Introduction
I have walked into hospitals that looked right and felt wrong.
Clean walls, functional equipment, trained doctors, good ambience, and yet, a quality of care that was consistently and inexplicably below what those inputs should have produced. Patients waiting in corridors because of a chaotic admissions process. Medicines running out mainly because nobody was in charge of monitoring the procurement timeline. Staff performing below their capability because there was neither a leader nor a manager.
Nigeria’s healthcare crisis is discussed, almost entirely, in terms of funding. We need more money. More doctors. More facilities. More government commitment. All of that is true. But it is not the whole truth.
The part we don’t discuss enough, and this is because it is harder to photograph and fundraise for it, is management.
Management is the way hospitals are run; the systems inside them; the accountability structures; the leadership culture; and ultimately, the staggering, measurable cost of getting all of that wrong.
The Management Gap
A 2024 study published in Health Affairs Scholar examined medical competence across 16,127 healthcare providers in eleven (11) Sub-Saharan African countries. What they found was quite striking: 81% of the variation in provider competence was within countries, not between them. In other words, the gap between the best-performing and worst-performing providers within a single country was larger than the gap between countries. The quality of care you receive in Nigeria depends less on where Nigeria is than on which Nigerian hospital you walk into and how that hospital is managed.
The World Bank has documented extensively that health system performance in Sub-Saharan Africa is constrained not primarily by clinical capability but by governance and management quality. Africa has 12% of the world’s population but employs only 3.5% of the global health workforce to serve 27% of the global burden of disease. Every person in that system needs to be operating at maximum effectiveness, but poor management makes that impossible.
I have seen this happen over and again. When we take over assets, we find that the first problem is rarely the clinicians. The doctors and nurses we work with are often extraordinarily capable, working under conditions that would have destabilized most people in similar roles in other parts of the world. The problem is usually the system around them.
