Nigeria Has 38 Healthcare Systems – Decentralization Is Their Lifeline

 

As I digested The Punch newspaper interview titled “Nigeria Drifting into Unitarism, True federalism Way out”, which was granted by one of Nigeria’s legal icons and former President, Nigeria Bar Association, Chief Wole Olanipekun, OFR, CFR, SAN, and published on 25th June 2025, I couldn’t but mull over my book “DIAL 811: DEFT or DAFT?” published in 2022. Incidentally, I was privileged to have Chief Wole Olanipekun write the foreword of the book, which already pontificates our shared position on decentralization. Nevertheless, his recent media reflections bring this important conversation to the fore of national discourse in my professional sector - healthcare. It is worth noting that I coined “DIAL 811” as a relatable acronym for Decentralization Is A Lifeline for 811 federating units. When disaggregated, these 811 units are 36 States, 1 Federal Capital Territory and 774 Local Government Areas – all recognized by the 1999 constitution of the Federal Republic of Nigeria (as amended).

While I take pride in knowing that the book also received a written endorsement from late legal titan, pro-decentralization activist, and former Governor of Ondo State, Arakunrin Oluwarotimi Akeredolu, SAN, CON, which he personally signed and is tucked in its preliminary pages, the realization that the inefficiency of my country’s healthcare system is significantly connected to the dysfunctional unitary system we practice is saddening. The core of the 216-paged volume is that an Abuja-based Federal structure with an overcentralized five-pronged authority (legal, geographical, administrative, political & economic) cannot suffice in managing the hydra-headed societal problems of a pluralistic nation like ours, no matter the good intentions of the occupiers of its needlessly pluralized offices that largely benefit the elite class at the expense of the overwhelming majority of Nigerians.

Today’s article is neither one drawn from sentiments nor targeted at stoking the embers of disunity in Nigeria’s health system. It is simply stating the obvious that Federalism is a pivot for improved health outcomes of Nigerians. Federalism is that system of government that divides power between a national and several subnational authorities. Our estimated 220 million population, disaggregated into 371 ethnic groups (listed by Vanguard newspaper, 10th May 2017 edition), and occupying an approximate total land area of 923,768 square kilometres on the global map have diverse health needs that the Federal power may never recognize, let alone attempt to effectively & efficiently superintend. In other words, Nigeria’s current healthcare delivery design that inverts the pyramid by tactically and overtly centralizing (at the Federal level) the political and financial authorities required for appropriate policy interventions (top-bottom approach) whereas majority of the served population lives at the subnational level is itself unhealthy. This anomaly is so, even though health is not listed in the exclusive list (but among the residual powers) enshrined in the 1999 constitution of the Federal Republic of Nigeria (as amended).  

When diagnosis fails, the physician-led clinical management team unknowingly institutes a wrong and possible lethal management plan for the patient. A wrong judgement – intentional or unintentional – of the causes of Nigeria’s inefficient healthcare delivery system with its splurge of weak health indices has continued to yield a poor intervention tactic wherein the current centralized structure led by the Federal Ministry of Health (FMoH) alongside its numerous national appendages is erroneously expected to administer a countrywide solution to our diverse disease burdens. And just before the convenient chants of “strengthening collaboration between the FMoH and State Ministries of Health (SMoH)” that can be categorized as short-term fixes, this treatise points to the medium- & long-term imperatives of resolving root causes and not merely treating surface symptoms.

Let’s be reminded that the strengths and weaknesses of the health sector of every nation across the world cannot be situated outside their respective political economies – as my internationally revered tutor at Manchester Business School, Emeritus Prof. Barry Munslow, who had visited from Liverpool School of Tropical Medicine, hammered into my learning consciousness during the one-year M.Sc. Healthcare Management course I completed in 2014. Let’s be reminded that on a scale of objective analysis, a hugely centralized homogenous healthcare policy framework cannot be the right prescription for a heterogenous population whose health determinants (genetics, culture, social, economic, population, environmental) vary widely from Sokoto to Lagos, Borno to Enugu, and Taraba to Akwa Ibom. Let’s be reminded that Nigeria does not have a single health system but one Federal healthcare system, thirty-six State healthcare structures, and one Federal Capital Territory (FCT) healthcare configuration.

Therefore, to institutionalize a virile system in a pluralistic nation like Nigeria along the six building blocks of a health system that World Health Organization (WHO) prescribes (leadership & governance, human resources, health financing, data & strategic information, medicines & technology, and service delivery), the Federal health system needs to begin to shelve the memo-conveying posture of “urging/advising states to either adopt/adapt national health policies”. To reconstruct a proper pyramid of healthcare command-and-control and not an inverted mutation of it, the decentralization and de-generalization of the requisite authority to sub-nationals is inevitable. This federalism-promoting restructuring will enable the following across 36 States & FCT healthcare delivery systems that will then add up at the center via a bottom-top approach.

1.  1. Design and implement State-specific healthcare policy & programme interventions – Some epidemiological concerns (distributions, patterns & determinants of diseases) may be cross-cutting in Nigeria, but several are not. For example, while HIV burden affects all States (though in different proportions), several other disease priorities of numerous communities within a State never become national priorities requiring policy design & programmatic formulations. However, decentralization will allow States to focus on their local health peculiarities by stimulating the apt design of specific policies by SMoH and programmatic interventions by relevant health sector Extra-Ministerial Departments & Agencies such as State Primary Health Care Development Board (SPHCDB), State Drug Management Agencies (DMAs) etc. States will then collate relevant data and share with the FMoH and/or its allies.

2.      2. Train, evolve and deploy mid-level Human Resources for Health (HRH) – The numerous Colleges of Health Technology (that produce all community health workers for Primary Health Care - PHC) and Schools of Nursing & Midwifery owned by State governments can focus their knowledge & skills training curriculum on local health needs, knowing that State health priorities now supersede national interests. States will then collate relevant data and share with the FMoH and/or its allies. 

3.    3. Generate revenue for fiscal sustainability – The Federation’s monthly allocations ‘shared’ among Federal, State & Local governments may have significantly increased but the medium- & long-term fiscal plan should be to devolve more powers to States to generate revenue from both tax and non-tax sources. Not until then, most States may not be able to meet & exceed the Abuja declaration (which mandates national & subnational government entities to commit not less than 15% of their total annual budgets to healthcare delivery). For example, this will allow the 37 (36 States & FCT) SMoH and their State Health Insurance Agencies (SHIAs) to be better capacitated for Domestic Resource Mobilization (DRM) for healthcare. Consequently, they’ll be better positioned to invest more in their nationally neglected secondary healthcare system (delivered through General Hospitals, Specialist hospitals, and their broad spectrum of HRH) through their respective State Hospitals’ Management Boards (HMBs). PHC is also likely to get more attention of the States & FCT. States will then collate relevant data and share with the FMoH and/or its allies.

4.     4. Develop cost-efficient Monitoring & Evaluation systems – Decentralization will strengthen States to conduct supportive supervisory visits to health care facilities and communities within their respective domains with lower logistic costs.  For example, the huge (running into billions of naira) annual operational costs of flights, hotel & per diem costs of transporting health officials from the center (Abuja) to States will drastically reduce. States will then collate relevant data and share with the FMoH and/or its allies.

5.     5. Attract direct collaborations, partnerships, aids & grants for State-specific healthcare interests – For example, the partnership coordination desks of respective State Ministries of Economic Planning  & Budget (SMEP&B) will be strategically positioned to work with their SMoH counterparts to attract and manage relationships with global healthcare development financing agencies, healthcare development financing institutions, philanthropists & donors (via both financial & technical support) for peculiar health needs. States will then collate relevant data and share with the FMoH and/or its allies.

6.      6. Drive medical research for development based on specific local contexts – Nigeria is rich in potential sources of medical research that remain suboptimal in exploration. For example, feeders for medical inventions and Implementation science across clinical, pharmaceutical, alternative medicine and other domains of the healthcare system should come from different physical environments, cultural behaviours and other diverse contributory sources at the sub-national levels. States will then collate relevant data and share with the FMoH and/or its allies.

    For the umpteenth time, Nigeria has 38 healthcare systems, and it is in the best interest of our aggregated healthcare outcomes for one central/Federal healthcare system to decentralize ‘more’ legal, geographic, administrative, political & economic powers to the other thirty-seven at the subnational level. Period!

Dr. Adetolu Ademujimi is a Medical Doctor, Health Finance Specialist, Author, Reformer, Coach, Public Policy expert and social entrepreneur who can be reached in Abuja via adetoluademujimi@gmail.com