In terms of healthcare accessibility in rural areas of Nigeria, bridging the gap will involve meeting the criteria set by the World Health Organization (WHO) for universal health coverage. This means ensuring that all individuals have access to necessary health services without facing financial hardship, regardless of when and where they need them.
The focus extends beyond mere treatment to include various aspects such as health promotion, prevention, rehabilitation, and palliative care, aiming at improving overall well-being and quality of life. Achieving universal health care requires policymakers’ commitment to investing in it, along with skilled health workers providing high-quality, people-centred care. This care should be delivered through a primary health care system deeply rooted in the communities it serves.
The two main pillars of healthcare access are financial accessibility and the quality of services provided. Emphasizing quality care is crucial as it determines the effectiveness of the services in promoting health.
Reformed primary health care is characterized by comprehensive, ongoing, and person-centred care delivered within the individual’s familial and communal context by a consistent provider. This approach ensures that patients receive suitable care for most of their health needs, including curative, preventive, promotive, and palliative aspects, while engaging their families and communities. The primary care provider takes responsibility for coordinating patients’ healthcare needs, even when specialist care is necessary, thereby ensuring continuity and efficiency in care delivery.
Globally, approximately half of the population lacks access to healthcare, and many are pushed into poverty due to excessive health expenditures. While access to healthcare and its quality have improved over the years, millions of people worldwide still lack essential health services, leading to preventable deaths, especially in low- and middle-income countries like Nigeria.
Access to healthcare is a multifaceted concept, including various dimensions such as identifying health needs, seeking and reaching care, affordability, and obtaining desired outcomes.
The Nigeria Health System
- Nigeria population: 217,373,637M.
- 36 states and the Federal Capital Territory.
- 774 local government areas.
- 52.0% live in urban areas.
- Health Budget % total budget: 5.97% (2022) NGN3,453/capita.
- Health Expenditure % GDP: 3.03% less than Ethiopia and Ghana
- Government Expenditure /capital: Nigeria: 15.95 USD, Ghana: 40.24 USD Ethiopia: 22.70USD, Canada: 70.17USD
- Private expenditure per capita: Nigeria: 71.30%, Ghana:48.48%, Ethiopia:43.19%, Chile 49.08%, Canada:29.83%.
Health indices
Life expectancy in Nigeria: 2021
- Total: 60.87, Males: 59.07, Female: 62.78
- Neonatal mortality (approximately in 2016/2017) 40/1000. Infant mortality: 80/1,000 Under-five mortality: 120/1000 (NSHDP II)
- Maternal mortality rate: 800/100,000 (approximate 2015, NSHDP II)
- Distribution of Health Facilities as at 2015 (NSHDP II)
- Type of health facility Public Private Total
- Primary Health Centers: 30,098 (Public: 21,808, Private: 8,290)
- Secondary Health Facilities: 3,992 (Public: 969 Private: 3,023)
- Tertiary Health Facilities: 86 (Public: 86, Private: 10)
- Total: 34,176
Distribution of health manpower
Doctors in Nigeria 2022
- Doctors: 24,600. Population ratio, 1:8,836.
- Dentists: 1,400. population ratio, 1: 155,267. Required at ratio of 1 doctor /600 population: 362,289 doctors. Deficit: 338,289
- Nurses: 249,566 Population ratio 1:1,677 (NHSDP II,2015)
- Senior CHEWs: Total: 42,938 population ratio 1:28,256 (NHSDP II,2015)
- Junior CHEWs: Total: 28,548 population ratio 1: 5,914 (NHSDP II,2015)
The healthcare system in Nigeria operates across three tiers: primary, secondary, and tertiary care levels. Primary health centres are established at the grassroots level within the ward health system, with one centre allocated to each political ward (totalling 9,560 wards) and overseen by local government authorities.
Secondary healthcare services are provided at general hospitals managed by state governments, each serving multiple local government areas. Tertiary hospitals, managed by the federal government, offer specialized care and health workforce training through teaching hospitals and federal medical centres.
At the primary level, healthcare delivery follows a hierarchical structure consisting of health posts serving small villages/neighbourhoods (covering around 500 individuals), primary health clinics catering to groups of villages (serving 2000–5000 individuals), and primary health centres serving entire political wards (comprising 10–20,000 individuals).
Staffing at these facilities typically includes community health extension workers at health posts, nurses or midwives at clinics, and doctors or nurses at health centres where available. Referral mechanisms connect these primary facilities with secondary and tertiary healthcare centres through a two-way system.
This primary healthcare system was envisioned to form the backbone of the country’s healthcare infrastructure, providing a foundation for further expansion and development. It was designed to deliver the Ward Minimum Package of Health Services (WMPHS), representing the proposed Essential Package of Health Services (EPHS) for all Nigerians. The system prioritizes primary health centres as the initial point of care, with referrals made to higher levels of care as needed beyond their capacity.
Failure of the Primary Health Care
The National Strategic Health Development Plan II (NSHDP II) in Nigeria aimed to enhance the country’s health system, particularly the Primary Health Care (PHC) subsystem, to provide comprehensive and accessible healthcare services to all citizens. However, despite deploying PHC facilities to grassroots levels, mere geographical accessibility did not ensure actual healthcare access, with approximately 80% of these facilities remaining underutilized by the population.
This underutilization stemmed from perceived low service quality, primarily due to the inability of available healthcare providers to deliver competent care meeting the population’s needs. The expressed healthcare needs of the populace, which often extend beyond preventive care to curative services, require the expertise of professional healthcare providers such as doctors, nurses, and pharmacists, rather than the community health extension workers (CHEWs) commonly found in PHC settings.
Consequently, poor utilization led to economic unviability and eventual abandonment of these facilities by both the community and the government, resulting in their deterioration.
The World Health Organization (WHO) has noted this phenomenon in countries employing low-level healthcare providers, in contrast to high-income nations where primary care is provided by specialist physicians capable of offering comprehensive, high-quality first-contact care. This mismatch between people’s needs and the services provided represents a failure of people-centred care and is identified by the WHO as a primary cause of health system stagnation in low- and middle-income countries (LMICs), including Nigeria.
Even individuals of low socioeconomic status recognize the need for professional-quality healthcare and are no longer satisfied with intervention programs targeting specific diseases. Despite acknowledging these challenges, previous reform efforts and investments in Nigeria’s healthcare system, as outlined in the NSHDP II, have failed to yield the desired results, leading to limited healthcare coverage and persistently poor population health outcomes.
The strategic goal of providing high-quality healthcare for all Nigerians through PHC, as outlined in the 2018 strategic health plan, reflects a contradiction, highlighting a lack of understanding of the misalignment between the current PHC concept, structure, and reality in the country. Despite two national strategic health development plans since 2008, which have documented system failures, subsequent reforms have been superficial and failed to address the root causes of these failures.
Recommendations from the WHO’s 2008 report on PHC reform have been overlooked in these plans, indicating poor leadership and a reluctance to reform the system based on local evidence and the WHO’s reform agenda.
Revitalizing Nigeria’s Healthcare System
It is important to address these fundamental flaws in our healthcare system, as the current situation is not only ineffective but also leads to ongoing underdevelopment.
Now, more than ever, is the time to overhaul Nigeria’s healthcare system to ensure better access to care and improved health outcomes. This reform effort will set the country on a path toward a healthcare system that can truly serve its purpose, laying the groundwork for development and bringing it up to speed with modern standards.
This reform needs to involve all stakeholders, including politicians, healthcare workers (including those in the private sector), the general public, community leaders, civil society organizations, global partners, and others, to ensure everyone is on board, takes ownership, and sustains the changes. It should encompass the four pillars of reform outlined by the World Health Organization (WHO): leadership and governance, public policies, universal health coverage, and service delivery.
Political leaders must take responsibility for the health of the population and adopt evidence-based reforms outlined by the WHO. However, the current political landscape may not have the capacity to drive these reforms effectively. Therefore, substantial changes in political leadership are necessary to generate the political will needed for reform. This also involves combating corruption within the healthcare sector and beyond.
Key areas requiring attention include reforming primary healthcare policies and restructuring healthcare workforce management to improve training opportunities, working conditions, and incentives, especially for primary care specialists and those serving rural areas.
A primary care movement is needed to educate and mobilize stakeholders to understand the importance of the new primary healthcare model and push for reform. This movement should be led by healthcare professionals and include civil society organizations, community leaders, the general public, Nigerian healthcare professionals abroad, and global partners.
The tasks ahead include educating stakeholders about the urgent need to build a healthcare system capable of delivering health while fostering a culture of solidarity, responsibility, and accountability. Health professional organizations need to engage in multifaceted empowerment initiatives, including leadership training, advocating for healthcare system reform, and improving interprofessional relationships.
Renewed commitment to societal health responsibility is essential, alongside crafting a more functional approach to engaging with political leadership to prevent frequent strikes that disrupt the system. Nigerian healthcare professionals abroad can contribute by sharing their experiences and mentoring local organizations to support human resources reform.
Overall, healthcare professionals must take a proactive role in driving change within the healthcare system, advocating for best practices, and working towards establishing structures that prioritize the system’s well-being.
Other Methods to revitalize the Healthcare system include:
Research and Innovation
Healthcare professionals must overhaul the current deficient research culture to foster research and evidence-based innovation within the system. Government and donor support is crucial, but it hinges on reforming the research culture. While all areas are important, there is an urgent need to focus on system-based practices, quality of care, and outcomes to generate evidence for guiding system development and practice. This will foster a culture of innovation, enhance acceptance, and improve ownership, service quality, and system efficiency.
Regulatory Framework
Developing and establishing a robust, effective regulatory framework is imperative. The country generally lacks a culture of regulation, which has serious implications for the healthcare sector. Without an effective regulatory framework akin to those in developed countries, the system cannot achieve its goals. Healthcare professionals and their organizations play a crucial role here and must lead the charge.
Measures such as continuing professional development, license renewal, reaccreditation through credible processes, and periodic relicensing examinations are vital for ensuring that professionals and facilities maintain technical quality of care. Regulation is necessary to curb the proliferation of unqualified practices, including the unauthorized consultation, prescription, and dispensing of drugs, which contribute to unsafe and poor-quality care prevalent in the system.
Global Partners
Donors should redirect donations and aid away from vertical programs entrenched in the outdated primary healthcare model and towards structures and processes that support the development of reformed primary healthcare and health insurance coverage, as exemplified by the Health Fund in Sokoto state. Additionally, they can create incentives to retain health workers in Nigeria, particularly in rural areas, to support the reform process.
The global community must take action to address the trans-border migration of health workers from low-resource countries to high-resource nations in the interest of global health equity. Donations and aid to impoverished nations cannot translate into desired cost-effective health outcomes if the critical input of health professionals necessary for success is unavailable.
Historically, the training of health professionals in Nigerian public universities has been largely government-funded, and the brain drain represents not just a loss of human capital but also of developmental resources invested in their training, leading to the impoverishment of the health system.
System Reconstruction
The national health insurance scheme presents an opportunity to revise the healthcare system and implement primary healthcare (PHC) reform. Currently, the National Health Insurance Scheme (NHIS) and the PHC system under the National Primary Health Care Development Agency (NPHCDA) are the two main pathways for healthcare delivery in Nigeria.
The new NHIS Act, which makes health insurance mandatory, requires healthcare services to be accessible everywhere and for everyone, thus mandating universal health coverage and necessitating a single delivery system.
The key challenge is how to create a system capable of fulfilling this mandate by aligning structures and processes with this goal. The World Health Organization’s (WHO) PHC reform provides a blueprint for achieving this by organizing the NHIS based on the reformed PHC model. However, there are resource constraints in implementing this remodelling across the entire system.
Therefore, the proposal is to create a roadmap whereby remodelling can commence where resources allow and gradually expand to other areas over time. This phased approach aims to steer the system in the right direction toward development and growth.
Conclusion
Transforming Nigeria’s healthcare demands adherence to WHO standards, ensuring universal coverage and quality care. Reconstruction is urgent, requiring stakeholder collaboration. Political will is vital amid systemic challenges. Priorities include policy reform and healthcare workforce restructuring.
