Strengthening primary health care in Nigeria: a means to achieve universal health coverage

Summary box.

• In Nigeria, 70% of Nigerians rely on primary health care (PHC) centres, accounting for a total of 85.3% of hospitals and clinics in the country.

• However, despite the need for the PHC centres to cater to the well-being of the citizens, only around 20% of PHC facilities are functional.

• To address the challenges facing PHC centres, the federal government commenced the renovation programme for 10 000 PHC c in 2017.

• This has improved the supply of necessary medications and medical supplies, equipping 110 PHC centres throughout Nigeria and educating and assigning healthcare staff to these centres.

• Additionally, following the collaboration of the National Health Insurance Authority and the National Primary Health Care Development Agency, at least 1400 PHC centres, which serve 8300 facilities, have received funding, improving professional birth attendance, and also over 2400 healthcare professionals have been hired to provide services to Nigerians.

• There is a need to strengthen public–private partnerships as a means to improve PHC services delivery, which will go a long way in achieving universal health coverage by 2030.

Introduction

Primary health care (PHC) is a comprehensive strategy involving the entire society in promoting health. It is an important facet in improving quality of life, emphasising equitable access to health promotion, disease prevention and treatment, rehabilitation and palliative care for all individuals, thereby reducing disparities and improving overall health outcomes.¹ One of the objectives stated by the world’s countries when they adopted the 2030 Sustainable Development Goals (SDGs) in 2015 was to achieve universal health coverage (UHC).¹

According to the WHO, more than 1 billion individuals globally risk becoming impoverished because their household’s out-of-pocket expenses account for 10% or more of their income. WHO advises shifting health systems’ focus to PHC as the cornerstone of UHC. Increasing the implementation of PHC interventions in low- and middle-income nations might prevent 60 million deaths and add 3.7 years to the average life expectancy.¹

However, Nigeria is currently ranked 187th among 191 countries in the WHO health system performance ranking, highlighting its significant lag in meeting the 2030 SDGs. The country faces challenges such as inadequate health infrastructure, a shortage of healthcare professionals and weak health systems, which impede its progress toward achieving UHC.² It is estimated that 70% of Nigerians rely on primary health facilities, so the state of the PHC sector is pivotal for the health of the populace as a whole.³

As of 2023, there are 34 076 PHC centres in Nigeria, accounting for 85.3% of the total hospitals and clinics in the country. Surprisingly, it is estimated that only about 6815, accounting for 20% of these, are functional.⁴ Therefore, this paper aims to assess the essence of PHC strengthening as it helps to achieve UHC.

Challenges faced by PHC

Unfunded healthcare system

A major challenge in Nigeria’s healthcare sector is the inadequate allocation of financial resources needed to improve and maintain the population’s overall health.³ The distribution of standard healthcare services in Nigeria needs to be more consistent and lags behind those of other West African countries. Nigeria is the 13th largest oil producer globally, but its health expenditure per GDP ranks the second lowest globally.⁵ In 2021, the federal government only allocated 5% of its budget to health, falling short of the 15% commitment made in the 2001 Abuja declaration, leaving the health sector ill-equipped.⁵ The health sector received only 4.9% of the N14.77 trillion 2022 federal government budget, amounting to N724.9 billion. A detailed analysis of the allocation revealed that just N3587 was designated for the medical needs of each Nigerian citizen for the entire year.⁶

Lack of infrastructure and essential medical supplies

In many PHC centres, there is a shortage of medical professionals, with only around 35 000 doctors available, despite a requirement of 237 000, according to the WHO. This leads to the mental drain of healthcare workers and poor working conditions.⁵ However, a staggering 75% of PHC centres in Nigeria lack the essential equipment package and vital supplies such as medicines, sphygmomanometers, glucometers and personal protective equipment necessary for their operations.⁷ As of 2019, Nigeria needs 386 000 more beds and $82 billion in investments in healthcare real estate assets to achieve the global average of 2.7 beds per thousand people. There were 183 CT scanners in Nigeria (as of March 2018) and 57.4% (105 units) of these scanners are privately owned, while public institutions own 42.6% (78 units), with three states in Northern Nigeria—Kogi, Kebbi and Zamfara—having no CT scanner installed.⁸

Under-utilisation of PHC

Despite PHC centres being described as the first point of contact, approximately 60%–90% of patients choose to bypass PHC facilities, opting to self-refer to higher levels of care. This leads to a lack of utilisation of PHC services and places unnecessary strain on secondary and tertiary health facilities as patients seek treatment for conditions that could have been managed at the PHC level.⁹ However, low-quality healthcare, medicine shortages, lengthy patient wait times and high primary care facility costs pose as the under-utilisation of PHC services. Utilisation of PHC services is also hampered by inadequate medical staff, notably a shortage of physicians. Rural residents typically believe that doctors have the best ability to provide healthcare. This knowledge may lead to community members seeking care at private and upscale medical facilities without realising that other primary healthcare providers who are assumed to have lower qualifications compared with their counterparts at secondary and tertiary healthcare facilities can handle the majority of health issues and can refer patients if needed.^{10 11}

Corruption in PHC

Corrupt behaviours are frequent and prevalent in PHC, and unless they are dealt with, Nigeria will not strive to attain UHC.¹² Corruption in this industry manifests in different forms that include bribery, drug diversion, ghost workers and procurement fraud. In addition to wasting money, these unethical actions damage public confidence in the healthcare system. However, procurement fraud—the exaggerated supply of subpar products—and the illegal sale of necessary medications for personal benefit are problematic.¹³ A lack of a health-focused anti-corruption strategy based on evidence, unclear or nonexistent rules and regulations, the carelessness or irresponsibility of authorities, and a lack of a health-focused anticorruption strategy are some of the factors that typically contribute to corruption in PHC.¹²

Challenges associated with Basic Health Care Provision Fund

Nigeria created the Basic Health Care Provision Fund (BHCPF) after the National Health Act was passed in 2014. This fund is essential to the nation’s efforts to improve health service indicators, attain UHC and reduce out-of-pocket spending by 30% in 5 years. The National Primary Health Care Development Agency (NPHCDA) receives 45% of the BHCPF to support the PHC system by supplying necessary medications, vaccines and consumables, as well as by maintaining facilities, labs, equipment, transportation and human resources development for high-quality PHC.¹⁴ However, the BHCPF faces obstacles like inadequate financial management, financing delays and accountability procedures that lead to systemic leaks and improper use of money. This hindered primary healthcare advancements and the BHCPF’s ability to meet expectations.^{14 15}

Efforts made to improve PHC

Government and non-governmental collaborative efforts

To revitalise the PHC centres, the federal government commenced the renovation programme for 10,000 PHC centres in 2017. The first phase improved the supply of necessary medications and medical supplies, equipping 110 PHC centres throughout Nigeria and educating and assigning healthcare staff to these centres.¹⁶ As of May 2024, the BHCPF and International Development Association financing have made 260 billion naira accessible at the state level for PHC revival.¹⁷ However, to ensure accountability, the movement of funds and resources at the primary healthcare level is being tracked through the implementation of improved monitoring and accountability procedures, which include the creation of phone and email hotlines, web portals for reporting irregularities and direct facility financing oversight.¹³

WHO and the Private Sector Health Alliance of Nigeria (PSHAN) have formally signed a Memorandum of Understanding (MOU) under the ‘Adopt-A-Healthcare Facility Programme’ as part of the creative drive to transform primary healthcare delivery in Nigeria through building PHC centres of international standards throughout Nigeria’s 774 local government areas. Following the MOU, WHO and PSHAN collaborated to determine the areas of greatest need for intervention, evaluate healthcare facilities that require assistance, mobilise resources to carry out specific interventions, monitor the outcomes of accomplishments and record best practices for continued learning and expansion.¹⁸ A new programme called the Community-based Health Research Innovative Training and Services Programme (CRISP) was created to strengthen PHC centres even more. It was implemented in 36 states and Abuja on 20 May 2023, allowing community resident doctors to treat patients at PHC centres within the university’s catchment areas while also imparting knowledge to the healthcare staff.¹⁹

Also, as part of its efforts to improve healthcare delivery, the federal government has committed N1 trillion to train over 60 000 health professionals and upgrade PHC centres across the country. The government has launched some programmes to improve healthcare access and quality, reaffirming its commitment to polio eradication, PHC strengthening and systemic health issues. Performance-based funding of N1 trillion ($1.2 billion) has been authorised by the federal government for states to increase the number of health workers and enhance services.²⁰

Furthermore, EngenderHealth’s Advocacy Solutions to Improve PHC Delivery and Health Outcomes in Nigeria programme, which is implemented in Kano, Kaduna and Lagos states in a consortium partnership with the Centre for Communication and Social Impact, the International Society of Media in Public Health and Legislative Initiative for Sustainable Development, strengthens primary healthcare services by increasing demand, improving quality and health outcomes through strategic advocacy in partnership with government and civil society funded by the Gates Foundation.

This programme employs five complementary strategies to create a more robust policy and funding environment that supports health commitments: establishing champions, bolstering accountability, improving health planning and budgeting, using media and communications and using data for advocacy and decision-making. The health and well-being of Nigerian communities are being improved by incorporating these strategies and increasing access to high-quality, gender-responsive primary healthcare services.²¹

Primary health care agency efforts

To improve PHC service delivery, the NPHCDA is working with the States to resurrect PHC centres nationwide through the retraining of 120 000 frontline healthcare professionals, which began in September 2023. Nearly every state has produced trainers, and in the next 3 years, at least 120 000 front-line health workers who serve rural populations will receive the training they need, aided by the infrastructure and tools made available.²²

As of May 2024, at least 1400 PHC centres, which serve 8300 facilities, have received funding from the National Health Insurance Authority and the NPHCDA, enabling them to offer professional birth attendance. Over 2400 healthcare professionals have been hired to provide services to Nigerians. Regarding immunisation, the pentavalent vaccine has protected more than 5 million Nigerian children from diphtheria.²² The tetanus and diphtheria vaccinations were administered to almost 10 million children in Nigeria, and Nigeria has reached a 71% countrywide coverage rate for females aged 9–14 after vaccinating nearly 12 million girls against the human papillomavirus across all states in less than 2 years since its implementation into the routine immunisation programme as of September 2023.^{22 23}

Recommendation

To address several gaps in PHC service delivery, the country should adopt a community-integrated, resourced, coordinated and equitable approach. This approach focuses on giving the healthcare workers in the community the chance to participate in decision-making, advocate for health education, enhance resource allocation and revitalisation of PHC centres, recruit and train healthcare workers, and collaborate across sectors to strengthen the role of PHC in achieving UHC. However, the government should strengthen the BHCPF to ensure the timely release of funds and proper accountability of fund usage to prevent corruption. The government should collaborate with the private sector in strengthening the PHCs through co-financing and investment into PHCs, bridging funding gaps and improving service delivery at PHC facilities. To prevent the brain drain of health workers, there is a need to improve working conditions, remuneration and career development opportunities for healthcare workers to curb workforce migration. Also, there is a need to expand the CRISP to ensure consistent integration of community healthcare workers and enhanced training for PHC staff. To further boost the accessibility of people to the PHC centres, there is a need to raise more awareness about the role of PHCs in the community, and individuals must also be advised to seek the most important preventive service at due time and promote health insurance enrolment to reduce out-of-pocket expenses and ensure financial protection for vulnerable populations.

Conclusion

As Nigeria faces an increasing burden of diseases, strengthening primary health care is more important than ever to provide the population with continuous and coordinated care throughout their lives. To meet the SDGs and UHC agenda, Nigeria’s health systems will need more resources and redesigning around the core elements of high-quality primary care. Establishing a robust monitoring strategy, fostering public–private collaborations, increasing awareness about the importance of PHC and encouraging health insurance subscriptions are crucial steps toward achieving UHC.

Data availability statement

No Data are available.