Blog Post 4
There is a hidden bill many Nigerians pay in healthcare:
a bill that is not printed.
a bill that is not receipted.
a bill that is not official.
Yet it is demanded, collected, and normalized.
It is called many names:
- “Something for weekend”
- “Support us”
- “Just settle them”
- “If you want it fast…”
- “You know how government hospital is…”
But in reality, informal payment is what it truly is:
a silent tax on the sick.
And it is one of the strongest reasons trust is dying in Nigeria’s healthcare system.
A Patient’s Lived Experience: “They Said It’s Free, But Nothing Was Free”
A pregnant woman arrived at a facility for antenatal care. She had heard government messages that maternal services were supported. She felt relieved because money was tight.
At the registration desk, she was told:
“Go and open folder.”
She paid.
Then:
“Go and do BP and test.”
She paid again.
Then:
“You need card.”
She paid again.
Then a staff member leaned close and whispered:
“If you want the doctor to attend to you well, you know what to do.”
She froze.
Because she had come with hope, not negotiation.
When she finally met the health worker, her dignity was already damaged.
She was no longer a patient seeking care.
She was a customer bargaining for survival.
On her way home, she said something painful:
“If you don’t have money, you don’t have value.”
What Informal Payments Do to Patients
Informal payments do more than drain money.
They destroy trust.
They create a system where:
- care is delayed until “something is dropped”
- patients are exploited when they are weakest
- the poor are punished for being poor
- quality becomes unequal
- fear replaces confidence
Worst of all, informal payments are often collected in silence, with no receipts, no accountability, and no protection for patients who refuse.
This is Not “Normal”. It is an Integrity Failure
Informal payment thrives when integrity collapses in the system.
It reflects failures in:
- Transparency: Patients don’t know official fees
- Accountability: There are no consequences
- Governance: Weak oversight and supervision
- Fairness: Patients are treated based on what they can “drop”
- Ethics: Exploitation becomes normalized
Informal payment is corruption at the point of care.
And corruption at the point of care is deadly.
Why Informal Payments Persist
We must be honest: informal payments persist because of a combination of:
- poor welfare and motivation of staff
- weak facility financing and stock-outs
- lack of enforcement and monitoring
- cultural normalization: “that’s how things work”
- fear: patients are afraid to report
- lack of complaint channels
But regardless of the reasons, one truth remains:
A patient should never have to bribe their way into dignity.
The Cost to the Health System
Informal payments destroy the health system in multiple ways:
- Patients stop trusting public facilities
- People delay care until emergencies
- Families become poorer due to hidden costs
- Health insurance credibility suffers
- Government reforms lose legitimacy
- Honest health workers become discouraged
- The system becomes transactional, not professional
A health system cannot build Universal Health Coverage on hidden extortion.
What Must Change: The Practical Actions
1) Make Fees Transparent
- Every facility should display approved service fees publicly.
- Patients should know what is free and what is not.
2) Enforce Receipts and Payment Channels
- Payments should be made through traceable channels.
- No cash to individuals.
3) Strengthen Facility Oversight
- Supervisors must actively monitor patient flow and complaints.
- Surprise checks and audits must become routine.
4) Protect Patients Who Report
- Patients must be able to report anonymously.
- Retaliation must be punished.
5) Improve Health Worker Welfare. But Demand Professionalism
- Staff welfare matters, but exploitation is not justified.
- Professional ethics must be enforced consistently.
6) Build Patient Voice Systems
- Complaints systems must be visible, simple, and responsive.
- Every complaint should receive feedback and corrective action.
The Integrity Call
Informal payments are not “small issues.”
They are a direct assault on fairness, dignity, and trust.
If Nigeria wants better health for all, then care must not be sold in whispers.
It must be delivered as a right, with transparency and accountability.
Trust renewal will not happen until patients can enter a facility and know:
“I will be treated fairly.
I will be safe.
I will not be exploited.
And my voice will matter.”
Insha’Allah, Nigeria will rise to build a health system where care is not a privilege for the connected, but a promise for all.
Dr. Abdullahi Jibril Mohammed
Health Systems Specialist and Integrity Champion
Author, Trust Renewal: The Integrity Call for Better Health for All
