Primary Health Care Systems (Primasys) : Case Study From Nigeria

PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Case study from Nigeria
PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Case study from Nigeria
Professor B.S.C. Uzochukwu
Institute of Public Health, College of Medicine, University of Nigeria, Enugu Campus

WHO/HIS/HSR/17.36
© World Health Organization 2017
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PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Contents
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Background to PRIMASYS case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
1. Overview of health care system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3. Health care financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
4. Human resources for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
5. Access to health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
6. Timeline of relevant PHC policies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
7. Planning and implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
8. Regulatory processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
9. Monitoring and evaluation system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
10. Policy considerations and ways forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
10.1 Pathways of success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
10.2 Pathways of barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
11. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Annex 1. Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Annex 2. Details of key informants identified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
CASE STUDY FROM NIGERIA

Figures
Figure 1. Map of Nigeria and its geographical divisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Figure 2. Organization of primary health care delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Figure 3. Proportion of budget for PHC activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 4. Zonal disparities in human resources for health . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure 5. Timeline of policies and other developments relevant to PHC in Nigeria . . . . . . . . . . . 21
Tables
Table 1. Key demographic, macroeconomic and health indicators of the country . . . . . . . . . . . . 4
Table 2. Demographic, macroeconomic and health profile of the country . . . . . . . . . . . . . . . . .4
Table 3. Basic information on Nigerian health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Table 4. Organization and provision of PHC services in Nigeria . . . . . . . . . . . . . . . . . . . . . . . 10
Table 5. Successes or failures and key barriers to and enablers of primary health care . . . . . . . . . 27
Table 6. Priorities in primary care at the district, regional and country levels . . . . . . . . . . . . . . . 27

iv
Abbreviations
CHEW community health extension worker
DFID Department for International Development
GDP gross domestic product
GPS global positioning system
ICD-10 International Classification of Diseases and Related Health Problems, 10th Revision
LGA local government area
NHMIS National Health Management Information System
PATHS2 Partnership for Transforming Health Systems phase II
PHC primary health care
PPP purchasing power parity
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VAT value-added tax
WHO World Health Organization

1
Background to PRIMASYS case studies
Health systems around the globe still fall short of The Alliance has developed full and abridged versions
providing accessible, good-quality, comprehensive of the 20 PRIMASYS case studies. The abridged
and integrated care. As the global health community version provides an overview of the primary health
is setting ambitious goals of universal health care system, tailored to a primary audience of policy-
coverage and health equity in line with the 2030 makers and global health stakeholders interested in
Agenda for Sustainable Development, there is understanding the key entry points to strengthen
increasing interest in access to and utilization of primary health care systems. The comprehensive case
primary health care in low- and middle-income study provides an in-depth assessment of the system
countries. A wide array of stakeholders, including for an audience of researchers and stakeholders who
development agencies, global health funders, policy wish to gain deeper insight into the determinants
planners and health system decision-makers, require and performance of primary health care systems
a better understanding of primary health care in selected low- and middle-income countries.
systems in order to plan and support complex health Furthermore, the case studies will serve as the basis
system interventions. There is thus a need to fill the for a multicountry analysis of primary health care
knowledge gaps concerning strategic information systems, focusing on the implementation of policies
on front-line primary health care systems at national and programmes, and the barriers to and facilitators
and subnational levels in low- and middle-income of primary health care system reform. Evidence from
settings. the case studies and the multi-country analysis will
in turn provide strategic evidence to enhance the
The Alliance for Health Policy and Systems
performance and responsiveness of primary health
Research, in collaboration with the Bill & Melinda
care systems in low- and middle-income countries.
Gates Foundation, is developing a set of 20 case
studies of primary health care systems in selected
low- and middle-income countries as part of an
initiative entitled Primary Care Systems Profiles
and Performance (PRIMASYS). PRIMASYS aims to
advance the science of primary health care in low-
and middle-income countries in order to support
efforts to strengthen primary health care systems
and improve the implementation, effectiveness
and efficiency of primary health care interventions
worldwide. The PRIMASYS case studies cover key
aspects of primary health care systems, including
policy development and implementation,
financing, integration of primary health care into
comprehensive health systems, scope, quality and
coverage of care, governance and organization, and
monitoring and evaluation of system performance.

2
1. Overview of health care system
Nigeria is one of the largest countries in Africa, With a gross domestic product (GDP) per capita of
occupying an area of 923 678 square kilometres. It US$ 1091 and an income or wealth inequality (Gini
lies within the tropics along the Gulf of Guinea on coefficient) of 43.7, Nigeria is still ranked among the
the west coast of Africa, between the latitudes of 4°1’ poorest countries in the world, with about 70% of
and 13°9’ N and longitudes 2°2’ and 14°30’ E (Figure 1). the population living below US$ 1 per day. About
It is bordered by Benin to the west, Cameroon to the 52.2% of the country’s population live in rural areas
east, Niger and Chad to the north and the Atlantic where poverty is more predominant, thus limiting
Ocean to the south. It is the most populous country access to adequate nutrition, quality health care and
in the continent, with a population of 177 155 754 other basic social services. Recent assessments have
and a population growth rate of 2.47% per annum. shown that the maternal mortality ratio is 576 per
The population is predominantly young, with about 100 000 live births, the under-5 mortality rate is 128
45% aged under 15 years and 20% under 5 years, per 1000 live births, the infant mortality rate is 69 per
while women of childbearing age (15–49 years) 1000 live births and life expectancy is 52.62 years (1).
account for about 22% of the total population (1).
Figure 1. Map of Nigeria and its geographical divisions
Abuja
FCT
Credit: commons.wikimedia.org

3
Table 1 presents information on the key demographic, A list of sources of information for the present study
macroeconomic and health indicators of Nigeria; is provided in Annex 1, and a list of key informants is
Table 2 presents the demographic, macroeconomic provided in Annex 2.
and health profile of the country; and Table 3 gives
basic information on the Nigerian health system.
Table 1. Key demographic, macroeconomic and health indicators of the country

Indicator Results Year Source
Total population of country 177 155 754 2014 estimate CIA World Factbook (2)
Sex ratio: male/female At birth: 1.06 2014 estimate CIA World Factbook (2)
0–14 years: 1.05
15–24 years: 1.05
25–54 years: 1.05
55–64 years: 1.04
65 years and over: 0.85
Total population: 1.01
Population growth rate 2.47% annual rate 2014 estimate CIA World Factbook (2)
Population density 442 people per sq km 2013 National Population

(people/sq km) Commission (1)
Distribution of population 49.6/50.4 (rural/urban) 2014 estimate CIA World Factbook (2)
(rural/urban)
GDP per capita (US$) US$ 1091 2014 estimate World Bank
Income or wealth 43.7 2014 estimate CIA World Factbook (2)

inequality (Gini coefficient)
Life expectancy at birth 52.62 years 2014 estimate CIA World Factbook (2)
Top five main causes Vaccine-preventable diseases, infectious and parasitic diseases 2013 National Population
of death (ICD-10 cause high mortality and morbidity in Nigeria. Commission (1)
classification) Major causes of mortality and morbidity in children are malaria,
diarrhoea, acute respiratory infections and malnutrition.
Malaria is responsible for about 11% of maternal deaths, 25% of
infant mortality and 30% of under-5 mortality.
Table 2. Demographic, macroeconomic and health profile of the country

Theme Summary Relevance for primary health care
Demographic profile Annual population growth rate: 2.7% High population growth places a major
Birth rate: 38.03/1000 strain upon the resources available for
health care.
Death rate: 13.16/1000
More young population implies a need
Net migration rate: –0.22/1000 for increased provision of child and
Rate of urbanization: 3.75% adolescent services.
Age structure: Very high total dependency ratio implies
0–14 years: 43.2% a need for more government funding for
primary health.
15–24 years: 19.3%
Relatively lower literacy rate in women
25–54 years: 30.5% implies a need to communicate
55–64 years: 3.9% medical advice and adverse health
65 years and over: 3.1% outcomes using non-written methods of
communication.
Total dependency ratio: 89.2% (84% youths and 5.2% elderly)
Literacy rate: 61.3% (72.1% male, 50.4% female)
Total fertility rate: 5.25
Contraceptive prevalence rate: 14.1%

4
Theme Summary Relevance for primary health care
Macroeconomic Nigeria is Africa’s largest economy with an estimated 2013 GDP of Macroeconomic shocks reduce household
profile US$ 502 billion. The annual economic growth rate is estimated at economic status, thereby reducing ability
6–8%, largely driven by growth in agriculture, telecommunications to access care and leading to consequent
and services. However, 70% of Nigerians live below the poverty line health outcomes
and approximately 62% live in extreme poverty. Taxes and other
revenues contribute 4.8% of GDP (2013 estimate). Budget estimates
for 2013 were US$ 23.85 billion for revenue and US$ 31.51 billion
for expenditure, giving a deficit of –1.5% of GDP. Household income
or consumption by percentage share was 1.8% for the lowest 10%
and 38.2% for the highest 10%, as at 2010. Other macroeconomic
indices are:
GDP, purchasing power parity (PPP): US$ 478.5 billion (2013)
GDP per capita (PPP): US$ 2800 (2013)
Gross national saving: 15.5% of GDP (2013)
GDP – composition by end use (2013):
Household consumption: 50.3%
Government consumption: 12.8%
Investment in fixed capital: 9.8%
Investment in inventories: 0%
Exports of goods and services: 49.9%
Imports of goods and services: 22.8%
GDP composition by sector (2012 estimate):
Agriculture: 30.9%
Industry: 43%
Services: 26%
Nigeria had an estimated labour force of 51.53 million in 2011, with
the unemployment rate estimated at 23.9%.
Health profile The health care system is largely public sector driven, with substantial
private sector involvement in service provision. Secondary- and
tertiary-level health facilities are mostly found in urban areas,
whereas rural areas are predominantly served by primary health care
(PHC) facilities. There is a shortage of PHC facilities in some states.
Health policy-making and national health care priority setting are the
responsibility of the federal government.
Nigeria ranks 187 out of 191 countries in health system efficiency
with respect to health expenditure per capita.
Under-5 mortality rate: 128/1000 live births
Infant mortality rate: 69/1000 live births
Maternal mortality ratio: 576/100 000 live births
Antenatal care attendance and delivery by skilled health providers:
61% and 38% respectively
Fully vaccinated children: 25%
No vaccination: 21%
Nigeria has one of the world’s highest rates of all-cause mortality
for children aged under 5 years, with health service utilization for
treatment of acute respiratory infections at 35% and diarrhoea
at 29%.
Nigeria accounts for one quarter of all malaria cases in Africa and has
a HIV prevalence of 3.1% (2012 estimate)
Sources: World Health Organization (WHO) (3); Index Mundi (4, 5).

5
Table 3. Basic information on Nigerian health system
Indicator Result Remarks
Total health expenditure as proportion of GDP 3.7% 2013 (3)
Public expenditure on health as proportion of 23.9% 2013 (6)

total expenditure on health
Private expenditure on health as proportion of 76.1% 2013 (6)

total expenditure on health
Out-of-pocket payments as proportion of total 69.35% 2013 (6)

health expenditure
Voluntary health insurance as proportion of 76% World Health Statistics

total expenditure on health (2005–2011) for 2013 estimate
Proportion of households experiencing 14.8% At a non-food expenditure

catastrophic health expenditure threshold of 40% (7)
Number of physicians per 1000 population 0.403 2008 (3)

3.7 2007 (8)
Number of nurses per 1000 population 1.605 2008 (3)

9.10 2007 (8)
Number of community health workers per 0.137 2008 (3)

1000 population 1.36 2007 (8)
This proportion includes
traditional health workers
Relative geographical distribution (rural/ There are 782 doctors and 1392 nurses working at tertiary No national data available:
urban) of doctors, nurses, and community level, representing about 50% respectively of the total state available data are from Enugu
health workers medical and nursing workforce. state human resources for
The primary level of care is rather dominated by community health policy
health extension workers (CHEWs) and junior CHEWs, who
make up about 36.8% of all care providers at the PHC level.
Enugu state has an average of 0.31 medical doctors per
primary-level care facility; 3.8 medical doctors per secondary
hospital; and 195.5 medical doctors per tertiary hospital.
Proportion of informal providers, and No national data available

practitioners of traditional, complementary
and alternative medicine, out of the total
health care workforce

6
2. Governance
The Constitution of Nigeria provides for the operation population served by the LGA health department is
of three tiers of government – the federal tier; 36 administratively determined by the state and local
semi-autonomous states and the Federal Capital government population (10).
Territory; and 774 local government areas grouped
The three tiers of the health system in Nigeria
into six geopolitical zones. Each state has an elected
(federal, state and LGA) have substantial autonomy
executive governor, an executive council and a
and exercise considerable authority in the allocation
house of assembly with powers to make laws. Each
and utilization of their resources. The National Health
local government area (LGA) is administered by an
Policy, and recently the National Health Bill, ascribe
elected executive chairperson and elected legislative
roles and responsibilities to each level. In practice,
council members from electoral wards. The 774 LGAs
however, the roles and responsibilities of the three
are divided into 9555 wards, which constitute the
tiers of government are not clearly defined by the
lowest political units. The state governments have
National Constitution or the National Health Policy.
substantial autonomy and exercise considerable
The existence of several comparatively better-funded
authority over the allocation and utilization of their
parastatals and single-disease vertical programmes
resources (9). Each state has a ministry of health,
further adds to the fragmentation (Figure 2) (11).
while each LGA has a health department. The
Figure 2. Organization of primary health care delivery
Tertiary hospitals FMoH FMoF
NPHCDA NHIS Development

partners
WHO
State hospitals
SMoH CSC SMoLG SHMB SPHCDA/B LGSC MoBP UNICEF
World Bank
DFID
Zonal/state
LGA NGOs PATHS2
offices for:
NPHCDA Health
centers Global Fund
NHIS BMGF
Private
FBOs
WHO FHI360
UNICEF WDC/HFC
UNH4+
Ward
FMoH health
system
Key: FMoH, Federal Ministry of Health; FMoF, Federal Ministry of Finance; NPHCDA, National Primary Health Care Development Agency; NHIS, National Health Insur-
ance Scheme; SMoH, State Ministries of Health; CSC, Civil Service Commission; SMoLG, Ministries of Local Government Affairs; SHMB, State Hospitals Management
Board; SPHCDA/B, State Primary Health Care Development Agency/Board; LGSC, Local Government Service Commission; MoBP, Ministry of Budget and Planning;
WHO, World Health Organization; UNICEF, United Nations Children’s Fund; LGA, local government area; NGOs, nongovernmental organizations; FBOs, faith-based
organizations; WDC/HFC, Ward Development Committee/Health Facility Committee; DFID, Department for International Development; PATHS2, Partnership for
Transforming Health Systems phase II; BMGF, Bill & Melinda Gate Foundation; FHI360, Family Health International 360; UNH4+, United Nations Health 4+

7
Federal responsibilities include setting standards, meet on a regular basis and ensure the delivery of
formulation of policies and implementation PHC services. The head of the board management
guidelines, coordination, regulating practices for team, otherwise known as the executive secretary
the health care system and delivering services at or director, whose duties are defined by law, is
tertiary care level. Specific diseases and specialized appointed by the state governor and reports directly
services are provided at the tertiary hospitals (10). to the board. The functions of the board include (a)
Tertiary health services are provided predominately approval of strategic and operational plans, including
by the federal government through the network the health budget; (b) policy development and
of teaching hospitals and specialist hospitals, but approval; and (c) oversight of policy implementation.
several states manage and finance tertiary health This structure is duplicated at the substate level,
care facilities within their state territories. The federal though all policies need to be aligned with relevant
government through the Federal Ministry of Health national and state government policies (14). Although
is primarily responsible for overall stewardship and most secondary health services are provided by state
leadership for health and provision of tertiary health governments, the federal government currently
care (12). The Federal Ministry of Health is made up of manages 23 medical centres (secondary care) across
the Secretariat with eight departments; five agencies, the country (15).
including the National health Insurance Scheme
At the primary level, which is the lowest level and
and National Primary Health Care Development
the entry point to health care services, are the health
Agency; five vertical control programmes; 53 federal
posts and clinics, health centres and comprehensive
health institutions (comprising teaching hospitals,
health centres providing basic primary care services,
federal medical centres and specialist hospitals);
spanning promotive, preventive, curative and
three research institutes; and professional regulatory
rehabilitative services. LGAs own and fund PHC
councils and boards for the various professional
facilities and have overall responsibility for this
health disciplines (13). In addition, the development
level of care. PHC is the foundation of the National
partners also provide resources to the Federal
Health System. The Ward Health System, which
Ministry of Health through the Federal Ministry of
takes on the political ward as the functional unit
Finance.
for PHC service delivery, was adopted as a suitable
Secondary health care provides specialized services strategy for addressing the numerous challenges
to patients through outpatient and inpatient services and accelerating progress in the attainment of the
of hospitals under the control of state governments. Millennium Development Goals. The LGA health
Patients are referred from PHC facilities to secondary departments are primarily responsible for managing
care hospitals. The state ministry of health provides primary care facilities. Each level of government
health care services through secondary-level health identifies its health priorities and pursues them with
facilities as well as technical assistance to the LGA minimal intervention from the other levels (13).
health departments. Each state is expected to
In addition to the efforts of the LGAs, PHC services
have a single PHC board consisting of a state-level
have been jointly managed by the state ministries
governing body (which meets at least quarterly) and
of health, ministries of local government affairs,
a board management team (full-time employees).
the Local Government Service Commission, the
The governing body includes women and men who
Civil Service Commission, the Ministry of Budget
represent the interest of their communities as well
and Planning, state hospitals management boards,
as their professional, official or political interests.
faith-based organizations, nongovernmental
They also include people who particularly represent
organizations, zonal and state offices of the National
historically or otherwise excluded groups such as
Primary Health Care Development Agency, the
women and children. The PHC board is required to
Federal Ministry of Health, the National Health

8
Insurance Scheme, development partners and more. The role and contribution of government in
Vertical and horizontal fragmentation of PHC service strengthening the National Health System
management, including management of staff, funds include playing a leadership role, domestication
and other resources, is the most significant issue of international and regional initiatives, effective
facing this tier of care (15). management allowing deliverables to be achieved
in a timely manner, national capacity-building,
In Nigeria the ward – which is the smallest political
strong political support, and monitoring and
structure, consisting of a geographical area with a
evaluation. At national level and at state and local
population range of 10 000 to 30 000 people – has
government levels, programme management is
been selected as an operational area for delivering
supported by multiple partners through various
a minimum health care package in the country
mechanisms, including direct secondment of staff,
(16). Thus, according to the Ward Health System
capacity-building and organizational or technical
operational guidelines (17), each section or group
support (11). The development partners, notably
of villages should have a health post and each ward
WHO, the United Nations Children’s Fund (UNICEF),
should have a health centre that should serve as
the World Bank, United Nations health agencies, the
the first reference to the health posts in the same
Partnership for Transforming Health Systems phase
ward. Thus, the PHC facilities are an outgrowth of
II (PATHS2) of the United Kingdom Department for
the LGAs, and the ward development committees
International Development (DFID), and FHI 360 of the
and health facility committees are linked to these
United States Agency for International Development
health facilities in the LGAs. The health facilities are
(USAID), provide guidance to states on how to
static or mobile structures where different types of
improve PHC service delivery through embracing
health services are provided by various categories of
the concept of “one management, one plan and
health workers. These health facilities are in different
one monitoring and evaluation for PHC” in the state,
groups and are called different names depending on
otherwise referred to as “PHC Under One Roof”
the structure (building), staffing, equipment, services
(14). “Bringing PHC Under One Roof” is modelled
rendered and ownership. Many terminologies have
on guidelines developed by the World Health
been used over the years, including dispensaries,
Organization for integrated district-based service
health clinics, health centres, primary health centres,
delivery to strengthen PHC services through reducing
maternities, health posts and comprehensive health
the fragmentation of PHC service management. This
centres. However, based on the Ward Health System,
basically involves the establishment of state PHC
the three recognized facility types are health posts,
management boards or state PHC development
primary health clinics and primary health care
agencies. It is based on the following key principles:
centres (17). These facilities are either owned by
integration of all PHC services delivered under one
the government, or by private for-profit and private
authority; a single management body with adequate
not-for-profit organizations. Private health facilities
capacity to control services and resources, especially
are classified according to their structure and the
human and financial resources; decentralized
services they provide. Private health care providers
authority, responsibility and accountability with an
in Nigeria are broadly clinics, maternity homes and
appropriate span of control at all levels; the principle
hospitals, while the ownership includes individual
of “three ones” (one management, one plan, and one
professionals, nongovernmental organizations,
monitoring and evaluation system); an integrated
faith-based organizations and other civil society
supportive supervisory system managed from a
organizations. The array of services they provide
single source; an effective referral system between
include PHC, but the institutions are not categorized
and across the different levels of care; and enabling
in line with public facilities.
legislation and concomitant regulations that
incorporate these key principles (18).

9
Table 4 summarizes the main structures for provision that would result in substantial health gains at
of PHC in Nigeria. low cost to the government and its partners. The
Ward Minimum Health Care Package includes the
The implementation of PHC is primarily through
following interventions: (a) control of communicable
services carried out at the primary health centres
diseases (malaria and sexually transmitted infections,
and home visits. These services are specifically
including HIV/AIDS); (b) child survival; (c) maternal
related to the minimum service components for PHC
and newborn care; (d) nutrition; (e) prevention
outlined in the WHO/UNICEF Alma-Ata Declaration
of noncommunicable diseases; and (f ) health
on Primary Health Care of 1978. The minimum
education and community mobilization. Strategies
standards for PHC in Nigeria are contained in the
for the provision and sustainability of the six
Ward Minimum Health Care Package, which was
interventions include service provision (for example
developed to address the strategy to deliver PHC
of essential drugs); improved quality and quantity of
services through the Ward Health System, utilizing
human resources for health; and health infrastructure
the electoral ward as the basic operational unit. It
development (17).
consists of a set of health interventions and services
that address health and health-related problems
Table 4. Organization and provision of PHC services in Nigeria
Sector (public Nature of Mode of employment Range of services provided Remarks

or private) facility of providers
Public Primary health Employed as local • Immunization and vitamin A Some bottlenecks identified are:
centre government staff and then supplementation • Unavailability of trained
posted to the PHC centres • Prevention of mother-to-child human resources
Mostly permanent transmission • High dropout rates in
employment • Integrated management of interventions requiring
childhood illness – malaria reasonable degree of
• Antenatal care continuity in order to attain
the required quality coverage
• Skilled birth attendance
• Geographical accessibility to
• Infant and young child feeding points of service delivery
• Community management of • Commodity availability
acute malnutrition
Private Nongovernmental Consultancy • Health services management

organization • Service delivery
• Research
• Promotion of primary mental
health care
• Health system support and
promotion of quality care

10
3. Health care financing
Health care in Nigeria is financed through different Revenue collection and administration is highly
sources, including tax revenue, out-of-pocket centralized; the federal government collects most
payments, donor funding, and health insurance, of the government revenues (primarily from oil) on
both social and community (19). Financing agents behalf of the three tiers of government. The revenues
in Nigeria include the federal government and that are collected by the federal government are
its parastatals, state and local governments, and pooled into the excess crude account, the federation
insurance companies (20). The government is account or the value-added tax (VAT) pool account,
responsible for the provision of quality health and are subsequently shared among the three tiers
services to the citizens, but evidence suggest of government in accordance with existing revenue-
that households through out-of-pocket spending sharing formula (15).
continue to be the major source of health financing
Of the funds in the federation account, 48.5% go to
in Nigeria (7, 21). In 2013, out-of-pocket expenditure
the federal government (and an additional 4.18%
as a percentage of total health expenditure was
are passed through the federal government to
69.35% and out-of-pocket expenditure as a
special funds), 26.72% go to the state governments
percentage of private expenditure on health was
and 20.6% go to the LGAs. Of the funds in the VAT
95.8%. High out-of-pocket expenditures expose
pool, 14% go to the federal government (and an
the poor to catastrophic health spending and trap
additional 1% goes to Federal Capital Territory
them in poverty, as well as aggravating the poverty
through the federal government), 50% go to the state
of others. Several studies have shown different
governments and 35% go to the LGAs. In addition to
levels of catastrophic expenditure in Nigeria. A
the shares from the federation account and VAT pool,
study conducted in two southern states showed
The state governments and LGAs also have their own
that 15% of the study households experienced
internally generated revenues, which are only a small
catastrophic health expenditure at a threshold level
proportion of their overall revenues (15).
of 40% of non-food expenditure (7). Another study
recorded a level of 24% (22). In terms of location, the The federal government channels resources for
incidence of catastrophic health expenditure was health through the Federal Ministry of Health, the
generally greater in the rural areas compared to the state ministries of health and the departments of
urban areas. health at the LGA level. The National Health Account
shows that the total government health expenditure
The contributions of development partners towards
as a proportion of total health expenditure was
primary care are mostly in terms of funding to
23.9% in 2013, while private expenditure on health
bolster the provision of primary care services and
as a proportion of total health expenditure was
infrastructural development. Their commitment
76.1% in 2013. Resource allocation to the health
to vertical health programmes, including through
sector at less than 5% of the total budget is less
funding for staff capacity-building and supply of
than the WHO recommendation and the 15% Abuja
medicines and commodities, has contributed to
Declaration target (23). Also, the proportion of state
control and eradication of some diseases, such as
and LGA budgets allocated to health remains below
polio. The government on the other hand pays staff
15% (19, 23).
salaries and maintains the infrastructure for provision
of all health services (15).

11
Although states allocate reasonable budgets to their Child Health (19). The contribution of development
health sectors, there is evidence of erratic or lack of partners to health care financing was about 4% of
release of the allocated budgets. For example, in total health expenditure (N 27.87 billion) in 2003,
Kaduna state, the health budget in 2009 constituted 4.6% of total health expenditure in 2004 (N 36.04
about 12.8% of total state government revenues, billion) and 4% of total health expenditure in 2005
and the actual amount of health funds released was (N 36.30 billion) (26).
about 6.7%. Actual release of funds for the health
The National Health Insurance Scheme was
sector in Kaduna state hovers at 53% of planned
launched in 2006 with the Formal Sector Social
budgetary allocations, and has been in decline since
Health Insurance Programme to protect households
2004 (15). All in all, the total federal-level capital
from continuing health expenditure (27). Other
budget allocation for health that was released was
programmes in the scheme aim to cover the students
38.8 billion Nigerian naira (N) out of the N 63.4 billion
of tertiary institutions, old and disabled people, and
budgeted (61.2%) for 2011, and of this, only N 26.02
those in the informal sector (28). The 2008 Nigeria
billion (67%) was utilized (24). In many states of the
Demographic and Health Survey found that about
federation, the non-release of funds affected both
98% of women and 97% of men had no insurance
recurrent and capital budgets and led to significant
coverage (29).
poor implementation of programme activities. At
the LGA level, the financial allocations do not extend The Federal Ministry of Health enunciated a National
beyond the payment of salaries and consequently Health Financing Policy in 2006. The policy seeks to
not much, if anything, remains to pursue health promote equity and access to quality and affordable
programmes, including the issue of monitoring and health care, and to ensure a high level of efficiency
supervision of and logistics support for outreach and accountability in the system through developing
services (19). a fair and sustainable financing system (20). The
National Health Act on the other hand targets
Accountability has been noted as a key element
universal coverage through an efficient primary
in implementing health sector reform and
health care system providing at least basic services
strengthening health system performance (25).
in primary care facilities. Specifically, the National
In Nigeria, accountability and transparency is one
Health Act establishes the Basic Health Care Provision
of the weakest areas of the public finance system,
Fund, which is to be financed from the consolidated
especially at the LGA level. The DFID-supported
revenue of the federation with an amount not less
PATHS2 project conducted a public expenditure
than 1% of its value, and from other sources such as
management review in five states (Kano, Kaduna,
grants by international donor partners.
Enugu, Jigawa, and the Federal Capital Territory)
and confirmed that sharing financial information Funds for PHC flow to the LGA level through a variety
in Nigeria is a very sensitive issue, with a lack of of disparate channels – through the Federal Ministry
political will to share financial data. In addition, lack of Health, the states, the National Primary Health Care
of financial information is widespread, especially at Development Agency, and from resource generation
the LGA level. at the LGA level itself (15). Also, local government
expenditure responsibilities are financed largely
The per capita health expenditure of US$ 10 is far below
through statutory allocations from the federation
the US$ 34 recommended by the Macroeconomic
account, with LGAs regularly receiving about 20%
Commission on Health (23). However, there has been
of total federal resources in the divisible pool (30,
significant improvement in funding for some diseases
31). Since oil revenues are part of the federation
and programmes, including for immunization, HIV/
account, LGAs receive substantial revenues from
AIDS, tuberculosis, malaria, midwife services and the
this statutory allocation. LGAs are also entitled to a
Subsidy Reinvestment Programme on Maternal and

12
share of federally collected VAT revenues (outside the The federal budget in recent years has included
federation account) (30, 31). programmes of construction of PHC facilities in LGAs
by the National Primary Health Care Development
Among government agencies, the LGA is the
Agency (31). LGAs are supposed to receive statutory
main source of financing of PHC service delivery
allocations from state government revenues;
at the facility level (31, 32). Staff salaries, facility
however, there are no established rules or policies for
construction and maintenance, and supply of drugs,
the provision of financial assistance from the higher
equipment and other medical commodities are all
tiers of government, and it is not clear how well
predominantly provided by local governments.
any assistance that is forthcoming is coordinated
Hence, financing of day-to-day facility functioning is
with LGA budgets and plans for PHC services. The
largely provided by local governments. However, the
federal PHC budget – which includes spending
National Health Policy provides general guidelines
on the National Programme on Immunization, the
to all three tiers of government to prioritize resource
Roll Back Malaria initiative, the Midwives Service
allocation in favour of preventive health services
Scheme, PHC, and community and environmental
and PHC, which is the cornerstone of the national
tutor programmes – has been steadily decreasing
programme. In this spirit of prioritization, the federal
over the past four years as a proportion of the total
and state governments are expected to provide
federal health budget. It decreased from 8.4% of total
logistical and financial assistance to the LGAs,
spending in the health sector in 2012 to 4.7% in 2015
primarily for programmes of national importance
(Figure 3) (13). Overall, there is the perception that
such as the National Programme of Immunization,
funding for health and for PHC is inadequate.
or controlling the spread of HIV/AIDS (31).
Figure 3. Proportion of budget for PHC activities
8.4% 7.5% 7.4% 4.7%
2012 2013 2014 2015

Source: Federal Ministry of Health (2012–2015 Budget)

13
4. Human resources for health
The main categories of human resources for health are CHEWs. Doctors, nurses and midwives are more
are doctors, nurses, midwives, laboratory staff, available in non-PHC health care centres (33).
public health nurses, public health nutritionists, and
Studies have shown that health workers perceive
community health and nutrition workers, including
rural life as difficult and lack the desire to work in
community health officers, community health
PHCs located in rural communities. Reasons include
extension workers and community health assistants
lack of basic amenities that characterizes rural areas;
(13). Health care workers are paid by the level of
poor personnel and equipment, leading to difficult
government where they work, though there are
working conditions and dissatisfaction; lack of
some exceptions where professionals working in PHC
electricity and water in the facilities, leading to poor
facilities are employed by the state (13). Staffing per
quality of care and performance; and inadequate
100 000 population varies from one zone to another.
supply of drugs, which is a considerable constraint
For example, whilst the national average for doctors
to service delivery (34–36). Separation from
per 100 000 population is estimated at 12, some
families is another significant challenge for health
zones – notably North West and North East – have
workers who have to leave their families and social
as low as 4 (Figure 4). Whereas the national ratio of
responsibilities to work in rural areas (37). These
nurses and midwives to 100 000 population stands at
factors have a negative impact on job satisfaction,
21, the South West, North West and North East zones
staff performance and health service delivery, and
have 16, 11, and 18 respectively (33). The majority of
consequently lead to high staff turnover.
health workers in PHC facilities across all the states
Figure 4. Zonal disparities in human resources for health
Community
Nurse Doctor Pharmacist health officers
60
50
per 100000 population
40
30
20
10
0
South West South East South South North Central North West North East FCT

14
There are provisions for quality professional education Federal, state and LGA entities were expected to
and in-service training as well as regular reviews of be actively using adapted versions of the National
training curricula to ensure standards are maintained. Human Resources for Health Policy and Plan by the
However, it seems that little attention is paid to end of 2015 (38). However, a midterm review of the
appropriateness, given emerging trends and new National Strategic Health Development Plan 2010–
technologies. There is the general perception that 2015 showed that only 15 states (42%) had adopted
in-service support is not sufficient and that targeting the Human Resources for Health Policy (39). None of
is poor. Although there are 14 professional regulatory the 774 LGAs in the country have so far elaborated
bodies charged with regulating and maintaining the policies or strategic plans for human resources
standards of training and practice for various health for health, leading to poor coordination of efforts
professionals (13), there are inconsistencies in training addressing critical shortages, maldistribution of the
of primary care professionals in terms of regularity available health workforce, weak governance and
and who gets trained. Those who require training capacity related to human resources for health, and
support are often not those who are selected to be limited production and training capacity (39).
trained, resulting in staff demotivation and attrition.
A major challenge limiting effective and evidence-
There are strategies for in-service support in terms of based planning and management of human
staff training at all levels of care in the Nigerian PHC resources for health is the dearth of data and
system. Staff of primary care teams are encouraged baseline information. Imbalances in the skills mix
to undergo recommended or self-driven trainings in and large disparities in the distribution of the health
health services management and update courses in workforce between rural and urban areas and across
service delivery (including prevention, treatment and the six geopolitical zones compound the matter
control) of priority health problems. However, there further, with the northern areas being particularly
appear to be limited opportunities to undergo these underresourced (40).
trainings, and the extent of support may vary by state
Mention was also made by respondents during
or LGA. A respondent observed: “There is [in-service
interviews of the gap between training and
training] but to a limited extent. Some states and
performance of roles. It was stated that the CHEWs
LGAs in Nigeria offer some benefits to their staff in
do not actually undertake community practice, as is
in-service training” (KI9).1
expected. This was attributed to a number of factors,
Nevertheless, in some states of the federation, including lack of understanding and clarity of roles;
some health care professionals benefit from poor staffing in terms of number and composition;
generous scholarships while undertaking their and negative organizational culture and attitude,
basic professional training. But upon graduation, which is transferred among staff. “There is a gap
they do not pay anything back to the sponsoring between training and performance of expected role
states through services and become “lost” within after training. CHEWs are expected to spend 80% of
the system, because there is no accountability or their working time in the community and 20% in
process in place for monitoring (24). And in other the health facility. This is not so … for the following
states, a range of health workers – doctors, nurses reasons: poor understanding of what the CHEWs
and midwives, pharmacists, and community health should do in the community; inadequate staff such
workers – are said to be trained at great expense to that many PHCs are manned by CHEWs instead of
the state and, upon graduation, are not employed, CHOs [community health officers]; and bandwagon
thus again being lost to the system (KI2). effect of those already in the system” (KI2).
Supportive supervision is a process of guiding,
monitoring, and coaching workers to promote
1 “KI” numbers refer to key informants, as detailed in Annex 2.

15
compliance with standards of practice and assure and oversee the primary care activities of the local
the delivery of quality care service. The supervisory government while the latter supervises the activities
process permits supervisors and supervisees the at the primary care facilities. The health facilities
opportunity to work as a team to meet common goals report monthly to the local government health
and objectives. Supervision is frequently thought of authority, which in turn reports to the state ministry
as the main link between CHEWs and the health of health. “Yes, we have a reporting channel for
system. The national strategic health development supervisory support. The state should support the
document recognizes the need to establish local government by having an oversight function,
and institutionalize a framework for integrated while they [states] get feedback from them [local
supportive supervision with adequate committed governments]. The local government should in turn
resources for all types and levels of care providers support the health facilities” (KI9). However, there is
across public and private sectors. Mechanisms will be the perception that inadequate capacity (in terms of
established to monitor health worker performance, people, equipment and funds) to provide supportive
including use of client feedback (exit interviews). supervision and misuse of available resources
However, despite the availability of mechanism for negatively impact quality of supervision. “The
supportive supervision, there is the perception that supportive supervision is poor – even if it is available,
inadequate capacity (in terms of people, equipment it is not thoroughly done. How many people will
and funds) to provide supportive supervision and you supervise? The government does not provide
misuse of available resources negatively impact enough funding to support supportive supervisory
quality of supervision. Nonetheless, many states and visits. And talking about vehicles with which to do
health facilities have reported improved quality of supervision, sometimes vehicles are given and they
care through improved supportive supervision and use them for other purposes” (KI9).
teamwork, but these are yet to be documented and
The interviews showed that there are no government-
validated by studies (24).
led, established strategies for staff recognition
Findings from the interviews indicate that there is a among primary care teams. However, this is said to
structure in place to ensure that primary care teams occur at the programme level and probably at the
are accountable to the health sector. There are also discretion of the programme manager. According to
guidelines for reviewing and reporting performance a respondent, the extent to which staff recognition
of primary care teams. According to one respondent occurs – if at all – at different levels of the health
(KI9), the state government is expected to support system is unclear (KI2).

16
5. Access to health care
Health care services in Nigeria are provided by a Most primary health facilities across the country
multiplicity of health care providers in the public are poorly equipped, with only a quarter of health
and private sectors. As at December 2011, 34 173 facilities having more than 25% of the minimum
health facilities from 36 states and the Federal Capital equipment package. A large proportion of these
Territory were listed in the National Health Facility facilities are in deplorable condition, largely due
Directory. Of this number, 30 098 (88%) are PHC to poor funding at the state and local government
facilities, 3992 (12%) are secondary-level facilities, levels. The functionality of PHC facilities varies with
while 83 (1%) are tertiary-level facilities. More geographical location and geopolitical zone. The
than 66% of the facilities are public (government) proportion of PHC facilities providing immunization
owned. There are efforts to make the master facility services ranges from 0.5% in the North East to 90%
list interoperable with the national District Health in the South West. The capacity to provide basic
Information System platform to strengthen routine emergency obstetric services remains very limited –
health data analysis (23). only around 20% of PHC facilities have that capacity
(23).
Most services provided by private and public formal
establishments are clinic based, with minimal The availability of basic amenities to support an
outreach, home and community-based services. enabling working environment and quality services
Provision of community-based health services by (for example electricity or generator, emergency
CHEWs is severely lacking, with very few or no CHEWs transportation system, and good sanitary and waste
spending 80% of their time in the community, management practices) is poor in many of the PHC
mainly because of challenges with logistics. There facilities. Data on the case management competency
is consequently weak community participation and of health facility staff across a number of tracer
ownership (23). diseases, including malaria and other common
conditions with a high burden, show that on average
Private providers include formal and informal for-
only 37.4% of all cases considered were correctly
profit or not-for-profit establishments such as private
diagnosed by all health workers (primary health care
hospitals, maternities, pharmacies, patent medicine
review, 2012).
vendors and traditional health care providers. The
private sector delivers health care to approximately Utilization of services in the primary health facilities
60% of the population and serves as the first point is limited and varies across socioeconomic and
of call for over 80% of people (23). However, the geopolitical categories. Antenatal care attendance
engagement of the private sector through private– ranges from 31% in the North East to 87% in the
public partnership mechanisms is currently weak, as South West, whereas health facility delivery ranges
the exact nature of the role that private sector actors from 8.4% in the North East to 73% in the South
might play is far from certain. Some see working West (23). In addition, the majority of PHC facilities
with the private sector as a pragmatic necessity in a in the country do not run 24-hour services, thereby
government-dominated system, others see the role denying many patients the opportunity to use such
for the private sector as focusing on service provision, centres in cases of emergency. The poor quality of
while others see a distinct role for private financing services at PHC facilities and the limited periods of
(41). operation force clients to use secondary and tertiary
facilities. There is a national referral system but its
functionality has not been assessed. Overall, there

17
is the perception that people have lost confidence There have been recorded improvements in the
in the PHC facilities and bypass this level of care to utilization of some primary care services, though
higher levels to access care when needed (37). there are still widespread variations in urban and
rural outcomes. For example, the proportion of births
Although primary health centres were established
attended by skilled birth attendants increased from
in both rural and urban areas in Nigeria with the
38.9% in 2008 to 53.6% in 2012 and further to 58.6%
intention of equity and ease of access, the rural
in 2014. The urban areas, with 79.2%, had a higher
population is seriously underserved compared TO
proportion of deliveries assisted by trained personnel
their urban counterparts (42). This inequity has
compared to about 46.6% in rural areas. The
been attributed to (a) governmental factors, such as
proportion of children aged under 1 year immunized
lack of political commitment, inadequate funding
against measles has increased, from 41.4% in 2008 to
or misappropriation of funds, weak intersectoral
55.8% in 2012 and 63.1% in 2014. However, rates of
collaboration and intergovernmental struggles for
immunization for children were higher in the urban
power and control; (b) people- or client-related
areas (56.2%) than in the rural areas (39.9%) (43).
factors, such as community perceptions of poor
quality and inadequacy of available services in With respect to access to medicines, less than half of
the PHC centres, underutilization of PHC services PHC facilities have the listed essential drugs in stock.
and low levels of community participation; and This results from lack of government commitment
(c) other factors, such as lack of motivation in the to the establishment of procurement systems for
workplace (for example due to poor remuneration), health commodities and allows for the proliferation
unhealthy rivalry between various categories of of patent medicine vendors and drug hawkers,
health workers, non-involvement of the private further compounding the problem of irrational drug
health sector in the planning and implementation of use (23). Irrational drug use and the potency of drugs
PHC, poor management of information systems and are major issues of concern, with about 40% of drugs
heavy dependence on initiatives funded by foreign in the market found to be fake or substandard (23).
donors (42).

18
6. Timeline of relevant PHC policies
The development of PHC in Nigeria follows the In 1992 the National Primary Health Care Development
1978 Health for All endorsement at the International Agency, with zonal offices in Enugu, Ibadan, Kaduna
Conference on Primary Health Care in Alma-Ata and Bauchi, was set up. The country was also
and prior reforms such as the Basic Health Service divided into health zones for effective programme
Scheme of the Third National Development Plan implementation and supervision, supported by the
(1975–1980), which set out the PHC philosophy (44). appointment of PHC coordinators in LGAs and zonal
The basic elements of the scheme were to build in and state coordinators. This was done to extend
each LGA one comprehensive health institution health care delivery services to the rural areas, a
(which would serve as the headquarters), four role that was taken over from the Federal Ministry
primary health centres, and 20 health clinics (14). This of Health. There was also the creation and training
complement of facilities was called the “basic health of a new staff line of community health workers to
unit”, designed to serve a threshold population of carry out the PHC programmes (CHEWs, community
150 000. The clinic was the base facility while the health officers). The mandate of the agency includes
primary health centre was a referral facility to four providing support to the National Health Policy as it
clinics. The arrangement was aimed to increase the relates to primary health care; providing technical
proportion of the population receiving health care support to the planning, management and
from 25% to 60%; initiate the provision of adequate implementation of PHC; mobilizing resources at the
and effective health facilities for all Nigerians; correct national and international levels for the development
the imbalance in the distribution and location of and implementation of PHC programmes; providing
health facilities; correct the imbalance between support to monitoring and evaluation of PHC and
preventive and curative care; establish a health care by extension the National Health Policy; promoting
system best adapted to the local conditions and level development of human resources for health; and
of health technology; and provide infrastructure for promoting and supporting the Village Health System
all preventive health programmes (45, 46). (13).
In 1986, the Federal Ministry of Health selected 52 There was also restructuring of the Federal Ministry
LGAs to be developed as models for PHC services, of Health, for example through creation of more
and these were paired with a college of medicine departments, such as a PHC department, which did
or school of health technology to provide technical not exist before the creation of National Primary
assistance. Village health services and village health Health Care Development Agency. Since inception,
committees were set up in these 52 LGAs. the agency has implemented a number of federal
government programmes aimed at revitalizing PHC
The Nigerian National Health Policy of 1988, which
in Nigeria, such as the Midwives Service Scheme and
was based on the principles of PHC, culminated
the Subsidy Reinvestment Programme on Maternal
directly from the Alma-Ata Declaration. In addition
and Child Health (45). Another policy, the Bamako
to the National Health Policy, a major element of
Initiative Programme, the health component of the
the new system was the creation of the Primary
National Economic Empowerment and Development
Health Care Directorate in the Ministry of Health,
Strategy (2003–2007), was implemented. All these
under Dr Ransome-Kuti as Minister. The directorate
reforms resulted in the revision of existing health
was charged with the responsibility of “formulating,
policies and plans or the production of new ones.
developing and implementing the National Primary
The need for collaboration between the public and
Health Care System” (47).
private sectors was addressed by the health sector

19
reform document and a framework was developed • development of several subsectoral policies,
to make this operational (12). including on public–private partnership, human
resources for health, health financing, health
The Health Sector Reform Programme was
research, equipment, infant and young children
implemented from 2004 to 2007 to reposition the
feeding, maternal, newborn and child health,
health sector for improved service delivery, leading
adolescent health, health sector response to HIV/
to better health outcomes. The seven strategic
AIDS, and health promotion, as well as a National
thrusts of the Health Sector Reform Programme
Drug Policy and National Malaria Strategic Plan;
were to (a) improve the stewardship role of the
• development of an integrated Maternal, Newborn
government; (b) strengthen the National Health
and Child Health Strategy.
System and its management; (c) reduce the burden
of disease; (d) improve health resources and their Two key policy documents were developed to
management; (e) improve access to quality health guide and sustain the reforms in the future. These
services; (f ) improve consumer awareness and policy initiatives laid a firm foundation for further
community involvement; and (g) promote effective action to revitalize the health sector and accelerate
partnership, collaboration and coordination. The previously stalled progress towards the health-
Health Sector Reform Programme however adopted related Millennium Development Goals. The
a top-down approach in its implementation, hence first was the Five-Year National Strategic Health
the persistence of the problems it was designed to Development Plan 2010–2015 with eight strategic
address. Also, despite the centrality of PHC to health priority areas developed by departments of the
development in Nigeria, the role and contributions Federal Ministry of Health, state ministries of health,
of local government to revitalization of PHC were local government departments of health and other
not defined in the Health Sector Reform Programme federal health institutions (13). The second was the
document (11). National Health Policy, which was reviewed, updated
Alongside the Health Sector Reform Programme, and harmonized into a National Health Bill that
several significant new policy initiatives in the health described the redefined National Health System and
sector were developed. These include: the functions of each level of government, including
the PHC level (48).
• the merger of the National Primary Health
Care Development Agency and the National Figure 5 presents a timeline of relevant PHC policies
Programme of Immunization; in Nigeria.
• revision of the National Health Policy;
• development of a framework for achieving the
health-related Millennium Development Goals in
Nigeria;
• formulation of the National Primary Health Care
Development Agency draft plan of action for
the delivery of the Ward Minimum Health Care
Package;
• drafting of the National Health Bill;
• revitalization of the National Council on Health;
• publication of a report on repositioning the
Federal Ministry of Health;
• the formal launch of the National Health Insurance
Scheme;

20
Figure 5. Timeline of policies and other developments relevant to PHC in Nigeria
2009
Development of a 5-year National Strategic
Health Development Plan (2010–2015)
1988
Launching of National
Health Policy
1986 2004–2007
Implementation of the health
Adoption of 52 Local sector reform programme
Government Areas as
models for PHC
1992
Set up of National PHC
Development Agency (NPHCDA)
1999/2004
Law enabling National Health
Insurance Scheme signed in
1999. Amended in 2004
1987
Adoption of Bamako 2004
Initiative programme
Merger of NPHCDA and National
Programme on Immunization
Revised National Health Policy
1975–1980
Basic Health Service Scheme
2014
National Health Act
with provision for Basic
Healthare Provision Fund
to strengthen PHC

21
7. Planning and implementation
The epidemiology units of the federal and state (50, 51). However, this practice has the tendency to
ministries of health, National Centre for Disease weaken health system accountability.
Control and Surveillance, and notification units of
The linkages within and between different levels of
the LGAs were said to be notable structures that are
care are perceived to be weak (52). The secondary
in place for identifying, measuring and responding to
care facilities in most states of Nigeria do not function
the disease burden. These structures are intended to
effectively, with implications for linkage with primary
track diseases using the surveillance and notification
care facilities. The challenge of access and mobility
system. The reporting system, which starts from the
from an initiating to a receiving facility compounds
community to the health facility, to the LGA, to the
the problem of referral in the Nigerian PHC system.
state and Federal level (13), is case based for the
In instances where initiating facilities have been able
different endemic and epidemic-prone diseases
to overcome the barriers of access and make an
(with 21 diseases on the reporting list), and the case
outward referral to a receiving facility, no feedback
reporting system is thought to be an effective strategy.
occurs from the receiving facility or the referred
However, there are inadequate human resources for
patient or client. Once referrals are made, there is
surveillance and a poor notification system, due to
practically no follow-up of the referred clients.
the weak network structure. “The case reporting is
good but the network is quite small compared to the The departments of primary health care at the state
population. The surveillance strength is inadequate, and local government levels have specialized units,
that is why you’d see outbreaks popping up from in line with the stipulations of PHC policy, whose
time to time” (KI8). Nevertheless, Nigeria’s response duty it is to ensure that health promotion and
to the Ebola virus disease outbreak and more recently prevention actions are implemented at health facility
the Lassa fever outbreak showed some evidence of a and community levels. The primary care facilities are
sensitive surveillance system. This was attributed to equipped for and are expected to deliver promotive,
the polio eradication initiative by some respondents: preventive and curative services. However, they
“The long struggle to eradicate polio in Nigeria has appear to have limited human resources capacity to
led to the strengthening of the surveillance system effectively implement services other than curative:
by the World Health Organization and other diseases “How comprehensive could it be when one person
surveillance has benefited from this” (KI1). is to give injections, do training and document the
data? I have already told you that the staff strength
Availability of medical products at the PHC level is
is an issue” (KI8). There is also the perception that
grossly inadequate, with reported cases of stock-
lack of incentives for staff is reflected in their
out of essential medicines due to irregularities in
demotivation to take on additional roles, such that
the supply of products from the local government
their commitment to service delivery depends on
stores to health facilities. This irregularity has been
“he who pays the piper”: “One human being is giving
attributed to weak logistics management and poor
antimalarial, doing immunization, … and they are
funding. The local governments’ first priority is often
paying him extra money for that. So, when malaria is
payment of staff salaries, and when this is done little
doing a project and pays him N 50 000, he abandons
is left for other recurrent costs such as procurement
all the other work to go and collect the money” (KI8).
of medical products and equipment (49, 50). It has
been reported that front-line providers often resort to The main approach deployed in the Nigerian
purchasing medicines and selling them privately to health system to represent the citizens’ voice is
clients to meet the challenge of frequent stock-outs

22
the involvement of community representatives and the failure to address the social, economic and
through the health facility committees, also referred environmental determinants of health and not just
to as village health committees. Health facility the proximal causes of illness and disease. Although
committees are recognized entities that are set some of the inequities in health outcomes are due to
up by the government to represent the citizens’ differences in access to health services, the majority
voice in health service planning and evaluation, are attributable to the conditions in which people
including identification of priority health needs are born, grow, live, work, and age. In turn, poor and
and community mobilization for action. They also unequal living conditions are largely the result of poor
act as a link between the health facility and nearby social policies and programmes, unfair economic
communities. Their roles include monitoring the arrangements, and politics driven by narrow interests
work of the health facility and supporting the health (55). Article VII(4) of the 1978 Alma-Ata Declaration
facility through community health volunteers (53). recognizes intersectoral collaboration as one of its
There is, however, the perception that health facility key principles, and the Nigeria National Strategic
committees lack the technical and managerial skills Health Development Plan makes provision for this.
to fulfil their roles as an external accountability
However, efforts to establish such mechanisms in
structure. The effectiveness of these committees
Nigeria have been very limited. Presently, there is little
towards performance of their roles and achievement
intersectoral collaboration with key relevant sectors
of their mandate is also limited by the absence of
such as finance (adequate budgetary allocation
incentives for members, unclear relationships and
and prompt release of funds); education (school
lines of reporting between the committee members
health and health promotion, girl child education);
and heads of health departments, and weak linkages
agriculture (food security, adequate and proper
to other health system institutions (53).
nutrition); water resources (adequate and safe clean
The Nigerian Government has long recognized water); environment (pollution and vector control);
the importance of community participation in the industry (production of critical inputs such as food
delivery of basic health care services and has thus and drugs and occupational health); and planning
tried to involve communities in the development (economic development and poverty reduction
of PHC along the lines of the Bamako Initiative’s strategies) (56). The major intersectoral approach
promotion of drug revolving funds (54). Indeed, the in Nigeria’s national response to the control of
guidelines for the development of the PHC system HIV/AIDS is a health sector initiative supervised by
(17) established the development of the following the Presidency (57). It includes a National Action
health committees as an accountability structure Committee on HIV/AIDS with membership drawn
to support activities at village and ward level: from the justice, social welfare, health, education,
village/community development committees, ward information, and other sectors. Similar bodies exist
development committees and local government at state and LGA levels. For a holistic approach to
development committees. These committees health, all sectors must be mobilized through good
have been in existence but with varying degrees governance, strong political will and commitment
of functionality. In principle, they are expected to to galvanize all stakeholders towards a common
perform the three main functions of accountability purpose – better health for all. However, respondents
at their different levels, namely financial, service have raised many issues concerning this approach
delivery performance and political/democratic that need to be addressed when a framework is
accountability. being produced.
The failure to achieve some of the Millennium
Development Goals has been linked in part to a
failure to reach the most vulnerable populations

23
8. Regulatory processes
There are policies and implementation guidelines government has the structure and regulation, but
for health service quality and medicines regulation complying with the regulation is not possible” (KI8).
among state and non-state sector health care
The government has a structure for regulating
providers. The ministries of health are responsible for
professional education. While the Medical and Dental
providing oversight and maintaining and enhancing
Council of Nigeria regulates the training of doctors,
the quality of health services provided within their
the Nursing and Midwifery Council of Nigeria
spheres of control (49, 50). Nigeria’s revised National
regulates the training of nurses and midwifes and the
Drug Policy (2003) aims to ensure access to safe,
Community Health Practitioners Council regulates
effective and good-quality drugs at all levels of health
the training of community health officers and CHEWs.
care and to strengthen regulatory controls. It clearly
Others include the Pharmacist Council of Nigeria for
stipulates that the government through the Federal
pharmacists and the Medical Laboratory Council for
Ministry of Health shall establish a National Drug
medical laboratory technologists. Existing policies
Policy Monitoring and Evaluation Division, and enact,
specify the training and skills requirement of various
strengthen and provide necessary resources for the
cadres of primary care providers. These policies are
enforcement of appropriate legislation to ensure
backed by training curricula with content appropriate
quality assurance (58). The quality, safety and efficacy
for specific health worker cadres and periodic reviews
of medicines are regulated by the National Agency
to ensure time relevant content: “Regular review of
for Food and Drug Administration and Control
curriculum that is used in training of the professionals
(49). Although the government appears to be well
[is done] … to ensure adequate training of different
structured and capacitated to regulate professional
cadres of primary care providers” (KI9). In practice,
practice, enforcement is a major challenge. Some
there appears to be a mismatch between training and
practitioners, particularly in the informal sector, were
performance of duties, due in part to the shortage
said not to abide by regulations and guidelines of
of skilled health care personnel at the primary care
practice, often overstepping their boundaries and
level, especially community health workers. This
avoiding any penalty even when they are caught.
results in tasks being shifted to health workers with
“The government has the capacity but not the
inadequate skills to perform them. “Training content
discipline. For example, the patent medicine vendors
may be adequate depending on the facilities and
are regulated … There are certain drugs that they
availability of committed teachers in the school but
should not even dispense, but they do not abide
the community practice is deficient” (KI2). “We have
to that, they go beyond their boundaries. You can
CHEWs performing the work of midwifes” (KI12).
get somebody arrested and he’d be released. So,

24
9. Monitoring and evaluation system
In 1988, Decree 43 of the Federal Government of lack of appropriate monitoring and enforcement
Nigeria created national monitoring and evaluation mechanisms.
units to provide necessary mechanisms for tracking
The establishment of an NHMIS for comprehensive
government budget and performance. This was
monitoring and evaluation of health care and as a
followed by the establishment of the Primary Health
management tool for informed decision-making at
Care Management Information System in 1990 with
all levels of government is enshrined in the National
a review in 2001. Equally, an integrated National
Health Policy. The minimum broad categories of
Health Management Information System (NHMIS)
indicators include health policy, health status, social
was formally developed in Nigeria in 1992, following
and economic indicators, and indicators on provision
previous attempts at vertical data collection,
and utilization of health care services. A review of
collation and analysis systems. In 2006, eventual
the system was carried out in 2004 with a view to
harmonization of vertical monitoring and evaluation
developing a more unified system with relevant
tools and systems culminated in the incorporation of
indicators to capture the Millennium Development
key programmatic indicators in the health sector into
Goals (59, 60). The Department of Planning, Research
the NHMIS, as captured in the current NHMIS Policy
and Statistics is responsible for collation of routine
(59).
health information from the community and facility
A health systems assessment in 2014 revealed a weak levels and onward transmission to the federal-level
NHMIS in Nigeria, despite the significant investments database (59).
made to date in this area of the health system.
Some improvements have been noted in the country’s
However, the analysis indicated that the NHMIS
NHMIS in terms of establishing an integrated disease
demonstrates the potential to be transformed into
reporting system in line with the recommended
a strong and viable building block for the Nigerian
horizontal approach. The DSN 001 form, which is used
health system. Most of the challenges are in the
at the PHC level, captures 48 health care indicators
areas of data governance, data quality and use of
and is adjudged to be comprehensive enough.
information. The roadmap for implementing this
Although the current information management
coordinated approach is guided by the national
system is deemed adequate in terms of structure
NHMIS Policy and elaborated in the Strategic Plan.
of collation and transmission, there are notable
Standard treatment protocols and job aids are shortfalls in its ability to deliver timely, reliable and
available to primary care teams to guide them complete data. The Nigeria Health sector performance
in making diagnoses and instituting appropriate report, however, showed that many states report in a
treatment for minor illnesses. The standing order timely manner and there is a regular return of NHMIS
contains specific guidance and instructions data from the LGAs, though it noted that a culture
regarding treatment of common conditions that the of routine analysis of NHMIS data and feedback to
community health worker may meet at the primary health institutions, and use of the data for health
care level. It gives the community health worker a planning and improvement of health outcomes, is
legal right to provide treatment for those conditions yet to take root (24).
in the absence of a nurse or doctor. However, it
Respondents also expressed the opinion that
appears that most of them, for personal reasons,
information on services delivered in the non-state
do not use the designated aids while attending
sector was lacking, and there was no mechanism to
to patients. One explanation for this could be the

25
capture such data. Weakness in data gathering was because of the capacity” (KI8). However, it was stated
apparent at all levels of the health system and was that health information management for vertical
attributed to weak governance, lack of commitment disease control programmes such as HIV and malaria
to duty, inadequate funding and infrastructure, low is more effective at generating reliable data than the
capacity, shortage of personnel, and deficient skills integrated system.
in data management. “The wrong people are used,
As a consequence of the above, health planning
in terms of their approach. … The infrastructure
and priority setting are not based on an accurate
backbone is not there, the human beings are not
epidemiological profile of the population. Data
there, the governance is weak, even the people
use for decision-making and programme planning
who are there are not ready to do the work” (KI6).
is generally poor; and on the rare occasions that
Capacity to collect, collate and analyse data is
evidence informs decision-making, population
perceived to be relatively poor at the primary care
estimates of disease profile and health service
facility level compared to higher levels of reporting
utilization rather than actual consumption rates
and service delivery: “Simple analysis happens at the
are used.
upper level but it cannot happen at the low level

26
10. Policy considerations and ways forward
Table 5 shows successes and failures related to PHC policy and strategy, and barriers to and enablers of
change, while Table 6 shows priorities in primary care provision at various levels.
Table 5. Successes or failures and key barriers to and enablers of primary health care
Successes or failures Barriers Enablers Remarks
PHC has been a veritable Gap between policy formation and implementation, NA
tool for achieving essential as only immunization services are provided in a
care for all in Nigeria comprehensive manner at PHC level
Poor utilization of services Lack of trust in the health system due to frequent NA Women wield enormous
offered in primary health stock-out of commodities and medicines influence in the
facilities Inadequate community participation community and this
should be harnessed by
bringing them into the
PHC mainstream
Poor coverage of primary Geographical inequities in distribution of resources NA

care services for PHC
Acute shortages of staff in the PHC facilities at the
rural level
Poor coordination between and within levels of
government and of partners
Weak governance and Inadequate managerial staff and poor management Provisions of the National
lack of transparency and capacity Health Act likely to address
accountability Weak external and internal accountability structures this
Donor-driven, technocratic approach to determining
health priorities detracts from the grass-roots
approach to health development recommended in
the Alma-Ata Declaration
Weak capacity to provide Inadequate and uneven distribution of health NA

basic and emergency workforce
services Poor infrastructure and insufficient or outdated
materials and equipment
High health staff attrition, Poor staff motivation and capacity development NA
particularly qualified and
higher cadres of staff
Reduced burden of vaccine- NA Delivery of quality routine

preventable diseases in vaccination supported by
most states and improved ad hoc campaigns, mobile
coverage of immunization in clinics and outreaches
children aged under 5 years Improved quality of care
mainly through in-service
training and supportive
supervision of health
workers
Table 6. Priorities in primary care at the district, regional and country levels
Priorities Type of respondent Health system level
Intersectoral collaboration Health policy analyst Primary
Control of priority diseases, including prevention, treatment and rehabilitation Academic All levels
Reduction of morbidity and mortality among women and children Programme officer All levels

27
10.1 Pathways of success routine immunization. In addition, the organization
and quick response times that stopped the Ebola
10.1.1 Basic Health Care Provision Fund virus from spreading in Nigeria have also been linked
under the new National Health Act to the sensitive surveillance system, as detection
In October 2014, following a decade of planning, delay could have facilitated the transnational
the Nigerian President signed into law the National spread of the virus. When the first Ebola case was
Health Act, which provides a legal framework for the confirmed in July 2014, health officials immediately
provision of health care services to all Nigerians and repurposed polio technologies and infrastructures to
for the organization and management of the health conduct Ebola case finding and contact tracing. The
system. A key component of the National Health Act use of cutting-edge technologies, developed with
is the establishment of the Basic Health Care Provision guidance from the WHO polio programme, put the
Fund, which will be predominantly financed through global positioning system (GPS) to work as support
an annual grant from the federal government of not for real-time contact tracing and daily mapping of
less than 1% of the Consolidated Revenue Fund links between identified chains of transmission (61).
(total federal revenue before it is shared to all tiers
of government). Half of the fund will be used to
10.2 Pathways of barriers
provide a basic package of services in PHC facilities 10.2.1 Corruption within the health system
through the National Health Insurance Scheme;
45% will be disbursed by the National Primary Corruption in the health sector has made various
Health Care Development Agency for essential health institutions ineffective, while scarce resources
drugs, maintaining PHC facilities, equipment and invested in the sector are wasted. Health system
transportation, and strengthening human resources corruption prevails in Nigeria because there is no
capacity; and the final 5% will be used by the Federal adherence to the rule of law, coupled with lack of
Ministry of Health to respond to health emergencies transparency and trust. In addition, the public sector
and epidemics. Additional sources of funding could in Nigeria is ruled by ineffective civil service codes
include grants by international donors and funds and weak accountability mechanisms, among others
generated from innovative sources such as taxes (62). Corruption occurs among different actors,
on cigarettes and alcohol. Respondents were of the including senior and junior administrative officers in
opinion that having a separate fund that is dedicated health ministries, parastatals and agencies. There is
to PHC and making this available at the primary care also corruption among health officials and personnel
level would improve access to services at that level. (including doctors, nurses, laboratory attendants
Leveraging of this new funding for health would and pharmacists), and among political office holders
also result in improved health indices and enhanced (health ministers and commissioners, chairpersons of
operational management of PHC activities. health-related boards and agencies) (62).
2
According to one report, Gavi, the Vaccine Alliance,
10.1.2 Strengthened surveillance system which provides funding to increase access to
through the polio eradication initiative immunization for children in the world’s poorest
programme countries, released its Nigerian audit report covering
One of the success stories of the Nigerian PHC system the expenditures incurred and procurement activities
is the eradication of polio. This has been linked to a conducted at the Federal Ministry of Health, the
strengthened surveillance system and other efforts, National Primary Health Care Development Agency,
such as increased domestic funding for polio, and states in the fiscal years 2011–2013. The cash
strengthened vaccination campaigns (particularly programme audit of Gavi in Nigeria determined that
in hard-to-reach and insecure areas), and improved 2
The Nigerian Standard newspaper, 17 August 2015.

28
US$ 2.2 million had been misused by Nigerian officials
and requested reimbursement of that amount,
which was subsequently refunded by the Nigerian
Government. A 10% increase in corruption could
reduce immunization rates by 10% to 20%. Reducing
corruption can therefore result in significant social
gains as measured by decreases in child and infant
mortality rates, as well as the proportion of low-
birthweight babies. The present political leadership
is addressing corruption in Nigeria and it is hoped
that this will be extended to the health sector.
10.2.2 Apportionment of responsibility to

deliver PHC to local government
The current National Health Policy document,
revised in 1996, indicates that local governments are
expected to be the main implementers of PHC policies
and programmes, with the federal government
responsible for formulating overall policy and for
monitoring and evaluation, and state governments
for providing logistical support to the LGAs, such
as personnel training, financial assistance, planning
and operations. Yet, the current Constitution (1999)
of Nigeria is ambiguous with regard to the authority
and autonomy of local governments in providing
basic services, such as primary health, for which they
have been assigned responsibility through sectoral
directives. According to the Constitution, it is the
state governments that have principal responsibility
for basic services such as primary health and primary
education, with the extent of participation of LGAs in
the execution of these responsibilities determined at
the discretion of individual state governments. The
constitutional existence of state-level discretion may
lead to disparities across local governments or across
states in the extent to which responsibility for PHC
services are effectively decentralized.

29
11. Conclusion
Summarily, the Nigeria PHC system suffers from Most health centres no longer have functional
fragmented services, weak referral systems and poor drug revolving schemes, resulting in shortage of
infrastructure, and there are serious gaps in access essential and critical medicines and commodities
to basic health services. The multiplicity of vertical at point of service delivery. A good number of the
disease control programmes, with poor integration of components of PHC are not provided at most service
services at suboptimal levels, results in low coverage delivery points. All of these challenges are worsened
of high-impact, cost-effective interventions. There by professional conflicts within the health system,
is poor linkage between the different levels of care. and by insurgence and conflict, especially in north-
Materials and equipment for service delivery at eastern Nigeria. This has hampered effective PHC
the PHC facilities are hardly available or functional. service delivery in the country.

30
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57. Adeleye OA, Ofili AN. Strengthening intersectoral collaboration for primary health care in developing countries: can the health sector play
broader roles? Benin City, Nigeria: Department of Community Health, School of Medicine, University of Benin; 2010.
58. Revised National Drug Policy 2003, second edition. Abuja, Nigeria: Federal Ministry of Health; 2005.
59. Revised Policy-Programme and Strategic Plan of Action. Federal Ministry of Health, Department of Health Planning and Research, NHMIS
Unit; 2006 (http://cheld.org/wp-content/uploads/2012/04/NATIONAL-HEALTH-MANAGEMENT-INFORMATION-SYSTEM.pdf, accessed 15
August 2017).
60. Adindu A. Health management information and the incongruity paradigm. DERHES Publications; 2008.
61. Courage KH. How did Nigeria quash its Ebola outbreak so quickly? Scientific American, 18 October 2014.
62. Kamorudeen A, Bidemi AS. Corruption in the Nigerian public health care delivery system. Sokoto Journal of the Social Sciences.
2012;2(2):98–114.

33
Annex 1. Sources of information
Key databases
The key databases identified and searched were:
Information source Website address
Primary Health Care Performance Initiative http://phcperformanceinitiative.org/sub-saharan-africa/nigeria-0
CIA World Factbook: Nigeria https://www.cia.gov/library/publications/the-world-factbook/geos/ni.html
National Bureau of Statistics: Socioeconomic statistics http://www.nigerianstat.gov.ng
National Population Commission: 2013 Nigeria Demographic https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf

and Health Survey
National Primary Health Care Development Agency (NPHCDA) http://www.nphcda.gov.ng/
World Bank: Nigeria economic report 2014 http://documents.worldbank.org/curated/en/2014/07/19883231/

nigeria-economic-report-no-2
World Health Organization – Global Health Observatory: http://apps.who.int/gho/data/node.country.country-NGA

Nigeria statistics summary 2002–present
Centre for Population and Environmental Development http://www.cpedng.org
Country statistics and global health estimates by WHO and http://who.int/gho/mortality_burden_disease/en/

United Nations partners, Global Health Observatory
Index Mundi: Nigeria demographics profile, Nigeria economy http://www.indexmundi.com/nigeria/demographics_profile.html;

profile http://www.indexmundi.com/nigeria/economy_profile.html
Key documents reviewed

The key reports, books and mimeographs reviewed were:
• Nigerian Health Review 2007–2008; published by Health Reform Foundation of Nigeria (HERFON)
• Reports of the expert group on revitalization of primary health care in Nigeria; published by NPHCDA
• Integrating primary health care governance in Nigeria: PHC under one roof; published by NPHCDA
• Institutionalization of the primary healthcare planning and reviews in Nigeria: progress and status;
published by NPHCDA
• 2009 external review of EU-Prime (Partnership to Reinforce Immunization Efficiency), version 2: final report
• National Health Accounts of Nigeria 2003–2005
• Nigeria in 2014: economic review and 2015–2017 outlook; published by National Bureau of Statistics
• Perspectives on primary health care in Nigeria: past, present and future; Omuta et al., 2014
• A Bill for an Act to Amend the National Primary Health Care Development Agency Act, 1992 No. 29, and for
Matters connected Therewith (2012); published by the Federal Government of Nigeria
• Strengthening National Health System: a country experience; published by Federal Ministry of Health
• National Strategic Health Development Plan (2010–2015); published by Federal Ministry of Health
• National Primary Health Care Development Agency (NPHCDA): minimum standards for primary health
care in Nigeria
• 10 years capacity profile and report of Primary Health Care and Health Management Centre (PriHEMAC):
1998–2008
• Nigeria health sector performance report 2011; published by Federal Ministry of Health, 2012

34
In addition, the following published articles and grey literature were reviewed:
• Olarenwaju et al. 2012. Economics of health system governance and financing in Nigeria
• Onoka et al. 2011. Examining catastrophic health expenditures at variable thresholds using household
consumption expenditure diaries
• Metiboba. 2009. Primary health care services for effective health care development in Nigeria: a study of
selected rural communities
• Adeyemo. 2005. Local government and health care delivery in Nigeria: a case study
• Alenoghena et al. 2014. Primary health care in Nigeria: strategies and constraints in implementation
• Aigbiremolen AO, Alenoghena I, Eboreime E, Abejegah C. Primary health care in Nigeria: from
conceptualization to implementation
• Uzochukwu B, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing
in Nigeria: implications for achieving universal health coverage. Nigerian Journal of Clinical Practice.
2015;18:437–44
• Ossai EN, Nwobi AN, Uzochukwu BSC. 2015. Spatial differences in quality of maternal health service in
primary health centers of Enugu state, Nigeria

35
Annex 2. Details of key informants identified
Descriptor Main areas of expertise Main constituency represented Remarks
KI1 Health system governance and accountability Politician, policy elite Face-to-face interview
KI2 Service delivery and health services management Bureaucrat Email interview
KI3 Health financing, governance and service delivery Implementing partner Face-to-face interview
KI4 Health care financing and citizens’ involvement in health Civil society actor Skype interview
KI5 Citizens’ involvement and health systems governance Commentator, civil society actor, Telephone interview
service provider
KI6 Health economics, health care financing, health systems Academician Face-to-face interview
governance
KI7 Health economics Academician Skype interview
KI8 Primary health care Development partner Face-to-face interview
KI9 Health services management, professional regulation Regulatory body, service provider Skype interview
KI10 Health policy and management, health economics Bureaucrat, policy elite Face-to-face interview
KI11 Citizens’ engagement and health systems governance Commentator Skype interview
and accountability
KI12 Child health and professional regulation Regulatory body, service provider Face-to-face interview

36
This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the
World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda
Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support
efforts to strengthen primary health care systems and improve the implementation, effectiveness and efficiency of primary health care
interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development
and implementation, financing, integration of primary health care into comprehensive health systems, scope, quality and coverage
of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and
abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system,
tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to
strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience
of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems
in selected low- and middle-income countries.
World Health Organization

Avenue Appia 20
CH-1211 Genève 27
Switzerland
[email protected]
http://www.who.int/alliance-hpsr

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PRIMARY HEALTH CARE SYSTEMS

Professor B.S.C. Uzochukwu

Institute of Public Health, College of Medicine, University of Nigeria, Enugu Campus

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Figure 1. Map of Nigeria and its geographical divisions

CASE STUDY FROM NIGERIA

Table 1. Key demographic, macroeconomic and health indicators of the country

Population density 442 people per sq km 2013 National Population

Income or wealth 43.7 2014 estimate CIA World Factbook (2)

Table 2. Demographic, macroeconomic and health profile of the country

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

Indicator Result Remarks

Total health expenditure as proportion of GDP 3.7% 2013 (3)

Public expenditure on health as proportion of 23.9% 2013 (6)

Private expenditure on health as proportion of 76.1% 2013 (6)

Out-of-pocket payments as proportion of total 69.35% 2013 (6)

Voluntary health insurance as proportion of 76% World Health Statistics

Proportion of households experiencing 14.8% At a non-food expenditure

Number of physicians per 1000 population 0.403 2008 (3)

Number of nurses per 1000 population 1.605 2008 (3)

Number of community health workers per 0.137 2008 (3)

Proportion of informal providers, and No national data available

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Figure 2. Organization of primary health care delivery

Tertiary hospitals FMoH FMoF

NPHCDA NHIS Development

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

Table 4. Organization and provision of PHC services in Nigeria

Sector (public Nature of Mode of employment Range of services provided Remarks

Private Nongovernmental Consultancy • Health services management

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Figure 3. Proportion of budget for PHC activities

8.4% 7.5% 7.4% 4.7%

2012 2013 2014 2015

CASE STUDY FROM NIGERIA

Figure 4. Zonal disparities in human resources for health

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

CASE STUDY FROM NIGERIA

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Successes or failures Barriers Enablers Remarks