85% PHCs in distress, without doctors despite N55.4b budget in 4yrs

• Only 8,309 facilities supported by BHCPF nationwide in 2025
• Bauchi has 5 doctors to 159 patients, Benue: 3 to 111, FCT: 3 to 58 PHCs
• Only 51 per cent of PHCs have electricity
• 38 per cent facilities lack water, 40 per cent without laboratory
• Experts blame weak local autonomy, poor state prioritisation

Despite N55.44 billion in disbursements to states’ primary healthcare centres between 2022 and the first half of 2025, Nigeria’s primary healthcare system remains under severe strain, with experts warning that thousands of Nigerians continue to face avoidable health risks because these facilities lack the personnel, infrastructure and basic resources needed to provide care.

Concerns persist even as Nigeria’s health budget rose by about 60 per cent and the Basic Health Care Provision Fund (BHCPF) is projected to reach N298 billion by the end of 2026.

Notwithstanding the increment in budgetary allocation, stakeholders say these allocations may not automatically translate into stronger primary healthcare delivery because delayed releases, weak accountability mechanisms and uneven spending priorities across states continue to undermine impact.

Data obtained exclusively by The Guardian showed that total disbursements to states under the BHCPF through the National Primary Health Care Development Agency (NPHCDA) gateway between 2019 and the first half of 2025 stood at about N82.69 billion.

A breakdown of the figures showed a steady upward trend over the period. Between 2019 and 2020, N13.5 billion was disbursed through the NPHCDA gateway. Allocations rose slightly to N13.7 billion in 2021 before increasing to N19.87 billion in the 2022/2023 disbursement cycle. Funding reached its highest level in 2024 at about N21.5 billion, while disbursements for the first and second quarters of 2025 had already reached N14 billion.

Within the last four years alone, from 2022 to the first half of 2025, cumulative disbursements stood at N55.44 billion.

Further analysis showed that Kano and Katsina were among the states with the highest cumulative allocations during the period. Kano received about N4.70 billion, while Abia and Anambra received about N2 billion and N2.9 billion, respectively.

However, health experts cautioned that the rising allocations remain inadequate when measured against the scale of need in Nigeria’s primary healthcare system. Nigeria delivers primary healthcare services through primary health centres, basic health clinics and comprehensive health centres, with more than 35,000 facilities spread across 8,810 wards in 774 local government areas.

Kano illustrates the scale of the challenge. The state has about 484 wards across 44 local government areas and more than 1,200 primary healthcare facilities. In 2024, Kano received N1.2 billion through the NPHCDA gateway. A breakdown of the allocation showed that each facility received roughly N1 million for the entire year.

However, NPHCDA told The Guardian that only about 8,309 facilities nationwide were supported under the BHCPF programme in 2025. The agency said coverage is expected to increase to 13,512 facilities in 2026.

According to the agency, funds are released to facilities quarterly. Under the current arrangement, high-volume primary healthcare centres receive N800,000 per quarter, while low-volume facilities receive N600,000 per quarter. Before the revision introduced last year, facilities received between about N300,000 and N750,000 quarterly.

The agency said the funds are meant to support basic service delivery needs, including power supply, minor repairs, consumables, staffing support and maintaining a clean and functional environment for patients.

Survey reveals grim picture
Yet, a 2025 Primary Health Care Systems Survey by BudgIT pointed to deep structural weaknesses across the country. The accountability report assessed and tracked 5,099 primary healthcare facilities across the 36 states and the Federal Capital Territory.

The report found that 85 per cent of facilities had no doctor or physician, 61 per cent had no nurse or midwife, 38 per cent lacked access to water, 40 per cent had no functional laboratory, while only 51 per cent had electricity.

Electricity coverage was especially poor in some states. In Zamfara, only 31.7 per cent of facilities had electricity, while Borno recorded 36.2 per cent. In Ebonyi, only 42 of the state’s 147 primary healthcare centres were electrified.

At the national level, the report said 30,236 medical personnel currently serve the 5,099 facilities surveyed, translating to an average of 5.93 health workers per facility. It, however, noted that the national average masked major disparities across states and professional categories.

A breakdown of the workforce showed that doctors accounted for only 1,322 personnel, representing 4.37 per cent of the total workforce. This means nearly three in four primary healthcare centres operate without a physician. Nurses and midwives numbered 10,810, representing 35.75 per cent, while community health extension workers stood at 18,103, accounting for 59.88 per cent of the workforce.

The report also highlighted severe shortages in several states. Benue had only three doctors across 111 facilities, Bauchi had five doctors across 159 facilities, while Kogi had seven doctors across 179 facilities. In the Federal Capital Territory, only three doctors were found to be serving 58 primary healthcare facilities.

What we are doing differently despite challenges
Speaking in an interview with The Guardian, Aina explained that the bulk of the funds under the BHCPF gateway are channelled directly to primary healthcare facilities, with about 85 per cent going to service delivery at the facility level, while smaller proportions are retained for coordination, oversight and supervision at federal and state levels.

He noted that adjustments had been made to strengthen oversight, with about eight per cent now allocated between the agency and ministerial oversight functions, following earlier lower deductions.

He further explained that although funds are released to states through the treasury single account system, they ultimately reach facility bank accounts only after health centres submit quarterly work plans detailing planned expenditure, which must be reviewed and approved before disbursement. He said this was intended to reduce waste and improve accountability.

He stressed that accountability mechanisms had been strengthened through quarterly verification visits by local government and state officials, as well as monitoring by performance and financial management officers. He disclosed that these officers recovered about N59 million in mismanaged funds over the past year following discrepancies identified during audits and field verification.

The NPHCDA chief executive also said the agency was increasingly deploying digital tools to easily detect misallocation of funds and improve real-time oversight. He said sanctions for financial infractions varied depending on severity, ranging from refunds of misused funds to transfers or dismissal of responsible personnel, implemented in collaboration with state and local government employers.

Although he emphasised that utilisation of PHC services had increased significantly, rising from about 29 million per quarter in mid-2023 to over 46 million per quarter in the third quarter of 2025, Aina acknowledged that funding remains insufficient to fully meet Nigeria’s primary healthcare needs, describing the system as one that has suffered chronic underinvestment for decades.

He said ongoing reforms, increased budgetary allocations and federal-state collaborations were gradually closing the gap, but stressed that full adequacy had not yet been achieved.

Stakeholders react
According to stakeholders, the figures show that while federal funding has increased, money alone will not resolve Nigeria’s longstanding gaps in service delivery.

They argued that the effectiveness of federal disbursements is shaped largely by how states prioritise health in their own budgets, as well as the continued non-implementation of full financial and administrative autonomy for local government councils, which directly oversee primary healthcare centres.

A 2024 Supreme Court ruling declared it illegal for state governments to hold or control funds allocated to local governments. The decision was intended to end the State Joint Local Government Account system and mandate direct allocation payments to local councils to curb state-level financial manipulation.

Experts maintained that the current centralised structure has weakened accountability and limited the ability of council authorities to respond to the specific needs of primary healthcare facilities under their supervision.

They warned that until governance bottlenecks are addressed, persistent shortages of health workers, essential commodities, infrastructure and basic services are likely to continue despite billions of naira committed to the sector.

A public health expert and Technical Director of the Network for Health Equity and Development, Dr Jerome Mafeni, insisted that funding alone does not explain the persistent weaknesses in the system and added that PHCs, which ought to form the foundation of the health system, have not received the level of attention it deserves.

Speaking in an interview with The Guardian, Mafeni said that money can never be enough for a population as large as Nigeria’s and for the level of demand placed on the healthcare system. However, he argued that the larger problem lies in how available resources are utilised.

He said funds deployed through different gateways, including the Basic Health Care Provision Fund, the National Health Insurance Authority and contributions from development partners, are not being optimally utilised because the current governance structure does not promote efficiency and effectiveness.

Mafeni explained that the system remains overly centralised, with strong control by state structures, creating a tendency to treat all primary healthcare facilities across local governments as though they face identical realities. He argued that centralised planning has created multiple avenues for leakage and inefficient use of scarce resources, adding that local facilities should be given enough flexibility to determine priorities based on their population, location and peculiar circumstances.

Mafeni also pointed to shortages of drugs, equipment, commodities, electricity, water and basic operational support as factors that weaken service delivery.

He said many patients arrive at health facilities expecting affordable and timely care but are instead asked to purchase essential items themselves.

According to him, once patients are forced to buy almost everything needed for treatment, they begin to question the value of visiting such facilities and often seek alternatives elsewhere.

Mafeni said the disbursed funds over the years could have made a meaningful impact if facilities had sufficient autonomy to deploy resources according to their direct needs.

He maintained that while resources may never be enough, more effective and independent utilisation at the facility level would have improved access to drugs, commodities, equipment and more conducive environments for both patients and healthcare workers.

He argued that when local governments control recruitment, incentives, drugs, commodities and operational support for facilities under their watch, citizens are better placed to monitor performance and demand results.

The expert said Nigeria must therefore urgently decentralise healthcare governance and resource allocation to reduce leakages, minimise wastage and improve efficiency.

Public Health Practice Lead at Gatefield, Ms Omei Bongos-Ikwue, told The Guardian that whether PHCs’ needs are met also depends heavily on how states prioritise health in their own budgets. While the Federal Government makes allocations, she said states ultimately determine how the funds are spent.

According to her, between 2022 and 2024, overall state fiscal expenditure increased, but health spending varied significantly across states. She cited Bauchi State as an example, noting that although it had some of the lowest resources per capita, it devoted nearly 15 per cent of its entire state budget to health, in line with the Abuja Declaration target.

Bongos-Ikwue noted that while the allocated sums, even if fully released, might not immediately cover the rising cost of supplies and growing population needs, they would still represent a significant step toward ensuring that vulnerable Nigerians at the last mile can access care.

Bongos-Ikwue said one way to improve accountability and impact would be the deployment of performance-based grants. She noted that although other sectors have used such mechanisms to improve service delivery, they are not commonly applied in the health sector.

She also called for stronger human resources for health at local government levels, warning that investments in primary healthcare facilities without addressing subnational governance deficiencies, such as weak documentation and erratic financing, could result in wasted resources.

According to her, linking funding to measurable results while strengthening subnational governance structures would improve accountability, reduce waste and enhance the impact of public health spending.

The Executive Director and Chief Executive Officer of the NPHCDA, Dr Muyi Aina, described Nigeria’s primary healthcare infrastructure as historically underfunded, and noted that most of the PHCs were in poor condition before recent interventions. He said an initial assessment showed that fewer than one in five facilities were in decent shape, but about 4,000 have since been refurbished under ongoing reforms.(Guardian)