A Systematic Review of Healthcare Governance and Pandemic Preparedness in Nigeria: Policy Failures and Transformative Solutions

Background: Nigeria's healthcare system, characterised by chronic underfunding and fragmented governance, faced a severe test during the COVID-19 pandemic. This systematic review synthesises evidence on the policy failures underlying this fragility and proposes transformative solutions. Methods: We conducted a systematic review (PRISMA 2020 guidelines) of 62 sources (42 peer-reviewed articles, 2019-2024; 20 policy documents, 2013-2024). A qualitative thematic synthesis, facilitated by NVivo software and framed by Complex Adaptive Systems theory, identified and quantified key policy deficiencies. Results: The analysis revealed a vicious cycle of systemic failure driven by five interconnected themes: governance fragmentation (93.5% of sources), financing barriers (88.7%), profound equity gaps (79.0%), reactive preparedness (75.8%), and an evidencepolicy disconnect (61.3%). This is evidenced by catastrophic out-of-pocket spending (76%), misallocation of 30-40% of primary healthcare funds, and stark disparities, such as a northern maternal mortality rate double that of the south. Conclusion: The study concludes that Nigeria's health system is trapped in a selfreinforcing cycle of dysfunction. Breaking this cycle requires transformative, multipronged reforms. We propose three core imperatives: (1) legislated governance clarity with performance-based financing; (2) a pro-poor financing revolution using mobile technology and blockchain; and (3) the institutionalisation of proactive health security. The primary barrier remains political will, not technical feasibility. This review provides an evidence-based roadmap for Nigeria and similar LMICs.