Imole Agunbiade (Lead writer)
The state of Nigeria’s Primary Healthcare (PHC) system is concerning. Despite its vital role, only one-in-five facilities nationwide are fully functional. Most of these centres cannot provide essential services, struggling with poor staffing, faulty infrastructure, a lack of essential drugs, and poor-quality healthcare.
In Nigeria today, few issues command as much consensus as the urgent need to strengthen the PHC system to achieve Universal Health Coverage (UHC). Nigeria’s PHCs hold the potential to address 70% of the nation’s disease burden, offering a powerful frontline defense for both treatment and disease prevention.
Data from various health surveys consistently highlight gaps in service delivery, drug availability, infrastructure, and staff motivation at the PHC level. The core issue is not just a lack of resources but a critical deficit in social accountability such as community-based mechanisms for citizens to directly provide feedback and hold health providers accountable for the quality of care.
Social accountability has been emphasised as an important strategy to increase the quality, equity, and responsiveness of health services especially in communities. Social accountability is also a fundamental governance concept that empowers citizens to hold those in power answerable for their actions.
It’s a proactive approach where the public moves beyond simply receiving services to actively shaping them. The 2008 World Health Report which had a focus on PHCs re-emphasises the values of community participation to achieve “people-centred” health systems. The report reframed health service users not as passive patients, but as active citizens with a right to be heard. This means empowering communities to voice their concerns, actively shape health policies in the public interest, and hold both providers and policymakers accountable for the quality of care they receive.
Making social accountability a conversation
Communities, the ultimate beneficiaries and often the most impacted by these health system shortfalls, frequently lack simple, open, and consistent channels to provide feedback, raise concerns, and hold service providers and policymakers accountable.
For instance, a pregnant woman who arrives at a PHC expecting essential maternal and neonatal care may instead encounter inadequate treatment and rude healthcare givers. At this point what does she do? What if there is no social accountability system in place how will her voice be heard and her life and that of her unborn child be safe? This gap leaves communities feeling disempowered, perpetuates inefficiencies, and ultimately jeopardises the nation’s health security, as seen during disease outbreaks where community trust and engagement are paramount.
Between April and May 2025, Nigeria Health Watch conducted a community listening surveyed six states, Lagos, Kano, Niger, Ebonyi, Cross River, and Borno, to understand the state of feedback mechanisms for quality of care.
Out of 6,494 respondents, 59% affirmed the presence of community feedback mechanisms in their community, while 41% reported having none. Of those who had a mechanism in place, a subset of 3,875 people assessed its effectiveness in improving PHC services. 92%, this subset confirmed that the accountability mechanisms were effective, with only 8% stating they were not.
The fact that nearly half of the respondents have no channel to provide feedback on their healthcare experiences is a serious issue. This widespread gap in accountability means that millions of people in Nigeria are still unable to report poor quality of care, express dissatisfaction with services, or raise concerns about public facility conditions.
Social accountability mechanisms for quality primary health care
Effectively strengthening Nigeria’s PHC system demands robust social accountability. The most successful approaches are built on three core principles: simplicity, diverse channels, and data-driven action.
Complex feedback mechanisms often deter participation. The most effective systems meet people where they are. As experts like Dr Shola Dele-Olowu, the Director of Regional Initiatives AMP Health; and Dr Stanley Ukpai, the Director of Projects Development Research and Project Centre stated during a panel discussion at the Africa Primary Healthcare Forum 2025, “the power lies in simple, open, and consistent,” community feedback systems.
A case study of a country that has successfully implemented these three core principles is Ghana. Through initiatives like the District League Table, Ghana has built on the core principle of simplicity, where complex government data is transformed into a simple ranking tool on the quality of their services, including health.
To ensure wide reach, Ghana employs diverse channels, disseminating this data through websites, text messages, radio clips, and posters. This ensures that a wide range of citizens, regardless of their location or literacy level, can access and understand the information.
Empowering voices through diverse channels
To truly empower communities, we must use diverse communication tools. Community scorecards, for example, directly involve community members in assessing PHC performance, leading to actionable insights.
In countries like Ethiopia and Ghana, community scorecards have proven to be a powerful tool for social accountability. By putting citizens at the centre of the process, these countries empower them to actively assess the quality of their health services and collaboratively work with providers to rectify service failures.
Similarly, phone-in radio programmes offer an immediate and widely accessible platform for citizens to voice concerns and receive direct responses. This demonstrates how media can be a crucial tool for bridging the accountability gap, empowering communities to engage directly with the health system.
Nigeria Health Watch has also promoted accountability and feedback by training and supporting community reporters in Kano, Niger, Kaduna, and Lagos States to document the state of PHCs and the experiences of patients and healthcare workers in their local communities.
The PHC Accountability Tracka by BudgiT is a prime example of how digital tools can be a springboard for accountability. The tracker allows citizens to directly report on the condition of a PHC in their community and provides a state dashboard for constant oversight on healthcare delivery. These tools demonstrate that accountability is not just about reports or audits — it’s about opening spaces for real voices to be heard and acted upon.
Recommendations
To truly strengthen social accountability requires a concerted effort from all stakeholders, with clear roles for government and healthcare providers. The government should integrate simple yet effective community feedback mechanisms — such as simplified scorecards. Policymakers should also leverage digital platforms, like the PHC Accountability Tracka, to enable citizens to report on PHC conditions and track the quality of care.
Policymakers should partner with local radio stations to create regular, interactive “health accountability” phone-in programmes. This approach allows for direct citizen engagement, immediate feedback, and a platform for public dialogue that can drive real change.
The journey to achieving UHC and robust health security in Nigeria is arduous, but it is not insurmountable. By truly listening to the voices of our communities — through simple, open, and consistent feedback channels, Nigeria can transform its PHC system.