Expert Insight

Let’s be clear! Increase accountability for Primary Health Care funding in Nigeria

Many countries have good policies and legislation to support Primary Health Care (PHC) frameworks. In Nigeria, the National Health Act specifies that primary health care facilities should be prioritized and that every facility should have a Ward Development Committee (WDC) in place, as an accountability structure that would have communities and healthcare workers at the core of PHC service delivery.

WDCs are groups that bring health facility staff and communities to work together to respond to community needs and to ensure a more accountable provision of primary health care (PHC). It consists of influential men and women responsible for overseeing social services in their community. Unfortunately, members of these committees often do not have access to the information they need to hold those responsible to account for the funding that their health facilities receive.

“When there is not enough funding at our local Primary Health Care facility, our work becomes even more difficult, people miss essential services. We don’t have the money to give them to buy drugs and other things they need” - Mr. Hussaini Baba, Chairman of WDC of PHCC Potiskum in Yobe State, North-eastern Nigeria.

PHC as a foundation for Universal Health Coverage
Nigeria has the Primary Health Care Under One Roof (PHCUOR) policy. Ideally, this policy aims to reduce fragmentation of Primary Health Care (PHC) services by grouping all PHC services under one authority. This reduces fragmentation which has been identified as the most significant problems facing PHC services.

A recently commissioned Operations Research, conducted by Nigerian National Primary Health Care Development Agency in partnership with the Evidence for Action (E4A)-MamaYe project, indicated that while PHCUOR reduces fragmentation in governance, PHC still receives funds through many sources. This causes insufficiency with facilities unable to  provide communities with the services they need. Inefficiency therefore remains a barrier to maximizing resources needed to achieve Universal Health Care (UHC).

The research also found that State governments and Local Government Authorities (LGAs) do not prioritise PHC facilities, with insufficient funds spent on PHC services. The COVID-19 pandemic has further hampered public funding for PHC, with most funds transferred to the emergency and other sectors. Therefore, facilities often rely on donor funding for providing quality services.

Governments need to mainstream funding for PHC

Seeing Mr. Baba’s health facility, it is clear the facility is under-resourced. Without proper checks and balances, resources that should be spent on improving health may get lost to systemic corruption and fraud in the health system .
PHC financing arrangements are comprised of: the amount of funding the PHC system receives, the ways funds are moved through the system to PHC providers at facilities, and the incentives created by the mechanisms to pay PHC providers. There are currently multiple funding sources for PHC and it is unclear how they coexist at different levels of the health system in Nigeria. This causes inefficient use of scarce resources, duplication of efforts and prevents transparency.

Power of communities for effective PHC accountability

To improve accountability for funds allocated and released to PHC facilities, healthcare providers should involve community committees like WDCs in the day-to-day affairs of healthcare provision. People like Mr. Baba and his allies should be supported to generate and use information on how budgets are spent. This will help them understand which funds are received at their local health facility and how these are spent, improving accountability.

Access to this critical information will empower Mr. Baba and his community, giving rise to strong PHC champions and advocates, especially now that global momentum to offer health for all by 2030 is approaching its peak.

As the 75th World Health Assembly (WHA) meeting is bringing together world leaders between 22nd to 28th May 2022, we are asking governments around the world to launch mechanisms that enable communities to engage in PHC services. In many countries, Community Accountability Structures such as Ward Development Committees (WDCs) serve as the intermediary between health care providers and users of health services. Ward Development Committees (WDCs) and Civil Society Organizations (CSOs) should be empowered to participate in the planning and budgeting processes at all levels. WDCs should be trained and mentored to oversee facility spending. With this in place, people like Mr. Baba and all other community accountability activists would be better placed to ensure checks and balances in their health facilities. 

This opinion piece is part of a blog series by the Allies Improving PHC for the 75th World Health Assembly that aims to highlight Primary Health Care as the foundation for achieving universal health coverage, health security and healthier populations globally. Pieces will be posted throughout the week of the 75th World Health Assembly, read more here.