Evidence Before Reform in Plateau State

Nigeria has significant ambition for health-system reform. The Basic Health Care Provision Fund, the National Health Insurance Authority Act of 2022 and state contributory schemes all point towards wider access and stronger systems. Yet implementation capacity and the quality of available evidence vary considerably across states.

Plateau State's Healthy Plateau initiative brings infrastructure renewal, digital health, workforce development and governance strengthening into a wider transformation programme. Before sequencing that investment, the government needed an independent view of the current system based on evidence from facilities, health workers and patients rather than assumptions or administrative records alone.

Carter built the assessment around seven questions a patient would ask:

• How easily can I reach a healthcare facility?
• Will the right health worker be there?
• Is the lab equipment working?
• Are the essential medicines in stock and affordable?
• If I need emergency care, will it be accessible and affordable?
• Will a referral lead to further care in a specialist facility I can access within the state?
• How will I get appropriate follow-up after treatment?

Over two months, field teams inspected and audited facilities, surveyed frontline health workers anonymously, interviewed patients as they left clinic appointments at health centres, checked medicine stocks and storage, and went door to door to survey households. National datasets were used to cross-check the findings.

The team then traced what it observed back to underlying causes across policy, infrastructure, financing and management. Findings were re-checked in the field, independently re-coded and validated with State Ministry of Health teams.

The evidence was used to build the Healthy Plateau Scorecard, supported by a Performance Intelligence Dashboard.

The Plateau State Government validated and adopted the diagnostic. It now underpins a four-pillar Improvement Framework Masterplan and a phased ten-year implementation roadmap, which identifies priority actions the state can take in developing its health infrastructure and service delivery programme.

The assessment also found strengths to build on, including the state's faith-based and private-sector providers and patients' positive views of health workers' attitude and clinical care.

The scorecard and dashboard give Plateau a way to monitor progress against the evidence base as implementation continues. This reduces the need to commission a new diagnostic simply to understand whether priorities are being addressed and creates a consistent basis for reviewing performance over time. The companion case study, Connecting Plateau's Health System, describes the digital architecture that carries this work forward.