Overview and key findings

In Nigeria, health care is devolved to the states and primary health care (PHC) is the responsibility of the local governments, but existing budget and capacity constraints impact delivery for an effective health program. To respond to this concern, the Federal Ministry of Health (FMOH) developed a National Strategic Health Development Plan (NSHDP, 2010-2015) prioritizing strengthening of PHC services. A partnership must be formed between the various administrative levels (federal, state and local government authorities) to support an effective delivery of PHC services. The implementation of the NSHDP requires ensuring sustainable financing, efficient use of resources as well as accountability of expenditure, for a functioning and results-oriented delivery system, and especially at the PHC level. Most revenue at the local government authority (LGA) level comes from the Joint Account, which is made up of statutory transfers from the Federation Account and allocation by the State Government. LGAs rely on both on- and off-budget resources through the various administrative levels and non-government sources (e.g. internally generated revenue [IGR]). The government of Nigeria has not been able to reliably track information from the various levels of governments and off-budget means on how much is spent on PHC services. This is partly due to (a) too broad classifications of expenditure in the health sector to capture such granular information, (b) the fragmented nature of these resource (both cash and in-kind) flows toward PHC services and (c) the absence of a system to aggregate and track them (including reporting and consolidating out of pocket payments) in the context of a highly-decentralized federation. One of the central issues identified by previous studies in Nigeria is governance challenges and the weakness of monitoring and accountability structures at the PHC facility and LGA levels. Given the existing reporting and monitoring constraints, a retrospective study could not capture all the desired information. A new approach of a continuous public expenditure tracking survey (CPETS) was developed to understand flows and leakages, and institutional and financial constraints for PHC. This report provides some of the findings of the study, which was conducted in Niger and Ekiti sates of Nigeria, and provides its implications on policy considerations. The study summary findings are provided in this volume one, while the in-depth study report is volume two.