From a public health perspective, Nigeria is in two places at once. Acute infectious diseases common in underdeveloped societies have not vanished, while chronic non-communicable diseases (NCDs), once associated with Western societies, have become predominant.
A changing demographic makeup is one of several factors driving this transition. A woman who might have died in childbirth survives the birth of five children; in her fifties, she confronts cervical cancer. A child who in decades past might have died from a vaccine-preventable disease now reaches middle age, and, because of changes in risk factors such as diet and lifestyle—another driver of this transition—he encounters type 2 diabetes and grapples with the new health and economic costs of living with a long-term illness.
Even as NCDs currently account for around 29% of total deaths in Nigeria, the infectious disease burden remains high. The WHO estimates that one quarter of Nigeria’s population contracted malaria in 2021. Cholera and tuberculosis outbreaks still ravage communities nationwide. Four of the five neglected tropical diseases that can be tackled through mass drug administration (MDA) are endemic in Nigeria. Despite these realities, our health systems have not adopted balanced policies that suitably confront the changing patterns of disease.
The 2014 National Health Act was a commitment to investing in the health system to achieve universal health coverage. Under the Act, the Basic Health Care Provision Fund (BHCPF) covers a limited suite of health services known as the Basic Minimum Package of Health Services (BMPHS), which includes maternal health, immunisation services and the treatment of childhood illnesses like diarrhoea and pneumonia, as well as screening and basic outpatient care for type 2 diabetes and hypertension.
While many PHCs provide key maternal and child health services, they are ill-equipped to manage NCDs. The WHO’s 2018 NCD Country Profile for Nigeria revealed that primary health care centres are unprepared to handle cardiovascular disease (CVD). The Country Profile also indicated that no PHC facilities reported offering CVD risk stratification or guidelines, while essential medicines and equipment for NCD treatment were largely unavailable. No PHC could provide information on the availability of drug therapy and counselling to prevent heart attacks and strokes.
Regional disparities compound the issue. Facility readiness for NCD care is higher in Nigeria’s Southern region compared to the North. Lagos, FCT and Rivers rank highest in readiness while Katsina and Gombe rank among the lowest.
Nearly 40% of Nigerians live with hypertension, the top risk factor for stroke and coronary heart disease. But with limited routine screening and subtle symptoms, it can go undiagnosed for years; patients arrive at health facilities in advanced stages of the disease.
In rural communities, where specialists are scarce, patients leave PHCs with referral slips and little relief. BHCPF coverage can extend to secondary facilities, but mainly for services defined within the minimum package: screening, diagnosis and disease management. Yet it is often insufficient to cover prolonged costs associated with chronic illness. Although the BHCPF recognises insulin as an essential medicine for managing diabetes, a coronary heart disease risk equivalent, funding and supply chain constraints mean it is often unavailable.
Tertiary facilities offer more specialised care, but a high patient burden and infrastructure challenges impede patient outcomes. The shortage of radiotherapy machines illustrates the infrastructure gap. Despite needing at least 280 machines to serve its current population of cancer patients, Nigeria has fewer than 10 consistently functional machines across tertiary facilities. These infrastructural and diagnostic challenges force patients to seek care in private facilities that demand high out-of-pocket costs.
State Matters
Across states, disparities in health spending are evident. Although the overall size of federal and state allocations determines the total resources available, decisions on how to fund primary health care lie with the states.
The Nigeria Health Commissioners Forum and Tekano Group analysed state budgets for 2022–2024, noting that during this timeframe, the average share of state health expenditure declined. Although overall state fiscal expenditure surged, state health spending showed wide divergence, ranging from less than 50 cents per capita to US$5.90. This variance was not determined solely by fiscal strength, as the highest-spending states were not necessarily those with the largest resource allocations, but those that prioritised health in their state budgets.
Bauchi State, for instance, with an overall resource allocation of less than US$50 per capita, dedicated over 14% of this share to health. In comparison, Bayelsa State, which received more than three times Bauchi’s overall resource allocation, devoted only around 4% of this to health.
One of the reasons Nigeria’s maternal health burden remains high, in spite of the donor funds invested, is rural–urban, state and zonal access disparities in service availability. A woman living in an urban area is twice as likely to give birth in a health facility as a woman living in a rural area, where distance, transportation, family and traditional beliefs can pose real barriers to skilled birthing care. This disadvantage extends to the child: the infant mortality rate in urban areas is 53 per 1,000 live births; in rural areas, this figure swells to 77 per 1,000 live births.
Ramping up local financing
Over the past few decades, donor funding and external aid have largely financed disease prevention and management. However, in 2025 and 2026, at a time when longtime donors were visibly scaling back aid, the Nigerian government raised its healthcare investment through a 60% budget increase and the expansion of the BHCPF, which is projected to reach ₦298 billion by 2026. Substantial international partnerships, such as US$515 million in targeted US assistance and a US$500 million World Bank credit facility, also continue to bolster domestic efforts.
In late 2025, a circulating “Red Letter” announced that the Health Minister, Muhammad Ali Pate, had released ₦32.9 billion to the BHCPF, primarily urging community ownership and accountability for rural PHCs. However, domestic budget lines do not disaggregate clear line items for NCD prevention interventions, and below the tertiary and secondary health systems, health worker capacity to detect NCDs such as heart disease, cancer, and diabetes (types 1 and 2) is nearly non-existent.
Despite these increased investments, Nigeria lags behind other low-income countries by nearly 40 percentage points in health spending and out-of-pocket medical expenditure. An even more disturbing systemic issue is that high budgetary allocations do not always translate to the actual release of funds.
Why do funds get stuck?
A critical barrier to bridging NCD health inequalities is ensuring that funds reach frontline facilities. In what is known as the “paper budget phenomenon,” large sums are appropriated for capital health projects, with only minimal funds reaching health facilities. A February 2026 report reveals that while ₦218 billion was allocated for health projects in 2025, only ₦36 million was released. This amounts to less than 1%: 0.02%, to be exact.
This inefficiency points to a fragmented stakeholder landscape. The Federal Ministry of Health blames the “cash planning system” of the Accountant-General’s office for delays. Health funds reach states through three primary gateways: the National Primary Health Care Development Agency (NPHCDA), the National Health Insurance Authority (NHIA) and the Nigeria Centre for Disease Control (NCDC). Although the NPHCDA gateway is designed for direct transfer, some states still experience delays. Funds can sit in state accounts for months before PHCs receive them.
In 2025, records in states like Kano showed that BHCPF releases for the first two quarters did not reach facilities until August. In some states, funding makes little difference. In Ogun State, where over ₦1.4 billion was received between 2023 and 2025, it is impossible to distinguish PHCs funded under the BHCPF from those that received no funding, as facilities are short-staffed, poorly equipped, lack safe infrastructure, and some centres are abandoned.
Partners, like Gavi and the World Bank, are taking a firmer stance, refusing to release funds without clear governance milestones. This is known as the Program-for-Results (PforR) model. It places a unique focus on results and withholds disbursements until institutions can prove that they have achieved specified results.
Far-reaching consequences
This disconnect carries more than logistical consequences. Hospital upgrades are delayed. Health workers are denied basic tools. Lives are lost. For women, this gap translates into a shortage of emergency obstetric care; for young medical professionals, it means seeing no future in under-equipped facilities, fuelling brain drain. Funding alone is insufficient without a parallel commitment to accountability in disbursement processes.
NCD rates are rising, and they come with a lifetime burden. These conditions are not absent from Nigeria’s most remote rural communities, yet domestic and donor funding still focuses mainly on infectious diseases. Without fiscal policies that prioritise prevention, crushing health care costs will impact individuals forced to bear out-of-pocket expenses and national health systems.
Preventive health is foundational to the health system. Beyond the health benefits, it reduces economic losses from low productivity and absenteeism. Public health advocacy campaigns often pursue policy shifts and strong provisions that can be implemented at the state and local levels. Many policy successes, however, remain as elite-level achievements that never translate to real systemic shifts. Strong implementation, tied to political will, is often the missing link.
Recommendations
Bridging inequalities will centre on expanding essential services under BHCPF 2.0. The government’s transition to BHCPF 2.0, which aims to expand direct financing from 8,000 to 13,000 facilities, must explicitly include basic NCD management, such as blood pressure medication, alongside its successful provision of emergency obstetric care to women.
To address bottlenecks to funds reaching communities, prevention-focused policies, such as taxes on sweetened beverages, alcohol and tobacco, can directly finance community-level interventions. Mass hypertension, breast and cervical cancer screenings, prostate exams, and school-based nutrition education, for instance, can shift the focus from expensive tertiary cures to cost-effective community prevention.
Resources must be made available, whether through state-run mobile clinics that traverse LGAs to reach hard-to-reach communities at scheduled outreach interventions, or more fully equipped frontline facilities. Strong, government-backed public awareness initiatives will counter public viewpoints that prevention costs more than treatment and normalise behaviours such as hygiene and healthy dietary practices that can keep both communicable and non-communicable diseases at bay.
Accountability must be treated as a prerequisite for investment, not an afterthought. This requires greater state-level oversight alongside community-led monitoring. Citizen-led budget tracking, where local communities verify if drugs actually arrive at their PHC, can force leakages to close organically.
Introducing financial incentives that reward proven impact can also close inequality gaps. In 2025, the Nigeria Governors’ Forum named Yobe the best-performing state for primary healthcare, citing rigorous data quality and community engagement. This award secured the state $1.2 million in performance rewards. Accountability not only prevents waste but also attracts more funding. To scale this success, the government must require the publication of financial reports on BHCPF use from the start and set transparency precedents to guide future programmes.
The HOPE-GOV Program (2025–2026) offers a model: $480 million is disbursed to states only after achieving specific Disbursement-Linked Indicators, such as producing audited financial statements or improving rural health worker deployment. By ensuring that allocated funds are released only upon proof of impact, this model can end the cycle of wasted paper budgets, create a fiscal environment where sorely needed funds can finally reach facilities—and people—at the last mile first, and meaningfully reduce health inequalities across Nigeria.
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Omei Bongos-Ikwue is a health communications and public health advocacy specialist at Gatefield Nigeria. She is the spokesperson of the National Action on Sugar Reduction (NASR) Coalition, through which she has led national campaigns for sweetened beverage taxes and NCD prevention policy. A graduate of Oral Roberts University, her work spans health financing advocacy, tobacco control, and NCD prevention across Nigeria and West Africa.
