In 2014, Nigeria passed its first-ever law, known as the National Health Act, for governing the healthcare system and established the Basic Health Care Provision Fund (BHCPF) as the funding mechanism for achieving Universal Health Coverage (UHC). BHCPF is disbursed through four gateways managed by four specific agencies and committees: the National Primary Health Care Development Agency (NPHCDA) Gateway (45%), which finances direct facility operations, medicines, vaccines, and consumables; the National Health Insurance Authority (NHIA) Gateway (48.75%), which provides insurance coverage to the poorest and most vulnerable Nigerians; the National Emergency Medical Treatment Committee (NEMTC) Gateway (5%), which funds ambulance services and rapid medical response; and the Nigeria Centre for Disease Control (NCDC) Gateway (1.25%), which strengthens state and grassroots capacity to prepare for and respond to public health emergencies.
This is a laudable feat for strengthening Nigeria’s path toward Universal Health Coverage. But the success of any social policy ultimately depends on transparent accountability systems, effective monitoring and evaluation, and sustained political commitment. The COVID-19 pandemic exposed significant weaknesses in health systems worldwide and elevated epidemic preparedness as a central priority in global health financing. Seeking to understand how Nigeria’s preparedness financing architecture functions in practice, my colleagues and I examined the implementation of the BHCPF–NCDC Gateway in Adamawa and Kano States through a project carried out by Connected Development (CODE).
We went in hoping to find evidence of how epidemic preparedness funds were translating into stronger preparedness at the community level across the two states. We came back with something more troubling: in some places, states could not access funds that had already been approved; in others, nobody could clearly account for what happened after the money was disbursed. The deeper we looked, the clearer it became that these were symptoms of wider governance, transparency, and capacity gaps in the operationalisation of the BHCPF-NCDC Gateway.
For example, one of my colleagues sat across from a government official and asked a simple question: How much money had the state received annually through the NCDC Gateway since its establishment? He couldn’t answer. Not because he was hiding anything, but because the data simply did not pass through his office. BHCPF funds, he explained, never enter the state treasury or central depository. They don’t show up on the intake side or the expenditure side of any budget performance report. There is literally a column in the state budget framework labelled “other sources,” built for exactly this kind of external flow, and it has never once been used since the fund began. He sits on the State Oversight Committee, reviews activity reports every quarter, and still has no line of sight into the money itself. If a government official at the state ministry of health can’t see it, I don’t know what we mean when we say BHCPF is “transparent.”
I encountered a different version of the same story in Kano.
While Kano has made deliberate efforts to strengthen its epidemic preparedness architecture, including establishing a state-owned Centre for Disease Control in 2022 and committing ₦1 billion to it in this year’s health budget, its receipts from the NCDC Gateway tell a different story. Since the Gateway was established, Kano has received funding only once: a single ₦13 million tranche in the first quarter of 2022. That finding stayed with me. If a state like Kano, which has comparatively stronger health institutions and a clear budgetary commitment to epidemic preparedness, has struggled to access these funds, what does that mean for states with weaker health systems?
I wanted to understand why. The answer was surprisingly mundane. The State Epidemiologist is a mandatory signatory to the NCDC Gateway account, and the position has changed hands several times. Each transition requires someone to restart a slow bureaucratic process to update the account signatories before another naira can move. In other words, access to critical preparedness financing has been stalled not because the money was unavailable, but because the administrative system could not keep pace with routine personnel changes.
For a state with 44 LGAs, 484 wards, and over 1,700 PHCs – already stretched by migration pressures from the Northeast – that is no small problem. Kano has effectively been locked out of its own emergency preparedness funding by a paperwork bottleneck that no single institution appears to own. What struck me was how easily well-intentioned public programmes can be undermined by the small, often invisible bottlenecks of implementation. We often focus on policy design and funding allocations, but far less attention is paid to whether the administrative machinery needed to sustain those policies can withstand the realities of staff turnover and institutional transitions.
Perhaps the clearest illustration of the problem emerged during our team’s discussions with the Ward Development Committees in Yola North. WDCs are supposed to be co-signatories on PHC facility accounts – that’s the whole design, community oversight built into the system. My colleagues sat with chairmen from eleven wards, and almost every one of them had a version of the same complaint: not inaugurated for two years, financial reports submitted without their consent, signatures bypassed under manufactured urgency. State officials separately confirmed that 29 facilities had signatory mismatches (that is, names on the account that no longer matched who actually held the role) because nobody updated the paperwork after a transfer or retirement. According to one of the respondents, a facility manager, who’d misappropriated roughly ₦7–8 million, was caught due to an official’s refusal to certify the accounts when something looked off. That’s the system working exactly as designed, for once. It’s also the only time we heard it had.
What ties all of this together isn’t corruption, at least not the kind people usually picture. It’s that nobody – not the Budget Officer, not the State Epidemiologist, not the WDC chairman, not our team – was looking at the same set of numbers. Every office we visited had its own partial picture, and none of them connected to the others. One participant in our Adamawa session put it better than I could: “There is no public project… especially if it’s government funding, that you are not supposed to account for.” People kept describing the result as a “trust deficit,” and after our engagements across both states, I understood exactly what they meant.
I don’t think the answer here is another guideline or another committee. Adamawa already has WDCs written into its governance structure; Kano already has a state CDC and serious budget commitment. What’s missing is the boring, unglamorous connective tissue, which is a budget line that actually gets used, a signatory process that survives staff turnover, a WDC that’s actually inaugurated. None of that requires new legislation. It requires institutions that work as intended.
That’s the part I keep coming back to. The fund exists. The money is being released. But somewhere between disbursement and delivery, transparency breaks down. Until that changes, citizens, oversight actors, and even government officials cannot confidently answer the simplest question: Where did the money go?
