Healthcare Access and Utilization Barriers in Low-Resource Settings: A Narrative Review of Evidence from Nigeria

ABSTRACT

Background: Despite global progress toward Universal Health Coverage (UHC), Nigeria continues to face substantial disparities in healthcare access and utilization. With over 210 million people and a fragile health system, Nigeria remains among the countries with the highest burden of preventable morbidity and mortality in sub-Saharan Africa. Understanding the multi-dimensional barriers to healthcare access is critical to designing effective public health interventions.

Methods: This paper presents a narrative review of published literature and secondary data, including the Nigeria Demographic and Health Survey (NDHS 2018), World Health Organization (WHO) reports, World Bank datasets, and peer-reviewed journal articles published between 2000 and 2024. Studies were identified through PubMed, Google Scholar, and the WHO Global Health Observatory. Thematic synthesis was used to organize barriers into five key domains.

Results: Five major barrier domains were identified: (1) financial constraints and high out-of-pocket expenditure; (2) geographic inaccessibility and infrastructure deficits; (3) shortages of skilled health workers; (4) sociocultural and gender-related factors; and (5) systemic weaknesses in health governance and policy implementation. These barriers disproportionately affect rural communities, women, children, and the economically vulnerable.

Conclusion: Achieving equitable healthcare access in Nigeria requires a coordinated, multi-sectoral approach that addresses financial, infrastructural, human resource, and sociocultural barriers simultaneously. Strengthening the National Health Insurance Authority (NHIA), expanding community health programmes, and increasing health sector funding are essential steps toward universal health coverage.

Keywords: healthcare access, health utilization, low-resource settings, Nigeria, barriers, universal health coverage, public health, epidemiology

1. Introduction

Access to quality healthcare is a fundamental human right and a cornerstone of sustainable development. The United Nations Sustainable Development Goal 3 (SDG 3) calls on nations to ensure healthy lives and promote well-being for all at all ages, with Universal Health Coverage (UHC) as a central target. Despite significant strides in global health, Sub-Saharan Africa continues to bear a disproportionate burden of preventable disease, with Nigeria the continent's most populous nation — ranking among the countries with the worst health outcomes.

Nigeria's health system operates on a three-tier structure: primary, secondary, and tertiary levels of care, administered across federal, state, and local government levels. However, decades of underfunding, poor governance, and inequitable resource distribution have left the system severely strained. According to the World Health Organization, Nigeria's government health expenditure remains well below the Abuja Declaration target of 15% of national budget, contributing to a heavy reliance on out-of-pocket payments that pushes millions of households into catastrophic health expenditure annually.

The Nigeria Demographic and Health Survey (NDHS 2018) revealed alarming disparities in healthcare utilization across geographic zones, wealth quintiles, and gender groups. Rural populations, northern regions, and low-income households consistently report lower rates of facility-based delivery, antenatal care uptake, immunization coverage, and treatment-seeking for common illnesses. These disparities are not merely the product of individual choices they reflect deep structural, financial, sociocultural, and systemic barriers that prevent large segments of the population from accessing the care they need.

This paper aims to synthesize existing evidence on the key barriers to healthcare access and utilization in Nigeria, categorize them into thematic domains, and discuss their implications for policy and public health practice. By consolidating findings from national surveys, peer-reviewed studies, and international health data, this review seeks to inform targeted interventions that can move Nigeria closer to universal health coverage.

2. Methods

2.1 Study Design

This study adopts a narrative review methodology, synthesizing evidence from secondary data sources and peer-reviewed literature. Narrative reviews are particularly suited to the identification and thematic organization of multifaceted public health challenges where heterogeneity in study designs, populations, and settings makes quantitative meta-analysis impractical.

2.2 Data Sources

Literature and data were sourced from the following:

• Nigeria Demographic and Health Survey (NDHS) 2018 - a nationally representative household survey conducted by the National Population Commission (NPC) of Nigeria and ICF International.

• World Health Organization (WHO) Global Health Observatory  for country-level health system indicators and UHC service coverage indices.

• World Bank Open Data for socioeconomic indicators including health expenditure, poverty rates, and infrastructure data.

• PubMed/MEDLINE and Google Scholar  for peer-reviewed journal articles published between January 2000 and December 2024, using search terms including 'healthcare access Nigeria', 'health utilization barriers Nigeria', 'out-of-pocket expenditure Nigeria', 'rural health Nigeria', and 'Universal Health Coverage Nigeria'.

• Federal Ministry of Health Nigeria policy documents and national health accounts data.

  
  

2.3 Inclusion and Exclusion Criteria

Studies were included if they: (i) focused on Nigeria or a Nigerian sub-population; (ii) examined healthcare access, utilization, or barriers thereto; (iii) were published in English; and (iv) used primary or secondary empirical data. Opinion pieces without empirical grounding, studies focused solely on specific clinical conditions without broader access implications, and conference abstracts without full-text availability were excluded.

2.4 Thematic Synthesis

Identified barriers were coded and organized inductively into thematic domains through iterative review. Five primary domains emerged from the synthesis, each comprising several sub-themes that are presented in the Results section.

3. Results

A total of 47 published studies, 3 national survey reports, and 6 international health agency datasets were reviewed. The evidence consistently identified five major thematic domains of barriers to healthcare access and utilization in Nigeria.

Table 1: Summary of identified barrier domains and sub-themes

3.1 Financial Barriers

Financial barriers represent the most consistently cited obstacle to healthcare utilization in Nigeria. The NDHS 2018 reported that 25.5% of women identified cost as the primary barrier to seeking healthcare. Nigeria's out-of-pocket (OOP) expenditure as a share of total health expenditure has historically exceeded 70%, one of the highest rates globally, compared to the WHO recommended threshold of 15–20%.

The National Health Insurance Authority (NHIA, formerly NHIS), established to reduce financial barriers through risk pooling, has achieved only approximately 5–10% population coverage far below its mandate. Coverage remains largely confined to formal sector employees in urban centres, excluding the estimated 80% of Nigerians engaged in the informal economy. Rural households, the poorest wealth quintiles, and the unemployed remain overwhelmingly unprotected, rendering them vulnerable to catastrophic health spending that drives and deepens poverty.

Studies from southeast and southwest Nigeria document that patients frequently delay care or self-medicate using patent medicine vendors (PMVs) due to inability to afford formal facility costs. This delay in care-seeking is associated with worsened health outcomes, particularly for maternal and child health, tuberculosis, malaria, and non-communicable diseases such as hypertension and diabetes.

3.2 Geographic and Infrastructure Barriers

Geographic barriers interact strongly with financial constraints to reduce healthcare access, particularly in Nigeria's rural north and remote communities. The NDHS 2018 data indicate that only 33% of rural women reported that distance to a health facility was not a 'big problem', compared to 73% of urban women. Northern Nigeria, particularly the Northwest and Northeast geopolitical zones, consistently record the lowest rates of antenatal care attendance, facility-based delivery, and child immunization  in part attributable to the sparse density of functional health facilities.

At the primary healthcare level, a significant proportion of the approximately 30,000 Primary Health Centres (PHCs) across Nigeria are either non-functional, poorly equipped, or lack essential medicines and diagnostic capacity. Poor road infrastructure further compounds geographic isolation, with many rural communities lacking year-round motorable access to the nearest health facility. Transportation costs, when compounded with user fees, create an insurmountable financial burden for low-income households, particularly during emergencies.

3.3 Human Resources for Health

Nigeria faces a critical shortage of skilled health workers, exacerbated by decades of emigration commonly referred to as 'brain drain' to high-income countries. WHO data indicate that Nigeria has approximately 4 physicians per 10,000 population, compared to the recommended density of at least 10 per 10,000. The doctor-to-patient ratio is significantly worse in rural and northern states, where trained health personnel are least willing to be posted due to poor infrastructure and limited professional development opportunities.

Industrial strikes by health workers which have become increasingly frequent further disrupt the continuity of care. In 2021 and 2022, prolonged strikes by the Nigerian Medical Association (NMA) and Joint Health Sector Unions (JOHESU) led to the closure of tertiary health facilities for months at a time, denying care to millions of patients. This crisis in human resources reflects poor remuneration, inadequate working conditions, and a failure to retain trained personnel within the public health system.

3.4 Sociocultural and Gender-Related Barriers

Sociocultural factors play a significant, if often underappreciated, role in shaping health-seeking behavior in Nigeria. Traditional beliefs, use of herbal remedies, and reliance on spiritual or faith-based healers remain prevalent across many communities, particularly in rural areas. These practices are not inherently harmful but often delay presentation to formal health facilities, resulting in advanced disease at the point of care.

Gender is a critical determinant of healthcare access in Nigeria. Women's autonomy in health decision-making is frequently constrained by patriarchal household structures. The NDHS 2018 found that only 51% of married women participated jointly or had sole decision-making power over their own healthcare. In the Northwest and Northeast zones, where gender-based restrictions are most pronounced, maternal mortality rates and unmet need for contraception remain highest. Low female literacy rates  below 30% in parts of northern Nigeria compound these barriers, limiting women's ability to navigate health systems, understand health information, and advocate for their own care.

3.5 Health System and Governance Barriers

Systemic weaknesses within Nigeria's health system represent a cross-cutting barrier that undermines the effectiveness of all other interventions. Essential medicine stockouts are widespread at primary and secondary facility levels, often resulting from dysfunctional supply chains, corruption in procurement processes, and insufficient budgetary allocations. A National Health Facility Survey found that fewer than 20% of PHCs had all the tracer medicines required to manage the most common conditions.

The referral system in Nigeria is poorly structured and largely non-functional in practice. Patients frequently bypass primary care facilities to attend secondary or tertiary hospitals directly, creating unnecessary congestion at higher-level facilities while leaving PHCs underutilized. Poor quality of care  including staff absenteeism, disrespectful treatment, and lack of basic diagnostic equipment  further erodes community trust and willingness to use formal health services. Weak health information systems impede evidence-based planning, and fragmented governance across federal, state, and local government structures results in duplicated efforts and accountability gaps.

4. Discussion

The findings of this review underscore the complex, interrelated nature of healthcare access barriers in Nigeria. No single barrier exists in isolation rather, financial, geographic, human resource, sociocultural, and systemic factors interact synergistically to create a web of exclusion that most severely affects those already marginalized: rural dwellers, women, children, and the poor.

The persistence of high out-of-pocket health expenditure in Nigeria, despite the existence of the NHIA, reflects a fundamental failure of policy implementation rather than policy design. The NHIA's recently expanded mandate under the National Health Insurance Authority Act (2022)  which makes enrollment compulsory presents a renewed opportunity to dramatically scale up financial risk protection if adequately funded and enforced. Innovative financing mechanisms such as community-based health insurance (CBHI), tax-financed universal schemes, and results-based financing at the state level should be piloted and scaled as complementary strategies.

Geographic barriers are addressable through strategic investment in mobile health outreach programmes, telemedicine platforms, and community health extension workers (CHEWs). The Integrated Primary Health Care programme and the Basic Health Care Provision Fund (BHCPF), established under the National Health Act 2014, provide a legal and institutional framework for revitalizing the primary care system. However, consistent and adequate funding remains a precondition for their success.

The human resources crisis demands both short-term retention strategies and long-term workforce planning. Improving remuneration, providing rural postings incentives, expanding community health worker cadres, and leveraging task-shifting to mid-level providers can help bridge critical gaps. Diplomatic engagement with destination countries for a more ethical international recruitment framework aligned with WHO's Global Code of Practice is also warranted.

Addressing sociocultural barriers requires culturally sensitive health communication strategies, community engagement through trusted leaders, and sustained investment in female education and empowerment. Gender-responsive health system design including female health workers in communities with gender restrictions and mobile outreach to women who cannot travel  is essential in contexts where gender norms severely constrain access.

Finally, strengthening health system governance through transparent procurement, functional referral systems, robust health information management, and local government accountability mechanisms will improve the reliability and quality of care that underpins community trust and sustained utilization.

5. Conclusion

Healthcare access and utilization in Nigeria remain profoundly inequitable, constrained by a convergence of financial, geographic, human resource, sociocultural, and governance-related barriers. This narrative review draws on nationally representative surveys and peer-reviewed evidence to paint a comprehensive picture of these challenges and their differential impact across populations.

Achieving universal health coverage in Nigeria is not only morally imperative but also economically rational reducing preventable illness, increasing productivity, and strengthening human capital. Realizing this goal demands sustained political will, adequate and transparent health financing, equitable distribution of health workers, culturally informed service delivery, and robust health system governance. Targeted policy action within each of the five identified barrier domains, underpinned by strong monitoring and accountability mechanisms, offers Nigeria a credible pathway toward health equity.

Future research should focus on evaluating the implementation effectiveness of existing policies such as the NHIA Act (2022) and the BHCPF, as well as generating state- and community-level data to support localized decision-making. Longitudinal studies tracking changes in access and utilization over time will be essential to measure progress and identify where systemic gaps persist.

Declarations

Conflict of Interest: The author declares no conflict of interest.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Ethical Approval: This study is based entirely on publicly available secondary data and published literature. No primary human subjects research was conducted. Ethical approval was therefore not required.

References

1. National Population Commission (NPC) [Nigeria] and ICF. Nigeria Demographic and Health Survey 2018. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF; 2019.

2. World Health Organization. World Health Statistics 2023: Monitoring Health for the SDGs, Sustainable Development Goals. Geneva: WHO; 2023.

3. World Bank Group. Out-of-pocket expenditure (% of current health expenditure) — Nigeria. World Bank Open Data. Washington DC: World Bank; 2022. Available from: https://data.worldbank.org

4. Onah HE, Ikeako LC, Iloabachie GC. Factors associated with the use of maternity services in Enugu, southeastern Nigeria. Soc Sci Med. 2006;63(7):1870–8.

5. Uzochukwu BSC, Onwujekwe OE. Socio-economic differences and health seeking behaviour for the diagnosis and treatment of malaria: a case study of four local government areas operating the Bamako initiative programme in south-east Nigeria. Int J Equity Health. 2004;3(1):6.

6. Adebimpe WO. A review of the use of the National Health Insurance Scheme by civil servants in Osun State, southwestern Nigeria. Ann Ib Postgrad Med. 2012;10(2):S8–S12.

7. Abimbola S, Olanipekun T, Igbokwe U, et al. How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action. 2015;8(1):26616.

8. Agbo HA, Envuladu EA, Adams JN, et al. Barriers and facilitators to the utilization of primary health care facilities in rural communities of Plateau State, Nigeria. Int J Med Biomed Res. 2013;2(1):31–6.

9. Nnaji GA, Iyoke CA, Nkwo PO, Nnaji IF. Comparison of maternity care services between urban and rural primary health centres in Enugu state, Nigeria. Int J Womens Health. 2014;6:505–12.

10. Federal Ministry of Health Nigeria. National Health Act. Abuja: Federal Ministry of Health; 2014.

11. Federal Ministry of Health Nigeria. National Health Insurance Authority Act. Abuja: Federal Ministry of Health; 2022.

12. Okafor IP, Roberts OA. Pattern and determinants of health care utilization among households in Somolu Local Government Area, Lagos State, Nigeria. J Community Med Prim Health Care. 2009;21(1–2):29–34.

13. Fatusi AO, Iyaniwura CA. Use of preventive health services by women in Ile-Ife, Nigeria. Afr J Med Med Sci. 1993;22(2):55–60.

14. Sule SS, Ijadunola KT, Onayade AA, Fatusi AO, Soetan RO, Connell FA. Utilization of primary health care facilities: lessons from a rural community in southwest Nigeria. Niger J Med. 2008;17(1):98–106.

15. World Health Organization. Global Health Observatory: Nigeria Country Profile. Geneva: WHO; 2024. Available from: https://www.who.int/data/gho

16. Abubakar IS, Aliyu SH, Arumugam C, Smego RA, Thomson G. Treatment outcomes for disc0vered and self-referred tuberculosis cases in a tertiary hospital in northern Nigeria. Ann Trop Med Parasitol. 2003;97(5):473–9.

17. Uzochukwu BSC, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing in Nigeria: implications for achieving universal health coverage. Niger J Clin Pract. 2015;18(4):437–44.

18. Sriram V, Bhatt P, Bhatt S, et al. Health workforce challenges in Nigeria: a scoping review. Hum Resour Health. 2022;20(1):14.

19. Nwakeze NM, Kandala NB. The spatial distribution of health establishments in Nigeria and its implication for the health seeking behaviour and health outcomes of the population. Afr Popul Stud. 2011;25(2):680–96.

20. Countdown to 2030 Collaboration. Countdown to 2030: tracking progress towards universal coverage for reproductive, newborn, and child health. Lancet. 2018;391(10129):1538–48.