Equity, Access, and Quality of Paediatric Emergency Care Across Nigeria’s Health System Tiers: A Mixed-Methods National Assessment with Health System Strengthening Recommendations

Paediatric emergency care (PEC) in Nigeria is fragmented across primary, secondary, and tertiary tiers with wide equity gaps in access, quality, and outcome. Despite its centrality to child survival, no comprehensive national assessment of PEC capacity and its determinants has been conducted. This mixed-methods national assessment employs a sequential explanatory design across 48 purposively selected health facilities spanning all six geopolitical zones and three tiers of care. Quantitative facility assessment used the Emergency Care Assessment Tool-Paediatric (ECAT-P) developed for this study through expert consensus among 24 Nigerian paediatricians and emergency care specialists. Qualitative components included 36 in-depth interviews with facility managers, paediatric nurses, and caregivers, and six health policymaker interviews. ECAT-P scores revealed critical PEC capacity deficits, with only 19.4% of assessed facilities meeting a threshold of adequate PEC readiness. Tertiary facilities scored significantly higher than secondary and primary facilities (mean scores 64.3, 38.7, and 21.4 out of 100, respectively). Oxygen availability was the most critical and common gap, absent or unreliable in 68.8% of primary and 41.7% of secondary facilities. Triage systems were absent in 77.1% of primary facilities. Geographic disparities were most pronounced in north-eastern and north-western zones. Qualitative findings attributed quality gaps to underfunding, staff attrition, and supply chain failures. A Nigerian Paediatric Emergency Care Strengthening Framework was developed from integrated findings. This study makes an original contribution to health systems research, delivering the first national PEC capacity dataset and a validated assessment tool for Nigeria. Keywords: paediatric emergency care, health system, equity, national assessment, Nigeria.