A Critical Analysis of the Performance of Nigeria’s National Health Act in Achieving Universal Health Coverage Goals

The National Health Act of 2014 established the most significant legal and institutional architecture for universal health coverage in Nigeria's post-independence history, yet a comprehensive critical analysis of its implementation performance and structural limitations in achieving UHC goals has not been conducted. This study conducted a critical theoretical and empirical analysis of the National Health Act's performance in advancing UHC in Nigeria. A policy analysis methodology drawing on implementation science, health systems theory, and political economy of health was employed. Document analysis covered the NHA text, subsidiary legislation, Basic Health Care Provision Fund implementation reports, State Health Law reviews, and presidential healthcare council documentation from 2014 to 2024. Structured interviews were conducted with 35 federal and state health policy officials, civil society health advocates, health finance specialists, and community health practitioners across all six geopolitical zones. Health outcomes and service coverage data trends from NDHS 2018 and 2023 were used as empirical benchmarks. Results showed that BHCPF operationalisation was delayed by six years due to political economy barriers, including fiscal federalism tensions and inter-ministerial coordination failures. Implementation quality assessment revealed significant shortfalls in all six NHA implementation pillars. UHC service coverage index improved only marginally from 41 to 47 between 2015 and 2023 nationally. The critical analysis develops an original Political Economy of Nigerian UHC Implementation Framework identifying four structural barriers: fiscal federalism governance deficit, elite political commitment volatility, weak accountability architecture, and informal health economy integration failure.