Gaps in Nigeria’s Flawed System for Universal Health Coverage
By Joshua Payne, Glenforest Secondary School, Mississauga, Ontario, Canada
Figure 1. Nigerian hospitals look very different from Canadian hospitals (Guardian Nigeria, 2017).
In Canada, when a teenager needs to get an immunization or a bandage, one can usually just go to a school nurse or a family clinic. They are very easy to reach and use, especially if you live in an urban area. You can almost always trust your doctor or nurse to give you the appropriate treatment and qualified health advice you need.
Unfortunately, this is rarely the case for developing countries. There, the budget, prioritization, and social support for a high-functioning healthcare system is often extremely limited.
A solution that many developing nations are exploring is a health system called primary healthcare (PHC). Essentially, this involves building health posts and repurposing houses to deliver basic health services with high patient satisfaction and low service fees (World Health Organization, 2017). In doing so, the coverage of health services could be affordably and effectively maximized across an entire country.
Nigeria is one in dozens of countries with a PHC system. Considering their high rates of disastrous health outcomes, ranging from maternal and child mortality, an effective PHC model could be revolutionary in improving the lives of their citizens (World Health Organization, 2018). For context, this country drastically falls behind global averages in crucial indicators of health; maternal mortality and morbidity, under-five mortality, cases of malaria, child immunization rates, and more (World Health Organization, 2017).
Let’s Dive Deeper into Nigeria’s Current PHC System
Primary healthcare is the most basic form of healthcare provided in Nigeria, designed to be the first point of contact for non-specialized health advice and treatment (like a family doctor). The functions of primary healthcare are the promotion of health, early diagnosis of disability and disease, and the prevention of disease (Nigeria, 2020).
Services are delivered through PHC facilities, which could infrastructurally be mere health posts or entire health centers (World Health Organization, 2017). A PHC facility looks like a mobile or static structure where different health services are provided by groups of different kinds of health workers (doctors, nurses, midwives, etc.) (Nigeria, 2020). Services can also be implemented through home visits.
Figure 2. Not quite the pinnacle of hospitals. (Onyeji, 2017)
So… what’s going wrong?
The status quo of PHC has gaps and issues everywhere - on both the quality of care supplied side, and the amount of care demanded by society. While there’s plenty of physical access barriers to reaching PHC centers, like long distances to walk with no other modes of transportation, the biggest issue is demand (World Health Organization, 2017). Quality of care is so poor that Nigerians would rather not receive healthcare at all than visit a PHC facility (World Health Organization, 2017).
This is the problem - if we can’t provide the majority of Nigerians with high-quality healthcare, we can’t improve health outcomes.
The high-level problem areas include (World Health Organization, 2017):
Poor infrastructure: facilities can have roofs caving in, no bathrooms, etc.
Lack of resources: counterfeit drugs are common, medical and facility equipment is often missing (ex. few beds for birth deliveries) .
Lack of qualified health workers: facilities can sometimes only have 1 formally trained doctor present at a time.
Physical access: long distances with roads in poor conditions, lack of transportation options for community members, etc.
Poor regulation and accountability: health workers at facilities aren’t held accountable enough for providing high-quality care, and government overseers aren’t monitored for fraudulence in handling funds designated for PHC.
What’s the underlying cause of these problems?
Nigeria’s federal government is the primary source of funding for the PHC system, and the financing scheme is very flawed (World Health Organization, 2017). Not enough money is invested into facilities in the first place. Ideally, funds should be allocated for the facility itself and its personnel - however, money is rarely left to maintain the health center after workers have been fairly compensated. Even when funds are provided, they can be delayed by weeks or months, and be less than promised because of corrupt authorities who aren’t held accountable enough (World Health Organization, 2017; Nigeria, 2020).
So how do we level up Nigeria’s PHC system, to provide healthcare on par with the rest of the world?
A few approaches have been deployed or planned over the past couple of decades to improve Nigeria’s primary healthcare system. Some are governmental, and some have been put forward by non-governmental organizations (e.g. The World Bank) and independent researchers.
Most try to tackle this core issue of facility financing - one of the most prominent examples being NSHIP (the Nigeria State Health Investment Project). In this model, the World Bank and federal government collaborated for primary healthcare centers to undergo performance-based financing. In essence, if facilities increased their quality of care and amount of patients, they’d receive increased compensation from local government authorities.
Unfortunately, the ministry of health relied on loans from the World Bank to fund this initiative - meaning it wasn’t self-sustainable. Once the World Bank finished sponsoring the project, the project finished as well.
However, while NSHIP existed, PHC facilities showed immense improvements in their service utilization and quality of care. If the project was continued, these improvements could be tied to benefits in health outcomes themselves. Thus, the opportunity lies for a self-sustainable version of NSHIP, that could be deployed at a national scale.
If seized, primary healthcare could finally meet the needs of Nigerian citizens, and drive visible impact in the country’s health status.
Guardian Nigeria. (2017, December 4). How poverty compounds poor medical treatment. The Guardian Nigeria News - Nigeria and World News. https://guardian.ng/opinion/how-poverty-compounds-poor-medical-treatment/
Nigeria. (2020, December 22). PHCPI. https://improvingphc.org/sub-saharan-africa/nigeria-0
Onyeji, E. (2017, November 13). INVESTIGATION: The terrible state of Nigeria’s Primary Healthcare Centres (PART ONE). Premium Times Nigeria. https://www.premiumtimesng.com/news/headlines/249167-investigation-terrible-state-nigerias-primary-healthcare-centres-part-one.html
World Health Organization. (2017). PRIMARY HEALTH CARE SYSTEMS (PRIMASYS) - Case Study from Nigeria. Professor B.S.C. Uzochukwu. https://www.who.int/alliance-hpsr/projects/alliancehpsr_nigeriaprimasys.pdf?ua=1
World Health Organization. (2018, May). Nigeria | Country Cooperation Strategy. https://apps.who.int/iris/bitstream/handle/10665/136785/ccsbrief_nga_en.pdf;jsessionid=C296E60189AAC1C92031B099E5B2F3FE?sequence=1#:~:text=HEALTH%20SITUATION&text=Maternal%20mortality%20ratio%20is%20814,divide%2C%20education%20%26%20social%20status.