The nation was rocked recently with the sad news that bestselling novelist Chimamanda Adichie had lost her young son in what seemed to be a case of medical negligence. The incident naturally put the spotlight on our healthcare system or perhaps more accurately, the lack of it.
I say the lack because, millions of Nigerians have to put up with the frustration of primary health care centres (PHCs: these are the first points of care for many Nigerians, particularly in the rural areas) that do not have basic equipment, clean water, or reliable power. This often renders routine services like checking one’s blood pressure impossible. In a nation where the better part of the populace lives in a state of multidimensional poverty, such circumstances force millions of Nigerians to pay for healthcare services out-of-pocket. For many, this could mean spending savings of several months.
Thankfully, government commitments to Universal Health Coverage (UHC) have grown, but the harsh reality is that most Nigerians still pay for healthcare themselves, with 69 to 76.6 per cent of total health spending coming directly from patients at the point of service. Some households spend over 40 per cent of their non-food income just to stay healthy.
Only 5 to 10 per cent of Nigerians have health insurance coverage, leaving informal sector workers, rural dwellers and poorer households most vulnerable to financial shocks when illness strikes.
Stakeholders in the healthcare sector said Nigeria’s under-resourced system is hampered by weak infrastructure, chronic workforce shortages and uneven service distribution. Rural communities often lack functional facilities, forcing patients to travel long distances.
Even where facilities exist, PHCs are frequently underutilized because of perceived low-quality care, long wait times, and insufficient staff. This consistently pushes more patients toward already overcrowded secondary and tertiary hospitals, intensifying pressure on the broader health system.
The shortage of healthcare professionals remains acute. In some states, there is one doctor per 5,000 patients, far below the World Health Organization’s recommended ratio of one per 600.
The continuing wave of brain drain has seen many Nigerian doctors, nurses and specialists relocate abroad for better pay and working conditions, leaving those who remain overstretched. This exodus has compounded the gap between demand and supply of critical healthcare services across the country.
Urgent reforms are required to strengthen quality, affordability and equity across the health sector. Stronger policy implementation, improved accountability and more citizen engagement are required to ensure that reforms translate into real gains across communities. Some healthcare stakeholders suggest that Nigeria is dire need of tax-funded healthcare system like the British National Health Service (NHS) or an insurance-funded one like America’s Medicare to guarantee that no citizen is denied essential care.
To address systemic challenges, the Nigerian government is implementing the Nigeria Health Sector Renewal Investment Initiative, focusing on governance, funding, infrastructure and accelerated UHC progress.
Government is revitalizing primary healthcare with plans to increase the number of fully functional PHCs from 8,300 to 17,600 within four years, supported by direct disbursements from the Basic Healthcare Provision Fund. Plans are also in the offing to tackle staff shortages by recruiting over 20,000 frontline workers, improving incentives and mitigating brain drain. New diagnostic and oncology centres are being built and equipped across the country through the Nigeria Sovereign Investment Authority (NSIA) Healthcare Expansion Programme.
There are also efforts afoot to unlock the healthcare value chain through the Presidential Initiative on Unlocking Healthcare Value Chain, designed to boost local manufacturing of medicines and medical devices and reduce dependence on imports. Digital technologies such as the national PHC dashboard and online training platforms are also being expanded to improve data collection and support continuous training for health workers.
The private sector has not been left out of all of this, as it collaborates on national programmes like the Basic Health Care Provision Fund (BHCPF) and the Maternal and Adolescent Health and Immunization Initiative to strengthen PHCs and expand access in underserved areas.
On a final note, it hasn’t gone unobserved by healthcare stakeholders that without accelerated progress, millions of Nigerians will continue to face preventable illnesses and financial hardship. It has been further noted that achieving UHC will require political will, smart investments, citizen engagement, and strong partnerships. Delay will only deepen the human and financial costs.
Background
Nigeria’s primary health care (PHC) system has faced decades of underfunding, poor implementation, and political neglect, leaving millions of citizens without affordable, accessible care. This failure has forced households to rely on costly private providers, making healthcare unaffordable for much of the population. A look at the history of PHC deployment in Nigeria, and the evolution of the healthcare system in general will enable us to better understand how we got here.
It all started with the 1978 Alma-Ata Declaration. The Alma-Ata Declaration was a landmark global health agreement that defined primary health care as the key strategy to achieve “Health for All” and affirmed health as a fundamental human right. The Declaration was adopted at the International Conference on Primary Health Care, held in Alma-Ata (now Almaty, Kazakhstan) between the 6th and 12th of September, 1978. The following were the core principles of the Alma-Ata Declaration:
- Health as a human right: Declared that health is “a state of complete physical, mental, and social well-being” and not merely the absence of disease.
- Equity: Stressed reducing health inequalities between developed and developing nations, and within countries.
- Primary health care (PHC): Identified PHC as the most effective and sustainable approach to deliver essential health services.
- Community participation: Called for active involvement of individuals and communities in planning and implementing health care.
- Intersectoral action: Recognized that health depends on social and economic development, requiring cooperation across sectors (education, agriculture, housing, etc.).
- Global solidarity: Urged governments, international organizations, and health workers to collaborate toward universal health coverage.
The Alma-Ata Declaration became the foundation for global health policy, inspiring initiatives like “Health for All by the Year 2000.” It influenced the design of national health systems, especially in developing countries, including Nigeria’s adoption of PHC in the 1980s. Despite challenges in implementation, it remains a reference point for universal health coverage (UHC) and equity in health.
Since its adoption, Nigeria has struggled with its implementation of the global PHC model. During the 1980s and 1990s, the PHC system was rolled out nationwide, but weak governance, corruption, and poor funding undermined its effectiveness. Facilities were built but not maintained, and staffing was inadequate.
During the 2000s, initiatives like the National Health Insurance Scheme (NHIS) and donor-funded programs (e.g., immunization campaigns) tried to strengthen PHC, but coverage remained limited.
To address the shortcomings of the PHC system, the Federal Government introduced the National Health Act. This established a framework for universal health coverage and a Basic Health Care Provision Fund (BHCPF). Implementation, however, was slow and inconsistent due to political and institutional bottlenecks.
Between 2015 and 2020, Programs like Saving One Million Lives (SOML) sought to improve maternal and child health through PHC, but results were uneven, with rural areas still underserved.
The 2020s have seen a host of reforms but despite that, PHC centers remain under-resourced, with many lacking electricity, water, medicines, or trained staff.
The consequences of the poor implementation of PHC are many. They include:
- Poor health outcomes: Nigeria’s life expectancy is just 62 years, and maternal mortality is among the highest globally (814 deaths per 100,000 live births).
- Overburdened tertiary hospitals: Because PHC centers are unreliable, patients bypass them, flooding secondary and tertiary hospitals with basic cases.
- Rural-urban health inequality: Rural communities, where most Nigerians live, face severe shortages of PHC facilities, widening inequality in access.
- Dependence on donor programs: Immunization, HIV, and malaria programs often rely on external funding, making PHC vulnerable to external shocks as a result of funding withdrawals.
These failures have led to an epidemic of unaffordable healthcare in Nigeria. Over 70% of healthcare financing in Nigeria comes directly from households, one of the highest rates globally. With PHC centers unreliable, millions turn to private clinics and pharmacies, where costs are significantly higher. Less than 5% of Nigerians are covered by health insurance, leaving the majority exposed to catastrophic health expenses. All of these combine to perpetuate a cycle of poverty.
Solving the problems that are beguiling Nigeria’s PHC is not a day’s job but a good place to start would be for Nigeria to implement the Abuja Declaration target of spending at least 15% of the national budget on health. Healthcare spending as a percentage of the national budget is currently less than 5%. Raising it to the Declaration target would go a long way to providing sustainable funding for Nigeria’s PHC centres.
