People should not have to travel over 50 kilometres to healthcare facilities and when they do get to these facilities they shouldn’t have to be turned back because they don’t have cash or there are no syringes or catheters to give at least first aid.


Have you ever had the capacity to offer help but at the same time you could not because of limitations you have no control over? And if you were at the end of the receiving line, what would you think of the one who could give help but did not? In a certain sense, Nigeria’s health care service delivery presents this dilemma to both those offering services and the ones receiving them. There have been so many told stories of woes faced by health care receivers and providers that most of us are familiar with these issues.

55.5 per cent of the total population of Nigeria lives in rural areas where access to basic infrastructural facilities and organised social support services are mostly lacking. What do you do when you live in an environment where getting on a good bus to tread on a good road to reach a good health facility, is nothing but a desire deeply buried behind the pragmatism required for mere daily living; and the cost of accessing that health care is from your daily income of $1.25 (about N500 at the current exchange rate), which is neither consistent or sufficient? Research shows that in Nigeria, a country with 44.3 per cent of its population living in extreme poverty, 69 per cent of patients pay for healthcare out of pocket, with 48 per cent relying on family relatives to pay for accessing healthcare. This has led inevitably to delay in seeking and accessing care, and to catastrophic health care expenditures on families that further steep them in poverty.

Nigeria runs a ward-based healthcare delivery system, where every community should have a health outpost or primary health care centre, according to the local population, with referrals going upward. But over the years, the increasing population’s needs have not been matched by increases in service and/or structure provision, with many facilities functioning far below standard. This has, over the years, led to the increased establishment of private healthcare providers, a necessary complement, but with increased financial and other human costs.

The National Health Insurance scheme (NHIS) was established as a platform for universal healthcare coverage, but its coverage at the moment is no more than workers within the federal civil service and a percentage of the organised private sector, and the agency has been beleaguered with several challenges of implementation. The absence of universal health coverage means the burden of cost is solely borne by citizens.

Most patients who visit public hospitals come from the low to middle income bracket; where funds are initially available either out of pocket or from social support, this soon runs out in the face of increasing treatment costs. The relatives of a patient who has lost his/her life apart from being grieved are also quite angry at the system. You see, most of what is used, especially to initiate treatment and sometimes even continue it, the medical consumables and the investigations which should otherwise have been basic provisions, are paid for by the relatives of the ill; and when the patient dies, relatives, like many others, question the sense in buying needles, catheters, drips from unavailable resources when “he/she was going to die anyway”. The value of a human life is reduced to the cost of needles and a bed space; the burden of paying for healthcare, in that moment, overshadows the connection to the now dead relative. What they cannot possibly understand in their grief stricken state from the loss of family and finances, is that doctors and the public institutions they work for are just as financially constrained as they are, and are unable to provide the care they swore an oath to provide.

Doctors are often just as traumatised by this gaping lack as their patients are, having to watch a child die of anaemia from severe malaria because the parents could not afford to buy the required blood from badly maintained or non-existent blood bank services in a hospital. Also, pregnant women brought in too late to save either mother or child because the family had tried to have a home birth because they could simply not afford to pay the hospital; doctors see cases even more heart wrenching everyday. And as patients and relatives plead and beg for services on credit till they can borrow some money or rail at them for being godless and heartless when the patient takes a turn for the worse and/or dies, the doctors’ calm demeanour only lasts till they get to their badly furnished and cramped doctors lounge, where they rail as loud as the victims, against the injustice of a country that cannot cater for the healthcare needs of its citizens, a need considered fundamental.

Whatever model of health care financing is adopted – not for profit, partly for profit, and/or entirely for profit- what citizens are entitled to, in all three instances, is easy access to care without the nagging complexities of payment out of pocket, especially at the point of accessing care.


The peculiarity, to attempt a nicer coinage, of Nigeria’s economy and social order that ensures the gap between rich and poor gets wider and wider, leaves majority of the people to make hard, sometimes impossible, choices, even on simple health matters such as deciding to have a baby delivered at a health facility or at home. Up to three out of four Nigerian children go un-immunised every year because their parents do not have access to resources to either directly or indirectly access immunisation services. These hard decisions are borne by the doctors, as much as by the health seekers.

Nigeria operates a combination of health financing models from tax-based public health sector financing, household out of pocket health expenditure (which include private health insurance), private sector (donor funding), to community-based health financing (which should be the NHIS in a perfect world). Many as the models are, health coverage is still abominably low, with only about 1.7 per cent of the country’s population covered by the NHIS and less than 1 per cent covered by private health insurance. That makes a total of about 2.7 per cent, which means just about 4,860,000 Nigerians have access to some form of healthcare, leaving a huge 175,140,000 (97.3 per cent) people without healthcare coverage or access.

Although Nigeria is a signatory to the Abuja declaration, which stipulates the allocation of 15 per cent of the budget of member states of the African Union to health, the country’s health budget, 15 years on, has been consistently less than 5 per cent. It would seem there has been little will both political and economical on the part of government to consciously increase expenditure on health.

All over the world, no one country uses a singular source to finance health care. A singular dominant method, alongside others, are combined to give an effective financing model based on the prevailing socio-economic factors and needs. What we do see in these countries is that the health care delivery system is coordinated in a manner in which care is accessible to persons who would otherwise be disadvantaged by their socio-economic status.

Whatever model of health care financing is adopted – not for profit, partly for profit, and/or entirely for profit- what citizens are entitled to, in all three instances, is easy access to care without the nagging complexities of payment out of pocket, especially at the point of accessing care. Nigeria needs to develop a system that would, first of all, deliver affordable and accessible health care to all, taking into cognisance the prevailing socio economic conditions and in line with the tenets of the Universal health coverage. The business of healthcare is peculiar because it touches the centre of being and living, upon which productivity and growth is premised. It therefore requires that whatever form is decided upon should not be an obstacle in itself in the end.

People should not have to travel over 50 kilometres to healthcare facilities and when they do get to these facilities they shouldn’t have to be turned back because they don’t have cash or there are no syringes or catheters to give at least first aid.

Doctors should not have to violate the Hippocratic oath, unable to provide the care for which they have been trained and to which they have sworn.

Tavershima Adongo is a medical doctor with a strong interest in Oncology and Environmental Medicine.