Sickness of a Nation: Nigeria’s healthcare crisis, Africa’s lessons, health system we must build before more lives are lost

A three-part series by The Conscience Chronicler

Part one- When a hospital becomes a last resort

There are few things more terrifying than being poor and sick in Nigeria. You may have a job. You may have a family. You may have worked honestly for decades. You may have done everything society expects of you. Then one morning, your child develops a complication.

Or your wife begins bleeding during childbirth. Or your father suffers a stroke. Or you are diagnosed with cancer. And suddenly, the question is no longer whether Nigeria has hospitals. The question is whether you can afford to reach the right one, whether it has the right personnel and equipment, whether the medicine is available, whether the diagnosis will be timely, whether the referral system will work, and whether you can pay before the treatment begins.

For millions of Nigerians, illness is therefore not merely a medical event. It is a financial event. A family event. Sometimes a catastrophe. And occasionally, a death sentence that should never have existed. This is the uncomfortable place from which Nigeria must begin its healthcare conversation. Not with another ribbon-cutting. Not with another policy launch. Not with another impressive-looking hospital building. But with the human being who walks through the door needing care.

The numbers are already shouting

Nigeria’s health indicators tell a sobering story. The World Bank’s latest comparable data put life expectancy at about 55 years in Nigeria in 2024, compared with about 66 years in South Africa, 68 years in Rwanda and 75 years in Morocco. That is not a minor statistical difference. It represents years of human life. Years in which parents could have watched children grow. Years in which children could have known their parents.

Years in which workers could have contributed to the economy. Years in which grandparents could have remained part of their families. And behind the aggregate figures lie enormous inequalities. Kolajo, B. F. et al. did a systematic review of 62 core sources: 42 peer-reviewed studies and 20 policy documents. They identified five interconnected weaknesses: governance fragmentation, financing barriers, equity gaps, reactive preparedness, and the disconnect between evidence and policy.

Governance fragmentation appeared in 93.5% of the sources reviewed; financing barriers in 88.7%; equity gaps in 79%; reactive preparedness in 75.8%; and evidence-policy disconnection in 61.3%. That finding matters because Nigeria’s healthcare problem is not simply “we need more money”, nor is it simply “we need more doctors”, nor is it “our hospitals are bad”; it is a systems problem.

The parts are connected. Weak financing weakens facilities. Weak facilities frustrate health workers. Frustrated health workers leave. Their departure increases the workload for those remaining. Poor data leads to poor decisions. Poor decisions produce poorly targeted spending. Poor governance permits leakage. Poor accountability undermines public confidence. Low insurance coverage forces people back into direct payment.

Direct payment delays treatment. Delayed treatment worsens outcomes. Worsened outcomes increase costs. And the cycle continues. The disease is systemic.

The most expensive hospital is the one that should never have been needed

There is a fundamental idea Nigeria must rediscover: Primary healthcare is not the poor cousin of medicine. It is the foundation of the entire health system. WHO describes primary care as the foundation for universal health coverage because it provides first-contact access, continuity, coordination, comprehensiveness and people-centred care.

Strong primary care can also reduce overall health costs and improve equity. Yet Nigeria has often behaved as though healthcare development means building more impressive tertiary hospitals. Specialist hospitals carry prestige.

A new medical centre offers political visibility. There are photographs. There are commissioning ceremonies. But little political glamour goes into ensuring that the rural woman has a functioning primary health centre ten minutes from home, staffed by competent personnel, supplied with essential medicines, connected to electricity, water, laboratories, ambulances, and a functioning referral network.

Yet that woman is precisely where the health system begins. A mother should not need to travel hundreds of kilometres before discovering whether her pregnancy has become dangerous.

A child with pneumonia should not need a teaching hospital. A diabetic patient should not wait until kidney failure before entering the health system. A hypertensive patient should not discover his condition only after a stroke. The rational system prevents, detects, treats and refers early. Nigeria too often waits until the disease becomes expensive.

The financing trap

Perhaps nowhere is the dysfunction more obvious than in health financing. The African Health Observatory Partnership’s 2025 Nigeria Health Systems and Services Profile reports that out-of-pocket spending accounts for more than 75% of total health expenditure, while only about 5% of Nigerians were covered by health insurance or other prepayment/risk-pooling mechanisms in the period assessed.

It also reports a UHC social coverage index of 38.4%. That is the architecture of financial vulnerability that has become the lot of most Nigerians. Yet they keep voting for leaders they think will not abandon them to an ugly fate when sickness comes knocking! Imagine a household where income barely covers food, transport, rent, and school fees. Then illness arrives.

The family pays. Savings disappear. Assets are sold. Children may leave school. A small business may collapse. A family may borrow at predatory rates. And sometimes treatment is abandoned. Healthcare financing is, therefore, not an abstract Ministry of Finance problem.

It is an anti-poverty policy. WHO defines universal health coverage precisely around this principle: people should obtain the health services they need without financial hardship. Nigeria’s 2022 NHIA Act provides a legal platform to expand mandatory health insurance and implement the Basic Health Care Provision Fund and Vulnerable Group Fund.

The BHCPF itself was designed to finance a basic package, strengthen primary healthcare, support emergency medical treatment, public-health security and vulnerable groups. So Nigeria does not lack every necessary instrument. We lack sufficient scale, consistency, execution and accountability. That is a different problem. And therefore potentially a solvable one.

Rwanda: The power of the first door

Rwanda offers perhaps the clearest lesson in this respect. The country has deliberately placed primary healthcare and community-level access near the centre of its health strategy. WHO reports that Rwanda expanded health posts to bring essential services closer to underserved populations, while its broader reforms have combined decentralised care, community-based insurance, workforce development and targeted interventions. Rwanda’s achievements should not be romanticised.

A country of roughly 15 million people is not administratively or geographically comparable to Nigeria, with a population of more than 230 million. But that is precisely why the lesson is institutional rather than numerical. Rwanda shows that clear responsibility, community participation, primary care, health financing, and performance management can produce substantial gains even under resource constraints.

Research similarly identifies Rwanda’s community-based health insurance and performance-based financing as important lessons for Nigeria. Nigeria does not need to become Rwanda. Nigeria needs to learn from what Rwanda has done deliberately.

South Africa: Two health systems in one country

South Africa presents a different lesson. It possesses highly sophisticated private healthcare alongside a much more resource-constrained public system. That creates a warning for Nigeria. Private healthcare can demonstrate what is possible. But if the ability to pay determines access to quality, a country’s healthcare system can become deeply unequal. South Africa enacted its National Health Insurance law in 2024 as part of a long-term attempt to move toward universal access and address fragmentation.

WHO describes the reform as a major milestone, while also continuing to support primary healthcare, financing, workforce and quality reforms. Nigeria should watch that experiment carefully. The lesson is not simply “build private hospitals.” Nor is it “nationalise healthcare.” It is: create a system in which public financing can purchase quality care from both public and properly regulated private providers, according to need rather than wealth. That is where Nigeria’s emerging private sector can become an enormous asset.

Morocco: Social protection as health policy

Morocco offers another important lesson. The country has been undertaking a major expansion of health insurance under its broader social-protection reforms.

WHO documents the development of mandatory health insurance and efforts to extend coverage to the entire population, with primary healthcare remaining important in service delivery. Again, the Nigerian lesson is not to transplant Morocco’s system wholesale. It is to understand the principle: health protection must be treated as part of social protection. A citizen should not become destitute because he became ill.

The private sector is not the enemy

This is where Nigeria’s healthcare conversation sometimes becomes unnecessarily ideological. There are outstanding private hospitals in Nigeria.

Specialist centres, diagnostic laboratories, pharmacies, health-tech companies, telemedicine platforms, community clinics, mission hospitals, faith-based institutions, corporate hospitals, entrepreneurial physicians, and innovative healthcare investors exist. Initiatives such as those associated with Dr Richard Okoye and other private-sector providers demonstrate that Nigerians can build impressive healthcare institutions.

But these successes remain too often islands of excellence in an ocean of fragmentation. The answer is not to suppress them. It is to connect them. Government should become an intelligent purchaser, regulator, standard-setter and system coordinator, rather than attempting to own every bed, every ambulance and every diagnostic machine.

Imagine a properly accredited private hospital in Lagos, Port Harcourt or Abuja being paid promptly by a state or national insurance purchaser to provide defined services to eligible citizens. Imagine the same model working in underserved areas, with the government guaranteeing minimum volumes or targeted subsidies. Imagine private diagnostic laboratories connected to a national digital referral system. Imagine specialist hospitals providing teleconsultation to rural doctors. Imagine teaching hospitals sharing protocols and specialist expertise with district facilities. Imagine private pharmaceutical manufacturers linked to transparent public procurement. That is not privatisation; it is strategic integration. And that is the direction Nigeria should pursue.

The real question

We should therefore stop asking: “How many hospitals has the government built?” The better questions are: How many Nigerians can access essential care when they need it? How long does it take? How much does it cost? How often is the medicine unavailable? How many patients die because the referral failed? How many mothers and babies die before reaching competent obstetric care? How many children are lost to preventable diseases? How many health workers are available where they are needed? How many facilities meet minimum quality standards?

How many citizens are financially protected? Those are the metrics of a functioning health system. And Nigeria can build one. But it will require us to stop treating healthcare as a collection of projects. It must become a national system.

The Conscience Chronicler.

Look out for Part 2 next week.