Improving health care services and outcomes in Nigeria will necessitate sustained investment and targeted programmes to address key challenges. The implementation of the Basic Health Care Provision Fund scheme and the recent introduction of state health insurance, however, marks an important starting point for reforms towards universal health insurance. Moreover, better infectious disease surveillance and pandemic response helped to address the health and social consequences of the Covid-19 pandemic.
Structure & Oversight
Nigeria’s public health sector follows a three-tiered structure, with responsibilities for primary, secondary and tertiary care assigned to the local, state and federal governments, respectively. The Federal Ministry of Health (FMH) oversees the provision of health services for all citizens, and coordinates health care-related activities carried out by the state and local governments. Its mission is to develop and implement policies that strengthen the national health system for effective, efficient, accessible and affordable delivery of health care services. At the federal level, health infrastructure includes federal medical centres, national laboratories and teaching hospitals.
The FMH implements its mandate in partnership with other stakeholders, including the Department of Public Health, which formulates public health policy and guidelines, and facilitates evaluations; the National Primary Health Care Development Agency (NPHCDA), responsible for streamlining the referral system of patients from primary health care to the secondary or tertiary health care level; the Department of Health Planning and Statistics; the National Agency for Food and Drugs Administration and Control; the Nigeria Centre for Disease Control; and the National Health Insurance Authority (NHIA). The FMH also oversees a number of health-related programmes such as the National AIDS, Sexually Transmitted Infections and Hepatitis Control Programme; the National Tuberculosis and Leprosy Control Programme; and the National Malaria Elimination Programme.
Primary & Secondary Care
Individual states and local governments play an important role in the provision of health care services across the country. Primary health care (PHC) and comprehensive health centres (CHCs) facilities operate at the local community level and are the first point of contact for Nigerian patients. Nurses and community health workers comprise the majority of staff at PHC centres, rather than doctors. Local government areas (LGAs) manage PHCs and CHCs by employing five levels of health workers: medical officers of health (medical doctors who supervise PHCs), nurses, community health officers, community health extension workers and volunteer health workers.
Secondary health care is provided by state governments through their respective ministries of health across an array of facilities, including general and specialist hospitals. Nigeria’s 36 states are also responsible for coordinating PHC implementation at the LGA level through the National Primary Health Care Development Agency. Moreover, the private sector participates in Nigeria’s pluralistic health system, where it plays a significant role in the provision of health care services, mainly at the secondary level.
According to the national health facility registry published by the FMH, the country had 38,645 operational public and private hospitals and clinics in late 2023. With an estimated population of 255.7m as of November of that year, that equates to 11 hospitals for every 100,000 people. Lagos led the way among Nigeria’s states with some 2206 health facilities, followed by Katsina (1945), Benue (1614) and Niger (1565). Rivers and Borno are significantly below the national average in terms of the number of health facilities, with 586 and 431, respectively.
As of 2022 there were more government-owned health facilities (67%) than privately owned (33%). Of the total, 88% were primary facilities, 12% offer secondary services and 0.3% were tertiary facilities.
Policy
Nigeria launched a revised National Health Promotion Policy (NHPP) for 2020-24 to accelerate efforts to reduce the burden on Nigerians caused by diseases. The NHPP sets overall standards and provides guidance on best practices regarding health promotion at various levels. In 2020 the federal government also introduced the Knowledge Management Guideline for Health Promotion 2020-24 to act as a one-stop shop knowledge centre for the health sector. Its focus is on empowering Nigerians to make timely decisions to prevent diseases and improve overall health. Key to this will be encouraging exercise and lifestyle changes that can reduce illnesses.
These initiatives build on several important policies, including the National Strategy Health Development Plan II 2018-22 – which sought to strengthen the health care system and prioritises primary care facilities – and the health sector next level agenda (HSNLA). The latter was introduced in 2020 and covers nine points intended to improve service delivery. Among its initiatives, the HSNLA aims to recruit and deploy approximately 50,000 community health extension workers; reduce the imbalance between primary, secondary and tertiary health care provision; collaborate with the private sector to create job opportunities and establish high-quality hospitals; reduce gaps in health-related Sustainable Development Goals by 60% by 2030; take 100m out of poverty by 2030; and advance the rollout of the government’s universal health care programme. In order to meet the goals of the programme, the FMH will work with entities such as the NPHCDA and the NHIA.
Public Spending
To achieve the goal of more efficient and accessible health care services for Nigerians and despite a financing drop during the pandemic – the country increased its health expenditures by over 323% in the eight years to 2022. The 2023 budget assigned 5.6% of the total, or N1.2trn ($2.8bn), to health, a higher allocation than any previous year and up from 4.2%, or N724bn ($1.7bn), in 2022. Of the 2023 allocation, N404bn ($962.5m) was earmarked for capital expenditure and almost N581bn ($1.4bn) for recurrent expenditure, marking increases of 94.8% and 25.5%, respectively, over the 2022 budget.
In light of the pandemic’s impact on the economy and the mid-pandemic drop in oil prices, the government earmarked less financing towards health expenditure in 2020 and 2021. Despite the increase in allocation in the 2023 budget, the amount assigned to health that year was below the 15% commitment outlined in the 2001 Abuja Declaration on Health. While the 2023 budget was just over one-third of the Abuja commitment, Nigeria’s efforts to increase health-related funding overall is a welcome development that has allowed the country to make notable improvements in several health indicators, while expanding the availability of care.
Health Challenges
According to the World Health Organisation’s health system ranking, in 2021 Nigeria rose to 163rd of 191 countries globally, up from 187th. The ranking assesses the overall quality of the health care system, in particular of its infra-structure, human talent, cost, medicine availability and government readiness. Despite this improvement, challenges remain. Indeed, the environment of constrained financial resources in the health sector combined with the growth of Nigeria’s population – set to almost double between 2025 and 2050 – poses a set of specialised issues, including ensuring that health care provision remains consistent and of high quality in communities across the country, and that it remains affordable enough for the disadvantaged. The country had an incidence of HIV for those aged 15 to 49 of 0.4 per 1000 uninfected population in 2021, down significantly from 3.2 in 1993 and below the sub-Saharan average of 1.1 in 2021. This broke down to a prevalence of 1.3% for the total population again below the regional average of 3.2% – and 0.3% for men and 0.7% for female. The country’s incidence of tuberculosis has remained relatively constant in recent years, at 219 per 100,000 people for the 2000- 21 period. This figure belies the fact that the country, in partnership with external stakeholders such as the World Health Organisation (WHO), have moved towards control and elimination of the disease. In 2020 case notification was up 15% from the previous year, according to a 2021 report from the WHO, which noted that tuberculosis detection and treatment is key to reducing the burden of the disease.
Life expectancy rose from 46 years in 1998 to 61 years in 2022, when life expectancy at birth was 59.5 years for men and 63.3 for women. Neonatal disorders was the primary cause of death in 2019, with 12.3%, followed by malaria (12%), diarrheal diseases (11.4%), respiratory infections (10.9%), HIV/AIDS (5.2%), heart disease (4.4%) and strokes (4%). The rise in the prevalence of non-communicable diseases since the beginning of the century has been attributed at least in part to higher life expectancy, poor diet and exercise, air pollution, and alcohol and tobacco use, among other factors.
Private Initiatives
The pandemic revealed weak-nesses in health sectors across the world. However, it also highlighted opportunities for private sector involvement. According to a 2021 poll by international real estate consultancy Knight Frank, 80% of 140 investors were considering investing in African health infrastructure in light of the pandemic. In recognition of this, the government issued credit facilities of over $254.6m for health care investment from pharmaceutical companies and product manufacturers to service providers in the first year of the health crisis.
Public-private partnerships (PPPs) were introduced into health care services in Nigeria via the government’s 2005 National Policy on PPP for Health as a way to address poor infant and maternal mortality rates. There are already a number of hospitals in the country operating under a PPP structure. Under this framework, there is ample opportunity for private sector participation in capital projects, such as upgrading facilities, in the coming years. For example, according to a July 2022 report Nigeria would need to expand its hospital bed capacity by over 386,000 and invest $82bn in health care real estate to reach the global average of 2.7 beds per 100,000 people.
Private initiatives can improve health service delivery, and attract and maintain staff. This is especially important, as one October 2022 report from local non-profit development Research and Project Centre, in partnership with the National Institute of Policy and Strategic Studies, found that 40 doctors leave Nigeria per week for more lucrative opportunities elsewhere.
Research & Pharmaceuticals
Public investment in medical research has risen in recent years, including a 13.3% increase in allocations to the Tertiary Education Trust Fund in 2021, to N8.5bn ($20.3m). Of this figure, N1bn ($2.4m) was allocated for research on Covid-19. That year the government pledged to spend 0.5% of GDP on research and development, a figure that, while small on a proportional scale, underscores the prioritisation of such activities.
These efforts are being supplemented by private players such as start-ups. For example, in August 2023 health tech start-up Remedial Health secured $12 in an equity and debt funding round to expand its service penetration in Nigeria and assist with delivering targeted financial services to community pharmacies. Another Nigerian start-up, Reliance Health, raised $40m in early 2022 to continue advancing its offer of telemedicine services in the country. Highlighting opportunities in the sphere, in 2021 African health technology companies raised $209m, with roughly a fifth of those funds going to Nigerian firms.
Meanwhile, the government has looked to support the pharmaceutical industry, and boost its economic and employment potential. The National Drug Control Master Plan 2021-25 seeks to increase local manufacturing capacity by 70% by 2025. Although pharmaceutical imports dropped steadily from $2.8bn in 2020 to $779m in 2022, local producers still imported around 90% of their inputs in 2022, making it a key challenge. Moreover, the African Continental Free Trade Area offers opportunities for the sector’s development and entry into new, regional markets.
Substandard or counterfeit pharmaceuticals are a critical issue in Nigeria. Initiatives to combat such pharmaceuticals have paid off: in the decade leading up to 2020 the prevalence of counterfeit drugs dropped from around 30% of the total to less than 10%, according to the African mPedigree scheme.
Outlook
Nigeria’s growing population poses a number of challenges for the provision of health services to all, but the longer-term prospects for investment in the sector remain promising, with the Covid-19 pandemic creating more opportunities for innovation from the private sector. Moreover, further reforms and higher government budgets allocated towards health have the potential to create significant positive effects on population health outcomes.
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