FOUNDATION AND GATEKEEPER IN CRISIS: THE STATE OF PRIMARY HEALTH CARE IN NIGERIA
By Dr. Abdullahi Jibril Mohammed
Convener/CEO,
Initiative for Health Accountability and Transparency
Author, Trust Renewal: The Integrity Call for Better Health for All
Introduction: The Foundation of the Health System Under Pressure
Primary Health Care (PHC) occupies a unique and indispensable position within every well-functioning health system. It is the foundation upon which all other levels of healthcare are built and the gateway through which individuals, families, and communities access health services.
Designed to be the first point of contact between people and the health system, PHC provides preventive, promotive, curative, rehabilitative, and referral services close to where people live and work.
When Primary Health Care functions effectively, it addresses most health needs within communities, reduces unnecessary demand on hospitals, promotes equity, and improves health outcomes. When it fails, however, the consequences extend far beyond individual facilities and affect the entire health system.
For decades, Nigeria has recognised PHC as the cornerstone of national health development. Since the adoption of the Primary Health Care approach following the Alma-Ata Declaration and its incorporation into national health policies, PHC has been expected to serve as the principal mechanism for achieving equitable access to healthcare and improving population health outcomes.
Yet, despite its importance and decades of reform efforts, Primary Health Care in Nigeria remains under significant pressure. The gap between policy aspiration and operational reality continues to widen, raising important questions about the ability of PHC to fulfil its intended role within the health system.
The Original Vision of Primary Health Care
The vision of Primary Health Care was never limited to the provision of basic medical services. It was conceived as a people-centred approach to health development that places communities at the centre of healthcare planning and delivery.
PHC was intended to bring healthcare closer to the people, ensuring that common health problems could be addressed quickly, affordably, and effectively without requiring citizens to travel long distances or incur excessive costs. It was expected to promote disease prevention, improve maternal and child health, support immunisation, encourage health education, and facilitate early diagnosis and treatment of illnesses.
Equally important was its role as the gateway into the broader health system. PHC was designed to resolve most health needs at the community level while referring more complex cases to secondary and tertiary facilities. This arrangement was intended to create an efficient and coordinated continuum of care.
From Cornerstone to Crisis
Despite substantial investments in health infrastructure, workforce development, and service delivery programmes, many Primary Health Care facilities across Nigeria continue to operate below expected standards.
In numerous communities, PHC facilities exist physically but struggle to deliver the range and quality of services expected of them.
Essential medicines may be unavailable. Equipment may be non-functional.
Health workers may be insufficient in number or inadequately supported.
Funding for routine operations may be inadequate.
Supervision and accountability mechanisms may be weak.
As a result, the existence of a facility often does not guarantee the availability of quality healthcare services.
The challenge confronting PHC is therefore not simply one of infrastructure. It is a challenge of functionality. A facility can only fulfil its purpose when the systems, resources, personnel, and support structures required for service delivery are consistently available and operational.
The Gatekeeper No Longer Guards the Gate
One of the most important functions of Primary Health Care is its role as the gatekeeper of the health system.
In an efficient healthcare system, patients first seek care at the primary level, where most health conditions can be managed. Only cases requiring specialised attention are referred to higher levels of care. This arrangement promotes efficiency, reduces costs, and ensures that specialist services are reserved for patients who genuinely require them.
In Nigeria, however, this gatekeeping function has weakened considerably.
Many citizens no longer view PHC facilities as capable of adequately addressing their health needs. Consequently, patients increasingly bypass primary care facilities and seek care directly from secondary hospitals, tertiary institutions, private clinics, pharmacies, patent medicine vendors, and other informal providers.
This trend has serious implications for health system performance.
Hospitals become overcrowded with conditions that could have been managed at the primary level. Healthcare costs increase.
Referral pathways weaken.
Continuity of care is disrupted.
Specialist resources become overstretched.
When the gatekeeper loses public confidence, the entire health system becomes less efficient.
The Difference Between Access and Functionality
For many years, efforts to strengthen Primary Health Care have focused heavily on expanding infrastructure and increasing the number of facilities. While these investments are important, they often create a misleading impression that physical presence alone guarantees access to healthcare.
Access is not simply about the existence of a building.
A health facility only provides meaningful access when it consistently delivers quality services that meet the needs of the population. Communities require health workers, medicines, diagnostic services, reliable operating hours, referral support, and respectful treatment. Without these elements, a facility may exist physically while remaining functionally inaccessible.
This distinction between physical presence and operational functionality is critical to understanding why many PHC investments have not produced the expected improvements in service utilisation and health outcomes.
The Human Consequences of Weak Primary Health Care
The consequences of weak Primary Health Care extend far beyond statistics and performance indicators.
They affect the daily lives of millions of Nigerians.
They affect the pregnant woman who must travel long distances because her nearest facility lacks skilled personnel. They affect the child whose illness progresses because early diagnosis was unavailable. They affect the elderly patient unable to access routine treatment for chronic diseases. They affect families who face financial hardship because affordable primary care services are inaccessible.
Every weak PHC facility represents missed opportunities for disease prevention, early intervention, health promotion, and community wellbeing.
The burden of PHC failure is ultimately borne by individuals, families, and communities.
Why Primary Health Care Matters More Than Ever
The importance of Primary Health Care has become increasingly evident as countries pursue Universal Health Coverage and stronger health security systems.
International experience consistently demonstrates that countries with strong primary care systems achieve better health outcomes, lower healthcare costs, greater equity, and improved population health.
Strong Primary Health Care allows health problems to be addressed early before they become severe and costly. It supports preventive services, improves continuity of care, strengthens disease surveillance, and creates stronger links between communities and the health system.
For Nigeria, strengthening PHC is not simply a healthcare priority. It is a national development imperative.
Without functional Primary Health Care, efforts to achieve Universal Health Coverage, improve maternal and child health, reduce preventable deaths, and strengthen health security will remain difficult to achieve.
Beyond Revitalisation: The Need for a PHC Renaissance
Nigeria's challenge today extends beyond revitalising individual facilities.
What is required is a comprehensive Primary Health Care renaissance.
This renaissance must address the structural and systemic factors that determine PHC performance. It must strengthen governance and accountability. It must improve workforce capacity, motivation, and supervision. It must ensure sustainable financing and reliable supply chains. It must strengthen referral systems and improve service quality. It must promote community ownership and participation.
Most importantly, it must restore public confidence in Primary Health Care as the trusted first point of contact within the health system.
Without trust, utilisation will remain low. Without utilisation, PHC cannot perform its gatekeeping role. Without effective gatekeeping, the broader health system will continue to experience inefficiencies and poor outcomes.
Conclusion: The Future of the Health System Will Be Determined at Its Foundation
The future of Nigeria's health system will not be determined primarily in teaching hospitals, specialist centres, or policy meetings. It will be determined in the thousands of Primary Health Care facilities that serve as the frontline of healthcare delivery.
These facilities represent the foundation upon which the entire health system depends.
If the foundation remains weak, health system performance will continue to suffer. If the foundation becomes strong, functional, accountable, and trusted, it can transform healthcare delivery and improve the lives of millions of Nigerians.
Today, the foundation is under strain and the gatekeeper is struggling. Yet this crisis also presents an opportunity. By confronting the challenges that have weakened Primary Health Care and committing to meaningful reform, Nigeria can restore PHC to its rightful place as the foundation of a resilient, equitable, people-centred, and high-performing health system.
The journey towards better health outcomes begins at the foundation. The future of healthcare in Nigeria depends on how successfully that foundation is rebuilt.
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