Structural Factors Perpetuating Pharmaceutical Inequity in Rural Nigeria: A Critical Realist Investigation Spanning North Central and North East Zones

Pharmaceutical inequity, defined as systematic and unjust disparities in access to essential medicines and quality pharmaceutical care based on geography, income, or social status, represents a profound structural challenge in rural Nigeria. Despite extensive documentation of medicine access gaps, the underlying structural mechanisms perpetuating pharmaceutical inequity have not been theorized using a critical realist ontological framework. This study conducted a critical realist investigation of structural factors perpetuating pharmaceutical inequity in rural communities spanning North Central and North East Nigeria, encompassing Nasarawa, Taraba, Adamawa, and Gombe States. A three-phase retroductive inquiry was adopted: phase one involved document analysis of health financing and medicine supply policies; phase two comprised in-depth interviews with 56 community members, rural health workers, pharmacists, local government health officers, and development sector representatives; and phase three involved causal mechanism identification through retroductive reasoning and expert panel triangulation. Analysis identified three generative mechanisms operating at distinct structural levels: the commodification mechanism, whereby essential medicines are treated as market goods rather than social rights; the infrastructural exclusion mechanism, whereby road, electricity, and cold chain deficits create systematic barriers; and the professional desert mechanism, whereby workforce distribution policies systematically deprioritize rural pharmacist deployment. The interaction of these mechanisms across contextual layers produces compounding inequity effects. The study offers the first critical realist theory of pharmaceutical inequity in rural Nigeria and proposes structural intervention pathways addressing each mechanism. Keywords: pharmaceutical inequity, critical realism, rural Nigeria, medicine access, structural determinants