In Nigeria, the deadliest barrier to health isn’t the absence of medical solutions—it’s the absence of money.

Picture a mother in rural Bayelsa. At dawn, she straps her feverish baby to her back and begins the long walk to the nearest clinic. After hours on foot, she finally arrives—only to be told she must pay a small registration fee. She has nothing. So she turns back. The care exists, the cure exists. But for her, it might as well be a thousand miles away.

For millions of families like hers, “access” exists on paper, but poverty makes it an illusion. Poverty, not pathogens, is the silent killer.

Poverty and Health: Inseparable Crises

Nigeria’s health challenges are almost inseparable from its poverty profile. With 133 million Nigerians (63%) living in multidimensional poverty, families face deprivation not just in income but in nutrition, sanitation, and access to services. Health statistics mirror these inequalities: Nigeria contributes nearly one-quarter of global maternal deaths, and under-five mortality remains stubbornly high, with the poorest households hit hardest.

And yet, medical infrastructure exists. Skilled doctors exist. Life-saving drugs exist. However, they are often reserved—by default—for those with an income level above a certain threshold. For everyone else, “access” is theoretical. It exists in policy briefs, not in lived reality.

Behind each statistic is a face. A child who misses a simple immunization because transport to the health post costs too much. A father who sells his only motorcycle to pay for hospital admission. A pregnant woman who risks delivery at home because the clinic is too far and the costs are too high. These are not failures of medicine; they are failures of affordability.

Interestingly, it’s a story not unique to Nigeria. In the United States, uninsured patients often find themselves standing outside hospitals that could treat them, but the cost keeps them away. Some go in and are buried under debt. Others don’t, and pay with their lives.

The Health Value Chain through the Poverty Lens

For poor families, prevention is a luxury. Malnutrition, the hidden driver of under-five deaths, remains high because families cannot consistently afford nutritious food. Immunization campaigns often record lower coverage in poor communities, not because of reluctance, but because of transport costs, lost wages, and hidden fees.

Nigeria’s Primary Health Care (PHC) system should be the backbone of equitable health access, but poverty weakens its reach. Facilities in poor communities are under-resourced, poorly staffed, or too far to access affordably. You find situations where women must travel hours at their own cost for antenatal care. Even where services are officially “free,” informal payments or stock-outs shift the burden back to families.

Ideally, this is the area where the NHIS should act as a buffer for access. The National Health Insurance Authority (NHIA) Act (2022) made health insurance mandatory and promised subsidized coverage. Yet as of 2024, only 19.4 million Nigerians (less than 10% of the population) were enrolled. Families pay 95% of private health costs from their pockets – the highest in Africa.

For poor households, referral to a secondary or tertiary hospital can mean selling farmland, withdrawing children from school, or simply abandoning treatment. Health care becomes a financial death sentence. For the poor, premiums remain out of reach. In an economy where most workers earn and spend informally, enrollment without full subsidy is unrealistic. The result is a scheme that risks widening inequality rather than reducing it.

Across this chain, poverty is the common denominator that erodes quality, blocks access, and undermines outcomes.

Healthcare and Poverty

Every reform in Nigeria’s health sector will succeed or fail depending on whether it accounts for the daily economic realities of the poorest households. Designing Nigeria’s health financing reforms, such as the Basic Health Care Provision Fund (BHCPF), the National Health Insurance Authority (NHIA), and the ongoing Primary Health Care (PHC) revitalization, with poverty in mind, is not optional. It is the only way to ensure that services are not just available on paper, but actually accessible and affordable for families who need them most.

Evidence shows that progress on SDG 1 (No Poverty) and SDG 3 (Good Health and Well-being) is inseparable. A household lifted out of poverty is more likely to afford nutritious food, safe delivery, and preventive care. In turn, healthier families are more productive, less indebted, and better able to escape deprivation.

What must be done

If poverty is the missing prescription in Nigeria’s health system, reforms must be designed to integrate poverty reduction at every level. This requires financing, governance, and delivery mechanisms that match the scale of need.

Nigeria must move decisively toward fully subsidized health insurance for its poorest households. The NHIA Act provides a legal framework, but without automatic enrollment and premium coverage, the poor remain excluded. Subsidies for at least the poorest 40%, which is roughly 80 million people, are not optional but essential. Using the National Social Register, vulnerable households can be auto-enrolled to ensure no family is excluded simply because they cannot pay.

Financing such subsidies will be challenging but achievable. Nigeria spends less than 5% of its annual budget on health, well below the 15% Abuja Declaration target. Redirecting even a fraction of fuel subsidy savings could sustainably finance insurance for the poorest. What is required is political will to place poverty reduction at the center of health financing, rather than leaving households to shoulder 95% of costs privately.

Protecting women and children must also be a national priority. Nigeria contributes nearly 20% of global maternal deaths, and the likelihood of survival is sharply shaped by income and location. Guaranteeing free maternal and child health services at the PHC level (antenatal care, safe delivery, immunization, and under-five treatment) would save lives. The Basic Health Care Provision Fund (BHCPF) should reimburse facilities directly, removing informal charges. Ethiopia’s experience shows that eliminating fees increases utilization dramatically; Nigeria can achieve similar results if women know that cost will never be a barrier.

Strengthening PHC in poor and rural communities requires more than renovating buildings. Nigeria has just 40 doctors per 100,000 people, far below the WHO recommendation, and most are concentrated in urban centers. Investment must focus on deploying health workers to underserved areas through incentives, training of community health extension workers, and ensuring reliable drug supply chains. For many poor families, distance is as fatal a barrier as cost. Transport networks must be strengthened so that living in poverty does not mean living hours away from functioning care.

Because health is a concurrent responsibility, federal promises will only succeed if states and local governments are aligned. State health insurance schemes must integrate with the NHIA, and LGAs must maintain PHC facilities. Without stronger intergovernmental accountability, reforms will remain trapped at the federal level, never reaching the families who need them most.

Private and community actors also play a central role. Over 60% of Nigerians first seek care from private providers, particularly pharmacies and patent medicine vendors. Partnering with these actors to deliver insured services, backed by government subsidies, can expand reach faster than relying solely on public facilities. Community health workers are equally vital but require training, fair pay, and proper integration into the formal system.

Finally, no reform can succeed without tackling governance and corruption. Nigeria loses billions to leakages in health financing, and funds like the BHCPF have been plagued by delays and misuse. Transparency alone is insufficient. Independent monitoring, citizen scorecards, and digital platforms to track disbursements are essential to ensure resources reach facilities and patients. Without such safeguards, even well-designed reforms will leave poor households unprotected.

Conclusion

Until we treat income inequality and economic exclusion as health emergencies, we will continue to lose lives—not because we didn’t know what to do, but because we didn’t make it affordable to do it.

A mother’s ability to save her child should not depend on whether she has cash in her pocket. Yet for millions of Nigerian families, it does. Poverty is the silent diagnosis behind too many preventable deaths. If we truly believe health is a right, then poverty reduction is the treatment plan we can no longer ignore. Ending poverty is Nigeria’s most urgent health intervention and the only way to ensure no child’s survival is left to chance.