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African health care systems are often portrayed as a uniform archetype: underfunded, understaffed, donor-dependent, and chronically unable to translate development rhetoric into reliable service delivery. That framing is analytically convenient but misleading. Ethiopia and Nigeria — two of Africa’s most important states in demographic, political, and symbolic terms — illustrate this diversity very clearly. They share severe fiscal constraints, they both declared universal health coverage (UHC) as a strategic objective, and both are struggling with rapidly growing burdens of non-communicable diseases alongside persistent tuberculosis, malaria, and maternal mortality. Yet the logic of their health systems is fundamentally different. Ethiopia represents a state-driven, community-based primary care model that has produced impressive, low-cost gains but has proven vulnerable to political breakdown. Nigeria represents a market-heavy, institutionally fragmented system with far more money in absolute terms, but where outcomes remain dramatically worse. Comparing them reveals that the principal problem in African healthcare is not a lack of knowledge or even a lack of financing per se, but rather structural political economy constraints and weak institutional accountability.
According to WHO data, Ethiopia has approximately 0.1 physicians per 1,000 population, while Nigeria has around 0.4. Life expectancy in Ethiopia is approximately 66 years, while in Nigeria, it remains even lower. Ethiopia spends approximately 2.8% of its GDP on health, Nigeria about 3%. But per capita, the difference is striking: Ethiopia, around USD 25–30, Nigeria, roughly USD 60–70. And yet maternal mortality in Ethiopia dropped from around 1,000 per 100,000 live births in 2000 to approximately 267 in 2020. In Nigeria, maternal mortality remains one of the worst globally, around 1,000 per 100,000 — a figure closer to conditions of civil-war-era Sierra Leone than to the supposed continental “giant” with one of Africa’s largest economies. Numbers like these reveal the paradox of the Nigerian model: more money in the system does not necessarily lead to better outcomes if that money flows through unregulated private channels, trust is low, insurance penetration is minimal, and the majority of actual care is financed through out-of-pocket payments.
Ethiopia: an ambitious state, a fragile system
Ethiopia’s health care system was globally recognized in the 2000s and 2010s as one of the strongest success stories in community health among low-income countries. The Health Extension Program, which trains tens of thousands of female community health workers, is one of the most significant public health experiments on the continent. In rural Oromia, Amhara, SNNPR, Somali, and Afar regions, the expansion of vaccination coverage, maternal health support, family planning, and basic disease surveillance was achieved with exceptionally low per-capita cost. Ethiopia became, for a time, a positive example in global health literature: a demonstration that a government with political will could achieve huge gains without focusing on quick profits.
However, this success was superficially institutionalized and closely tied to the political order. When the Tigray war erupted in 2020, and later when violent conflict spread to Amhara and insecurity escalated in Oromia, the system collapsed at a rapid pace. Thousands of health posts, clinics, and hospitals were destroyed or looted. The inflation shock — 30–40% annual inflation — shredded budget predictability. Community health insurance premiums became unaffordable for households that saw incomes collapse, especially after COVID-19 added an external shock to domestic instability. Ethiopia remains donor-dependent for many key vertical programmes — immunization, HIV, TB, and pharmaceuticals — and donor agencies themselves struggled to operate amid the war. Ethiopia, therefore, exemplifies an uncomfortable truth: a system can be technically well-designed, socially legitimate, and locally effective — and still be institutionally fragile if the state that underpins it comes under military, territorial, and fiscal stress.
Nigeria: a giant with weak legs
Nigeria, in contrast, appears to have sufficient funds (at least at first glance). But the governance structure is extraordinarily fragmented. Federal and state competencies overlap; responsibility is diffuse; political cycles are driven not by policy but by patronage. Roughly 70% of spending is out-of-pocket. Lagos, Abuja, and Port Harcourt have private clinics that meet middle-income standards, but they serve a small elite. For most Nigerians, the health system is essentially cash-based and unpredictable. People delay care until symptoms become life-threatening. Insurance penetration is marginal, and most of the population never interacts with the National Health Insurance Authority in a meaningful way. The result is a health care economy, where spending is high in aggregate terms but dramatically unequal in distribution, and where inequality directly translates into increased mortality.
Perhaps the most devastating challenge in Nigeria is the brain drain. The Nigerian Medical Association and WHO/UNDP estimates suggest Nigeria loses thousands of doctors every year to the UK, Canada, and the Gulf. The cost is not only the loss of human capital but the loss of future institutional learning, and Nigeria bears the training cost for countries that poach its workforce. Monetary calculations suggest annual losses of USD 1.5–2 billion once training costs plus lost productivity are combined. Unlike Ethiopia, which retained most of its health workforce until the war disrupted everything, Nigeria’s deterioration is chronic, not sudden, a slow institutional bleeding out.
The meaning of the contrast
The Ethiopia–Nigeria contrast exposes the core structural dilemma of African health systems:
Ethiopia demonstrates that political will — when stable — can deliver tangible outcomes, even at low-income levels. Nigeria demonstrates that economic size is meaningless if the state cannot effectively convert resources into equitable health outcomes. Both countries talk about UHC. Neither is realistically on a path to reach it because neither has the fiscal space to sustain a public system at scale. The internationally accepted lower threshold for sustainable UHC is about 6% of GDP health spending. Neither country currently reaches even half of that.
Ethiopia’s model is one of centralization: when the center works, the periphery receives services; when the center collapses, the periphery collapses with it. Nigeria’s model is decentralisation through dysfunction: the centre is too weak to enforce accountability, and therefore, no region becomes a genuine model of success except in isolated urban pockets.
What they share — and this is the real continental problem — is dependency: dependency on external funding for critical programmes, dependency on imported medicines, dependency on foreign recognition, training, and visas for their best doctors. Africa imports around 99% of its vaccines and 80–90% of its pharmaceuticals. No country — not even the richest African states — can achieve health sovereignty without developing its own continental manufacturing capabilities.
Conclusion
Ethiopia demonstrates that progress is possible with limited financial resources but high state capacity. Nigeria demonstrates that money alone does not guarantee progress without adequate state capacity. The next decade will determine whether either of them can expand fiscal space, retain health workers, and reduce reliance on narrow, donor-dependent vertical programmes. If not, inequality will deepen — not only between Africa and the rest of the world, but inside each African society itself.
