Trust Renewal Blog Series
Health System Fragmentation, the Silent Barrier to Better Health Outcomes in Nigeria.
Dr Abdullahi Jibri Mohammed
Convener/Chief Executive Officer,
Initiative for Health Accountability and Transparency
Author: Trust Renewal: The Integrity Call for Better Health for All
Nigeria's health sector is often described as underfunded, understaffed, and overstretched. While all of these challenges are real, there is another problem that receives far less attention but may be undermining health system performance more than any other: fragmentation.
Across the country, governments invest in health programmes, development partners support interventions, health workers deliver services, and institutions implement policies. Yet despite these efforts, many of the expected improvements in service delivery and health outcomes remain difficult to achieve and sustain.
One major reason is that the health system often functions less like a unified system and more like a collection of separate structures operating alongside one another.
When a Health System Stops Functioning as a System
A health system performs best when its various components work together toward common goals. Financing, service delivery, workforce development, information systems, medicines, infrastructure, governance, and community engagement should function as interconnected parts of a single whole.
In Nigeria, however, these components frequently operate in silos.
The Federal Government plans and implements programmes. States pursue their own priorities. Local governments struggle with service delivery responsibilities. Disease-specific programmes maintain separate reporting systems, supervision structures, and funding arrangements. Donor-supported projects often operate through parallel implementation mechanisms.
The result is fragmentation.
Fragmentation occurs when different parts of the health sector function independently, pursue separate priorities, and fail to coordinate effectively. Instead of a seamless continuum of care, patients encounter disconnected services, institutions, and programmes.
The consequences are far-reaching.
Resources are duplicated. Accountability becomes blurred. Data systems become complicated. Referral pathways weaken. Patients experience gaps in care. Health workers become overwhelmed by multiple reporting requirements. Valuable resources are consumed by administration rather than service delivery.
Most importantly, health outcomes suffer.
The Cost of Fragmentation
The impact of fragmentation is visible throughout the health system.
A Primary Health Care facility may receive malaria commodities through one programme, immunisation support through another, nutrition supplies through a third, and reporting requirements from multiple agencies.
Health workers may spend significant amounts of time completing different forms for different programmes, even when they are serving the same patient.
A pregnant woman visiting a health facility may move through separate service streams for antenatal care, malaria prevention, HIV testing, nutrition counselling, and immunisation rather than receiving coordinated, integrated care.
Meanwhile, patients often bypass Primary Health Care facilities entirely and seek treatment directly at hospitals because referral systems are weak and confidence in frontline services has diminished.
The system spends more effort managing programmes than managing patient outcomes.
The Anti-Malaria Agency Debate: A Testb of Health System Thinking
Creating More Agencies May Not Improve Health Outcomes. The current discussions around creating a standalone Anti-Malaria Agency offer an important opportunity to reflect on how Nigeria approaches health sector reform.
There is no question that malaria remains a major public health challenge. It continues to contribute significantly to illness, deaths, lost productivity, and economic burden.
The question, however, is not whether malaria deserves attention.
The question is whether creating another agency is the best way to address it.
Malaria prevention, diagnosis, treatment, surveillance, community mobilisation, health education, and follow-up care are all activities that should naturally occur within a strong Primary Health Care system.
Yet creating a separate anti-malaria agency risk reinforcing the very fragmentation that already weakens health system performance.
A new agency would require governance structures, management teams, reporting systems, operational budgets, supervision mechanisms, monitoring frameworks, and administrative support structures.
In effect, Nigeria would be creating another vertical programme in a health sector already struggling with multiple vertical programmes.
Why More Structures May Not Mean Better Results
One of the most important lessons from global health system experience is that sustainable health improvements rarely come from multiplying institutions.
They come from strengthening systems.
Most of the functions a malaria agency would perform already exist within the health sector.
Community mobilisation is a Primary Health Care function.
Malaria diagnosis and treatment occur within health facilities.
Commodity management is part of existing logistics systems.
Health worker training already takes place through established institutions.
Health information systems already collect malaria-related data.
Creating a separate agency could therefore duplicate responsibilities already assigned to existing institutions while increasing administrative complexity and operational costs.
It may also weaken accountability.
If malaria outcomes deteriorate, who becomes responsible? The Ministry of Health? The malaria agency? The Primary Health Care agency? State governments?
When multiple institutions share responsibility, accountability often becomes diluted.
The Real Solution: Strengthen Primary Health Care
The challenge is not that malaria lacks attention.
The challenge is that the Primary Health Care system responsible for delivering malaria services remains insufficiently strengthened.
A strong Primary Health Care system should be capable of providing malaria prevention, diagnosis, treatment, health education, maternal and child health services, nutrition interventions, immunisation, family planning, and chronic disease management through an integrated approach.
When communities access comprehensive services through a well-functioning Primary Health Care system, health outcomes improve across multiple areas simultaneously.
Strengthening Primary Health Care therefore strengthens malaria control.
Strengthening Primary Health Care strengthens maternal and child health.
Strengthening Primary Health Care strengthens disease surveillance.
Strengthening Primary Health Care strengthens community trust.
Strengthening Primary Health Care strengthens the entire health system.
From Managing Programmes to Managing Outcomes
Nigeria's health sector has reached a point where the central challenge is no longer the absence of programmes, institutions, or policies.
The challenge is integration.
The future lies not in creating additional structures but in ensuring that existing structures work together more effectively.
What Nigeria needs is:
- Stronger Primary Health Care.
- Better integration across levels of care.
- Unified planning and budgeting.
- Coordinated financing mechanisms.
- Harmonised reporting systems.
- Functional referral pathways.
- Clear accountability structures.
- A stronger focus on health outcomes rather than programme activities.
The goal should be to build a health system that functions as a system.
Conclusion
Fragmentation remains one of the most significant obstacles to improved health outcomes in Nigeria. It weakens efficiency, increases costs, dilutes accountability, undermines service delivery, and reduces the impact of health investments.
The debate around establishing a standalone Anti-Malaria Agency should therefore be viewed within a broader health system context.
While malaria deserves sustained attention and investment, the long-term solution lies not in creating another bureaucracy but in strengthening the Primary Health Care system that should serve as the foundation of malaria control and the foundation of the national health system itself.
Nigeria's greatest health gains will come not from building more structures, but from making the existing system work as one.
Upcoming Release Alert!
Primary Health Care Renaissance Nigeria: Strengthening the Foundation of the National Health System
Secure your copy now through pre-order.
Contact via WhatsApp: +2349133488988
Email: ihatnigeria@gmail.com
