Utilization of primary healthcare services in Nasarawa state, Nigeria: addressing structural and sociocultural barriers

INTRODUCTION

Nigeria’s primary healthcare (PHC) system was conceptualized to serve as the foundational tier of the national health system, providing the first point of contact between individuals and the formal health system.¹ Particularly in rural and peri-urban regions such as Nasarawa State, PHC services are critical for achieving universal health coverage (UHC), reducing preventable deaths, and improving maternal, newborn, and child health (MNCH) outcomes.² Yet, despite years of health sector reforms, the utilization of PHC services remains significantly suboptimal across much of the state. This persistent underutilization undermines the impact of policy interventions and threatens progress toward global health targets.³ Nasarawa state, like many parts of Nigeria, continues to record poor health indicators, including high maternal and child mortality rates, low immunization coverage, and late presentation for antenatal care.⁴ While infrastructure development has expanded access to health facilities, and policies such as the Basic Health Care Provision Fund (BHCPF) have aimed to improve service delivery and financing, these structural advancements have not translated into widespread PHC utilization.⁵ The disconnect between access and use suggests that deeper, more complex barriers may be at play.

Multiple studies have highlighted how sociocultural norms, economic limitations, and weak institutional capacity interact to constrain healthcare-seeking behaviours.⁶ In Nasarawa state, where a significant proportion of the population resides in rural areas and operates within traditional value systems, the decision to seek care is often shaped by gender roles, religious beliefs, and the influence of family hierarchies.⁷ In some communities, women require spousal consent to access services, while others defer to traditional healers due to longstanding cultural practices. These dynamics contribute to delayed or complete avoidance of PHC engagement, particularly for maternal and child health needs.^8-10 Infrastructural and systemic deficits further exacerbate the situation. Health facilities frequently experience shortages, of essential medicines, skilled personnel, and basic utilities such as water and electricity.^11,12 The uneven distribution of healthcare workers between urban and rural areas compounds the problem, leaving many PHCs under-resourced and ill-equipped to provide even the most basic care.^13-15 Additionally, misinformation, health illiteracy, and a lack of culturally adapted health education contribute to widespread misconceptions about the relevance and safety of PHC services.^16,17 To unpack these multilayered challenges, this paper adopts the Andersen Behavioral Model of Health Services use, a conceptual framework that categorizes the determinants of health service utilization into predisposing, enabling, and need factors. This model allows for a systematic exploration of how individual and community characteristics interact with health system variables to influence care-seeking behaviour. By applying this lens to the context of Nasarawa state, the paper aims to critically examine the factors impeding PHC utilization and offer policy recommendations to promote equitable, sustainable, and people-centred health service uptake.

LITERATURE REVIEW

The utilization of primary healthcare services in low and middle-income countries (LMICs), particularly in sub-Saharan Africa, has been the focus of considerable scholarly attention over the last two decades. In Nigeria, where PHC is positioned as the fulcrum of the national health system, there exists a paradox of physical access without meaningful utilization. Several national surveys and independent studies consistently show that although over 80% of Nigerians live within 5 km of a PHC facility, less than half routinely use these services.¹⁸ This underutilization has sparked debates around the adequacy of policy design, the sociocultural acceptability of services, and the capacity of the health system to meet community needs.^19-21

Studies by Nurani et al, (2023) argued that utilization is not merely a function of proximity but is deeply influenced by individual beliefs, perceived service quality, and health literacy. Individual health beliefs shape when and from whom people seek care, while perceptions of quality affect satisfaction and future use. Health literacy is crucial because it influences a person's ability to understand health information and navigate the healthcare system effectively.²² These observations are particularly relevant in Nasarawa state, where cultural practices, misinformation, and low levels of formal education shape health-seeking behaviours. A key finding from local qualitative research Ntoimo et al, (2019) reveals that many residents, especially women, perceive PHCs as being limited in scope and authority, often bypassing them in favour of traditional healers or private chemists for maternal and child health issues.²³ Moreover, evidence from the Nigeria Demographic and Health Survey (NDHS 2023) underscores that household wealth status, female autonomy, and education are critical determinants of PHC use. The same survey highlights regional disparities within states like Nasarawa, where rural communities fare far worse in health indicators compared to urban centres.²⁴ These findings align with global observations: a World Health Organization (WHO, 2020) synthesis indicates that rural populations in LMICs are three times more likely to face service gaps than their urban counterparts, even when facilities exist.²⁵

Barriers to utilization can also be traced to systemic weaknesses, the poor condition of PHC infrastructure marked by dilapidated buildings, lack of electricity and water, and erratic drug supplies significantly discourages use.²⁶ Additionally, health worker shortages, often worsened by urban-rural imbalances, result in long wait times and reduced service quality.²⁷ Nasarawa state’s health workforce density remains far below WHO’s recommended minimum of 4.45 doctors, nurses, and midwives per 1,000 population. In 2023, the ratio stood at 0.5 per 1,000 in rural PHCs.

In 2023, Nasarawa state Primary Health Care Development Agency flagged that drug availability crucial determinant of health utilization. Only 34.3% of PHC facilities in Nasarawa state reported consistent availability of essential medicines.²⁸ These gaps were seen to have led many patients to self-medication or seek care in private pharmacies, further marginalizing the PHC system. Unreliable drug supply not only diminishes the credibility of PHCs but also undermines trust in public health infrastructure.²⁹ On the other hand, policy innovations such as the BHCPF have begun to yield some positive outcomes. The fund, introduced under the National Health Act, allocated 1% of Nigeria’s Consolidated Revenue Fund to basic healthcare delivery. A review by Jemchang Yildam found that PHCs benefiting from BHCPF recorded improvements in client volume, staffing, and drug availability, albeit inconsistently. However, implementation challenges such as delays in fund disbursement and limited local capacity to manage funds continue to hinder widespread impact.³⁰

International experiences offer valuable insights. Rwanda’s performance-based financing scheme incentivized quality service delivery at the PHC level, resulting in increased skilled birth attendance and reduced maternal mortality.³¹ Ghana’s National Health Insurance Scheme (NHIS) introduced a capitation model that encouraged preventive care and improved PHC utilization.³² These models demonstrate the potential of contextually adapted financing mechanisms to catalyse health system responsiveness. The literature paints a complex but consistent picture: PHC utilization is shaped by an interplay of cultural, infrastructural, economic, and systemic factors. While policy interventions such as the BHCPF show potential, a more integrated approach combining financing reforms, community engagement, and structural strengthening is needed to transform PHC utilization in Nasarawa state. Future research and programmatic design must pay closer attention to contextual realities, emphasizing locally-driven solutions that reflect the lived experiences of target populations.

METHODS

This study employed a narrative review methodology to synthesize evidence on the utilization of primary healthcare (PHC) services in Nasarawa state, Nigeria. A narrative review was deemed appropriate given the aim to explore a wide array of evidence sources, identify thematic patterns, and contextualize findings within existing theoretical models of health service utilization. The Andersen Behavioural Model served as the guiding conceptual framework, categorizing factors influencing PHC utilization into predisposing, enabling, and need components.³³

The literature search was conducted between January and April 2024 using a comprehensive range of sources. These included peer-reviewed journal articles, grey literature, national policy documents, health facility performance reports, and global health databases. Databases searched included PubMed, Scopus, Web of Science, and African Journals Online (AJOL). Grey literature sources encompassed reports from Nigeria’s Federal Ministry of Health, the Nasarawa State Primary Health Care Development Agency, UNICEF, WHO, and World Bank repositories.

Inclusion criteria were defined as follows:

The studies included in this review were published between 2015 and 2024 and focused on Nigeria or other countries in sub-Saharan Africa with relevance to primary healthcare (PHC) utilization. Only sources that addressed determinants of healthcare access, service readiness, or overall health system performance were considered.

Excluded were studies unrelated to PHC or those focusing solely on tertiary-level care without reference to PHC integration. An initial pool of 230 records was identified, of which 72 met the inclusion criteria after title and abstract screening. Following full-text review and quality appraisal, 36 sources were included in the final synthesis. Thematic content analysis was used to extract and organize findings into four overarching categories: cultural factors, infrastructure and health workforce, community health education, and drug availability. These categories were then mapped against the Andersen Behavioural Model to provide explanatory depth and guide policy recommendations. To enhance methodological transparency, key findings were triangulated across multiple data types quantitative surveys, qualitative studies, and administrative reports. Although this review was not designed to be exhaustive or systematic in the conventional sense, the robust synthesis of diverse evidence sources and the application of an established theoretical model contribute to the credibility and policy relevance of the analysis. The use of both academic and programmatic literature allowed for a more grounded understanding of the sociocultural and systemic barriers affecting PHC utilization in Nasarawa state.

DISCUSSION

The findings of this review illustrate a deeply rooted and multidimensional problem underlying the underutilization of PHC services in Nasarawa state. Despite substantial national and subnational efforts to bolster PHC infrastructure and funding, significant structural and sociocultural barriers continue to limit the uptake of essential health services.³⁴ These findings are consistent with the broader literature on PHC utilization in low- and middle-income countries, which emphasizes the interaction between service availability, user acceptability, and the responsiveness of health systems.

A recurring theme in the review is the role of cultural norms and traditional beliefs in shaping healthcare-seeking behaviour. The Andersen Behavioural Model categorizes such norms as predisposing factors that influence individual perceptions of illness and decisions to seek formal care. In Nasarawa state, cultural preferences for traditional medicine, gender dynamics requiring spousal permission, and community-level mistrust in PHC services have significantly discouraged timely and consistent use. These cultural barriers are not unique to Nasarawa, but they are particularly acute given the rural and conservative nature of many of its communities.

Enabling factors, such as health system infrastructure and the availability of human resources, also featured prominently in the evidence. The chronic shortage of skilled health workers and the poor distribution of existing personnel between urban and rural settings remain central impediments to service delivery.³⁵ Compounding this issue is the inadequate availability of essential medicines and the poor physical state of many PHC facilities, which undermines public trust and service reliability. These findings echo observations in similar contexts, such as in parts of Northern Ghana and Eastern Uganda, where infrastructural weakness and stock-outs led to diminished service demand despite geographic proximity.

Moreover, the discussion must consider the dynamic between health education and health-seeking behaviour. The review highlights that misinformation, low literacy levels, and inadequate public communication strategies contribute to a weak understanding of the benefits of PHC services within the community. Programs that have embedded health education into broader community engagement, such as those seen in Rwanda’s CHW model, have shown promise in shifting norms and improving uptake. In Nigerian health system, the introduction of Community Health Influencers, Promoters and Services (CHIPS) as a model to restructure our PHC, being the first point of call in the community. Policy interventions such as Nigeria’s BHCPF were designed to address some of these systemic issues, and early evidence indicates a degree of success. However, the BHCPF's impact has been limited by operational inefficiencies, inconsistent fund disbursement, and weak accountability mechanisms. These realities underscore the need for stronger governance and more transparent financing systems. Without these, even well-intentioned reforms risk failing to deliver their intended outcomes.

The implications of the COVID-19 pandemic further highlight the fragility of the PHC system in Nasarawa. Disruptions in service delivery, particularly in maternal and child health, have reversed gains made in recent years. This points to the need for building resilience into PHC systems not just through infrastructure and funding, but also through adaptive community engagement, health information systems, and emergency preparedness strategies.³⁶ Importantly, lessons from other African countries offer valuable insights into potential solutions. Rwanda’s performance-based financing approach linked funding to service quality and coverage, driving improvements in maternal and child health indicators. Ghana’s experience with capitation payment models under the National Health Insurance Scheme revealed the potential of financial incentives to promote preventive service use. Nigeria’s decentralized facility financing (DFF) model could benefit from these lessons, particularly if paired with strengthened local capacity for financial and service monitoring.

In summary, the discussion reveals that improving PHC utilization in Nasarawa state requires a systemic and culturally sensitive approach. Addressing supply-side constraints must be matched with investments in demand-side enablers, such as community mobilization, community system strengthening and health literacy programs. More importantly, the political will to finance PHC at scale, strengthen accountability mechanisms, and institutionalize local ownership will be critical in reversing current trends and achieving meaningful health outcomes. The Andersen Behavioural Model provides a useful structure for analysing these multifaceted challenges and offers a pathway for evidence-informed reform design.

CONCLUSION

The underutilization of primary healthcare services in Nasarawa state reflects a complex web of cultural, infrastructural, and systemic challenges. While access to PHC facilities has improved in recent years, meaningful use remains limited by deep-seated beliefs, inadequate service readiness, and governance gaps. This review has shown that addressing PHC utilization requires more than just physical access it demands a multisectoral, equity-focused approach grounded in behavioural insights, community engagement, and sustainable financing.

By applying the Andersen Behavioural Model, this study has identified actionable levers for reform that align with both user needs and system capabilities. Improving PHC utilization in Nasarawa is not only vital for achieving better health outcomes but also central to Nigeria’s progress toward universal health coverage. A concerted effort by policymakers, health workers, and communities is essential to transform PHC from a nominal gateway to a trusted and effective platform for delivering essential healthcare services.

Recommendations

To reverse the trend of underutilization of PHC services in Nasarawa state, a set of integrated and contextually grounded policy interventions is required. These recommendations are informed by the evidence synthesized in this review and aligned with the predisposing, enabling, and need components of the Andersen Behavioural Model.

The government should commit to meeting the Abuja Declaration target of allocating at least 15% of the national and state budgets to health, with a designated proportion earmarked for PHC. This will ensure sustained financing for infrastructure upgrades, drug procurement, and health worker salaries.

Recruitment, training, and retention of skilled health professionals must be prioritized. This includes offering rural posting incentives, expanding community health worker programs, and decentralizing recruitment processes to allow PHC facilities greater autonomy in addressing staffing gaps.

Invest in culturally sensitive and multilingual health education campaigns tailored to the beliefs and values of local populations. Leveraging community leaders, religious figures, and local media can help dispel myths, improve health literacy, and increase trust in PHC services.

Establish robust logistics and inventory management systems to address frequent drug stock-outs. Digital tracking tools and public-private partnerships can enhance the transparency and efficiency of medicine distribution to rural PHCs.

Operationalize community health development committees and facility health commitees to create formal feedback loops between health providers and service users. This participatory model can foster local ownership, improve service design, and strengthen accountability.

Develop emergency preparedness protocols to ensure continuity of PHC services during health crises like pandemics or natural disasters. This includes training personnel, creating mobile outreach capabilities, and investing in telehealth infrastructure.

Ensure timely and equitable disbursement of BHCPF funds, accompanied by capacity-building for financial and service monitoring at the local level. State-level dashboards and performance-based incentives can enhance transparency and responsiveness.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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