A newly renovated primary health care (PHC) centre can still fail a woman who arrives at 2 a.m. If there is no midwife on duty, no oxytocin, no reliable electricity, and no referral transport, the renovation is an infrastructure improvement, not yet a functioning health service.

This distinction sat at the centre of a civil society and media mid-year review of Nigeria’s health sector reforms held in Abuja on 14 September 2026. Convened by the Health Sector Reform Coalition and the Nigeria UHC Forum, in collaboration with the Federal Ministry of Health and Social Welfare, the dialogue asked whether reform commitments are translating into better care.

Stakeholders argued that the success of the Nigeria Health Sector Renewal Investment Initiative (NHSRII) should be judged less by the number of facilities renovated and more by whether those facilities can reliably deliver the services people need. It is a simple test, but an important one.

Nigeria is not short of health sector commitments. The NHSRII, launched in 2023, is being implemented through the Sector-Wide Approach (SWAp) built around “one plan, one budget, one report and one conversation”. The Health Sector Renewal Compact, signed in December 2023 by all 36 state governors and development partners under federal leadership, created a shared framework for reform.

At the 2025 Joint Annual Review, an addendum widened the accountability framework to include local governments, the private sector, civil society, and traditional and religious institutions. The government later reported that 84% of the key Compact indicators assessed had been achieved by the third quarter of 2025.

That is encouraging, but performance against selected Compact indicators should not be read as an overall 84% implementation rate, nor does it mean that 84% of PHCs are ready to provide quality care. Health systems can record progress against agreed-upon activities and indicators, while significant gaps persist in the locations where patients actually receive care.

From transparency to accountability

Nigeria has also developed additional tools to make health-sector performance more visible. The State of Health of the Nation Report, required annually under the National Health Act 2014, is intended to show how the system is performing. In 2026, the Federal Ministry of Health and Social Welfare announced a ₦32.9 billion disbursement from the Basic Health Care Provision Fund (BHCPF), supporting more than 8,300 PHCs. The 2025 Joint Annual Review also set out plans for digital expenditure tracking across BHCPF-supported facilities and biometric verification to strengthen workforce and financial accountability.

But transparency and accountability are not the same thing. Publishing a figure tells the public what happened. Accountability requires a responsible institution to explain a gap, act on it within a defined period, and show that the problem has been corrected.

This is where the health sector needs to become more demanding about what it measures. WHO and UNICEF’s PHC measurement framework follows a results chain from structures and inputs, through outputs, to outcomes and impact. A renovated building, health workers, medicines and equipment are inputs. Whether services are available, facilities are ready, and people actually use those services are outputs. Service coverage and financial protection are outcomes, while reductions in preventable maternal and child deaths reflect impact. These are connected measures of progress, but they should not be treated as interchangeable achievements.

BudgIT’s 2026 Health Financing Report found that 34 states allocated ₦1.97 trillion to health in 2025 but spent ₦1.18 trillion. The report puts aggregate health budget performance at 61.74%. Akwa Ibom and Rivers were excluded because detailed fourth-quarter 2025 budget implementation reports were unavailable. The figures reinforce a persistent problem where larger budget allocations do not necessarily translate into equivalent actual expenditure, let alone better services at the point of care.

A 2025 study using the nationally representative Nigeria General Household Survey 2023/24 found that 45.5% of households experienced catastrophic health spending when health costs exceeded 10% of total household consumption; 43.1% did so using a capacity-to-pay measure. Financial protection is not an abstract UHC indicator. It is the difference between seeking care early and delaying treatment due to a lack of money.

The functionality test

The strongest point in the dialogue was that PHC reform should be judged by functionality rather than appearance. A functioning facility needs health workers, essential medicines, basic diagnostics, water, electricity, infection-prevention systems, maternal and child health services, and a referral pathway that works.

Recent evidence shows why this distinction is urgent. Orodata Science’s 2026 PHC Operational Capability Report assessed 1,480 PHCs across 16 states and found that 97% of the facilities assessed did not meet the national minimum staffing requirement. 38% lacked electricity, 39% relied on unsafe water sources, and 75% lacked essential neonatal resuscitation equipment.

When accountability produces a remedy

The National Health Insurance Authority (NHIA) offers one example of what a stronger accountability chain can look like. Its 2025 Complaints and Resolution Analysis recorded 4,477 complaints, of which 3,878 (87%) were resolved. 62% of resolved complaints were concluded within 48 hours, and 95% within the prescribed 21-day timeline.

The significance is not simply that complaints were recorded, but that identified problems could trigger investigation, restitution and sanctions. Accountability becomes meaningful when detecting a failure leads to a remedy, and when that remedy can itself be tracked.

Community accountability has a similar problem. Evidence presented at the review from the Social and Citizen Accountability for Primary Health Care Performance (SCAPP) project in Kaduna State showed that, across 862 Ward Development Committee meetings, only 11.6% discussed the BHCPF.

Communities cannot track funds they do not know about. If citizens are expected to monitor PHC financing, facility-level allocations, expenditure and service obligations must be understandable and routinely disclosed.

The missing link is corrective action

Nigeria’s accountability architecture is becoming more sophisticated. The Compact creates commitments. The Joint Annual Review measures performance. The State of Health of the Nation Report makes sector information public. The BHCPF reforms are strengthening financial tracking. Civil society and the media are increasingly following budgets, facilities and political promises.

But the missing link remains what happens after a failure is identified. Every red flag should have a named owner, a deadline and a public resolution. If a state repeatedly underperforms in health budget execution, the explanation and corrective action should be visible. If a PHC receives funds but lacks medicines, the responsible authority should be identifiable. If a facility has been ‘revitalised’ but cannot provide 24-hour maternal care, the gap should remain open on the public record until it is fixed.

The Health Sector Reform Coalition (HSRC) has said it will publish a quarterly reform tracker, conduct independent facility monitoring, maintain a public register of commitments and produce an annual scorecard on delivery of the Health Sector Renewal Compact. Those tools will be most useful if they follow problems through to closure rather than stopping at detection.

The 2027 elections offer another accountability test. Nigeria Health Watch’s Health Manifesto Tracker is designed to turn broad health promises into commitments that can later be checked against public evidence. What exactly will be done? How much will it cost? Who is responsible? By when? What evidence will show that it happened?

For the Nigerian who needs care, the distance between a signed Compact and a functioning health system is not theoretical. It is the distance between an allocation and money reaching a facility; between a renovated building and a staffed clinic; between a policy promise and a service that works when it is needed.

For a woman arriving in labour, health reform is a midwife on duty, the medicines she needs, light in the delivery room, a referral that works and care her family can afford. Nigeria’s accountability system should be judged by how reliably it closes that distance.