Abstract Background: Despite the National Health Insurance Authority (NHIA) Act 2022 mandating health insurance for all Nigerians, enrollment remains critically low. In Anambra State, preliminary observations suggested a paradox: high awareness coexists with minimal uptake. Understanding the barriers to enrollment is essential for achieving Universal Health Coverage (UHC) targets. Objective: To assess health insurance awareness, enrollment patterns, barriers to uptake, and patient-provider perspectives in Awka and Idemili South, Anambra State, Nigeria. Methods: A cross-sectional survey design was employed. Structured questionnaires were administered to 413 community members and 54 healthcare providers across eleven locations (hospitals, Primary Health Centres, faith-based venues, and community events) between July and December 2025. Data were analyzed using descriptive statistics and Chi-square tests for associations. Results: Awareness of health insurance was high (87%), but actual enrollment was low (28.1%), creating a 59.8-point conversion gap. The primary barrier was process opacity: 58.1% of respondents reported "I've heard about it, but I don't know where to start." A significant trust deficit was identified, with 65.0% of patients believing insurance negatively affects treatment quality, compared to 77.8% of providers claiming equal care for all patients. Policy knowledge was low: only 38.0% knew Nigerians are entitled to yearly coverage under the NHIA Act. Patient priorities were clear: 89.1% prioritized coverage for drugs, diagnostic scans, and emergencies. Enrollment varied significantly by location, ranging from 33.8% at community events to 17.6% at Primary Health Centres (χ²=52.4, p<0.001). Chi-square tests confirmed significant associations between enrollment and: awareness (χ²=142.3, p<0.001), trust perception (χ²=38.7, p<0.001), policy knowledge (χ²=28.9, p<0.001), and perceived accessibility (χ²=95.1, p<0.001). Conclusion: The study reveals that awareness alone is insufficient for health insurance enrollment. Process complexity, trust deficits, coverage misalignment, and geographic disparities create a multifaceted barrier ecosystem. Interventions must shift from raising awareness to simplifying enrollment, rebuilding trust, aligning benefits with patient priorities, and strengthening provider partnerships to achieve meaningful progress toward Universal Health Coverage. Keywords: Health Insurance, Perception, Utilization, Awareness, Enrollment Patterns, Barriers to Uptake, Patient-Provider, Perspectives
Nzewi et al. (Mon,) studied this question.