A political economy analysis of health policymaking in Nigeria: the genesis of the 2014 National Health Act

Abstract

This article explores the ideologies, interests, and institutions affecting health policymaking in Nigeria, and the role of the private sector therein. It covers the period from the late-1950s, the years leading up to independence, to 2014, when the country enacted its first-ever law to govern its healthcare system. The National Health Act (NHAct) was adopted after a decade of preparation and civil society-driven advocacy, making the objective of universal health coverage (UHC) explicit. However, in its final version, the NHAct earmarked only a small share of public funds for UHC, solidifying the country’s reliance on private healthcare and out-of-pocket payments. To examine the specific set of ideologies, interests, and institutions defining Nigeria’s pathway toward UHC and the contribution of the private sector, we adopted the political economy framework, situating the genesis of the 2014 NHAct within the broader political and economic context of Nigeria’s health system reform process since the 1950s. Drawing on qualitative data collected during interviews and focus groups, we found that the deep entrenchment of private-sector healthcare in Nigeria is the result of a path-dependent process. This implies that Nigeria’s current reliance on the private sector is influenced by historical patterns, competing interests, and institutional practices that have reinforced the role of private actors over time. We identified three major explanatory factors that have shaped health policymaking in Nigeria. First, since the 1980s, the ideology that private healthcare is the solution to an underfunded and underperforming public healthcare system has been reinforced by leading international organizations. Second, private actors in Nigeria have been in a strong position to influence health policymaking since independence. Third, Nigeria’s challenging socio-economic context and the limitations of its federal governance structure have fostered a general level of public distrust in the capacity of the public sector to provide quality healthcare.

Key messages.

• The 2014 National Health Act (NHAct) marked a significant milestone in Nigeria’s healthcare system reform process, making the attainment of universal health coverage (UHC) an explicit policy objective. While seeking to address long-standing challenges within Nigeria’s healthcare system, the final version of the NHAct revealed a notable discrepancy between its stated objectives and the allocation of resources, which effectively reinforced Nigeria’s reliance on the private healthcare sector.

• Three major factors played a crucial role in shaping health policymaking in Nigeria from the 1950s to 2014. First, the prevailing ideology that private healthcare is a solution to an underfunded public system has gained significant traction over time. Second, since Nigeria’s independence, private sector actors have exerted a strong influence on health policymaking processes, aligning health policies with their own interests. Third, widespread public distrust in the capacity of the public sector to provide quality healthcare services entrenches the role of the private sector in the healthcare system.

• The prominent role of the private sector in Nigeria’s healthcare system is not a recent development but rather the result of a complex, path-dependent process that has unfolded over decades. This process is shaped by a combination of historical patterns, competing interests among various stakeholders, and deeply entrenched institutional practices.

• Globally, the concept of what UHC should look like in practice has shifted from assuring access to a broad range of necessary healthcare services to providing a selective package of healthcare services. Correspondingly, the NHAct proposes the provision of selected essential healthcare services to targeted population groups.

Introduction

This article explores how evolving ideologies, interests, and institutions affect health policymaking in Nigeria. It covers the period from the late-1950s to 2014, placing the genesis of the 2014 National Health Act (NHAct) into the political, economic, and historical context of a long-running health system reform process. In 2014, Nigeria’s then-President Jonathan Goodluck signed the NHAct into law, making it the country’s first formal legal framework to govern its healthcare system. It was adopted after a decade of preparation and civil society-driven advocacy and made the objective of universal health coverage (UHC) in Nigeria explicit (Adeoye et al. 2024, Croke and Ogbuoji 2024). Specifically, the law mandated the establihment of a new public health financing mechanism, the Basic Health Care Provision Fund (BHCPF), to mobilize additional resources for primary healthcare (FMOH 2014). The BHCPF aims to sponsor a basic minimum package of health services (BMPHS) for all Nigerians and to financially support vulnerable population segments especially, in order to fast-track progress toward UHC (FMOH 2020). (In 2022, the 2014 NHAct was complemented by the National Health Insurance Authority Act, which made health insurance mandatory and re-emphasised the Nigerian government’s commitment to facilitate the attainment of UHC.) While celebrated as a milestone in a country characterized by high levels of regressive out-of-pocket healthcare expenditures and deeply entrenched health inequities (Uzochukwu et al. 2010, Edeh 2022), the NHAct’s potential to serve as a catalyst for expediting the attainment of UHC was adversely affected by the involvement of different interest groups with varying degrees of power in developing its final text. In its final version, the NHAct solidified Nigeria’s reliance on private sector participation in healthcare service delivery, earmarking only a small share of the federal government’s public budget for the objective of UHC (Chukwuma 2023).

Generally, ample scholarly research exists highlighting the risks associated with a dominant private sector in a country’s healthcare delivery system. (Mills et al. (2002) define the private sector as ‘all providers who exist outside the public sector, whether their aim is philanthropic or commercial, and whose aim is to treat illness or prevent disease’. In this article, we employ their definition of the private sector as both non-profit and for-profit actors are heavily involved in Nigeria’s healthcare system, contributing to the fragmentation of service delivery.) Such risks include overpriced provision; the prescription of unnecessary treatment, testing, and medication; the marginalization of high-risk groups; the exclusion of poorer population groups from accessing quality healthcare; catastrophic impacts on welfare as a consequence of illness; higher risks of complications due to weak regulation; suboptimal quality of services, especially if provided by informal private providers; and the exacerbation of broader social inequalities (Hanson et al. 2008, Oxfam 2009, Wilkinson and Pickett 2011, Basu et al. 2012, Mackintosh et al. 2016, MacGregor 2017, Coveney et al. 2023). Additionally, research has shown that market-based healthcare provision can create localized monopolies (i.e. only one hospital serving a specific geographic area) and enable inappropriate rent seeking, given that for-profit private enterprises operate in their own interests and demand for healthcare is inelastic (Mooney 2012, Fischer 2018, Clarke et al. 2019). Reasons for strengthening public healthcare systems include the positive effects of universal social policies on economic growth, enhanced social cohesion, and increased public trust in government institutions (Martinez Franzoni and Sanchez-Ancochea 2016, MacGregor 2017).

Despite many reasons in favour of public healthcare delivery, it is necessary to acknowledge that many African countries—faced with constrained budgets and inflationary pressures—currently operate pluralistic healthcare systems with strong interlinkages between the public and private sectors (McPake and Hanson 2016, MacGregor 2017, Clarke et al. 2019). However, the degree of involvement of the private sector is contingent on the behaviour and size of the public sector, and vice versa (Mackintosh et al. 2016). In this way, the privatization of the healthcare system in response to underperforming public systems solidifies a reality, where poorly funded public sectors (try to) cater to the lowest-income members of society, while a highly variegated private sector addresses the needs of the members of society with financial means (Mackintosh 2001). The question remains as to what extent ongoing UHC reform processes across countries of the Global South foster continued collaboration with the private sector or prioritize efforts that aim to strengthen public healthcare delivery.

In this article, we pose this question for the Nigerian context, investigating which ideologies, interests, and institutions affect the shape and form of UHC in the country and the role of the private sector therein. We adopted the political economy framework proposed by Rizvi et al. (2020) as an analytical tool to aid our investigation of Nigeria’s health system reform process between the 1950s and 2014. By placing the genesis of the 2014 NHAct in the political, economic, and historical context of health policymaking in Nigeria, we seek to shed light on the specificities that define the country’s approach to implementing UHC and that explain Nigeria’s emphasis on private-sector participation in healthcare delivery. Drawing on qualitative data collected during field research in Nigeria, we argue that the deep entrenchment of private sector healthcare provision in Nigeria is the result of a path-dependent process. This implies that Nigeria’s current reliance on the private sector has been influenced by historical patterns, competing interests, and institutional practices, thus reinforcing the role of private actors over time.

Materials and methods

National healthcare system reforms are complex and highly political processes, characterized by localized political struggles and processes (McKee et al. 2013, Fox and Reich 2015, Greer and Méndez 2015). Unsurprisingly, historical decisions and conditions created by past events influence health policymaking in the present, impacting the potential for change as suggested by path dependency theory (Whyle and Olivier 2024). However, while the concept of path dependency is valuable in foregrounding that ‘history matters’, it must be complemented with theories that can help explain the specific set of factors that affect health policymaking (Kay 2005). A plethora of such theories and analytical frameworks exist that support the examination of how political economy factors affect national health system reforms. Given that the design and implementation of UHC policies often depend on rather technical political factors, political economy analysis is a useful analytical approach to unpack how the power dynamics between and competing interests of different stakeholders and socio-economic and institutional conditions determine health policymaking over time (Sparkes et al. 2019, 2022, Rizvi et al. 2020, Rodríguez et al. 2023).

Four major groups of theories stand out in the scholarly literature on health policymaking. These include pluralist theories (popular choice theories), which highlight the interplay and preferences of multiple actors and citizens and their impact on policymaking (e.g. via voting systems or behaviour as a market participant); institutional theories (power groups theories), which focus on institutions and interest groups such as medical professionals and representatives of pharmaceutical enterprises and insurance providers and how they impact and are impacted by policy dynamics; development theories, which suggest that when countries get richer, they will also increase their public social spending; and class theories, which see systems of healthcare provision as an outcome of struggles between the capitalist and the working classes (Navarro 1989, Stuckler et al. 2010, McKee et al. 2013 cited in Chukwuma 2021).

A noteworthy cross-cutting framework that seeks to explain policy reform processes is the framework put forward by Fox and Reich (2015). (Chukwuma (2021) provides an overview of other theories seeking to explain health policymaking processes and the degree of universalism in national health systems.) They single out four key factors (known as the ‘four Is’), namely: interests (all actors and interest groups that will benefit or lose out as a consequence of a certain policy change); institutions (both formal and informal political institutions and norms that influence policy change); ideas (i.e. specific policy solutions, concepts, information, etc.); and ideology (i.e. a particular world view used to justify policy change). Rizvi et al. (2020) used Fox and Reich’s model as their starting point but combined ‘ideas’ and ‘ideology’ and changed the order of the political economy elements that shape UHC reform processes. In their view ‘“ideas and ideology” are logically linked to the “interests” that embody them, and are shaped by them—and subsequently by the “institutions” that operationalize their policy directions’ (Rizvi et al. 2020). We find their reasoning convincing and have adopted their analytical framework for our investigation of Nigeria’s UHC policymaking process and the role of the private sector (see Fig. 1).

Figure 1.

Applying Rizvi et al. (2020)’s political economy framework to an analysis of policymaking for UHC.

Source: authors’ illustration.

We thus explore the following, paying particular attention to the developments that have led to the adoption of the NHAct in 2014.

• The effect of evolving ideas, perceptions, and ideologies at global and national levels of how UHC should look in practice on health policymaking in Nigeria.

• The effect of competing interests of stakeholders involved in Nigeria’s healthcare system [such interests of professional groups (notably private doctors), government officials across different tiers of government, implementing agencies, civil society organizations, international organizations, and, importantly, healthcare users] on health policymaking in Nigeria.

• The effect of formal and informal institutions, understood as economic and political structures and processes as well as prevailing norms and popular views, on health policymaking in Nigeria.

By conducting an in-depth assessment of country-specific factors shaping access to healthcare in Nigeria, this article responds to appeals made by Mackintosh and Tibandebage (2004) to employ contextualized and localized policy analyses rooted in political economy and social theory. It is based on a thorough analysis of the existing scholarly and grey literature and mobilizes material collected through fieldwork between January and April 2019 in parts of Nigeria (Abuja, Enugu State, Anambra State, and Niger State). A total of 50 interviews were conducted with individuals with different roles in Nigeria’s healthcare system. The selection of interview partners was the result of purposive sampling (see Table 1). Furthermore, 12 focus group discussions (FGDs) covering a total of 83 participants were conducted (see Table 2). All participants received an information leaflet and provided written informed consent prior to the start of the interviews and the FGDs. All interviews were transcribed verbatim using NVivo version 12. (All the interviews were conducted in English by the lead author. FGDs were facilitated by a research assistant and were conducted in Igbo, Hausa, and English.)

Table 1.

Semi-structured interviews

		Number of
Identified interest groups within Nigeria’s healthcare system		interviewees
iFederal government and federal-level parastatals	Federal Ministry of Health, Federal Ministry of Finance, National Assembly, National Health Insurance Scheme, National Primary Health Care Development Agency, National Social Safety Net Coordinating Office, Nigeria Centre of Disease Control	10
State and local government and state-level parastatals	State Ministry of Health, State Houses of Assembly, state-supported health insurance schemes, State Primary Health Care Development Agencies and Boards, Local Governments	12
Healthcare providers and health insurance providers (public and private)	Health personnel working in public establishments, notably primary healthcare centres (e.g. nurses, midwives, community health extension workers), private healthcare providers, representatives of for-profit private HMOs	9
Civil Society Organisations and research institutes/academia	Health Foundation Reform of Nigeria, Nigeria Health Watch, Health Policy Research Group	10
International organizations	World Bank, UN agencies, Bill and Melinda Gates Foundation, Clinton Health Initiative, Results for Development	11

Table 2.

Focus Group Discussions

Identified interest groups within Nigeria’s healthcare system	Number of FGDs
Public healthcare providers, ward development and health facility committees members	4
Health services users/women’s group	4
Village heads	2
Youth groups	2

Results

The development of the 2014 NHAct was a process that spanned more than a decade. During this period, the involvement of different agents in the development of the law impacted its final text in a way that decreased its potential to expedite the attainment of UHC. The law solidified Nigeria’s dependence on the private sector by making only scarce public resources available for UHC, maintaining that private providers remain integral to the provision of a BMPHS (Chukwuma 2023). In the following, we illustrate that the NHAct’s attachment to the private sector is the result of path-dependency. We identified three key determining factors that characterize the genesis of the 2014 NHAct. First, since the 1980s especially, the ideology that private healthcare is the solution to an underfunded and underperforming public healthcare system has been reinforced by leading international organizations. Nigeria has adopted this ideology. Second, while Nigeria’s civil society played a decisive role in assuring the adoption of the NHAct, private sector actors have been in a strong position to influence health policymaking since independence. The private sector remains a central actor in Nigeria’s contemporary vision of UHC, as laid out in the NHAct. Third, Nigeria’s challenging socio-economic context and the limitations of its federal governance structure have fostered a general level of public distrust in the capacity of the public sector to provide quality healthcare.

Ideas and ideologies

After many African countries formally gained independence from colonial rule throughout the 1960s, numerous governments conceptualized social policy as a way of facilitating nation-building (Mkandawire 2009, Kpessa and Béland 2013, Adésínà 2015). Such an inclination reflected the general spirit of the time, which was to reject colonial exploitation and facilitate the integration of the newly/soon-to-be independent nations into the international system on equitable terms. These ideas were discussed at the 1955 Bandung Conference, which represented an important step towards the establishment of the Non-Aligned Movement in 1961 and the United Nations Conference on Trade and Development in 1964. What followed was the adoption of the Declaration on the Establishment of a New International Economic Order in 1974, as well as the 1978 Declaration of Alma-Ata 4 years later. The latter emphasised that access to a comprehensive set of primary healthcare services is a universal human right, while maintaining that achieving ‘health for all’ was only possible if global efforts to fight imperialism and neo-colonialism and to correct international inequities and injustice, as outlined in the New International Economic Order, are simultaneously reinforced (UNGA 1974, Yi et al. 2017).

In this climate, in the years leading up to independence in 1960 and in the first few years after independence (prior to the on-set of the first military junta in 1966), Nigeria’s regional governments were determined to provide social services to their people. [As a consequence of the limited financial aid to the British colonies at the time, Nigeria’s three regional governments mobilized their own revenue; in particular, economic and social policymaking in Nigeria’s Western region between 1953 and 1961 has been hailed as a success story (Adésínà 2012). From 1954 onwards, regional governments were allowed to collect their own taxes and retain 100% of their mining rents and royalties (Rupley 1981, Salami 2011).] The first generation of post-independence leaders adopted a position that promoted investments in social domains as crucial for post-colonial development, using revenues and tax income to fund freely accessible universal healthcare in public facilities (Adésínà 2007, 2012, Odeyemi and Nixon 2013). Notably, Nigeria’s first development plan (World Bank 1962) envisaged increasing living standards by prioritizing public investments in agriculture, industry, transport, and human development (Ibietan and Ekhosuehi 2013). Accordingly, the first parliamentary bill for a social health scheme, known as the Lagos Health Bill, was tabled as early as 1962 (Onoka et al. 2015). While it was not adopted at that point in time, mainly because of considerable resistance from private physicians (Awosika 2005), the focus on providing free education and basic healthcare services as part of an overall development strategy was maintained throughout the 1970s (Ogaji and Brisibe 2015). Prominently, the country’s third development plan (adopted in 1975, a few years after the end of Nigeria’s civil war) sought to provide a basis to improve the health status of particularly poorer people and appears to have been designed with the goal of ‘health for all’ in mind (Lambo 1982, Ityavyar 1987).

However, while in the 1950s–1970s social spending was seen as an investment in nationhood, social cohesion, and development, there was a rupture of such thinking and policymaking from the late 1970s onwards with the ascendency of neoliberalism globally. In particular, the Berg Report (World Bank 1981), which singled out bad governance and poor policy choices of African governments as being responsible variables for limited economic performance in their analysis, influenced ideas around social policymaking in the African context, shifting the general tenor towards reducing social expenditure and promoting privatized social service delivery (Craig and Porter 2006, Holmes and Lwanga‐Ntale 2012).

In Nigeria, social sector budget cuts and the privatization of healthcare were encouraged as part of the country’s 1986 structural adjustment programme (SAP) (Lewis 1996, Olaopa et al. 2012). As part of Nigeria’s SAP, the government committed to reducing its subsidies to healthcare centres, shifted to a policy of licencing private providers, and introduced user fees (Orubuloye and Oni 1996, Adésínà 2012, Anaemene 2013). The latter especially demonstrates the shift in policy away from collectivism toward making the individual responsible for catering for their health needs privately. Changes in health policymaking with the emergence of neoliberalism were highlighted during an interview with a former government official:

The Governments of the 1960s and [the] 1970s, up to the early 1980s, were even more [concerned] with healthcare. …During that period, we had huge and ambitious, gigantic dreams for the country. These teaching hospitals were flourishing, and Nigerians were attending. (Interview with Federal Ministry of Finance official conducted in Abuja on 30 January 2019.)

A defining feature of Nigeria’s health system reform trajectory thus relates to how global ideas and ideologies pertaining to social policy and the right to health have evolved over time and have been translated into practice in Nigeria.

More recently, calls for UHC have been made at the global level. In 2010, the Word Health Organization (WHO) called for UHC in its 2010 World Health Report ‘Health systems financing: the path to universal coverage’ (WHO 2010), and in 2012, the United Nations General Assembly (UNGA) adopted a resolution on UHC (UNGA, 2012). However, today, the concept of what UHC should look like in practice is far removed from the spirit of the Alma-Ata declaration, despite a (nominal) return to universalism and a (nominal) renunciation of selectivity. The definition of UHC remains ‘nebulous’ (Stuckler et al. 2010) and, overall, the meaning of universalism has been diluted. The contemporary focus appears to be on increasing the proportion of people ‘covered’ with services, but discussions on who is responsible for guaranteeing and financing access to which health service as well as whether healthcare services are being provided in an integrated and equalizing manner have been marginalized (Fischer 2018). In Nigeria, this shift in ideology is reflected in the choice to operationalize UHC by concentrating on the delivery of a basic minimum package of selective healthcare services to a targeted group of Nigerians only, including via the (for-profit) private sector. The prevalence of a narrow vision of UHC alongside the dominance of neoliberal principles (notably, a commitment to fiscal consolidation) means that insufficient resources are being made available in Nigeria to provide necessary healthcare services universally via the public healthcare delivery system.

Interests

The process of elaborating the NHAct throughout the 2000s has proven difficult, with various stakeholders involved at different points in time throughout the process of agreeing on the final text of the NHAct. Two key agents, with distinct sets of interests, stand out. These are: a pro-private-sector lobby, and Nigeria’s organized civil society, notably represented by the ‘Health Reform Foundation of Nigeria’ (HERFON).

First, agents promoting pro-private-sector interests have influenced health policymaking in Nigeria since the early 1960s. While the commercialization of healthcare systems occurred across many low- and middle-income countries (Mackintosh et al. 2016), in Nigeria, the promotion of the private sector reflected an arrangement between the Nigerian state and the prestigious profession of medical doctors (Alubo 1986). On the one hand, health policy was designed to benefit the wealthier segment of society to which state officials belonged; on the other hand, the liberalization of privatized medicine allowed physicians to open their own hospitals in urban centres (Ityavyar 1987). In this context, the Nigeria Medical Association (NMA) was able to successfully oppose the introduction of a social health insurance scheme in 1962 and fight back against an attempt to ban private practice (Awosika 2005, Onoka et al. 2015). Similarly, in the 1970s, the NMA liaised with the Nigerian state, impersonated by the then-chief Medical Advisor (himself a physician), with the aim of promoting privatized medicine with an emphasis on curative care, opposing the suggestion of expanding preventive healthcare and training mid-level health personnel (Ityavyar 1987). While, in 1984, the adoption of the Private Practice Prohibition decree prohibited public officials from pursuing private practices in parallel, in 1992, the NMA secured an exemption for the medical profession. [While the 1999 Constitution prohibits dual practice, this is still habitually done in Nigeria today (with the NMA defending its actions with reference to the 2008 Code of Medical Ethics in Nigeria) and continues to be a point of contestation (Eze et al. 2023).]

A few years later, when social insurance was finally introduced to Nigeria in the form of the National Health Insurance Scheme (NHIS), the interests of the private sector were also influential in shaping health policy. A strong pro-private-sector lobby ensured that the NHIS decree (No. 35 of 1999) incorporated private healthcare providers and profit-oriented so-called Health Maintenance Organisations (HMOs). While the overall responsibility to set guidelines and standards remains with the NHIS, HMOs are accredited and tasked with the collection of contributions from employer and employee (a concept often referred to as ‘managed’ or ‘integrated’ care), thus acting as intermediaries for the financing and purchasing of healthcare (Odeyemi and Nixon 2013, Onoka et al. 2015, 2016). As the HMO business model was lucrative, its profitable nature encouraged more and more people to establish HMOs, as highlighted in an interview: ‘But, you know, because of the money that was now coming from health insurance, almost everybody now had a HMO’. (Interview with a civil society representative conducted in Enugu on 28 February 2019.)

The interviewee continued by highlighting that HMO representatives were able to influence the 1999 NHIS decree in their favour:

‘They were dominant because they helped to develop …the health insurance law in 1999. So, they wrote themselves into [the law]. …[T]hese managed care companies that were in Lagos …they understand health insurance, so they were called to write the law. So, they just wrote themselves into the law.’

Simultaneously, the private sector lobbied for the NHIS to be made voluntary: ‘the law that set up the NHIS was faulty. You cannot talk about UHC [and use] a system that is voluntary. …It must be mandatory and there should be [a] subsidy’. (Interview conducted with a NHIS representative in Enugu on 1 March 2019.)

Currently, the NHIS is at the heart of Nigeria’s UHC implementation. However, although HMOs no longer feature by name in the NHAct, the facts that the private sector is deeply entrenched in Nigeria’s health system and that the NHIS has only limited reach because of its voluntary nature make it difficult for Nigeria to deliver on the promise of UHC. The private sector provides >50% of care across Nigeria (Abubakar et al. 2022) and some state governments in Nigeria (for example, Lagos and Edo States) continue to rely on HMOs as operators of their social insurance schemes (Chukwuma 2021). In 2022, the National Health Insurance Authority Act made health insurance participation mandatory. However, it remains to be seen in what ways the Nigerian government will be able to make this a reality, with social health insurance coverage in Nigeria currently standing at <5% (Aregbeshola and Khan 2018, Eze et al. 2024).

A second decisive force in shaping Nigeria’s health system reform process since the early 2000s, and that advocated for the adoption of the 2014 NHAct, was Nigeria’s organized civil society, notably the HERFON and its predecessor the Change Agents Programme (CAP). In the early 2000s, the WHO identified Nigeria’s healthcare system as one of the four worst healthcare systems in the world (WHO 2000), which drove a group of like-minded Nigerians dedicated to improving Nigeria’s healthcare system to come together to discuss possible ways to ameliorate access to primary healthcare (PHC) services. In 2001, through funding from the UK’s Department for International Development, the CAP was formed. [The Department for International Development’s aim was to strengthen Nigeria’s civil society and to strengthen its capacity to advocate for and oversee change (International Development Committee 2009).] Members of the CAP included health professionals, policy makers, members of government, of labour unions, and of civil society organisations, who were pushing for a country-led health system reform. Comparing the performance of the Ghanaian and South African healthcare systems to the Nigerian healthcare system prompted one (former) change agent to say: ‘when we came back to Nigeria, we were ashamed of ourselves’. (Interview conducted with a civil society representative in Abuja on 27 March 2019.) Born out of the CAP after its funding expired and largely consisting of CAP members, HERFON was founded in 2004 and took over efforts targeted at pushing for a new legal framework, which was expected to form the basis of substantive health reform in Nigeria. Around the same time, the CAP’s former director, and hence a longstanding advocate for health system reform, was appointed as the Federal Minister of Health, making him the first health economist to hold this role in Nigeria. Under the auspices of Professor Eyitayo Lambo, Nigeria adopted a wide-ranging health policy in 2004, which reiterated the importance of strengthening PHC delivery and saw the implementation of a comprehensive health sector reform programme (the 2004–2007 Health Sector Reform Programme). However, both the 2004 health policy and the inaugurating report of the Health Sector Reform Programme emphasised the need for the private sector to support healthcare delivery in Nigeria (FMOH 2004a, 2004b). Similarly, the National Strategic Health Development Plan (2010–2015) spotlighted pilot schemes with the private sector as an alternative way of extending healthcare coverage (FMOH 2010, Holmes et al. 2012).

Nevertheless, the publication of the WHO (2010) report on health system financing provided renewed impetus to Nigerian policymakers to move forward with the country’s health system reform. Between 2010 and 2014, inefficient law-making procedures, electoral cycles, and interventions by other agents within Nigeria’s health policymaking sphere, such as the Catholic Church, the Muslim community, professional groups, and the Minister of Finance, slowed down the process of adopting Nigeria’s first-ever law to govern its healthcare system (Obi 2014, Croke and Ogbuoji 2024). At different points throughout this period, HERFON mobilized other civil society organizations under the umbrella of the Health Sector Reform Coalition, spoke to political and religious leaders, and liaised with international figures to gather support for enactment of the legislation. The NHAct was signed into law in 2014, not least because of the continued efforts of Nigeria’s civil society, and notably, HERFON in advocating for its adoption. Nevertheless, while civil society (unsuccessfully) fought for the NHAct to earmark a larger share of the public budget to strengthen public primary healthcare delivery, it did not sufficiently challenge the envisaged role of the private sector in Nigeria’s roadmap for UHC. This largely relates to Nigeria’s challenging political and economic structures, which have fostered a general level of distrust in the capacity of the public sector to provide quality healthcare (including from within government).

Institutions

Two central factors have solidified the general view in Nigeria that the government is unable to deliver healthcare equitably through the public system. First, Nigeria’s political system—notably the contentious relationship between federal and state governments—has negatively affected health policymaking and healthcare provisioning at regular intervals. Second, while there is widespread frustration with the current results that the Nigerian healthcare system produces, Nigeria’s political economy is complex, and the country faces a variety of challenges, with health and healthcare not specifically seen as a priority by the general public or by decisive figures within the government (such as the Minister of Finance). We will address these in turn.

Nigeria’s organization into three tiers of government (federal, state, and local governments) has impacted health policymaking since before independence. In 1939, the British colonial government put into place three regional governments in Nigeria of the Western, Eastern, and Northern regions. The fiscal independence granted to regions by the central government contributed to different paces of development across regions, impacting social service delivery (Rupley 1981). While left-leaning leaders in the Western and Eastern regions of Nigeria were committed to universal and publicly funded social delivery (Awolowo 1960, Ayoade 1985, Abdulraheem and Olukoshi 1986, Lynn 2002, Adésínà 2007), the Northern region was ruled by the less progressive Northern People’s Congress, which enjoyed the support of the British (Ochonu 2017). As a result, the legacy of British colonialism, coupled with the way Nigeria was structured, translated into better access to healthcare in the southern parts of Nigeria compared to the north, and a focus on supporting hospitals in urban centres rather than establishing healthcare infrastructure in Nigeria’s rural areas (Awa 1960, Falola 2004).

In addition, after Nigeria’s regions were replaced with states in 1967 by military decree, Nigeria’s federal character continued to influence health outcomes across the country. In the late-1970s, for example, the implementation of Nigeria’s third development plan, which sought to provide a basis for improving the health status of vulnerable people, proved difficult, as there was insufficient clarity on how responsibilities to operationalize the plan were to be divided between Nigeria’s federal, state, and local governments (Ogaji and Brisibe 2015). As Nigeria’s 1999 constitution also fell short of providing clearer guidance on the roles and responsibilities of the three tiers of government with regard to primary, secondary, and tertiary care, the 2014 NHAct was expected to fill this gap (FMOH. 2016, Adegboye and Akande 2017). As highlighted during interviews, the ‘constitution [states that] health is on the concurrent list. So, anybody can literally do health and all that’. (Interview with a civil society representative conducted in Abuja on 20 March 2019.) However, while in 2005, the first draft of the law clearly outlined the responsibilities of federal, state, and local governments, throughout the process of designing the NHAct, state governments continuously objected to the concentration of power at the federal level, insisting that the NHAct should not infringe on their autonomy, slowing down its development. The end-effect was that ‘everything related to the states was taken out [of the NHAct]’ (Interview with civil society representative conducted in Abuja on 27 March 2019.) and yet again another legal document lacks explanatory power as to what the different levels of government are primarily responsible for, emblematic of how Nigeria’s federal character, and the power of (some of the) state governments, are hampering progress toward UHC.

At the same time, the NHAct design process was surrounded by a debate on the extent to which states could financially contribute to the implementation of the NHAct. This relates to our second factor, namely Nigeria’s challenging socio-economic context and its impact on health policymaking over time, including the design of the NHAct. Nigeria’s economic situation, at different points in time, has significantly impacted the volume of resources put towards social sectors more broadly, and healthcare particularly. Especially the collapse in oil revenues in the 1980s, which coincided with the global emergence of neoliberal ideology, had profound implications for healthcare delivery in Nigeria as public resources plummeted (World Bank 1994). At the time, the government introduced several cost recovery mechanisms, such as user fees, and accelerated the privatization of healthcare (Odeyemi and Nixon 2013), both interventions representing a ‘major departure from the welfare philosophies of the pre- and post-independence eras’ (Orubuloye and Oni 1996).

Similarly, in the run-up to the enactment of the 2014 NHAct, volatile global oil prices, paired with low levels of tax income, made the then-Minister of Finance (Ngozi Okonjo-Iweala, a former World Bank economist and now Director General of the World Trade Organization) wary of the financial implication of committing a higher share of the public budget to funding healthcare. Today, the BHCPF (the main programme that the NHAct put into place to serve as a platform to progress toward UHC) is expected to be primarily financed by a 1% allocation of the federal government’s consolidated revenue fund, which is channelled through an annual grant that is added to the budget of the Federal Ministry of Health. Earlier drafts of the law proposed a 2% allocation, mirroring a similar law for the education system. However, Okonjo-Iweala wrote ‘so many memos against the Fund’, (Interview with civil society representative conducted in Enugu on 28 February 2019.) as she was particularly worried that the NHAct would reproduce the failures associated with the Universal Basic Education Commission (UBEC), where states failed to utilize earmarked funding for education:

The BHPCF was modelled after UBEC. But while UBEC [receives a] 2% [allocation], [the] BHCPF’s [allocation] is 1%. But UBEC had significant implementation problems. Under its implementation arrangement, state governments were meant to provide counterpart funding. …as of today, the UBEC fund has accumulated up to 150 billion [Nigerian Naira] at the central bank. Why? Because states were not leveraging on the UBEC funds as expected. (Interview with international organization employee conducted in Abuja on 17 March 2019.)

In Nigeria, states’ capacity to mobilize their own internally generated revenues and provide counterpart funding is limited, and they remain dependent on a grant from the federation account (Gatt and Owen 2018). Lagos State has been cited as the only state in Nigeria that has achieved true fiscal independence, mobilizing enough internally generated revenues via channels such as the collection of personal income taxes, land sales taxes, car licences, and transfer fees (RESYST. 2015, Gatt and Owen 2018).

Thus, as the budgets of both the federal government and states are limited, health and healthcare are competing against other priorities, such as infrastructure projects or security, which often take precedence. A budget officer working in the office of the Senate President highlighted the issue of competing priorities:

When the budget is released… we tend to have priority projects… like the construction of roads, …power, all of this that will enhance the economy. These are priority projects that the Government looks at when there is shortfall of revenues. (Interview with an employee in the Office of the Senate President conducted in Abuja on 24 March 2019.)

Insufficient public funding for the public healthcare delivery system, in turn, solidifies the already prevalent view that the ‘private sector [is] …assumed to be better’. (Interview with civil society representatives conducted in Abuja on 27 March 2019.) For instance, one female FGD participant emphasised that ‘we are all saying the same thing. I am thinking of attributing the women’s suffering to the government because when you get to the private hospitals, they are clean, and you will see all the required drugs there’. (FGD with a women’s group conducted in Enugu State on 19 February 2019.) On the contrary, ‘when you come to the government hospital, you don’t see drugs until you move out to [the] private hospital before you get it’. (FGD with health facility committee members conducted in Niger State on 11 March 2019.)

Discussion

Our examination of Nigeria’s health system reform process is emblematic of how ideologies, interests, and institutions shape health policymaking in a specific setting. Moreover, it shows the criticality of path dependency as a concept guiding the analysis of health policymaking, highlighting how past conditions and decisions have affected Nigeria’s health system reform process. In Nigeria, the dominance of neoliberal thinking and the adoption of a narrow conception of what UHC should look like in practice, an influential pro-private sector lobby, an insufficiently strong civil society to act as a counterweight, and a challenging socio-economic context and inefficient political system have conjointly resulted in a law that has significant limitations in delivering UHC.

Specifically, the interplay of these dynamics has led to a range of noteworthy changes to the final version of the law, with implications for healthcare delivery in Nigeria (as summarised in Table 3). Mostly notably, the overlap of economic crises, competing policy priorities, and assent to the (narrow) concept of UHC rather than the Alma-Ata vision of ‘health for all’ is best reflected in the following facts. Only 1% of the federal government’s consolidated revenue fund is earmarked annually for the operationalization of the BHCPF. A BMPHS rather than comprehensive PHC is provided via the public and private system to a targeted group. (While the BHCPF implementation guidelines state that all Nigerians are eligible to access the BMPHS, they propose prioritizing rural public facilities as a way of targeting poor households and populations in the lowest wealth bracket (FMOH 2020). In reality, the limited funds made available for the delivery of the BMPHS makes targeting necessary.) The BHCPF is no longer only focused on strengthening the PHC system but includes emergency care and social insurance. [During the process of developing the law, the Federal Ministry of Health insisted that a share of the BHCPF should be diverted to emergency care (Oloriegbe et al. 2011).] PHC, however, is broadly considered to be the backbone of a country’s strategy to achieve UHC (Sacks et al. 2020, Singh et al. 2021, Walker and Peterson 2021). Finally, the delivery of selective primary healthcare has long been considered to be the ‘antithesis’ of delivering PHC (Newell 1988).

Table 3.

Content analysis of the 2004, 2008, 2011 drafts of the Health Bill and the final 2014 NHAct

Subject	2004, 2008 and 2011 Health Bill drafts	2014 NHAct
Clarification on roles and responsibilities of the three tiers of government	Outline that the federal level is responsible for tertiary-level care, the state level for secondary-level care, and the local level for primary-level care	No longer clearly assigns clear responsibilities to the three tiers of government
Establishment of a dedicated fund for primary healthcare	Propose the establishment of a National Primary Health Care Development Fund	Mandates the establishment of the BHCPH
Federal government annual allocation	Propose a 2% annual budget allocation	Stipulates that the BHCPF shall be funded through a 1% annual budget allocation
Emergency medical treatment	Make no provision for emergency medical treatment	Stipulates that 5% of resources earmarked for the BHCPF need to be used for emergency medical treatment
Counterpart funding	Propose that state and local governments provide 10 and 5%, respectively, in counterpart funding as a condition to access the federal grant	Requires state and local governments to provide 25% in counterpart funding
Chairpersonship of the National Tertiary Health Institutions Standards Committee	Suggest that the committee shall be chaired by a professor of ≥10 years of experience and the person must be a medical doctor	Suggests that any experienced person in the health sector with skills in service delivery and planning can chair the committee
Control of use of blood, products, tissue, and gametes in humans	Do not include a waiver of the consent clause for the use of blood and tissue products from living persons for medical investigations and emergency treatment	Stipulates that the consent clause for the use of blood and tissue products from living persons may be waived for medical investigations and emergency treatment
Cloning	Prohibits the reproductive and therapeutic cloning of humankind, but stipulates that the Federal Minister of Health can approve exceptions	Prohibits the reproductive and therapeutic cloning of humankind and no exemptions are possible

Source: Based on Chukwuma (2021).

Similarly, Nigeria’s difficult economic context, coupled with how federalism manifests in the country and the powerful role the private sector plays, has resulted in the limited buy-in of state governments in the federal government’s vision for the Nigerian health system, as a result of path dependency. States’ scepticism towards federal initiatives dates back to the introduction of the 1999 NHIS, when state governments felt that they had been sidelined in favour of the private sector (Onoka et al. 2015). Consequently, as states were fearful of any attempt to concentrate too much power at the federal level and wanted to maintain their budget autonomy (Croke and Ogbuoji 2024), the 2014 NHAct fell short of defining the exact roles and responsibilities of the three tiers of government regarding healthcare provision. However, there was insistence on the side of the federal government that state governments need to provide counterpart funding to access federal funds. As states have disparate (but mostly limited) capacity to mobilize their own revenues, this raises concerns for health equity, given that UHC in Nigeria is currently being rolled out via 38 different social health insurance schemes (one scheme per state, one scheme in Nigeria’s capital, and one national scheme). Such in-built fragmentation makes it difficult to ensure adequate cross-subsidization, which is required in a functional insurance scheme (Fenny et al. 2021).

Furthermore, the path-dependent process which has concentrated considerable influence in the hands of the private sector and, notably, medical doctors, has left its mark on the NHAct, and on the context in which the NHAct, particularly via the BHCPF, is currently being operationalized. On the one hand, dissatisfaction with the apparent supremacy of doctors over other medical professionals contributed to delays in passing the NHAct (notably, the passage on who can chair the National Tertiary Health Institutions Standards Committee needed to be amended). On the other hand, the dominance of the private sector weakens the public system, as in Nigeria the latter is commonly perceived as less efficient. Compared to other countries, the risk persists that the focus on private sector provision weakens the public healthcare system (Derakhshani et al. 2024).

Finally, in addition to the changes to the final version of the NHAct that materialized due to diverging ideas, interests, institutional realities, and path dependency, the interference of other key groups, notably religious groups in the Nigerian context, as well as election cycles, negatively affected the speed at which the NHAct was enacted. Ultimately, the NHAct was signed into law in October 2014 by then-President Jonathan Goodluck (a devoted Christian) after all concerns by both the Christian and Muslim community were addressed in the months leading up to the country’s next national elections. In Nigeria, Buhari’s 2015 electoral campaign included the promise for his government to implement the NHAct, and indeed, in other countries too, UHC has frequently become an electoral asset (Pisani et al. 2017, Srivastava and Shah 2022). For example, Thailand’s public health insurance scheme, championed by President Shinawatra and introduced in 2021, now covers the entire Thai population (via three different programmes) and brought down catastrophic health spending from 7.1% in 1990 to 2.1% in 2016 (Tangcharoensathien et al. 2019). At the same time, in Thailand (similar to Brazil), an empowered civil society played an important role in driving efforts towards UHC (Machado and Silva 2019, Tangcharoensathien et al. 2019). In Turkey, the strategic management of different interest groups, including those likely to oppose the healthcare system reform process, formed an integral part of the UHC implementation process (Reich et al. 2016). In Ghana, earmarking a share of the value-added tax and social security payments for UHC has been attributed to a significant increase in social insurance coverage (Novignon et al. 2021, Amporfu et al. 2022).

Conclusion

The Nigerian experience of designing a law designated to expedite progress toward UHC provides valuable lessons for UHC reform processes in other contexts.

First, it highlights that the narrow scope of social policy is particularly visible in the area of health. The rise of neoliberal ideology has had significant implications for the distribution of roles between the private and public sectors in health, and has impacted practices in healthcare provision. Today, there are a multitude of ideas and perceptions of what universal healthcare (nowadays, UHC) is and entails, and of how it can and should be attained. Different actors understand and conceptualize universalism differently, and while the goal of UHC ‘has risen to the top of the global health agenda, even becoming one of the key pillars of the UN’s Sustainable Development Goals, …[the] UHC cooptation story is illustrative of the fate of many progressive international and global health policy efforts in the context of neoliberal globalization over the past three decades’ (Birn et al. 2016, p. 735). As such, today’s inclination in Nigeria to rely on private sector healthcare provision and a general distrust in the capacity of the public sector, including from within the government, is reinforced by leading agencies within the international community, promoting a distinct set of ideas of what an equitable healthcare system should look like. Ultimately, the way UHC is understood, and the shape of different countries’ healthcare systems, depends on localized political struggles and processes and the extent to which global ideas have permeated policymaking. In the Nigerian context, there is an urgent need for re-enforced political commitment across all tiers of the government to make quality healthcare accessible. This crucially requires that a higher proportion of financial resources be earmarked for the healthcare sector, particularly the BHCPF. Given that a large share of Nigeria’s budget is reserved for debt service, advocacy for UHC reform needs to include a broader discussion of challenging existing international economic and financial structures, mirroring efforts during the 1960s and 1970s.

Second, the Nigerian case study highlights how the persistent influence of the private sector on the process leading to the NHAct can be accounted for in terms of the existence of a pro-private-sector lobby from independent Nigeria’s beginnings, but also in terms of an explicit market-centric turn in social policymaking in the mid-1980s. In the 1950s, 60s and 70s, social policies promoted public investment in healthcare and education as a way of investing in citizens and fostering national unity. However, social spending on healthcare (and education) declined significantly in the early 1980s as a result of a global oil price crush and a shift in policymaking. Notably, the adoption of the neoliberal SAP in 1986 was accompanied by an emphasis on privatizing healthcare delivery systems as well as the introduction of user fees. The path dependency of the strong emphasis on private provisioning and private responsibility was that when Nigeria’s National Health Insurance Scheme was enacted in 1999, private HMOs were invited to serve as an interface between the beneficiaries of the social insurance scheme and (public or private) health providers. Consequently, solid private-sector involvement in Nigeria’s healthcare system remains a governance reality, and private providers continue to be an important component of Nigeria’s healthcare system. To counterbalance private interests, a strong and unified civil society that regains trust in the possibility of public healthcare delivery is required. At the same time, the regulatory landscape needs to be strengthened to ensure that poor-quality private provision is contained.

Third, and crucially, Nigeria’s UHC pathway highlights the critical importance of gathering the support of sub-national units in federal systems, such as those currently operating in Nigeria, for any health system reform process to be successful. For a decentralized health system to strengthen and improve localized healthcare delivery, sub-national units need to be sufficiently involved in the policymaking process and go along with the proposed UHC reforms. In this sense, the UHC reform process in Nigeria needs to emphasise the need for a clear distribution of roles and responsibilities of federal, state, and local governments, and must support efforts that seek to put into place mechanisms that allow the public to hold government officials accountable. Therefore, social movements and an organized civil society are critical. At the same time, civil society efforts need to challenge narratives that distract from the need to prioritize and adequately fund healthcare delivery, including during times of economic distress.

Author contributions

This article was conjointly developed by J.N.C. and F.A.O. on the basis of the former’s PhD project.

Conception or design of the work, data collection, data analysis and interpretation, and drafting of the article: J.N.C.

Critical revision of the article and final approval of the version to be submitted: J.N.C and F.A.O.

Reflexivity statement

J.N.C. is a female Nigerian–Austrian early-career scholar based in the Global North with a disciplinary background in political economy. F.A.O. is a male Nigerian, who is the programme director and Nigeria country manager of a civil society organization based in the Global South, working in the area of health systems policy and financing. As Nigerians, both authors have strong interest in engaging in research activities that can support evidence-based health policymaking in Nigeria that contributes to improving health outcomes for Nigerians.

Ethical approval

Ethical approval was obtained from SOAS University of London and the Nigerian National Health Research Ethics Committee of Health (NHREC/01/01/2007).

Conflict of interest

None declared.

Funding

None declared.

Abbreviations

BHCPF = Basic Health Care Provision Fund

BMPHS = Basic minimum package of health services

CAP = Change Agents Programme

FGD = Focus group discussion

HERFON = Health Reform Foundation of Nigeria

HMO = Health Maintenance Organizations

NHAct = 2014 National Health Act

NHIS = National Health Insurance Scheme

NMA = Nigeria Medical Association

PHC = Primary healthcare

SAP = Structural adjustment programme

UBEC = Universal Basic Education Commission

UNGA = United Nations General Assembly

UHC = Universal Health Coverage

WHO = World Health Organization