Improving Primary Health Care Delivery in

This paper, based on quantitative surveys at the level of primary health care facilities, health care personnel, and households in their vicinity, aims at understanding the performance of primary health care providers in four states in Nigeria. As possible ways to improve performance, the paper concludes that clearly defining lines of responsibility, implementing performance-based financing of local governments and providers, and collecting, analyzing, and sharing information are some options that can help realign incentives and improve accountability in the service delivery chain and service provision.This working paper was produced as part of the World Bank#xE2;#xAC;"s Africa Region Health Systems for Outcomes (HSO) Program. The Program, funded by the World Bank, the Government of Norway, the Government of the United Kingdom, and the Global Alliance for Vaccines and Immunization (GAVI), focuses on strengthening health systems in Africa to reach the poor and achieve tangible results related to Health, Nutrition, and Population. The main pillars and focus of the program center on knowledge and capacity building related to Human Resources for Health, Health Financing, Pharma-ceuticals, Governance and Service Delivery, and Infrastructure and ICT.

Foreword	p. ix
Acknowledgments	p. x
Acronyms and Abbreviations	p. xi
Executive Summary	p. xiii
Primary Health Care Delivery in Four States	p. xiii
Understanding the Performance of Primary Health Care in the States	p. xvii
Division of Responsibility among Government Levels	p. xvii
Citizens/Clients-Policy Makers	p. xviii
Policy Makers-Providers	p. xx
Clients-Providers	p. xxi
Possible Ways Forward	p. xxii
Introduction	p. 1
Objectives	p. 2
Conceptual Framework	p. 3
Methodology	p. 5
Context	p. 7
Health Outcomes and Access to Health Services in Nigeria	p. 7
Context in States Included in the Study	p. 9
Status of Primary Health Care Services	p. 11
Organization of the Primary Health Care System	p. 11
Survey Results	p. 12
Infrastructure and Amenities	p. 13
Services Available	p. 14
Equipment and Medical Supplies	p. 15
Pharmaceuticals	p. 16
Health Personnel	p. 17
Exemption and Waiver Programs	p. 20
Education and Promotion Activities of PHC Services	p. 30
Service Charges	p. 31
Division of Responsibilities among Government Levels	p. 33
Laws and Policies Informing the Division of Responsibilities for the Delivery of Primary Health Care	p. 33
Division of Responsibilities in Practice	p. 34
Policies and Guidelines	p. 34
Personnel Training	p. 36
Health Care Personnel Management	p. 36
Infrastructure: Construction and Maintenance	p. 37
Procurement and Distribution of Pharmaceutical Products	p. 39
Supervision	p. 41
Possible Ways Forward	p. 41
Clients-Policy Makers	p. 43
Local Government Revenues and Responsibilities	p. 43
Public Financial Management	p. 46
Local Government Civil Service	p. 49
Local Government Health Expenditure	p. 50
Local Government Accountability for Service Delivery	p. 54
Possible Ways Forward	p. 55
Policy Makers-Providers	p. 61
Characteristics of Health Personnel	p. 62
Education Level	p. 63
Incentives to Providers	p. 64
Mechanisms to Reward and Discipline PHC Personnel	p. 67
Other Negative Incentives Faced by PHC Personnel	p. 68
Health Personnel Coping Mechanisms	p. 70
Possible Ways Forward	p. 71
Clients-Providers	p. 74
Increasing Clients' Power	p. 74
Survey Results	p. 75
Possible Ways Forward	p. 77
References	p. 81
Appendixes	p. 85
Sample Size	p. 85
Household Survey Sample Characteristics	p. 88
Tables
Primary Health Care Facilities Infrastructure across States and Facility Ownership (in %)	p. xiii
Analysis of Survey Questionnaires	p. 6
Health Outcomes and Health Care Utilization across Geopolitical Zones, Nigeria 2003	p. 8
Population, Poverty, and Inequality Indicators, Nigeria 2004	p. 10
Health Facility Type by LGA Type	p. 12
Basic Information from All States (in %)	p. 13
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Improving Primary Health Care Delivery in Nigeria : Evidence from Four States

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