“Pay before treatment” is a widespread, though largely unregulated, practice in Nigerian hospitals, forcing patients, especially those in emergencies, to make upfront deposits or payments before receiving care. While unethical in emergencies, this often results from low insurance coverage, high out-of-pocket (OOP) expenses, and limited facility funding. With an increasing number of death-related incidents associated with the controversial practice, many call for stricter enforcement of ethical standards, particularly in emergencies in hospitals. Weekend Trust reports. At 3:15 am on a Monday in Abuja, Aderonbi Folake held her 13-year-old son, Seyi, as his breathing became shallow. His small body burning with fever, she had already been to two hospitals that night and was told the same thing at both hospitals: ‘No deposit, no treatment’. SPONSOR AD “They told me to bring N60,000 before they could admit him. I begged and told them that I had only N8,000. They said I should go and come back when I had the money,” Folake said. Ironically, Seyi never made it to the third hospital, as he died in his mother’s arms inside a tricycle, barely 500 metres from the gate of a private clinic in Kubwa. In another scenario, in Keffi, Nasarawa State, Mrs Egbosa Ruth recalls the night 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 said. She said some of the staff stood by as her husband lay on a stretcher. “They were just stared at my husband, and one of the nurses said, ‘Make una bring the money first.’ By the time we managed to get help elsewhere, it was too late. My husband died,” Ruth said tearfully. At 11:40pm. on a rainy Thursday at Mpape, Musa Hassana cradled her six-month-old son, Bello, who was gasping for breath. “He was gasping for air, his lips were already turning blue,” Hassana recalled. At a nearby private hospital, she said nurses asked her to pay N40,000 before oxygen could be administered. “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 said. Hassana said she rushed out to look for help elsewhere, but Bello stopped breathing on the way. “My baby died before we reached the next place. I still hear him crying in my head,” she said. Thomas Okon was returning from work when a commercial bus hit him, leaving him with a fractured leg and internal injuries. “I was in serious pain, and couldn’t talk properly,” he said. Yusuf said he was taken to a private hospital where staff allegedly asked his relatives to either pay N70,000 upfront or sign documents taking full responsibility if he died. “They were argued while I bled, and a doctor said, ‘We can’t start anything without clearance,’” he recalled. He noted that he was later moved to a government hospital. “I survived, but I almost didn’t make it. I kept thinking, what if nobody came for me?” Yusuf asked. Fortune Ukanwa said her elder sister, Precious, complained of severe abdominal pain late one evening in Uyo. “We thought it was something minor. By midnight, she couldn’t stand,” Fortune said. At a private clinic, Blessing said they were asked to pay N45,000 before tests could be done. “They told us to wait outside while we sort out payment. My sister was sitting on a bench, groaning. By the time Precious was eventually taken to another hospital, her condition had worsened. “They said it was a ruptured appendix. She didn’t survive surgery. I keep asking myself—what if they had attended to her earlier?” she said. For Adam Ibrahim, the night his pregnant wife went into labour remains unforgettable. “She was shouting in pain. The baby was coming too fast,” he said. At a private maternity facility in Ilorin, Adam said he was told to pay N100,000 before his wife could be taken into the delivery room. “I told them I had only N35,000. I begged them to help us, and someone said, ‘go and look for the balance,” he recalled. His wife eventually delivered the baby with the help of a traditional birth attendant nearby, the baby, however did not survive. “I don’t blame anyone directly. That night, I knew that money mattered more than life,” he said. These stories are not isolated. Across Nigeria, the practice of demanding upfront payment before providing emergency medical treatment remains a critical issue, causing preventable deaths and persisting despite existing laws meant to stop it. This, often referred to as “deposit before treatment,” continues to occur across both private and occasionally public health care facilities. The law versus reality In 2014, the federal government signed the National Health Act provision. The Act includes provisions requiring that emergency treatment not be denied (it obliges health facilities to provide emergency care and promotes patients’ rights to emergency services). However, on the ground, many Nigerian hospitals still withhold or delay emergency care in practice. “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,” said a health rights advocate, Emmanuel Owu. Why hospitals insist on payment- hospital The managing director of God is Able Hospital, Kubwa, Abuja, Ajasa Kehinde, explained that health care services, like any other sector, come with unavoidable financial costs. Kehinde said hospitals must pay for electricity, water, staff salaries, equipment, consumables and maintenance, adding that without steady income, especially in private hospitals, services would simply collapse. He noted that health care systems around the world are funded through a mix of government spending, insurance, community contributions and personal payments. While some countries fully fund health care through taxation, most rely on insurance schemes that allow patients to receive treatment without paying cash at the point of care. “In Nigeria, the government subsidises some services, but individuals and families are still expected to shoulder part of the cost,” he said. According to him, government hospitals are required to treat emergency cases regardless of a patient’s ability to pay, while private hospitals can only waive fees, depending on their own financial capacity. He urged Nigerians to embrace health insurance, particularly the National Health Insurance Scheme (NHIS), as the best way to avoid cash-before-treatment situations. ‘High bills, TSA remittances crippling public hospitals’ A former medical director of the Federal Medical Centre (FMC), Abeokuta, Prof Adewale Musa-Olomu, noted that rising electricity tariffs, huge operational costs and compulsory remittances to the Treasury Single Account (TSA) make it increasingly difficult for public hospitals to deliver care without demanding deposits from patients. Speaking to Weekend Trust, Musa-Olomu explained that although federal medical centres are fully funded by the government in theory, they are required to remit a large portion of the money they generate internally, leaving them with limited resources to run their facilities. “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 the FMC, Abeokuta, as medical director, I knew that this percentage had been increased, first to 40 per cent, then to 50 per cent,” he said. He said the impact of these deductions was compounded by soaring electricity tariffs, which hospitals have little control over. “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,” he said. According to him, constant electricity is critical to 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 highlighted the high cost of water supply at the centre. He recalled that during his tenure, he had to intervene personally to ensure a steady water supply. He added that two industrial boreholes were later provided by the Ogun-Osun River Basin Development Authority, helping to stabilise supply, but at an additional cost. Beyond utilities, the former medical director said hospitals also struggled 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. He explained that maintenance of equipment, buildings and consumables also placed a heavy burden on hospitals, especially since they do not receive running cost directly 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 said. Despite these constraints, Musa-Olomu said public hospitals still provided free emergency care, particularly 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,” he said. However, he noted that many families failed to 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 noted. He said this created a unique challenge for hospitals, 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 said. He added that some recovered patients would also remain in hospital beds because they cannot afford to pay. “Some patients remain in hospital beds, even after recovery, occupying space needed for other patients who can pay. Yet we must still house them, give them electricity and water. This creates a very precarious situation,” he said. On the way forward, the former medical director urged the federal government to reduce the proportion of hospital revenue remitted to the TSA and to take responsibility for key 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 said. He also said recent changes in fuel pricing offered a small sign of relief. “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. Musa-Olomu, however, warned that broader fiscal pressures on the government were still affecting the health sector. He advised that investing savings from subsidy removal into health care would have far-reaching benefits. “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 added. Doctors weigh in In separate interviews with Weekend Trust, some doctors admitted that the system forced hospitals into impossible choices. A senior doctor at the Kubwa General Hospital, who asked not to be named, said funding gaps had made emergency care difficult. “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 said. However, he insisted that ethics must come first. “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 said. Another medical practitioner at the hospital, Dr Hammed Alausa, said, “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,” he noted. Physician Chukwudi Ifeanyi stressed that health care would not be sustained without financial backing. “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,” Ifeanyi said. He noted that in public hospitals, the government would pay on behalf of patients, but in private facilities, the patient would bear the cost directly. Dismissing claims that hospitals were being heartless, he said, “This is not an emotional issue. Health care is a service that requires funding. Without proper financing, no hospital can survive.” For Chuks Emmanuel, a trader at Dutse market, Abuja, when his younger brother, Ike was shot during a robbery attack in 2004, he was taken to a private hospital, but treatment was delayed as they were asked to provide a police report. “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 from the police before commencing treatment. “They told us clearly: ‘Bring police report first. We cannot treat gunshot wounds without police paperwork.’ We begged them to at least stop the bleeding. A nurse insisted that ‘it is the rule,”’ he said. Okafor said they immediately left to locate the nearest police station to get the report. “By the time we came back with the report, my brother had lost a lot of blood. They tried to revive him, but he died that night. If they had treated him first and asked questions later, he would still be alive today,” he said. Similarly, Musa Aisha, a resident of Mararaba, Nasarawa State, recounted how her cousin, Sadiq died after being taken to different hospitals following a shooting incident. “He was hit by a stray bullet during a clash in our area. We didn’t even know who fired it. We just wanted to save his life,” she said. Aisha alleged that the first hospital they approached declined to admit him without police clearance. “They said it was a gunshot case and they couldn’t get involved unless the police documented it. We kept explaining that it was an emergency,” she said. According to her, the delay proved fatal. “We drove to the police station where we wrote a statement. All that time, he was bleeding at the back seat of the car. Before we got to another hospital, he had stopped responding. It is painful because he survived the bullet. What killed him was the delay,” she said. Another resident, Ibrahim Abdulrasheed, shared how his neighbour, Taiye, lost his life after a late-night shooting incident in 2021. Abdulrasheed, a commercial motorcyclist in Nyanya, Abuja, said Taiye was caught in a crossfire when gunmen attacked a nearby shop. They rushed Taiye to a private clinic to stabilise him before moving him elsewhere. “When we got there, they looked at the wound and asked if we had reported it to the police. We said no, that we came straight from the scene. They said gunshot cases were sensitive and they could not touch him without a police extract. We pleaded that they could at least give him first aid to stop the bleeding,” Abdulrasheed said. He explained that he and another neighbour quickly rode to the nearest police station. “By the time we returned, he was weak and barely speaking. We rushed him to the hospital with the paper, but he didn’t survive the surgery. We felt helpless,” he said. Police law on gunshot victims The Compulsory Treatment and Care for Victims of Gunshot Act 2017 mandates all Nigerian hospitals (public or private) to provide immediate and adequate treatment to gunshot victims, explicitly prohibiting the requirement of a police report or upfront monetary deposit before care. It protects victims from degrading treatment, requires police notification within two hours of treatment, and mandates that security agents assist victims. Mandatory treatment: Every hospital must accept and treat any person with a gunshot wound immediately without demanding a police report. No deposit required: Treatment must be provided, regardless of whether the victim has made an initial monetary deposit. Assistance obligation: Every citizen and security agent is mandated to provide reasonable assistance to a person with a gunshot wound. Police reporting: Hospitals must report to the nearest police station within two hours of beginning treatment. Protection of victims: Gunshot victims cannot be subjected to inhuman or degrading treatment/torture by any person, including the police. Police investigation constraint: The police cannot invite a victim for investigation until the chief medical director certifies them fit and no longer in need of immediate medical care. Penalties for neglect: Any person or hospital that fails to act, resulting in the unnecessary death of a victim, is guilty of an offence and liable to five years imprisonment or a fine of N500,000. Restitution: The High Court can order restitution for the victim from any person or institution convicted of violating the act. A trauma surgeon in Abuja, Dr Samson Ogunyemi, said delays linked to requests for police clearance in gunshot cases had 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 said. According to him, although the law permits emergency treatment without prior police documentation, fear of legal complications still 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. Similarly, a public health policy analyst, Dr Akeem Ibrahim, described the insistence on police reports before commencing treatment as a “systemic problem that affects young Nigerians caught in violent incidents.” “We have documented cases where gunshot victims were shuttled between hospitals because there was no police report. By the time documentation was secured, the patient had deteriorated beyond recovery,” he said. Ibrahim noted that the fear of treating gunshot wounds without police involvement often stemmed from past experiences where hospital staff were harassed or questioned. “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 a clearer enforcement of existing laws and stronger 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 said.