IS THE THREE-TIER HEALTH SYSTEM STRUCTURALLY WEAKENING PRIMARY HEALTH CARE?
The System Design Question Nigeria Must Confront
By Dr Abdullahi Jibril Mohammed,
Public Health Physician and Health System Consultant
Convener/CEO, Initiative for Health Accountability and Transparency.
Introduction: When Structure Becomes Destiny
For decades, discussions about Nigeria’s health sector have focused heavily on funding gaps, workforce shortages, infrastructure deficits, medicine stock-outs, and governance failures. These are all important challenges. Yet beneath them lies a deeper and often insufficiently discussed issue: whether the very structure of Nigeria’s health system governance is itself weakening Primary Health Care (PHC).
This is not merely a constitutional or administrative debate. It is fundamentally a question of health system design. It asks whether the architecture through which healthcare responsibilities are distributed across the Federal, State, and Local Government levels is supporting or undermining the functionality of PHC as the foundation of national health development.
On paper, Nigeria’s three-tier arrangement appears orderly and decentralised. The Federal Government oversees tertiary institutions and national policy. State Governments manage secondary healthcare services. Local Governments are expected to oversee Primary Health Care.
In theory, this structure should bring healthcare closer to communities while ensuring layered coordination across the system.
In practice, however, the reality has often been different.
Rather than functioning as one integrated health system organised around the needs of citizens, the arrangement frequently behaves like three loosely connected systems operating in parallel. The consequences of this fragmentation are felt most severely at the PHC level, which should ordinarily serve as the entry point, coordinating centre, and foundation of the entire health system.
The Structural Contradiction at the Heart of PHC
One of the deepest contradictions within Nigeria’s health system is that the level of care expected to carry the largest burden of service delivery is assigned primarily to the weakest and least institutionally supported tier of government.
Primary Health Care is expected to provide preventive services, maternal and child healthcare, immunisation, disease surveillance, health promotion, community engagement, management of common illnesses, and referral coordination for millions of Nigerians. Yet the Local Government structures responsible for PHC in many parts of the country often face serious fiscal, administrative, technical, and managerial limitations.
Funding is frequently unstable and unpredictable. Governance systems remain weak. Technical oversight is inconsistent. Workforce management suffers from fragmentation and political interference. Accountability mechanisms are underdeveloped. Supervision systems are often weak or irregular.
This creates a dangerous mismatch between responsibility and institutional capacity.
PHC facilities become underfunded and poorly supported. Rural and underserved communities experience severe workforce shortages. Essential medicines become inconsistently available. Data systems weaken. Community participation declines. Referral coordination deteriorates.
Over time, the very foundation upon which the national health system depends becomes structurally unstable.
The irony is profound: the level of care expected to prevent disease, reduce hospital burden, promote equity, and improve population health outcomes is often the least institutionally protected part of the system.
Fragmentation Instead of Functional Integration
One of the clearest consequences of the three-tier structure is institutional fragmentation.
Instead of functioning as one coordinated continuum of care, the Nigerian health system often operates through administrative silos.
Federal institutions pursue national programmes and vertical interventions. State systems manage hospitals and secondary care structures. Local Government PHC systems operate with varying levels of autonomy and coordination. Development partners frequently establish parallel programme systems. Health insurance schemes introduce additional operational layers.
The result is a fragmented ecosystem where coordination becomes difficult and accountability becomes blurred.
Patients experience this fragmentation directly in their everyday journeys through the health system.
A mother may take her child to a PHC facility for immunisation but encounter major obstacles when referral to higher-level care becomes necessary. Clinical records may not follow the patient across facilities. Referral feedback mechanisms are weak or absent. Diagnostic investigations are unnecessarily repeated. Patients themselves become the coordinators of their own fragmented care pathways.
Continuity of care suffers.
Inefficiencies increase.
And gradually, trust begins to erode.
This fragmentation affects not only service delivery but also planning, financing, supervision, workforce deployment, monitoring, and accountability.
A system divided administratively often becomes divided functionally.
Decentralisation Without Sufficient Capacity
The problem is not decentralisation itself.
Many countries operate decentralised health systems successfully. Decentralisation can improve responsiveness, local participation, contextual decision-making, and community ownership when properly designed and adequately supported.
The challenge in Nigeria lies in decentralising responsibilities without sufficiently strengthening the operational systems required to support those responsibilities.
Authority is distributed, but financing systems remain weak. Workforce structures remain fragmented. Accountability mechanisms remain inconsistent. Coordination systems remain underdeveloped. Technical support systems remain uneven.
This produces a recurring problem of blurred accountability.
When PHC facilities perform poorly, responsibility becomes difficult to clearly assign. Federal agencies point toward State Governments. State Governments refer to Local Government responsibilities. Local Governments cite inadequate funding and limited authority. Development partners focus on programme-specific outcomes. Facility managers operate within multiple overlapping reporting systems.
The result is a system where accountability becomes diffused across institutions.
And when accountability becomes diffused, implementation discipline weakens.
Problems persist because no single structure possesses both full responsibility and full operational authority.
PHCUOR: An Attempt to Correct Structural Fragmentation
The introduction of Primary Health Care Under One Roof (PHCUOR) represented an important acknowledgement that fragmentation was weakening PHC governance and performance.
PHCUOR sought to unify PHC management systems at the State level through the establishment of State Primary Health Care Development Agencies and Boards. The objective was to harmonise planning, workforce management, supervision, financing coordination, monitoring, and service delivery oversight within PHC systems.
This was a significant governance reform.
In several states, PHCUOR improved coordination and strengthened aspects of PHC governance. It created clearer institutional structures and reduced some forms of duplication.
Yet implementation has remained uneven across the country.
In many settings, integration remains partial. Institutional overlaps persist. Political and administrative tensions continue beneath the surface. Most importantly, PHCUOR primarily addressed governance fragmentation within PHC itself, but did not fully resolve the broader fragmentation between PHC, secondary care, and tertiary care across the entire health system architecture.
The larger structural challenge therefore remains unresolved.
The Missing WHO District Health System Logic
Historically, the World Health Organization promoted the district health system model as a framework for functional integration.
Under this approach, district hospitals, PHC facilities, referral systems, workforce management, disease control programmes, planning systems, and public health functions operate within unified district-level management systems.
Such systems encourage coordinated planning, resource pooling, integrated supervision, functional referral systems, shared accountability and continuity of care
Nigeria’s operationalisation of decentralisation evolved differently.
The separation of PHC under Local Governments, secondary care under State Governments, and tertiary care under Federal institutions gradually produced vertical institutional silos. These silos weakened referral integration, fragmented workforce coordination, complicated local planning systems, and undermined continuity across levels of care.
The system became administratively segmented in ways that reduced functional coherence.
What emerged was not simply decentralisation, but fragmentation without sufficient integration.
Why PHC Suffers Most Within Fragmented Systems
Primary Health Care suffers disproportionately within fragmented systems because PHC depends fundamentally on coordination, continuity, prevention, community trust, and long-term relationships between providers and populations.
Unlike episodic hospital-based care, PHC requires sustained integration across multiple levels of the health system.
PHC cannot function effectively where, referral systems are weak, workforce management is inconsistent, data systems are disconnected, financing is unstable, accountability is fragmented and community engagement is weak
When these conditions persist, PHC gradually loses its gatekeeping role.
Patients begin bypassing PHC facilities in favour of secondary hospitals, private providers, pharmacies, informal care, or self-medication.
This creates cascading consequences:
Preventive services weaken
Higher-level hospitals become overcrowded
Out-of-pocket spending increases
Health inequities deepen
System efficiency declines
Most importantly, public confidence in frontline care deteriorates.
From Structural Fragmentation to a Trust Crisis
Over time, structural fragmentation evolves into a trust crisis.
Citizens may not fully understand the constitutional arrangements behind service failures, but they experience the consequences directly through delayed care, failed referrals, absenteeism, medicine shortages, poor responsiveness, and inconsistent service quality.
What people ultimately judge is not the administrative structure itself.
They judge whether the system works when they need it.
A PHC facility may physically exist within a community, yet fail functionally because the larger system surrounding it is poorly coordinated.
Repeated experiences of dysfunction gradually shape public perception.
Patients begin to lose confidence in PHC facilities. Utilisation declines. Preventive care uptake weakens. Communities increasingly seek care elsewhere.
In this way, structural weaknesses become behavioural realities.
And behavioural realities eventually become trust crises.
Does Nigeria Need Structural Rethinking?
This raises a difficult but necessary national question:
Does Nigeria require deeper structural rethinking in the organisation of its health system?
The issue is not whether federalism should be abandoned. Rather, the question is whether existing governance arrangements are sufficiently designed to support an integrated, patient-centred, and high-performing PHC system.
There may be a need to rethink:
Operational integration between PHC and secondary care
Unified subnational health service models
District-style integrated health systems
Workforce coordination systems
Referral architecture
Shared health information systems
Financing integration
Accountability mechanisms built around functional performance rather than administrative separation
The focus should shift from protecting bureaucratic boundaries toward ensuring coherent patient-centred care.
Because patients do not experience healthcare according to constitutional tiers.
They experience healthcare as one system.
Beyond Administrative Tiers Toward Functional Integration
Ultimately, health systems should not be judged solely by constitutional arrangements or institutional boundaries.
They should be judged by whether they deliver accessible care, coordinated services, responsive systems, accountable governance, continuity of care, high-quality outcomes and public trust
A structurally fragmented system may produce policies, facilities, projects, and programmes, yet still fail to deliver coherent patient-centred healthcare.
Nigeria’s PHC future may therefore depend not only on additional financing, infrastructure expansion, or workforce recruitment, but also on deeper structural and functional integration across the health system.
Because Primary Health Care does not merely require more institutions.
It requires a system that works together.
