A world-class hospital cannot compensate for a weak primary and secondary healthcare system.
This is the central issue that must accompany the development of the Enugu International Hospital. The state has made a major investment in advanced specialist healthcare, but the success of that investment will depend on whether the human and institutional infrastructure beneath it is strong enough to make the entire system work.
The broader health-system investments of the Mbah administration therefore matter enormously. The state has reported interventions across 260 Type-2 primary healthcare centres, alongside investments in equipment, digital transformation, solarisation, electronic health records and real-time health data systems. The World Health Organisation has also recognised the administration’s broader health-system investments.
The International Hospital can provide the apex. Primary healthcare can provide the foundation. Secondary hospitals should provide the critical middle. Digital systems can connect the different levels.
The real opportunity is to build a continuum of care in which a patient can move from community-level prevention and primary treatment to secondary care and, where necessary, to advanced specialist services. The International Hospital should therefore be the apex of an integrated referral architecture, not an isolated mega-project.
But this is precisely where an uncomfortable reality must be confronted.
The latest Human Resources for Health assessment presents a stark picture of Enugu’s primary healthcare workforce. Across 566 PHC facilities in the state’s 17 LGAs, the system requires 8,274 clinical and frontline personnel but currently has only 1,810, leaving a gap of 6,464 personnel, or 78.1 percent. That is not a minor staffing problem. It is a structural constraint.
The cadre-specific figures are even more revealing. Medical Officers face an 81.8 percent gap; Pharmacists, 96.7 percent; Medical Laboratory Scientists, 90.0 percent; Nurses and Midwives, 90.9 percent; Medical Laboratory Technicians, 92.0 percent; Pharmacy Technicians, 96.1 percent; and Medical Records personnel, 99.4 percent.
Community Health Extension Workers have a deficit of 1,116 personnel, representing 49.3 percent of the requirement, while Junior CHEWs face a 61.5 percent gap.
The 2024 audit also captured non-clinical personnel, including Environmental Health Officers, who have since been repositioned to the Water, Sanitation and Hygiene unit under ENRUWASA. This required a recalibration of the clinical workforce baseline.
These figures fundamentally change how the International Hospital should be understood.
The question is not whether Enugu should build advanced specialist capacity. It should. The question is whether the state can build the human and institutional infrastructure beneath that capacity quickly enough to make the entire system work.
There has already been encouraging progress. Following approval for 2,200 PHC workforce positions, the Enugu State Primary Health Care Development Agency launched an online recruitment exercise that attracted 6,000 applicants, of whom 4,000 completed the Computer-Based Test. Phase One has successfully onboarded 450 candidates.
This deserves recognition. It demonstrates that the administration understands that buildings and equipment must be matched by people. But the scale of the remaining challenge is enormous. The 450 recruits represent only about seven percent of the identified workforce gap. With approval secured for aggregated two-phase recruitment, the Agency projects onboarding 1,350 personnel by the end of 2026. Even if that target is achieved, approximately 5,114 positions would remain to be filled by the end of 2027.
The implication is clear: workforce development must become a sustained, multi-year strategy rather than a series of recruitment exercises.
The most urgent gaps should receive priority, particularly Medical Officers, Pharmacists and Medical Laboratory Scientists. At the same time, Enugu should expand the capacity of its schools of health to train additional CHEWs. The shortage of 1,116 CHEWs is particularly important because they provide one of the most direct links between communities and formal healthcare.
Recruitment, however, is only half the problem. Retention matters just as much.
Health professionals do not leave only because of salaries. They also leave because they cannot practise effectively, equipment is unavailable, workloads are excessive, professional development is limited and career progression is uncertain. Enugu therefore needs a deliberate retention strategy covering career development, continuing professional education, supportive supervision, performance incentives and improved working conditions.
This is especially important for the International Hospital. A specialist hospital will require specialists who can work with advanced technology, undertake complex procedures, train younger professionals and participate in research.
Nigeria’s medical diaspora should be part of this strategy. Enugu does not necessarily have to persuade every Nigerian specialist abroad to return permanently. It can develop structured opportunities for visiting specialists, specialist procedures, telemedicine, mentorship, training, research collaboration and technology transfer.
The International Hospital should also become a centre of learning, not merely treatment. Specialist training, advanced nursing education, clinical research, biomedical engineering and international partnerships should form part of its long-term development. This would enable Enugu gradually to move from being primarily a consumer of medical services to becoming a producer of medical knowledge and specialist expertise.
There is, however, another question that cannot be avoided: opportunity cost.
The government operates within a finite fiscal envelope. Every major investment involves choices about how public resources are allocated. The question is therefore not whether the International Hospital is desirable. It clearly is. The question is whether investment in advanced specialist healthcare is being appropriately balanced with the enormous requirements of primary and secondary healthcare.
Enugu does not have to choose between the two. It needs the International Hospital and functional PHCs. It needs advanced specialist care and strong secondary hospitals. It needs sophisticated equipment and the people capable of using it. The danger would be creating an impressive apex while the foundation and middle remain too weak to support it.
This is why the 260 PHCs are so important. Their success should not be measured merely by how many have been constructed or renovated. The real test is whether they are functional when citizens need them, whether qualified personnel are available, whether medicines and consumables are present, whether electricity and water are reliable, whether equipment works and whether referrals function.
Infrastructure is necessary. Functionality is decisive.
The same principle applies to secondary healthcare. Secondary hospitals should absorb cases that exceed PHC capacity without unnecessarily sending every patient to the International Hospital. A strong secondary-care network would reduce pressure on the specialist facility, lower costs for patients and improve referral efficiency.
Digital health can strengthen this architecture. The reported deployment of electronic health records and digital systems across PHCs and secondary facilities could improve referrals, reduce duplication of investigations, strengthen continuity of care and enable clinicians at different levels to share relevant patient information. Real-time dashboards could improve resource allocation, surveillance and performance management.
But technology should not become another collection of impressive statistics. The question should always be simple: Does it help a patient receive better, faster and more affordable care?
The same outcome-based approach should apply to the International Hospital itself. Nigeria has seen public facilities deteriorate after commissioning because construction received more attention than long-term maintenance. The Enugu International Hospital must avoid that trap.
Sophisticated equipment requires preventive maintenance, biomedical engineering capacity, reliable power and water, spare-part arrangements and equipment-replacement plans. The true test of an MRI machine is not whether it is installed; it is whether it remains operational five, ten and fifteen years later.
The hospital also needs strong institutional governance. It should have professional autonomy, rigorous clinical governance, transparent procurement, measurable performance standards and clear accountability for clinical outcomes, patient safety, financial performance, equipment uptime, staff performance and patient experience. Government ownership does not require government micromanagement.
Most importantly, the institution must be designed to survive beyond the administration that created it. That may ultimately be the most important test of Governor Mbah’s healthcare legacy.
The same discipline should apply to primary healthcare. How quickly is the 6,464-person workforce gap being reduced? Are health workers equitably distributed across the 17 LGAs? How many PHCs are actually functional? Are medicines available? Are referrals improving? Are maternal, child and other health outcomes improving?
These are the indicators that will determine whether the investment has produced value for money.
The 260 PHCs can provide the foundation. A strengthened secondary-care network can provide the middle. The International Hospital can provide the specialist apex. Digital systems can connect the different levels. Health insurance can finance access. A comprehensive HRH strategy can provide the people. Universities and research institutions can provide knowledge. Professional governance can sustain the institutions.
If these elements are successfully integrated, the International Hospital could become one of the most consequential health-sector investments in Enugu’s recent history.
But its ultimate value will not be determined by the grandeur of the facility. It will be measured in patients treated, lives saved, professionals trained, specialists retained, families protected from catastrophic healthcare costs, healthcare expenditure retained and communities given reliable access to quality care.
The real legacy of the investment will therefore not be in concrete, steel, machines or beds, but in the health system built around them.
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Chiwuike Uba, Ph.D., CPA, FCMA, a professor of economics with a keen focus on public financial management and public sector reforms, serves as chairman of the board of the ACUF Initiative for Policy and Governance Ltd/Gte. He can be reached at chiwuike@gmail.com and via (SMS) at + 234 803 309 5266
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