By Sola Ogundipe
Reform of the global health architecture is now being driven by a Member State-led process established by the 79th World Health Assembly in May 2026.
Hosted by the World Health Organisation (WHO), it brings together UN agencies, Gavi, the Global Fund, the Pandemic Fund, the World Bank and regional health organisations to develop a more coherent, country-led system with clearer mandates and financing aligned with national priorities.
The reform options will go before participating institutions’ governing boards between late 2026 and February 2027, ahead of recommendations to the World Health Assembly in May 2027. The process is linked to the UN80 reform initiative and Africa’s Accra Reset, which promotes health sovereignty. In this interview, the World Health Organisation (WHO) Representative and Head of Mission, Nigeria, Dr. Pavel Ursu, reflects on the Global Health Architecture Reform from the country level perspective.
Excerpts:
What the reset means for health outcomes in Nigeria
The first point is that the reset is a Member State-driven process. As institutions and partners in global health, we respect that process and look forward to its outcomes and the decisions of Member States on how we should focus and adapt our work. The structural questions being considered are important, and the reshaping of the global health architecture should follow this process. However, if you ask what this should ultimately mean for Nigerians, my perspective is pragmatic. The reset itself will not change health outcomes in Nigeria, certainly not in the short term. What matters is whether the changes it produces help countries translate resources, partnerships and technical capacity into stronger services and better health outcomes. For a mother in Sokoto or a child in Borno, the global health architecture is quite distant. What matters is whether it strengthens the services people depend on: primary healthcare, functioning supply chains, surveillance and laboratory systems, and adequately equipped and supported health workers.
Countries do not have to wait for the global process to accelerate progress. When governments invest domestic resources through national plans, strengthen accountability and align partners behind national priorities, they build the foundations that any future global health architecture should support. Nigeria already has important foundations through the Health Sector Renewal Investment Initiative and the Sector-Wide Approach (SWAp). These offer opportunities to strengthen country ownership, partner alignment and accountability. The Joint Annual Review, alongside quarterly performance reviews, should go beyond assessing progress to identifying bottlenecks, correcting course and accelerating measurable results.
The Lusaka Agenda and Africa’s Accra Reset reinforce this direction towards greater country leadership and stronger alignment of global health initiatives with national priorities. Nigeria has an opportunity not only to accelerate its own progress but also to demonstrate what country-led transformation can achieve. Ultimately, the test of the reset will be whether it enables countries such as Nigeria to lead more effectively, mobilise sustainable domestic financing, coordinate partners behind national priorities and translate these efforts into better health outcomes.
Role of country capacity in achieving impact
National capacity is the pillar on which the others rest. Sustainable progress depends on countries being able to plan, finance, deliver, measure and continuously improve health services. International support is most effective when aligned with national priorities, systems and accountability mechanisms. I would assess any proposal, whether it involves merging agencies, pooling funds or setting timelines for reducing external aid, against one question: will it leave Nigeria’s health system more capable five years from now than it is today?
Where results should show: Polio and immunisation
Nigeria was certified free of wild poliovirus in 2020, a remarkable national achievement that many once considered impossible. However, variant poliovirus continues to circulate. According to the Global Polio Eradication Initiative’s October 28, 2026 update, Nigeria had reported 36 type 2 variant cases this year, down from 66 in 2025, alongside 15 type 3 cases, up from eight. The August IHR Emergency Committee noted that Nigeria remains the largest contributor to the global variant poliovirus caseload.
The priority now is improving delivery and making better use of limited resources. Transmission is concentrated in a number of local government areas in the North-West, where campaign quality, access and routine immunisation remain weak. We are working with NPHCDA and state governments to address each of these LGAs as a specific delivery challenge, with clearly assigned responsibilities, weekly performance reviews and a focused set of indicators. Rather than applying uniform national measures, interventions must respond to local realities. A better-aligned global health architecture can help by providing predictable funding for targeted interventions, but Nigerian programme managers must lead implementation on the ground.
Where routine immunisation stands
This is where polio will ultimately be won or lost. WHO and UNICEF estimates put Nigeria’s zero-dose children at approximately 2.2 million in 2025. National administrative data often show higher immunisation coverage than surveys and modelled estimates. That discrepancy highlights the need to improve data quality and population denominators. The surveillance systems, microplanning structures and community networks built around polio must increasingly support routine immunisation and primary healthcare. Making that transition is one of Nigeria’s most important health system capacity challenges.
Making global funding instruments work for malaria, TB and HIV
External investments have saved millions of lives globally and remain important. However, their effectiveness must be measured against the disease burden. WHO’s World Malaria Report 2025 estimates that Nigeria accounted for 24.3 per cent of global malaria cases and 30.3 per cent of deaths in 2024, representing approximately 68.5 million cases and 185,000 deaths. Nigeria therefore carries the largest share of the global malaria burden.
A country facing this level of burden needs malaria funding to do more than procure commodities. It must also strengthen surveillance, disease stratification and subnational management to ensure that bed nets, chemoprevention and vaccines reach the populations where they can have the greatest impact.
The tuberculosis control programme demonstrates what is possible. National notifications increased from approximately 107,000 in 2018 to 459,000 in 2025, against WHO’s estimated annual burden of about 510,000 new cases. This progress is largely attributed to improved diagnostics, private-sector engagement and active case-finding. The remaining detection gap and low enrolment for drug-resistant TB treatment are now key priorities.
HIV presents a more urgent transition challenge. Nigeria’s response has relied heavily on external funding, with PEPFAR historically supporting much of the treatment programme. The National HIV and AIDS Strategic Plan 2026–2030 and the government’s US$346 million co-financing commitment for HIV, TB and malaria in 2026 are important signals.
The priority now is ensuring that these commitments are released on time and that services are integrated into primary healthcare and health insurance without disruption.
What would make global funding instruments more effective?
Three things are important. First, investments must align with national health priorities, plans and annual operational frameworks, while strengthening country systems and accountability. Second, funding must predictably support the shared capacities on which all programmes depend, including health information systems, supply chains, the health workforce and primary healthcare. Third, governments and partners need joint transition plans with clear milestones to ensure that domestic financing increases as external support declines, rather than after funding gaps emerge.
Nigeria’s domestic financing and response to declining external funding
Domestic financing is critical to sustainability. Nigeria has established important policy foundations. The 2022 National Health Insurance Authority Act made health insurance coverage mandatory, while NHIA reports that enrolment had risen to more than 22 million by mid-2026. This represents progress from the low coverage levels that persisted for nearly two decades before the Act.
However, it still covers only about one in 10 Nigerians, leaving most people exposed to out-of-pocket healthcare costs. Enrolment alone does not guarantee financial protection or quality care. The next phase must extend coverage to informal-sector workers and poorer households while tracking not just who is registered but also what people pay and the quality of services they receive.
Effect of the reset on maternal mortality
Reducing maternal mortality remains one of Nigeria’s most important health priorities. UN inter-agency estimates put the country’s maternal mortality ratio at approximately 993 deaths per 100,000 live births in 2023
However, national and other estimates differ considerably, sometimes by almost half. For instance, the 2024 Nigeria Verbal Autopsy and Social Autopsy Study (NVASA) puts the ratio at 572 deaths per 100,000 live births.
We are working with the government and partners to improve measurement. But the response requires action across the continuum of care, from family planning and antenatal services to skilled delivery, emergency obstetric care and effective referral systems. The 2023–24 Demographic and Health Survey found that only about 15 per cent of married women used a modern contraceptive method, while approximately one in five had an unmet need for family planning.
Helping women avoid unintended pregnancies, space births and prevent unsafe abortions can reduce high-risk pregnancies before obstetric care is even required. This must be complemented by quality antenatal care, skilled birth attendance, emergency obstetric services, access to blood and functioning referral systems. These are health system investments, not isolated programme interventions. They are precisely the kinds of services that health insurance, the Basic Health Care Provision Fund and the SWAp are designed to support.
Requirements for a reset to translate into better outcomes: Where does primary healthcare fit?
Primary healthcare is the foundation of universal health coverage. It is where immunisation, maternal care, malaria services, HIV, tuberculosis and other essential health interventions reach communities. Nigeria has approximately 31,800 primary healthcare facilities, representing about four in five of all health facilities. However, many were non-functional for years. The government’s plan to establish at least one fully functional PHC in every political ward, covering approximately 17,600 facilities, with Basic Health Care Provision Fund resources flowing directly to facilities, provides an important framework.
NPHCDA reports that about 8,000 PHCs are functional, with approximately 3,000 upgraded. While encouraging, these are administrative figures. The next step is to verify functionality through joint facility assessments, ensure states access and utilise available funds, and demonstrate improvements in service utilisation and quality. Integrating disease-specific programmes into this platform, rather than running them alongside it, is also essential to managing the transition from external funding without disrupting services.
How serious is the health workforce gap?
Health workers are the backbone of the health system, and shortages remain one of its most binding constraints. Government figures put Nigeria’s doctor density at approximately four per 10,000 people nationally, while the 2025 workforce report shows that some northern states have as few as 0.5 doctors per 10,000 people. Emigration has accelerated, and states with some of the highest burdens of maternal deaths, malaria and zero-dose children often have the fewest health workers. Nigeria is responding through its National Policy on Health Workforce Migration, expanded training intake and the retraining of tens of thousands of frontline workers. With WHO support, it has also developed a National Health Workforce Registry and country workforce profile. The priority now is retention and equitable deployment. Midwives, nurses and community health workers must be available in the wards and states that need them, supported to remain there, and enabled to provide more services through appropriate task-sharing. Internationally, the WHO Global Code of Practice and managed migration arrangements should encourage destination countries to support the training pipelines on which they depend.
How should progress towards UHC be judged?
Progress should be measured by outcomes for people, not simply by inputs. WHO’s UHC service coverage index for Nigeria remains below the regional average, while out-of-pocket payments account for approximately 70–75 per cent of health expenditure. Functioning PHCs, an adequate workforce, reliable medicines and health insurance are the means. The real test is whether essential service coverage improves and fewer households face catastrophic health expenditure. There are, however, reasons to expect progress. Government investments and policy reforms at federal and state levels are increasingly focused on the foundations of UHC: stronger primary healthcare, a fit-for-purpose workforce, reliable access to essential medicines and expanded financial protection through health insurance. If implemented consistently and at scale, these reforms should translate into more people accessing essential services, fewer inequalities between states and population groups, and fewer families pushed into financial hardship by healthcare costs. Ultimately, that is the improvement Nigerians should expect and what the government and its partners must be held accountable for.
How will Nigeria measure the effect of the reset on health outcomes?
Strong data and analytics are essential. Countries need reliable information to track progress, identify gaps, allocate resources and improve outcomes. On maternal mortality, Nigeria has national figures, UN inter-agency estimates and IHME estimates that do not agree. Each uses different data and methodologies, and each is defensible on its own terms. However, policymakers need reliable figures for planning, while the public needs confidence in the data. We are supporting the government to harmonise these efforts through a technical working group on mortality estimation involving WHO, UNFPA, IHME and agencies working on HIV, TB, malaria and injuries.
This includes working with WHO headquarters to strengthen national and subnational analytical capacity, as well as improving civil registration and vital statistics, including maternal and perinatal death surveillance. The objective is to reduce reliance on periodic surveys and build more reliable national data systems. This is what we mean by an impact focus: using data to monitor progress, identify bottlenecks, solve problems and mobilise the resources and partnerships needed to achieve results. The quarterly performance reviews and Joint Annual Review under the SWAp provide opportunities to put this into practice. Better data will make those assessments more meaningful and help drive corrective action.
Why sub-national capacity matters
National averages can conceal significant inequalities in a country as large and diverse as Nigeria. States and local government areas make critical decisions on polio, malaria chemoprevention and obstetric care. State teams must therefore be able to analyse their own data, reconcile administrative and survey estimates, and use the findings to guide interventions. That capacity will remain long after individual grants expire, and we believe strengthening it is one of the most enduring contributions WHO can make.
Where do digital solutions and artificial intelligence fit in?
Digital transformation in health is not primarily about technology. It is about building stronger, more equitable and people-centred health systems, with technology serving as an enabler. Data and digital transformation is one of the six pillars of WHO’s cooperation with Nigeria for this reason. The ambition is not simply to expand digital health but to build connected systems that use technology to deliver measurable improvements. Too often, countries end up with multiple disconnected platforms, each funded by a different partner and unable to communicate with the others. Telemedicine, electronic health records and reporting tools should be integrated into primary healthcare, referral networks and the national health information system, rather than operating alongside them. Artificial intelligence also offers significant opportunities to support health workers, strengthen surveillance, improve decision-making and enhance service delivery. However, AI should complement, not replace, professional judgement.
Its application must follow WHO guidance on ethics, governance, equity, transparency, accountability, privacy and human rights. Successful deployment depends on strong digital foundations, including quality data, interoperability, cybersecurity, appropriate regulation and a well-trained workforce. Its value should ultimately be measured by improvements in health outcomes, service quality and equity. For Nigeria, three priorities matter. First, governance, standards, interoperability and digital architecture must be treated as national public goods, owned and led by government. Second, digital investments should be judged by their impact on service delivery and health outcomes, not the number of platforms launched. Third, AI should be pursued responsibly, guided by ethics, evidence, safety, national regulation and priorities, with data sovereignty protected and benefits extended to rural communities, women and people with limited digital access. This is also part of the global health architecture debate. Partners, philanthropies and technology companies should invest through Nigeria’s national digital health architecture, not around it.
What does the reset mean for WHO?
There have been concerns that WHO country offices have sometimes assumed substantial operational responsibilities, particularly during disease eradication efforts and public health emergencies. In some contexts, this was necessary to sustain critical public health functions and support national priorities. However, such arrangements are not intended to replace sustainable national capacity and leadership in the long term. Our role is evolving in three directions. First, we are increasingly focused on helping countries lead and sustain public health functions by strengthening institutions and systems to independently plan, implement, monitor and improve health programmes. Second, we are shifting from individual projects towards strengthening the health system through norms, guidelines and technical advice that improve multiple programmes. Third, we are moving from reporting activities to demonstrating accountability for outcomes we can reasonably influence. WHO remains fully committed to supporting a nationally led, demand-driven and less fragmented approach.
How do you demonstrate WHO’s contribution?
We have to be precise. WHO rarely causes a national result on its own. Governments, communities and many partners contribute to the work. What we can demonstrate is our contribution: a guideline adopted, a surveillance gap closed, a state team equipped to analyse its own data or a policy decision informed by better evidence. We are aligning our country plan around a smaller set of national outcome indicators, each with a clear description of WHO’s role and the assumptions behind it. Honest attribution builds more trust than inflated claims.
What should the reform process deliver for Nigeria, and what should Nigeria do?
The reform process should be judged by what changes in countries. It should deliver fewer parallel plans, reports and coordination meetings, and more funding and reporting through a single national plan, budget and accountability framework, such as the SWAp already provides. It should also support predictable investment in shared health system foundations, including data, the workforce, supply chains and primary healthcare, alongside clear and jointly agreed transition timelines.
Nigeria, for its part, must release domestic financing commitments on time, ensure partners channel their funding and reporting through the SWAp, and hold the health system accountable for outcomes rather than activities. If both sides deliver, Nigerians should see fewer children missed by vaccines, fewer deaths from malaria and childbirth, and less money paid out of pocket for healthcare. That is how the reset should ultimately be measured: in lives improved and saved.
I am cautiously optimistic. Nigeria has demonstrated that it can deliver difficult public health interventions at scale, from ending wild poliovirus transmission to vaccinating more than 100 million children through integrated campaigns and significantly expanding TB detection. The capacity exists, although it remains uneven and requires consistent support. WHO’s role is to strengthen that capacity, clearly demonstrate its contribution and step back as national institutions take over and sustainably perform these functions. That transition is the real measure of whether our time-limited support has built lasting capacity. If we get it right in Nigeria, the reforms agreed by global health institutions will have greater meaning and deliver more lasting results.
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