To understand why the gap between policy and outcomes persists, The Guardian spoke with Lucky Ilodigwe, a medical biochemist and healthcare strategist with PwC Nigeria, on why many Nigerian healthcare reforms struggle in execution and what sustainable transformation could realistically look like.

Nigeria has launched numerous healthcare reforms over the years. Why do so many struggle to produce lasting outcomes?

I would push back slightly on the idea that they fail entirely. Many of these reforms are serious pieces of policy work. The National Health Act is substantial legislation. The BHCPF design is technically sound. State social health insurance laws being passed across the country are important developments.

What usually fails is the translation layer. We legislate brilliantly and execute partially.

Take the BHCPF as an example. Operational guidelines were finalised years before large-scale disbursement actually reached states. When readiness assessments were conducted, many states had the policy framework but lacked the operational structures required to absorb the funds effectively.

The money existed. The operational capacity did not.

That, to me, is the real challenge in Nigerian healthcare reform. The issue is rarely ambition. It is building the systems that connect policy to implementation at the level of an actual clinic in Ikorodu or Birnin Kebbi, and sustaining those systems across political cycles.

You have written previously that Nigerian reforms often “start with solutions rather than strategy.” What do you mean by that?

A good example is the early rollout of the NHIS framework. Nigeria essentially imported the HMO-based insurance structure first and only later confronted the strategic question of who the system was truly designed to serve.

Because formal-sector workers were easier to enrol, the system naturally concentrated there, while the much larger informal sector remained dependent on fragmented community schemes that never achieved scale.

Compare that to countries like Rwanda or Ghana. In those systems, policymakers first defined universal enrolment as the strategic objective and then designed financing structures around that objective.

In Nigeria, the instrument often arrives before the strategy.

You also see this in digital health projects. A platform gets procured before fundamental questions are answered: What decisions will this data improve? Who is accountable for acting on it? What workflow changes are required? Without answering those questions first, technology simply becomes an additional reporting burden layered on top of existing inefficiencies.

How much of the problem is tied to incentives inside the healthcare system itself?

A great deal of it. In several parts of the system, incentives are actively misaligned with the outcomes we say we want.

You see it in recurring industrial disputes across the healthcare workforce. As long as different professional groups feel structurally disadvantaged within the same system, coordinated care becomes difficult.

You also see it in provider payment structures. Fee-for-service models reward patient volume rather than long-term health outcomes. An HMO-accredited clinic earns more from repeated consultations than from successfully preventing complications over time.

If Nigeria wants stronger chronic disease management over the next decade, then payment models eventually have to evolve toward systems that reward continuity and outcomes.

That is why some of the work happening through the Lagos State Health Management Agency and the Ilera Eko scheme is interesting. The architecture increasingly reflects actuarial discipline and blended payment structures designed for sustainability rather than simply expansion.

Every state government now seems eager to launch digital health initiatives. How transformative can technology realistically be?

Technology is currently both over-celebrated and under-strategised in Nigerian healthcare reform.

I am not anti-technology at all. But technology amplifies the operating model it sits inside. If the operating model is unclear, technology amplifies the confusion.

Take DHIS2, for example. It is globally respected software. Countries like Kenya run large portions of their health systems through it successfully.

But in many Nigerian facilities, data collection still begins with paper registers that are later manually transferred. If the reporting discipline underneath is inconsistent, the dashboard simply inherits those inconsistencies.

The COVID-19 response showed the difference clearly. The Nigeria Centre for Disease Control’s SORMAS platform worked relatively well because there was a clear institutional operating structure around it, clear reporting lines, clear accountability and clear decision rights.

Technology succeeds when the governance structure behind it is already functioning.

Nigeria’s healthcare financing environment remains heavily constrained. How does that shape strategic decision-making?

It makes prioritisation much more important. When health budgets remain below the Abuja Declaration target, every poorly allocated intervention has larger consequences. A failed pilot programme in a wealthy country is an audit issue. In Nigeria, it can mean a primary healthcare centre remains under-equipped for years longer than necessary.

That means strategy has to become more disciplined. States cannot realistically pursue thirty priorities simultaneously. They need to identify the few interventions that matter most and execute them consistently.

There is also the equity issue. New healthcare capacity naturally flows first toward populations that are easier to serve — urban populations, formally employed populations, places with stronger institutional capacity.

Without explicit equity targeting, transformation risks widening existing gaps instead of reducing them.

Based on your advisory work across states, what separates the reforms that succeed from the ones that stall?

Three things consistently. First is clarity of priorities. The healthcare reforms in Kaduna under former Governor Nasir El-Rufai are instructive because they focused on a small number of measurable goals rather than broad wish lists.

Second is operational design. A strategy document is not an operating model. An operating model defines who does what, how approvals happen, how data flows and how institutions interact day-to-day.

Most strategies stop before reaching that level of detail.

Third is continuity. Healthcare transformation is not a launch event. The states making meaningful progress usually had teams that remained focused on the same agenda over multiple years rather than constantly resetting priorities with every political transition.

If a state health commissioner called you tomorrow asking what to prioritise over the next two years, what would you recommend?

First, close operational gaps preventing states from fully accessing BHCPF funds. A lot of money is still being left unused because basic administrative requirements have not been completed.

Second, strengthen data-reporting discipline at the facility level rather than launching entirely new technology systems.

Third, engage frontline healthcare workers before announcing reforms publicly. One recurring mistake is designing transformation programmes without early workforce buy-in.

If frontline workers feel excluded initially, governments often end up renegotiating under industrial pressure later.

Looking beyond the short term, what structural shifts does Nigeria need over the next decade?

Three things stand out. The first is financing reform. Out-of-pocket spending at current levels is not sustainable. Mandatory social health insurance expansion will eventually become unavoidable if Nigeria wants broader risk protection.

The second is provider payment reform. Moving gradually toward capitation, bundled payments and outcome-oriented financing mechanisms will matter significantly for chronic disease management.

The third is healthcare workforce retention. Nigeria continues to lose highly trained doctors, nurses and specialists abroad at rates the system struggles to absorb.

The answer is not restricting migration. The answer is making the domestic system competitive enough that staying remains a serious professional option.

Finally, what would “getting it right” actually look like for Nigeria?

It looks like ordinary healthcare interactions becoming predictable, affordable and functional.

It looks like a woman in Bida walking into a primary healthcare centre, presenting her insurance card and receiving quality care without catastrophic payment at the point of service.

It looks like state governments being able to track health outcomes across LGAs in real time and respond quickly when indicators worsen.

It looks like healthcare institutions functioning collaboratively rather than through recurring industrial conflict.

The encouraging part is that much of the legislative and policy architecture already exists. The National Health Act is sound. The BHCPF exists. State insurance laws are expanding.

What remains is execution discipline, and that is something Nigeria can build within the next decade if the political and institutional commitment remains consistent.