operates a 24-hour toll-free call centre that enrollees can contact if authorisation delays exceed the allowed timeframe. In such cases, the agency can intervene, issue the authorisation, and later deduct the cost from the HMO. HumAngle attempted to reach the agency through the toll-free line, and the line was active at the time of reporting.

Beyond awareness gaps, however, fundamental system weaknesses are a factor. Many health facilities still rely on manual processes, and digital literacy among healthcare workers remains low, slowing down requests.

“We discovered low digital literacy among healthcare workers as one of the bottlenecks,” Ujulu admitted. “A good number of them either are not willing or don’t know how to log into the platform to request the code.”

In practice, this means insurance verification is hardly real-time or reliable. 

At New Boshang Hospital, staff say such delays are common once care goes beyond the primary level. Godiya James, a technician at the dental unit, explained that authorisation requests often stall.

“We send the diagnosis and treatment plan for authorisation,” she said. Sometimes it takes a day or two for us to get a response. Sometimes it takes longer. Sometimes there won’t be a response until we resend it.” 

Some patients, she added, can’t wait longer. 

For patients like Jimmy, long wait periods mean prolonged pain. 

What’s the issue?

Health insurance schemes like ASCHMA are designed to reduce out-of-pocket spending, which dominates healthcare expenditure in Nigeria, yet the systems that support them are not well-connected. Many facilities and HMOs rely on emails, phone calls, paper records or ad-hoc networks to verify coverage. 

Without digital interoperability, the ability for different software and data systems to talk to one another, each verification becomes a manual transaction, dependent on network stability, personal responsiveness, or manual cross-checking.

Farida Abalis Paul, Chief Operating Officer of A&M Healthcare, one of the HMOs working with ASCHMA, said verification depends largely on monthly enrolment lists. 

“Once a facility requests verification, we check the list. If the person’s name is there, they can go ahead with treatment,” she explained. However, the process is delayed when a patient’s name is missing from the list, even if they hold a valid insurance card. 

This can result from delayed updates, data entry errors, or changes in facility selection.

“You may have an ID card, but when we check the list, your name is not there,” she said. “Today you’re on the list, tomorrow you’re not. Along the line, something happened.”

When this happens, HMOs cannot approve care until ASCHMA corrects the records. 

For patients, the consequences are immediate. 

Aishatu Haliru, a lecturer at Adamawa State Polytechnic, Yola, was turned away from the Specialist Hospital despite presenting her insurance card.

“They told me my name was not on the list,” she said. “I couldn’t understand how that happens when nothing has changed.”

She was referred to ASCHMA, where an official confirmed that her record had been omitted during a routine database update. Although the issue was corrected the same day, Aishatu missed the clinic schedule and had to wait several more days for care.

“But the question is, why did it disappear in the first place?” she asked.

Ujulu, ASCHMA’s Executive Secretary, argued that such disappearances could result from platform migration, noting that data loss also slows down authorisation processes for patients like Jimmy.

These gaps highlight a broader challenge within Nigeria’s evolving digital health system. 

Nigeria’s push toward efficient digital healthcare systems

At the national level, Nigeria has begun laying policy foundations for digital transformation in healthcare, although implementation remains uneven. 

One of the key efforts is the Nigeria Digital in Health Initiative (NDHI), which aims to build a national digital health architecture that supports interoperable electronic medical records and efficient data exchange between healthcare facilities, insurers, and government systems. In practical terms, such a system would allow clinics to instantly confirm a patient’s insurance coverage, treatment entitlements, and provider claims eligibility, eliminating the kind of long delays Jimmy experienced.

Alongside this, the National Digital Public Infrastructure (DPI) Framework and the emerging Nigerian Data Exchange standards, coordinated by the National Information Technology Development Agency (NITDA), seek to promote shared digital rails for public services. These include interoperability, data security, and service integration. 

Applied to healthcare, these principles mean that insurance verification, patient identity, and claims processing should function as shared public infrastructure: secure, privacy-preserving, and accessible across institutions. In practice, a hospital should be able to instantly confirm a patient’s coverage without manual escalation.

NITDA’s ongoing strategic roadmap also emphasises inclusive access to digital infrastructure across the country and equitable digital literacy, both of which are foundational to reliable nationwide digital service delivery. 

The goal of such policies is straightforward: when systems can talk to each other securely and immediately, services like insurance verification become almost instant, reducing delays and unnecessary costs.

“Interoperability sounds like a technical word, but in reality, it’s about time, trust, and dignity,” said Muhammed Bello Buhari, a Nigerian-based digital rights activist. 

In a state like Adamawa, where insecurity and economic pressure already shape access to care, the ability of systems to speak to one another determines whether insurance works in practice or remains theoretical, leaving people insured on paper but uninsured in practice. 

Muhammed argues that without shared, real-time systems, patients are pushed into delays and out-of-pocket payments not because they lack coverage, but because institutions cannot confirm what they already know. 

“Interoperability is less about cutting-edge innovation and more about treating health information as essential public infrastructure that respects patients’ vulnerability and ensures care moves quickly, reliably, and with dignity,” he added. “When a patient arrives sick or in pain, insurance must work immediately, or it loses its value.”

This report is produced under the DPI Africa Journalism Fellowship Programme of the Media Foundation for West Africa and Co-Develop.

Kolo Askumto sits on a small mat outside her makeshift shelter, a shawl draped around her shoulders for warmth. Her eyes remain fixed on the farmland ahead, not out of desire but necessity. Rows of guinea corn and beans stretch into the darkness. While she scans the fields, careful not to blink for too long, her ears strain at every unfamiliar rustling of leaves. 

It is midnight, and Kolo is at the Lainde fields in Mayo-Ine, a community in Fufore Local Government Area of Adamawa State, in North East Nigeria.

The 55-year-old has been living on her farm during every harvest season for the past three years. Before 2022, guarding her ripe beans or guinea corn was never a concern. That changed when thieves began invading their fields at night, carting away crops — sometimes even those already harvested and packed, waiting to be transported home. 

Kolo lives with her family at the Malkhohi displacement camp in Yola, the state capital. She managed to secure farmland in Lainde after fleeing Madagali in Borno State due to Boko Haram attacks. Since 2016, subsistence farming has helped her support her husband in providing for their family. 

This year, Kolo has slept on her farm for more than two weeks. Every night, she spreads her blanket on her mat, switches on her torch, and scans her surroundings like an owl. When the night deepens, she retreats to her thatched tent but barely blinks while she’s there. 

She is not the only one keeping watch. The isolation of the area adds to the danger. Located on the outskirts of the Mayo-Ine area, Lainde lie far from residential settlements, with only a few people living there permanently. There is no police station nearby, farmers said, except in the main village several kilometres away, leaving those who sleep on the fields largely on their own through the night.

The vigil

Every night, several farmers keep watch across open fields. Some sit in small groups, whispering as they stay awake until dawn. At sunrise, some resume their harvest, while others head home to return by evening for the night shift. The women mostly stick together. 

To stay awake, the farmers told HumAngle that they drink herbal concoctions believed to chase sleep from their eyes. Sometimes, they light a fire and huddle around it for warmth. 

“We pray that God should protect us before we sleep, but we wake up to every sound we hear,” Kolo said. 

Though the vigil has helped keep her farm safe this year, fear still lingers. Two years ago, criminals struck in the dead of night and stole all the grains she had packed in sacks. She was not physically harmed, but the memory of that night has never left her. Since then, she sleeps with a machete by her side.

Unlike some women who return home during the day to rest, Kolo plans to remain on the farm for nearly a month — until the crops are fully harvested. The journey from the IDP camp is long and exhausting. “If we are to trek before we get here, we will be tired, and we will not have enough strength to work,” Kolo said. It takes about an hour to reach Lainde from Yola by tricycle, and much longer on foot.

While she has not encountered any security problems this year, she fears she might encounter the same group that robbed her the last time. However, Kolo says she is willing to go to any length to protect her farm. “If we don’t sleep here, we can lose everything,” she said.

“We can’t afford to pay”

Not every farmer in Lainde stays on the field all night. Some pay guards, mostly young men, to keep watch on their behalf. It costs around ₦60,000 to ₦70,000 monthly. In some cases, the guards are paid with a bag or two of harvested crops.  

For many women, that option is simply out of reach. “We have to buy fertilisers, herbicides, and other inputs,” Kolo explained. “There is nothing left to pay guards.”

Elizabeth Joseph has farmed maize, groundnuts, and beans in the Lainde fields for three years. Every harvest season, she says, comes with anxiety. Once, she harvested several bags of beans and left them in the field while she went to find transport. When she returned, everything was gone. Not even a single grain remained.

In 2024, a bag of beans sold for between ₦110,000 and ₦130,000, while a bag of maize cost about ₦60,000; losing even a few bags can undo months of back-breaking work for these small-scale farmers. That loss left her with little choice but to keep watch herself.

But the vigil is exhausting.

“If I have money, I won’t have to come to the farm. I will just assign labourers to do the work for me, and I will just come during the harvest season. I will even pay those who will harvest, and there won’t be any stress, but since I don’t have the money, I have to come and guard myself,” Elizabeth added. 

Although her husband could sleep on the farm while she managed the household, they switched roles. According to Elizabeth, men are more likely to be attacked or killed by thieves at night.  Her fear is not unfounded.

Recently, in Bare, another community in Adamawa State, twelve young men working on a farm at night were attacked; three of them were killed. Even on the Lainde fields, such attacks that claimed lives have occurred. 

Such thefts are not isolated to Lainde or Bare. Across the BAY states — Borno, Adamawa, and Yobe — farmers have repeatedly reported nighttime farm thefts and attacks during harvest seasons. Communities continue to call on authorities to address the insecurity, saying the losses threaten their livelihoods and food supply.

These threats compound the vulnerability of rural communities to hunger and poverty. Nearly 35 million people in Nigeria, particularly in the BAY states, are facing acute food insecurity, according to the World Food Programme. Displacement, rising food prices, and ongoing violence have further worsened the risk of malnutrition in the region.

Living with danger

However, the robbers are not the only thing farmers are afraid of; they face other threats such as snakes, scorpions, cold weather, and isolation. 

Zara Abba, who began farming in Lainde in 2023, said the environment becomes frightening after sunset. “By 7 p.m., everywhere looks like it is midnight; the whole place gets dark,” she stated. 

Like Kolo and Elizabeth, Zara cannot afford night guards. A mother of four, she brings her children to the farm and lives with them in a thatched tent. At night, the children sleep while she stays awake, watching the fields.

Zara said the women had once raised their concerns with the community leader, hoping for intervention or improved security. But nothing changed.

“If I could afford guards, I would stay home with my children,” she said. “But I don’t have a choice.” She carries gallons of water, cooking utensils, and clothes, staying on the farm for nearly a month until the harvest is complete.

“The other women, too, have been sleeping here for a long time,” she said. “We decided to come here because if we don’t, we will lose our harvest.”

As someone who has lost her ripened crops to thieves in the past, Zara says she does not mind living on the open field with her four children, where she can keep an eye on all of them. 

While they continue to find ways to adapt, the women who spoke to HumAngle said staying on the fields has impacted their other responsibilities, especially for those who can’t bring their children to the open fields. “When coming to sleep here, we leave the children at home and make sure we give them food that would sustain them with the older ones who take care of them before we get back,” Kolo said. 

Though the routine has become familiar, it remains exhausting. 

“The nights are harsh, and sometimes we feel like not selling our farm produce because of the suffering, but we end up selling it at a cheaper price sometimes,” Elizabeth lamented. The exposure often leaves them with flu. “Every harvest season comes with its stress.”

Elizabeth is also frightened by snakes and scorpions; people have been bitten in the fields in the past. To protect herself, she keeps a machete by her side.

As the harvest season draws to a close, the women of Lainde fields look forward to when they can return home, carrying the fruits of both their labour and sleepless nights. Yet even as they prepare to leave, another harvest season will come, and they will be forced to face long nights under open skies again.