Bridging The Gap: Addressing Healthcare Inequality Between Urban and Rural Nigeria

This article is part of our collaboration with International Policy Review at IE University. Photo Credits: The Borgen Project.

Abstract

Access to healthcare is a fundamental aspect of human development and essential to leading a dignified and fulfilled life. However, this is not the case in most countries as health inequalities persist. Health inequalities are shaped by factors such as poverty levels and education. In the case of Nigeria, disparities in income inequality are closely linked to the rural and urban divide which affects equal access to healthcare services. This article examines how Nigeria’s healthcare system exacerbates inequalities due to its dependence on households’ out-of-pocket payments and how it disproportionately serves urban populations. It also assesses government policies such as the National Health Insurance Act and projects completed through public-private partnerships to increase access to hospitals and other health services. In order to improve equal access to healthcare across Nigeria, policy recommendations prioritize reducing the financial hardship of rural households and strengthen the infrastructure of facilities through equitable allocation of funds.

1. Introduction

Every human in their lifetime can encounter sickness and struggles with their health, yet, what makes a real difference amongst groups of people, is the manner in which they are able to address it. The accessibility of healthcare services across a country is closely tied to the well-being of a society. For instance, the Human Development Index (HDI), a key measure of societal development, accounts a country’s average life expectancy at birth to reflect overall health conditions. However, the extent to which health services, doctors, vaccines, sanitation, and more, are accessible to different communities depends heavily on their socioeconomic status and environment, more specifically urban and rural areas. These variations in income levels and living areas lead to unequal access to healthcare services thus affecting prospects of a healthy life but also to the broader health indicator that contributes to a country’s HDI.

Reducing inequalities in the world is a mission of utmost importance as someone’s outcome in life should not be determined by their race, gender, income, religion or ethnicity. The international community has recognized the urgency of the matter and translated this mission into the Sustainable Development Goals (SDG) which have been active for over a decade. The SDGs were founded at the 2012 UN Conference on Sustainable Development in Rio de Janeiro with the objective to set universal targets for nations to work towards in order to address the urgent environmental, political and economic challenges. This international initiative aims to promote a safer, more sustainable and inclusive future for humanity.

Nevertheless, these objectives are still far from reach. According to the World Inequality Report of 2022, the top 10% of the world population owns 76% of the global wealth whereas the bottom 50% of the population only owns 2%. The disparity of wealth and inequalities based on sex, age, gender, race, class, religion and opportunity are the core challenges the SDG 10 tackles. More specific targets are identified in order to concentrate efforts on particular aspects of inequality. The study targets 10.1, ‘reduce income inequalities’ and 10.3, ‘ensure equal opportunities and end discrimination’ are interconnected. Income inequality can be a result of discriminatory practices and the lack of access to essential resources such as healthcare or education for certain groups. 

Many regions in the world experience large disparities of wealth but since 2011, Sub-Saharan Africa has had the largest and growing share of the world’s extremely poor population. This places a critical focus on those African countries that display high levels of poverty and a lower life expectancy compared to the global average at 73.3 years with both sexes combined. For instance, Nigeria is one of the countries with the lowest healthy life expectancy according to the World Health Organization with an average of 54.4 years in 2019. Using Nigeria as a case study, how does wealth inequality between urban and rural communities affect healthcare access? 

Health inequality is discussed in relation to the accessibility of healthcare services in Nigeria. This analysis highlights and evaluates the efficiency of the current policies implemented by the Nigerian government to improve healthcare delivery. The discussion concludes with possible policy suggestions to better the distribution of medical services to Nigerian citizens with the goal of raising the health standards and wellbeing of its population.

1.1 Health Inequality in Nigeria: A Source of Low Human Development

Health inequalities can be defined as systematic differences in the opportunities groups have to achieve and maintain good health, which leads to unfair health outcomes. In examining the rural-urban divide of healthcare access, one can identify structural inequalities as being a determinant for this disparity. In other words, the institutional and systemic biases in policies and government practices indirectly classify people from different income levels into neighbourhoods or cities where living standards will not be the same. 

Nevertheless, quality of health, income inequality and living standards are interconnected since an increase in the population’s well-being results in a rise in labor availability and economic performance. Good health enables individuals to be productive physically and mentally as well as reduce uncertainty in one’s life since sickness would be easily repairable. However,  the urban-rural divide of Nigeria is characterized by high levels of income inequality since only 10% of the population has access to the majority of national income while the rest is left behind. This economic disparity is rooted in unequal income distribution which is due to corruption within the leadership of the Nigerian government. 

2. Healthcare System in Nigeria: How It Works and its Challenges

The delivery of health care in Nigeria is a public and private business. The way healthcare is paid for in Nigeria is through different mechanisms including allocation of funds from the government budget, out-of-pocket payments and social and private health insurances. Despite some healthcare facilities being publicly funded, most Nigerians pay for medical services out of their own pocket. The burden of personal expenditure on healthcare rose from 60.2% in 2000 to 70.5% in 2019  based on the Global Health Expenditure Database. Moreover, private expenditure accounts for 75% of total health health expenditure while public expenditure only covers 15% to 20% of the total. This means that most costs to access medical care relies on households’ ability to pay. This imposes a great financial risk on low income Nigerian families as the majority has to resort to selling private possessions or go into debt to sustain their health. Furthermore, since hospitals are predominantly privately funded, they operate in a way that their infrastructure is based in areas with anticipated high profits which tends to correlate with large urban cities such as Lagos as opposed to rural Jigawa. Consequently, the structural distribution of healthcare facilities is influenced by the resources and external funds allocated to private hospitals. While government-funded hospitals experience restricted access and limited resources, the private sector is abundant and available to anyone that can afford its costs. This system takes a great toll on the quality of life of Nigerians due to its widespread poverty levels. According to Worldometer, Nigeria is the most populous country in Africa with over 230 million people in 2025, and in 2023, it was estimated that over 105 million people were living in poverty. 

The uneven distribution of health resources in Nigeria reflects a larger problem of structural inequality in the country’s health system. The urban and rural divide in Nigeria becomes apparent when looking at health statistics comparing Northern and Southern regions of the country. Since levels of poverty are higher in the Northern regions of Nigeria, the amount of resources available to be spent towards healthcare is very limited. Contributing factors include a lack of well trained personnel and a lack of medical equipment which leads to unsatisfactory healthcare. In addition, the Nigerian Bureau of Statistics has reported that among the 3,5000 secondary and tertiary medical facilities, no hospitals have been constructed since 2004. These systemic weaknesses, coupled with a lack of governmental spending, contribute to the issue of medical brain drain in Nigeria, as trained medical professionals move abroad or towards larger cities in search for a higher income or better living conditions. Considering the growing population of Nigeria, the country would currently need 237,000 medical professionals to meet the World Health Organisation (WHO) standards. However, there is a short supply of 35,000, many of whom aren’t available throughout the regions of the country.

These barriers to the access and quality of healthcare can be illustrated through the low health status of rural communities. For instance between 2013 and 2018, the northwest of the country reported  the highest under-5 child mortality toll at 179 deaths per 1000 live births. More evidence reinforces the idea of a divide in the quality of life and health between rural and urban cities. For example, maternal mortality remains a critical issue in Nigeria, referring to death due to complications during childbirth.  Studies show that these levels vary within the country depending on geographical location. In 2008, the northern state of Kano experienced 1600 deaths for 100,000 live births as opposed to the national average being 576 deaths per 100,000 live births. This connects back to the limited availability of public health programs for the majority of Nigerians because the costs exacerbate income inequality. Since access to health is dependent on employment and a steady income, paying out of pocket generates a situation where low-income households have to cut back on basic necessities such as food, water, clothing, and utilities, otherwise they cannot afford professional care. As a result, a cycle emerges: impoverished regions have less resources to cover the cost of healthcare, while rural facilities are still underdevelopment due to minimal government investment and medical brain drain. Considering these challenges, what is the government doing to address them?

2.1 Government Action Towards Healthcare  

Multiple initiatives have been implemented by the government in order to expand health insurance for all Nigerians in order to decrease the burden of out-of-pocket expenses which is an aspect driving poverty in rural areas. Under the 1999 Nigerian Constitution, individuals are guaranteed the right to sufficient healthcare, yet, issues with the effective implementation of insurance policies persist. In May 2022, the President of Nigeria passed the National Health Insurance Act to replace the 2014 National Health Act. Its primary goal is to install a prepayment program for vulnerable populations to receive minimal economic coverage in case of unforeseen health circumstances. Currently, state health insurance agencies only cover about 3% of individuals, therefore, this bill aims to promote and regulate these health insurance programs as well as working with the private sector to improve health care delivery. Additionally, a key feature of this Act is the Vulnerable Group Fund which was designed to support more vulnerable individuals such as children under five years old, pregnant women, the elderly, and disabled people. 

Furthermore, an important mechanism used in Nigeria to provide health insurance to its population is the National Health Insurance Scheme (NHIS), which in the past has had very low levels of enrollment and remained ineffective in helping communities in need. Nonetheless, the recent 11% increase in enrollment in 2023 opens the door for potential improvements. The NHIS goals are centered on attaining Universal Health Coverage, which entails that all Nigerians should have access to healthcare without suffering financial hardship. This goal represents a target for government expenditure on health for middle and low income citizens. While expanding health insurance is important, modernising equipment for healthcare services has proved to be more difficult to implement. Multiple agreements made by the Nigerian Sovereign Investment Authority (NSIA) partnered with the Federal Ministry of Health to develop new infrastructure and hospitals with the help of the private sector. In 2022, the Federal Ministry of Health planned to build an additional 10,000 primary care facilities across the regions of Nigeria to facilitate access across a large geographic area. Nevertheless, the success of this project stagnates because of insufficient funding or human resources available. 

This status quo highlights an issue that needs to be considered in government policies. Is the expansion of health insurance enough to ensure equal access between rural and urban areas? While increased coverage leads to increased usage of medical services, rural areas of Nigeria still face limited access to quality healthcare due to the lack of resources and infrastructure in more remote areas. For instance, in rural areas, the patient-to-doctor ratio varies from 1 doctor per 10,000 to 30,000 people according to the Journal of Global Health Economics and Politics. These low numbers are part of a larger trend of patients going abroad to get treated which significantly decreases Nigeria’s human resources, referring to the medical staff available. This occurs mostly because Nigeria is a big exporter of professional labor to developed countries. A 2018 NOI poll, conducted in partnership with Nigeria Health Watch, revealed that around 88% of Nigerian doctors were considering work opportunities abroad due to poor working conditions, and low and irregular payment. Taking this into account, an expansion of health insurance would ease the financial burden of many households but the quality of medical care in urban and rural areas would still remain disproportionate. 

3. Policy Recommendations

3.1. Public-private partnerships (PPP)

Public-private partnerships are an indispensable player in the modernization of Nigeria’s health care facilities. While government spending mostly covers for public infrastructure and essential health services, it is limited by budget constraints. Whereas, the investment from private companies allows rapid modernization and expansion of medical facilities due to the entreprises’ larger budgets and operational efficiency

On the other hand, the Nigerian government’s ability to fund public services depends on international oil prices, so when they become volatile or production drops, the budget declines as Nigeria is heavily reliant on the revenue of oil exports. With that being said, in the state of Lagos, the federal and state governments have partnered with Medical Park clinics to open a new hospital with 120 to 150 beds that will also welcome cutting-edge medical technology and specialists. This is only one example amongst many projects put in place to further develop Nigeria’s health sector. 

3.2. Increase health financing

Improving the federal government’s financing of the health sector is crucial to alleviate the burden of out-of-pocket payments which is a main factor exacerbating inequalities between households. Government spending on different sectors is usually quantified by how much percentage of the national Gross Domestic Product (GDP) is allocated to a cause. Some targets provided by the WHO states that in order to achieve Universal Health Coverage, governments would be advised to spend at least 4 to 5% of their GDP on the health sector. In 2021, a WHO report stated that Nigeria dedicates 4.08% of its public budget on healthcare which in theory would meet that target. However, this health expenditure target doesn’t take into account the status of health of different countries. For instance, Nigeria would require more funding due to its poor medical infrastructure and high frequency of diseases such as malaria and tuberculosis. By taking this into account, it would cost Nigeria 1.2 trillion Naira or 9% of its current budget in order to cover the health insurance for the households that cannot afford the current state health insurance schemes. In addition, while federal government funding should increase, it should also be distributed amongst Nigeria’s six geopolitical zones where state governments would work closely with local communities in order to meet their needs. 

4. Conclusion

In conclusion, the unequal access to healthcare between urban and rural areas remains a pressing issue in Nigeria as it infringes human development and life expectancy outcomes. Urban areas benefit from more resources and higher incomes while rural communities face systemic neglect that increases health risk. It is imperative to address this divide through inclusive policy reforms and incentivize investment in healthcare across the country. Geography or income level should not determine an individual’s health outcome. Therefore, through collective effort, Nigeria can lay the groundwork to build an equitable healthcare system for all its citizens.

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