The Policy Architecture Needed to Make Nigeria’s Universal Health Coverage Ambition a Practical Reality

The Core Components of a Nigerian Universal Health Coverage Architecture

Universal health coverage architecture in Nigeria requires four coherent components working in concert: a service delivery infrastructure that reaches every Nigerian with the primary health care services that form the foundation of any UHC system; a health financing architecture that pools health risk across the population and reduces out-of-pocket payment at the point of care; a health workforce of adequate size, quality, and geographic distribution to deliver the services that UHC promises; and a governance and accountability system that ensures the resources invested in UHC actually produce the health service access they are intended to provide.

Nigeria has made partial progress on each of these components — the National Health Insurance Authority provides the framework for health financing reform; the Basic Health Care Provision Fund provides a mechanism for primary health care delivery financing; the Community Health Influencers Promoters and Services programme provides a framework for community health worker deployment; and the Health Sector Renewal Investment Initiative provides the most recent federal government framework for integrating these components into a coherent whole.

The challenge is that these components have not been implemented with the consistency, the funding, and the accountability that moving from framework to reality requires.

Health Financing Reform as the Central UHC Policy Challenge in Nigeria

Health financing reform — transforming Nigeria’s predominantly out-of-pocket health payment model into a system of pooled risk that protects households from catastrophic health expenditure — is the central UHC policy challenge because it directly addresses the financial barrier that prevents millions of Nigerians from accessing health services when they need them.

The National Health Insurance Authority Act 2022 provided the legal framework for a more comprehensive national health insurance system than the previous NHIS covered — extending mandatory coverage to the formal sector and creating mechanisms for subsidised coverage of informal sector and vulnerable populations.

Implementing this expanded NHIA framework comprehensively — registering the entire formal sector workforce, establishing the state social health insurance schemes that will extend coverage to informal sector workers, and creating the portable benefit packages that protect coverage continuity — is the most important near-term UHC policy implementation task.

State governments that establish credible state social health insurance schemes, with adequate benefit packages and reliable financing, are building the most important UHC infrastructure investment available at the state level.

Primary Health Care Revitalisation as the Service Delivery Foundation of UHC in Nigeria

UHC cannot be built on a hospital-centric health system — it requires a primary health care system that provides first-contact care, continuous care, comprehensive care, and coordinated care to every Nigerian within accessible distance.

Nigeria’s primary health care system — the network of more than 30,000 primary health centres and the community health workers who extend the system’s reach beyond facility walls — is both the most important and the most neglected component of the UHC architecture.

Primary health care revitalisation — rehabilitating the physical infrastructure of primary health centres; ensuring reliable supply of essential medicines; deploying and supporting adequate numbers of trained health workers; implementing the Basic Health Care Provision Fund’s operational financing mechanism; and establishing the governance and accountability frameworks that ensure PHC facilities function as intended — is the service delivery foundation on which every other UHC component must rest.

Investments in health insurance and health financing reform that are not complemented by primary health care system improvement will pool resources to purchase services that the primary health care system cannot reliably provide.

Accountability Mechanisms for Universal Health Coverage Progress in Nigeria

Nigeria’s UHC progress is not currently tracked with the systematic, publicly reported accountability that a commitment of this importance requires.

The Service Availability and Readiness Assessment provides periodic data on health facility functionality, the NDHS provides periodic coverage indicators, and the National Health Accounts tracks health expenditure flows — but the integration of these data sources into a regular, publicly reported UHC progress tracking framework that creates accountability pressure for government action does not yet exist.

Developing a Nigerian UHC progress monitoring framework — specifying the coverage indicators, financial protection measures, and health outcome benchmarks that will be tracked regularly and reported publicly — would create the accountability infrastructure that UHC implementation requires.

Civil society monitoring of UHC progress — independent assessment of coverage trends, financial protection outcomes, and health equity indicators — provides the external accountability that government self-reporting cannot substitute for.

International and Domestic Resource Mobilisation for Nigerian UHC

Achieving universal health coverage in Nigeria requires a sustained increase in health expenditure — from current levels that fall significantly below the fifteen percent Abuja Declaration target — combined with a shift in how health resources are raised and pooled.

The domestic resource mobilisation strategies most important for Nigerian UHC financing — health taxes, formal sector health insurance premiums, state government health budget increases, and BHCPF capitalisation — are the primary financing strategies that Nigerian UHC architecture must build on.

International health financing — from the Global Fund, Gavi, the Global Financing Facility, and bilateral development partners — provides important complementary resources for specific health challenges and system strengthening investments.

But international financing is time-limited, conditional on government priorities that may not perfectly align with Nigerian needs, and insufficient in scale to substitute for the domestic financing mobilisation that sustainable Nigerian UHC requires.

Building the case for domestic health financing mobilisation — demonstrating the economic returns on UHC investment, the equity case for financial protection, and the governance benefits of a health-financing architecture that protects Nigerian households from medical impoverishment — is the advocacy task that Nigeria’s health policy community must lead.