27 Years Of Democracy And Nigeria’s Health Renewal (I): Rebuilding The Foundations

By ‘Lade Bandele

Twenty-seven years after the return to democratic governance, Nigeria’s health sector remains one of the clearest measures of the country’s broader development journey. It is where public policy meets everyday life: in the primary healthcare centre that opens on time, the maternity ward that has skilled personnel, the pharmacy shelf that has medicines, the cold chain that keeps vaccines safe, the ambulance that arrives when called, and the family that can seek treatment without being driven into financial hardship.

The sector’s challenges are neither new nor insignificant. Population growth has increased demand for services. Maternal mortality remains unacceptably high. Out-of-pocket spending still weighs heavily on households. Workforce shortages persist across many parts of the country. Specialist services remain unevenly distributed, particularly outside major urban centres. Medicines and medical consumables are still not consistently available where they are most needed.

A fair assessment of the sector, however, requires attention to both the problems that remain and the changes that are beginning to take root.

The Case for Renewal

Many of the developments recorded in recent years have been pursued under the Nigeria Health Sector Renewal Investment Initiative, introduced by the administration of President Bola Ahmed Tinubu in 2023 and coordinated through the Federal Ministry of Health and Social Welfare under the leadership of the Coordinating Minister of Health and Social Welfare, Professor Muhammad Ali Pate.  The framework was designed to improve coordination across financing, service delivery, workforce development, health security, and the healthcare value chain. Its organising principle is simple: one conversation, one plan, one budget, and one report.

The initiative emerged against the backdrop of a system in which programmes, funding streams, reporting requirements and implementation arrangements often operated in parallel. Federal agencies, state governments, development partners and implementing organisations frequently pursued similar objectives through separate structures, producing varying levels of duplication, fragmentation and inefficiency. The reform framework sought to align priorities, strengthen government stewardship, improve accountability and create a common basis for measuring performance across the sector.

The conditions confronting the sector at the outset were significant. Health insurance coverage remained below nine per cent in most states. Health expenditure stood at about three per cent of GDP, below the World Health Organization’s five per cent benchmark. Only about 21 per cent of BHCPF-supported primary healthcare centres met Level-2 service readiness standards. Approximately 16,000 health workers had emigrated within five years. Family planning commodities recorded stock-out rates of about 41 per cent. Maternal mortality was estimated at 512 deaths per 100,000 live births.

These indicators pointed to problems that extended beyond funding alone. Financing gaps mattered, but so did fragmentation, weak coordination, uneven service readiness, workforce losses, commodity stock-outs, and the absence of a common framework for measuring performance across the system. The challenge was not simply how much money was available, but whether institutions were working together effectively enough to translate resources into results.

Primary Healthcare and the Frontline of Care

Primary healthcare is the appropriate place to begin any assessment of the sector because it is where most Nigerians first encounter the health system. It is where children are immunised, pregnant women receive antenatal care, common illnesses are treated, and referrals into higher levels of care begin.

Recent data suggest a substantial increase in activity at that level. Health sector performance reports recorded about 45 million health visits and treatments in the third quarter of 2025 alone. Across the country, 2,382 primary healthcare centres have been upgraded, while another 1,607 are undergoing improvement. These upgrades include provisions for skilled birth attendants, reliable power supply, staff accommodation, extended service hours, and the capacity to provide antenatal, immunisation and delivery services.

The financing of primary healthcare has also become more direct. More than ₦65.9 billion has been disbursed to facilities through the Basic Health Care Provision Fund, while Direct Facility Financing allocations increased from about N300,000 to between N600,000 and N800,000 per facility.

Alongside increased financing has come greater emphasis on accountability. Digital management systems, facility dashboards, and strengthened financial oversight are intended to ensure that resources reach facilities and can be linked to actual service delivery. In a sector where funding has often been discussed separately from performance, that distinction is increasingly important.

The significance of these developments lies not only in the volume of resources deployed but in what they seek to achieve. For many years, debates about health financing focused primarily on allocations. Increasingly, attention is also being directed toward whether resources reach facilities, whether they are properly managed, and whether investments translate into improvements that citizens can actually experience.

Maternal Health and the Burden of Mortality

Maternal and newborn health offers another important test.

Nigeria’s maternal mortality burden remains one of the gravest public health challenges in the world. No serious assessment should minimise that reality. Equally important, however, is whether interventions are addressing the factors most closely associated with preventable maternal and newborn deaths.

Under the Maternal and Neonatal Mortality Reduction Innovation Initiative (MAMII), 172 priority local government areas across 33 states were identified as accounting for approximately 55 per cent of the country’s maternal mortality burden. The programme focuses on identifying pregnant women early, linking them to care, supporting referrals, reducing transportation barriers, improving emergency obstetric services, and strengthening follow-up and mortality review systems.

The scale of implementation has been substantial. More than 5.26 million antenatal care visits were recorded between 2023 and December 2025, alongside approximately 1.96 million skilled deliveries. Across NHSRII-supported interventions, 236 Comprehensive Emergency Obstetric and Newborn Care facilities have been established, while hundreds of primary healthcare centres in priority areas have been upgraded to provide improved maternal and newborn services.

The programme has also sought to address barriers that frequently separate women from care. About 438,000 pregnant women have been identified and registered across priority local government areas. More than 4,000 free Caesarean sections have been performed in approved facilities, approximately 15,000 women and newborns have been transported through emergency referral systems, and more than 110,000 delivery support kits have been distributed.

– Lade Bandele is a public affairs analyst based in Lagos.