NIGERIA’s quest for Universal Health Coverage (UHC) by 2030 rests heavily on one ambitious policy instrument: the Basic Health Care Provision Fund (BHCPF). Enshrined in the National Health Act of 2014 and operationalised nationally in 2019, the BHCPF earmarks at least one per cent of the country’s Consolidated Revenue Fund to strengthen primary healthcare, protect vulnerable populations from catastrophic health spending, and close long-standing inequities in access to care.

This report consolidates findings from investigations by The ICIR’s SPARK  2 project across Oyo, Kano, Ogun, Niger and Anambra States, tracing how the BHCPF is improving or failing access to primary healthcare. The findings reveal a stark national pattern, where infrastructure, staffing, leadership, community oversight and accountability align, the BHCPF delivers measurable gains; where even one pillar collapses, access collapses.

Oyo State: when the system begins to work

Shortly after midday at Ojoo Primary Healthcare Centre (PHC) in Akinyele Local Government Area, Oyo State, the cry of a woman in labour cut through the murmur of patients waiting to be seen. Minutes later, the cry of a newborn followed.

“We have a baby boy. Mother and child are doing fine,” said Catherine Adebola, the officer-in-charge (OIC), after returning from the delivery room.

For Adebola, the moment symbolised a quiet turnaround. When she was posted to the facility in 2023, power outages forced staff to rely on rechargeable lamps during night deliveries. “It was terrible,” she recalled.

Today, Ojoo PHC runs on a solar-powered system funded through the BHCPF. The facility treats an average of 3,000 patients monthly and receives N300,750 quarterly in Direct Facility Funding (DFF) money used to purchase delivery instruments, laboratory reagents, water repairs, and infection-control equipment.

“The fund has really helped us because in times past, you would not even want to come to this PHC, not because of the staff, but because of the tools to work with,” Adebola said.

Just 23 kilometres away at Ayegun PHC, renovated under Oyo State’s IMPACT Project, 21-year-old Sakinah Ariyayo remembers delivering her first child by candlelight in 2023.

“There were only two nurses on duty that night. Even though they had a small solar, it was dim, so we had to light up candles for the delivery,” she said.

When she returned for her second pregnancy, the experience had changed. “But now, there is light everywhere. I felt encouraged to return for my second pregnancy. I feel very happy. It is a good development. See, now everywhere is well ventilated, we have a lab, good restrooms and drugs.”

State officials say these improvements reflect growing momentum. Out of Oyo’s over 760 PHCs, 351 receive BHCPF support. Since 2023, at least 264 facilities have been renovated, health insurance enrollment has more than tripled, and staffing levels in select centres have improved.

At Adifase PHC in Ibadan South-West LGA, a 2024 investigation documented severe understaffing, with one heavily pregnant worker running the facility alone. By October 2025, four nurses were on duty.

“We used to run two shifts — 7 am to 7 pm — instead of the standard three. Staff would break down, but now that challenge is gone,” said  Adeyemo.

Yet even in Oyo, progress is uneven. Some PHCs still lack cleaners, delivery instruments, functional power supply, or basic diagnostic equipment. At Adifase, staff improvise a faulty delivery bed. “We’re just managing it,” Adeyemo said.

Across facilities, delayed approvals, absence of ultrasound machines, and limited awareness among enrollees continue to slow gains, a reminder that reform remains fragile even where it shows promise. Read the full report on Oyo HERE

A reform designed to reach the most vulnerable

The BHCPF channels funding through three gateways: the National Primary Health Care Development Agency (NPHCDA) for facility strengthening and Direct Facility Funding (DFF); the National Health Insurance Authority (NHIA) to expand coverage for vulnerable populations; and the National Emergency Medical Treatment Committee (NEMTC) to support emergency care. The fund targets pregnant women, children under five, the elderly, persons with disabilities, and the poorest households, groups meant to be shielded from financial hardship as Nigeria advances toward UHC.

In policy design, the architecture is sound. In practice, the reality of patients and frontline health workers reveals a system struggling with uneven execution, weak governance, staffing shortages, delayed disbursements, exclusionary identification requirements, and fragile referral networks.

Kano State: despite fat budgets, empty shelves mar healthcare services

If Oyo represents tentative progress, Kano State illustrates the consequences of weak governance and accountability. At Tshohuwar Rogo PHC in Rogo LGA, wooden shelves hold little more than dusty boxes of paracetamol and syringes. For Khadija Auwal, a mother of three, visits to the PHC often end with mere prescriptions instead of medicines.

“It pains us whenever we have to buy drugs outside. They are expensive here, but what other option do we have?” she said.

For pregnant women like Maryam Musa, the cost has been devastating. When malaria drugs were unavailable, her family sold a goat to buy medicine.

“Women die here because of small things like medicines and equipment. These things can be avoided if our PHC worked like it should,” she said.

This persists despite Kano State receiving about N2.67 billion from the BHCPF in 2024 alone. At Yandadi PHC in Kunchi LGA, records show that ₦425,790 was released for drug procurement in October 2025, yet only a few cartons of basic supplies were visible weeks later.

“There is no proper tracking. Once the funds hit the accounts, there’s no effective monitoring of what is bought or delivered,” said a health worker who spoke off record.

Ward Development Committee (WDC) leaders echo the concern. “Every month, we hear that money has been sent, but when you come to the PHC, you don’t see the impact,” said Abubakar Haruna, WDC chairman at Yandadi PHC.

Patients say shortages deepen poverty. “We shouldn’t have to buy what the government has already paid for,” said Yusuf Ibrahim, a maize farmer who now rations leftover malaria drugs at home.

Budget data reinforce the disconnect. Between 2021 and early 2024, Kano executed less than 20 per cent of its approved health budget on average. In 2025, only 0.7 per cent of N10.75 billion allocated to the state’s primary healthcare board had been spent by the first quarter.

Health policy expert Kabiru Sabo of Bayero University Kano said, “The problem is not funding; it is what happens after the money is released.”

Officials offer conflicting explanations. Gali Sule, director-general of the Kano State Drugs & Medical Consumables Supply Agency, blamed diversion by staff, saying, “Some workers get drugs cheaply but direct them outside for personal gain.”

The Kano State Primary Healthcare Management Board acknowledged delays, noting that BHCPF releases for the first two quarters of 2025 did not arrive until August.

A Freedom of Information Act(FOIA request seeking detailed expenditure records was ignored by the Ministry of Health, deepening transparency concerns. Read the full report for Kano here

Ogun State: funded, yet functionally broken

In Ogun State, a tour across Ogun West and Ogun East senatorial districts reveals a troubling paradox: PHCs funded under the BHCPF often look indistinguishable from unfunded ones.

Despite receiving N458 million in 2023, N580 million in 2024, and N377 million in early 2025, many of Ogun’s 227 BHCPF facilities remain understaffed, poorly equipped, inaccessible to persons with disabilities, and in some communities, abandoned.

At Ogbere PHC, a BHCPF beneficiary, Ogunnowo Abiodun, the only worker on duty, said, “The only issue we have here is the bad borehole. It got damaged recently, so we don’t have water. We always have to fetch water outside. That is the reason I have not had my bath by this time.”

Across six funded PHCs visited, none met NPHCDA staffing standards; only three had functional ambulances.

The staffing crisis reflects a national shortfall. With 1.83 skilled health workers per 1,000 people, Nigeria falls well below WHO benchmarks. A doctor and a public health specialist, Joyce Foluke Olaniyi-George warned:

“You can imagine a PHC with maybe one senior person and a fresh graduate. Nothing is going to get done there because the person is about to retire and is tidying things up to get out. We will find out that there will be a lot of frustration on the part of the staff, which could be transferred to the patients, and poor treatment meted out to patients when they come in, as a result of the poor motivation.”

She added that “This creates a vicious cycle that would give rise to poorly trained health workers, nurses, or community health extension workers who would also be poorly motivated. Ultimately, the system suffers as a result. If they have the opportunity, they will likely consider exiting the system.”

The PHCs in Ogbere, Alaga, Atan, and Oja Odan have ramps for people with physical disabilities, but the target beneficoaries insist that disability inclusion remains largely symbolic.

“Ramps are like motorways; they do not stipulate full access,” said Femi Adeosun, the lead for Ogun State Joint National Association of Persons with Disabilities (JONAPWD) Deaf Cluster. “After the wheelchair-bound patient enters the building, what transpires thereafter will determine the accessibility.”

From conversations with healthcare workers during visits to six PHCs – Ogbere, Oja Odan, Alaga, Atan, Aiyepe, and Okun-owa PHCs – they all lack sign-language interpreters or braille for visually impaired people. The PHCs in Aiyepe and OkunOwa do not even have ramps.

Hearing-impaired patient Funmilayo Obasa said, “I have noticed that when I am calm and polite, my concerns seem to get overlooked, but when I get frustrated and speak up, things start to happen. It is concerning that I have to escalate my tone to get proper care”.

When the situation was raised with Ogun State Commissioner for Health, Oluwatomi Coker, she said, “You have to define a need. If I were you, the first thing I would find out is the number of people who visited that PHC with hearing impairment. So, you have to prove that there is a need for it.”

For border communities like Ipokia and Yewa North, abandoned PHCs mean dangerous journeys.

“The roads are terrible. It is the worst I have seen. It needs urgent repair. The poor road conditions make going outside the community very inconvenient. Whenever I get on a bike to go out of the community, I feel so much pain,” said Olorunwa Tapa, a pregnant resident. Read the report from Ogun HERE

Niger State: free care, fragile outcomes when policy meets distance, delay and power

Beyond individual stories, Niger State exposes the structural fragility of free healthcare when geography, delayed financing, and weak referral systems collide. Spanning vast rural terrain with scattered settlements, Niger has some of the longest travel times to health facilities in the country, a factor that repeatedly undermines emergency obstetric care.

While the BHCPF formally guarantees free antenatal care, delivery, and postnatal services, it does not cover the costs of emergency surgery, blood transfusions, or long-distance referrals. For rural families living on subsistence farming, these gaps quickly erase the promise of “free” care.

At Mokwa Central PHC, the Officer-in-Charge, Jubril Isah, described how cost barriers resurface the moment complications arise.

“Pregnant mothers who are not enrolled pay N1,000 for the first antenatal visit and N500 for subsequent visits. For delivery, non-enrollees pay ₦2,000 for medications and consumables such as gloves, sanitary pads, and detergents”.  Even enrolled women, he noted, must find funds for transport, feeding, and surgery once referred.

While these fees may seem small, in communities where disposable income is measured in daily subsistence, N2,000 can be the difference between choosing a supervised facility birth and resorting to a traditional home delivery, with its attendant risks.

Referral journeys are often long, expensive, and dangerous. Several women interviewed across Mokwa and Kontagora LGAs reported travelling between 80 and 150 kilometres to access comprehensive emergency obstetric care. For families without cash on hand, referrals are delayed  sometimes fatally.

The reliance on the National Identity Number (NIN) as a prerequisite for enrollment to access the free healthcare further deepens exclusion. Women without IDs, often those in the poorest or most restrictive households are systematically locked out of BHCPF benefits. Although state officials insist facilities can enroll such patients on the spot, multiple women reported being turned away or asked to pay or not getting the permissions of their husbands to go to the enrollment centres.

Delayed disbursements worsen the situation. PHCs interviewed across Niger State said BHCPF funds arrive unpredictably, making it impossible to plan drug procurement or sustain free services.

“We are supposed to get ₦300,000 four times in a year. But it’s usually just once or twice in the first quarter or last quarter of a year. This year, we received just twice” said Bernice Egboch, the ward focal person at Tundun Wada MCH Clinic.

The WDC chairman, Mohammed A. Aliyu, confirmed, this.

“Funding for the BHCPF is usually delayed. It can take two to three months. So, providing free medications for the women who visit these PHCs can be difficult.”

When funds dry up, PHCs quietly charge patients,  a practice that erodes trust and reinforces perceptions that free healthcare is unreliable.

The staffing crisis compounds these failures. Many PHCs operate without doctors, pharmacists, or laboratory scientists. A nurse at Kawo PHC in Kontongora LGA, said, “A permanent doctor? We haven’t had one here asince  I joined the fcacility five years ago.”

In emergencies, midwives and community health workers must decide whether to stabilise patients with limited supplies or refer them immediately,  a choice that often determines survival.

Civil society organisations working in Niger State warn that uneven deployment of midwives under the MSS has created pockets of progress surrounded by vast areas of neglect. Rigolo’s transformation shows what sustained human presence can achieve, but Kwangwara demonstrates how absence can be fatal.

In Rigolo, a quiet village in Niger State’s Magama LGA, a young mother once died from postpartum haemorrhage (PPH), her body laid under a mango tree because the community’s primary healthcare centre (PHC) had no electricity, no drugs, and no capacity to save her. PPH, Nigeria’s leading cause of maternal death, went untreated. Her death mirrored a reality long familiar to rural communities: empty PHCs, reliance on traditional birth attendants, and preventable loss of life.

Yet, just a few kilometres and a few policy decisions away, another reality exists, one shaped by the Midwives Service Scheme (MSS) and BHCPF. Read the full report here

When the system works: Rigolo and the MSS effect

Rigolo’s turning point came in 2017, when the MSS finally reached the village. Among the deployed midwives was Janet Adonai Muazu, a retired nurse-midwife with decades of experience. She arrived to find a PHC without water, electricity, or trust.

“We had women arriving in labour with their lives at risk. One health worker tampered with a placenta instead of referring a patient. The woman nearly died,” Janet recalls of her earlier rural postings.

In Rigolo, she rebuilt care from the ground up, securing water deliveries, linking the PHC with Physicians for Social Justice (PSJ) for free prenatal vitamins, and training the only community health worker, Aisha Mansur, to recognise and manage PPH. Attendance surged as women abandoned unsafe deliveries, telling each other, “Mama is there.”

Janet also established a referral pathway to Yauri General Hospital in Kebbi State for caesarean sections and severe complications. “Even if a woman needed a caesarean, families knew they could always go to Yauri,” she said.

The impact was measurable.

“Mama clamped the bleeding, gave IV fluids, and saved her. Now I proudly tell anyone: ‘The MSS is a good government plan,’” said Hassan Ibrahim, whose wife survived PPH.

When the system is absent: Kwangwara and unequal deployment

Rigolo’s gains throw into sharp relief the situation in Kwangwara, a community in Kontagora LGA that has never received an MSS midwife. Its PHC offers no antenatal care, no emergency services, and no essential supplies. Deliveries are handled by community health workers and TBAs, often without sterile equipment.

“I lost my sister during childbirth. No one could stop the bleeding,” said Shamsiya, a resident.

The Ward Focal Person Shehu Tijjani warned that “the government needs partners to sponsor midwives to PHCs,” underscoring how uneven deployment determines who lives and who dies.

In Niger State, the difference between survival and loss often hinges on kilometres, cash, and whether a midwife is present when labour begins. Read the full report here.

Anambra State: Telemedicne frustrated by infrastructure as  innovation outpaces access

Anambra State’s telemedicine programme was conceived as a bold answer to rural staffing shortages, offering PHC workers instant access to doctors through digital platforms. On paper, the model is elegant. On the ground, it exposes how technological fixes falter without foundational infrastructure.

Across multiple PHCs, unstable electricity and mobile networks repeatedly interrupt consultations. Health workers described pausing emergency care to search for stronger signals, move devices outdoors, or switch SIM cards,  a process that consumes precious minutes in critical situations.

At Umudora PHC, OIC Stella Ogolor said the telemedicine device is rarely reliable during emergencies. “In critical cases, we use our phones to call the doctor.” Similar improvisation occurs across Awka North, Ogbaru, and Anambra West LGAs, where OICs routinely hotspot personal data to compensate for poor connectivity.

Despite these limitations, N20,000 is deducted monthly from BHCPF allocations for telemedicine data, funds that PHCs say could otherwise support drugs, consumables, or basic facility maintenance.

“That N20,000 they are collecting is reducing the value of basic money. The quarterly disbursement is not even enough,” said Ogoamaka Atuenyi, a Ward Development Committee chairperson.

Beyond infrastructure, time has emerged as a silent barrier. Telemedicine doctors serve multiple facilities, and delayed responses can turn manageable conditions into emergencies. “They are human, they have other responsibilities,” said Lauretta Nwoye, an OIC. “But it makes things difficult in emergencies.”

For patients, these delays erode trust. Some interpret phone consultations as incompetence rather than collaboration. “If they know you, they wonder why you have to call someone before treating them,” said Eunice Obi, OIC of Amansea PHC.

Disability inclusion further exposes systemic blind spots. While the BHCPF formally recognises persons with disabilities as a priority group, most PHCs lack sign-language interpreters, braille materials, or trained staff. The result is silent exclusion.

“They never understood what I was trying to say,” said Elizabeth Ibeabuchi, who lost a long-awaited pregnancy after repeated miscommunication.

For others, the cost of “free” care is indirect but prohibitive. Vincent Onwubuya, who is visually impaired, explained that transport for guides, poor labelling of drugs, and unsafe infrastructure make routine care risky.

Governance gaps persist. Persons with disabilities are largely absent from Ward Development Committees, despite being affected by every decision about facility design, service delivery, and spending. Advocates insist participation is essential. “Nothing about us without us,” they argue.

State officials maintain that progress is being made. Commissioner for Health Afam Obidike said, “There is nowhere in Anambra where you cannot browse though you may have to switch between networks.” Yet for frontline workers swapping SIM cards and patients navigating exclusion, connectivity remains inconsistent and care uncertain.

Despite its limitations, frontline workers and doctors say Anambra’s telemedicine initiative has expanded clinical decision-making at the primary healthcare level, particularly in facilities without resident doctors. Health workers report that access to real-time medical guidance has helped them manage cases that would previously have been referred late or mishandled.

Oluebube Agba, a telemedicine doctor supporting PHCs in Anaocha LGA, said, “I have helped PHC workers to manage many complex cases without casualty. I remotely guided the OICs or their staff.” For overstretched facilities serving remote communities, such guidance has reduced uncertainty for nurses and community health workers, enabling earlier interventions and more informed referrals.

In Anambra, technology has expanded possibilities, but without electricity, inclusion, reliable networks, and accountability, innovation alone cannot deliver universal access. Read the full report here 

This report was made possible with support from the International Centre for Investigative Reporting (ICIR) under the Strengthening Public Accountability for Results and Knowledge (SPARK 2.2) project.

Note: The headline of this report was updated.