Organization: The Lancet
Site of publication: thelancet.com
Type of publication: Article
Date of publication: March 15, 2022
Section 1: introduction
Nigeria is at an important crossroad. Nigeria’s population is projected to increase from approximately 200 million people in 2019 to an estimated 400 million in 2050, and 733 million people by 2100, becoming the world’s third most populous country after India and China.
These estimates assume that the average number of children per mother will decline from 5·1 currently to 3·3 on average by 2050 and 2·2 children on average by 2100. If this projected decline in fertility is to fall short by half a child per mother, Nigeria’s population will reach 985 million by 2100.The potential gain from this expansion will only be possible if population growth is managed and supported by equitably distributed prosperity.
A rapidly rising population, coupled with the absence of reliable access to high-quality health care education, and other public services will serve only to increase the potential for unrest, drive large-scale unplanned migration, and consequent regional and even global destabilization.
A large population of uneducated and unemployed youth risks further instability and security challenges. These demographic and socio-economic challenges are further compounded by climate vulnerability. Nigeria is one of the ten countries most vulnerable to climate change due to extreme weather, rising sea levels, and increasing land temperature.
Conversely, a healthy and secure Nigerian population living within planetary boundaries could make untold contributions to human progress, now and in the future. Accordingly, integrated efforts to address health inequalities and climate vulnerabilities is a crucial priority for the country. If the right policies are implemented, Nigeria is poised to become a global superpower.
A rapidly rising population, coupled with the absence of reliable access to high-quality health care education, and other public services will serve only to increase the potential for unrest, drive large-scale unplanned migration, and consequent regional and even global destabilization
Nigeria’s significance to global health and the health of Africans is self-evident, particularly considering its large and mobile population. Major health gains in Nigeria should improve health outcomes in Africa by directly improving health security and through the sharing of good practice and policy to neighboring nations.
But Nigeria faces numerous challenges in confronting both population growth and climate vulnerability ensuring a healthy future for its population. The country did not achieve any of the health-related Millennium Development Goals (MDGs), and progress towards health-related Sustainable Development Goal (SDG) targets has been modest at best.
According to almost all health metrics, Nigeria’s health outcomes are dismal with inadequate progress made over the past three decades for the majority of its population. Investment in health is low at 4% of GDP in 2018, whereas substantial resources continue to be spent fighting insecurity without addressing its root causes, and sustaining a large and complex governance structure, with too little left over for health and education. The macro-fiscal environment is not favourable, with only modest economic growth and a sharp worsening of the economic outlook due to the COVID-19 pandemic.
Conversely, given Nigeria’s low starting base, reforms towards achieving universal access to high-quality public health services have the potential to achieve large positive effects on population health outcomes.
Despite its considerable human and material assets, achieving universal health coverage will be challenging. The modest resources allocated to health have been mismanaged by successive governments since independence in 1960. A series of national plans, strategies, and policy documents have only ever been partially implemented, with missed opportunities to apply health as a tool for development. Given the scale of the challenge, there has also arguably been an inadequate focus, with the most recent plan outlining 48 strategic objectives. Several policy documents allude to “quality, effective, efficient, equitable, accessible, affordable, acceptable and comprehensive health care services” for all Nigerians, yet these goals are elusive. Nigeria’s most recent development plan ended in 2020 with, at best, partial success, presenting an opportunity to better frame health as a determinant of national achievement in the next plan.
Nigeria faces numerous challenges in confronting both population growth and climate vulnerability ensuring a healthy future for its population. The country did not achieve any of the health-related Millennium Development Goals (MDGs), and progress towards health-related Sustainable Development Goal (SDG) targets has been modest at best
There are immense opportunities to alter Nigeria’s population health and economic development trajectory, if only they can be seized. Reducing maternal and child mortality and unmet need for family planning are basic first steps to improve families’ well-being, with implications for security, resource utilization, economic growth, and shared prosperity. Reducing the burden of HIV, tuberculosis, malaria, and other communicable diseases will change the epidemiological landscape, allowing greater scope to simultaneously tackle rising non-communicable diseases.
Taking bold multisectoral preventive action on the determinants of health can in turn prevent and even reverse the rise of non-communicable diseases. Government action needs to move away from treating disease to creating health. And importantly, such efforts must be integrated with climate action for healthy resilient futures.
The Lancet Nigeria Commission aims to reposition future health policy in Nigeria to achieve universal health coverage and better health for all. A detailed critical evaluation of the historical and current challenges facing the health of the country is presented to contextualize recommendations for the future.
Section 2: evolution of a health system skewed away from population needs
Independent Nigeria’s recurring crises and governance challenges hinder efforts to improve population health
Nigeria’s independence in 1960 ushered in new hopes to realign state and society and re-orient public spending and governance towards the good of the population. For example, in the 1960s, following the Ashby Commission reports second-generation medical schools were established in Zaria in the north of Nigeria, Lagos and Ilé-Ifé̀ in the west, and Enugu in the east. Unfortunately, recurring economic crises and ongoing political instability, with a series of military coups in 1966, 1975–76, 1983, 1985, 1993 and persisting until 1999, created a challenging environment for sustained reform. Since the return to democracy in 1999, the political situation has arguably stabilized, albeit with ongoing popular agitation rooted in grievances about the allocation of political and economic benefits. Insecurity is still a major problem in many parts of the country, as are fragile and incomplete democratization and fiscal weakness. Taken together, these trends have complicated durable progress towards improving population health.
The development of the PHC system in the 1980s and the 1990s under the leadership of Professor Olikoye Ransome-Kuti is a notable exception. Prof Ransome-Kuti, as the health minister, helped develop the first National Health Policy in 1988, and led the introduction of the PHC model in 52 pilot Local Government Areas (LGAs), with the primary focus of promoting preventive medicine at the community level. Among other successes, child immunization coverage reached over 80% by 1990, meeting the Universal Child Immunization target.
To ensure the continued progress of PHC service delivery, the National Primary Health Care Development Agency (NPHCDA) was established in 1992. However, the 1993 military coup d’état hastened the collapse of the PHC system and brought an end to the giant strides recorded under the leadership of Ransome-Kuti from 1985 to 1992, and other successes from that period, for example in immunisation coverage, have also not been sustained to the present day. Although PHC is a focus of health reforms—for example with the 2011 Primary Health Care Under One Roof policy, which integrates PHC service delivery under one authority— implementation by states and local governments has been slow and fragmentary.
Key informants familiar with the development of the Nigerian health system in the post-independence period offered varying explanations, many of which appear linked to underlying political issues such as citizens’ inability to hold leaders to account. Although the colonial inheritance of a generally weak, unequal, curative-oriented system offered a poor start to independent Nigeria, there has arguably been a failure to re-establish a social contract, including an underlying ethos and expectation of the government’s duty to provide health-creating conditions, including a functioning basic health system.
One key challenge has been Nigeria’s complex, opaque, and poorly specified governance arrangements, which obscure constitutional responsibility and accountability. Since 1979, Nigeria’s federal presidential system has divided responsibilities between federal, state, and LGAs, and although the 1999 constitution asserts that “The State shall direct its policy towards ensuring that there are adequate medical and health facilities for all persons” (a provision it transparently does not meet), little further detail is enshrined about how this entitlement is meant to be delivered. Since the 2014 National Health Act, the tertiary level of care is nominally the responsibility of the federal government, states manage secondary healthcare, and the primary level, including PHC centers, are managed by LGAs. In reality, the separation is non-existent as states still have their own tertiary care facilities, whereas for primary care, the federal government provides a regulatory advisory function, alongside centralized provision of some services (such as immunization) and finances infrastructural improvements through the NPHCDA.
The poor delineation of responsibilities among these levels has resulted in a complex and contested distribution of resources, a referral system widely agreed to be defective, and an unclear responsibility structure that frequently results in neglect at all three levels. This division of responsibilities partly explains why primary care is generally weak in Nigeria as responsibility for this critical level of care has been devolved to the weakest level of government (ie, LGAs) while control of primary care resources is driven by the state governors.
The division between federal, state, and local obligations also risks entrenching historical inequities between geographical regions, with areas that were formerly highly centralised and autonomous during colonial rule (eg, in the north of Nigeria) resisting federal autocratic regimes, which has led to retaliation through under-investment in federal services.
These trends can help explain some of the greater concentration of hospitals (managed at tertiary level) and other formal health structures in the south as compared with the north, despite the proportionally larger population in the north. Subsequent investment by the state governments and the private sector further ensured that the density of hospitals and health centers in the south of Nigeria improved and diverged further post-independence. Furthermore, although the rural population constitutes about 50% of residents, it is served by fewer health facilities.
Further compounding these issues, population health has not been highly prioritized in national and state budgets throughout Nigeria’s modern history. It is difficult to escape the conclusion that the political will to deliver “health for all”, including universal health coverage, has been grossly inadequate, due to in part the population’s limited ability to effectively demand improved health services. Since the 1970s, financial gains from oil revenues have been a funding source for health, albeit one that political leaders have repeatedly failed to harness.
Political turnover has not been an impetus for change; for example, the dire state of the health system was cited as one of the reasons for the 1985 coup overthrowing General Muhammadu Buhari however his successor, General Ibrahim Babangida, allocated only 2·7% of the national budget to the health sector. Following the collapse of petroleum prices thereafter, Nigeria was subjected to the well-documented ravages of the Structural Adjustment Programme, during which both allocation to the health sector and per capita expenditure on health were reduced. Out-of- pocket payments have since become the most common mechanism of financing health care for individuals and households, creating a cost barrier and decreasing the use of health-care services and adherence to medications. Prospective patients are thus driven to use traditional medicine, which is easily accessible and relatively affordable.
Government health expenditures have risen somewhat under the Fourth Republic, however, Nigeria’s total government spending as a share of overall health spending was at 4·6% in 2017, lower than the African average of 7·2% and the world average of 10·3%. In contrast, out-of-pocket expenditure is extremely high, at 77% of total health spending in Nigeria, compared with 37% for the African average, and a much lower 18% for the world average. Compounding Nigeria’s health inequities are low in investment in water and sanitation infrastructure compared with other low-income and middle-income countries (LMICs), as well as generally low government spending across sectors.
Overall, Nigeria’s model of health-care financing since the First Republic has gradually transformed into one focused on the generation of revenue for hospital management through the charging of user fees. Public health centers have been pseudo-commercialized as they are restructured to generate funds to work efficiently and independently. In the public and organized private sectors, neoliberal reforms have led health-care provision to be more market-oriented, even though 60% of the Nigerian population are estimated to have minimal disposable income. As a result of underfunding, the capacity and quality of government health facilities and health services dwindled due to the persistent unavailability of drugs and equipment, resulting in increasing reliance on home treatment, medicine sellers, traditional medical systems, and faith healing by the Nigerian populace. The accumulated results of this history can be traced throughout the health system, with a case study of maternal health services providing an example of the resulting challenges and opportunities.
Section 3: an evolving burden of disease challenges a system focused on curative care Burden of disease
With an estimated population of 206 million, of which almost 44% is aged under 15 years, Nigeria is both the most populous nation in Africa and one of the youngest. Almost 111 million Nigerians are of working age (25–64 years) compared with 95 million of non-working age, and the size of the workforce is projected to grow substantially. Although the UN Population Fund refers to such a situation in which the share of the working-age population is larger than the non-working-age group as a demographic dividend with the potential to drive economic growth into the future, no country has tapped into these benefits while faced with unchecked population growth. East Asian countries (eg, Singapore, Indonesia and South Korea) used demographic changes to achieve economic development by incorporating new workers and driving up incomes, productivity, and development indicators. However, these countries also simultaneously tackled population growth by lowering fertility rates; between the 1950s and 2010, the total fertility rate in east Asia declined from 5·8 to 2·3.
Unfortunately, Nigeria still ranks very low on the World Bank’s Human Capital Index 2020, as one of only 24 countries out of 174 globally with a score below 0·4.65 Indeed Nigeria’s score of 0·36 out of 1 means a Nigerian child born today will only be “36 percent as productive when she grows up as she could be if she enjoyed complete education and full health”. Therefore, investments need to be made now to enable the demographic dividend and to avoid population growth outstripping economic growth and pushing more people into poverty.
The country can harness its human resources by ensuring population growth is managed well and a demographic dividend is realized. By investing in reducing unmet need for family planning, closing the gender gap in education through increasing education of the female population, increased opportunities for women’s participation in the labor market, and reducing child mortality, Nigeria’s fertility rate can decrease towards replacement levels (2·1 children per woman) so that the large proportion of children and youths today at the bottom of the population pyramid become the engine of the economy (Onwujekwe O, unpublished). Such a bulge in the middle of the population structure if realised would mean a high workforce to dependents ratio and can drive growth. This growth is conditional on large investments in good education and health now so that the potential workers of tomorrow are skilled and healthy.
Despite modest decreases in fertility over the past four decades, the fertility rate is high relative to the global average, at around five livebirths per woman.
The number of births across the country has continued to increase, leading to population growth of 2·6% a year, a rate that will lead to a doubling of the population within less than 27 years, placing extensive pressure on communities and social services.
Faster decreases in fertility driven by family planning and female education, especially in regions and groups with the highest growth rate, will be required for Nigeria to effectively reap its demographic dividend. Ensuring access to family planning and contraception is vital to ensuring gender equality and human rights, reducing unplanned pregnancies and achieving broader improvements in health, education, and economic outcomes. Yet, unmet need for modern contraception in Nigeria is estimated at over 20%, with only slight decreases in the past two decades. Unmet need among married women is estimated to be lower than among unmarried women but still high.
Meeting the demand for contraception and increased investment in and access to education services is therefore essential, and will require wide-reaching efforts to overcome gender inequities across the population and taking into account sociocultural challenges that drive high fertility. Indeed, the link between the empowerment of women and increased demand for modern contraception has been shown around the world. More broadly, education has been shown to be a key determinant of health seeking behaviour, with the effect particularly pronounced for girls.
Although, the proportion of Nigerian women 15–49 years with no education has reduced between 1999 and 2018, it is still relatively high, with 34·9% of women having no formal education as of 2018. The percentage of women with secondary education or higher is highest in the south of Nigeria and lowest in the north, indicating the long distance to travel in improving female education and in addressing the country’s regional disparities.
Healthy life expectancy, morbidity, and mortality
Nigeria continues to bear an extremely high burden of death, disease, and disability, even compared with other LMICs. The UN estimates life expectancy at birth in Nigeria to be just over 54 years, the fifth lowest in the world. The burden of death and disability in Nigeria has historically been dominated by communicable, maternal, and neonatal diseases along with nutritional deficiencies, which continue to be the case in 2019, although non-communicable diseases are having an increasing effect on the population over time. Much of Nigeria’s disease burden is uncertain given the near absence of relevant data; for example, in its latest SCORE assessment, WHO estimates that only 10% of deaths in Nigeria are registered.
The paucity of data is strongly indicative that decision making is rarely based on appropriate evidence, an enormous challenge that is nonetheless surmountable provided key hurdles are scaled.
To focus the work of the Commission in understanding and analysing Nigeria’s complex burden of disease, an e-Delphi process was conducted in late 2020 with twenty-three commissioners and key Nigerian policy makers to identify the conditions and risk factors most important to address to improve population health in Nigeria. Eleven conditions and five risk factors were prioritised as particularly important to the Nigerian health system. We present GBD data for these prioritised conditions, including communicable diseases and non-communicable diseases, diseases with epidemic potential, and maternal and child health. A comprehensive analysis of the burden of disease in Nigeria compared with other west African countries is presented in full elsewhere, with key results referenced here.
Nigeria continues to bear an extremely high burden of death, disease, and disability, even compared with other LMICs. The UN estimates life expectancy at birth in Nigeria to be just over 54 years, the fifth lowest in the world
Nigeria has achieved substantial improvements in the rate of morbidity and mortality of historically leading causes of death. The three leading causes of death in 1998 have shown large declines in age- standardised mortality rates; diarrhoeal diseases have reduced by 59% from 227 deaths to 92 deaths per 100 000 population, malaria from 161 to 112 deaths per 100 000 population (–30%), and lower respiratory infections from 148 to 97 deaths per 100000 popula- tion (–34%). Malaria had the highest age-standardised mortality rate in Nigeria in 2019, however, the importance of cardiovascular diseases has grown with ischaemic heart disease (105 deaths per 100 000 popula- tion), the second leading contributor to age-specific mortality, and stroke the fifth (91 deaths per 100 000 population), despite decreases in the mortality rates of 18% for ischaemic heart disease and 31% for stroke since 1998.
Taken together, cardiovascular diseases were the leading contributor to age- standardised mortality over the comparison period. Infections and neonatal disorders were the largest contributors to age-standardized years of life lost and disability-adjusted life-years across the population in both 1998 and 2019, reflecting their effect on younger population groups. This progress over the past 25 years is salutary, but the burden of communicable diseases is untenably high in Nigeria and the rate of progress has slowed considerably in the past decade.
Nigeria has experienced outbreaks of cholera, meningococcal meningitis, Lassa fever, and monkey pox over the last decade, with variable case fatalities. Nigeria’s epidemic detection and response mechanism is becoming more responsive with improved laboratory diagnostics, a better trained cadre of field epidemiologists who can be rapidly deployed when needed, and better coordination from the NCDC.
WHO’s Joint External Evaluation of Nigeria’s pandemic preparedness suggested an improvement in the score from 39% in 2017 to 46% in 2019, leaving much room for continued improvement. Some of these gains have the potential to be leveraged for other diseases of epidemic and pandemic concern including Ebola haemorrhagic fever, and, most recently, COVID-19. The COVID-19 pandemic has however shown how easily this growing capacity can be strained and there is need to continue to develop the response capacity, and resilience within it, because Nigerians are at risk of several epidemic-prone diseases in addition to the threat from future pandemics.
Health is made within communities and at home: health creation and disease prevention
Since the late 1990s, it has been widely accepted that improved health outcomes observed across the world’s population, and particularly in LMICs, resulted predominantly from improvements in socioeconomic and environmental factors including education, income, and progress in overcoming entrenched social inequalities. Although a well-functioning and resourced health system will be vital to improve the health of Nigerians, much of the disease burden experienced across the country results from factors that lie outside the health system.
A multisectoral or Health- in-all-Policies (HiaP) approach to address key risk factors and social determinants of health including nutrition, access to clean water and sanitation, family planning, and healthy environments would be a cost-effective approach to improve population health outcomes and drive sustainable development, while simultaneously relieving pressure on health services. Cities in particular concentrate many of these social and environmental exposures that adversely affect health. Accordingly, without due attention to health equity, the rapid rate of urbanisation occurring in Nigeria coupled with climate vulnerability can further accelerate health inequities.
Water, sanitation, handwashing, and nutrition
By addressing maternal and child malnutrition, and ensuring access to clean water, facilities for handwashing, and sanitation for all Nigerians, the country could substantially decrease preventable neonatal and child deaths. Poor access to wash predisposes Nigerians, and in particular vulnerable children, to enteric infections, among the most common causes of under-five mortality. Both trachoma and schistosomiasis, which can be controlled by improving wash, are endemic in the poorest communities of Nigeria; cholera outbreaks in some parts of the country are also attributable to poor access to wash.
Insufficient or non-existent water supply in health facilities is also a major barrier to infection prevention and control, which predisposes for hospital-acquired infections, and are an important risk factor for maternal and neonatal mortality. Infection Prevention and Control gaps are exacerbated by Nigeria’s long-standing infrastructural deficits such as poor access to running water, even for health facilities, and chronic, seemingly intractable, electric power shortages. These in turn make it challenging to implement hand hygiene and other requirements of Nigeria’s most recent Infection Prevention and Control policy (SITANstudies).
Environmental and cardiometabolic risk factors
In line with the increased burden of non-communicable diseases on the Nigerian population, a growing number of deaths and DALYs in Nigeria are attributable to cardiometabolic risk factors. Although the majority of this burden falls on older Nigerians, evidence suggests that cardio metabolic risk factors are occurring at increasingly earlier ages. As such, the risk factors for cardiometabolic disease need to be addressed at younger ages, not later, as is commonly believed.
As the Nigerian population continues to grow, the relationship between the population and the environment will be increasingly important. Almost 200000 deaths were estimated to be attributable to air pollution across Nigeria in 2019 (12% of total deaths). Air pollution was included as a key driver of 24% of neonatal deaths and half of all deaths resulting from lower respiratory infections.
Air pollution is also an important cause of the increased burden of non-communicable diseases alongside the metabolic risks identified, with 31% from ischaemic heart diseases, 38% from stroke, 23% from diabetes, and 58% from chronic obstructive pulmonary disease being attributed to air pollution. Despite these alarming contributions of air pollution to mortality in Nigeria, previous institutional and legislative frameworks have often focused on mitigating pollution from the oil and gas sector, including transport and generators, even though there is substantial ambient air pollution from other sources such as cooking.
The built environment is also a key determinant of population health, in large part because it affects physical activity.
Section 4: health system reform—a pathway to universal health coverage
Achievements and flaws of the current health system Indicators of health outcomes and coverage of basic health services in Nigeria show long-standing underperformance. However, the overall trend of indicators such as infant and child mortality since independence in 1960 indicate a slow decline. In the past decade, successes against Guinea-worm disease, poliomyelitis, and Ebola virus disease are areas of high performance despite systemic weaknesses. Numerous health policies and development plans in Nigeria culminated in the National Health Act of 2014, which has the potential to improve Nigeria’s health system, by guaranteeing federal funding through the Basic Healthcare Provision Fund and defining state government responsibility for financing and delivery of PHC.
Implementation of health policies as intended is a core challenge as illustrated by the incomplete realisation of the Second National Strategic Health Development Plan (NSHDP II), partly due to governance challenges, with the division of responsibilities between federal, state and local governments. Additionally, the role of development partners in initiating some policies through vertical funding often leads to a lack of ownership by national and sub-national policy makers, and the policy- making process itself not taking formal and informal political considerations into cognisance.
As discussed in Section 2, the three levels of health service delivery in Nigeria (primary, secondary, and tertiary) do not function equally well, and many potential patients bypass the PHC level when not available, trusted, affordable, or of sufficient quality. Individuals who can afford it enter the system at a higher level, and those who cannot afford care at higher levels sometimes resort to seeking informal care from drug shops, pharmacies, and traditional healers, or seek no care at all.
The weakness of the PHC system is linked to the divided allocation of responsibilities between federal, state, and LGA level. The weak state of PHC places a heavy burden on tertiary hospitals, especially where secondary care is also weak or mostly provided by the private sector, such that the bulk of patients are seen at the general outpatient departments of tertiary hospitals staffed by family physicians (ie, general practitioners).
A 2019 survey of all federal government-owned tertiary care hospitals and five state-owned tertiary institutions across Nigeria recorded a national monthly average of about 42000 visits by patients per facility. Only 3% of these visits were due to referrals from other facilities, which is consistent with the observed trend of patients bypassing primary care. In addition, less than 45% of these visits led to specialist referrals within the surveyed facilities further confirming that these tertiary institutions served as PHC facilities for the patients.
These statistics further reflect a heavy burden on general out patient departments of tertiary hospitals in Nigeria.
Previous efforts to provide federal support for PHC have been largely unsustainable—one example is the Midwives Service Scheme. The ambitious nationally implemented government-run Midwives Service Scheme was designed such that each of the three levels of government made monthly contributions towards the salary and support of midwives posted to rural communities to improve the quality of maternal health services. As salaries were inconsistent and insufficient, and in some cases not provided at all (with federal contributions proving the most reliable), the Midwives Service Scheme led to deep dissatisfaction among the midwives employed.
A legislative measure to improve PHC delivery has been to centralise the governance of PHC at the statelevel, so that state governments rather than local governments take primary responsibility for PHC, in addition to their responsibility for secondary care. Delivering on these responsibilities requires each state government to give due political priority to PHC and increase their health budgets accordingly.
A similar federal initiative to the Midwives Service Scheme, the Free Maternal and Child Health programme, was implemented in 12 states from 2009 to 2015. This pilot initiative, which provided insurance coverage for mothers and children in selected LGAs in those states, had a similar fate as the Midwives Service Scheme State governments defaulted on payment of their agreed counterpart funds, which made the federal government terminate the project at the end of the pilot phase.
The Free Maternal and Child Health programme was not scaled up within pilot states or to other states. However, it has been shown that the insufficient funds provided for the Basic Health Care Provision Fund could be used to revitalize and scale-up the Free Maternal and Child Health project if mothers and children most in need are targeted for coverage, while sourcing for additional funds to ensure universal coverage of maternal and child health services.
Rationalization of policy making at federal, state, and local government levels
To strengthen domains for action and policy in the health system in Nigeria, we propose a reformed set-up of centrally determined but locally delivered systems. Nigeria urgently needs to digitize its health system at all levels. Centrally, there is a need to standardize services, pool and streamline resources, and improve supply chains, manufacturing and data management for products. Concurrently, there is a need to strengthen local production of basic products, allocation decisions, defining basic health services packages to align with local risk factors, and modes of community service delivery sensitive to sociocultural norms.
With regards to information systems, evidence and experience indicate the need to nationalise guidelines on completion and use of national surveillance forms, utilization of data, health information system training and mentoring, data quality assurance processes, and supervision manuals. These guidelines need to be created and made available nationally, with resources provided centrally to support their implementation. Implementation support could be phased out over time and means-tested, based on the level of available financial and technical resources in each state, with appropriate federal assistance. However, during the development of the national guidelines, the specific roles and responsibilities of the three levels of government, and of health facilities in health information system management, should be clearly outlined.
Alongside digitising the health information system and centralisation of responsibility, capacity to use information system across Nigeria will require reliable nationwide internet coverage. Stable internet connectivity (which also requires constant electric power), technology hardware, and continuous technical support are core prerequisites for the implementation and utility of electronic information system tools—these requirements are yet to be met in Nigeria.
The vaccine supply chain system (as with other centrally purchased health commodities) receives inadequate and unreliable government funding and is stymied by a complex multilayered governance architecture that depends on several decision-makers at the federal, state, LGA, and health facility levels, and a poorly executed mix of push and pull distribution mechanisms. Re-designing supply chain systems can reduce costs and gaps in cold storage capacity—for example, by decreasing the number of levels of vaccine in cold storage, increasing the use of local data in procurement of vaccines, and implementing a central (ie, federal or state government) push mechanism and a local (ie, LGA and health facility) pull mechanism.
The push mechanism involves pushing vaccines (within a state) directly from a few state stores to PHC facilities equipped with solar refrigerators, thus bypassing LGA cold stores. PHC facilities draw from LGA stores when needed and only when transport can be organised, which occurs often in PHC facilities with a shortage of resources, resulting in frequent stock outs. In the re-designed system, frontline health workers no longer have to leave their posts to collect vaccines. Reverse logistics, such as waste collection from service points, is a complementary intervention that can be added to the direct delivery programme. As most vaccines, diagnostics, medicines, and other health care consumables are currently imported, centralising supply chains will also help to streamline and strengthen the logistics and quality assurance of border transactions on importation.
A long-term strategy to produce vaccines, diagnostics and other consumables in Nigeria is however necessary, as indicated by the challenge of procuring and distributing personal protective equipment and vaccines in the COVID-19 response.
To increase the demand for and use of health services, the federal government can develop national approaches to shifting normative practices, and improving and standardising quality of care. National guidelines and quality standards could be used to formalise processes and standards of care, for example, beginning with a national pilot of protocols and guidelines for particular services such as maternal health services, which would include antenatal care, delivery, and postnatal care. These protocols and guidelines need to be matched with a national adoption and scale-up strategy, including electronic mobile phone platforms through which their use will be facilitated, and the training, supervision, and monitoring processes to facilitate their use, all made available nationally to all health-care staff, preferably electronically and in a format that would allow for local adaptation.
PHC workers at the community level are the mainstay of an effective and functional surveillance system. To localise information systems, attention should be paid to strategies to increase the quality (including completeness and timeliness) of data collected, beginning at local community level. One strategy is for health workers to analyse and use the data they collect to make informed decisions in the communities they serve.
The goal of data collection should not be solely for transmission to higher levels for analysis and decision making, rather, information should be used at the level at which it is collected. Local use of information can improve data quality as corrections can easily be made at the point of collection in addition to helping health providers monitor their performance. This strategy requires training and ongoing mentoring on data use and interpretation at the local level. Introducing mobile technologies at local level can further improve data quality due to its potential to reduce data entry error and increase speed of reporting, thus enhancing the accountability that local use of data collected at local level can trigger.
Rationalization of links between public and private sectors
Strengthen public sector primarily but leverage private sector for specific tasks
To develop the overall health system landscape in Nigeria, it is important to strengthen the public sector (especially at the PHC level) and expand the capacity of private sector providers to increase their competitiveness in terms of breadth, quality, and cost of services.
Public sector financing should address taxation corruption while increasing health expenditure. Details on economic, and systemic budget reforms needed to strengthen the overall Nigerian health system are presented in Section 5. At the moment, many state governments struggle to mount the required funding to support their health systems. In many instances, when there are limited functional PHC facilities within communities, the private sector fills the service delivery gap in the form of for-profit services (for those who can afford it), non-profit services (by non-governmental organisations [NGOs] and faith-based organisations sometimes aimed at individuals who cannot pay for services) and informal service providers.
To improve health care at the PHC level, state governments could strategically secure funding for health systems development with international donors and NGOs in addition to their federal allocation (including specifically for health, guaranteed through the legislative change that centralised PHC governance at the state level). Although foreign funding is not sustainable, with evidence-based planning and foresight, programmes supported by international NGOs and bilateral or multilateral organisations can lead to sustainable health system improvements by establishing health system infrastructure, especially technical and physical infrastructure.
A long-term strategy to produce vaccines, diagnostics and other consumables in Nigeria is however necessary, as indicated by the challenge of procuring and distributing personal protective equipment and vaccines in the COVID-19 response
Nigeria has a dynamic private sector that can reposition the health system and improve access and quality of care, as shown during the COVID-19 pandemic. The partnership built between the private sector-led Coalition Against COVID-19 (CACOVID) and the government during the pandemic was a potent force in the country’s response to COVID-19, successfully mobilising over 200 donors, including large corporate bodies, to generate 96% of an initial ₦40 billion resource target (Aliyu S, unpublished). CACOVID worked closely with the national and state COVID-19 task force teams to support a wide array of interventions (from case management to economic recovery), representing the first time that the private sector took health system strengthening initiatives to scale, and delivered the mina efficient and coordinated manner, without the encumbrances of public sector bureaucracy, but with appropriate supervision and evidence based decision making from the Presidential Task Force on COVID-19.
CACOVID, through its partners, contributed to the establishment of 39 isolation centres and donated about 400 000 test kits early in the pandemic, supplied food relief materials to an estimated 5% of the poorest Nigerian population, facilitated the vaccine roll out through the provision of logistics and IT support, and provided storage facilities nationwide for food and medical equipment. The logistic systems operated by CACOVID provided broad- based innovative solutions to the challenges of the COVID-19 vaccine and oxygen distribution in the country, thus enabling a more cost-effective and efficient delivery system for goods. CACOVID also helped set up the Nigeria International Travel Portal using their existing IT platforms and skilled staff to expedite the reopening of international airports and economic recovery.
It is important to note, however, the different contexts represented by the pandemic and the provision of health services on an ongoing basis. Evidence and experience suggest that effective contracting of services to the private sector will require a substantial capacity in the government sector to monitor and oversee these providers. Private providers have been found to more frequently deviate from evidence-based practice, have poorer patient outcomes, and be more likely to provide unnecessary testing and treatment in LMICs.
Data on the comparative performance of private and public providers in Nigeria are scarce, although treatment at private providers has been shown to be associated with higher levels of catastrophic health expenditure, poorer patient satisfaction and prescription of poor-quality medications. To reinforce public and private sector collaboration in Nigeria, the framework should be contingent on partnerships that are based on mutual trust, sharing of information, joint planning, policy formulation, implementation and evaluation, and joint financing of programmes and activities.
Strategies for human resources and ameliorating brain drain
Deficits in human resources contribute to disparities in health and health-care access. Nigeria has a large health workforce training capacity (and one of the largest health workforce stocks) in Africa, but still has substantial deficits. These deficits are partly due to a correspondingly large emigration of skilled health workers from the country, known as brain drain, which is predominantly due to push factors. It is not so much that the professionals plan from the beginning (ie, as students) to leave because they are seeking greener pastures, but the conditions (eg,of life and work) in the country typically experienced after graduation that makes them want to leave.
Emigration occurs at all stages of professional life, from early to late, so what really matters in the long run is for Nigeria to have a health system that works, so that they can stay. In addition, there are substantial disparities in the supply and distribution of health professionals across states and geopolitical zones. There are no national or sub- national policies guiding the postings and transfers of health workers in Nigeria. Within states and LGAs, deployment is often based on the discretion of administrative officers with multiple influences and competing interests. Such policies are required at different levels of government.
The share of health personnel is relatively low. As of 2010, there are around ten doctors per 100 000 population on average in each state in the country, a figure that is lower than the sub-Saharan African average of 17 doctors per 100 000 population, according to WHO Global Health.
Workforce estimates. Community Health Extension Workers are local residents who receive training to provide basic health services to their communities. They generally have less medical training than doctors or nurses and make up the vast majority of healthcare workers at PHC facilities, consisting of up to 57% of staff at health facilities in LGAs, much more than the proportion of doctors (8%), nurses (14%) and nurse-midwives (21%) at health facilities at LGAs. There are opportunities to up- skill Community Health Extension Workers, creating a professional career path linked to PHC facilities with defined income, roles and responsibilities, and reporting and supervision arrangements, potentially improving access to health services.
To minimize drain and maldistribution, it is important to establish local structures for the main regulatory bodies so as to ease the process of licensure, employing, and tracking of health professionals at state level. Also, state and federal level technical support (eg, digitised registers) should be provided to regulatory bodies to track exit of health workers effectively.
These registers need to capture internal and external migration, as well as retiring and deceased health workers, with data periodically updated. Further, human resources for health tracking and data management systems should be set up at state ministries of health and linked to all training institutions and service delivery points, including the private sector, to facilitate human resources for health planning.
Inter-professional rivalries (eg, among pharmacists, doctors, nurses, and laboratory scientists) undermine collaborative care and the ability of the health workforce to meet the care needs of the population. This rivalry, as well as disputes around remuneration, has led to multiple industrial actions like strikes and lawsuits in Nigeria. Such actions can last from a few weeks to several months, disrupting health-care services, worsening health outcomes, and further deteriorating working relationships among health-care professionals. These challenges require an overarching human resource for health framework developed in a way that secures the relevant buy-in of professional groups.
To improve quality of care, it is important to standardize the training of skilled health workers with national guidelines (eg, in undergraduate training institutions, postgraduate specialist colleges, and for continuing education), in the public and private training and service delivery sectors. There are examples of pilot experiences of using WHO training manuals, local training manuals, or adapting international manuals. However, efforts to standardise training and practice will require a national process for developing (and adapting from international examples), accrediting, and disseminating in-service or pre-service training manuals, and incorporating them into nationally approved training curricula.