State Capacity and Health Justice: Evaluating the Edo State Health Insurance Scheme in Nigeria

Abstract

The relationship between state capacity and health justice remains insufficiently theorised despite its central importance to the realization of Universal Health Coverage (UHC) in developing democracies. Existing scholarship has largely examined health justice through normative theories of rights, equity, and distributive justice or evaluated health insurance reforms from administrative and health systems perspectives, with limited integration between these traditions. This article addresses this conceptual gap by developing the Capacity–Justice Nexus, an interdisciplinary analytical framework that integrates normative theories of health justice with contemporary state capacity theory to explain how institutional capability shapes the realization of equitable healthcare. Using the Edo State Health Insurance Scheme (EdoHIS) in Nigeria as a qualitative case study, the article draws on Michael Mann's concept of infrastructural power alongside the state-capacity perspectives of Peter Evans and Francis Fukuyama, while adopting Venkatapuram's capability approach as its normative benchmark. The analysis examines four interrelated dimensions of institutional capacity—infrastructural reach, administrative coordination, financial sustainability, and informal sector inclusion to evaluate the extent to which EdoHIS translates legal entitlements into substantive healthcare access. The findings demonstrate that although EdoHIS has achieved significant progress through provider expansion, equity-focused financing, increased enrolment, and administrative innovation, persistent weaknesses in territorial penetration, bureaucratic coordination, digital infrastructure, fiscal sustainability, and informal-sector integration continue to constrain the realization of health justice. The study argues that these limitations are better understood as manifestations of constrained state capacity rather than failures of policy design alone. The article advances the theoretical proposition that state capacity is not merely an implementation variable but a constitutive condition of health justice because legal rights become largely symbolic where governments lack the institutional capability to implement them effectively. The Capacity–Justice Nexus therefore contributes a novel framework for analysing health governance in federal developing democracies and provides policy guidance for strengthening subnational health insurance systems through sustained investment in administrative, fiscal, governance, and service-delivery capacities as prerequisites for achieving Universal Health Coverage.